MATERNAL

and CHILD
NURSING
WEEK 4
PATELLAR REFLEX

PURPOSE:
To evaluate sensation in a specific
area of the body as well as cranial
nerves, spinal cord and deep
tendon reflex.
PATELLAR REFLEX

ASESSMENT:
1. Complete a health history,
focusing on the neurologic and
musculoskeletal system
PATELLAR REFLEX

ASESSMENT:
2. History of presence of pain and
numbness in the upper
extremities as well as onset of
aggravating and alleviating
factors
PATELLAR REFLEX

ASESSMENT:
3. Assess the client’s level of
consciousness and ability to
follow instructions
PATELLAR REFLEX

ASESSMENT:
4. Identify the medications taken by
the patients (specifically MgSO4
for Pre-Eclamptic Patients)
PATELLAR REFLEX

PROCEDURE
1. Locate the patellar tendon in the
midline of the anterior leg just
below the knee cap.
2. Strike it firmly and quickly with a
reflex hammer or the side of your
hand
PATELLAR REFLEX
YOUTUBE LINK
FINDINGS
0 No response: hypoactive; abnormal

1+ Somewhat diminished response but not abnormal

2+ Average response

3+ Brisker than average but not abnormal

4+ Hyperactive; very brisk; abnormal

PATELLAR REFLEX
YOUTUBE LINK
FINDINGS
0 No response: hypoactive; abnormal

1+ Somewhat diminished response but not abnormal

2+ Average response

3+ Brisker than average but not abnormal

4+ Hyperactive; very brisk; abnormal

GESTATIONAL HYPERTENSION
BLOOD SYSTOLE DIASTOLE PROTEINU EDEMA
PRESSUR RIA
E
140/90mm
>30mmHg >15mmHg Negative Negative
Hg

BP RETURNS TO NORMAL AFTER BIRTH!

PREECLAMPSIA WITHOUT SEVERE
FEATURES
BLOOD
PROTEINU
PRESSUR SYSTOLE DIASTOLE EDEMA
RIA
E
1+ or 2+ on Mild on
140/90mm
>30mmHg >15mmHg random upper
Hg
sample extremities

WEIGHT GAIN:
• more than 2 lb/week in 2nd trimester
• 1 lb/week in 3rd trimester
PREECLAMPSIA WITH SEVERE
FEATURES
BLOOD
PROTEINU
PRESSUR OTHER SYMPTOMS EDEMA
RIA
E
• Oliguria (500mL or 3+ or 4+on
less in 24 hours) random
• Altered renal function sample
tests (elevated serum
creatinine more than 5g on 24
1.2 mg/dL) hour
NORMAL: 0.84- sample
1.2mg/dL
• Visual disturbances Extensive
160/110
peripheral
mmHg • Pulmonary or cardiac
edema
involvement
ECLAMPSIA

SEIZURE OR COMA
accompanied by signs and symptoms of
preeclampsia
OTHER ASSESSMENT

ANKLE CLONUS
QUESTION
The nurse routinely assesses all pregnant women for signs of hypertension
while interviewing them at the prenatal clinic and then documents the
findings in the electronic health record. Which statement by Beverly would
the nurse document as possible evidence that she might be developing
gestational hypertension?

A. “My feet are so swollen at night I can’t put on my bedroom slippers.”

B. “I never guessed I would feel as tired as I do just from being pregnant.”
C. “My abdomen feels firm, as if I had a blown-up balloon inside me.”
D. “I can live with my puffy feet, but now it’s also my hands and wrists.”
 D.
The nurse recognizes that edema is often a first
symptom of gestational hypertension a woman notes.
The edema associated with gestational hypertension can
be separated from the typical ankle edema of pregnancy
because it begins to accumulate in the upper part of
the body as well. Beverly’s other statements are not
necessarily indicative of gestational hypertension.
 PRELIM SKILLS

1 HAND
WASHING
3 MONITORING
INTAKE & OUTPUT
DONNING &

2 REMOVING
MAGNESIUM
PPE
SULFATE
4 CBG
MONITORING
ADMINISTRATIO
TESTING OF
N
PATELLAR
 3
NTAKE & OUTPUT
MONITORING
INTAKE AND OUTPUT

DEFINITION:
Measurement and recording of all
fluid intake and output during a
24-hour period provides
important data about the client’s
fluid and electrolyte balance
INTAKE AND OUTPUT

DEFINITION:
Unit of measurement of intake and
output is mL (milliliter)
Sometimes its cc (cubic
centimetre)
INTAKE AND OUTPUT

DEFINITION:
Unit of measurement of intake and
output is mL (milliliter)
Sometimes its cc (cubic
centimetre)
INTAKE AND OUTPUT

PURPOSE:
1. To monitor and ensure effective
hydration and elimination
2. To obtain an accurate
assessment of client’s fluid and
electrolyte balance
INTAKE AND OUTPUT

ASSESSMENT:
1. Assess the client’s level of consciousness
and ability to follow instructions

2. Identify whether your patient has undergone

surgery or if he has medical condition or take
medication that can affect your monitoring
INTAKE AND OUTPUT

IMPORTANCE:
 Are they hydrated?
 Are they dehydrated
 Are they in Fluid Overload
 Is there and obstruction?
INTAKE AND OUTPUT

Body
Compartments

Intracellular Extracellular
INTAKE AND OUTPUT

Extracellular

Intravascular Interstitial Transcellular

INTAKE AND OUTPUT
INTAKE AND OUTPUT

HYPOTONIC ISOTONIC HYPERTONIC

• 0.45% NaCl • 0.9% NaCl • 3% NaCl
• 0.33% Nacl • Lactated Ringer • 5% NaCl
• 0.2% NaCl • Ringer’s Solution
• 2.5% Dextrose • 5% Dextrose in
Water Water
INTAKE AND OUTPUT
INTAKE AND OUTPUT

MEASUREMENTS:
• 1 mL = 1 cc
• 1 ounce = 30 mL or cc
• 1 pint = 500 mL or cc
• 1 quart = 1000 mL or cc
QUESTION
When administering a hypertonic solution the nurse should
closely watch for?

A. SIGNS OF DEHYDRATION
B. PULMONARY EDEMA
C. FLUID VOLUME DEFICIENT
D. INCREASED LACTATE LEVEL
QUESTION
_______ solutions cause cell dehydration and help increase fluid
in the extracellular space.

A. HYPOTONIC
B. OSMOSIS
C. HYPERTONIC
D. HYPOTONIC
INTAKE AND OUTPUT

MEASUREMENTS:
1 glass 8 oz 240 mL

1 cup 8 oz 240 mL

1 teacup 6 oz 180 mL
INTAKE AND OUTPUT

FURTHER ASSESSMENT
• Is the patient drinking at least 1500cc a
day?
• Urinates 30cc/hr
• Has concentrated or foul smelling urine
• Dry skin
• Perspiring excessively
INTAKE AND OUTPUT

FURTHER ASSESSMENT
• Is the patient drinking at least 1500cc a
day?
• Urinates 30cc/hr
• Has concentrated or foul smelling urine
• Dry skin
• Perspiring excessively
INTAKE AND OUTPUT

MEASUREMENT
INTAKE OUTPUT
Ice Emesis
Juice Urine
Coffee Blood/drainage
Yogurt Liquid stools
Jello NG drainage
IV/Tube feedings
Anything liquid at room
temperature
MONITORING INTAKE AND OUTPUT
 4
CAPILLARY BLOOD
GLUCOSE
MONITORING
CAPILLARY BLOOD GLUCOSE
MONITORING

DEFINITION:
Plays an important role in achieving
levels of diabetes control which are
associated with reduction in the risk of
developing diabetes complications.
HYPERGLYCEMIA

DEFINITION:
Technical term for high blood
glucose (blood sugar). High blood
sugar happens when the body
has too little insulin or when the
body can't use insulin properly.
HYPERGLYCEMIA
HYPOGLYCEMIA

DEFINITION:
Deficiency of glucose
concentration in the blood that
may lead to variety of symptoms. .
HYPOGLYCEMIA
TYPE 1 and TYPE 2 DIABETES
GESTATIONAL DIABETES

DEFINITION:
Gestational diabetes is a type of diabetes
that is first seen in a pregnant woman who
did not have diabetes before she was
pregnant. Some women have more than
one pregnancy affected by gestational
diabetes.
GESTATIONAL DIABETES

DEFINITION:
Gestational diabetes usually shows up in
the middle of pregnancy. Doctors most
often test for it between 24 and 28
weeks of pregnancy.
GESTATIONAL DIABETES

COMPLICATIONS
1. Extra Large Baby
2. C-Section
3. High Blood Pressure - Preeclampsia
 GOING BACK TO
CBG MONITORING!
CAPILLARY BLOOD GLUCOSE

PURPOSE:
Used for the care of people with
diabetes as a monitoring tool
giving a guide to blood glucose
levels at a specific moment in
time.
CAPILLARY BLOOD GLUCOSE

ASSESSMENT
1. Client’s LOC and ability to follow instructions
2. Review the client’s record for medications that
may prolong bleeding, such as anticoagulants.
3. Signs and symptoms of hyperglycemia and
hypoglycemia
CAPILLARY BLOOD GLUCOSE

PROCEDURE

CAPILLARY BLOOD GLUCOSE VIDEO

ANY QUESTIONS?