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OB Peds Womens Health Notes

Nurses Clinical Pocket Guide
Brenda Holloway, CRNP, FNP, MSN Cheryl Moredich RNC, MS, WHNP Kathie Aduddell, Ed.D, MSN, RN-BC
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Copyright 2006 by F. A. Davis.

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), initial cervical screen for cancer should begin 3 years after first sexual intercourse or by age 21, whichever comes first However, ACOG recommends that a visit to an obstetrician/gynecologist occur before that time for health guidance, screening, 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, with three consecutive negative cervical screens, are recommended to have repeat exams every 23 years



Copyright 2006 by F. A. Davis.

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], 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; 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 for latest treatment guidelines for STIs

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Sexually Transmitted Infections (STIs) (Continued) Infection


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, some associated with cervical dysplasia Visible wartlike growths in genital area associated with subtypes 6, 11

Endocervical culture Urine test


Endocervical culture Urine test


Saline wet mount of vaginal discharge viewed under microscopy Serological testing


Human Papilloma Virus (HPV)

Pap smear report Colposcopy/biopsy

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Copyright 2006 by F. A. Davis.

Sexually Transmitted Infections (STIs) (Continued) Infection


Symptoms (May be asymptomatic)

Primary Chancre (painless raised ulcer) Secondary Skin rash, lymphadenopathy Latent Lacking clinical manifestations Tertiary Cardiac, ophthalmic, auditory involvement

Serological testing Nontreponemal (RPR, VDLR) Reported quantitatively (titers) Four-fold change in titers clinically significant Effective treatment will result in falling titers False-positive possible; 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


Fever Malaise Lymphadenopathy Skin rash


Herpes Simplex Virus (HSV)

Painful, recurrent vesicular lesions Fever, malaise Enlarged lymph nodes

Copyright 2006 by F. A. Davis.

Breast Health
Monthly breast self-exam, starting at age 20, instructed to woman as an optional tool for identifying and reporting breast changes Clinical breast exam at least every 3 years (age 2040) during a physical exam by a health professional; yearly after age 40 Annual mammogram starting at age 40

Instructions for Breast Self Exam (BSE)

Step 1: Inspection 1. Visually inspect the breasts, looking for dimpling, lumps, skin irregularities, symmetry 2. Visually inspect in several positions; may accentuate an abnormality Hands at the side Hands above the head Hands pressed onto hips Leaning over

BSE positions. (From Dillon PM. (2003) Nursing Health Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F.A. Davis, p. 459.)



Copyright 2006 by F. A. Davis.

Step 2: Palpation 1. Feel the breast tissue and lymph node chain for lumps or thickening by using three finger pads while exerting light, medium, and deep pressure in a systematic fashion

BSE palpation patterns. (From Dillon PM. (2003). Nursing Health Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F.A. Davis, p 461.)

Copyright 2006 by F. A. Davis.

2. Begin by lying down on a flat surface with arm raised and a folded towel under the back of the breast being examined 3. After examining breast tissue, bring arm toward body and feel the axilla and the skin above as well as below the collar bone 4. Repeat technique on the other side 5. Report lumps, thickening, 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. Discuss chromosomal abnormalities associated with advanced maternal age Incorporate 400 mcg of folic acid daily (for low-risk women) Avoid alcohol, smoking, 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, discussing the risks, benefits, and efficacy of each method Efficacy of each method influenced by correct and consistent use, user preparedness, motivation, dexterity, 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), which stimulates the anterior pituitary to release



Copyright 2006 by F. A. Davis.

follicle stimulating hormone (FSH), encouraging maturation of the Graafian follicle Estrogen, produced by the maturing follicle, 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, the corpus luteum (remaining cells of the follicle) produces estrogen and progesterone, which stimulates endometrial thickening If conception does not occur, the corpus luteum regresses, 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, as well as monitor gynecological health To prevent pregnancy, couples abstain during recognized period of fertility

Copyright 2006 by F. A. Davis.

Cervical Mucus
Amount and character of cervical mucus changes throughout the menstrual cycle in response to hormones Following menses, cervical mucus scant, thick, and cloudy At ovulation, cervical mucus becomes more abundant, slippery, clear, and stretchable in response to estrogen (known as spinnbarkeit), promoting sperm motility; increased likelihood of pregnancy with unprotected intercourse After ovulation, cervical mucus scant, thick, cloudy, and is no longer stretchable Cervical mucus should be evaluated and charted daily Monitor and graph BBT daily before rising Prior to ovulation, BBT decreases slightly in response to estrogen After ovulation, a surge of progesterone increases BBT by 0.51.0 F BBT remains high with conception, but falls without conception, prior to menses Certain activities may alter BBT: smoking, use of electric blanket or heated waterbed, restless sleep, illness

Basal Body Temperature (BBT)

Calendar Method

Based on assumption that ovulation occurs 14 days before the onset of menses Record menstrual cycles for 68 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 1021 fertile time; abstain from intercourse



Copyright 2006 by F. A. Davis.

Lactation Amenorrhea Method (LAM)

Prolactin suppresses follicle stimulating hormone (FSH), and therefore suppresses ovulation Postpartum woman who exclusively breastfeed during the first 6 months after childbirth, including at least one night feeding, 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


Dome-shaped rubber cup with a flexible ring that fits over the cervix; 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; teach to report symptoms of UTI Wash with soap and water after each use; 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


Copyright 2006 by F. A. Davis.

New condom should be used with each act of intercourse Store in unopened package in cool, 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, inhibiting ovulation, altering the endometrial lining, and thickening cervical mucus. 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, hampering sperm transport Suppression of midcycle LH peak prevents ovulation Decreases cilia movement within the fallopian tube Advantages of hormonal contraceptives include decreased dysmenorrhea, 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, vomiting, breast tenderness, breakthrough bleeding, headaches, mood changes, decreased libido, or weight change



Copyright 2006 by F. A. Davis.

May cause serious health issues; advise hormonal contraceptive users not to smoke and teach reportable symptoms of possible complications: Abdominal pain (severe) Chest pain Headache (severe) Eye problems (blurred, double vision) Severe leg pain, redness, and swelling Shortness of breath Worsening depression Jaundice Contraindications to hormonal contraceptives History of heart attack, stroke, blood clot; estrogen promotes blood clotting History of breast or female reproductive cancer; tumors may be hormonally provoked Diabetes with vascular involvement; estrogen promotes blood clotting Impaired liver function; OCs are metabolized through the liver and use may adversely affect existing liver disease Suspected or confirmed pregnancy Uncontrolled hypertension; increased risk for cardiovascular complications Smoker over 35 years of age; increases the risk for cardiovascular complications History of migraine headaches (with aura); increased risk for stroke Major surgery planned with immobilization; 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, followed by 7 hormone-free days (either no pills taken or placebos taken for 7 days) Pill selection based on amount of estrogen, type of progestin, adrenergic effect, or symptoms presented


Copyright 2006 by F. A. Davis.

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, followed by 7 days of inert pills; 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; patients should report use of contraceptive agents to all health-care providers

Transdermal Patch
Patch applied to skin weekly for 3 weeks; fourth week is patchfree to allow withdrawal bleeding Acceptable application sites include abdomen, buttocks, upper outer arm, and upper torso (but not the breasts); site should vary weekly Application involves cleansing skin, avoiding lotion, and firmly applying patch making sure all corners adhere to skin May engage is usual activities (bathing, swimming, exercising) Partial removal and skin reactions possible Decreased effectiveness noted in women who weigh more than 198 pounds

Vaginal Ring
Small, flexible hormone-impregnated ring inserted and left in the vagina for 3 weeks; removed in fourth week to allow for withdrawal bleeding Ring should be kept inside unopened package before insertion; protect from sunlight and high temperatures Side effects include increase in vaginal discharge, vaginal irritation, or infection Expulsion may occur; if out for more than 3 hours, back-up method of birth control needed for the next 7 days



Copyright 2006 by F. A. Davis.

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, 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, 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


Copyright 2006 by F. A. Davis.

Signs of IUD complications:
Period late (pregnancy) Abdominal pain (infection) Infection Not feeling well (infection) String missing (IUD expelled)

1. T-shaped hormone-releasing (levonorgestrel) device placed in the uterus to prevent pregnancy for up to 5 years 2. Copper IUD contains no hormones; 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, preventing passage of ovum Low failure rate, however, if pregnancy occurs, may be ectopic

Tubal Ligation (Incisional Method)

Performed in a hospital or outpatient surgical unit under general anesthesia Fallopian tubes cut, cauterized, and/or clipped Complications may include bleeding, infection, incomplete tube closure, injury to adjacent organs, or complications from anesthesia



Copyright 2006 by F. A. Davis.

Hysteroscopic Tubal Sterilization (Nonincisional method)

Microinserts placed into the opening of the fallopian tubes, causing scar tissue to grow in approximately 3 months Performed in physicians office or outpatient procedure lab with local anesthetic to cervix Follow-up hysterosalpingogram performed at 3 months to ensure both tubes have been blocked; alternate method of birth control used until tube status verified Complications may include incorrect placement requiring second or operative procedure, ectopic pregnancy, infection, 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.S. Department of Agriculture (USDA)

Prevention and Treatment of Osteoporosis

Risk increases after menopause; 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


Copyright 2006 by F. A. Davis.

Early Detection of Colorectal Cancer
Screening starting at age 50 (ACOG, 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.m. to 4 p.m. and tanning beds Perform self-evaluation of the skin; report suspicious lesions Thorough skin exam every 3 years age 20 to 39; annually after age 40

Cessation of menses with amenorrhea for 12 months Symptoms Vasomotor symptoms Hot flushes Night sweats Urogenital symptoms Thin, friable vaginal mucosa Vaginal dryness and irritation Dyspareunia Other Systemic Symptoms Sleep disturbance Mood swings Memory loss Skin changes Hair thinning



Copyright 2006 by F. A. Davis.

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.S. 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, noting the risk/benefit ratio for each woman If HRT prescribed solely for vaginal/vulvar symptoms, local hormone therapy should be considered Alternatives to HRT should be considered if HRT used for sole purpose of osteoporosis prevention


Copyright 2006 by F. A. Davis.

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 Hegars sign (softening of lower uterine segment) Goodells sign (softening of cervix) Chadwicks 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, fetal pole, and fetal cardiac activity Validates location of pregnancy (intrauterine versus ectopic)



Copyright 2006 by F. A. Davis.

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. estimated date of confinement EDB. estimated date of birth

Naegeles 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


Copyright 2006 by F. A. Davis.

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. 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, either spontaneous or induced Number of living children



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Documentation Example 1: The prenatal client states having three children at home. She reports that her son was born on his due date, but her daughters were both born a month early. She states that she lost a baby in her second month. G: 5 (currently pregnant, 3 children at home, 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); pregnancies ended before 20 weeks are not counted as P in this method. 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


Copyright 2006 by F. A. Davis.

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



White blood cells

Glomerular filtration rate


Urine output


Basal metabolic rate

No change

Respiratory rate

Hormonal Changes in Pregnancy Hormone


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



Copyright 2006 by F. A. Davis.

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, 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 2136 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.


Copyright 2006 by F. A. Davis.


Fundal height. (From Dillon PM. (2003). Nursing Health Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F Davis, p 736.) .A.

Provide appropriate education for gestational age Discuss procedure for lab testing



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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, B, AB, O Negative/Positive Negative 11.5 mg/dL 33% 150,000400,000 mm3 5,00012,000 mm3 Negative Negative 1:8 Immune AA, unaffected Negative Negative Normal cytology


Copyright 2006 by F. A. Davis.

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 1012 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, hCG, and estriol)

Nursing Considerations
Position to avoid supine hypotension; folded towel under right hip if supine

Review blood type, 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. A positive result suggests the need for further testing
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Copyright 2006 by F. A. Davis.

Diagnostic Test
Performed at 1518 weeks Clinical Applications: Serum screen for neural tube defects/ Down syndrome

Nursing Considerations
Results adjusted according to documented gestational age, maternal age, race, and weight, presence of diabetes/multiple gestation; 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, causing pregnancy associated discomforts Offer suggestions to lessen discomforts Teach patient to report symptoms that may indicate a potential complication (in red)

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, frequent meals Eat crackers before rising Avoid pungent odors, spicy or greasy food Discuss limited time frame for nausea (subsides around 12 weeks gestation) Report excessive vomiting
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Nausea and vomiting


Copyright 2006 by F. A. Davis.

Education in the Early Prenatal Period (Contd)
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, inability to care for self, 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, vaginal bleeding, 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, green/yellow nasal discharge, or frequent nosebleeds


Breast discomfort


Nasal stuffiness/ epistaxis



Copyright 2006 by F. A. Davis.

Teratogen Exposure
Teratogens are substances that are harmful to the developing fetus; advise patient to avoid exposure. Teratogen Viruses Patient Education Avoid contact with ill persons Report fever, rash, 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




Copyright 2006 by F. A. Davis.

Pregnancy Classification of Medications Drug Class

Pregnancy Safety
No evidence of fetal risk No animal risk demonstrated; 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.S. Food and Drug Administration

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 68 glasses of water daily Encourage to follow food pyramid in daily choices


Copyright 2006 by F. A. Davis.

Fat (naturally occurring and added) Sugars (added)
These symbols show fats and added sugars in foods

Fats,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


Bread, cereal, pasta and grain group 6-11 servings

Food Pyramid. (From U.S. Department of Agriculture and Department of Health and Human Services.)


Copyright 2006 by F. A. Davis.

Weight Gain in Pregnancy
Recommended weight gain depends on prepregnancy weight/BMI

Prepregnant Weight
Normal Overweight Underweight

Recommended Weight Gain

2535 pounds 1525 pounds 2840 pounds

Assess and document the pattern of weight gain

1st 2nd & 3rd

Suggested Weight Gain

14 pounds total 0.51 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



Copyright 2006 by F. A. Davis.

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


Copyright 2006 by F. A. Davis.

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 Leopolds 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)

Leopolds Maneuver. (From Dillon PM. (2003). Nursing Health Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F Davis Company, p 739.) .A.



Copyright 2006 by F. A. Davis.

Place Doppler on maternal abdomen over fetal back to monitor fetal heart tones (FHT)

Placement of Doppler. (LSA = left sacral anterior; LOP = left occiput posterior; LMA = left mentum anterior; LOA = left occiput anterior; RMA = right mentum anterior; ROA = right occiput anterior; ROP = right occiput posterior; RSA = right sacral anterior) (From Dillon PM. (2003). Nursing Health Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F Davis Company, p 737.) .A.

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


Copyright 2006 by F. A. Davis.

Diagnostic Tests
1-hour glucose screen Performed at 2428 weeks

Nursing Considerations
Administer 50 g glucose load Patient should not eat, drink, 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 3537 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



Copyright 2006 by F. A. Davis.

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, 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, 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)


Copyright 2006 by F. A. Davis.

Changes in pigmentation Linea nigra (pigmented line from umbilicus to pubic bone) Chloasma (deeper facial pigment) Striae (stretch marks) Round ligament pain (occasional, sharp lower abdominal pain)

Patient Education
Related to hormone changes in pregnancy; fade after pregnancy Moisturizers decrease itching, but will not prevent striae Report body rashes

Braxton-Hicks contractions (false labor contractions) Ankle edema

Varicose veins


Related to round ligament stretching as uterus grows Change positions slowly Encourage good body mechanics Report abdominal cramping, constant pain, 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 68 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, redness, 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)



Copyright 2006 by F. A. Davis.

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, frequent meals Lightening will lessen symptoms Report dyspnea with rest Related to fetal movement, 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, redness, localized heat Related to decreased gastric motility; iron supplement may worsen constipation Increase dietary fiber and water intake Encourage exercise Discourage enemas and laxatives Report painful or bleeding hemorrhoids


Shortness of breath


Leg cramps

Constipation Hemorrhoids


Copyright 2006 by F. A. Davis.

Pregnancy Complications
Vaginal Bleeding (before 20 weeks gestation)
May be related to spontaneous abortion, ectopic pregnancy, 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 Cullens 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, absence of fetus



Copyright 2006 by F. A. Davis.

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 patients 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, cesarean birth necessary If bleeding controlled and labor absent, 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


Copyright 2006 by F. A. Davis.


Internal os Blood External os

Membranes Internal os Blood External os

Membranes Internal os Blood External os

Placenta previa.



Copyright 2006 by F. A. Davis.

Abrupto Placentae
Clinical Findings Abdominal pain (sudden onset, intense and localized) Fundus firm, boardlike, 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 patients 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


Copyright 2006 by F. A. Davis.

Abruptio Placentae
Premature separation of the placenta; may be partial or complete


Partial separation (concealed hemorrhage)

Partial separation (apparent hemorrhage)

Abruptio placentae.

Complete separation (concealed hemorrhage)



Copyright 2006 by F. A. Davis.

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 FerningMicroscopically, amniotic fluid will resemble the leaves of a fern plant Nitrazine paperDue to the alkaline nature of amniotic fluid, 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


Copyright 2006 by F. A. Davis.

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 -adrenergic agonist terbutaline ritodrine

Prostaglandin antagonist indomethacin Calcium channel blockers nifedipine

Hypertensive disorder of pregnancy with multisystem involvement Clinical Findings Blurred or altered vision Epigastric pain Headache Edema Proteinuria Hyperreflexia Hypertension



Copyright 2006 by F. A. Davis.

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

Clinical Findings Worsening of symptoms of preeclampsia Seizure activity

HELLP Syndrome
Clinical Findings Worsening symptoms of preeclampsia Malaise


Copyright 2006 by F. A. Davis.

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



Copyright 2006 by F. A. Davis.

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, REPORT immediately

Fetal Surveillance in Pregnancy

Nonstress Test (NST)
Procedure used to monitor fetal response to movement; FHR acceleration with fetal movement is reassuring and a sign of fetal well being Place patient in a Semi-Fowlers or side-lying position Record vital signs and apply electronic fetal monitor Record baseline fetal heart rate and monitor FHR pattern for 2030 minutes Patient marks paper with each perceived fetal movement NST may take longer with absence of accelerations; 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)


Copyright 2006 by F. A. Davis.

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



Copyright 2006 by F. A. Davis.

Patients present to labor and delivery for medical procedures, triage, and birth Upon admission to labor and delivery, 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


Copyright 2006 by F. A. Davis.

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 Leopolds maneuver to determine fetal position Assess fetal heart rate (FHR) Measure fundal height Determine the frequency, duration, and intensity of contractions Determine the stage and phase of labor Assess cervical changes Dilation (0 to 10 cm) Effacement (0100%) 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



Copyright 2006 by F. A. Davis.


Note presence, color, and amount of bloody show Check status of amniotic membranes Intact Bulging Ruptured (note color, amount, 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. (From Dillon PM. (2003). Nursing Health Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F Davis, p. 737.) .A.

Count FHR between, during, and immediately following a contraction Note both rate and rhythm of FHR Frequency of auscultation based on: Phase/stage of labor Hospital protocol


Copyright 2006 by F. A. Davis.

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 3060 minutes 1530 minutes 515 minutes 515 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 2030 minutes on admission
Ultrasound transducer Toco transducer (FHR) (uterine contractions)

External fetal monitor


Copyright 2006 by F. A. Davis.


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 515 mmHG Contraction tone of uterus averages 5085 mmHG
Scalp electrode


Internal fetal monitor

Evaluating the Baseline Fetal Heart Rate

Normal baseline FHR is 110160 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


Copyright 2006 by F. A. Davis.


Normal fetal heart rate. (Top: fetal heart rate; bottom: contractions.)


Copyright 2006 by F. A. Davis.


Changes to Baseline Fetal Heart Rate

TACHYCARDIA FHR greater than 160 BPM for 10 minutes Possible cause: Infection/hyperthermia Fetal hypoxia Maternal medications (ex. 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 (02 BPM) Minimal (35 BPM) Average (610 BPM) Moderate (1125 BPM) Marked ( 25 BPM)

Possible Cause
Maternal medication Fetal sleep Fetal hypoxia Adequate fetal oxygenation Early sign of mild fetal hypoxia Fetal stimulation


Copyright 2006 by F. A. Davis.

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; bottom: contractions.)

DECELERATIONS (Early, Late, 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


Copyright 2006 by F. A. Davis.


Early deceleration. (Top: fetal heart rate; bottom: contractions.)

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. (Top: fetal heart rate; bottom: contractions.)


Copyright 2006 by F. A. Davis.

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, contraction status, and maternal temperature Verify that fluid is exiting uterus

Variable deceleration. (Top: fetal heart rate; bottom: contractions.)


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 810 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

Monitoring Contractions
Frequency Beginning of one contraction to the beginning of the next contraction Documented as range, for example, every 25 minutes Duration Beginning of the one contraction to the end of the same contraction Documented as a range, for example, lasting 6090 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

During contraction

Before contraction

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



Counting contractions.


Copyright 2006 by F. A. Davis.

First Stage

Stage 1: Latent Phase

Power: Contractions palpate mild, every 510 minutes, lasting 3045 seconds Psyche: Patient is usually excited about the start of labor Measuring progress in labor: Cervical dilation (03 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 3060 minutes Fetal heart tones every 3060 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 25 minutes lasting 4060 seconds


Copyright 2006 by F. A. Davis.

Psyche: Patient may have greater difficulty coping with the pain of contractions Measuring progress in labor: Cervical dilation (47 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 1530 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, may cause respiratory depression (in the neonate) Caution with women who are opiate dependent, 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


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 Ringers 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 1.53 minutes lasting 4590 seconds Psyche: Patient may feel a loss of control; provide encouragement to patient Measuring progress in labor Cervical dilation (810 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 515 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 23 minutes lasting 6090 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 1530 minutes Fetal heart tones every 515 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 infants 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


Copyright 2006 by F. A. Davis.

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, encourage skin-to-skin contact with mother Assign Apgar Score at 1 and 5 minutes Score of 10 possible; Score of at least 8 desirable

Apgar Score Score

Heart Rate Respiratory Effort Muscle Tone Reflex irritability Color

Absent Absent Limp No response Blue or pale

Less than 100 Slow, irregular Some flexion of extremities Grimace Body pink; extremities blue

Greater than 100 Good; crying Active motion Cough, sneeze or vigorous cry Completely pink

Assess for abnormalities that may need immediate attention (example: neural tube defects, open lesions, or birth injuries) Examine umbilical cord and count number of vessels: 2 arteries and 1 vein; 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; ophthalmic antibiotic ointment (based on hospital protocol) to prevent chlamydial or gonococcal eye infection Administer vitamin K, IM to boost production of clotting factor (needed due to sterile gut at birth)


Copyright 2006 by F. A. Davis.


Weigh and measure infant (head, chest, and abdominal circumference as well as length) Assess skin for lacerations, bruising, 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; 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, encouraging skin-to-skin contact Assist with positioning for breastfeeding and bonding


Copyright 2006 by F. A. Davis.

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 Bishops score Any contraindications for procedure Bishops Score Assigned by primary health-care provider prior to induction of labor Higher scores indicate increased likelihood of successful labor induction Parameters of Bishops score Degree of Dilation (13 points) Percent of Effacement (03 points) Station (02 points) Consistency of cervix (02 points) Cervical position (02 points) Use of Oxytocin (Pitocin): Hormone that stimulates uterine contractions to induce or augment contractions Assess mother and fetus 2030 minutes prior to oxytocin administration Prepare and clearly label solution 10 units of Pitocin into 5001000 ml of isotonic IV solution Administer IV piggyback per electronic infusion pump Started at small dose and gradually increased until contractions every 23 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, variability, changes) Cervical dilation and effacement Vital signs Patient comfort


Copyright 2006 by F. A. Davis.


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 810L/min Increase rate of nonadditive IV solution Call primary health-care provider Cervical Ripening Facilitates cervical softening, 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, Prepidil Gel) Nursing care Monitor fetal heart rate and contraction status for 2030 minutes prior to procedure Encourage patient to void prior to insertion Position side-lying position after procedure Monitoring maternal vital signs, contractions, and fetal status (per hospital protocol) Report adverse reactions to physician Hyperstimulation of uterus Nonreassuring fetal heart tones Nausea, 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


Copyright 2006 by F. A. Davis.

Document fetal heart tones immediately following amniotomy Note color and amount of amniotic fluid Document cervical dilation, effacement, station, and fetal presentation If presenting part is not engaged, limit patient activity to prevent cord prolapse Once amniotic sac is ruptured, there is potential for infection Monitor maternal temperature every 12 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, 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.


Copyright 2006 by F. A. Davis.


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


Copyright 2006 by F. A. Davis.

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, nail polish, jewelry, prosthetic device, 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


Copyright 2006 by F. A. Davis.


Fourth Stage of Labor
First 12 hours after birth

Immediate Nursing Care

Assess height, location, 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 14 hours


Copyright 2006 by F. A. Davis.

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, demonstrated, 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, filling, or firm Nipple type and integrity Type: Inverted or everted Integrity: Bleeding, cracked, intact Redness Comfort Breast care (lactating) Patient should wear a supportive bra Montgomery glands secrete oil to keep nipples supple; soap should not be used on breasts After feedings, leave colostrum/breast milk on nipples and expose the breasts to air


Copyright 2006 by F. A. Davis.


Encourage frequent nursing (812 feedings in 24 hours) Teach positioning of infant for increased comfort Side-lying Football hold Cradle hold

Breastfeeding positions. (Used with permission from Ross Products Division Abbott Laboratories Inc.)


Copyright 2006 by F. A. Davis.

Instruct on proper latch-on Elicit the rooting reflex by stroking the infants lower lip As the infants mouth opens wide, bring the infant to the breast, ensuring both the nipple and part of the areola are in the infants mouth Correct latch-on: infants jaws will rhythmically move with an audible swallow; mother will express comfort Incorrect latch-on: clicking noise as infant sucks with nipple pain expressed by mother; break suction by placing one finger by the infants mouth and relatch

Latch-on. (Used with permission from Ross Products Division Abbott Laboratories Inc.)

If separated from newborn, initiate breast pump Breast care (nonlactating) Supportive bra, breast binder or sports bra No nipple stimulation Do not express breast milk Ice packs/analgesics for engorgement Teach breast self exam (BSE)


Copyright 2006 by F. A. Davis.


TEACHING TIPS: BREASTFEEDING Advantages to Breastfeeding Cost Convenience Immunoglobulins, which protect the infant from infection, are passed via breast milk Decreased incidence of infant: Allergies Otitis media Upper respiratory infections Positioning The infants body should face the breast, with the ear, 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 infants 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, burp the infant, and continue feeding on the other breast Start breastfeeding on the breast ended with the last feeding Unless medically indicated, supplemental feeding should be avoided


Copyright 2006 by F. A. Davis.

Engorgement (Firm, tender breasts) May occur on postpartum day 35, when the volume of breast milk increases Prevent engorgement with frequent feedings; 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, smoking, 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

Up to 8 hours 35 days 3 months 612 months


Copyright 2006 by F. A. Davis.


Weaning Gradual weaning suggested to decrease the likelihood of engorgement Remove one feeding per week If infant is less than 1 year, infant formula, instead of cows milk, must be given Breast Care Breast pads inside a supportive bra will collect leaking breast milk Teach signs of mastitis Unilateral breast pain, 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; urine is amber-colored Nipple pain or cracking is present Community Resources Lactation consultant La Leche League Primary health-care provider


Copyright 2006 by F. A. Davis.

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.


Copyright 2006 by F. A. Davis.


Assess the tone, height, and location of the fundus TONE of the uterus assessed while patient is supine Fundus should be firmly contracted If fundus is not firm, 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, fundus is located at or just above the umbilicus The fundus should be midline and not deviated to the left or right

Uterine involution. (From Dillon PM. (2003). Nursing Health Assessment: A Critical Thinking, Case Study Approach. Philadelphia: F Davis, .A. p. 744.)


Copyright 2006 by F. A. Davis.

TEACHING TIPS: UTERINE/VAGINAL CHANGES The Fundus The fundus lowers one fingerbreadth below the umbilicus each day until returning to pelvis (day 1014) 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, 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, lactation amenorrhea while exclusively breastfeeding infant (first 6 months) If bottle feeding, menses usually returns 68 weeks postdelivery Sexuality Sexual intercourse may be resumed after lochia ceased and episiotomy healed; 46 week delay generally recommended Vaginal lubrication may be diminished; use water-soluble gel Female superior or side-lying position may assist in comfort Discuss family planning methods


Copyright 2006 by F. A. Davis.

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, which occurs in response to decrease in estrogen, 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 3,000 cc/day Catheterization may be necessary if unable to void or with urinary retention

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

Vaginal discharge after delivery called lochia Blood loss with vaginal birth approximately 500 cc Blood loss with cesarean birth approximately 1000 cc


Copyright 2006 by F. A. Davis.

Assess the amount of lochia Note time of last perineal pad change Document amount of lochia on perineal pad (scant, small, moderate, large) If weighing perineal pads, 1 gm 1 ml of blood loss Assess the color of lochia Lochia rubra (red): day 13 Lochia serosa (brownish-pink): day 49 Lochia alba (yellow-white): day 1014 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, consistency of discharge Approximated edges Lacerations described by degree of tissue involvement Degree
1st 2nd 3rd 4th

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


Copyright 2006 by F. A. Davis.


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, sprays, 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, tighten perineal muscles as though stopping the flow of urine (this technique is only used to locate the muscles, not to perform the exercise) Hold contraction for several seconds, release, and repeat 1015 times; 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


Copyright 2006 by F. A. Davis.

TEACHING TIPS: EMOTIONS Postpartum Blues Symptoms of postpartum blues include tearfulness, insomnia, 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; 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, temperature, blanching Assess for signs of deep vein thrombosis Pain Swelling Redness Increased skin temperature


Copyright 2006 by F. A. Davis.


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; encourage oral fluids If temperature 100.4 F call physician Pulse: assess rate, rhythm, 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


Copyright 2006 by F. A. Davis.

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, 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


Copyright 2006 by F. A. Davis.


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

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

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


Copyright 2006 by F. A. Davis.

Clinical findings Perineal pad saturated in less than 1 hour Continuous trickle of vaginal bleeding Firm, 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, hold and call primary care provider Ergonovine maleate (Ergotrate) Prostaglandin F2a (Prostin/Hemabate)

Symptoms Temperature elevation 100.4F 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


Copyright 2006 by F. A. Davis.


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, 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


Copyright 2006 by F. A. Davis.

Inadequate social or partner support Large number of life stressors Clinical findings Symptoms extend beyond 2 weeks postpartum; may occur 312 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, redness, and pain to affected leg Interventions dependent on severity of findings Administer anticoagulants Monitor coagulation profile Compression stockings Apply warm, moist heat Rest Observe for symptoms of pulmonary embolism Dyspnea Chest pain Hemoptysis Patient fearful


Copyright 2006 by F. A. Davis.


TEACHING TIPS: POSTPARTUM COMPLICATIONS Teach the patient to report the following signs and symptoms to the primary health-care provider. Signs of infection Elevated temperature Localized redness or pain to either breast Persistent abdominal tenderness Persistent pain to perineum Burning, frequency, or urgency of urination Foul odor to lochia Redness, pain, 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, 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


Copyright 2006 by F. A. Davis.

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 97.898.6 F Decreased body temperature may be a sign of sepsis Auscultate apical pulse for one full minute 110160 beats per minute Sustained resting heart rate below 100 or above 160 Respirations counted for one full minute 3060 per minute Sustained resting respiratory rate below 30 or above 60


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, or asymmetrical gluteal folds (hip dysplasia) Resistance to neck flexion


Copyright 2006 by F. A. Davis.


TEACHING TIPS: NORMAL NEWBORN BEHAVIOR Pattern of Sleep Newborns sleep in short periods for a total of 1316 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, sing and hold newborn close


Color uniformly pink Normal variations Acrocyanosis (bluish hue to hands/feet) Milia (plugged sebaceous glands on nose) Lanugo (downy hair on arms, back, face) Mongolian spot (area of increased pigmentation, resembles bruise) Telangiectases stork bites Erythema toxicum (newborn rash) REPORT Cyanosis (other than in hands and feet) Skin lesions, bruises, abrasions Jaundice


Copyright 2006 by F. A. Davis.

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 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, unilateral swelling of scalp tissue caused by collection of blood between the skull and periosteum


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; pinna well-formed and hearing intact Oral mucosa pink and moist; tongue mobile Hard and soft palate intact Strong suck; able to coordinate suck and swallow REPORT Absence of red reflex Purulent discharge of eyes immediately after birth


Copyright 2006 by F. A. Davis.


Low set ears Lack of response to sound Nasal flaring Cleft lip or palate Large, protruding tongue (possible Down syndrome) White patches in mouth (Candidiasis) Absent rooting, suck, 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, 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 manufacturers instructions Shake well to distribute powder Formula Preparation Clean off can with soap and water before opening If water supply questionable, 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


Copyright 2006 by F. A. Davis.

Bottle Preparation Bottles should be washed with a brush and rinsed thoroughly; if water supply is questionable, 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 34 hours) Increased alertness or activity Smacking of the lips Suckling motion Moving of the head in search of the breast Newborns generally drink about 0.52 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 12 ounces The type, amount and pattern of feedings should be discussed with the pediatrician before hospital discharge Formula remaining in the bottle must be discarded

Respirations unlabored Chest rises and falls symmetrically Lung sounds clear bilaterally Clavicals intact REPORT Nasal flaring, chest retractions, or expiratory grunting Asymmetrical breath sounds Chest asymmetrical or circumference greater than head circumference Loud cardiac murmur with thrill


Copyright 2006 by F. A. Davis.


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


The cord will fall off spontaneously in 1014 days; do not tug at cord Cleanse cord insertion site at diaper changes Fan fold diaper to expose cord to air REPORT redness, drainage, bleeding, foul odor from cord

Site may be covered with petroleum gauze dressing; tell parents when to remove dressing Clean area with warm water for diaper change


Copyright 2006 by F. A. Davis.

Apply petroleum jelly to head of penis to decrease friction with diaper A yellow exudate forms on the head of the penis on day 23; 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


Spine straight, intact, 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; 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, well-fit mattress No smoking around baby Dress baby for comfort; do not overheat


Copyright 2006 by F. A. Davis.


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 newborns 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


Copyright 2006 by F. A. Davis.

Peds Basics
Common Developmental Milestones (ages are aproximate)

06 mo

Physical Ht 1 in/mo Doubles wt by 56 mo Wt 1.5 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: 56 mo Language Coos: 12 mo Laughs: 24 mo Makes consonant sounds: 34 mo Imitative sounds: 6 mo Personal-Social Regards a persons face: 1 mo Displays social smile and follows object 180 degrees: 2 mo Recognizes familiar faces: 3 mo Stranger anxiety begins: 6 mo

612 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: 23 mo Ant. fontanel closes: 1218 mo Central incisors erupt: 57 mo Gross/Fine Motor Holds head erect: 4 mo Grasps voluntarily: 5 mo


Copyright 2006 by F. A. Davis.


Begins to crawl: 7 mo Sits unsupported: 8 mo Pulls up to stand: 9 mo Drinks from cup: 9 mo Pincer grasp: 810 mo Builds two-block tower: 12 mo Walks alone or holding onto one hand: 12 mo Language Pronounces syllables (da-da, ma-ma) : 8 mo Says 410 words: 12 mo Personal-Social Marked stranger anxiety: 8 mo Emotions such as jealously: 12 mo

13 yr

Physical Ht 3 in/yr Wt 5 lb/yr Weighs about 4 times birth wt: 2 yr HC equals chest circumference: 12 yr HC 1 in during 2 yr 1014 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 34 block tower: 18 mo Jumps with both feet: 30 mo Language Says 300 words: 2yr Uses 23 word phrases and pronouns Understands speech: 2 yr States first and last name: 2.5 yr Personal-Social Separation anxiety peaks Ritualism Negativism Independence


Copyright 2006 by F. A. Davis.

36 yr
Physicial Ht 2.53 in/yr Wt 46 lb/yr HC 0.5 in/yr Vision is 20/20 with color vision intact: 56 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 910 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, numbers and name: 5 yr Language Says 900 words: 3 yr Speaks 34 word sentences: 3 yr Says 1500 words: 4 yr Tells stories, 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


Copyright 2006 by F. A. Davis.


612 yr

Physical Ht 23 in/yr Wt 4.56.5 lb/yr Secondary teeth erupt with central incisors and first molars Tanner stage 2 may begin Gross/Fine Motor Rides bicycle Roller skates Run, jumps, 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 1821 yr

Physical Puberty beings in girls: 814 yr (lasts about 3 yr) Puberty begins in boys: 916 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 thoughtincludes idealism, egocentrism, and ability to consider abstract possibilities Personal-Social Works through identity issues, status, and relationships


Copyright 2006 by F. A. Davis.

Use Growth Charts from National Center for Health Statistics (NCHS), for ht, wt, wt for ht, HC, 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

01 month 24 months 560 months 5 years

Caloric Expenditure Per Day

100110 kcal/kg/day 90100 kcal/kg/day 7090 kcal/kg/day 1500 kcal for first 20 kg additional kg/day

25 kcal for each

From Hay WW, et al. (2005). Current Pediatric Diagnosis & Treatment: (17th ed.). New York: Lange Medical Books/McGraw-Hill, p. 309.

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 (34 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, based on infants desireusually between 8 to 9 months of age.


Copyright 2006 by F. A. Davis.

Total Water Requirements/24 Hours

Infant 6 yr

5001300 mL; Child 20002700 mL

6 yr

11502000 mL;

Daily Urine Output/24 Hours

0.52 mL/kg/hr depending on childs age and hydration status Infant 350550 mL; Child 5001000 mL; Adolescent 7001400 mL
From Behrman RE, Kliegman RM, Jenson TB. (2004). Nelson Textbook of Pediatrics, (17th ed). Philadelphia: W.B. Saunders, p. 2415.

Average Ranges for Pediatric Vital Signs Age Group

Infant Toddler Preschooler School-age Adolescent

Heart Rate
80150 70110 65110 6095 5585

Respiratory Rate
2555 2030 2025 1422 1218

BP Systolic
65100 90105 95110 100120 110135

BP Diastolic
4565 5570 6075 6075 6585

Adapted from Behrman RE, Kliegman RM, & Jenson TB. (2004). Nelson Textbook of Pediatrics (17th ed). Philadelphia: W.B. Saunders, p. 280; and National Heart, Lung, and Blood Institute. (1987). Normal Blood Pressure Readings from the Second Task Force on Blood Pressure Control in Children. Author, Bethesda, MD.

Rule of Thumb to Determine BP: Normal systolic ranges: 17 yr age in yr 90; 818 yr age in yr) 83 Normal diastolic ranges: 15 yr 56; 618 yr 52



Copyright 2006 by F. A. Davis.

Introduction of Food Types Birth-6 mo

Types of Foods Usually breast milk; commercially prepared iron-fortified formula

6 mo
Begin with infant rice cereal, then vegetables, and fruits with meats the last food to introduce; start with 12 tsp Introduce one food at a time for 35 days to watch for food allergies; do not use honey on young infants because of the association with infant botulism; use small spoon to feed infant

89 mo
Finger foods such as teething crackers or raw fruits

12 mo
Eating normal table foods; healthy habitsgo to www.

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 childs nutritional needs; avoid allergenic foods such as nuts, egg whites, shellfish, strawberries, or chocolate



Copyright 2006 by F. A. Davis.

Pediatric Coma Scale


Right Left

Size Reaction Size Reaction 4 3 2 0 6 5 4 3 2 1 5 4 3 2 1 T


Spontaneously To Speech To Pain None Obeys Commands Best Motor Response (use Localizes Pain best arm or age- 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, closed due to swelling


deep coma)
No reaction, C


Adapted from Hahn YS, et al. (1988). Head injuries in children under 36 months of age. Child Nervous System 4: 34.


Copyright 2006 by F. A. Davis.

Normal Breath Sounds
Vesicular Breath Sounds: Soft, swishing noise heard over entire area of lung surface except for upper scapular area and beneath sternum; inspiration is louder, longer, and higher pitched than expiration Bronchovesicular Breath Sounds : Heard over sternum and upper scapular regions where trachea and bronchi bifurcate; 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, pneumothorax, pleural effusion, pneumonia Rhonchi : Low-pitched, snoring-like, continuous sound associated with respiratory infections Crackles : Soft, high-pitched, intermittent sounds due to small collapsed airways popping open Grunting : Harsh sound on expiration due to early closure of glottis and chest wall contraction, which causes increased expiratory airway pressure to prevent airway collapse Stridor : High-pitched, crowing sound on inspiration due to upper airway obstruction associated with croup or foreign body aspiration; low-pitched, muffled sound associated with epiglottis Wheezing : Musical, 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


Copyright 2006 by F. A. Davis.


Endotracheal Tube Suctioning

Select size of suction catheter based on size of child (infant 58 F child 810 F older child 1214 F) , , 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 0.5 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 childs foot or hand), cold extremities/hypothermia, and hypovolemia. Watch for false highs associated with carbon monoxide poisoning and anemia.

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


Copyright 2006 by F. A. Davis.

Cardiac/Apnea Monitors (Cont.)
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.


Copyright 2006 by F. A. Davis.

Childrens 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

Strangers and strange places, loud noises, sudden movements, loss of physical and emotional support Strangers, dark, being alone, physical contact/interventions from strangers, strange or unknown equipment and places Mutilation, the unknown, any intrusive procedures



Exhibits reactions such as agitation, temper tantrums, uncooperativeness and clinging to parents; separation anxiety peaks 1215 mo Fewer reactions but more somatic signs such as vomiting, urinary frequency or incontinence, diarrhea, dizziness; still may become withdrawn or aggressive


Perceived disruption in the loss of their own power and altered family roles

(Continued text on following page)


Copyright 2006 by F. A. Davis.

Childrens Responses to Illness and Hospitalization (Continued) Separation Anxiety School Age
Anxious behaviors as well as loneliness, boredom, isolation or depression; 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, loneliness, or boredom

Loss of Control
Enforced dependency and altered family roles

Bodily injury, pain, inability to stay in control, lack of control over modesty, school and peer concerns, death Loss of peer interactions and relationships, body disfigurement, rejection by others, loss of physical abilities, death


Enforced dependency and possible identity/role changes


Eight Questions to Ask About Pain: 1. Are you having pain? 2. If yes, what does the pain feel like? (burning, aching, pinching, stabbing?) 3. When did the pain start? (Did anything happen to start the pain?) 4. Where is the pain? (Point to where the pain is.)

5. How long have you been having pain? 6. How often does it occur? 7. Does anything make it worseor better? 8. Has it changed what you do?


Copyright 2006 by F. A. Davis.


Developmental Differences in Children Related to Pain Age Infants Comments

Preverbal. Signs of possible pain: diffuse body movement, high-pitched cry, tearing, stiff posture, fisting, and lack of play; obvious sign is facial expression with brows lowered and drawn together, eyes tightly closed, and mouth open Limited vocabularies still make it difficult to express pain; may use words such as owie; can sometimes describe pain but not the intensity. Signs of possible pain: regression with arms and legs thrashing or withdrawal such as clinging to parent or significant other, loud crying or screaming Use pain scale for this group; may have difficulty in distinguishing between types of pain such as sharp or dull; may act tough even when in pain; may show fewer overt pain behaviors. Signs of possible pain: muscular rigidity such as clenched fists, gritted teeth, body stiffness, closed eyes, wrinkled forehead or lying in fetal position Use pain scale for this group; may be stoic because of fear of being labeled so may be quiet and withdrawn. Signs of possible pain: fist-clenching, clenched teeth, rapid breathing, and guarding affected body part, lack of interest and decreased ability to concentrate

Young child

Older child



Copyright 2006 by F. A. Davis.

Nursing Interventions Related To Pain Management
Distractionuseful for mild pain relief (example: tell child to say Oh when giving an injection or blow bubbles when performing a procedure) Guided imageryaid the child in creating a pleasurable mental image during the painful situation Thought stoppingstop the painful thought with a positive thought Soothing music or aromatherapyuse to calm emotions and state of mind Thermotherapyapply warm and cold to painful areas to promote circulation or reduce edema with limited numbing effect Gentle massagerelax or focus child away from pain toward more gentle soothing touch Sucrose Sweet Nipplecalm young infants by allowing them to suck on nipple dipped in sucrose solutioneffective method in reducing pain during procedure Provide ordered pharmacological interventions such as topical anesthetic creams, PO/IV/IM analgesia, patientcontrolled analgesia (PCA), conscious sedation, or epidural analgesia

Numerical Scale Pain Assesment Tool

None 012345678910 Worst Pain (Scale of 010 to describe pain) Explain to older child: 0 means you feel no pain and 10 means you feel the worst pain possible. Ask the child to choose number that best describes his or her own pain.


Copyright 2006 by F. A. Davis.

FLACC Pain Assessment Tool Rating:


No particular expression or smile Normal position or relaxed Lying quietly, normal position, moves easily No cry (awake or asleep) Content, relaxed

Occasional grimace or frown, withdrawn, disinterested Uneasy, restless, tense Squirming, shifting back and forth, tense Moans or whimpers, occasional complaint Reassured by occasional touching, hugging, or talking to, distractible
no pain, 10 worst pain.

Frequent to constant frown, clenched jaw, quivering chin Kicking, or legs drawn up Arched back, rigid or jerking Crying steadily, screams or sobs, frequent complaints Difficult to console or comfort






Ages of use: 2 mo to 7 yr. Scoring range: 0

From Merkel S, Voepel-Lewis T, Shayevitz J, Malviya, S. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing 23(3): 293297.


Copyright 2006 by F. A. Davis.

Use of Play for Children Age Group Infants Type and Purpose of Play Safe Toys


Solitary (noninteractive but may be 13 mo: mobiles, music boxes, imitative in later part of infancy) nonbreakable mirrors, stuffed Stimulates psychological and animals, and rattles sensorimotor development, offers 46 mo: squeezable toys, busy boxes, diversion, means of communication play gyms 79 mo: cloth textured toys, splashing bath toys, large blocks and large balls 1012 mo: durable books with pictures, nesting cups, push-pull toys, and building blocks Parallel (along side but not interactive) Dolls, housekeeping toys, books, singEnhances locomotion skills (gross and a-long tapes, rocking horses, pull fine), language development, toys, finger paints, clay, large piece imitates adult roles puzzles, blocks, and balls Associative (interactive and cooperative but defines own rules) Promotes fine/gross motor skills, contact with playmates, and encourages imagination Tricycle/big wheels, wading pools/sandboxes, gym sets, blocks/puzzles/simple crafts, crayons/paints, puppets/dolls stuffed animals, imaginary items, and ageappropriate electronic games
(Continued text on following page)




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

Safe Toys
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 childs 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 childs 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 childs 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 23 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!


Copyright 2006 by F. A. Davis.

Quick Evaluation of Sick Child Observation Quality of Cry Normal

Strong normal tone or content and not crying Cries briefly, then content and not crying If awake, stays awake; if asleep and stimulated, quickly wakes Pink Skin warm and dry, eyes and mouth moist Smiles; alert

Moderate Impairment
Whimpering or sobbing Cries off and on

Severe Impairment
Weak, moaning, 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, or wakes with prolonged stimulation Pale hands, feet or acrocyanosis Skin and eyes normal and mouth slightly dry Brief smile; or briefly alert


Color Hydration

Pale or blue or gray or mottled Skin doughy or tented and eyes sunken and dry No smile, anxious face, not alert

Response to Social Overtures

From McCarthy PL, Sharpe MR, Spiesel SZ, et al. (1982). Observation scales to identify serious illness in febrile children. Pediatrics; 78: 802.


Communication with Child and Family Age Group Infant Important Aspects
Trust is developing; communicates through coos, smiles, and cries at first. First words around 89 mo. Understands simple one word commands at 1 yr. If primary caregiver is comfortable, many times the infant is calm and trusting. Allow infant to be held by caregiver as much as possible. Sense of self and being independent is becoming important; understands simple two- and three-word commands. Has 300 word vocabulary. Short attention span of 15 minutes.

Provide gentle touching; firm holding, and smiles to infant. Speak to primary caregiver first. If not contraindicated, offer pacifier and use security blankets and stuffed animals.

Copyright 2006 by F. A. Davis.



First, direct eyes and questions to caregiver. Assume eye level of child. Ask simple questions with appropriate choices such as would you like to sit on your mothers lap or up on the table? Use childs language for specific words in short and simple sentences. Be attentive to nonverbal cues. Use puppets and dolls.
(Continued text on following page)


Copyright 2006 by F. A. Davis.

Communication with Child and Family (Continued) Age Group Preschooler Important Aspects
Developing a concept of self; understands simple sentences. Has 900 words in vocabulary. Let children know that they did not cause the illness. Prepare child for procedure right before the treatment. Interested in achievement; get child to help you. Understands most mature thoughts especially when allowed to manipulate and see objects. Transition between childhood and adulthood; begin conversation with them first then ask questions of caregivers. Verify with adolescent that they understand. Can use brochures and videos.

Assume eye level of child. Provide appropriate choices. Offer appropriate medical equipment for play to reduce fear of equipment. Use concrete sentences. Allow child to ask questions. Show the child equipment and use clear simple instructions. Use teaching aids and explain what you do. Would you like to have your mother leave the room while I examine you? Provide privacy and ensure confidentiality.





Copyright 2006 by F. A. Davis.


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, 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, school achievements, play Sleep Review of systems

All children
Include type of housing, others in household, car seat and smoke detector use, type of home heating, pets, family cultural beliefs and practices.


Copyright 2006 by F. A. Davis.

Systems Approach to Assessment
Although the systems approach works well and is often used in the documentation of your findings, remember you must adapt your method to the individual child!

Eyes (redness, drainage, alignment) Ears (response to sound, pulling at ears) Mouth (excessive drooling, white patches in mouth)

Level of alertness, affect, and responsiveness (awake, verbalizes, awareness of surroundings, lethargic, obtunded, etc.) Pupil check (darken room before trying to check, simultaneous closing of eyelids, movements of eyesany deviations to right or left, color of sclera and conjunctiva, any drainage, visual acuity) Movement of extremities (involuntary, voluntary, on verbal commandfor older child, moves in response to painful or other stimuli, uncoordinated movements, twitches, tremors) Hand grasps and pedal pushes (equality, remember you need to adapt to developmental age) Reflexesdeep tendon reflexes, presence or absence of newborn reflexes Speech (clear, slurred, etc.) Signs of seizure activity (describe type, how often, when, etc.) Nuchal rigidity Head circumference and size of fontanels (adapt to the developmental age)

Inspect shape and contour of chest (expose the patients chest to get a good look! Posture, spinal curvature, any equipment such as chest tubesif present, describe site, type, etc.) Palpate expansion of chest for full and equal excursion (Inspect for retractions, unequal expansion, etc.) Respirationseasy, quiet, unlabored? Abdominal breathing? (Children are often abdominal breathers until 67 yr)


Copyright 2006 by F. A. Davis.


Auscultate the lungs from the top to the bottom, front and back and laterally, include over the neck and trachea (compare right and left sides, abnormal soundsdescribe) Does child breathe through nose or mouth (any drainage? if present describe amount, color, and consistency) Note Pulse oximetry (%02 saturation) Ventilatorstart at the nearest point to the patientET or trach and work distally toward the machine Size of ET or trach tube, whether tube is cuffed, amount of air in cuff for seal, whether seal is intact, appearance of trach site, tube placement, equality of bilateral lung expansion, quality and equality of breath sounds, tubing and integrity of connections Make sure there is no water in the tubes, know tidal volume, measure O2 concentration Note settings your patient is oncheck the system pressures any change needed? Recheck all settings and alarms. Is the alarm on? Suction the patient, if needed. Observe the patients tolerance to the procedure and type and amount of secretions Check other O2 equipment such as croup tents, etc. Do you have the right set-up? Proper concentration of O2? Water in containers that should have water? Patients tolerance to the equipment? Is there any cyanosis?

Respiratory Equipment

Inspect and palpate the point of maximum impulse (PMI) Auscultate the heart sounds. What is rate and rhythm? Run a strip if you can. Check the P QRS, and T wavesany , abnormalities? Are all peripheral pulses present and equal? Any edema? (Check dependent areas like the sacral area) Any signs of dehydration? (Sunken fontanels, lethargic, sunken eyes, mucous membranes, etc.) Overall perfusion? (Skin warm, dry and pink? Or cool, clammy, mottled?) Nail beds(Good capillary refill, pink, etc.?) Check IV sites for signs of infiltration, phlebitis, etc., type and rate of IV, infusion pump, etc. Hemodynamic monitoring: various line(Note the reading, equipment, sites, and dressing)


Copyright 2006 by F. A. Davis.

Carotid Temporal

Apical Brachial

Aortic area Tricuspid area

Pulmonic area Mitral or apical area

Femoral Radial


Posterior tibial
Auscultation areas and peripheral pulses.

Dorsal pedis


Copyright 2006 by F. A. Davis.


Start from nose and mouth and work down. NG tube (Inspect for patency, how long has it been in, any suctioning-type, any drainagedescribe odor, amount, color, consistency, pH, quaiac, and so on)? Any other type of GI drainage? Abdomen (Inspect, auscultate bowel sounds in all four quadrants, palpate and percuss for size, consistency [soft or firm], distention, rigidity, pain [location, intensity, quality]). Stool inspect for amount, color, consistency, guaiac, reducing substance, when did child last have one? To decrease ticklish or tense sensation, have child place feet flat on bed or table with knees elevated and place childs hand under your hand as you palpate and percuss

Foley (Describe type, when inserted, does it need to be changed?). Foley care? Any urine? (What does it look like color, clarity, sediment or blood present? Test it forspecific gravity, glucose, pH, etc.) Do you observe any urethral, penile, vaginal discharge Circumcised? Determine weight of diaper: 1 g 1 cc (first weigh dry diaper and deduct weight of dry diaper)

Look at it!! All of it. Rashes, lesionslocation, pattern, size, color elevation, blanching? Breakdown?? Petechiae, purpura, bruising? General skin conditiondry, oily, itchy, scaly? Skin turgor? Lice? Color of the skin, any cyanosis, temperature, moisture? Note dressings (dry and intact??) Note mucous membranes (hydration, color) Tongue (is it moist?)


Copyright 2006 by F. A. Davis.

Assess while doing other systems Note if child is walking, sitting, or turning, ROM in all joints Check spinal curvature and mobility, sacral dimples or tufts of hair Note strength, symmetry, and movement of extremities

Safety Education Topics for Specific Age Groups

Infant Car seats. Water temperature (water heater setting lower than 130 F), smoke detectors, bath safety Car seats, pedestrian safety, water safety, medications, and household poisons Pedestrian safety, bicycle helmets, seat belts, no firearms in household, water safety Auto safety, alcohol/drug use, occupational injuries, no firearms in household


School age



Copyright 2006 by F. A. Davis.


5 Rights of Drug Administration

Right Drug Right Dose Right Time Right Route Right Patient

Determining Dosage and Route

Variations based on age, weight, body surface area (BSA), and maturity of kidneys and liver Physician orders, dosage, and route Nurse checks for safety of dosage and route

Methods to Determine Safety of Dose

Dosage Based on Body Weight

Determine childs 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 1.7 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 ask child to verbally identify himself; child may say yes to any name or give false name to avoid taking medication; do not use name card on bed to ID childchildren may switch beds


Copyright 2006 by F. A. Davis.

Give choices when possiblewould 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 prefersbe 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, syringe with needle removed, or plastic measuring cup Take care to prevent aspirationhold childs head up and administer liquids to infant by carefully using a syringe or dropper to place small amounts of med into infants cheek, near back of mouth or by putting med into nipple for infant to suck. 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), Orogastric, or Gastrostomy Route

Crush pills finely to prevent clogging of tube Check tube placement and infuse slowly After med administration, flush line with water to ensure med has cleared tube and to prevent clogging


Copyright 2006 by F. A. Davis.

Optic Route (eye)

Ensure that med is room temperature DropsPlace med in conjunctival sac; apply slight pressure to inner puncta for 1 minute to keep drops from draining into nose If child is uncooperative, immobilize childs head, place drop(s) over inner punctamed will drain into eye when child opens his eye. Explain to child that med may be tasted Ointmentapply from inner to outer canthus

Otic Route (ear)

Ensure that med is room temperature Position child with affected ear upmaintain position for one full minute after administration of med Child 3 yr, pull pinna down and back Child 3 yr, pull pinna up and back

Nasal Route (nose)

Ensure that med is room temperature DropsTip head backmay use towel roll between shoulders of small childmaintain position for one full minute after administration of med SprayChild 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 proceduredrape child to provide privacy Position child on left side Insert rounded end of suppository gently into rectum Hold childs buttocks together for 5 minutes to avoid expulsion of med


Copyright 2006 by F. A. Davis.

Intramuscular (IM), Subcutaneous (SQ), 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 syringes dead space may result in very small dose being inaccurate) Anticipate resistance from childenter 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 childs efforts

Intravenous (IV) Route

See comments regarding syringe size and clearing syringes dead space under Intramuscular Route If not specified in med order, 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


IM Injection Sites Age Group Preferred Site

Vastus lateralis Vastus lateralis Vastus lateralis or Ventrogluteal (relatively free of major nerves and blood vesselslarge muscle with little subcutaneous tissue, less painful than vastus lateralis and easily accessible) Deltoid (faster absorption rates than gluteal and less painful; limit to 1 mL) or ventrogluteal

Needle Length/Gauge
5/8 inch*/2425 G no more than 0.5 mL 5/81 inch*/2325 G no more than 1 mL 1 inch*/2223 G no more than 1 mL

Copyright 2006 by F. A. Davis.

Newborn & Young Infant Infant Toddler

Older Children

1 inch*/2223 G no more than 1.52 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. Administer EMLA cream or topical vapocoolant spray to injection site prior to giving the injection to decrease discomfort.


Copyright 2006 by F. A. Davis.

Pediatric Injection Sites
Greater trochanter

Femoral nerve, artery,vein

Tensor fascia latae

Sartorius Vastus lateralis Rectus femorus

Vastus lateralis.
j (gluteus medius) Anterior superior iliac spine Posterior iliac crest

Tensor fascia latae

Palm over greater trochanter

Gluteus maximus



Copyright 2006 by F. A. Davis.


Clavicle Acromion process Deltoid


Intravenous Maintenance Fluids Calculations by Body Weight

10 kg in weight 1120 kg in weight 20 kg in weight 100 cc per kg of weight cc for 24 hours 1,000 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 (15002000 mL/m2/day)

24 hour total divided by 24 hours rate in milliliters per hour Maintenance Sodium: 23 mEq/kg/24 hours Maintenance Potassium: 12 mEq/kg/24 hours For initial IV, potassium is generally added to the IV fluids AFTER the child voids


Copyright 2006 by F. A. Davis.

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, Soluset, Volutrol) in pediatrics Macrodrip Tubing 10, 20, 15 gtts/mL depending on brand of tubingmay 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, glucose, and protein

Peripheral Intravenous Access In Children Comments Related to Children Available Sites Needle Gauge
2024 G

Veins are more fragile External jugular and scalp so protect with tape, veins: frontal, superficial arm board, or surgical temporal, posterior netting. Choose site auricular; upper that will not interfere extremities veins: dorsal with activity for specific hand, radial vein of wrist, age group. Use EMLA anterior ulnar-forearm, cream, Fluori-Methane median cephalic-lateral vapocoolant spray, etc., antecubital fossa, median for nonemergent basilica-medial antecubital insertion. fossa; veins of the lower During infusion, hang extremity: superficial 4 hours worth of veins of dorsum of foot, IV fluid at any one saphenous vein anterior time (to prevent fluid and superior to the medial overload). Check site malleolus of the ankle, frequently for signs of and along proximal length infiltration or phlebitis on medial foreleg


Pediatric I.V. Sites MEDS/ ACUTE

Median antebrachial v. Median basilic v.

Median cephalic v. Cephalic v.

Supraorbital v.

Copyright 2006 by F. A. Davis.

Umbilical v. Basilic v. (newborn only) Great saphenous v.

Frontal v.

Dorsal venous arch Median marginal v. Dorsal arch

Superior temporal v. Posterior auricular v. Jugular v. Cephalic v. Basilic v. 5th interdigital v.

Preferred sites for peripheral intravenous access and venipuncture in infants and young children.


Copyright 2006 by F. A. Davis.

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, chemotherapy, TPN, or blood products; contraindicated with inadequate veins, bleeding disorders, immunosuppression, noncompliance, trauma to extremity, severe burns, or infections Total Implantable Used for long-term IV fluids, DevicePort-A-Cath medications, blood products, TPN, and venous blood sampling and analysis; use 1922 gauge rightangled needle with topical anesthesia to access and typically monthly flushing with heparinized saline solution; 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 CatheterBroviac, used for same purposes as Hickman, Groshong implantable device but better suited in very small children and infants; requires site care and frequent flushing with heparinized saline or saline solution Complications related to CVADs include infections, phlebitis, thrombosis, occlusions, breaks, migration, or accidental removal



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

18 yr old

8 yr old

Copyright 2006 by F. A. Davis.

If collapses suddenly and known cardiac conditionactivate EMS; otherwise activate after 1 min resuscitation

Determine unresponsiveness then activate EMS No trauma suspectedhead-tilt/chin-lift position. If trauma, use jaw thrust only. Look listen, 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 1/21 in100/min Carotid Heel of hand on lower half sternum and depress chest 11 1/2 in100/min Heel of one hand on top of other hand on lower half sternum and depress chest 1 1/22 in 100/min 15:2 1 & 2 & 3 & 4 & 5

Compression/ Ventilation Ratio Count Sequence

5:1; pause for ventilation if patient is not intubated 1,2,3,4,5 1&2&3&4&5

Adapted from the American Heart Association. (2002). PALS Provider Manual. American Heart Association, pp. 4380.


Copyright 2006 by F. A. Davis.

Key Points for Pediatric Choking Foreign Body 1 yr old

Conscious Victim Assess breathing to determine if ineffective or no strong cry

18 yr old

8 yr old

Ask, Are you choking?Can the child speak or cough? May demonstrate universal choking sign

Perform up to 5 subdiaphragmatic Give 5 back blows; then 5 chest abdominal thrusts (Heimlich) thrusts Repeat until obstruction relieved or becomes unconscious Child Becomes Unconscious Place child on back; active EMS after 1 min rescue effort Open airway and do finger Open airway, if see foreign body sweep then remove Give rescue breaths, if airway blocked, reposition head according to age requirements, try rescue breaths again Perform up to 5 subdiaphragmatic Give 5 back blows; 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, 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, if needed reposition & try again
Adapted from the American Heart Association. (2002). PALS Provider Manual., American Heart Association, pp. 4380.



Copyright 2006 by F. A. Davis.

Defibrillation Guidelines

Paddle Size

Paddle Placement

Energy Dose

4.5 cm for infants; 813 cm for children. 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; heart should be situated between paddles 2 Joules/kg for initial defibrillation with 24 Joules/kg for all subsequent attempts; for cardioversion, use 0.51 Joules/kg with 2.0 Joules/kg for all subsequent attempts

Bradycardia in Children:
Definition: too slow for age; HR 60/min in infant and young child with evidence of poor perfusion Causes: Hypoxemia (most common cause), hypothermia, head injury, heart transplant, toxins/poisons/drugs Treatment: Assess ABCs, ensure patent airway, monitor vital signs, attach ECG monitor, start IV/IO and oxygenation per order/protocol, treat cause Common Medications Used: Oxygen, epinephrine, atropine

Tachycardia in Children:
Definition: too fast for age; rapid heart rate associated with shock and hemodynamic instability Causes: Hypoxemia, hypovolemia, hyperthermia, electrolyte disturbances, tamponade, tension pneumothorax, toxins/poisons/drugs, thromboembolism, pain Treatment: Assess ABCs, if no pulse-initiate CPR, if pulse presentoxygenate, ventilate, and follow orders/protocols, treat cause Common Medications Used: Oxygen, amiodarone, procainamide, lidocaine, adenosine, may also use vagal maneuvers or cardioversion depending on type of tachycardia


Copyright 2006 by F. A. Davis.

Pulseless Arrest in Children:
Definition: Complete collapse confirmed by ECG in more than one lead Causes: Hypoxemia, acidosis, hypovolemia, tension pneumothorax, cardiac tamponade, electrolyte imbalance, drug overdose, and embolism Treatment: Determine pulselessness and begin CPR Ventricular fibrillation or Pulseless ventricular tachycardia: Defibrillation up to 3 times, continue CPR, secure airway, hyperventilate with 100% oxygen, secure IV/IO, administer medications such as amiodarone, lidocaine, magnesium per protocol. Asystole/Pulseless Electrical Activity: CPR, secure airway and IO/IV, hyperventilate with 100% oxygen, administer epinephrine per protocol and treat cause.

Pediatric Trauma Score Clinical Assessment

Child Size Airway

20kg Normal



1020 kg Maintainable 5090 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, decerebrate Major penetrating Open/Multiple fractures

Obtunded/loss of consciousness Minor Closed fracture

From Ford EG, Andrassy RJ. (1994). Pediatric Trauma Initial Assessment and Management. Philadelphia: W.B. Saunders, p. 112.


Copyright 2006 by F. A. Davis.


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 childs development

Emergencies Related to Diabetes Hypoglycemia

Too much insulin, delayed food intake, exercise without adjustment Shaky, weak, sweaty, hungry, dizzy, light-headed, palpitations, visual changes, gait disturbances, changes in affect, confusion, slurred speech, sleepiness, unconsciousness, seizures 60 mg/dL

Stress, infection, too little insulin Increased thirst, increased urination, weight loss, increased appetite, decreased energy level Fasting: 240 mg/dL Random: 300 mg/dL Give IV fluids, insulin, K


Blood Glucose Levels Treatment

Give glucose, IV/PO


Copyright 2006 by F. A. Davis.

General Types of Seizures
Obtain Seizure History: type, typical frequency, description and frequency of corresponding events, auras experienced before seizure, and any specific meds

Types of Partial: Simple

Description & Treatment

Confined to one hemispherechange in posture, hallucinations, or flushing, no aura and LOC alteration. Use anticonvulsants such as carbamazepine and phenytoin to control seizures. Starts in one focal area and spreads to both hemispheres; consciousness not completely lostconfusion, aura may occur, postictal response. Use anticonvulsants such as carbamazepine or phenytoin to control seizures; may need more than one drug. Sudden onset, lasts 510 sec, loose responsiveness but no falling, eyelids twitching, lip smacking, no postictal response; anticonvulsants/ketogenic diet. Opposite muscles contract/relax in rhythmic pattern, may occur in one or more limbs; use anticonvulsants. Muscles maintain continuous contracted state (rigid posture) with variable loss of consciousness; use anticonvulsants. Violent total body tonic then clonic movements with aura and postictal response, loss of consciousness. Phenobarbital, carbamazepine, phenytoin, or other similar drugs may be combinations.
(Continued text on following page)


Types of Generalized: Absence (petit mal) Clonic


Tonic-clonic (grand mal)


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 2060 minutes, correct metabolic problems, may start midazolam drip, treat underlying cause, establish maintenance anticonvulsant drugs.

Types of Miscellaneous: Febrile

Status Epilepticus

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, auraif 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)

Pale, warm

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

Skin turgor




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 Childs 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

130150 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 46 hoursmild dehydration 100 mL/kg over 46 hours-moderate dehydration 10 mL/kg or 48 oz of ORS for each diarrhea stool If vomiting: 510 mL every few minutes
Adapted from Behrman, p. 250.

Quick Restoration of Circulatory Volume:

If 10% dehydrationfluid 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.


Copyright 2006 by F. A. Davis.

Selected Emergency Drug Information Drug

Adenosine (3 mg/ml) Amiodarone Hydrochloride Atropine Sulfate (0.4 mg/ml)

Antiarrhythmic especially for SVT Antiarrhythmicprevent or treat Vfib, Vtach, SVT especially artial F Anticholinergic used for bradycardia and to restore normal heart contraction during cardiac arrest Electrolyte used to maintain cardiac contractility, treat hypocalcaemia, hypomag. Anticonvulsant used to treat seizures and for intubation

Rapid IV, IO

Dose in mg
0.10.2 mg/kg/dose, (maximum single dose 12 mg) repeat q 23 min 5 mg/kg/dose, (maximum dose 15 mg/kg/day) may infuse IV 2060 min 0.010.02 mg/kg/dose, may repeat q 2 minutes (maximum dose 1 mg children; 2 mg in adolescent) 1030 mg/kg/dose of 10% Ca Chloride, use with caution, not for asystole

Rapid IV, IO



CaChloride 10% (100 mg/ml)

Slow IV, IO

Diazepam (5 mg/ml)

Slow IV, IO

0.10.2 mg/kg/dose (maximum single dose 5 mg in 5 yr, 10 mg in 5 yr)

(Continued text on following page)



Selected Emergency Drug Information (Continued) Drug

Dobutamine (12.5 mg/ml)

Beta-adrenergic agonist used to depress myocardial contractility Beta-adrenergic agonistvasopressor in cardiogenic or septic shock or to maintain renal perfusion Adrenergic agonist, sympathomimetic used to treat asystole, bradyarrhythmias, Vfib See above

IV, IO infusion

Dose in mg
2.515 mcg/kg/minute (see drug insert for further instructions) 220 mcg/kg/minute (see drug insert for further instructions and infusion)

Copyright 2006 by F. A. Davis.

Dopamine (40 mg/ml)


Epinephrine 1:10,000 (0.1 mg/ml) Epinephrine 1:1,000 (1.0 mg/ml)



0.01 mg/kg/dose; this concentration is first drug of choice for pediatric arrest 0.10.2 mg/kg/dose; second and subsequent doses, repeat 35 min (may also infuse at 0.11 g/kg/minute)
(Continued text on following page)


Copyright 2006 by F. A. Davis.

Selected Emergency Drug Information (Continued) Drug

Lidocaine (0.1 ml/ kg-10 mg/ml concentration)


Rapid IV, IO, ET

Dose in mg
0.51 mg/kg bolus; (maximum dose 3 mg/kg) Infusion 1050 g/kg/min of 20 mg/ml solution 0.51 mEq/kg/dose;repeat 510 min only if oxygenated and ventilated 0.3 wt. kg base deficit efficient dosing 5 yr: 0.1 mg/kg/dose; 5 yr: 2.0 mg/kg/dose; repeat 23 min to 10 mg; ET dose 2- to 10-fold higher


Na Bicarbonate (1 mEq/ml) dilute 1:1 with saline

Electrolyte used to correct metabolic acidosis

Slow IV, IO

Naloxone (Narcan) (1 mg/ml)

Narcotic antagonist used for narcotic overdose


Refer to pharmacological inserts and other resources for complete information regarding drug use, side effects, contradictions, etc.
Adapted from Guidelines 2000 for Cardiopulmoary Resuscitation and Emergency Cardiovascular Care, American Heart Association; and Hay WW, Levin MJ, Sondhelmer JM, Deterding RR. (2005). Current Pediatric Diagnostic Treatment (17th ed.). New York: Lange Medical Books/McGraw Hill, p. 324.


Copyright 2006 by F. A. Davis.


Selected References
American College of Obstetricians and Gynecologists. (2000). Breastfeeding: Maternal and infant aspects. (Educational Bulletin No. 258). Washington DC: Author. American College of Obstetricians and Gynecologists. (2003). Management of preterm labor. (Practice Bulletin No. 43). Washington DC: Author. American College of Obstetricians and Gynecologists Office of Communications. (2003). Cervical cytology screening. ACOG Practice Bulletin No. 45. Washington DC: Author. American College of Obstetricians and Gynecologists Office of Communications. (2004). ACGOG issues state-of-the-art guide to hormone therapy: Experts expand prior post-WHI advice on estrogen ACOG News Release: September 30, 2004. Retrieved March 4, 2005, from nr09-03-04-2.cfm. American Cancer Society. (2004). Can breast cancer be found early? Cancer reference information: American Cancer Society, September, 2004. Retrieved March 4, 2005, from breast_cancer_be_found_early_5.asp. American Cancer Society. (2005). Cancer prevention and early detection worksheet for women. Retrieved August 4, 2005, from http:// Prevention_Worksheet_for_Women_pdf.asp. American Heart Association. (2002). PALS Provider Manual. American Heart Association. Atkins DL, et al. (1988). Pediatric defibrillation: Importance of paddle size in determining transthoracic impedance. Pediatrics; 82: 914918. Behrman RE, Kliegman RM, & Jenson TB. (2004). Nelson Textbook of Pediatrics (17th ed.). Philadelphia: W.B. Saunders.


Copyright 2006 by F. A. Davis.

Binder R, & Howry L. (2005). Pediatric Drug Guide with Nursing Implications (p. 156). Upper Saddle River, NJ: Prentice Hall. Brown K. (2004). Management Guidelines for Nurse Practitioners Working with Women (2nd ed.). Philadelphia: F Davis .A. Company. Centers for Disease Control (CDC)-Growth Charts. National Center for Chronic Disease Prevention & Health Promotion. (last reviewed 5/30/00). Centers for Disease Control (CDC). (2002). Sexually transmitted disease guidelines 2002. MMWR 2002; 51 (No. RR-6). Chameides L, et al. (1977). Guidelines for defibrillation in infants and children: report of the AHA target activity group: Cardiopulmonary resuscitation in the young. Circulation; 56: 502A503A. Curran C. (2003). Intrapartum emergencies. JOGNN; 32: 302312. Dillon PM. (2003). Nursing Health Assessment: A Critical Thinking, Case Studies Approach. Philadelphia: F Davis .A. Company. Ford EG, & Andrassy RJ. (1994). Pediatric Trauma Initial Assessment & Management. Philadelphia: W.B. Saunders. Hahn YS, et al. (1988). Head injuries in children under 36 months of age. Child Nervous System; 4: 34. Hatcher R, Trussell J, Stewart F Nelson A, Cates W, Guest F et al. , , (2004). Contraceptive Technology (18th ed.). New York: Ardent Media, Inc. Hay WW, et al. (2005). Current Pediatric Diagnosis and Treatment (17th ed.). New York: Lange Medical Books/McGraw-Hill. Hazinski MF (1999). Manual of Pediatric Critical Care. St. Louis: . Mosby. Hockenberry MJ. (2003). Wongs Nursing Care of Infants and Children (7th ed.). St. Louis: Mosby. Holloway BW. (2004). Nurses Fast Facts. Philadelphia: F A. Davis . Company.


Copyright 2006 by F. A. Davis.


James HE. (1986). Neurologic evaluation and support in child with acute brain insult. Pediatric Annals; 15: 17. Lowdermilk D & Perry S. (2004). Maternity and Womens Health Care (8th ed.). St. Louis: Mosby. Martin E. (2002). Intrapartum Management Modules (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. Mattson S, & Smith J. (2004). Core Curriculum for MaternalNewborn Nursing (3rd ed.). St. Louis: Elsevier. MBI for Children & Teens. Division of Nutrition & Physical Activity, National Center for Chronic Disease Prevention & Health Promotion, (last reviewed 6/08/05). bmi/oobinaries. McCarthy PL, et al. (1982). Observation scales to identify serious illness in febrile children. Pediatrics; 70: 802. Merkel S, et al. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing; 23(3): 293297. Murray M. (2004). Maternal or fetal heart rate? Avoiding intrapartum misidentification. JOGNN, January/February, 93104. National Heart, Lung, and Blood Institute. (1987). Normal Blood Pressure Readings from the Second Task Force on Blood Pressure Control in Children. Author: Bethesda, MD. New Food Guide Pyramid for Children. Center for Nutrition Policy and Promotion, U.S. Dept. of Agriculture, Reif M. (2003). How to identify and manage preeclampsia. Womens Health Gynecology Edition; 3: 249255. Roberts J. (2003). A new understanding of the second stage of labor: Implications for nursing care. JOGNN; 32: 794800. Shelton TL, & Stepanek J. (1994). Family-Centered Care for Children Needing Specialized Health and Developmental Services. Association for Care of Childrens Health.


Copyright 2006 by F. A. Davis.

Simpson K, & Creehan P (2001). Association of Womens Health, . Obstetric and Neonatal Nurses Perinatal Nursing (2nd ed.). Philadelphia: Lippincott. U.S. Preventive Services Task Force (USPSTF). (2005). The Guide to Clinical Prevention Services. Silver Spring: Agency for Healthcare Research and Quality Publications. Retrieved August 31, 2005, from U.S. Food and Drug Administration. (2001). Pregnancy and the drug dilemma. FDA Consumer magazine, May-June 2001. Retrieved August 12, 2005, from U.S. Food and Drug Administration. (2003). FDA approves new labeling and provides new advice to postmenopausal women who use or who are considering using estrogen and estrogen with progesterone. FDA Fact Sheet. Retrieved June 27, 2005, from Hormone therapy for the prevention of chronic conditions in postmenopausal women: Recommendations from the U.S. Prevention Services Task Force. (2005). American College of Physicians; 142(10): 855860. Wong D, Perry S, & Hockenberry M. (2002). Maternal Child Nursing (2nd ed.). St. Louis: Mosby.


Copyright 2006 by F. A. Davis.


Illustration Credits
Pages 5, 6, 25, 35, 36, 54, 84 from Dillon PM: Nursing Health Assessment: A Critical Thinking, Case Study Approach. FA Davis, Philadelphia. 2003 Pages 78, 79 from Ross Products Division Abbott Laboratories Inc. Page 109 from Hay WW, et al: Current Pediatric Diagnosis & Treatment (17th Ed.) New York: Lange Medical Books/McGraw-Hill. 2005 Pages 110, 152 from Behrman RE, Kliegman RM, Jenson TB: Nelson Textbook of Pediatrics, 17/e. Philadelphia: W.B. Saunders. 2004 Page 112 from Hahn YS, et al: Head injuries in children under 36 months of age, Child Nervous System. 4:34, 1988 Page 120 from Merkel S, Voepel-Lewis T, Shayevitz J, Malviya, S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23(3): 293297. Copyright 2002, The Regents of the University of Maryland. Page 125 from McCarthy, PL, Sharpe, MR, Spiesel, SZ, et al (1982). Observation scales to identify serious illness in febrile children. Pediatrics, 78:802 Page 147 from Ford EG, Andrassy RJ. Pediatric Trauma Initial Assessment & Management, p.112, Philadelphia: WB Saunders. (1994)


Copyright 2006 by F. A. Davis.


Note: Page numbers followed by f and t indicate figures and tables, respectively. A Abortion, spontaneous, 41 Abruptio placentae, 44, 45f Abuse, child, 148 Activity level in newborn, assessment of, 97 postpartum, 90 Adenosine, 153 AIDS. See HIV Amiodarone, 153 Amniotomy, 7273 Apgar score, 69 Apnea monitors, 114 electrode placement for, 115f Atropine sulfate, 153 B Basal body temperature, fertility awareness and, 9 Bathing, newborn, teaching tips, 99 Bed/crib choices, by age group, 122 Biophysical profile (BPP), 51 Bishops score, 71 Bladder, postpartal status, 86 Blood pressure, pediatric, normal ranges, 112 BMI. See Body mass index Body mass index (BMI) pediatric, calculation of, 109 Bottle feeding, teaching tips, 100102 Bowel, postpartal assessment, 86 BPP See Biophysical profile . Bradycardia in children, 146 fetal, 58 Breast, infection of (mastitis), 94 Breast self exam (BSE), 57, 5f, 6f Breastfeeding advantages to, 80 breast care during, 82 engorgement, 81 nutrition during, 81 positioning, 79f, 80 pumping and storing, 81 supply and demand, 81 C Calcium chloride, 153 Calendar method, of fertility awareness, 9 Caloric requirements, for children, 109 Cancer. See specific types Cardiac monitors, pediatric, 114 electrode placement for, 115f Cardiopulmonary resuscitation (CPR), pediatric, key points for, 144 Cardiovascular health, promotion of, 16


Copyright 2006 by F. A. Davis.

Cardiovascular system, assessment of, 130 heart sounds and peripheral pulses, 131f Catheters, pediatric suction, 114 Central venous access devices (CVAD), 143 Cervical cancer screening, ACOG/ACS guidelines for, 1 Cervical mucus, fertility awareness and, 9 Cervical ripening, 72 Cesarean birth, 75 postpartal assessment in, 91 vaginal birth after, 7374 Child abuse, recognizing, 148 Children caloric requirements for, 109 communications with, 126t128t developmental milestones in, by age group, 105t108t pain in developmental differences in, 118 nursing interventions related to management of, 119 questions in assessment of, 117 responses to illness/hospitalization, by age group, 116t117t safety education topics, 133 sick, quick evaluation of, 125 systemic assessment, 129 cardiovascular, 130, 131t gastrointestinal, 132 genitourinary, 132 musculoskeletal, 133 neuromuscular, 129 respiratory, 129130 respiratory equipment, 130 skin, 132 10-minute assessment of, 123124 use of play for, by age group, 105t108t Chlamydia, symptoms and detection, 3t Choking, pediatric, key points for, 145 Circumcision, teaching tips, 102103 Clonic seizures, 149 Colorectal cancer, early signs of, 17 Coma scale, pediatric, 112 Communication with child and family, 126t127t in newborn, teaching tips, 98 Condoms, 1112 Contraception barrier methods, 1011 educating women on, 7 emergency, 15 fertility awareness methods, 89 hormonal methods, 1114 contraindications to, 12 intrauterine system, 1415 lactation amenorrhea method, 10 permanent methods, 1516


Copyright 2006 by F. A. Davis.

intramuscular, 137 sites for, 139f, 140f intravenous, 137 sites for, 142f nasal, 136 nasogastric/orogastric/ gastrostomy, 135 optic, 136 oral, 135 otic, 136 rectal, 136 subcutaneous, 137 E Eclampsia, 48 Ectopic pregnancy, 41 Electrode placement, pediatric cardiac/apnea monitors, 115f Electrolyte/water deficit, calculation of, 152 Emotional response, postpartal assessment of, 88 support for, 89 Endometrial cycle, 8 Endometritis, 94 Epinephrine, 154 Estrogen contraindications to, 12 effects of, 11 Extremities, assessment of in newborn, 97 in postpartal patient, 89 F Family planning. See Contraception Fears, in children as response to illness/hospitalization, 116117 Febrile seizures, 150

Contraction stress test (CST), 5051 CPR. See Cardiopulmonary resuscitation CST. See Contraction stress test CVAD. See Central venous access devices D Deep venous thrombosis, 95 signs of, teaching tips, 96 Defibrillation, pediatric guidelines, 146 Dehydration, pediatric degree/signs of, 151 water/electrolyte deficit, calculation of, 152 Delivery, estimated date of, 20 Depo-medroxyprogesterone (DMPA), 14 Developmental milestones 01 year, 105 13 years, 106 36 years, 107 612 years, 108 1218/21 years, 108 Diabetes emergencies related to, 148 gestational, 4950 Diaphragms, 10 Diazepam, 153 DMPA. See Depo-medroxyprogesterone Dobutamine, 154 Dopamine, 154 Drug administration, 134135 5 rights of, 134 routes of determination of, 134 intradermal, 137


Copyright 2006 by F. A. Davis.

Fertility awareness methods, 89 Fetal heart tones (FTH), Doppler placement for, 36f Fetal monitoring baseline heart rate changes to, 5862 evaluating, 56, 57f continuous external, 55f internal, 56f intermittent auscultation, 5455 nursing responsibilities in, 54 Fetoscope, 54f FLAAC pain assessment tool, 120t Fluid deficit. See Dehydration Food pyramid, 31f Formula, infant, 100 Fundus height of, 25f by weeks of gestation, 24 massage of, 83f postpartal assessment of, 8485 G Gastrointestinal system, assessment of, 132 Genetic screening, in newborn, teaching tips, 104 Genitourinary system, assessment of, 132 Gestational trophoblastic disease, 4142 Gonorrhea, symptoms and detection, 3t Grand mal seizures, 149 H Health maintenance, in newborn, teaching tips, 103 Heart rate, fetal changes to baseline, 5862 accelerations, 59, 59f early decelerations, 59, 60f late decelerations, 6061, 60f nursing interventions for, 62 variable decelerations, 61, 61f evaluation of, 56 normal, 57f Heart sounds, 131f HELLP syndrome, 4849 Hemorrhage, in postpartal patient, 9293 Hepatitis, symptoms and detection, 3t Herpes simplex virus (HSV), 2 symptoms and detection, 4t History(ies) intrapartum, 5253 pediatric, concerns by age group, 128 prenatal health, 2122 HIV, symptoms and detection, 4t Hormonal contraceptives, 11 combined methods, 1214 contraindications to, 12 Hormonal replacement therapy (HRT), 18 Hospitalization, childrens responses to, by age group, 116117


Copyright 2006 by F. A. Davis.

Intravenous access sites, pediatric, peripheral, 141, 142f Intravenous maintenance fluids, calculations by body weight, 140 of IV rates, 141 IUD. See Intrauterine device K Kegel exercises, 88 L Labor active phase (stage 1), 6466 epidurals in, 66 expulsion (stage 2), 6769 fourth stage, 76 induction of, 7173 latent phase (stage 1), 64 monitoring contractions, 6263 nursing care in, 63 placenta delivery (stage 3), 70 preterm, 4647 systemic pain medications in, 65 transition phase (stage 1), 6667 Lactation amenorrhea method (LAM), 10 LAM. See Lactation amenorrhea method (LAM) Leopolds maneuver, 35f Lidocaine, 155 Lochia, 86 assessment of, 87 normal progression of, 85 Loss of control, in children as response to illness/hospitalization, 116117

HPV. See Human papillomavirus HRT. See Hormonal replacement therapy HSV. See Herpes simplex virus Human papillomavirus (HPV), 2 symptoms and detection, 3t Hyperemesis gravidarum, 45 Hyperglycemia, 148 Hypoglycemia, 148 Hysteroscopic tubal sterilization, 16 I Illness, childrens responses to, by age group, 116117 Immunizations genetic and hearing screen, teaching tips, 104 in newborn, teaching tips, 104 Infants developmental milestones, 105 feeds, number/volumes, 109 food types, introduction of, 111 vital signs, 110 See also Newborns Infection, in postpartal patient, 9394 Injections intradermal, 137 intramuscular sites, 138, 139f, 140f intravenous, 137 sites for, 142f subcutaneous, 137 Intrauterine device (IUD), 1415


Copyright 2006 by F. A. Davis.

M Mastitis, 94 Menopause hormonal replacement therapy in, 18 symptoms of, 17 Menstrual cycle, 7 postpartal return of, 85 Musculoskeletal system, assessment of, 133 N Naegeles Rule, 20 Naloxone, 155 Neglect, child, 148 Neuromuscular system, assessment of, 129 Newborns breastfeeding of, 78f, 7982, 79f care of, teaching tips bathing/skin care, 99 bottle feeding, 100102 circumcision, 102103 communication, 98 reportable symptoms, 104 safety and health maintenance, 103 sleep patterns, 98 umbilical cord care, 100 immediate care of, 6870 nursery care of, 97 physical assessment of, 97 Nonstress test (NST), 50 NST. See Nonstress test Nutrition of children, caloric requirements, 109 food pyramid, 31f in pregnancy, education on, 31 O OCT. See Oxytocin challenge test Osteoporosis, prevention and treatment of, 16 Ovarian cycle, 8 Oxytocin, in induction of labor, 7172 Oxytocin challenge test (OCT), 5051 P Pain developmental differences in children related to, 118 FLAAC assessment tool, 120t nursing interventions related to management of, 119 questions in assessment of, 117 Parenteral nutrition calculations by body weight, 140 of IV rate, 141 keys for monitoring child on, 140 Pediatric coma scale, 112 Pediatric trauma score, 147 Perineum, postpartal assessment, 87 Petit mal seizures, 149 Pitocin. See Oxytocin Placenta previa, 42, 43f, 45


Copyright 2006 by F. A. Davis.

preeclampsia, 4748 preterm labor, 4647 vaginal bleeding, 42 delivery date estimating in, 20 early diagnostic testing in, 2728 education in, 28 establishing, 19 exercise in, 33 fetal surveillance in, 5062 biophysical profile, 51 contraction stress test, 5051 nonstress test, 50 hormonal changes in, 23 low-risk, prenatal visits, scheduling of, 21 physiological changes in, 23 second/third trimester, education in, 3840 sexuality in, 34 teratogen exposure in, 30 trimesters of, 20 warning signs during, 34 weight gain in, 33 Prenatal visits first diagnostic tests for, 26 history taking in, 2122 nursing care with, 24 patient education in in early prenatal period on discomforts/ reportable symptoms, 28t29t on exercise, 33 on nutrition, 31, 32f

Play, type/purpose of, by age group, 121122 Postpartum blues/depression, 89, 9495 signs of, teaching tips, 96 Postpartum patient breast assessment, 77 cesarean, assessment of, 9192 complications in hemorrhage, 9293 infection, 9394 education of, 77 in breastfeeding, 7882 emotional response, assessment/support of, 8889 laboratory data in, 91 nursing assessment of, 7677 return of menstrual cycle in, 85 sexuality in, 85 uterine involution in, 8384, 84f Preconception counseling, 7 Preeclampsia, 4748 Pregnancy classification of medications in, 31 common laboratory tests in, 26 complications in abruptio placentae, 44f eclampsia, 48 gestational diabetes, 4950 HELLP syndrome, 4849 hyperemesis gravidarum, 45 placenta previa, 42, 43f, 45


Copyright 2006 by F. A. Davis.

on sexuality, 34 on teratogen exposure, 30 on warning signs, 34 on weight gain, 33 in second/third trimester, 38 on discomforts/ reportable symptoms, 39t40t return diagnostic tests for, 37 nursing care for, 3536 scheduling, 21 Preterm labor, 4647 Progestin contraindications to, 12 effects of, 11 single agent preparations, 14 Pulse oximetry, pediatric, 114 Pulseless arrest, in children, 147 Pulses, peripheral, 131f R Rehydration, 152 Respiratory failure, cardinal signs of, 148 Respiratory system, assessment of, 129130 S Safety of drug dose, determination of, 134 education topics, by age group, 133 in infant/child assessment, 123124 in newborn, teaching tips, 103 of toys, by age group, 121122 Screening, cervical cancer, ACOG/ACS guidelines for, 1 Seizures, general types of, 149150 Separation anxiety, in children as response to illness/hospitalization, 116117 Serum pregnancy test, 19 Sexuality postpartal, 85 in pregnancy, 34 Sexually transmitted diseases (STDs), 2, 3t4t Skin assessment of, 132 care of, in newborn, teaching tips, 99 Skin cancer, early detection/prevention of, 17 Sleep patterns, in newborn, teaching tips, 98 Sodium bicarbonate, 155 Status epilepticus, 150 STDs. See Sexually transmitted diseases Suctioning, pediatric, 114 Syphilis, symptoms and detection, 4t T Tachycardia in children, 146 fetal, 58 Teratogens, in pregnancy, education on, 30


Copyright 2006 by F. A. Davis.

V Vaginal birth after cesarean (VBAC), 7374 Vaginal bleeding, in pregnancy, 42 VBCA. See Vaginal birth after cesarean Venipuncture sites, pediatric, 142f Vital signs newborn, 97 pediatric, average ranges, 110 postpartum, 90 W Water/electrolyte deficit, calculation of, 152 Water requirements, pediatric, 110 Weight gain, in pregnancy, 33 Weight loss, at birth, 91 Weight management, promotion of, 16 Women, health promotion in, 1617 nurses role in, 1

Thrombophlebitis, 95 signs of, teaching tips, 96 Tonic seizures, 149 Toys, safe, by age group, 12122 Trauma, score, pediatric, 147 Trichomoniasis, symptoms and detection, 3t Tubal ligation hysteroscopic, 16 incisional method, 15 U Ultrasonography, in establishing pregnancy, 19 Umbilical cord care of, teaching tips, 100 prolapse of, 74 Urinary tract infection, in postpartal patient, 9394 Urine output, pediatric, 110 Urine pregnancy test, 19 Uterus infection of (endometritis), 94 involution of, 83 subinvolution signs, teaching tips, 96


Copyright 2006 by F. A. Davis.