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Copyright © 2006 by F. A. Davis.
OB Peds Women’s Health Notes
Nurse’s Clinical Pocket Guide
Brenda Holloway, CRNP, FNP, MSN Cheryl Moredich RNC, MS, WHNP Kathie Aduddell, Ed.D, MSN, RN-BC
Purchase additional copies of this book at your health science bookstore or directly from F A. Davis by shopping . online at www.fadavis.com or by calling 800-323-3555 (US) or 800-665-1148 (CAN) A Davis’s Notes Book
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The fee code for users of the Transactional Reporting Service is: 8036-1466/06 0 + $. or transmitted in any form or by any means. expressed or implied.Copyright © 2006 by F. Davis Company . or the internal or personal use of specific clients.10 per copy is paid directly to CCC.com Copyright © 2006 by F A. photocopying. Richman Developmental Editor: Marla Sussman Consultant: Kim Cooper.10. electronic. All rights reserved. This book is protected by copyright. Caution is especially urged when using new or infrequently ordered drugs. No part of it may be reproduced. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. Davis. A. is granted by F A. a separate system of payment has been arranged. Danvers. mechanical. up to date. recommended treatments and drug therapies undergo changes. MA 01923. Martone Project Editor: Ilysa H. without written permission from the publisher. registered with the Copyright Clearance Center (CCC) Transactional Reporting Service. F A. 222 Rosewood Drive. or otherwise. editors. in regard to the contents of the book.fadavis. Davis Company . PA 19103 www. Printed in China by Imago Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher. Nursing: Robert G. recording. The author(s). The author(s) and publisher have done everything possible to make this book accurate. Authorization to photocopy items for internal or personal use. and make no warranty. RN. . provided that the fee of $. For those organizations that have been granted a photocopy license by CCC. 1915 Arch Street Philadelphia. Davis Company for users . and publisher are not responsible for errors or omissions or for consequences from application of the book. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. and in accord with accepted standards at the time of publication. stored in a retrieval system. MSN As new scientific information becomes available through basic and clinical research.
A. GYN ANTE.INTRA. Place 2 78 2 78 / / Sticky Notes here for a convenient and refillable note pad ✓ HIPAA Compliant ✓ OSHA Compliant Waterproof and Reusable Wipe-Free Pages Write directly onto any page of OB Peds Women’s Health Notes with a ballpoint pen. Davis.POSTPEDS PEDS BASICS PARTUM PARTUM PARTUM BASICS ASSESS MEDS/ ACUTE TOOLS . Wipe old entries off with an alcohol pad and reuse.Copyright © 2006 by F.
A. Look for our other Davis’s Notes titles Available Now! Nurse’s Clinical Pocket Guide.fadavis. visit www. Davis.Copyright © 2006 by F. 2nd edition ISBN-10: 0-8036-1335-0 / ISBN-13: 978-0-8036-1335-5 ECG Notes: Interpretation and Management Guide ISBN-10: 0-8036-1347-4 / ISBN-13: 978-0-8036-1347-8 IV Therapy Notes: Nurse’s Clinical Pocket Guide ISBN-10: 0-8036-1288-5 / ISBN-13: 978-0-8036-1288-4 LabNotes: Guide to Lab and Diagnostic Tests ISBN-10: 0-8036-1265-6 / ISBN-13: 978-0-8036-1265-5 LPN Notes: Nurse’s Clinical Pocket Guide ISBN-10: 0-8036-1132-3 / ISBN-13: 978-0-8036-1132-0 MedNotes: Nurse’s Pharmacology Pocket Guide ISBN-10: 0-8036-1109-9 / ISBN-13: 978-0-8036-1109-2 New edition coming Fall 2006 MedSurg Notes: Nurse’s Clinical Pocket Guide ISBN-10: 0-8036-1115-3 / ISBN-13: 978-0-8036-1115-3 NutriNotes: Nutrition & Diet Therapy Pocket Guide ISBN-10: 0-8036-1114-5 / ISBN-13: 978-0-8036-1114-6 PsychNotes: Clinical Pocket Guide ISBN-10: 0-8036-1286-9 / ISBN-13: 978-0-8036-1286-0 For a complete list of Davis’s Notes and other titles for health care providers. RNotes®: .com.
A. Davis. screening.Copyright © 2006 by F. are recommended to have repeat exams every 2–3 years GYN BASICS . with three consecutive negative cervical screens. ACOG recommends that a visit to an obstetrician/gynecologist occur before that time for health guidance. 1 Nurses Impact the Health of Women Through ■ ■ ■ ■ ■ Educating women about healthy lifestyle choices Role modeling healthy behavior and promoting wellness Describing the role of prevention and early detection Informing women about disease treatment and progression Being an advocate and resource for community referrals Cervical/Gynecological Health ■ According to the guidelines of the American College of Obstetrician and Gynecologists (ACOG) and the American Cancer Society (ACS). 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. initial cervical screen for cancer should begin 3 years after first sexual intercourse or by age 21. whichever comes first ■ However.
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].gov for latest treatment guidelines for STIs (Continued text on following page) 2 . A. herpes simplex virus [HSV]) may still be transmitted with use of latex condoms ■ Sexual partners should be tested and treated when an STI is identified. Davis.cdc.GYN BASICS Copyright © 2006 by F. sexual activity should be avoided until treatment regimen completed ■ Patients diagnosed with a viral STIs should consult their health-care provider for long-term management ■ Reportable STIs must be forwarded to the local health department along with treatment rendered ■ Encourage immunization against hepatitis B ■ Visit CDC Web site www.
Sexually Transmitted Infections (STIs) (Continued) Infection Gonorrhea Symptoms (May be asymptomatic) Yellow-green vaginal discharge Dyspareunia Abdominal pain Dysuria Mucopurulent discharge Postcoital bleeding Dyspareunia Abdominal pain Dysuria Frothy malodorous vaginal discharge Dyspareunia Vaginal itching/irritation Dysuria Fatigue Dark urine Clay-colored stool Jaundice/abdominal pain Many subtypes exist. A.Copyright © 2006 by F. some associated with cervical dysplasia Visible wartlike growths in genital area associated with subtypes 6. 11 Detection Endocervical culture Urine test Chlamydia Endocervical culture Urine test 3 Trichomoniasis Saline wet mount of vaginal discharge viewed under microscopy Serological testing Hepatitis Human Papilloma Virus (HPV) Pap smear report Colposcopy/biopsy (Continued text on following page) GYN BASICS . Davis.
Davis. malaise Enlarged lymph nodes 4 . A.Copyright © 2006 by F. verify with treponemal test Treponemal (FTA-ABS) Reported as positive or negative Serological testing (Pretest and posttest counseling with informed consent required) Positive screen must be confirmed by more specific test (Western blot) Viral culture with DNA probe HIV Fever Malaise Lymphadenopathy Skin rash GYN BASICS Herpes Simplex Virus (HSV) Painful. auditory involvement Detection Serological testing Nontreponemal (RPR. lymphadenopathy Latent Lacking clinical manifestations Tertiary Cardiac. ophthalmic. VDLR) ■ Reported quantitatively (titers) ■ Four-fold change in titers clinically significant ■ Effective treatment will result in falling titers ■ False-positive possible. Sexually Transmitted Infections (STIs) (Continued) Infection Syphilis Symptoms (May be asymptomatic) Primary Chancre (painless raised ulcer) Secondary Skin rash. recurrent vesicular lesions Fever.
Copyright © 2006 by F. 5 Breast Health ■ Monthly breast self-exam. Davis. looking for dimpling. starting at age 20. yearly after age 40 ■ Annual mammogram starting at age 40 Instructions for Breast Self Exam (BSE) Step 1: Inspection 1.) GYN BASICS . Philadelphia: F. A. Davis. 459. instructed to woman as an optional tool for identifying and reporting breast changes ■ Clinical breast exam at least every 3 years (age 20–40) during a physical exam by a health professional. p. Visually inspect in several positions. Visually inspect the breasts. symmetry 2. may accentuate an abnormality ◆ Hands at the side ◆ Hands above the head ◆ Hands pressed onto hips ◆ Leaning over BSE positions. lumps. skin irregularities.A. (2003) Nursing Health Assessment: A Critical Thinking. Case Study Approach. (From Dillon PM.
p 461. Davis. (From Dillon PM. A. Davis. Nursing Health Assessment: A Critical Thinking.A. and deep pressure in a systematic fashion BSE palpation patterns. Step 2: Palpation 1. Feel the breast tissue and lymph node chain for lumps or thickening by using three finger pads while exerting light. (2003).GYN BASICS Copyright © 2006 by F.) 6 . Philadelphia: F. medium. Case Study Approach.
dexterity. benefits. Report lumps. which stimulates the anterior pituitary to release GYN BASICS . Begin by lying down on a flat surface with arm raised and a folded towel under the back of the breast being examined 3. A. Davis. After examining breast tissue. and efficacy of each method ■ Efficacy of each method influenced by correct and consistent use. 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. user preparedness. ■ Discuss chromosomal abnormalities associated with advanced maternal age ■ Incorporate 400 mcg of folic acid daily (for low-risk women) ■ Avoid alcohol.Copyright © 2006 by F. motivation. 7 2. discussing the risks. 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). 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. thickening. Repeat technique on the other side 5. bring arm toward body and feel the axilla and the skin above as well as below the collar bone 4. smoking.
encouraging maturation of the Graafian follicle Estrogen. as well as monitor gynecological health ■ To prevent pregnancy. A. produced by the maturing follicle. Davis. couples abstain during recognized period of fertility 8 . 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.GYN BASICS Copyright © 2006 by F. the corpus luteum (remaining cells of the follicle) produces estrogen and progesterone. ■ ■ ■ ■ ■ follicle stimulating hormone (FSH). 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. the corpus luteum regresses. which stimulates endometrial thickening If conception does not occur. causing a decrease in estrogen and progesterone.
a surge of progesterone increases BBT by 0. 9 Cervical Mucus Amount and character of cervical mucus changes throughout the menstrual cycle in response to hormones ■ Following menses.Copyright © 2006 by F. and cloudy ■ At ovulation. thick. prior to menses ■ Certain activities may alter BBT: smoking. restless sleep. cervical mucus scant. cloudy. slippery. cervical mucus scant. increased likelihood of pregnancy with unprotected intercourse ■ After ovulation. thick.5–1. abstain from intercourse GYN BASICS . use of electric blanket or heated waterbed. and is no longer stretchable ■ Cervical mucus should be evaluated and charted daily ■ Monitor and graph BBT daily before rising ■ Prior to ovulation. promoting sperm motility. illness Basal Body Temperature (BBT) Calendar Method ■ Based on assumption that ovulation occurs 14 days before the onset of menses ■ Record menstrual cycles for 6–8 months ■ Calculate fertile period Subtract 18 from the shortest menstrual cycle (28 18 10) Subtract 11 from the longest menstrual cycle (32 11 21) Days 10–21 fertile time. cervical mucus becomes more abundant. Davis. BBT decreases slightly in response to estrogen ■ After ovulation. and stretchable in response to estrogen (known as “spinnbarkeit”). A.0 F ■ BBT remains high with conception. clear. but falls without conception.
and therefore suppresses ovulation ■ Postpartum woman who exclusively breastfeed during the first 6 months after childbirth. inspect integrity of rubber by holding up to light to inspect for holes Male Condom ■ Thin latex sheath that covers the erect penis during sexual intercourse ■ Provides protection from STIs ■ Space should be left at the end of the condom for ejaculate ■ Hold condom at base of the penis upon withdrawal to prevent spillage ■ Only water-soluble gel should be used for lubrication to prevent degradation of the latex 10 . 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. including at least one night feeding. teach to report symptoms of UTI ■ Wash with soap and water after each use. Davis. A. may postpone ovulation ■ Instruct patients that ovulation and return of fertility may occur before first menses with a risk of unintended pregnancy Barrier Methods Prevents conception by blocking entry of sperm into the cervix Diaphragm ■ Dome-shaped rubber cup with a flexible ring that fits over the cervix. Lactation Amenorrhea Method (LAM) ■ Prolactin suppresses follicle stimulating hormone (FSH).GYN BASICS Copyright © 2006 by F.
Copyright © 2006 by F. ■ Mechanism of Action ■ Effects of Estrogen • Ovulation inhibited by suppression of follicle stimulating hormone (FSH) and luteinizing hormone (LH) • Endometrial lining altered making the endometrium less receptive to implantation ■ Effects of Progestin • Cervical mucus thickened. inhibiting ovulation. Davis. breast tenderness. headaches. or weight change GYN BASICS . 11 ■ New condom should be used with each act of intercourse ■ Store in unopened package in cool. 5-year shelf life Remove prior to standing by twisting the outer ring to contain semen and pull out ■ Material degradation could occur if both male and female condoms used simultaneously Hormonal Methods Hormonal contraceptives Hormonal contraceptives alter the normal menstrual cycle. and reliability ■ Requires addition of condom for STI protection or as back-up with user error ■ Side effects may include nausea. 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. altering the endometrial lining. mood changes. breakthrough bleeding. and thickening cervical mucus. decreased libido. A. 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. vomiting.
estrogen promotes blood clotting ■ History of breast or female reproductive cancer. increased risk for stroke ■ Major surgery planned with immobilization. increased risk for cardiovascular complications ■ Smoker over 35 years of age. 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. double vision) ■ Severe leg pain. OCs are metabolized through the liver and use may adversely affect existing liver disease ■ Suspected or confirmed pregnancy ■ Uncontrolled hypertension. tumors may be hormonally provoked ■ Diabetes with vascular involvement. increases the risk for cardiovascular complications ■ History of migraine headaches (with aura). redness. and swelling ■ Shortness of breath ■ Worsening depression ■ Jaundice ■ Contraindications to hormonal contraceptives ■ History of heart attack. advise hormonal contraceptive users not to smoke and teach reportable symptoms of possible complications: ■ Abdominal pain (severe) ■ Chest pain ■ Headache (severe) ■ Eye problems (blurred. or symptoms presented 12 . type of progestin. adrenergic effect. stroke. A. followed by 7 hormone-free days (either no pills taken or placebos taken for 7 days) ■ Pill selection based on amount of estrogen. Davis.GYN BASICS Copyright © 2006 by F. blood clot. ■ May cause serious health issues. estrogen promotes blood clotting ■ Impaired liver function.
followed by 7 days of inert pills. exercising) ■ Partial removal and skin reactions possible ■ Decreased effectiveness noted in women who weigh more than 198 pounds Vaginal Ring ■ Small. swimming. vaginal irritation. and upper torso (but not the breasts). removed in fourth week to allow for withdrawal bleeding ■ Ring should be kept inside unopened package before insertion. buttocks.Copyright © 2006 by F. avoiding lotion. if out for more than 3 hours. and firmly applying patch making sure all corners adhere to skin ■ May engage is usual activities (bathing. fourth week is patchfree to allow withdrawal bleeding ■ Acceptable application sites include abdomen. upper outer arm. flexible hormone-impregnated ring inserted and left in the vagina for 3 weeks. or infection ■ Expulsion may occur. patients should report use of contraceptive agents to all health-care providers Transdermal Patch ■ Patch applied to skin weekly for 3 weeks. 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. 13 ■ Combined OCs may be monophasic (estrogen and progestin remain constant) or multiphasic (hormone dosing changes throughout the month) ■ Extended-cycle OCs are taken consistently for 12 weeks. back-up method of birth control needed for the next 7 days GYN BASICS . A. Davis. site should vary weekly ■ Application involves cleansing skin. protect from sunlight and high temperatures ■ Side effects include increase in vaginal discharge.
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. 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. 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. 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. Davis.GYN BASICS Copyright © 2006 by F. instruct patient to check for presence of string monthly ■ Teach patient the following reportable warning signs 14 . A.
however. 15 Signs of IUD complications: Period late (pregnancy) Abdominal pain (infection) Infection Not feeling well (infection) String missing (IUD expelled) Types 1.Copyright © 2006 by F. 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. infection. Copper IUD contains no hormones. incomplete tube closure. and/or clipped ■ Complications may include bleeding. injury to adjacent organs. T-shaped hormone-releasing (levonorgestrel) device placed in the uterus to prevent pregnancy for up to 5 years 2. if pregnancy occurs. A. 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. preventing passage of ovum ■ Low failure rate. or complications from anesthesia GYN BASICS . cauterized. Davis. may be ectopic Tubal Ligation (Incisional Method) ■ Performed in a hospital or outpatient surgical unit under general anesthesia ■ Fallopian tubes cut.
causing scar tissue to grow in approximately 3 months ■ Performed in physician’s office or outpatient procedure lab with local anesthetic to cervix ■ Follow-up hysterosalpingogram performed at 3 months to ensure both tubes have been blocked. Davis. ectopic pregnancy. alternate method of birth control used until tube status verified ■ Complications may include incorrect placement requiring second or operative procedure. 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. Hysteroscopic Tubal Sterilization (Nonincisional method) ■ Microinserts placed into the opening of the fallopian tubes. A. 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 16 .GYN BASICS Copyright © 2006 by F. infection.
m. friable vaginal mucosa • Vaginal dryness and irritation • Dyspareunia ■ Other Systemic Symptoms • Sleep disturbance • Mood swings • Memory loss • Skin changes • Hair thinning GYN BASICS . Davis.Copyright © 2006 by F. to 4 p.m. 17 Early Detection of Colorectal Cancer ■ ■ ■ ■ ■ Screening starting at age 50 (ACOG. annually after age 40 Menopause ■ Cessation of menses with amenorrhea for 12 months ■ Symptoms ■ Vasomotor symptoms • Hot flushes • Night sweats ■ Urogenital symptoms • Thin. 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. and tanning beds ■ Perform self-evaluation of the skin. report suspicious lesions ■ Thorough skin exam every 3 years age 20 to 39. A.
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. A.GYN BASICS Copyright © 2006 by F. 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 18 . 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. Davis.S.
and fetal cardiac activity ■ Validates location of pregnancy (intrauterine versus ectopic) ANTEPARTUM . Davis. A. 19 Establishing Pregnancy ■ Pregnancy may be assumed based on the presence of certain signs and symptoms Presumptive signs are subjective and recorded under the history of present illness ■ Probable and positive signs of pregnancy are objective and recorded as physical assessment findings Presumptive Amenorrhea Breast tenderness Quickening Nausea/ Vomiting Urinary frequency Probable ■ Positive pregnancy test ■ Uterine enlargement ■ Hegar’s sign (softening of lower uterine segment) ■ Goodell’s sign (softening of cervix) ■ Chadwick’s sign (bluish hue to cervix/vagina) ■ Braxton Hicks contractions Positive Fetal heart beat auscultated Fetal movement palpated per practitioner Ultrasound of gestation ■ Urine pregnancy test ■ Reacts with human chorionic gonadotropin (hCG) ■ Performed on first voided urine sample of the day. fetal pole.Copyright © 2006 by F. 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.
ANTEPARTUM Copyright © 2006 by F. pregnancy continues for 40 weeks or 280 days 1st trimester 2nd trimester 3rd trimester conception until 12 weeks’ gestation 13 weeks until 27 weeks’ gestation 28 weeks until 40 weeks’ gestation 20 . …………………… estimated date of confinement ■ EDB. …………………… estimated date of birth Naegele’s Rule ■ Formula used to estimate date of delivery ■ Count back 3 months and add 7 days to the last normal menstrual period (LNMP) reported by the patient Example: The patient states that her LNMP was April 20th April is the 4th month 20th day 3 months 1st month 7 days 27th day The baby is estimated to be due on January 27th of the following year Trimesters of Pregnancy Normally. 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. A. …………………… estimated date of delivery ■ EDC. Davis.
Copyright © 2006 by F. A. either spontaneous or induced Number of living children ANTEPARTUM . Davis. 21 Schedule of Prenatal Visits (low-risk pregnancy) ■ Monthly until 28 weeks’ gestation ■ Biweekly from 28 weeks until 36 weeks ■ Weekly from 36 weeks until delivery Prenatal Health History Performing a thorough health history in the prenatal period is essential to planning nursing care and identifying highrisk women. ■ 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.
but her daughters were both born a month early. Davis. 3 children at home. She reports that her son was born on his due date. 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). ■ Sexual history ■ Number of sexual partners ■ Sexually transmitted infections ■ Sexual abuse ■ Methods of contraception ■ Condom use ■ Social history ■ Use of recreational drugs ■ Smoking ■ Domestic abuse ■ Educational level/ability to read ■ Economic status ■ Type of health insurance ■ Need for community referrals • Transportation • Nutrition • Medications 22 . Documentation Example 1: The prenatal client states having three children at home. She states that she lost a baby in her second month. G: 5 (currently pregnant.ANTEPARTUM Copyright © 2006 by F. A. pregnancies ended before 20 weeks are not counted as “P” in this method.
Davis.Copyright © 2006 by F. 23 Physiological Changes in Pregnancy Heart rate ↑ Cardiac output ↑ Blood volume ↑ Blood pressure * Systemic vascular resistance ↓ *slight↓ with return to baseline by 3rd trimester Stroke volume ↑ Red blood cells ↑ Hemoglobin ↓ Hematocrit ↓ White blood cells ↑ Glomerular filtration rate ↑ ↑ Increase ↓ Urine output ↑ Decrease ↔ Basal metabolic rate ↑ No change Respiratory rate ↔ Hormonal Changes in Pregnancy Hormone Estrogen ↑ ↑ ↑ ↑ ↑ ↑ Functions Increase uterine muscle mass Increase blood flow to uterus Prepare breasts for lactation Relax venous walls Inhibit uterine contractions Stimulate estrogen/progesterone production Discourage uterine contraction Remodeling of collagen Maturation of breast ducts/alveoli Stimulate lactation Insulin antagonist Allow adequate glucose for fetal demand Progesterone Human chorionic gonadotropin (hCG) Relaxin Prolactin Human placental lactogen ANTEPARTUM . A.
and body mass index (BMI) ■ Obtain urine specimen and test for presence of: Substance Glucose Protein Expected Finding Negative/Trace Negative/Trace ■ Auscultate fetal heart tones ■ Measure fundal height in centimeters from symphysis pubis to the top of the fundus ■ Uterine size increases in pregnancy in a predictable pattern and is measured to gauge fetal growth ■ Fundal height that is lagging or greater than expected should be further investigated Weeks’ Gestation 12 16 20 21–36 Fundal Height Just above symphysis pubis Halfway between symphysis pubis and the umbilicus At the umbilicus Fundal height generally matches weeks gestation in centimeters EXAMPLE: Fundal height at 28 weeks should be approximately 28 cm. weight. 24 . Davis. A.ANTEPARTUM Copyright © 2006 by F. 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.
A. (2003). A. ■ Provide appropriate education for gestational age ■ Discuss procedure for lab testing ANTEPARTUM . Philadelphia: F Davis.Copyright © 2006 by F. Case Study Approach. Nursing Health Assessment: A Critical Thinking.) . 25 Fundal height. p 736. (From Dillon PM. Davis.
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. Davis.000–400.000 mm3 Negative Negative 1:8 Immune AA. O Negative/Positive Negative 11. A.000 mm3 5. unaffected Negative Negative Normal cytology 26 .ANTEPARTUM Copyright © 2006 by F.5 mg/dL 33% 150. B. AB.000–12.
27 Diagnostic Testing in Early Pregnancy Diagnostic Test Ultrasound Performed throughout pregnancy Clinical Applications: ■ Confirm and date pregnancy ■ Verify pregnancy location ■ Detect fetal cardiac activity ■ Measure fetal growth ■ Detect fetal anomalies ■ Measure amniotic fluid index ■ Determine fetal position ■ Determine placental position ■ Measure cervical length ■ Adjunct to invasive procedures Chorionic villi sampling (CVS) Performed at 10–12 weeks Clinical Application: ■ Chromosomal analysis Amniocentesis Performed throughout pregnancy Clinical Applications: ■ Chromosomal analysis is desired ■ Measure AFP ■ Measure bilirubin level ■ Determine lung maturity ■ Lecithin/Sphingomyelin Ratio (L/S Ratio) ■ Phosphatidylglycerol (PG) ■ L/S Ratio of 2:1 and positive PG indicative of fetal lung maturity Maternal Serum Triple Screen (tests maternal serum for AFP.Copyright © 2006 by F. A positive result suggests the need for further testing (Continued text on following page) ANTEPARTUM . and estriol) Nursing Considerations Position to avoid supine hypotension. hCG. 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. folded towel under right hip if supine Review blood type. A. Davis.
frequent meals Eat crackers before rising Avoid pungent odors.ANTEPARTUM Copyright © 2006 by F. Diagnostic Test Performed at 15–18 weeks Clinical Applications: ■ Serum screen for neural tube defects/ Down syndrome Nursing Considerations Results adjusted according to documented gestational age. presence of diabetes/multiple gestation. and weight. 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. Davis. maternal age. A. race. causing pregnancy associated discomforts ■ Offer suggestions to lessen discomforts ■ Teach patient to report symptoms that may indicate a potential complication (in red) Discomfort Urinary frequency Patient Education Related to uterine position/weight Encourage frequent emptying of bladder Discourage limiting oral fluids Report burning or pain with urination Related to elevated hormone levels Encourage small. spicy or greasy food Discuss limited time frame for nausea (subsides around 12 weeks’ gestation) Report excessive vomiting (Continued text on following page) Nausea and vomiting 28 .
Davis. A. green/yellow nasal discharge. or frequent nosebleeds Leukorrhea Breast discomfort Fatigue Nasal stuffiness/ epistaxis ANTEPARTUM . suicidal thoughts Related to vasocongestion of mucous membranes Avoid tampon use and douching Wear peri-pad to absorb discharge Encourage cotton underwear Report vaginal discharge with an odor or color. or 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. 29 Education in the Early Prenatal Period (Cont’d) Discomfort Emotional lability Patient Education Related to hormone changes Discuss normalcy of emotional changes with patient and partner Ambivalence normal in first trimester Report constant crying. inability to care for self.Copyright © 2006 by F. vaginal bleeding.
ANTEPARTUM Copyright © 2006 by F. Teratogen Exposure Teratogens are substances that are harmful to the developing fetus. advise patient to avoid exposure. illness to primary health-care provider Infections causing serious harm to fetus: Toxoplasmosis Other (hepatitis B) Rubella Cytomegalovirus Herpes simplex virus (HSV) Avoid exposure to: Mercury Radiation Lead Other environmental toxins Recreational Discourage alcohol use Encourage patient to stop smoking Refer to smoking cessation classes Assess use of illicit drugs Refer to addiction counselors Discuss the role of drug screening Discuss adverse effects to fetus OTC/Herbal Caution patient to discuss use of all OTC/herbal medications with primary health-care provider Prescription List all medications prescribed since LNMP on prenatal record Investigate drug classification in drug guide book Inform primary health-care provider of drug list Record drugs/dosages on prenatal record Environmental Drugs 30 . Teratogen Viruses Patient Education Avoid contact with ill persons Report fever. rash. A. Davis.
A.Copyright © 2006 by F. Davis. human fetal risk not demonstrated Animal study demonstrates risk No adequate study in humans Evidence of human risk Weigh risk/benefit ratio of drug Definite fetal risk Contraindicated Source: U. 31 Pregnancy Classification of Medications Drug Class A B C D X Pregnancy Safety No evidence of fetal risk No animal risk demonstrated.S. Food and Drug Administration Nutrition ■ ■ ■ ■ ■ ■ Inquire about dietary practices Gather 24-hour diet recall Suggest an addition of 300 healthy calories per day Encourage daily prenatal vitamin with 400 g folic acid Suggest 6–8 glasses of water daily Encourage to follow food pyramid in daily choices ANTEPARTUM .
S. KEY Fat (naturally occurring and added) Sugars (added) These symbols show fats and added sugars in foods Fats. A.Copyright © 2006 by F. (From U. Davis. Department of Agriculture and Department of Health and Human Services. pasta and grain group 6-11 servings Food Pyramid.) 32 .oils and sweets Use sparingly Dairy group 2-3 servings Protein group 2-3 servings Vegetable group 3-5 servings Fruit group 3-5 servings ANTEPARTUM Bread. cereal.
Davis. 33 Weight Gain in Pregnancy ■ Recommended weight gain depends on prepregnancy weight/BMI Prepregnant Weight Normal Overweight Underweight Recommended Weight Gain 25–35 pounds 15–25 pounds 28–40 pounds ■ Assess and document the pattern of weight gain Trimester 1st 2nd & 3rd Suggested Weight Gain 1–4 pounds total 0.Copyright © 2006 by F.5–1 pound per week Exercise in Pregnancy ■ Physical activity in pregnancy is recommended unless contraindicated by medical complications ■ Avoid sports with potential for abdominal trauma or falls ■ Avoid overheating and supine positioning ■ STOP exercise if experiencing ■ Vaginal bleeding ■ Cramping ■ Leaking of amniotic fluid ■ Decreased fetal movement ■ Dizziness ■ Headache ■ Chest pain ■ Calf pain ■ Dyspnea ANTEPARTUM . A.
ANTEPARTUM Copyright © 2006 by F. Davis. A. Sexuality in Pregnancy ■ Sex not restricted in pregnancy unless risk factors exist for bleeding or preterm labor ■ Discuss expected changes in sexuality ■ Change in libido ■ Body image changes ■ Braxton-Hicks contractions with orgasm ■ Comfortable positioning for intercourse Warning Signs During Pregnancy Patient should be instructed to notify primary health-care provider if experiencing any of the following symptoms: Warning Sign Vaginal bleeding Possible Cause Abortion Placenta previa Abruptio placentae Preterm labor Premature rupture of amniotic fluid Incontinence of urine Urinary tract infection Pregnancy-induced hypertension (PIH) Pregnancy-induced hypertension (PIH) Preterm labor Pregnancy-induced hypertension (PIH) Fetal demise Infection Hyperemesis gravidarum Leakage of vaginal fluid Dysuria Headache Altered vision Blurred vision Flashes of light Abdominal cramping Severe epigastric pain Decreased fetal movement Elevated temperature Persistent vomiting 34 .
p 739.A. Davis. (2003).Copyright © 2006 by F. 35 Nursing Care for Return Prenatal Visits ■ Measure pulse and blood pressure (BP) ■ Compare BP to initial reading (measured in the same position at each visit) ■ Measure weight and compare to last reading ■ Note total weight gain ■ Note pattern of weight gain ■ Obtain urine specimen and test for protein and glucose ■ Measure fundal height ■ Determine fetal position ■ Perform Leopold’s Maneuver • Palpate fetal body part in fundus (A) • Palpate for fetal back (B) • Palpate for presenting part (C) • Palpate for attitude of presenting part (D) Leopold’s Maneuver. ANTEPARTUM . Case Study Approach. (From Dillon PM. A. Nursing Health Assessment: A Critical Thinking.) . Philadelphia: F Davis Company.
(LSA = left sacral anterior. LMA = left mentum anterior. (2003). LOP = left occiput posterior. ■ Place Doppler on maternal abdomen over fetal back to monitor fetal heart tones (FHT) Placement of Doppler.) .ANTEPARTUM Copyright © 2006 by F. ROA = right occiput anterior. p 737. LOA = left occiput anterior. A. ROP = right occiput posterior. Nursing Health Assessment: A Critical Thinking. Davis. Philadelphia: F Davis Company. Case Study Approach. ■ ■ ■ ■ ■ Record presence of fetal movement Assess for presence of edema/deep tendon reflexes Record symptoms since last visit Discuss procedure for diagnostic testing Provide patient education appropriate for gestational age 36 . RSA = right sacral anterior) (From Dillon PM.A. RMA = right mentum anterior.
drink. 37 Diagnostic Tests 1-hour glucose screen Performed at 24–28 weeks Nursing Considerations Administer 50 g glucose load Patient should not eat. Davis.Copyright © 2006 by F. A. or smoke during the test Serum sample drawn in 1 hour EXPECTED RESULT 140 mg/dL Clinical Application Detection of gestational diabetes Group B vaginal culture Performed between 35–37 weeks Clinical Application Positive culture treated with antibiotics in labor to prevent newborn transmission Fetal fibronectin (fFN) Performed between 22 and 35 weeks in women at high risk for preterm labor Clinical Application Negative predictive value for preterm labor Antibody screen Performed at 28 weeks in Rh negative women Explain test to patient Collect vaginal/rectal specimen EXPECTED RESULT Negative NO intercourse 24 hours prior to exam Cervical/posterior fornix specimen EXPECTED RESULT Negative Clinical Application Detects presence of positive antibodies in serum of Rh negative women Administer Rh (D antigen) immune globulin at 28 weeks to prevent antibody formation if Rh negative and antibody screen negative EXPECTED RESULT Negative ANTEPARTUM .
Davis.ANTEPARTUM Copyright © 2006 by F. A. if indicated Explore preparing for the newborn ■ Breastfeeding ■ Circumcision ■ Choosing a pediatrician ■ Car seat safety ■ Discuss the discomforts associated with late pregnancy and teach reportable symptoms (in red) 38 . if indicated Epidural anesthesia class. 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. 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.
Copyright © 2006 by F. fade after pregnancy Moisturizers decrease itching. Davis. or bleeding Instruct patient how to palpate contractions Labor should occur after 38 weeks gestation Teach patient to differentiate between true and false labor Report signs of preterm labor Related to decreased venous return due to pressure of the gravid uterus Rest in lateral recumbent position Elevate legs when sitting Continue with 6–8 glasses water daily Report generalized edema Caused by increased venous stasis related to pressure from the gravid uterus Wear pregnancy support hose Avoid lengthy standing Change positions frequently Report pain. but will not prevent striae Report body rashes Braxton-Hicks contractions (false labor contractions) Ankle edema Varicose veins Faintness Related to round ligament stretching as uterus grows Change positions slowly Encourage good body mechanics Report abdominal cramping. constant pain. redness. sharp lower abdominal pain) Patient Education Related to hormone changes in pregnancy. A. 39 Discomfort Changes in pigmentation Linea nigra (pigmented line from umbilicus to pubic bone) Chloasma (deeper facial pigment) Striae (stretch marks) Round ligament pain (occasional. localized heat to legs Related to hemodynamic changes Avoid sudden position change Avoid long periods without eating Avoid lying supine Report loss of consciousness (Continued text on following page) ANTEPARTUM .
A. localized heat Related to decreased gastric motility. frequent meals Lightening will lessen symptoms Report dyspnea with rest Related to fetal movement. redness. iron supplement may worsen constipation Increase dietary fiber and water intake Encourage exercise Discourage enemas and laxatives Report painful or bleeding hemorrhoids Backache Shortness of breath Insomnia Leg cramps Constipation Hemorrhoids 40 . nocturia Teach relaxation techniques Encourage side-lying with pillow support Warm milk/shower before sleep Related to uterine pressure on the pelvic nerves or calcium imbalance Review daily calcium intake Teach signs of deep vein thrombosis Report pain. Patient Education Related to increased pressure on abdominal organs and sphincter relaxation Encourage small.ANTEPARTUM Discomfort Heartburn Copyright © 2006 by F. Davis. 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.
Davis. 41 Pregnancy Complications Vaginal Bleeding (before 20 weeks’ gestation) May be related to spontaneous abortion. or gestational trophoblastic disease Spontaneous Abortion Loss of pregnancy before viability ■ Clinical Findings ■ Vaginal spotting (may pass clots) ■ Abdominal cramping ■ Cervical changes ■ Fetal heartbeat may be present or absent Ectopic Pregnancy Products of conception implant outside the uterus ■ Clinical Findings ■ Vaginal spotting ■ hCG lower than expected for dates ■ Lower abdominal pain ■ Ultrasound findings: absence of intrauterine gestational sac ■ If rupture occurs: • Positive Cullen’s sign (periumbilical bluish hue) • Shoulder pain • Signs of shock Gestational Trophoblastic Disease Abnormal proliferation of trophoblastic cells without viable fetus ■ Clinical Findings ■ Vaginal spotting (dark brown) ■ Fundal height greater than expected for dates ■ hCG greater than expected for dates ■ Excessive nausea and vomiting ■ Absence of fetal heart tones ■ Ultrasound findings: Snowflake-like clusters. absence of fetus ANTEPARTUM . ectopic pregnancy. A.Copyright © 2006 by F.
■ Nursing Care (vaginal bleeding/early pregnancy) ■ Monitor amount of bleeding ■ Assess vital signs ■ Observe for signs of shock ■ Auscultate for fetal heart tones (FHTs) ■ Collect passed tissue/clots ■ Monitor patient comfort ■ Check blood type and Rh factor ■ Administer Rh(D) immunoglobulin if indicated ■ Initiate IV fluids as ordered ■ Report lab/ultrasound findings ■ Attend to patient’s emotional needs Vaginal Bleeding (after 20 weeks’ gestation) May be related to placenta previa or abruptio placentae Placenta Previa Low-lying position of placenta in the uterus that partially or completely covers the cervical os ■ Clinical Findings ■ Painless bright red vaginal bleeding ■ Bleeding may be reported after intercourse ■ Uterine tone soft upon palpation ■ Interventions dependent on amount of bleeding and labor status ■ If partial placenta previa is noted in early gestation. repeat ultrasound later in pregnancy (may demonstrate absence of previa as uterus grows) ■ If labor active and os is covered. conservative management • Patient Teaching (Conservative Management) – No tampon use – No sexual intercourse – Monitor and report bleeding – Patient instructed to report placenta placement when admitted to hospital – Cesarean preparation class – Count fetal movements 42 . Davis. cesarean birth necessary ■ If bleeding controlled and labor absent.ANTEPARTUM Copyright © 2006 by F. A.
Davis. A. 43 Internal os Blood External os A Membranes Internal os Blood External os B Membranes Internal os Blood External os Placenta previa.Copyright © 2006 by F. C ANTEPARTUM .
Abrupto Placentae ■ Clinical Findings ■ Abdominal pain (sudden onset. intense and localized) ■ Fundus firm.ANTEPARTUM Copyright © 2006 by F. A. Davis. 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 patient’s emotional needs Hyperemesis Gravidarum Intractable vomiting in pregnancy with resultant weight loss and dehydration ■ Nursing Care ■ Assess vital signs ■ Observe for signs of dehydration ■ Review electrolytes ■ Access IV site as ordered ■ Record fetal heart tones ■ Record intake and output ■ Record daily weight ■ Check urine for ketones ■ Administer antiemetics as ordered 44 .
Davis. may be partial or complete 45 Partial separation (concealed hemorrhage) Partial separation (apparent hemorrhage) Abruptio placentae. Complete separation (concealed hemorrhage) ANTEPARTUM . Abruptio Placentae Premature separation of the placenta. A.Copyright © 2006 by F.
the nitrazine paper will change from yellow to blue ■ Perform vaginal exam to determine dilation and effacement of the cervix ■ Position side-lying ■ Initiate IV fluids as ordered ■ Administer corticosteroid to mother • Accelerates maturity of fetal lungs • Most benefit 24 hours after administered ■ Initiate tocolytic therapy 46 . Davis.ANTEPARTUM Copyright © 2006 by F. Preterm Labor Onset of regular labor before the 37th completed week of gestation ■ Clinical Findings ■ Rhythmic lower abdominal cramping ■ Complaints of backache ■ Increased vaginal discharge ■ Downward pelvic pressure ■ Leaking of amniotic fluid ■ Vaginal spotting ■ Cervical effacement/dilation ■ Shortening cervical length ■ Nursing Care ■ Determine gestational age ■ Assess uterine tone ■ Auscultate fetal heart tones and apply EFM ■ Obtain vaginal/urine cultures ■ Assess for leaking amniotic fluid • Ferning—Microscopically. amniotic fluid will resemble the leaves of a fern plant • Nitrazine paper—Due to the alkaline nature of amniotic fluid. A.
Copyright © 2006 by F. A. 47 Tocolytic Medication Nursing Precautions (Closely monitor maternal and fetal tolerance to medication) ■ Monitor for respiratory depression ■ Assess deep tendon reflexes ■ Watch level of consciousness ■ Monitor intake and output ■ Assess fetal heart tones ■ Monitor for contractions ■ Auscultate lungs ■ Report magnesium sulfate levels ■ Monitor for hypotension ■ Assess for tachycardia ■ Assess patient for tremors ■ Assess for pulmonary edema ■ Screen glucose/potassium ■ Assess for cardiac arrhythmias and chest pain ■ Monitor fetal heart tones ■ Monitor contractions ■ May lead to premature closure of ductus arteriosus ■ Monitor for hypotension ■ Assess for tachycardia Magnesium Sulfate ANTIDOTE: Calcium gluconate at bedside β-adrenergic agonist terbutaline ritodrine Prostaglandin antagonist indomethacin Calcium channel blockers nifedipine Preeclampsia Hypertensive disorder of pregnancy with multisystem involvement ■ Clinical Findings ■ Blurred or altered vision ■ Epigastric pain ■ Headache ■ Edema ■ Proteinuria ■ Hyperreflexia ■ Hypertension ANTEPARTUM . Davis.
■ Nursing Care ■ Closely monitor vital signs ■ Assess deep tendon reflexes ■ Dipstick urine for protein ■ Record presence of edema ■ Palpate tone of fundus ■ Auscultate fetal heart rate and apply EFM ■ Monitor patient comfort ■ Collect 24-hour urine ■ Place patient in side-lying position ■ Keep environment quiet and dim ■ Institute seizure precautions • Side rails up and padded • Bed in low position • Suction equipment available at bedside • Oxygen available at bedside ■ Initiate IV fluids as ordered ■ Monitor intake and output ■ Initiate medications as ordered Drug Therapy Magnesium sulfate Anti-hypertensives Nursing Precautions See precautions listed under preterm labor for magnesium sulfate Administer slowly Closely monitor for hypotension Eclampsia ■ Clinical Findings ■ Worsening of symptoms of preeclampsia ■ Seizure activity HELLP Syndrome ■ Clinical Findings ■ Worsening symptoms of preeclampsia ■ Malaise 48 . Davis.ANTEPARTUM Copyright © 2006 by F. A.
Davis. 49 ■ Epigastric pain ■ Nausea/vomiting ■ Laboratory findings: Hemolysis Elevated Liver enzymes Low Platelets Gestational Diabetes Glucose intolerance that is first recognized in pregnancy ■ Clinical Findings ■ Polyuria ■ Polydipsia ■ Polyphagia ■ Fatigue ■ Blurred vision ■ Glucosuria ■ Recurrent yeast infections ■ Slow healing wounds ■ Abnormal glucose results • 1-hour glucose 140 mg/dL • Abnormal 3-hour glucose tolerance test: 2 out of 4 values elevated FBS 1-hour 2-hour 3-hour 95mg/dL 180mg/dL 155mg/dL 140mg/dL ■ Outpatient Management ■ Dietician consult for ADA diet instructions ■ Discuss pathophysiology of gestational diabetes with patient ■ Demonstrate home glucose monitoring ■ Review range for glycemic control ■ Demonstrate logging of glucose results ■ Discuss role of exercise in glycemic control ■ Demonstrate urine ketone testing ANTEPARTUM .Copyright © 2006 by F. A.
ANTEPARTUM Copyright © 2006 by F. FHR acceleration with fetal movement is reassuring and a sign of fetal well being ■ Place patient in a Semi-Fowler’s or side-lying position ■ Record vital signs and apply electronic fetal monitor ■ Record baseline fetal heart rate and monitor FHR pattern for 20–30 minutes ■ Patient marks paper with each perceived fetal movement ■ NST may take longer with absence of accelerations. A. ■ 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. 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. Davis. test stimulates contractions) 50 .
Davis. A. 51 ■ ■ ■ ■ Place patient in side-lying position Record vital signs Apply EFM and record baseline fetal heart rate for 20 minutes Stimulate uterine contractions until three contractions occur within 10 minutes lasting 40 seconds each ■ Contractions can be stimulated with ■ Nipple stimulation or ■ IV Oxytocin per hospital protocol ■ Document FHR response to contractions EXPECTED FINDING: NEGATIVE Three contractions that last at least 40 seconds within 10 minutes without the presence of late or significant variable decelerations Biophysical Profile (BPP) ■ Ultrasound exam observing four specific fetal criteria ■ Nonstress test included as a fifth parameter ■ Scoring of Biophysical Profile (BPP) Parameter Measured Fetal tone Fetal breathing Gross fetal movement Amniotic fluid volume FHR reactivity per NST Expected Findings (within 30 minutes) Active flexion/extension One or more episodes lasting 30 seconds Three or more discrete movements Single vertical pocket 2 cm Reactive Score 2 2 2 2 2 EXPECTED FINDING: NEGATIVE BPP Score of at least 6/8 if NST omitted BPP Score of at least 8/10 if NST included ANTEPARTUM .Copyright © 2006 by F.
triage.INTRAPARTUM Copyright © 2006 by F. the nurse should: ■ Determine reason for admission ■ Gather patient history ■ Review prenatal health record ■ Perform a physical exam Prenatal History ■ ■ ■ ■ ■ ■ ■ ■ ■ Estimated date of delivery Current gestational age Complications in pregnancy Results of laboratory tests and ultrasounds Medications used in pregnancy Presence of vaginal discharge or bleeding Amniotic fluid status Presence of fetal movement Onset and pattern of contractions Obstetrical History Type of births ■ Vaginal ■ Instrumentation ■ Episiotomy ■ Length of labor ■ Cesarean ■ Reason for cesarean ■ Document type of incision • Low-transverse • Classical ■ Complications of birth ■ Neonatal outcomes Medical History ■ ■ ■ ■ Chronic health problems Current medications Time and description of last oral intake Allergies to food/medicine 52 . and birth ■ Upon admission to labor and delivery. A. Davis. Intrapartum ■ Patients present to labor and delivery for medical procedures.
53 Surgical History ■ Complications with anesthesia ■ Date/reason for surgery Perform a Physical Exam ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Assess maternal vital signs Collect urine specimen for protein and glucose Assess for presence of edema Assess deep tendon reflexes Perform Leopold’s maneuver to determine fetal position Assess fetal heart rate (FHR) Measure fundal height Determine the frequency.Copyright © 2006 by F. duration. Davis. A. and intensity of contractions Determine the stage and phase of labor Assess cervical changes ■ Dilation (0 to 10 cm) ■ Effacement (0–100%) ■ Station (Level of presenting fetal part in relation to the ischial spines of the maternal pelvis) Iliac crest Iliac crest Ischial spine Ischial tuberosity –5 –4 –3 –2 –1 0 1 2 3 4 5 Ischial spine Ischial tuberosity Perineum Station INTRAPARTUM .
Davis. ■ Count FHR between. 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. Case Study Approach. and amount of bloody show ■ Check status of amniotic membranes ■ Intact ■ Bulging ■ Ruptured (note color.A. INTRAPARTUM ■ Note presence. amount.Copyright © 2006 by F. A. 737. Nursing Health Assessment: A Critical Thinking. Philadelphia: F Davis. p. color.) . during. (2003). (From Dillon PM. and immediately following a contraction ■ Note both rate and rhythm of FHR ■ Frequency of auscultation based on: ■ Phase/stage of labor ■ Hospital protocol 54 .
A. 55 ■ Risk status ■ Labor interventions ■ Physician orders Stage/Phase of Labor Stage Stage Stage Stage 1: Latent phase 1: Active phase 1: Transition 2 Frequency of FHR Monitoring Every Every Every Every 30–60 minutes 15–30 minutes 5–15 minutes 5–15 minutes Continuous Fetal Monitoring Monitored with external or internal fetal monitoring External Fetal Monitoring (EFM) ■ ■ ■ ■ ■ Encourage patient to void before applying EFM Test internal circuitry of EFM Place ultrasound transducer over fetal back Place toco transducer over uterine fundus Monitor for 20–30 minutes on admission Ultrasound transducer Toco transducer (FHR) (uterine contractions) External fetal monitor INTRAPARTUM . Davis.Copyright © 2006 by F.
Davis. INTRAPARTUM Internal Fetal Monitoring ■ Indicated when EFM not providing adequate FHR or contraction tracing ■ May be implemented only after amniotic sac is ruptured ■ FHR measured by spiral electrode attached to presenting part ■ Uterine tone measured by intrauterine pressure catheter (IUPC) ■ Resting tone of uterus averages 5–15 mmHG ■ Contraction tone of uterus averages 50–85 mmHG Scalp electrode Catheter Internal fetal monitor Evaluating the Baseline Fetal Heart Rate ■ ■ ■ ■ ■ Normal baseline FHR is 110–160 BPM Evaluated between contractions over 10 minutes Documented as a range Does not include accelerations or decelerations Influences on the fetal heart rate ■ Central nervous system Fetal sleep ↓ variability of FHR Fetal movement ↑ variability of FHR ■ Autonomic nervous system Sympathetic branch (↑ FHR) Parasympathtic branch (↓ FHR) ■ Baroreceptors respond to ↓ blood pressure with subsequent ↓ FHR ■ Chemorecptors sense ↓ oxygen and ↑ FHR 56 .Copyright © 2006 by F. A.
A. Davis. (Top: fetal heart rate. bottom: contractions.Copyright © 2006 by F. 57 Normal fetal heart rate.) INTRAPARTUM .
Davis. terbutaline. A. albuterol) ■ BRADYCARDIA ■ FHR less than 110 BPM for 10 minutes ■ Possible cause: • Vagal stimulation • Hypoxia • Anesthetic agents ■ VARIABILITY ■ Fluctuations in FHR over time ■ Important indicator of fetal well-being ■ Sensitive to hypoxia and changes in Ph ■ Short-term variability (STV) • Beat-to-beat changes in FHR • Documented as present or absent • Most accurate with internal FHR monitoring ■ Long-term variability (LTV) • Pattern of fluctuations in FHR baseline (Expected pattern highlighted in blue) Long-Term Variability Absent (0–2 BPM) Minimal (3–5 BPM) Average (6–10 BPM) Moderate (11–25 BPM) Marked ( 25 BPM) Possible Cause Maternal medication Fetal sleep Fetal hypoxia Adequate fetal oxygenation Early sign of mild fetal hypoxia Fetal stimulation 58 . INTRAPARTUM Changes to Baseline Fetal Heart Rate ■ TACHYCARDIA ■ FHR greater than 160 BPM for 10 minutes ■ Possible cause: • Infection/hyperthermia • Fetal hypoxia • Maternal medications (ex.Copyright © 2006 by F.
Copyright © 2006 by F. (Top: fetal heart rate. A. Davis. Late. bottom: contractions. 59 Changes in Fetal Heart Rate ■ The nurse interprets changes to baseline FHR as reassuring or nonreassuring ■ The nurse must act on nonreassuring FHR patterns ■ ACCELERATIONS ■ Sudden increase of fetal heart rate over baseline ■ Indication of fetal well-being ■ Reassuring pattern ■ Possible cause: Fetal movement/stimulation Acceleration.) ■ DECELERATIONS (Early. Variable) ■ EARLY DECELERATION • Decrease in FHR occurring with contractions • Onset occurs before the contraction peak • Recovery to baseline rate occurs by contraction end • Commonly seen in active phase of first stage of labor • Mirrors the contraction • Usually benign finding • Continue to monitor FHR pattern for nonreassuring patterns • Possible cause: Fetal head compression INTRAPARTUM .
INTRAPARTUM Early deceleration. A. (Top: fetal heart rate. bottom: contractions. bottom: contractions.Copyright © 2006 by F.) 60 . (Top: fetal heart rate. Davis.) ■ 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.
) INTRAPARTUM . and maternal temperature – Verify that fluid is exiting uterus Variable deceleration. A. 61 • Etiology: decreased uteroplacental blood flow/oxygen delivery related to – Maternal supine hypotension – Hypertension – Hyperstimulation of uterus – Diabetes – Preeclampsia – Anemia – Chronic maternal disease ■ VARIABLE DECELERATIONS • Decrease in FHR occurring without regard to contractions • Can range from mild to severe • May be persistent or occasional • Shaped like a “V” or “W” • Onset variable • Nonreassuring variable decelerations – Repetitive and/or deep decrease in FHR – Associated with minimal variability – Prolonged with slow return to baseline FHR • Possible causes: – Cord prolapse – Umbilical cord compression • Intervention: AMNIOINFUSION may be performed to try to relieve cord compression – Infusion of warmed normal saline into uterus via sterile catheter – Monitor FHR.Copyright © 2006 by F. bottom: contractions. (Top: fetal heart rate. contraction status. Davis.
Copyright © 2006 by F. A. Davis.
Nursing Interventions for Nonreassuring FHR Patterns
■ Turn patient to side-lying position ■ Shifts weight of gravid uterus off the inferior vena cava ■ Allows for improved uteroplacental blood flow ■ O2 per mask at 8–10 L/min ■ Improve oxygen delivery to fetus ■ Discontinue IV Oxytocin ■ Decreases uterine contractions, thus improving uteroplacental blood flow ■ Hydrate patient as indicated ■ Corrects identified maternal hypotension ■ Notify primary health-care provider ■ Document findings ■ Document baseline FHR (baseline FHR should be between 110 and 160 BPM) ■ Describe variability ■ Note changes in FHR in relation to contractions ■ Document nursing interventions, effectiveness of interventions and notification of primary health-care provider
■ Frequency ■ Beginning of one contraction to the beginning of the next contraction ■ Documented as range, for example, “every 2–5 minutes” ■ Duration ■ Beginning of the one contraction to the end of the same contraction ■ Documented as a range, for example, “lasting 60–90 seconds” ■ Intensity ■ Palpate uterus both during and after contraction ■ Resting tone palpated between contractions ■ Document intensity of uterine contractions (findings subjective unless monitored with IUPC)
Copyright © 2006 by F. A. Davis.
Intensity Mild Moderate Strong Palpated by nurse Fundus easily indented Requires more pressure to indent fundus Unable to indent fundus
Beginning of contraction I n cr eme n
Interval between contractions
Duration of contraction
Beginning of contraction
Frequency of contractions
Nursing Care of the Laboring Patient
First Stage of Labor: Dilation Divided into Three Phases: Latent, Active, Transition
e re m Dec
Copyright © 2006 by F. A. Davis.
Stage 1: Latent Phase
■ Power: Contractions palpate mild, every 5–10 minutes, lasting 30–45 seconds ■ Psyche: Patient is usually excited about the start of labor ■ Measuring progress in labor: Cervical dilation (0–3 cm) ■ Passageway: Encourage frequent position changes that optimize fetal descent, rotation, and widen pelvic outlet ■ Ambulation (with intact amniotic sac) ■ Squatting ■ Hands and knees position ■ Rocking chair ■ Side-lying ■ Check bladder status and encourage patient to void every 2 hours ■ Nursing considerations ■ Monitor vital signs every 30–60 minutes ■ Fetal heart tones every 30–60 minutes ■ Hydration • Oral fluids as ordered • Monitor intake and output ■ Pain management ■ Pain medication usually avoided until in active labor ■ Techniques for pain management • Hydrotherapy – Shower – Labor tub • Massage – Effluerage: light, circular stroking of gravid abdomen – Counter-pressure to back • Relaxation techniques – Progressive relaxation – Patterned breathing – Soft music and lighting – Distraction
Stage 1: Active Phase
■ Power: Contractions palpate moderate to strong, every 2–5 minutes lasting 40–60 seconds
65 ■ Psyche: Patient may have greater difficulty coping with the pain of contractions ■ Measuring progress in labor: Cervical dilation (4–7 cm) ■ Passageway ■ Encourage frequent position changes ■ Check bladder status and encourage patient to void every 2 hours ■ Nursing considerations ■ Monitor vital signs every 30 minutes ■ Fetal heart tones every 15–30 minutes ■ Pain management ■ Continue with effective techniques used in latent phase ■ Systemic medications to decrease pain perception • Document and report maternal and fetal response to systemic medications • Neonatal side effects related to both dose and timing of administered medication Systemic Pain Medications in Labor Medication Class Opioid analgesics Meperidine Butorphanol fentanyl Nalbuphine Drug Action Reduce pain perception Nursing Considerations Side effect: nausea and vomiting Long-acting active metabolite. A.Copyright © 2006 by F. Davis. may cause withdrawal IV push dosing should be at the beginning of a contraction to limit transfer to fetus No analgesic effect Adjunct drugs Promethazine Hydroxyzine Sedatives Reduce nausea Reduce anxiety Promotes rest with prolonged latent phase May have prolonged depressant effect on neonate INTRAPARTUM . may cause respiratory depression (in the neonate) Caution with women who are opiate dependent.
Copyright © 2006 by F. A. Davis.
■ Epidurals in labor • Oxygen, suction equipment, emergency medications should be at bedside • Document vital signs and monitor fetal heart rate prior to procedure • Encourage patient to void • Administer IV bolus prior to epidural insertion (500 cc to 1000 cc of saline or lactated Ringer’s solution) to prevent maternal hypotension • Position and support patient during insertion of epidural catheter • Note maternal vital signs before and after test dose, then every 5 minutes with administration; thereafter, monitor vital signs and FHR per hospital protocol • Evaluate bladder status every hour and encourage to void; catheterize if unable to void or bladder overdistended • Assess for level of anesthesia • Monitor for comfort with contractions • Monitor progress of labor • Assist with position changes • Report adverse effects Hypotension Pruritis (itching) Pyrexia (fever) Respiratory depression
Stage 1: Transition
■ Power: Contractions palpate strong, every 1.5–3 minutes lasting 45–90 seconds ■ Psyche: Patient may feel a loss of control; provide encouragement to patient ■ Measuring progress in labor Cervical dilation (8–10 cm) Fetal descent (0/ 1 station) ■ Physical changes common with transition ■ Urge to push if presenting part is low ■ Nausea/vomiting ■ Trembling limbs
Copyright © 2006 by F. A. Davis.
■ Beads of sweat on upper lip ■ Increased bloody show ■ Passageway: Activity more restricted, however, encourage positions that promote fetal rotation and descent ■ Squatting ■ Hands and knees position ■ Side-lying ■ Nursing considerations ■ Encourage patient to void ■ Monitor vital signs and fetal heart tones every 5–15 minutes ■ Pain management ■ Continue with effective techniques used in active phase ■ If systemic medications are given, consider amount of time estimated until birth and potential for newborn effects (respiratory depression) ■ Have naloxone hydrochloride (Narcan) available to reverse effects if needed ■ Document maternal and fetal response to medications
Second Stage of Labor: Expulsion
■ 10 cm dilated until the birth of the baby ■ Power: Contractions palpate strong, every 2–3 minutes lasting 60–90 seconds ■ Psyche: Patient may be eager or afraid to push ■ Measuring progress in labor ■ Descent of fetus: from 1 station to crowning ■ Cardinal movements of labor (changes in fetal position that facilitate birth) • Engagement/Descent/Flexion • Internal rotation • Extension • External rotation • Expulsion ■ Passageway ■ Promote effective pushing • Wait for urge to bear down called the “Ferguson reflex” • Discourage prolonged breath-holding • Encourage open glottis pushing
Copyright © 2006 by F. A. Davis.
■ Position for pushing • Squatting • Side-lying • Modified Lithotomy Encourage patient to void Patient may pass stool with pushing Nursing considerations ■ Monitor vital signs every 15–30 minutes ■ Fetal heart tones every 5–15 minutes Pain management per primary health-care provider ■ Pudendal block: Local anesthetic that blocks pudendal nerve to numb lower vagina and perineum for vaginal birth; useful with forcep delivery ■ Local anesthesia to perineum: Numbs perineum for episiotomy/laceration repair Prepare for the birth of the baby ■ Cleanse the perineum ■ Check working order of suction equipment, oxygen, radiant warmer ■ Neonatal resuscitation equipment should be readily available for every delivery ■ Prepare delivery instruments Note precise time of birth Provide immediate care of the newborn ■ Assess airway and suction as needed • Remove excess fluid from infant’s nose and mouth (infants are obligate nose breathers) • If meconium is noted in nose or mouth, endotracheal intubation and suctioning must be performed immediately ■ Assess breathing effort (rate of at least 30 per minute) • If respiratory effort is not observed, gently stimulate infant by tapping sole of foot or stroking the back • Positive pressure ventilate if tactile stimulation does not result in respiratory effort ■ Assess circulation: heart rate 100 BPM ■ Temperature regulation • Dry infant
open lesions. sneeze or vigorous cry Completely pink ■ Assess for abnormalities that may need immediate attention (example: neural tube defects. IM to boost production of clotting factor (needed due to sterile gut at birth) INTRAPARTUM . crying Active motion Cough. extremities blue 2 Greater than 100 Good. encourage skin-to-skin contact with mother ■ Assign Apgar Score at 1 and 5 minutes • Score of 10 possible. or birth injuries) ■ Examine umbilical cord and count number of vessels: 2 arteries and 1 vein. Davis. A. ophthalmic antibiotic ointment (based on hospital protocol) to prevent chlamydial or gonococcal eye infection • Administer vitamin K.Copyright © 2006 by F. 69 • Place infant under prewarmed radiant warmer with temperature probe applied • Remove wet towels and lay infant on warm blankets • Keep temperature of labor room warm • Once infant is stabilized. 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. irregular Some flexion of extremities Grimace Body pink. Score of at least 8 desirable Apgar Score Score Heart Rate Respiratory Effort Muscle Tone Reflex irritability Color 0 Absent Absent Limp No response Blue or pale 1 Less than 100 Slow.
INTRAPARTUM ■ Weigh and measure infant (head.Copyright © 2006 by F. Davis. encouraging skin-to-skin contact ■ Assist with positioning for breastfeeding and bonding 70 . bruising. and abdominal circumference as well as length) ■ Assess skin for lacerations. A. chest. 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.
A. variability. duration. and intensity • Intake and output • Fetal heart tones (baseline. changes) • Cervical dilation and effacement • Vital signs • Patient comfort INTRAPARTUM . 71 Nursing Care with Intrapartum Procedures Induction of Labor ■ Artificial stimulation of uterine contractions to facilitate vaginal delivery ■ Commonly performed in postterm pregnancy ■ Prior to induction of labor the nurse should note ■ Indication for induction ■ Gestational age ■ Bishop’s score ■ Any contraindications for procedure ■ Bishop’s Score ■ Assigned by primary health-care provider prior to induction of labor ■ Higher scores indicate increased likelihood of successful labor induction ■ Parameters of Bishop’s score • Degree of Dilation (1–3 points) • Percent of Effacement (0–3 points) • Station (0–2 points) • Consistency of cervix (0–2 points) • Cervical position (0–2 points) ■ Use of Oxytocin (Pitocin): Hormone that stimulates uterine contractions to induce or augment contractions ■ Assess mother and fetus 20–30 minutes prior to oxytocin administration ■ Prepare and clearly label solution • 10 units of Pitocin into 500–1000 ml of isotonic IV solution • Administer IV piggyback per electronic infusion pump • Started at small dose and gradually increased until contractions every 2–3 minutes (follow hospital protocol) ■ Monitor maternal-fetal tolerance to procedure • Uterine resting tone • Contraction frequency.Copyright © 2006 by F. Davis.
Davis. INTRAPARTUM ■ Monitor for complications of oxytocin (may become evident as dosage increases) • Uterine hyperstimulation (excessive frequency/duration of contractions without uterine relaxation) • Nonreassuring fetal heart rate patterns • If complications become apparent: – Change position to lateral side-lying – Discontinue IV oxytocin – Provide oxygen per mask at 8–10L/min – Increase rate of nonadditive IV solution – Call primary health-care provider ■ Cervical Ripening ■ Facilitates cervical softening. vomiting. contractions. effacement. and fetal status (per hospital protocol) • Report adverse reactions to physician – Hyperstimulation of uterus – Nonreassuring fetal heart tones – Nausea. 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. A. Prepidil Gel) ■ Nursing care • Monitor fetal heart rate and contraction status for 20–30 minutes prior to procedure • Encourage patient to void prior to insertion • Position side-lying position after procedure • Monitoring maternal vital signs. diarrhea • Ensure proper waiting period between cervical ripening and Oxytocin administration ■ Amniotomy ■ Artificial rupture of amniotic sac performed by the primary health-care provider during a vaginal exam to augment contraction frequency and intensity ■ Nursing care • Pad bed to absorb amniotic fluid • Document time of amniotomy 72 .Copyright © 2006 by F.
effacement. INTRAPARTUM . limit patient activity to prevent cord prolapse • Once amniotic sac is ruptured.Copyright © 2006 by F. there is potential for infection – Monitor maternal temperature every 1–2 hours – Limit number of vaginal exams Vaginal Birth After Cesarean (VBAC) ■ Women who have had a previous cesarean birth may be candidates for vaginal birth ■ Previous cesarean uterine incision documented as lowtransverse ■ No contraindications noted to VBAC ■ Physician and surgical team readily available for emergent cesarean birth ■ Patient and physician agree that VBAC is desirable ■ Risks of vaginal birth following cesarean must be explained. 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. Davis. 73 • Document fetal heart tones immediately following amniotomy • Note color and amount of amniotic fluid • Document cervical dilation. A. and fetal presentation • If presenting part is not engaged. station.
Copyright © 2006 by F. INTRAPARTUM ■ Nursing care ■ Closely monitor uterine response to labor ■ Monitor fetal response to labor ■ Initiate IV access ■ Monitor for signs of uterine rupture • Severe abdominal pain • Nonreassuring fetal heart rate patterns • Cessation of uterine contractions • Ascending station of presenting part • Vaginal bleeding • Signs of shock Complications in the Intrapartum Period Prolapsed Umbilical Cord ■ Umbilical cord slips below/wedges next to presenting part ■ May lead to fetal hypoxia due to cord compression ■ Possible cause ■ Rupture of membranes without engaged presenting part ■ Non-cephalic fetal presentation ■ Symptoms ■ Prolonged variable deceleration ■ Pulsating cord palpated upon vaginal exam ■ Visible cord at introitus ■ Nursing actions ■ Stay with patient and call for assistance ■ Apply sterile glove and hold pressure of presenting part off umbilical cord ■ Place patient in Trendelenburg position ■ Notify physician ■ Monitor fetal heart tones ■ Place sterile saline gauze over any exposed cord ■ Prepare patient for cesarean birth 74 . A. Davis.
dentures ■ Perform preoperative teaching ■ Assist significant other to prepare for observation of surgery ■ Administer preoperative medications ■ Continue to monitor vital signs and fetal heart rate ■ Postoperative care ■ Assess respiratory/cardiac status ■ Encourage patient to turn cough and deep breath ■ Assess level of pain and medication needs ■ Monitor intake and output ■ Assess bowel sounds ■ Assess incision ■ Monitor vaginal bleeding and provide pericare ■ Assess vital signs and level of consciousness ■ Assess extremities for circulation ■ Assist with positioning for breastfeeding and holding baby INTRAPARTUM . nail polish. 75 Cesarean Birth ■ Indications for cesarean birth ■ Cephalopelvic disproportion (CPD) ■ Malpresentations ■ Placenta previa/abruption ■ Umbilical cord prolapse ■ Fetal intolerance to labor ■ Maternal medical conditions ■ Preoperative Care ■ Place signed consent on chart ■ Insert urinary catheter ■ Shave prep to the abdomen ■ Remove contact lenses. Davis. A. jewelry. prosthetic device.Copyright © 2006 by F.
Davis.Copyright © 2006 by F. A. POSTPARTUM Postpartum Fourth Stage of Labor First 1–2 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 1–4 hours 76 .
A. 77 ■ ■ ■ ■ Fluid balance Circulation to extremities Comfort/level of consciousness Newborn interaction Postpartum Education ■ Education of the postpartum family is an essential role of the postpartum nurse ■ New skills should be discussed. demonstrated.Copyright © 2006 by F. leave colostrum/breast milk on nipples and expose the breasts to air POSTPARTUM . intact ■ Redness ■ Comfort ■ Breast care (lactating) ■ Patient should wear a supportive bra • Montgomery glands secrete oil to keep nipples supple. or firm ■ Nipple type and integrity ■ Type: Inverted or everted ■ Integrity: Bleeding. cracked. soap should not be used on breasts • After feedings. filling. 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. Davis.
Davis. A. POSTPARTUM ■ Encourage frequent nursing (8–12 feedings in 24 hours) ■ Teach positioning of infant for increased comfort • Side-lying • Football hold • Cradle hold Breastfeeding positions.) 78 .Copyright © 2006 by F. (Used with permission from Ross Products Division Abbott Laboratories Inc.
79 ■ Instruct on proper latch-on • Elicit the rooting reflex by stroking the infant’s lower lip • As the infant’s mouth opens wide. bring the infant to the breast. Davis. (Used with permission from Ross Products Division Abbott Laboratories Inc. break suction by placing one finger by the infant’s mouth and relatch Latch-on. A.Copyright © 2006 by F. mother will express comfort • Incorrect latch-on: clicking noise as infant sucks with nipple pain expressed by mother.) ■ If separated from newborn. breast binder or sports bra ■ No nipple stimulation ■ Do not express breast milk ■ Ice packs/analgesics for engorgement ■ Teach breast self exam (BSE) POSTPARTUM . ensuring both the nipple and part of the areola are in the infant’s mouth • Correct latch-on: infant’s jaws will rhythmically move with an audible swallow. initiate breast pump ■ Breast care (nonlactating) ■ Supportive bra.
A. burp the infant. and hip aligned ■ Position pillows to support the weight of the infant ■ Demonstrate positions for breastfeeding Supply and Demand ■ The newborn should be fed on demand. prolactin release in response to suckling will stimulate the alveolar cells of the breast to produce the appropriate amount of milk to meet the infant’s needs ■ The mother should initiate breastfeeding when the infant demonstrates hunger cues: ■ Increased alertness or activity ■ Smacking of the lips ■ Suckling motion ■ Moving of the head in search of the breast ■ Continue to feed until the infant detaches spontaneously. with the ear. shoulder.Copyright © 2006 by F. 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 80 . which protect the infant from infection. are passed via breast milk ■ Decreased incidence of infant: ■ Allergies ■ Otitis media ■ Upper respiratory infections Positioning ■ The infant’s body should face the breast. POSTPARTUM TEACHING TIPS: BREASTFEEDING Advantages to Breastfeeding ■ Cost ■ Convenience ■ Immunoglobulins. Davis.
81 Engorgement (Firm. tender breasts) ■ May occur on postpartum day 3–5. A. 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. smoking.Copyright © 2006 by F. when the volume of breast milk increases ■ Prevent engorgement with frequent feedings. 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. Davis. or recreational drugs ■ Consult with pediatrician before using any over-the-counter or prescription medication Pumping and Storing ■ Demonstrate use of breast pump ■ Discuss appropriate storage containers ■ Write the date of expression on storage container and use oldest milk first ■ Length of storage dependent on location Location Room temperature Refrigerator Refrigerator freezer (with separate door) Deep freeze Guideline Up to 8 hours 3–5 days 3 months 6–12 months POSTPARTUM .
POSTPARTUM Weaning ■ Gradual weaning suggested to decrease the likelihood of engorgement ■ Remove one feeding per week ■ If infant is less than 1 year. must be given Breast Care ■ Breast pads inside a supportive bra will collect leaking breast milk ■ Teach signs of mastitis ■ Unilateral breast pain. A. infant formula. 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 82 .Copyright © 2006 by F. instead of cow’s milk. Davis.
A. 83 Uterus ■ Uterine Involution ■ Process by which the size of uterus decreases in a predictable pattern ■ Documented in fingerbreadths above or below the umbilicus Postpartum Period Immediately after birth 12 hours 24 hours Day 2 Day 3 U Umbilicus Level of the Fundus at the umbilicus 1 fingerbreadth (FB) above the umbilicus 1 FB below the umbilicus 2 FB below the umbilicus 3 FB below the umbilicus Documentation at U or U/U 1/U U/1 U/2 U/3 ■ Measures that promote uterine involution • Breastfeeding • Voiding • Fundal massage • Oxytoxic medications Fundal massage. Davis.Copyright © 2006 by F. POSTPARTUM .
p. and location of the fundus ■ TONE of the uterus assessed while patient is supine ■ Fundus should be firmly contracted ■ If fundus is not firm. Philadelphia: F Davis. (2003). Nursing Health Assessment: A Critical Thinking. Davis. 744. . Case Study Approach.) 84 . height. (From Dillon PM.A.Copyright © 2006 by F. POSTPARTUM Assess the tone. fundus is located at or just above the umbilicus • The fundus should be midline and not deviated to the left or right Uterine involution. 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. A.
4–6 week delay generally recommended ■ Vaginal lubrication may be diminished. menses usually returns 6–8 weeks postdelivery Sexuality ■ Sexual intercourse may be resumed after lochia ceased and episiotomy healed. lactation amenorrhea while exclusively breastfeeding infant (first 6 months) ■ If bottle feeding. use water-soluble gel ■ Female superior or side-lying position may assist in comfort ■ Discuss family planning methods POSTPARTUM . 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. Davis. 85 TEACHING TIPS: UTERINE/VAGINAL CHANGES The Fundus ■ The fundus lowers one fingerbreadth below the umbilicus each day until returning to pelvis (day 10–14) Normal Progression of Lochia ■ Lochia progresses from bright red to brown to light pink with decreasing amount ■ If lochia returns to bright red or increases in amount. A.Copyright © 2006 by F.
Copyright © 2006 by F.000 cc/day ■ Catheterization may be necessary if unable to void or with urinary retention Bowel ■ ■ ■ ■ Auscultate for bowel sounds Assess for abdominal distention Assess for presence/status of hemorrhoids Educate on prevention of constipation ■ Increased roughage in the diet ■ Increased oral intake of fluids ■ Temporary use of prescribed stool softeners Lochia ■ Vaginal discharge after delivery called lochia ■ Blood loss with vaginal birth approximately 500 cc ■ Blood loss with cesarean birth approximately 1000 cc 86 . 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. which occurs in response to decrease in estrogen. Davis. A. POSTPARTUM Bladder Status ■ Postpartum women may have difficulty voiding after birth due to: ■ Decreased urethral sensation from pressure exerted by the passage of the fetus ■ Side effects of local/epidural anesthesia ■ Delivery trauma to the perineum ■ Palpate for bladder distention ■ Track fluid balance: intake and output ■ Assess for periurethral edema/trauma ■ Postpartum diuresis.
Copyright © 2006 by F. moderate. 1 gm 1 ml of blood loss ■ Assess the color of lochia • Lochia rubra (red): day 1–3 • Lochia serosa (brownish-pink): day 4–9 • Lochia alba (yellow-white): day 10–14 ■ Document number and size of blood clots ■ Turn patient to assess blood loss under buttocks Assessment of the Perineum Requires a direct light source and positioning of the patient in side-lying with top leg forward ■ Assess Episiotomy or laceration ■ Redness ■ Swelling ■ Ecchymosis ■ Color. small. large) • If weighing perineal pads. A. 87 ■ Assess the amount of lochia ■ Note time of last perineal pad change ■ Document amount of lochia on perineal pad (scant. consistency of discharge ■ Approximated edges ■ Lacerations described by degree of tissue involvement Degree 1st 2nd 3rd 4th Definition Vaginal mucous membrane and skin of perineum Subcutaneous tissue of the perineal body Involves fibers of the external rectal sphincter Through rectal sphincter exposing the lumen of the rectum ■ No enemas or rectal suppositories should be used with 3rd and 4th degree lacerations POSTPARTUM . Davis.
discourage breath-holding Emotional Response ■ Assess interaction with newborn ■ Eye contact with infant ■ Talks to infant ■ Holds infant close ■ Feeds infant ■ Assess emotional status ■ Assess for postpartum blues 88 . sprays. POSTPARTUM TEACHING TIPS: PERINEAL HYGIENE Perineal Cleansing ■ Stress importance of hand washing before and after perineal care ■ Demonstrate use of perineal cleansing bottle ■ Change perineal pads after each void ■ Keep perineal pad/underwear from touching floor Comfort Measures ■ Apply perineal ice packs intermittently for the first 24 hours after birth ■ Sitz baths may be ordered after 24 hours ■ Apply creams. and repeat 10–15 times. release. 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. A.Copyright © 2006 by F. tighten perineal muscles as though stopping the flow of urine (this technique is only used to locate the muscles. Davis. not to perform the exercise) ■ Hold contraction for several seconds.
89 TEACHING TIPS: EMOTIONS Postpartum Blues ■ Symptoms of postpartum blues include tearfulness. A. encourage patient to report symptoms of postpartum depression ■ Extreme or unswerving sadness ■ Compulsive thoughts ■ Feelings of inadequacy ■ Inability to care for infant and/or self ■ Suicidal thoughts Extremities ■ Assess circulation to lower extremities ■ Pedal pulse ■ Color.Copyright © 2006 by F. temperature. blanching ■ Assess for signs of deep vein thrombosis ■ Pain ■ Swelling ■ Redness ■ Increased skin temperature POSTPARTUM . and moodiness ■ Postpartum blues common in the early postpartum period ■ Duration less than 2 weeks ■ Possible cause ■ Hormonal changes after birth ■ Exhaustion ■ Physical discomfort Emotional Support ■ Encourage patient to discuss feelings ■ Encourage private time when baby naps ■ Discuss the difference between “blues” and depression. Davis. insomnia.
Copyright © 2006 by F. POSTPARTUM TEACHING TIPS: ACTIVITY Activity Level ■ Frequent rest periods will help with healing of body and mind (nap when baby sleeps) ■ Do not lift anything heavier than the baby ■ Limit activities to care of newborn/self ■ Ask for assistance with housework/shopping Vital Signs ■ Temperature ■ Slight increase in temperature in first 24 hours common due to dehydration. encourage oral fluids ■ If temperature 100. and amplitude ■ Blood pressure ■ Watch for signs of shock (↓ blood pressure and ↑ pulse) ■ Be alert for orthostatic hypotension upon rising ■ Dangle at bedside before rising ■ Respirations: ■ Note rate and depth ■ Lungs should be clear on auscultation Level of Comfort ■ Pain location and intensity ■ Afterbirth cramps: intense contractions of the uterus that are more intense with multiparity and occur with nursing ■ Incisional pain ■ Hemorrhoid pain ■ Postpartum diaphoresis: intense sweating that occurs in the early postpartum period ridding the body of excess fluid ■ Effects of epidural anesthesia ■ Leg movement/strength ■ Presence of numbness and tingling ■ Assist with ambulation 90 . rhythm. Davis.4 F call physician ■ Pulse: assess rate. A.
the nurse should assess the following ■ Effects of anesthesia ■ Level of consciousness ■ Ability to hold and care for infant may be limited due to • Comfort level • Limitation in movement ■ Respiratory status • Pulse oximetry Patient Controlled Anesthesia (PCA) ■ Effectiveness ■ Number of attempts/amount given ■ Side effects Abdominal Assessment ■ Bowel sounds POSTPARTUM . Davis. A.Copyright © 2006 by F. 91 Nutrition ■ Assess dietary needs and concerns ■ Average weight loss 12 pounds at birth Laboratory Data ■ Examine postpartum laboratory findings and compare to prenatal levels (usually drawn at 24 hours postpartum) ■ Hemoglobin/hematocrit ■ White blood cell count ■ Platelet count ■ If mother is RH negative check Rh status of infant Mother Negative Negative Infant Negative Positive Rho(D) Immune globulin (300 g) No treatment needed Administer within 72 hours of birth Cesarean Birth In addition to routine postpartum assessment.
A.Copyright © 2006 by F. Davis. magnesium sulfate) ■ Etiology ■ Uterine atony (hypotonia of the uterus) ■ Retained placental fragments ■ Vaginal/cervical laceration ■ Hematoma 92 . POSTPARTUM ■ Abdominal distention ■ Ability to pass flatus ■ Avoid straws and carbonated beverages ■ Incision/dressing ■ Circle drainage and mark with date and time ■ Assess incision with dressing change • Approximation • Redness • Drainage • Edema • Hematoma • Odor Nutrition ■ ■ ■ ■ ■ ■ ■ ■ Intake and output Nausea/vomiting Presence of bowel sounds Progression of diet Turn/cough/deep breathe Dangle at side of bed Sit up in chair Ambulate with assist Progression of Activity Complications in the Postpartum Period Hemorrhage ■ Risk factors ■ High parity ■ Overdistention of the uterus ■ Precipitous labor or prolonged labor ■ Medications (oxytocin.
93 ■ 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. Davis. A.Copyright © 2006 by F.4F ■ Elevated white blood cell count ■ Complaint of chills and aching ■ Malaise ■ Interventions ■ Obtain culture of discharge as ordered ■ Report abnormal laboratory findings ■ Administer antibiotic therapy as ordered ■ Consider medications contraindicated for breastfeeding ■ Monitor temperature ■ Clean and monitor site ■ Teach patient reportable signs and symptoms POSTPARTUM . hold and call primary care provider ■ Ergonovine maleate (Ergotrate) ■ Prostaglandin F2a (Prostin/Hemabate) Infection ■ Symptoms ■ Temperature elevation 100.
warmth and redness • Malaise and flu-like symptoms ■ Incisional infection ■ Contributing factors • Inadequate care of incision • Operative delivery • Laceration ■ Clinical findings • Incision not well approximated • Incision red with purulent drainage ■ Urinary tract infection ■ Contributing factors • Catheterization of bladder • Retention of urine in bladder ■ Clinical findings • Dysuria • Frequency of urination • Flank pain Postpartum Depression ■ Risk factors ■ History of depression or anxiety disorder ■ Prenatal depression 94 . A. POSTPARTUM ■ Endometritis (uterine infection) ■ Contributing factors • Operative birth • Long labor with multiple vaginal exams • Internal monitoring • Premature rupture of membranes • Manual removal of placenta ■ Clinical findings • Subinvolution of the uterus • Foul-smelling vaginal discharge • Lower abdominal cramping ■ Mastitis (breast infection) ■ Contributing factors • Alteration in nipple integrity • Delayed emptying of breast milk ■ Clinical findings • Unilateral breast pain. Davis.Copyright © 2006 by F.
moist heat ■ Rest ■ Observe for symptoms of pulmonary embolism • Dyspnea • Chest pain • Hemoptysis • Patient fearful POSTPARTUM .Copyright © 2006 by F. and pain to affected leg ■ Interventions dependent on severity of findings ■ Administer anticoagulants ■ Monitor coagulation profile ■ Compression stockings ■ Apply warm. Davis. redness. A. 95 ■ Inadequate social or partner support ■ Large number of life stressors ■ Clinical findings ■ Symptoms extend beyond 2 weeks postpartum. may occur 3–12 months after birth ■ Extreme or unswerving sadness ■ Compulsive thoughts ■ Feelings of inadequacy ■ Inability to care for infant and/or self ■ Suicidal thoughts ■ Interventions ■ Psychotherapy ■ Medications Thrombophlebitis/Deep Vein Thrombosis ■ Risk factors ■ Varicosities ■ Advanced maternal age ■ Obesity ■ Long periods of bed rest ■ Occupation that requires long periods of standing ■ Clotting disorder ■ Etiology ■ Increased clotting factors in postpartum period ■ Infection in the vessel lining to which a clot attaches ■ Clinical findings ■ Pain with dorsiflexion ■ Affected site hot to touch ■ Swelling.
POSTPARTUM TEACHING TIPS: POSTPARTUM COMPLICATIONS Teach the patient to report the following signs and symptoms to the primary health-care provider. or urgency of urination ■ Foul odor to lochia ■ Redness.Copyright © 2006 by F. Signs of infection ■ Elevated temperature ■ Localized redness or pain to either breast ■ Persistent abdominal tenderness ■ Persistent pain to perineum ■ Burning. or discharge at incision Sign of Uterine Subinvolution ■ Change in the character of lochia ■ Increased amount of lochia ■ Resumption of bright red color ■ Presence of clots Signs of Thrombophlebitis/Deep Vein Thrombosis ■ Pain. frequency. increased temperature and redness to legs Signs of Postpartum Depression ■ Extreme or unswerving sadness ■ Compulsive thoughts ■ Feelings of inadequacy ■ Inability to care for infant and/or self ■ Suicidal thoughts 96 . pain. A. Davis.
leg length. 97 Nursery Care of the Newborn ■ ■ ■ ■ ■ Keep infant warm during all care and procedures Assess and record daily weight Role model back sleeping Keep bulb syringe at bedside Check identification bands at each encounter with parents Physical Assessment of the Newborn Reportable findings in red Vital Signs ■ Axillary temperature 97.Copyright © 2006 by F. A. or asymmetrical gluteal folds (hip dysplasia) ■ Resistance to neck flexion POSTPARTUM .6 F ■ Decreased body temperature may be a sign of sepsis ■ Auscultate apical pulse for one full minute ■ 110–160 beats per minute ■ Sustained resting heart rate below 100 or above 160 ■ Respirations counted for one full minute ■ 30–60 per minute ■ Sustained resting respiratory rate below 30 or above 60 Extremities/Activity ■ Newborn posture flexed ■ Extremities equal length with full range of spontaneous motion ■ Gluteal folds even ■ Ten fingers and 10 toes without webbing (syndactyly) or extra digit (polydactyly) ■ Grasp reflex intact ■ REPORT ■ Poor muscle tone or asymmetry of muscle tone ■ Failure to spontaneously move all extremities or decreased range of motion ■ Chewing type mouth movements combined with noticeable changes in eye and/or body movements (may represent neonatal seizure activity) ■ Unequal knee height. Davis.8–98.
resembles bruise) ■ Telangiectases “stork bites” ■ Erythema toxicum (newborn rash) ■ REPORT ■ Cyanosis (other than in hands and feet) ■ Skin lesions. face) ■ Mongolian spot (area of increased pigmentation. sing and hold newborn close Skin ■ Color uniformly pink ■ Normal variations ■ Acrocyanosis (bluish hue to hands/feet) ■ Milia (plugged sebaceous glands on nose) ■ Lanugo (downy hair on arms. bruises. POSTPARTUM TEACHING TIPS: NORMAL NEWBORN BEHAVIOR Pattern of Sleep ■ Newborns sleep in short periods for a total of 13–16 hours per day ■ Lying the baby on the back for sleep is recommended Communication ■ Crying is a means of communication and a late sign of hunger ■ Teach parents hunger cues ■ Teach techniques for comforting the fed newborn ■ Swaddling ■ Burping ■ Massage ■ Soft music ■ Diaper change ■ Gentle rocking ■ Encourage parents to talk. back.Copyright © 2006 by F. abrasions ■ Jaundice 98 . Davis. A.
A. Davis. tongue mobile ■ Hard and soft palate intact ■ Strong suck. pinna well-formed and hearing intact ■ Oral mucosa pink and moist.Copyright © 2006 by F. able to coordinate suck and swallow ■ REPORT ■ Absence of red reflex ■ Purulent discharge of eyes immediately after birth POSTPARTUM . unilateral swelling of scalp tissue caused by collection of blood between the skull and periosteum Face ■ Face symmetrical with rest and crying ■ Eyes symmetrical in size and shape with intact red and corneal reflex ■ Nose midline with nares patent ■ Ears aligned with outer canthus of eyes. 99 TEACHING TIPS: SKIN CARE AND BATHING ■ Sponge baths recommended until the umbilical cord stump has fallen off and circumcision has healed ■ Stay with baby and hold securely at all times when bathing ■ All supplies should be within easy reach ■ No soap is needed on the face ■ The eye area can be cleansed with wet cotton balls (inner to outer canthus) ■ Only soap recommended for newborn skin should be used ■ Dry the baby quickly to avoid chilling ■ Wash hair last to avoid heat loss ■ Encourage frequent diaper changes ■ Cleanse genital area with mild soap and water ■ Cleanse the female genitalia from front to back ■ Do not forcibly retract the foreskin of uncircumcised boys Head ■ Head round with slight molding (cone-shaped with overriding cranial bones) or caput succedaneum (tissue edema that crosses suture lines) ■ Anterior and posterior fontanels (soft spots) flat ■ REPORT ■ Sunken or bulging fontanels when infant is at rest ■ Cephalhematoma.
POSTPARTUM ■ ■ ■ ■ ■ ■ ■ ■ Low set ears Lack of response to sound Nasal flaring Cleft lip or palate Large. A. use bottled nursery water ■ Prepared bottles can be fed at room temperature. 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.Copyright © 2006 by F. run refrigerated bottles under warm water to bring to room temperature ■ Avoid use of microwave for heating formula 100 . protruding tongue (possible Down syndrome) White patches in mouth (Candidiasis) Absent rooting. suck. Davis. but most convenient ■ Use without dilution ■ Opened cans can be stored in the refrigerator for 48 hours ■ Concentrated ■ Dilute with equal parts of water ■ Prepare enough bottles for the day ■ Prepared bottles can be stored in refrigerator for 48 hours ■ Powdered ■ Least expensive ■ Add water for every one scoop of powder per manufacturer’s instructions ■ Shake well to distribute powder Formula Preparation ■ Clean off can with soap and water before opening ■ If water supply questionable.
A. chest retractions. if water supply is questionable. Davis.Copyright © 2006 by F.5–2 ounces of formula per feeding for the first several days of life ■ Elicit the rooting reflex to initiate feeding ■ Keep bottle tipped to ensure the nipple remains full of formula ■ Burp every 1–2 ounces ■ The type. sterilization recommended ■ Choose nipples that allow a steady flow of formula but not so large as to cause choking Technique for Feeding ■ Encourage parents to hold the baby close and talk to the infant during feedings ■ Do not prop bottles ■ On-demand feeding recommended/watch baby for hunger cues (usually every 3–4 hours) ■ Increased alertness or activity ■ Smacking of the lips ■ Suckling motion ■ Moving of the head in search of the breast ■ Newborns generally drink about 0. or expiratory grunting ■ Asymmetrical breath sounds ■ Chest asymmetrical or circumference greater than head circumference ■ Loud cardiac murmur with thrill POSTPARTUM . 101 Bottle Preparation ■ Bottles should be washed with a brush and rinsed thoroughly. amount and pattern of feedings should be discussed with the pediatrician before hospital discharge ■ Formula remaining in the bottle must be discarded Chest ■ ■ ■ ■ ■ Respirations unlabored Chest rises and falls symmetrically Lung sounds clear bilaterally Clavicals intact REPORT ■ Nasal flaring.
foul odor from cord Circumcision ■ Site may be covered with petroleum gauze dressing. tell parents when to remove dressing ■ Clean area with warm water for diaper change 102 . drainage.Copyright © 2006 by F. Davis. do not tug at cord ■ Cleanse cord insertion site at diaper changes ■ Fan fold diaper to expose cord to air ■ REPORT redness. A. POSTPARTUM Abdomen/Genitals ■ ■ ■ ■ ■ ■ ■ ■ Abdomen round and soft without palpable masses Three vessel umbilical cord with drying base Bowel sounds present First void within 24 hours (may be rust-stained from uric acid crystals) Meconium stool passed within 24 hours Female genitalia ■ Labia majora covers minora ■ May have mucoid vaginal discharge or pseudomenses Male genitalia ■ Urinary meatus at tip of penis ■ Testes descended REPORT ■ Drainage of urine or feces from umbilicus ■ Liver more than 3 cm below right costal margin ■ Abdomen markedly distended or flat ■ Palpable abdominal mass ■ Visible peristaltic waves ■ Poor feeding or excessive spitting or vomiting ■ Failure to urinate or pass meconium within 24 hours ■ Hypospadias or epispadias ■ Mass in scrotal or inguinal area ■ Imperforate anus TEACHING TIPS: NEWBORN CARE Umbilical Cord Care ■ The cord will fall off spontaneously in 10–14 days. bleeding.
and easily flexed ■ REPORT ■ Arched back ■ Tuft of hair on spine TEACHING TIPS: SAFETY. 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.Copyright © 2006 by F. 103 ■ Apply petroleum jelly to head of penis to decrease friction with diaper ■ A yellow exudate forms on the head of the penis on day 2–3. well-fit mattress ■ No smoking around baby ■ Dress baby for comfort. Davis. this is part of the healing process and removal should not be attempted ■ Reportable symptoms ■ Difficulty urinating ■ Persistent bleeding from the site ■ Pus oozing from the site ■ Redness or swelling Back ■ Spine straight. A. 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. do not overheat POSTPARTUM . intact.
Copyright © 2006 by F. POSTPARTUM Immunizations ■ Discuss importance of immunizations for disease prevention ■ Provide current schedule of recommended childhood immunizations ■ Provide documentation of any immunization given in the hospital Neonatal Genetic and Hearing Screen ■ Blood test for metabolic defects are performed on all newborns after feeding is established ■ Exact tests vary by state ■ Infants who are discharged early may need to be brought back for newborn screen ■ Hearing screen done before hospital discharge for early identification of hearing deficits Reportable Symptoms ■ Parents should call the pediatrician with the following signs or any time they are concerned with their newborn’s behavior ■ Difficulty breathing ■ Vomiting or diarrhea ■ Less than expected voids/stools ■ Yellow hue to the skin or sclera ■ Constant crying ■ Difficulty awakening baby ■ Altered temperature ■ Body rash ■ Lack of interest in eating 104 . Davis. A.
Davis.5 lb/mo ■ HC ↑ 0. A.Copyright © 2006 by F. 105 Peds Basics Common Developmental Milestones (ages are aproximate) 0–6 mo ■ Physical ■ Ht ↑ 1 in/mo ■ Doubles wt by 5–6 mo ■ Wt ↑ 1. fontanel closes: 12–18 mo ■ Central incisors erupt: 5–7 mo ■ Gross/Fine Motor ■ Holds head erect: 4 mo ■ Grasps voluntarily: 5 mo PEDS BASICS .5 in/mo ■ Gross/Fine Motor ■ Rolls back to side: 3 mo ■ Holds head erect: 4 mo ■ Voluntary grasp: 5 mo ■ Rolls from front to back: 5–6 mo ■ Language ■ Coos: 1–2 mo ■ Laughs: 2–4 mo ■ Makes consonant sounds: 3–4 mo ■ Imitative sounds: 6 mo ■ Personal-Social ■ Regards a person’s face: 1 mo ■ Displays social smile and follows object 180 degrees: 2 mo ■ Recognizes familiar faces: 3 mo ■ Stranger anxiety begins: 6 mo 6–12 mo ■ Physical ■ Ht ↑ 50% of birth ht by 1 yr ■ Wt ↑ 1 lb/mo ■ Triples wt by 1 yr ■ HC ↑ by 33% ■ Chest circumference 1 in HC ■ Post fontanel closes: 2–3 mo ■ Ant.
5 yr ■ Personal-Social ■ Separation anxiety peaks ■ Ritualism ■ Negativism ■ Independence 106 .Copyright © 2006 by F. A. ma-ma) : 8 mo ■ Says 4–10 words: 12 mo ■ Personal-Social ■ Marked stranger anxiety: 8 mo ■ Emotions such as jealously: 12 mo 1–3 yr ■ Physical ■ Ht ↑ 3 in/yr ■ Wt ↑ 5 lb/yr ■ Weighs about 4 times birth wt: 2 yr ■ HC equals chest circumference: 1–2 yr ■ HC ↑ 1 in during 2 yr ■ 10–14 temporary teeth ■ Gross/Fine Motor ■ Walks without help: 15 mo ■ Walks up and down stairs placing both feet on each step: 24 mo ■ Scribbles spontaneously: 15 mo ■ Builds 3–4 block tower: 18 mo ■ Jumps with both feet: 30 mo ■ Language ■ Says 300 words: 2yr ■ Uses 2–3 word phrases and pronouns ■ Understands speech: 2 yr ■ States first and last name: 2. PEDS BASICS ■ Begins to crawl: 7 mo ■ Sits unsupported: 8 mo ■ Pulls up to stand: 9 mo ■ Drinks from cup: 9 mo ■ Pincer grasp: 8–10 mo ■ Builds two-block tower: 12 mo ■ Walks alone or holding onto one hand: 12 mo ■ Language ■ Pronounces syllables (da-da. Davis.
A.Copyright © 2006 by F. 107 3–6 yr ■ Physicial ■ Ht ↑ 2. Davis. sings songs: 4 yr ■ Asks “why” questions: 4 yr ■ Says over 2000 words: 5 yr ■ Knows and can name colors: 5 yr ■ Names days of week: 5 yr ■ Personal-Social ■ Shares toys with others ■ Imitates caregivers ■ Domestic role-playing PEDS BASICS .5–3 in/yr ■ Wt ↑ 4–6 lb/yr ■ HC ↑ 0. numbers and name: 5 yr ■ Language ■ Says 900 words: 3 yr ■ Speaks 3–4 word sentences: 3 yr ■ Says 1500 words: 4 yr ■ Tells stories.5 in/yr ■ Vision is 20/20 with color vision intact: 5–6 ■ Gross/Fine Motor ■ Rides tricycle: 3 yr ■ Climbs stairs using alternate feet: 3 yr ■ Stands on one foot: 3 yr ■ Broad jump: 3 yr ■ Builds 9–10 block tower: 3 yr ■ Draws a cross: 3 yr ■ Hops on one foot: 4 yr ■ Skips: 4 yr ■ Catches a ball: 4 yr ■ Walks downstairs using alternate feet: 4 yr ■ Laces shoes: 4 yr ■ Copies square: 4 yr ■ Adds three parts to stick figure: 4 yr ■ Balances on alternate feet: 5 yr ■ Ties shoelaces: 5 yr ■ Uses scissors well: 5 yr ■ Prints letters.
PEDS BASICS 6–12 yr ■ Physical ■ Ht ↑ 2–3 in/yr ■ Wt ↑ 4.Copyright © 2006 by F. Davis.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. swims ■ Cursive writing: 8 yr ■ Computer and craft skills ■ Language ■ Devlops ability to read at grade level ■ Personal-Social ■ School relationships and work important ■ Separating from family 12 to 18–21 yr ■ Physical ■ Puberty beings in girls: 8–14 yr (lasts about 3 yr) ■ Puberty begins in boys: 9–16 yr (lasts longer) ■ Ht and wt ↑ variable during puberty ■ Progressive Tanner stages of development ■ Gross/Fine Motor ■ Gross motor reaches adult levels ■ Fine motor continues to be refined ■ Language ■ Develops formal thought—includes idealism. status. jumps. A. and relationships 108 .5–6. and ability to consider abstract possibilities ■ Personal-Social ■ Works through identity issues. egocentrism.
p. A. wt. PEDS BASICS . and BMI ■ Use 5th and 95th percentiles as parameters in determining if children are within normal limits for growth Average Daily Caloric Requirements for Children Age 0–1 month 2–4 months 5–60 months 5 years Caloric Expenditure Per Day 100—110 kcal/kg/day 90—100 kcal/kg/day 70—90 kcal/kg/day 1500 kcal for first 20 kg additional kg/day 25 kcal for each From Hay WW. 109 Growth ■ Use Growth Charts from National Center for Health Statistics (NCHS) www. et al.cdc.Copyright © 2006 by F.). HC. Current Pediatric Diagnosis & Treatment: (17th ed. based on infant’s desire—usually between 8 to 9 months of age. wt for ht. 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 (3–4 ounce) for each feeding for first month to 5 feedings/24 hours for each feeding when solid foods introduced at 6 months Weaning: Should be gradual.gov/growthcharts. for ht. (2005). New York: Lange Medical Books/McGraw-Hill. Davis.
Lung. Bethesda. (17th ed). 280. 2415. Adolescent 700–1400 mL From Behrman RE. Nelson Textbook of Pediatrics (17th ed). Davis. MD. Child 500–1000 mL. & Jenson TB. Average Ranges for Pediatric Vital Signs Age Group Infant Toddler Preschooler School-age Adolescent Heart Rate 80–150 70–110 65–110 60–95 55–85 Respiratory Rate 25–55 20–30 20–25 14–22 12–18 BP Systolic 65–100 90–105 95–110 100–120 110–135 BP Diastolic 45–65 55–70 60–75 60–75 65–85 Adapted from Behrman RE. (2004). Saunders. A. Author. (2004). Kliegman RM. and Blood Institute. and National Heart. Philadelphia: W. Nelson Textbook of Pediatrics.B.Copyright © 2006 by F. Kliegman RM. Child 2000–2700 mL 6 yr 1150–2000 mL. Rule of Thumb to Determine BP: Normal systolic ranges: 1–7 yr age in yr 90.B. p. PEDS BASICS Total Water Requirements/24 Hours Infant 6 yr 500–1300 mL. Saunders. Philadelphia: W. 8–18 yr age in yr) 83 Normal diastolic ranges: 1–5 yr 56. Daily Urine Output/24 Hours 0. p.5–2 mL/kg/hr depending on child’s age and hydration status Infant 350–550 mL. Normal Blood Pressure Readings from the Second Task Force on Blood Pressure Control in Children. 6–18 yr 52 (2 110 . Jenson TB. (1987).
shellfish. do not use honey on young infants because of the association with infant botulism. then vegetables. avoid allergenic foods such as nuts. healthy habits—go to www. Introduction of Food Types Birth-6 mo Types of Foods Usually breast milk. start with 1–2 tsp Introduce one food at a time for 3–5 days to watch for food allergies. use small spoon to feed infant 8–9 mo Finger foods such as teething crackers or raw fruits 12 mo Eating normal table foods.gov Comments Sometimes give rice cereal mixed with breast milk or formula around 4 mo Watch sizes and types of food for possible choking Provide a variety of foods that meets child’s nutritional needs. A.Copyright © 2006 by F. or chocolate 111 PEDS BASICS . egg whites. Davis. and fruits with meats the last food to introduce. commercially prepared iron-fortified formula 6 mo Begin with infant rice cereal. mypramid. strawberries.
A. 3 deep coma) No reaction. (1988). C Sluggish.Copyright © 2006 by F.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. — Adapted from Hahn YS. et al. PEDS BASICS Pediatric Coma Scale Pupils Right Left Size Reaction Size Reaction 4 3 2 0 6 5 4 3 2 1 5 4 3 2 1 T Eye Spontaneously To Speech To Pain None Obeys Commands Best Motor Response (use Localizes Pain best arm or age. Davis. Child Nervous System 4: 34. 112 . Head injuries in children under 36 months of age. closed due to swelling coma.
intermittent sounds due to small collapsed airways popping open ■ Grunting : Harsh sound on expiration due to early closure of glottis and chest wall contraction. longer. swishing noise heard over entire area of lung surface except for upper scapular area and beneath sternum. 113 Normal Breath Sounds ■ Vesicular Breath Sounds: Soft. high-pitched. pleural effusion. pneumothorax. continuous sound associated with respiratory infections ■ Crackles : Soft. low-pitched. inspiration is louder. pneumonia ■ Rhonchi : Low-pitched. muffled sound associated with epiglottis ■ Wheezing : Musical. A. more continuous inspiratory or expiratory sounds due to lower airway obstruction with bilateral wheezing indicative of asthma or bronchiolitis and unilateral wheezing suggestive of foreign body aspiration PEDS BASICS . snoring-like.Copyright © 2006 by F. Davis. and higher pitched than expiration ■ Bronchovesicular Breath Sounds : Heard over sternum and upper scapular regions where trachea and bronchi bifurcate. crowing sound on inspiration due to upper airway obstruction associated with croup or foreign body aspiration. 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. which causes increased expiratory airway pressure to prevent airway collapse ■ Stridor : High-pitched.
cold extremities/hypothermia. Davis.5 cm beyond tip of artificial airway ■ Limit suction to less than 5 seconds Pulse Oximetry Normal ranges: 95%-100% Mild hypoxia: 91%-94% Moderate hypoxia: 86%-90% Severe hypoxia: 86% Watch for false lows associated with nonsecure connection (movement of child’s foot or hand).Copyright © 2006 by F. Cardiac/Apnea Monitors Electrode placement for ECG monitoring: White color for right side of chest Green (or red) color for ground Black color for left side of chest Electrode placement for apnea monitoring: Two electrodes placed two fingerbreadths below nipple on midaxillary line of each side 114 . and hypovolemia. A. Watch for false highs associated with carbon monoxide poisoning and anemia. ■ 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. . PEDS BASICS Endotracheal Tube Suctioning ■ Select size of suction catheter based on size of child (infant 5–8 F child 8–10 F older child 12–14 F) .
115 Cardiac/Apnea Monitors (Cont. Davis. PEDS BASICS .Copyright © 2006 by F. A.) 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.
loss of physical and emotional support Strangers. any intrusive procedures PEDS BASICS Toddler Exhibits reactions such as agitation. diarrhea. Davis. uncooperativeness and clinging to parents. strange or unknown equipment and places Mutilation. separation anxiety peaks 12–15 mo Fewer reactions but more somatic signs such as vomiting.Copyright © 2006 by F. temper tantrums. dark. urinary frequency or incontinence. dizziness. A. Children’s Responses to Illness and Hospitalization Separation Anxiety Infant Develops ~6 mo and lasts until 30 mo with reactions of crying or agitation Loss of Control Disruption of care from primary caregiver and normal routines Disruption from normal routine and rituals as well as care from parents Fears Strangers and strange places. physical contact/interventions from strangers. sudden movements. still may become withdrawn or aggressive Preschooler Perceived disruption in the loss of their own power and altered family roles (Continued text on following page) 116 . being alone. the unknown. loud noises.
body disfigurement. Are you having pain? 2. Does anything make it worse—or better? 8. rejection by others. How long have you been having pain? 6. stabbing?) 3. death Adolescent Enforced dependency and possible identity/role changes 117 Eight Questions to Ask About Pain: 1. death Loss of peer interactions and relationships. loneliness. or boredom Loss of Control Enforced dependency and altered family roles Fears Bodily injury. school and peer concerns.) 5. loss of physical abilities. Children’s Responses to Illness and Hospitalization (Continued) Separation Anxiety School Age Anxious behaviors as well as loneliness. Has it changed what you do? PEDS BASICS . isolation or depression. Where is the pain? (Point to where the pain is. lack of control over modesty. How often does it occur? 7. If yes. pain. Davis. aching. When did the pain start? (Did anything happen to start the pain?) 4. boredom. pinching. 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. A. what does the pain feel like? (burning. inability to stay in control.Copyright © 2006 by F.
Signs of possible pain: fist-clenching. high-pitched cry. stiff posture. Signs of possible pain: muscular rigidity such as clenched fists. Signs of possible pain: diffuse body movement. closed eyes. clenched teeth. may have difficulty in distinguishing between types of pain such as “sharp” or “dull.Copyright © 2006 by F. body stiffness. Davis. eyes tightly closed. Signs of possible pain: regression with arms and legs thrashing or withdrawal such as clinging to parent or significant other. PEDS BASICS Developmental Differences in Children Related to Pain Age Infants Comments Preverbal. may show fewer overt pain behaviors. A. loud crying or screaming Use pain scale for this group. rapid breathing. and lack of play. and guarding affected body part.” can sometimes describe pain but not the intensity. gritted teeth.” may act “tough” even when in pain. obvious sign is facial expression with brows lowered and drawn together. may use words such as “owie. lack of interest and decreased ability to concentrate Young child Older child Adolescent 118 . and mouth open Limited vocabularies still make it difficult to express pain. tearing. wrinkled forehead or lying in fetal position Use pain scale for this group. fisting. may be stoic because of fear of being labeled so may be quiet and withdrawn.
PEDS BASICS . ” Ask the child to choose number that best describes his or her own pain. patientcontrolled analgesia (PCA). PO/IV/IM analgesia. conscious sedation. or epidural analgesia Numerical Scale Pain Assesment Tool None 0—1—2—3—4—5—6—7—8—9—10 Worst Pain (Scale of 0–10 to describe pain) Explain to older child: “0 means you feel no pain and 10 means you feel the worst pain possible. A.Copyright © 2006 by F. 119 Nursing Interventions Related To Pain Management ■ Distraction—useful for mild pain relief (example: tell child to say “Oh” when giving an injection or blow bubbles when performing a procedure) ■ Guided imagery—aid the child in creating a pleasurable mental image during the painful situation ■ Thought stopping—stop the painful thought with a positive thought ■ Soothing music or aromatherapy–use to calm emotions and state of mind ■ Thermotherapy–apply warm and cold to painful areas to promote circulation or reduce edema with limited numbing effect ■ Gentle massage–relax or focus child away from pain toward more gentle soothing touch ■ Sucrose “Sweet” Nipple—calm young infants by allowing them to suck on nipple dipped in sucrose solution—effective method in reducing pain during procedure ■ Provide ordered pharmacological interventions such as topical anesthetic creams. Davis.
or “talking to. tense Moans or whimpers. FLACC Pain Assessment Tool Rating: Face 0 No particular expression or smile Normal position or relaxed Lying quietly. distractible ” no pain. shifting back and forth. moves easily No cry (awake or asleep) Content. The FLACC: A behavioral scale for scoring postoperative pain in young children. Shayevitz J. hugging. normal position. withdrawn. quivering chin Kicking. relaxed 1 Occasional grimace or frown. Davis.Copyright © 2006 by F. S. 10 worst pain. A. occasional complaint Reassured by occasional touching. clenched jaw. screams or sobs. Malviya. Pediatric Nursing 23(3): 293–297. restless. frequent complaints Difficult to console or comfort Legs PEDS BASICS Activity Cry Consolability Ages of use: 2 mo to 7 yr. Voepel-Lewis T. 120 . disinterested Uneasy. tense Squirming. rigid or jerking Crying steadily. 2 Frequent to constant frown. (1997). Scoring range: 0 From Merkel S. or legs drawn up Arched back.
and balls Associative (interactive and cooperative but defines own rules) Promotes fine/gross motor skills.Copyright © 2006 by F. and encourages imagination Tricycle/big wheels. and building blocks Parallel (along side but not interactive) Dolls. pull fine). crayons/paints. music boxes. nesting cups. busy boxes. puppets/dolls stuffed animals. Use of Play for Children Age Group Infants Type and Purpose of Play Safe Toys Toddlers Solitary (noninteractive but may be 1–3 mo: mobiles. wading pools/sandboxes. A. language development. books. blocks. blocks/puzzles/simple crafts. diversion. gym sets. toys. rocking horses. large piece imitates adult roles puzzles. imitative in later part of infancy) nonbreakable mirrors. splashing bath toys. contact with playmates. singEnhances locomotion skills (gross and a-long tapes. finger paints. offers 4–6 mo: squeezable toys. Davis. housekeeping toys. clay. and ageappropriate electronic games (Continued text on following page) 121 Preschoolers PEDS BASICS . large blocks and large balls 10–12 mo: durable books with pictures. and rattles sensorimotor development. push-pull toys. stuffed Stimulates psychological and animals. imaginary items. means of communication play gyms 7–9 mo: cloth textured toys.
Copyright © 2006 by F. A. Davis.
Use of Play for Children (Continued) Age Group School Age Type and Purpose of Play
Competitive and complex-”team” play Develops social skills through learning rules and rituals of games and continued refinement of fine/ gross motor skills Group/peer type play Continues to enhance social skills and roles, cognitive skills, and wellness with sports or exercise activities
Board games, card games, music and art, athletic activities, team activities, movies, and interactive video games Sports, camping, video and computer games, radios, disc players, phones, models, and collectibles
Safe Hospital Bed/Crib Choices
Premature infants and newborns Infants/young toddler Toddlers/young preschoolers Older preschooler to adolescents Isolette or radiant warmer Open crib When child is left alone, use the enclosed bubble-top crib Hospital bed with rails in lowered position
In general, bed/crib selection based on child’s age, developmental abilities, LOC, and health conditions
Copyright © 2006 by F. A. Davis.
Quick 10-Minute Assessment
Look At the Child and Environment
■ Is the child THERE? ALIVE? ■ In the crib or hanging from the sides? (Children can do amazing stunts!) ■ Are the parents with the child? ■ What type of equipment is at the bedside?
Begin with Safety
■ Is the child breathing? ■ Do you observe any signs of distress? (Follow the ABCs you learned in CPR) ■ What is the child’s color? (pale, red, blue …) ■ Is the child on a monitor? (What is the rate & pattern?) ■ Any IVs? (Note type, rate, & site) ■ Note last set of vital signs (Include other findings based on child’s condition, PIC line, chest tubes, and so on) Abnormal? If so, check again. ■ When was the last time the child voided? ■ Do you observe anything unusual that needs immediate interventions? DO IT NOW!
Copyright © 2006 by F. A. Davis.
Check the Equipment
■ Are the monitor and respirator alarms set at the proper limits? ■ Is the 02 set up correctly? Does it work? ■ Is the suction equipment set up and ready to be used? TEST IT! ■ Is there an appropriate resuscitation bag with the proper size mask? ■ Is the correct equipment at the bedside for the child on seizure precautions? ■ Are the crib rails up? ■ Are restraints applied correctly? (Is there an order for the restraints?) ■ Are tabletops and crib or bed cleared of unsafe articles?
Focus Assessment on Area of Major Diagnosis
■ This initial assessment takes about 2–3 minutes. ■ Do the same initial assessment on all patients then return to do the more in-depth assessment. ■ If the patient is in critical condition do the in-depth assessment NOW!
eyes and mouth moist Smiles. stays awake. or wakes with prolonged stimulation Pale hands. A. Quick Evaluation of Sick Child Observation Quality of Cry Normal Strong normal tone or content and not crying Cries briefly. (1982). Davis. quickly wakes Pink Skin warm and dry. not alert Response to Social Overtures From McCarthy PL. Sharpe MR. Spiesel SZ. 78: 802. PEDS ASSESS . 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 briefly alert 125 Color Hydration Pale or blue or gray or mottled Skin doughy or tented and eyes sunken and dry No smile. alert Moderate Impairment Whimpering or sobbing Cries off and on Severe Impairment Weak. et al. anxious face. feet or acrocyanosis Skin and eyes normal and mouth slightly dry Brief smile. if asleep and stimulated. Pediatrics.Copyright © 2006 by F. then content and not crying If awake. Observation scales to identify serious illness in febrile children. moaning.
direct eyes and questions to caregiver. Speak to primary caregiver first. Copyright © 2006 by F. Use puppets and dolls. If not contraindicated. Assume eye level of child. First words around 8–9 mo. understands simple two. Short attention span of 1–5 minutes. communicates through coos. Ask simple questions with appropriate choices such as “would you like to sit on your mothers lap or up on the table?” Use child’s language for specific words in short and simple sentences.and three-word commands.Communication with Child and Family Age Group Infant Important Aspects Trust is developing. Understands simple one word commands at 1 yr. Has 300 word vocabulary. If primary caregiver is comfortable. Davis. offer pacifier and use security blankets and stuffed animals. Examples Provide gentle touching. Allow infant to be held by caregiver as much as possible. and cries at first. Be attentive to nonverbal cues. (Continued text on following page) 126 . smiles. many times the infant is calm and trusting. firm holding. Sense of self and being independent is becoming important. and smiles to infant. A. PEDS ASSESS Toddler First.
Verify with adolescent that they understand. begin conversation with them first then ask questions of caregivers. understands simple sentences. Provide appropriate choices. Offer appropriate medical equipment for play to reduce fear of equipment. Let children know that they did not cause the illness. Interested in achievement. School-Age 127 Adolescent PEDS ASSESS . Use concrete sentences. A. Allow child to ask questions. Transition between childhood and adulthood. Use teaching aids and explain what you do. Examples Assume eye level of child.Copyright © 2006 by F. Davis. Communication with Child and Family (Continued) Age Group Preschooler Important Aspects Developing a concept of self. Understands most mature thoughts especially when allowed to manipulate and see objects. get child to help you. Has 900 words in vocabulary. Show the child equipment and use clear simple instructions. Prepare child for procedure right before the treatment. Can use brochures and videos. “Would you like to have your mother leave the room while I examine you?” Provide privacy and ensure confidentiality.
family cultural beliefs and practices. Davis. others in household. play Sleep Review of systems All children Include type of housing.Copyright © 2006 by F. PEDS ASSESS Subjective Assessment by Age Group Infant (Per parent) ■ Chief complaint and HPI ■ Past history including ■ Prenatal history ■ Natal history (type birth) ■ Postnatal (with APGAR) ■ Allergies ■ Developmental milestones ■ Immunizations. school achievements. safety issues ■ Nutritional intake (type. type of home heating. car seat and smoke detector use. 128 . A. pets. 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.
) ■ Nuchal rigidity ■ Head circumference and size of fontanels (adapt to the developmental age) Respiratory ■ Inspect shape and contour of chest (expose the patient’s chest to get a good look! Posture. and responsiveness (awake.) ■ Respirations—easy. awareness of surroundings. affect. uncoordinated movements. white patches in mouth) Neuro ■ Level of alertness. on verbal command—for older child. etc.) ■ Signs of seizure activity (describe type. twitches. etc. voluntary. movements of eyes—any deviations to right or left. color of sclera and conjunctiva. A. etc. quiet. simultaneous closing of eyelids. any drainage. pulling at ears) ■ Mouth (excessive drooling. tremors) ■ Hand grasps and pedal pushes (equality. unlabored? Abdominal breathing? (Children are often abdominal breathers until 6–7 yr) PEDS ASSESS . presence or absence of newborn reflexes ■ Speech (clear. remember you need to adapt to developmental age) Reflexes—deep tendon reflexes. verbalizes. Davis. alignment) ■ Ears (response to sound. type. etc. any equipment such as chest tubes—if present. etc. remember you must adapt your method to the individual child! HEENT ■ Eyes (redness.Copyright © 2006 by F. when. slurred. spinal curvature. obtunded.) ■ Palpate expansion of chest for full and equal excursion (Inspect for retractions. describe site. lethargic. moves in response to painful or other stimuli. unequal expansion. 129 Systems Approach to Assessment Although the systems approach works well and is often used in the documentation of your findings.) ■ Pupil check (darken room before trying to check. how often. visual acuity) ■ Movement of extremities (involuntary. drainage.
front and back and laterally. sunken eyes. equipment. etc. equality of bilateral lung expansion. Hemodynamic monitoring: various line—(Note the reading.?) ■ Check IV sites for signs of infiltration. etc. if needed. phlebitis. pink. Observe the patient’s tolerance to the procedure and type and amount of secretions ■ Check other O2 equipment such as croup tents. What is rate and rhythm? Run a strip if you can. quality and equality of breath sounds. and T waves—any . etc.) Overall perfusion? (Skin warm. tube placement. dry and pink? Or cool. amount of air in cuff for seal. etc. whether tube is cuffed. color. tubing and integrity of connections ■ Make sure there is no water in the tubes. Do you have the right set-up? Proper concentration of O2? Water in containers that should have water? Patient’s tolerance to the equipment? Is there any cyanosis? Respiratory Equipment Cardiovascular ■ Inspect and palpate the point of maximum impulse (PMI) Auscultate the heart sounds. Check the P QRS. mucous membranes.Copyright © 2006 by F. abnormalities? Are all peripheral pulses present and equal? Any edema? (Check dependent areas like the sacral area) ■ Any signs of dehydration? (Sunken fontanels. sites. include over the neck and trachea (compare right and left sides. abnormal sounds—describe) ■ Does child breathe through nose or mouth (any drainage? if present describe amount. measure O2 concentration ■ Note settings your patient is on—check the system pressures— any change needed? Recheck all settings and alarms.. and consistency) ■ Note Pulse oximetry (%02 saturation) ■ Ventilator—start at the nearest point to the patient—ET or trach and work distally toward the machine ■ Size of ET or trach tube. PEDS ASSESS ■ Auscultate the lungs from the top to the bottom. A. lethargic. mottled?) Nail beds—(Good capillary refill. know tidal volume. infusion pump. Is the alarm on? ■ Suction the patient. appearance of trach site. Davis. whether seal is intact. etc. clammy. type and rate of IV. and dressing) 130 .
131 Carotid Temporal Apical Brachial Aortic area Tricuspid area Pulmonic area Mitral or apical area Femoral Radial Popliteal Posterior tibial Auscultation areas and peripheral pulses. Davis. A. Dorsal pedis PEDS ASSESS .Copyright © 2006 by F.
temperature. consistency. penile. Stool— inspect for amount. any cyanosis. itchy. amount. rigidity. glucose. Davis. consistency [soft or firm]. sediment or blood present? Test it for—specific gravity. and so on)? Any other type of GI drainage? Abdomen (Inspect. intensity. etc. oily. have child place feet flat on bed or table with knees elevated and place child’s hand under your hand as you palpate and percuss GU ■ Foley (Describe type. does it need to be changed?). any drainage—describe odor. distention. size. Foley care? Any urine? (What does it look like— color. quality]). NG tube (Inspect for patency. when inserted. color) ■ Tongue (is it moist?) 132 . palpate and percuss for size. lesions—location. when did child last have one? To decrease ticklish or tense sensation. pattern. scaly? Skin turgor? Lice? Color of the skin. pH. clarity. purpura.) Do you observe any urethral. pH. how long has it been in. A. color elevation. reducing substance. quaiac. auscultate bowel sounds in all four quadrants. color. color. ■ Rashes. bruising? ■ General skin condition—dry. any suctioning-type. moisture? ■ Note dressings (dry and intact??) ■ Note mucous membranes (hydration. pain [location. PEDS ASSESS GI ■ Start from nose and mouth and work down. guaiac. consistency. vaginal discharge Circumcised? Determine weight of diaper: 1 g 1 cc (first weigh dry diaper and deduct weight of dry diaper) Skin ■ Look at it!! All of it.Copyright © 2006 by F. blanching? Breakdown?? Petechiae.
symmetry. seat belts. sacral dimples or tufts of hair ■ Note strength. no firearms in household Toddler/Preschooler School age Adolescent PEDS ASSESS . and household poisons Pedestrian safety. Davis. Water temperature (water heater setting lower than 130 F). medications.Copyright © 2006 by F. no firearms in household. pedestrian safety. smoke detectors. water safety. sitting. bicycle helmets. and movement of extremities Safety Education Topics for Specific Age Groups Infant Car seats. A. alcohol/drug use. or turning. occupational injuries. ROM in all joints ■ Check spinal curvature and mobility. water safety Auto safety. bath safety Car seats. 133 Musculoskeletal ■ Assess while doing other systems ■ Note if child is walking.
child may say “yes” to any name or give false name to avoid taking medication. do not use name card on bed to ID child—children may switch beds 134 . body surface area (BSA). and route ■ Nurse checks for safety of dosage and route Methods to Determine Safety of Dose Dosage Based on Body Weight ■ Determine child’s weight in kg ■ Establish safe dose from pharmacy text ■ Calculate dose using weight Body Surface Area (BSA) ■ Use nomogram to determine where straight line connects height and weight levels and bisects the BSA ■ Divide the BSA in meters by 1. weight. dosage. do not ask child to verbally identify himself. MEDS/ ACUTE 5 Rights of Drug Administration ■ ■ ■ ■ ■ Right Drug Right Dose Right Time Right Route Right Patient Determining Dosage and Route ■ Variations based on age. A. and maturity of kidneys and liver ■ Physician orders.Copyright © 2006 by F.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. Davis.
or plastic measuring cup ■ Take care to prevent aspiration—hold child’s head up and administer liquids to infant by carefully using a syringe or dropper to place small amounts of med into infant’s cheek. Orogastric. 135 ■ Give choices when possible—”would you like to take your medicine with water or juice?” ■ Ask parent for suggestions regarding how child prefers to take medication ■ Allow parent to give medication if child prefers—be sure to observe while entire dose is administered ■ NEVER leave med at beside Routes for Medication Administration Oral Route (by mouth) ■ Use tool that ensures accurate measurement: calibrated dropper. syringe with needle removed. or Gastrostomy Route ■ Crush pills finely to prevent clogging of tube ■ Check tube placement and infuse slowly ■ After med administration.Copyright © 2006 by F. 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). flush line with water to ensure med has cleared tube and to prevent clogging MEDS/ ACUTE . Davis. A.
A.Copyright © 2006 by F. apply slight pressure to inner puncta for 1 minute to keep drops from draining into nose ■ If child is uncooperative. immobilize child’s head. pull pinna down and back Child 3 yr. Davis. place drop(s) over inner puncta—med will drain into eye when child opens his eye. pull pinna up and back Nasal Route (nose) ■ Ensure that med is room temperature ■ Drops—Tip head back—may use towel roll between shoulders of small child—maintain position for one full minute after administration of med ■ Spray—Child should be seated with head up Rectal Route ■ Suppository may be moistened with water or water soluble jelly ■ Note that children usually consider this to be an invasive procedure—drape child to provide privacy ■ Position child on left side ■ Insert rounded end of suppository gently into rectum ■ Hold child’s buttocks together for 5 minutes to avoid expulsion of med 136 . ■ Explain to child that med may be tasted ■ Ointment—apply from inner to outer canthus Otic Route (ear) ■ Ensure that med is room temperature ■ Position child with affected ear up—maintain position for one full minute after administration of med Child 3 yr. MEDS/ ACUTE Optic Route (eye) ■ Ensure that med is room temperature ■ Drops—Place med in conjunctival sac.
Copyright © 2006 by F. A. 137 Intramuscular (IM). consider desired effect and stability of med to determine whether to administer: ■ Slow IV push (over several minutes) ■ Retrograde infusion (med is injected into a Y-port after temporarily clamping IV line below Y-port) ■ Instilling med into mini IV chamber such as Buretrol or using syringe pump MEDS/ ACUTE . Davis. Intradermal Route ■ Use small syringe to ensure accurate measurement ■ Use proper needle length for size of child and route of administration (needle usually not more than 1 inch) ■ Do not draw up air bubble (clearing med from the syringe’s dead space may result in very small dose being inaccurate) ■ Anticipate resistance from child—enter room with assistant to immobilize child if needed ■ Do not ask parent to immobilize child ■ Ask older child about preference of administration site ■ Tell child that is it okay to cry ■ Complete procedure as quickly as possible ■ Offer bandage after administration ■ Praise child’s efforts Intravenous (IV) Route See comments regarding syringe size and clearing syringe’s dead space under Intramuscular Route If not specified in med order. Subcutaneous (SQ).
Administer EMLA cream or topical vapocoolant spray to injection site prior to giving the injection to decrease discomfort.5–2 mL * Consider amount of body fat when selecting needle length Notes: Use dorsogluteal in children older than 3 years because it takes more than a year of walking to develop larger muscle mass appropriate for this route.5 mL 5/8–1 inch*/23–25 G no more than 1 mL 1 inch*/22–23 G no more than 1 mL MEDS/ ACUTE Copyright © 2006 by F. limit to 1 mL) or ventrogluteal Needle Length/Gauge 5/8 inch*/24–25 G no more than 0. A. 138 . Davis. less painful than vastus lateralis and easily accessible) Deltoid (faster absorption rates than gluteal and less painful. Newborn & Young Infant Infant Toddler Older Children 1 inch*/22–23 G no more than 1.IM Injection Sites Age Group Preferred Site Vastus lateralis Vastus lateralis Vastus lateralis or Ventrogluteal (relatively free of major nerves and blood vessels—large muscle with little subcutaneous tissue.
A.Copyright © 2006 by F.vein Tensor fascia latae Sartorius Vastus lateralis Rectus femorus Vastus lateralis. 139 Pediatric Injection Sites Greater trochanter Femoral nerve. MEDS/ ACUTE . Davis. j (gluteus medius) Anterior superior iliac spine Posterior iliac crest Tensor fascia latae Palm over greater trochanter Gluteus maximus Ventrogluteal. artery.
000 cc 50 cc/kg for each kg 10 kg cc for 24 hours 1500 cc 20 cc/kg for each kg 20 kg cc for 24 hour BSA in m2 Surface Area – Fluid maintenance requirements in mL/day 1500 mL/day/m2 (1500–2000 mL/m2/day) 24 hour total divided by 24 hours rate in milliliters per hour Maintenance Sodium: 2–3 mEq/kg/24 hours Maintenance Potassium: 1–2 mEq/kg/24 hours For initial IV. potassium is generally added to the IV fluids AFTER the child voids 140 . Davis. MEDS/ ACUTE Clavicle Acromion process Deltoid Deltoid. Intravenous Maintenance Fluids Calculations by Body Weight 10 kg in weight 11–20 kg in weight 20 kg in weight 100 cc per kg of weight cc for 24 hours 1. A.Copyright © 2006 by F.
Fluori-Methane median cephalic-lateral vapocoolant spray.Copyright © 2006 by F. cream. posterior netting. median for nonemergent basilica-medial antecubital insertion. fossa. frequently for signs of and along proximal length infiltration or phlebitis on medial foreleg MEDS/ ACUTE . hang extremity: superficial 4 hours’ worth of veins of dorsum of foot.. etc. glucose. IV fluid at any one saphenous vein anterior time (to prevent fluid and superior to the medial overload). Use EMLA anterior ulnar-forearm. Check site malleolus of the ankle. antecubital fossa. 15 gtts/mL depending on brand of tubing—may be used for adolescent Key Monitoring for Child on Parenteral Nutrition ■ ■ ■ ■ Daily weight Weekly height/length Hourly intake and output amounts Every 8 hours note urine specific gravity. or surgical temporal. age group. 20. veins: frontal. upper that will not interfere extremities veins: dorsal with activity for specific hand. Volutrol) in pediatrics Macrodrip Tubing 10. 141 To Calculate IV Rates Total Volume Drop Factor ÷ Infusion Time in Minutes Drops/minutes Microdrip Tubing 60 gtts/mL used in volume control chamber (Buretrol. Choose site auricular. radial vein of wrist. Soluset. superficial arm board. veins of the lower During infusion. and protein Peripheral Intravenous Access In Children Comments Related to Children Available Sites Needle Gauge 20–24 G Veins are more fragile External jugular and scalp so protect with tape. Davis. A.
Basilic v. (newborn only) Great saphenous v. A. Posterior auricular v. Cephalic v. 142 . 5th interdigital v. Preferred sites for peripheral intravenous access and venipuncture in infants and young children. Basilic v. Umbilical v. Median cephalic v. Copyright © 2006 by F. Jugular v. Frontal v. Dorsal venous arch Median marginal v. Sites MEDS/ ACUTE Median antebrachial v.Pediatric I.V. Median basilic v. Dorsal arch Superior temporal v. Cephalic v. Supraorbital v. Davis.
migration. occlusions. Davis. noncompliance. requires site care and frequent flushing with heparinized saline or saline solution Complications related to CVADs include infections. Device—Port-A-Cath medications. TPN. immunosuppression. or blood products. and venous blood sampling and analysis. severe burns. thrombosis. phlebitis. Groshong implantable device but better suited in very small children and infants. bleeding disorders. A. breaks. same type of contraindications as in PICC and not used in child requiring less than 6 mo of intermittent IV therapy External/Tunneled Long-term central venous catheter Catheter—Broviac.Copyright © 2006 by F. TPN. blood products. 143 Central Venous Access Devices (CVADs) Examples of Types Peripherally Inserted Central Catheter (PICC) Comments Related to Use and Contraindications Used for long-term IV antibiotics. chemotherapy. use 19–22 gauge rightangled needle with topical anesthesia to access and typically monthly flushing with heparinized saline solution. used for same purposes as Hickman. contraindicated with inadequate veins. or infections Total Implantable Used for long-term IV fluids. or accidental removal MEDS/ ACUTE . trauma to extremity.
Look listen.3. use jaw thrust only. 43–80. PALS Provider Manual. If collapses suddenly and known cardiac condition—activate EMS. A.4. 144 .PEDS ACUTE Key Points for Pediatric Cardiopulmoary Resuscitation (CPR) 1 yr old Assess responsiveness Open Airway and Assess Breathing Perform Rescue Breathing begin with 2 breaths Assess Pulse Provide Compressions 1–8 yr old 8 yr old Copyright © 2006 by F. Davis. If trauma.5 1&2&3&4&5 Adapted from the American Heart Association. otherwise activate after 1 min resuscitation Determine unresponsiveness then activate EMS No trauma suspected—head-tilt/chin-lift position. pause for ventilation if patient is not intubated 1. American Heart Association. pp.2. (2002). feel 10 sec 1 breath per 3 sec (20/min) 1 breath per 5 sec (12/min) Brachial or femoral 1 finger below intermammary line with 2 fingers depress chest 1/2–1 in—100/min Carotid Heel of hand on lower half sternum and depress chest 1–1 1/2 in—100/min Heel of one hand on top of other hand on lower half sternum and depress chest 1 1/2–2 in— 100/min 15:2 1 & 2 & 3 & 4 & 5… Compression/ Ventilation Ratio Count Sequence 5:1.
American Heart Association. Key Points for Pediatric Choking – Foreign Body 1 yr old Conscious Victim Assess breathing to determine if ineffective or no strong cry 1–8 yr old 8 yr old Ask. active EMS after 1 min rescue effort Open airway and do finger Open airway. 145 PEDS ACUTE . 43–80. reposition head according to age requirements. then 5 chest abdominal thrusts (Heimlich) thrusts Repeat until obstruction relieved or becomes unconscious Child Becomes Unconscious Place child on back. pp. if needed reposition & try again Adapted from the American Heart Association.. Davis. if airway blocked. “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 thrusts Repeat steps until foreign object is removed Unconscious Victim Gently shake to determine “Are you okay?” alertness level If unresponsive.Copyright © 2006 by F. (2002). if see foreign body sweep then remove Give rescue breaths. try rescue breaths again Perform up to 5 subdiaphragmatic Give 5 back blows. 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. A. PALS Provider Manual.
adenosine. toxins/poisons/drugs Treatment: Assess ABCs. hyperthermia. tension pneumothorax. PEDS ACUTE Defibrillation Guidelines Paddle Size Paddle Placement Energy Dose 4. atropine Tachycardia in Children: Definition: “too fast” for age. hypothermia. 8–13 cm for children. HR 60/min in infant and young child with evidence of poor perfusion Causes: Hypoxemia (most common cause). rapid heart rate associated with shock and hemodynamic instability Causes: Hypoxemia.0 Joules/kg for all subsequent attempts Bradycardia in Children: Definition: “too slow” for age. electrolyte disturbances. head injury. 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. ensure patent airway. use 0. treat cause Common Medications Used: Oxygen. hypovolemia. ventilate.Copyright © 2006 by F. monitor vital signs. and follow orders/protocols.5 cm for infants. for cardioversion. toxins/poisons/drugs. may also use vagal maneuvers or cardioversion depending on type of tachycardia 146 . pain Treatment: Assess ABCs. if pulse present–oxygenate. thromboembolism. start IV/IO and oxygenation per order/protocol. epinephrine. if no pulse-initiate CPR. heart transplant. tamponade.5–1 Joules/kg with 2. heart should be situated between paddles 2 Joules/kg for initial defibrillation with 2–4 Joules/kg for all subsequent attempts. Davis. procainamide. attach ECG monitor. A. amiodarone. treat cause Common Medications Used: Oxygen. lidocaine.
Andrassy RJ. tension pneumothorax. administer medications such as amiodarone. 147 Pulseless Arrest in Children: Definition: Complete collapse confirmed by ECG in more than one lead Causes: Hypoxemia. hyperventilate with 100% oxygen.Copyright © 2006 by F. Pediatric Trauma Initial Assessment and Management. acidosis. A. secure airway. lidocaine. electrolyte imbalance. secure IV/IO. p. Davis. drug overdose. and embolism Treatment: Determine pulselessness and begin CPR Ventricular fibrillation or Pulseless ventricular tachycardia: Defibrillation up to 3 times. magnesium per protocol.B. Pediatric Trauma Score Clinical Assessment Child Size Airway Score 20kg Normal 2 Score 1 Score 1 10–20 kg Maintainable 50—90 mm Hg 90 mmHg Systolic Blood Pressure Awake Central Nervous System Open wound None Skeletal None 10 kg Not maintainable 50 mmHg (no pulse) Coma. Philadelphia: W. Asystole/Pulseless Electrical Activity: CPR. continue CPR. hyperventilate with 100% oxygen. PEDS ACUTE . Saunders. secure airway and IO/IV. decerebrate Major penetrating Open/Multiple fractures Obtunded/loss of consciousness Minor Closed fracture From Ford EG. 112. administer epinephrine per protocol and treat cause. hypovolemia. (1994). cardiac tamponade.
sweaty.Copyright © 2006 by F. insulin. changes in affect. gait disturbances. Davis. slurred speech. light-headed. K Symptoms Blood Glucose Levels Treatment Give glucose. sleepiness. PEDS ACUTE Cardinal Signs of Respiratory Failure ■ ■ ■ ■ ■ ■ Restlessness/Altered LOC Tachypnea Tachycardia Evidence of ↑ Work of Breathing Cyanosis Diaphoresis Recognizing Abuse/Neglect in Children ■ ■ ■ ■ ■ Physical signs of abuse/neglect reported by child Repeated ED visits/previous history of abuse Parents blaming siblings for injury Inappropriate response to injury by child/caregiver to injury Inconsistency between physical findings and cause of injury or injury and child’s development Emergencies Related to Diabetes Hypoglycemia Causes Too much insulin. hungry. confusion. weak. infection. palpitations. increased appetite. unconsciousness. increased urination. seizures 60 mg/dL Hyperglycemia Stress. dizzy. visual changes. too little insulin Increased thirst. IV/PO 148 . decreased energy level Fasting: 240 mg/dL Random: 300 mg/dL Give IV fluids. A. delayed food intake. exercise without adjustment Shaky. weight loss.
or other similar drugs may be combinations. use anticonvulsants. Use anticonvulsants such as carbamazepine or phenytoin to control seizures. or flushing. carbamazepine. Violent total body tonic then clonic movements with aura and postictal response. no aura and LOC alteration. loss of consciousness. lasts 5–10 sec. Davis. phenytoin. no postictal response. anticonvulsants/ketogenic diet. Muscles maintain continuous contracted state (rigid posture) with variable loss of consciousness.Copyright © 2006 by F. eyelids twitching. Sudden onset. Phenobarbital. may need more than one drug. Starts in one focal area and spreads to both hemispheres. description and frequency of corresponding events. and any specific meds Type Types of Partial: Simple Description & Treatment Confined to one hemisphere—change in posture. loose responsiveness but no falling. Opposite muscles contract/relax in rhythmic pattern. postictal response. 149 General Types of Seizures Obtain Seizure History: type. (Continued text on following page) Complex Types of Generalized: Absence (petit mal) Clonic Tonic Tonic-clonic (grand mal) PEDS ACUTE . use anticonvulsants. hallucinations. aura may occur. Use anticonvulsants such as carbamazepine and phenytoin to control seizures. typical frequency. lip smacking. A. consciousness not completely lost—confusion. may occur in one or more limbs. auras experienced before seizure.
Copyright © 2006 by F. A. Davis.
General Types of Seizures (Continued)
Description & Treatment
Drop and fall attack with loss of posture tone. Must wear helmet and use anticonvulsants. Elevated temp leads to seizure activity 5 minutes in young infants and children, generalized, transient and nonprogressive. Treat underlying illness/fever, diazepam PO, monitor for neurological deficits. Prolonged or repetitive seizures without interruption lasting longer than 30 minutes that results in anoxia, cardiac and respiratory arrest; loss of consciousness. Assess airway, breathing, circulation. IV glucose and other drugs such as diazepam, phenytoin, phenobarbital used to control problem within 20–60 minutes, correct metabolic problems, may start midazolam drip, treat underlying cause, establish maintenance anticonvulsant drugs.
Types of Miscellaneous: Febrile
For All Seizures: Do: Stay with child; call for help; move to flat surface out of danger; position on side with head supported and clothing loosened. Maintain patent airway; record seizure activity and assess neurological status and vital signs; document time started and ended, aura–if present, color change, presence of incontinence, oral tissue damage (if any), postictal (postseizure) response. Do Not: Try to interrupt seizure or restrain child; use tongue blades.
Copyright © 2006 by F. A. Davis.
Degree and Signs of Fluid Deficit (Dehydration) in Children Common Clinical Signs
Mild ( 5% loss of body weight)
Moderate (5%-9% loss of body weight)
Pale, mottled, cool Decreased
Severe ( 10% loss of body weight)
Mottled to cyanotic, cool Markedly decreased, tenting Sunken, no tear production Very dry and cracked Sunken
Mucous membranes Anterior fontanel (if still open) Heart rate
Slightly dry Normal
Appears sunken, poor tear production Dry Slightly depressed Increased
Respiratory rate Blood pressure Capillary refill Mental status Urine output
Normal Normal Normal Alert but may be irritable Decreased
Increased Slight decreased Slight delay Irritable, restless Oliguria
Increased, pulse often not palpable Increased Decreased Delayed ( 4sec) Lethargic to comatose Oliguria to anuria
Copyright © 2006 by F. A. Davis.
Calculation of Deficit Water & Electrolytes
■ Water Deficit % Dehydration Child’s Weight ■ Sodium Deficit Water Deficit 80 mEq/L ■ Potassium Deficit Water Deficit 30 mEq/L
From Behrman RE, Kliegman RM, Jenson TB. (2004). Nelson Textbook of Pediatrics (17th ed.). Philadelphia: W.B. Saunders, p. 247.
Type of Dehydration Based on Electrolyte Deficits Type of Deficit
Isotonic Hypotonic Hypertonic
Serum Sodium Level
130–150 mEq/L 130 mEq/L 150 mEq/L
Oral Rehydration for Mild to Moderate Dehydration
Use solution such as WHO solution or Rehydralyte: ■ 50 mL/kg over 4–6 hours—mild dehydration ■ 100 mL/kg over 4–6 hours-moderate dehydration ■ 10 mL/kg or 4–8 oz of ORS for each diarrhea stool ■ If vomiting: 5–10 mL every few minutes
Adapted from Behrman, p. 250.
Quick Restoration of Circulatory Volume:
■ If 10% dehydration—fluid boluses intravenously ■ 20 mL/kg of crystalloid solution such as normal saline over 20 minutes, or ■ 10 mL/kg of colloid solution such as 5% albumin ■ Continue as ordered until clinical status improved
Adapted from Behrman, p. 247.
IO. IO 0. IO Diazepam (5 mg/ml) Slow IV. IO Dose in mg 0. (maximum single dose 12 mg) repeat q 2–3 min 5 mg/kg/dose. Davis.2 mg/kg/dose. 10 mg in 5 yr) (Continued text on following page) PEDS ACUTE . Vtach. use with caution. 2 mg in adolescent) 10–30 mg/kg/dose of 10% Ca Chloride. treat hypocalcaemia. IO IV. ET 153 CaChloride 10% (100 mg/ml) Slow IV. A.01–0. may repeat q 2 minutes (maximum dose 1 mg children. (maximum dose 15 mg/kg/day) may infuse IV 20–60 min 0. SVT especially artial F Anticholinergic used for bradycardia and to restore normal heart contraction during cardiac arrest Electrolyte used to maintain cardiac contractility.2 mg/kg/dose (maximum single dose 5 mg in 5 yr.1–0. Anticonvulsant used to treat seizures and for intubation Route Rapid IV.Copyright © 2006 by F. hypomag. not for asystole Rapid IV.1–0.4 mg/ml) Use Antiarrhythmic especially for SVT Antiarrhythmic—prevent or treat Vfib.02 mg/kg/dose. Selected Emergency Drug Information Drug Adenosine (3 mg/ml) Amiodarone Hydrochloride Atropine Sulfate (0.
000 (1. A.5–15 mcg/kg/minute (see drug insert for further instructions) 2–20 mcg/kg/minute (see drug insert for further instructions and infusion) Copyright © 2006 by F. Vfib See above Route IV. ET 0. IO Epinephrine 1:10.000 (0.1–1 g/kg/minute) (Continued text on following page) 154 . this concentration is first drug of choice for pediatric arrest 0. Dopamine (40 mg/ml) IV. sympathomimetic used to treat asystole.5 mg/ml) Use Beta-adrenergic agonist used to depress myocardial contractility Beta-adrenergic agonist–vasopressor in cardiogenic or septic shock or to maintain renal perfusion Adrenergic agonist.2 mg/kg/dose. IO IV.01 mg/kg/dose.1–0. bradyarrhythmias. second and subsequent doses. IM. IO.0 mg/ml) IV. Davis.PEDS ACUTE Selected Emergency Drug Information (Continued) Drug Dobutamine (12. repeat 3–5 min (may also infuse at 0. IO infusion Dose in mg 2.1 mg/ml) Epinephrine 1:1.
IO Refer to pharmacological inserts and other resources for complete information regarding drug use. ET Dose in mg 0. p. IO Naloxone (Narcan) (1 mg/ml) Narcotic antagonist used for narcotic overdose IV. Deterding RR. ET dose 2.to 10-fold higher 155 Na Bicarbonate (1 mEq/ml) dilute 1:1 with saline Electrolyte used to correct metabolic acidosis Slow IV. Current Pediatric Diagnostic Treatment (17th ed. New York: Lange Medical Books/McGraw Hill. 324. Adapted from Guidelines 2000 for Cardiopulmoary Resuscitation and Emergency Cardiovascular Care.). A. side effects.1 ml/ kg-10 mg/ml concentration) Use Antiarrhythmic Route Rapid IV. American Heart Association.5–1 mg/kg bolus. PEDS ACUTE . kg base deficit efficient dosing 5 yr: 0. Sondhelmer JM. (maximum dose 3 mg/kg) Infusion 10–50 g/kg/min of 20 mg/ml solution 0. contradictions. etc. IO. (2005). ET. Selected Emergency Drug Information (Continued) Drug Lidocaine (0. and Hay WW.3 wt.0 mg/kg/dose.repeat 5–10 min only if oxygenated and ventilated 0.1 mg/kg/dose.5–1 mEq/kg/dose.Copyright © 2006 by F. 5 yr: 2. Levin MJ. Davis. repeat 2–3 min to 10 mg.
PALS Provider Manual. American College of Obstetricians and Gynecologists Office of Communications. ACOG Practice Bulletin No. 2005.). 258). (2003). Cancer prevention and early detection worksheet for women. Cervical cytology screening. & Jenson TB.Copyright © 2006 by F. Pediatric defibrillation: Importance of paddle size in determining transthoracic impedance. American College of Obstetricians and Gynecologists.asp. Breastfeeding: Maternal and infant aspects. (2003). (Practice Bulletin No. Can breast cancer be found early? Cancer reference information: American Cancer Society. 82: 914–918. from http://www.acog.com/from_home/publications/press_releases/ nr09-03-04-2. Saunders. (Educational Bulletin No. Washington DC: Author. (2004). ACGOG issues state-of-the-art guide to hormone therapy: Experts expand prior post-WHI advice on estrogen ACOG News Release: September 30. (2002). et al. 156 . (2004). Behrman RE. TOOLS Selected References American College of Obstetricians and Gynecologists. A.B. Management of preterm labor. American Heart Association.cancer. (1988). Washington DC: Author.cfm. Atkins DL.org/docroot/CRI/content/CRI_2_4_3X_Can_ breast_cancer_be_found_early_5. American Cancer Society. (2000). 43). 45. (2004).asp. September. Retrieved March 4. 2005. Washington DC: Author. Davis. American College of Obstetricians and Gynecologists Office of Communications.org/docroot/PED/content/PED_4_1x_Cancer_ Prevention_Worksheet_for_Women_pdf. Philadelphia: W.cancer. from http:// www. (2005). American Heart Association. Retrieved March 4. 2004. Retrieved August 4. Nelson Textbook of Pediatrics (17th ed. 2004. Pediatrics. from http://www. Kliegman RM. 2005. American Cancer Society.
Centers for Disease Control (CDC)-Growth Charts. Philadelphia: W. Louis: . (2004). Hazinski MF (1999). Hay WW. (1994). RR-6).gov/growthcharts Centers for Disease Control (CDC).). Hahn YS. St. . Circulation. Stewart F Nelson A. (1988). Louis: Mosby. Company. Contraceptive Technology (18th ed. et al. Mosby. 4: 34. Pediatric Trauma Initial Assessment & Management. Cates W. . (2004). Sexually transmitted disease guidelines 2002.A. 157 Binder R.A. Ford EG.cdc. (2002).). (2004). National Center for Chronic Disease Prevention & Health Promotion. A. Pediatric Drug Guide with Nursing Implications (p. Child Nervous System. Chameides L. Nurse’s Fast Facts. Philadelphia: F A.Copyright © 2006 by F. Hatcher R. & Andrassy RJ.). Case Studies Approach. Nursing Health Assessment: A Critical Thinking. Hockenberry MJ. (2005). Dillon PM. 32: 302–312. Philadelphia: F Davis . Curran C. (2005). Upper Saddle River. Inc. MMWR 2002. et al. Davis. Holloway BW. (2003). Intrapartum emergencies. Guest F et al. Guidelines for defibrillation in infants and children: report of the AHA target activity group: Cardiopulmonary resuscitation in the young. Trussell J. (2003). NJ: Prentice Hall. (1977). & Howry L. Manual of Pediatric Critical Care. New York: Ardent Media. St. Philadelphia: F Davis . TOOLS . 1–56). et al. JOGNN. Davis . www. Brown K. 51 (No. Current Pediatric Diagnosis and Treatment (17th ed. 56: 502A–503A. Company. Saunders. (2003). Head injuries in children under 36 months of age.B. Wong’s Nursing Care of Infants and Children (7th ed. (last reviewed 5/30/00). New York: Lange Medical Books/McGraw-Hill. Company. Management Guidelines for Nurse Practitioners Working with Women (2nd ed.).
Center for Nutrition Policy and Promotion. Lung. Core Curriculum for MaternalNewborn Nursing (3rd ed.).cdc. Murray M. www.). 70: 802. Shelton TL. (2004). Louis: Elsevier. Martin E. St. Roberts J. Davis. Louis: Mosby. (last reviewed 6/08/05). (2004). Lowdermilk D & Perry S.gov. & Smith J. How to identify and manage preeclampsia. Observation scales to identify serious illness in febrile children. Family-Centered Care for Children Needing Specialized Health and Developmental Services. 32: 794–800. Dept. Reif M. Pediatrics. Women’s Health Gynecology Edition. U. Division of Nutrition & Physical Activity. & Stepanek J. 158 . Author: Bethesda. (1986). et al.).gov/nccdphp/dnpa/ bmi/oobinaries. The FLACC: A behavioral scale for scoring postoperative pain in young children. (1987). 15: 17. 93–104. New Food Guide Pyramid for Children. MBI for Children & Teens. Mattson S. MD. National Heart. (2002). TOOLS James HE. (1994). Merkel S. 23(3): 293–297. St. A new understanding of the second stage of labor: Implications for nursing care. (1997).S. January/February. (2004).Copyright © 2006 by F. (2003). A. Maternal or fetal heart rate? Avoiding intrapartum misidentification. Neurologic evaluation and support in child with acute brain insult. 3: 249–255. Association for Care of Children’s Health. et al. Philadelphia: Lippincott Williams & Wilkins. JOGNN. National Center for Chronic Disease Prevention & Health Promotion. (1982). and Blood Institute. Pediatric Annals. McCarthy PL. Intrapartum Management Modules (3rd ed. JOGNN. of Agriculture. Maternity and Women’s Health Care (8th ed. Normal Blood Pressure Readings from the Second Task Force on Blood Pressure Control in Children. Pediatric Nursing.mypyramid. www. (2003).
S.html. from http://www. .). Perry S. U. 2005.gov/fdac/features/2001/301_preg. May-June 2001. FDA approves new labeling and provides new advice to postmenopausal women who use or who are considering using estrogen and estrogen with progesterone. (2002). & Creehan P (2001). The Guide to Clinical Prevention Services. St.Copyright © 2006 by F.gov/clinic/uspstfix. Obstetric and Neonatal Nurses’ Perinatal Nursing (2nd ed.). (2005). Association of Women’s Health. Food and Drug Administration. U. Retrieved August 31. Retrieved August 12. Maternal Child Nursing (2nd ed.htm.S. Retrieved June 27.fda.S. FDA Fact Sheet. 2005.ahrq. (2003). FDA Consumer magazine. from http://www. & Hockenberry M. A.html. (2005). Wong D.gov/oc/factsheets/WHI. U. (2001). 142(10): 855–860. Hormone therapy for the prevention of chronic conditions in postmenopausal women: Recommendations from the U. Louis: Mosby. Prevention Services Task Force.fda. Food and Drug Administration.S. TOOLS . Davis. Preventive Services Task Force (USPSTF). from http://www. American College of Physicians. 159 Simpson K. Pregnancy and the drug dilemma. 2005. Silver Spring: Agency for Healthcare Research and Quality Publications. Philadelphia: Lippincott.
Kliegman RM. SZ. (1994) 160 . Jenson TB: Nelson Textbook of Pediatrics. 36. 79 from Ross Products Division Abbott Laboratories Inc. PL. Pediatric Trauma Initial Assessment & Management. 84 from Dillon PM: Nursing Health Assessment: A Critical Thinking. 1988 Page 120 from Merkel S. The FLACC: a behavioral scale for scoring postoperative pain in young children. et al: Head injuries in children under 36 months of age. 2003 Pages 78. Philadelphia: WB Saunders. Pediatric Nursing.) New York: Lange Medical Books/McGraw-Hill. 17/e. Voepel-Lewis T. Sharpe. TOOLS Illustration Credits Pages 5. Observation scales to identify serious illness in febrile children. A.Copyright © 2006 by F. 152 from Behrman RE. S. The Regents of the University of Maryland. Page 125 from McCarthy. Andrassy RJ. Philadelphia: W. p. 23(3): 293–297. Child Nervous System. 78:802 Page 147 from Ford EG. 25.B. 4:34. Davis. Philadelphia. Copyright 2002. et al: Current Pediatric Diagnosis & Treatment (17th Ed. Shayevitz J. Spiesel. 35. et al (1982). 2004 Page 112 from Hahn YS. 2005 Pages 110.112. Page 109 from Hay WW. MR. Case Study Approach. FA Davis. Saunders. Pediatrics. 54. 6. Malviya.
69 Apnea monitors. 99 Bed/crib choices. 94 Breast self exam (BSE). TOOLS Index Note: Page numbers followed by “f” and “t” indicate figures and tables. spontaneous. 82 engorgement. pediatric. teaching tips. 81 C Calcium chloride. 41 Abruptio placentae. 90 Adenosine. 16 160 . 115f Cardiopulmonary resuscitation (CPR). for children. 114 electrode placement for. A. 144 Cardiovascular health. promotion of. pediatric. 109 Cancer. 100–102 Bowel. by age group. assessment of. key points for. of fertility awareness. fertility awareness and. 5f. 114 electrode placement for. 146 fetal. 153 Amniotomy. pediatric. 122 Biophysical profile (BPP). 79f. A Abortion. Davis.Copyright © 2006 by F. 97 postpartum. Bradycardia in children. 58 Breast. 72–73 Apgar score. 80 breast care during. 5–7. 112 BMI. 148 Activity level in newborn. respectively. 51 Bishop’s score. infection of (mastitis). 86 Blood pressure. child. 6f Breastfeeding advantages to. 115f Atropine sulfate. calculation of. 45f Abuse. 81 positioning. See Body mass index Body mass index (BMI) pediatric. 9 Caloric requirements. normal ranges. 153 B Basal body temperature. See HIV Amiodarone. 80 pumping and storing. teaching tips. See specific types Cardiac monitors. 86 BPP See Biophysical profile . 81 supply and demand. postpartal status. 109 Bottle feeding. newborn. 44. 153 AIDS. 153 Calendar method. 9 Bathing. 71 Bladder. 81 nutrition during. postpartal assessment.
98 Condoms. quick evaluation of. 17 Coma scale. 114 Central venous access devices (CVAD). 148 Children caloric requirements for. 123–124 use of play for. 129 respiratory. 11–14 contraindications to. 133 sick. fertility awareness and. Davis. teaching tips. 14–15 lactation amenorrhea method. 105t–108t pain in developmental differences in. 119 questions in assessment of. 7 emergency. by age group. 15–16 TOOLS . 75 postpartal assessment in. teaching tips. 9 Cervical ripening. 102–103 Clonic seizures. ACOG/ACS guidelines for. 112 Communication with child and family. 133 neuromuscular. 130. 149 Colorectal cancer. 129–130 respiratory equipment. 125 systemic assessment. 12 intrauterine system. 132 musculoskeletal. pediatric suction. 15 fertility awareness methods. 10 permanent methods. 3t Choking. 132 genitourinary. 117 responses to illness/hospitalization. pediatric. pediatric. by age group. 91 vaginal birth after. 129 cardiovascular. 8–9 hormonal methods. 11–12 Contraception barrier methods. 143 Cervical cancer screening. A. 130 heart sounds and peripheral pulses. recognizing. by age group. 1 Cervical mucus. 126t–127t in newborn. 73–74 Child abuse. 130 skin. 10–11 educating women on. 161 Cardiovascular system. 131f Catheters. 72 Cesarean birth. 126t–128t developmental milestones in. symptoms and detection. 109 communications with. 105t–108t Chlamydia.Copyright © 2006 by F. key points for. 131t gastrointestinal. assessment of. 116t–117t safety education topics. 118 nursing interventions related to management of. 145 Circumcision. 132 10-minute assessment of. early signs of.
pediatric cardiac/apnea monitors. 146 Dehydration. 94 Epinephrine. 136 rectal. calculation of. 136 subcutaneous. 41 Electrode placement. 154 Drug administration. 154 Dopamine. 134–135 5 rights of. 134 routes of determination of. 10 Diazepam. pediatric guidelines. 97 in postpartal patient. 20 Depo-medroxyprogesterone (DMPA). 136 oral. 8 Endometritis. 154 Estrogen contraindications to. TOOLS intramuscular. 14 Developmental milestones 0–1 year. 153 DMPA. 142f nasal.Copyright © 2006 by F. 108 Diabetes emergencies related to. 134 intradermal. 89 F Family planning. See Cardiopulmonary resuscitation CST. 137 E Eclampsia. See Contraception Fears. 137 sites for. 137 sites for. 137 162 . 48 Ectopic pregnancy. 140f intravenous. Davis. 106 3–6 years. 96 Defibrillation. in children as response to illness/hospitalization. 139f. 89 Endometrial cycle. 95 signs of. 108 12–18/21 years. See Depo-medroxyprogesterone Dobutamine. 151 water/electrolyte deficit. 152 Emotional response. 11 Extremities. 105 1–3 years. estimated date of. 115f Electrolyte/water deficit. See Contraction stress test CVAD. postpartal assessment of. A. pediatric degree/signs of. 107 6–12 years. 116–117 Febrile seizures. 88 support for. 136 nasogastric/orogastric/ gastrostomy. teaching tips. 152 Delivery. 135 optic. See Central venous access devices D Deep venous thrombosis. 12 effects of. 49–50 Diaphragms. calculation of. assessment of in newborn. 148 gestational. 135 otic. 50–51 CPR. 150 Contraction stress test (CST).
48–49 Hemorrhage. teaching tips. 54–55 nursing responsibilities in. 41–42 Gonorrhea. A. 60–61. 104 Genitourinary system. 54f FLAAC pain assessment tool. 57f continuous external. 131f HELLP syndrome. 4t History(ies) intrapartum. 54 Fetoscope. 11 combined methods. in postpartal patient. See Dehydration Food pyramid. 120t Fluid deficit. 100 Fundus height of. 3t Grand mal seizures. 4t Hormonal contraceptives. Doppler placement for. concerns by age group. 60f late decelerations. 128 prenatal health.Copyright © 2006 by F. 62 variable decelerations. 132 Gestational trophoblastic disease. 61f evaluation of. 12 Hormonal replacement therapy (HRT). 83f postpartal assessment of. by age group. 58–62 accelerations. 24 massage of. infant. 56. 60f nursing interventions for. 59. 163 Fertility awareness methods. 59. 31f Formula. 116–117 TOOLS . 132 Genetic screening. 55f internal. 12–14 contraindications to. 149 H Health maintenance. 84–85 G Gastrointestinal system. 36f Fetal monitoring baseline heart rate changes to. fetal changes to baseline. 18 Hospitalization. 103 Heart rate. 3t Herpes simplex virus (HSV). 56 normal. 61. 25f by weeks of gestation. Davis. 21–22 HIV. assessment of. symptoms and detection. in newborn. 58–62 evaluating. assessment of. 56f intermittent auscultation. 52–53 pediatric. 2 symptoms and detection. 92–93 Hepatitis. 59f early decelerations. children’s responses to. symptoms and detection. in newborn. 57f Heart sounds. symptoms and detection. 8–9 Fetal heart tones (FTH). teaching tips.
116–117 HPV. in children as response to illness/hospitalization. teaching tips. 141. 63 placenta delivery (stage 3). 46–47 systemic pain medications in. See Human papillomavirus HRT. 14–15 164 . 137 intramuscular sites. 86 assessment of. 62–63 nursing care in. 104 in newborn. Davis. 10 LAM. 88 L Labor active phase (stage 1). See Intrauterine device K Kegel exercises. 35f Lidocaine. peripheral. See Lactation amenorrhea method (LAM) Leopold’s maneuver. 116–117 Immunizations genetic and hearing screen. 67–69 fourth stage. pediatric. 155 Lochia. 111 vital signs.Copyright © 2006 by F. by age group. 3t Hyperemesis gravidarum. 93–94 Injections intradermal. 142f Intravenous maintenance fluids. 148 Hysteroscopic tubal sterilization. 138. A. 137 Intrauterine device (IUD). 85 Loss of control. introduction of. 142f subcutaneous. 45 Hyperglycemia. TOOLS Intravenous access sites. 137 sites for. 148 Hypoglycemia. teaching tips. 104 Infants developmental milestones. 2 symptoms and detection. 65 transition phase (stage 1). 76 induction of. See Herpes simplex virus Human papillomavirus (HPV). 70 preterm. 64–66 epidurals in. 66 expulsion (stage 2). 110 See also Newborns Infection. 16 I Illness. 140f intravenous. 71–73 latent phase (stage 1). 105 feeds. 141 IUD. in postpartal patient. 109 food types. 87 normal progression of. 140 of IV rates. 66–67 Lactation amenorrhea method (LAM). calculations by body weight. children’s responses to. 139f. See Hormonal replacement therapy HSV. number/volumes. 64 monitoring contractions.
child. assessment of. 165 M Mastitis. 42. 117 Parenteral nutrition calculations by body weight. 109 food pyramid. 17 Menstrual cycle. education on. 103 sleep patterns. A. 119 questions in assessment of. assessment of. 133 N Naegele’s Rule. Davis. 68–70 nursery care of. 147 Perineum. 140 Pediatric coma scale. 155 Neglect. 140 of IV rate. postpartal assessment. 118 FLAAC assessment tool. 50 NST. 85 Musculoskeletal system. 100–102 circumcision. 97 Nonstress test (NST). 87 Petit mal seizures. See Nonstress test Nutrition of children. 112 Pediatric trauma score. 78f. teaching tips bathing/skin care. 18 symptoms of. 129 Newborns breastfeeding of. 45 TOOLS . 20 Naloxone.Copyright © 2006 by F. See Oxytocin challenge test Osteoporosis. caloric requirements. 94 Menopause hormonal replacement therapy in. 149 Pitocin. 16 Ovarian cycle. 104 safety and health maintenance. 7 postpartal return of. 31 O OCT. See Oxytocin Placenta previa. 79f care of. prevention and treatment of. 102–103 communication. 31f in pregnancy. 120t nursing interventions related to management of. 148 Neuromuscular system. 98 reportable symptoms. 99 bottle feeding. in induction of labor. 71–72 Oxytocin challenge test (OCT). 43f. 97 physical assessment of. 141 keys for monitoring child on. 98 umbilical cord care. 8 Oxytocin. 50–51 P Pain developmental differences in children related to. 100 immediate care of. 79–82.
assessment of. A. scheduling of. prenatal visits. 77 in breastfeeding. 85 sexuality in. type/purpose of. 121–122 Postpartum blues/depression. by age group. 23 low-risk. 7 Preeclampsia. 94–95 signs of. 31. 85 uterine involution in. 28 establishing. 33 fetal surveillance in. 92–93 infection. 28t–29t on exercise.Copyright © 2006 by F. 83–84. 34 weight gain in. 77 cesarean. 38–40 sexuality in. 27–28 education in. 91 nursing assessment of. 43f. 47–48 preterm labor. 45 166 . 33 Prenatal visits first diagnostic tests for. 78–82 emotional response. 23 second/third trimester. 89. 20 early diagnostic testing in. 21–22 nursing care with. 20 warning signs during. assessment/support of. 42 delivery date estimating in. 50–62 biophysical profile. 48 gestational diabetes. 42. 31 common laboratory tests in. 47–48 Pregnancy classification of medications in. education in. 34 teratogen exposure in. teaching tips. 21 physiological changes in. 19 exercise in. 50–51 nonstress test. 30 trimesters of. 50 hormonal changes in. TOOLS preeclampsia. 33 on nutrition. 24 patient education in in early prenatal period on discomforts/ reportable symptoms. 91–92 complications in hemorrhage. 51 contraction stress test. 96 Postpartum patient breast assessment. 44f eclampsia. 49–50 HELLP syndrome. 93–94 education of. 26 complications in abruptio placentae. Davis. 45 placenta previa. 84f Preconception counseling. 88–89 laboratory data in. 76–77 return of menstrual cycle in. 26 history taking in. 32f Play. 48–49 hyperemesis gravidarum. 46–47 vaginal bleeding.
99 Skin cancer. symptoms and detection. assessment of. 12 effects of. 152 Respiratory failure. 30 TOOLS . 114 Syphilis. in children. 131f R Rehydration. in children as response to illness/hospitalization. teaching tips. 11 single agent preparations. peripheral. pediatric. 148 Respiratory system. 4t T Tachycardia in children. 34 on weight gain. 37 nursing care for. 21 Preterm labor. 3t–4t Skin assessment of. 150 STDs. by age group. A. See Sexually transmitted diseases Suctioning. 167 on sexuality. 17 Sleep patterns. cervical cancer. 121–122 Screening. 114 Pulseless arrest. Davis. 123–124 in newborn. 103 of toys. early detection/prevention of. cardinal signs of. 33 in second/third trimester. 58 Teratogens. 38 on discomforts/ reportable symptoms. 85 in pregnancy. 155 Status epilepticus. 132 care of. 116–117 Serum pregnancy test. teaching tips. 134 education topics. 30 on warning signs. 133 in infant/child assessment. in newborn. general types of. 46–47 Progestin contraindications to. 14 Pulse oximetry. 129–130 S Safety of drug dose. 39t–40t return diagnostic tests for. 98 Sodium bicarbonate. in pregnancy. 149–150 Separation anxiety. 2. 34 on teratogen exposure.Copyright © 2006 by F. education on. teaching tips. pediatric. 147 Pulses. 34 Sexually transmitted diseases (STDs). by age group. in newborn. 1 Seizures. 19 Sexuality postpartal. ACOG/ACS guidelines for. determination of. 146 fetal. 35–36 scheduling.
152 Water requirements. symptoms and detection. in establishing pregnancy.Copyright © 2006 by F. safe. 83 subinvolution signs. pediatric. 110 postpartum. in pregnancy. 97 pediatric. 33 Weight loss. A. promotion of. pediatric. pediatric. teaching tips. 3t Tubal ligation hysteroscopic. 91 Weight management. 73–74 Vaginal bleeding. 90 W Water/electrolyte deficit. 110 Urine pregnancy test. teaching tips. 1 Thrombophlebitis. 96 Tonic seizures. 142f Vital signs newborn. 96 168 . teaching tips. 19 Uterus infection of (endometritis). in postpartal patient. in pregnancy. Davis. 93–94 Urine output. score. 19 Umbilical cord care of. 95 signs of. 16–17 nurses’ role in. average ranges. health promotion in. 15 U Ultrasonography. by age group. at birth. 42 VBCA. 110 Weight gain. 94 involution of. See Vaginal birth after cesarean Venipuncture sites. calculation of. 147 Trichomoniasis. TOOLS V Vaginal birth after cesarean (VBAC). pediatric. 16 incisional method. 149 Toys. 100 prolapse of. 74 Urinary tract infection. 16 Women. 121–22 Trauma.
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