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NUR 2633 MCH final exam review,100% CORRECT

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NUR 2633 MCH final exam review Dysmenorrhea -Painful period- could be from endometriosis, or fibroid. -Heating pads, exercise, stretching, good nutrition, avoid alcohol and drugs, decrease caff... eine. Heat, NSAIDS is most common prescribed. Normal bleeding: Friability or easy bleeding of cervix when scraped (after sex or vaginal exams) is normal. Leukorrhea : Is a white or gray discharge with a musty odor, normal during pregnancy, do not douche or wear tampons, peri-pads are ok. Since vaginal pH increases from 4-6.5 mother at risk for yeast infections. Hyperemesis Gravidarum a problem of extreme nausea and vomiting causing electrolyte imbalance, dehydration and severe weight loss What is the nursing intervention for Hyperemesis? Advise to take multivitamins regularly, Promote Rest Teach to avoid foods and stimulus that evoke vomiting; avoid spicy foods, eat crackers early in the morning Eat small frequent meals; bland food, high protein Ginger capsule beneficial for vomiting (In hospital) - NPO and antiemetic’s administers IV Therapy- fluids with dextrose and vitamins are given. Breast changes in pregnancy are due to estrogen-progesterone production. -The breasts may have a feeling of fullness, tingling or tenderness. - The breast size increases and the areola of the nipple darkens and the vascularity increases. -The secretions from the sebaceous glands (Montgomery tubercles) help keep the nipple supple and prevent cracking. -By the 16th week of pregnancy colostrum can be expelled from the nipples. Linea nigra Is a dark colored line extending from symphysis pubis to top of fundus, common. Striae gravidarum AKA stretch marks common, fade but never disappear. Morning sickness is due to: secretion of hCG by placenta, subsides end of 1st trimester, management includes eating crackers upon awakening and eating small frequent meals. Placenta previa An implantation of the placenta in the lower uterine segment, near or over the internal cervical os. It accounts for 20% of all antepartal hemorrhages. There are three different types of placenta previa: Complete (total)-covers entire cervical os. Partial-partially occludes the cervical os. Marginal-encroachment of the placenta to the margin of the cervical os Risk factors: conditions that cause scarring of the uterus (C-section, multiparity, increased maternal age), large placental mass, smoking, cocaine use, prior history of placenta previa, closely spaced pregnancies, African or Asian ethnicity. Fetal results for poor nutrition: -B12 deficiency; megaloblastic anemia, neurodevelopmental delays. *Inadequate nutrition - low birth weight, inadequate development, preterm birth, neurological defects Drugs (fetal results): -meth; tremors, poor muscle tone, -heroin; withdrawal, -cocaine; teratogenic malformations, structural or organ anomalies, later in fetal life or during early infancy may cause mental retardation, blindness, hearing loss, deafness, stillbirth, or malignancy HTN (fetal results): -Growth restriction, neonatal morbidity, decreased placental perfusion; decreased fetal heart rate, fetal death. DM: Effect on growth & development of fetus -DM 1 & 2- Major congenital defects in CNS, cardiac, skeletal anomalies (due to hyperglycemia), Increase risk of perinatal death, adverse effects throughout child's life *GDM- risk for impaired insulin tolerance & DM later in life, macrosomia (big baby) Anemia; maternal and fetal risks increased need for oxygen requires the pregnant woman to increase her iron intake Physiological Anemia of Pregnancy (pseudoanemia) -occurs in wks 32-34 and shows low Hct and increase in total plasma volume -Educate to drink 6-8 glasses of water to stay hydrated and diet high in protein and iron [May need to supplement iron] fetal need for iron is greatest in last 4 weeks of gestation What is Preeclampsia? A multisystem, vasopressive disease process that targets the cardiovascular, hematologic, hepatic, renal, and central nervous system. If you are pregnant and your systolic pressure is 140+ or the diastolic pressure is 90+ on several readings, it is too high. Pregnancy-induced hypertension (PIH); Is a type of hypertension (high blood pressure) that happens only during pregnancy? It can be mild or become very serious. (1) high blood pressure, which is the first sign, followed by (2) Protein in your urine. This may happen early in your pregnancy or not until the end. Most often, it occurs after the 20th week or so of your pregnancy and lasts until a week after childbirth. S/Sx of Pre-Eclampsia: Sudden weight gain or gaining more than a pound a week especially in the last trimester. -Swollen face, hands and feet which worsens in the morning -Headaches, Blurred vision, seeing spots -Persistent painful heartburn -Decreased production of urine (oliguria) -Hyperreflexia -Nausea or vomiting, Epigastric pain (pain between your sternum and navel) Manage pre-eclampsia Meds: -Magnesium sulfate- (MGSO4) seizure prophylactic; drug of choice because of CNS depressing. -Antihypertensive (when diastolic pressure reaches 110 mm/hg) [NOT First line intervention!] Chronic HTN treated with: Alpha-methyldopa (Aldomet), Labetalol (Trandate), nifedipine (Procardia), furosemide (Lasix), HCTZ (HydroDiuril) Acute HTN treated with: Labetalol hydrochloride, Hydralazine, Nifedipine, Sodium nirtroprusside (Nitropress) *Note: #delivery is the only cure for preeclampsia otherwise -laying on left lateral side, seizure prophylaxis with magnesium sulfate, antihypertensive Manage preterm labor: Goal is to decrease the strength and frequency of the contractions, and to make sure of optimal fetal status. Tocolysis - use of meds to inhibit uterine contractions: Beta-adrenergic agonist (aka beta mimetics)- ritodrine (Yutopar), turbutaline sulfate (Brethine), Magnesium sulfate- (MGSO4) Calcium gluconate is antidote -Prostaglandin synthetase inhibitors- indomethacin (Indocin) -Calcium Channel Blockers (CCB)- nifedipine (Procardia) What is Pre-Term labor? Cervical changes and regular uterine contractions occurring between 20 and 37 weeks of pregnancy. Risk factors of Pre-Term Birth history of preterm birth, uterine or cervical anomalies, multiple gestation, hypertension, diabetes, obesity, clotting disorders, infection, fetal anomalies, premature rupture of membranes, vaginal bleeding, late or no prenatal care, drug use, smoking, alcohol, violence, stress. -early predictive factors of preterm labor and birth include fetal fibronectin, there presence in women with intact membranes suggest an increased risk for preterm labor. And salivary estriol, this increases before the spontaneous onset of term and preterm labor. Diabetes Mellitus Type 1 concerns, management and fetal surveillance *Surveillance- Insulin dependent DM; symptoms (polyuria, polydipsia, weight loss); age <30, 10% of those diagnosed with DM. *Risks to baby: effect growth and development of fetus [risk of major congenital defects due to hyperglycemia during organ development phase], increased risk of perinatal death, adverse effects throughout life for child. Diabetes Mellitus Type 2 *Surveillance- Insulin resistance or inadequate production of insulin; age >30; slow onset, can be treated with insulin or diet *Risks to baby: effect growth and development of fetus (risk of major congenital defects due to hyperglycemia during organ development phase), increased risk of perinatal death, adverse effects throughout life for child. Gestational Diabetes Mellitus (GDM) *Surveillance- Cannot metabolize carbohydrates (manifests during latter half of pregnancy because of altered "hormone milieu"); age >25; obese, history of large babies, family history of DM, ethnicity risk factor, treated with diet or insulin (depends on blood sugar) *Risks to baby: risks for impaired insulin tolerance and DM later in life, macrosomia (big baby) Define Macrosomia - and what are the risks? -Big baby 90th Percentile- shoulder dystocia, -Increased fundal height is common -Monitor Blood sugar and Respiratory (meconium) During fetal development a nurse can recognize well- being of the fetus through 3 things? *3 Methods baby is growing/active: - fetal movement -fetal heart rate -fundal height How do you determine EDD? Naegele's rule- add 7 days and subtract 3 months from 1st day of LMP -Fundal height - correlates to weeks of gestation from approx. 22-34 weeks’ gestation; -12 wks. gestation fundus should be at level of symphysis pubis; -20 weeks at umbilicus; initiated at around 22 weeks -Fetal heart sounds heard w/ Doppler 10-12wks or by 17-19wks w/ fetal stethoscope Non-stress test (NST) a test that monitors fetal heart rate. A positive test would be in which the heart rate accelerates by at least 15 beats per minute for at least 15 seconds, with at least two acceleration episodes, in a 20- minute period. For "high risk maternal or fetal factors" Biophysical profile (BPP) is a noninvasive "fetal physical examination" -The fetus responds to central hypoxia by alterations in movement, muscle tone, breathing, and heart rate patterns. 5 Components: NST (HR), fetal breathing, fetal movement, fetal tone, amniotic fluid volume. [8 to 10 good, 6 meh... and repeated in 24 h]. *Done for high-risk pregnancies; mother has DM, GDM, HTN, baby small, baby less active, PAST DUE DATE. Amniocentesis: when and for what reason? > 35 years old [Chromosomal testing: Down Syndrome], genetics testing -Typically done after 15 weeks -Need informed consent and know risks of procedure -MSAFP (Maternal Serum Alpha-Fetoprotein)- Quad screen (screen for genetic issues) -Identify kidney and lung functions Purpose of amniotic fluid: -cushion the fetus/cord -helps baby maintain normal body temperature -allows for symmetrical growth -prevents fetus from sticking to amnion -allows freedom of movement for baby What is oligohydramnios? -decreased amniotic fluid (<300 ml) Resulting in: Intrauterine fetal restraint or compression [clubbing of feet], renal abnormalities, poor placental perfusion, premature rupture of membranes, can lead to cord compression during labor and decreased fetal blood flow. What is Polyhydramnios (hydramnios)? Too much amniotic fluid (>2L) -Usually occurs in multiple gestations, fetal anomalies, and complications of maternal diabetes -Too much fluid can obscure fetal heart tracings -Incorrect (malpostioning) of fetus -Risk for prolapsed cord since baby is pushed high up into cavity -Preterm rupture of the membranes [Increased risk of infections]. How to promote perfusion to the placenta, and what can interfere? *Any disease or substance that interferes with vascular perfusion: HTN, DM, smoking, drugs, poor nutrition, etc. -"work horse" -AVA (2 Arteries, 1 vein) -It is the mechanism for gas exchange. -Educate to promote bedrest, adequate hydration, good nutrition, lateral side lying position -Part of the endocrine; secretes HCG, HCS, progesterone -Pre-eclampsia, smoking, drugs, poor nutrition can all affect perfusion -Placenta starts to breakdown on postdates. 5 Parts to fetal monitoring Baseline; Variability; Accelerations; Decelerations; maternal activity Late; Variable; Early; Prolonged. Baseline (Always know parameters) 110-160 HR of fetus. Variability -beat to beat change, how well baby is managing his environment [fetal health/wellbeing] -Marked, moderate, minimal, & absent. Accelerations happens with movement above the baseline. - Good Thing! Decelerations [Early, late, variable] *Early- head compression *Variable- cord compression *Late- placental insufficiency! Example of late decels -140 min. variable, NOT decelerate after contractions -Pt at risk for late deceleration- cocaine, high BP, postdates, smoking Prolong deceleration right now cut off O2 to mom; seizure, PE, CVA really compressed cord. V (Variability) C (Cord) E (Early) H (Head) A (Accelerations) O (OK) L (Late) P (Placenta) Maternal Uterine Activity - what are the expectations? Example: Primigravida 160 fetal heartrate, contractions every 7 min. baby sleeping, dehydrated mom, baby depressed, Braxton hicks; give IV fluids [fetal movement; increased variability], monitor, postdate (give O2 then see increase in variability; more efficient contractions), fetal monitoring. Normal Fetal heart rate, when movement occurs, and when you can palpate fundal height and begin measuring with a tape measure. *Normal fetal HR 110-160 BPM -Fundal Height at 10-12 weeks; symphysis pubis -Usually initiated at 22 wks. -Fundal Height at 20 weeks- umbilicus -Measure: 1cm per week after 20 weeks [22-34 wks. fundal measurement correlates w/ wks. gestation] If there is a non-reassuring Fetal Heart rate - what are the nursing interventions? -Position change -O2 (by mask 8-10 L- getting it down to the placental bed), IV floods, Stop the Pitocin [all at the same time] -Call the provider -Document very carefully the time exactly/ Epidural anesthesia: -Administered during 1st and 2nd stage of labor, -Preload patient w/ rapid infusion of IV fluids prior to administration to help prevent hypotension. *Risks - maternal hypotension, if administered improperly can cause CNS effects, decreased placental perfusion -Consent before epidural, 1L bolus of fluids, CBC w/ platelets, sit in C-position -Check vitals q5min until ok from anesthesia then q30min OB Drugs: Terbutaline (Bricanyl) -(SubQ) Makes the smooth muscles of the uterus relax when under stress. -Reduce number & frequency of contractions. -S/E: "fight or flight" response, racing HR, flushing, tremors. **Don't give to women with heart disease, hyperthyroidism, poorly controlled DM. Magnesium sulfate -4 g bolus, 2 g maintenance. Inhibit uterine contraction (delay birth) -S/E: include flushing, feeling uncomfortably warm, headache, dry mouth, nausea, and blurred vision. -Women often say they feel wiped out, as though they have the flu. These side effects can be uncomfortable, but they are not dangerous. -Too much Mag sulfate you get Knee-Jerk reflex (DTR); -reversal is calcium gluconate. Misoprostol (cytotec) - (Not approved by the FDA for OB use); used for cervical ripening to induce labor & contractions/decrease loss of blood after labor. -S/E: torn uterus, death to fetus, h/a, abdominal pain, N/V. Dinoprostone (Cervidil) -cervical ripening; produces contractions, dilation & effacement of cervix, initiate labor or expulsion of fetus. -S/E: abnormal contractions, warmth in vagina, back pain, amniotic fluid embolism, fever Pitocin (Oxytocin) -Stimulate uterine smooth muscle; induce labor, control post-partum bleeding. -S/E: seizure, hypotension, increased uterine motility, painful contractions, decreased uterine blood flow, hyponatremia. ↑BP -Titrate 1 to 2 mU in 3 ml of fluids. Risk: uterine rupture, severe hypoxia, Tachysystole Methergine - [This drug should not be administered I.V. routinely because of the possibility of inducing sudden hypertensive and cerebrovascular accidents. If I.V. administration is considered = lifesaving measure] Uterine stimulant; increase contraction force & frequency-stim smooth muscle. Control post-partum hemorrhage in 2nd Stage of labor. -S/E: HTN, atrial spasm, h/a, seizure, N/V. Hemabate [Abortion drug] termination of pregnancy (13-20 weeks) & control post-partum hemorrhage -S/E: Dizzy, paresthesia, dystonia, HTN, pulmonary edema, respiratory distress, abd pain, uterine rupture, fever, pain. Rhogam -(Immunoglobulin) Prevent the formation of Rho(D) antibody in rH- pt. for prophylaxis threatened abortion in (rH-neg mom & future rH+ baby). -S/E: Joint muscle pain, h/a, dizzy, weakness, N/V/D, stomach pain, rash, itching -Give to mom @ 28-32 weeks and @ birth if baby is positive then another dose is given within 72 hours. Vaginal exams 3cm, 90%, -2 (what does this mean) Measuring: Effacement, dilation, presentation, (descent) station, position * 3 cm dilated, 90% effaced and 2 cm above ischial spine [active phase of labor—admit pt.] -Ex/ what is 1, 50 and minus 1? Answer: 1 cm dilated, 50% effaced, 1 cm above ischial spine -Ex/ Complete, complete (or fully, fully) and +2? Answer: 10 dilate, 100%, below ischial spines. Note: +4 on the floor, - is away from -Presentation of baby: vaginal exam and Leopold's head down or vertex Labor 1st stage of labor Is variable [last up to 12 hrs], be aware of what's happening with your patient Latent phase [of stage 1] *not many risk factors; baby is not in any stress, contractions are far enough apart not very strong, uterus not too tired yet, really affecting baby. *Active phase [of stage 1] 2-3 min apart contractions, baby is undergoing hypoxia during contractions, contractions getting stronger, dilation and effacing happening 1-2 cm/hr, should not take more than 4-6 hours if lasts longer -Risk factor is decreased perfusion to baby and fatiguing uterus, augment labor nonpharmacological: position change, artificial rupture of membranes -Pharmacological: Pitocin risks raises BP, titrate very carefully begins 1-2 mU in 3 ml of fluid, can cause uterine rupture, uterine hyper-stimulation (tachysystole of uterus), can only raise every 20-30 min, behavior of mom in this phase is in pain and focused, give meds during this phase: nubain, stadol and give during peak of contraction gives less med to baby (vessels are constricted). Transition phase [of 1st stage] - 8-10 cm dilated, start to feel pushy, contractions 2- 3 min apart, fastest most difficult try not to stay in this phase for more than 2 hours, getting more meds to baby at this time. 2nd Stage of Labor Begins w/ 10 cm dilation and ends w/ birth of fetus -Urge to push, concentration w/ pushing efforts -Delivery of Baby; 2nd stage delivery of baby (2-3 hrs), baby crowning and close to delivery, 3rd stage delivery is of placenta - biggest risk is hemorrhage, 4th stage is recovery is complete 2 hrs. 3rd Stage of Labor Placental separation *5-30min to get it out, gush of blood shows placenta is detached, cord gets longer, uterus gets very firm (cramping and pressure), -visual inspection of placenta (dirty Duncan or shiny Schultz), cord is centered in placenta, - 3 (AVA) 2 arteries and 1 vein, (if not; renal disease of baby). Biggest risk to mom is hemorrhage 4th Stage of Labor -Physiological adaption following placenta delivery (1-2 hrs) Lochia rubra, bright red blood flow, bonding w/ infant, breastfeeding. When labor is not progressing… *Induction- chemical or mechanical modalities to initiate uterine contractions Mechanical initiation of induction -Amniotomy- artificial rupture of membranes (AROM) to augment or induce labor; Relaxation and breathing techniques -Non-Invasive; Nipple stimulation, Ambulation, hydration, hydrotherapy -Acupuncture -Ingestion of laxative (castor oil) Chemical initiation of induction Cervical Ripening agents; Dinoprostone (Cervidil) -Induce labor contractions; Misoprostol (Cytotec) -Stimulate uterine contractions; Ocxtocin Delivery of the baby and delivery of the placenta - what are the risks? Biggest risk to mom is hemorrhage Placenta abruption risks Severe pain and bleeding -DO NOT CHECK CERVIX!! Shoulder dystocia -At Risk Diabetic mother with out of control w/ diabetes; -large babies, shoulder is stuck in pubic bone, labor is not progressing, nurse push above symphysis [not fundus] to help pop shoulder out from under symphysis; -brachial plexus (severe), fractured clavicle (no mvmt of arm). Cord Prolapse - At risk: -Premature rupture of membrane, -multiple fetuses, -transverse position, -head too high, breech position; -Vagina exam, -Take pressure off cord of the presenting part, -Head to get C-section, -Place in reverse Trendelenburg position, -fetal monitor; decelerations Postpartum Issues -NSAIDs; Motrin for pain management, Ice, sitz bath, stool softener (tears) -Breast engorgement- warm showers, cabbage leaves, empty breast, manual expressing, snug bra to support tissues of breast -Non lactating- cold compress, very snug bra, ice -Mastitis- hot red streaks, unilateral, warm to touch, flu-like symptoms, engorged lymph nodes under arms Tx; Keflex, keep breast empty (milk duct infected) -Blues- normal phenomenon, hormone changes, scared that baby will take up energy. Last 2 to 3 weeks -Depression- more severe. Meet basic needs but, no longer care for yourself, not taking a shower, not engaged Require meds and outpatient therapy. At higher risk for post-partum depression if needed meds prior, -Psychosis- most severe form. Disengaged with life and reality. Hears voice. Needs to be hospitalized to keep baby safe. AFE (amniotic fluid embolus) - risk: everyone at risk, -mother's do not survive if AFE is released into cardiac or resp. systems, -Causes by change in intrauterine pressure [rupture membranes, IUPC, manipulation within uterus] - S/Sx of AFE: dyspnea, chest pain Uterine Rupture - risk: -Prior C-section, multiple babies, prior abortion, large baby, contractions too close together, rapid labor; -S/Sx: late and prolonged decels, rigid abdomen, contractions stop! -C-section to resolve the issue Postdates (past 42 weeks) -risks: placenta breakdown, baby gets bigger, meconium, stillbirth. IUGR IUGR-Poor growth of baby in womb; not enough oxygen & nutrients from placenta. -Causes: High altitudes, multiple pregnancy, placenta problems, Preeclampsia, Eclampsia, infections during pregnancy (cytomegalovirus, rubella, syphilis, toxoplasmosis), -Risk factors: ETOH, smoking, drug addiction, clotting disorders, HTN, heart disease, kidney disease, poor nutrition -Baby is Flaccid, risk for cold stress (no brown fat), immature lungs What are the signs of placental separation - risks and nursing interventions? Placenta abruption - severe pain and bleeding [DO NOT CHECK CERVIX] -Lack of gas exchange to fetus, mom could hemorrhage -May require delivery if serious -If non-catastrophic just require hospitalization, labs, monitoring Postpartum risks - how do we intervene if a patient has a postpartum hemorrhage - the initial response? Intervention #1- Massage her FUNDUS [If +2 deviated to right- full bladder] -Pitocin [no need to titrate once baby is out], fundal massage (first), administer methergen (But contraindicated in HTN), cytotec, hemobate. Newborn assessment - what is the first assessment? Typically: Length 46-54cm, HC 34-35cm, Temp. 97.6-98.6 (axillary), Chest Circumference: 32- 33cm, HR 120-140, Respirations 30-60, Weight 2.5- 3.4kg. -First assessment is ALWAYS Respiratory! -APGAR next - Activity, Pulse (HR >110), Grimace, Appearance (color; pink, acrocyanosis), Respiratory Rate [>30] Done at 1 min and 5 min. of life APGAR: Can score 0-10, "Normal" score of 7-9 APGAR score of 3 - [O2 by ambu bag, call code] APGAR of 3-7 - [stimulate baby, give blow by O2, suction, dry them; Prevent cold stress in baby. -Temp should be 36.5-37.2C taken axillary [rectal can be done in nursery to check anal patency] Take HR through pulse in cord -Gestational markers -Apical pulse -Listen to bowels sounds, soft belly -Head to toe on baby [Head - OFC, fontanelles, suture lines, eyes, ears (alignment and coiling), mouth, flexibility of tongue, cleft, suck and swallow, check clavicles] -Blood sugar -Plantar reflex, club foot, genitals, descended testes, scrotum enlarged, dimple at base of spine. How do we keep babies safe in the hospital setting? -Electronic tracking of infants -Identification bands placed on mother and infant shortly after birth (matching) -Follow hospital protocol when transferring baby from nursery to mother's room (bassinets, no carrying child in halls) -When two or more babies have similar last names, "NAME ALERT" name followed by another letter. -Hospital personnel visible ID at all times, visitors all need name badges. What is jaundice? -yellowing of the skin; RBC changing from fetal to adult -common in breast fed babies, traumatic injury at birth w/breakdown of RBCs. -Jaundice is the condition in which blood contains excessive amounts of bilirubin. -The deposition of conjugated and unconjugated bilirubin in the skin gives the yellow color seen in jaundice. -Jaundice is not a disease, but the symptom of a disease; 20% of newborn infants have jaundice. What is Pathological Jaundice Before the 24th hour and after the 7th day [Born with this] What is Physiological Jaundice 24 hours to the 7th day [appears later; it resolves itself sometime] Tx/Risks associated with bili treatment: -Concerned about eye damage (covered), -feed a lot more frequently (poop and pee out faster), Thermoregulation, Bili lights and Bili blanket. NAS - neonatal abstinence syndrome -S/Sx- Tremors, irritable, crying, vomiting, constant eating still not enough, weight loss, hyperreflexia, arching of back, baby in pain seizure. -Sample- Urine, meconium (stool) -Treat with medications; methadone or morphine to ween, time, swaddle (swing), watch baby closely. -Score every 3 hours. Milestones of infancy Double weight at 6 mos. Triple weight at 1 yr. -Babble 4-6 mo. -Tummy to back 5 mo. -Back to tummy at 6 mo. -Sit up 8 mo. Stand 11 -Walk 12 months ICP in children - specifically infants. Know possible causes, nursing interventions, priority care. -The intracranial pressure (ICP) is the pressure of the CSF in the subarachnoid space between the skull and the brain. -Causes: contusions (bruises), brain tumor, subdural or epidural hematoma, abscess, ischemic anoxic- states, hypertensive encephalopathy, acute liver failure, hypercapnia, Reye's Syndrome, venous sinus obstruction, CSF obstructed; hydrocephalus, meningeal disease choroid plexus tumor, subarachnoid hemorrhage. -Priority nursing interventions: maintenance of a patent airway; inadequate oxygenation or excess carbon dioxide causes cerebral blood vessels to dilate, resulting in an increase in ICP. Monitor vitals closely (intracranial bleeding = increase in body temp.), HOB elevated, loosen clothing around neck, protect child from injury (seizures). -S/Sx: Irritability, bulging fontanelles About consents -If a child is of age, they don't need their parent's signature. -If emancipated they can sign as well. If not the parent must sign. -In emergencies physician can approve if parents are not available. -Religious beliefs can be overturned by courts in some cases. *Need signature consent for invasive procedures; from parent, guardian or emancipated; pregnant, military, court order *Consents are Voluntary, understanding of procedure (cognitive/language barriers; interpreter if needed), attempt to contacts [document] telephone attempt; life or limb. Communication with children and families. What are the general rules to communicate with everyone, and specifically children? *No medical jargon, get to their eye level, engage child and address child, talk slowly & clearly (concrete words), assess child's cognitive ability, utilize play, transitional objects, drawings, colors, pictures, use a child life specialist to assist with communication & interactions, allow child to make noise and be upset, give child something to do. Play is important - know the different play methods seen by each group of children. *5 types of play "Play is the work of the child" -Solitary (0-2 Years) - infant/ toddlers. Adolescent. Child should be socialized. Can be at any stage, but do not want this type of play only. Video games. -Parallel (2.5-3 Years) - toddlers. Two toddlers doing the same task, hasn't learned to play with each other. Egocentric. (two children playing together but oblivious to the fact, don't understand the concept of someone outside of themselves) -Associative (3-4 Years) - preschool, early child. Get together to something accomplished, but no rules. -Organized/cooperative (4-6 Years) - school aged/adolescents. Organized sports, rules. Concept of rules upholding. Need moderators. Sports w/Rules -Onlooker/Spectator (2-2.5 Years) - toddlers, young preschool. RED flag if it continues with this type of play; autism, cognitive development problems (can see in toddler or preschooler, but should want to participate) How do we communicate with children and respond to their fears - separation/ pain? Basic fears are: separation, abandonment and fear of pain/unknown. -Separation comfort care with favorite items or activity, distraction, parents room in or go with child to procedures. -Child will protest separation due to anxiety, (prep with tours and explanation, use transitional objects) reinforce when they will see parent again. -Despair follows due to grief of separation, detachment due to ongoing anger/coping skills. -Alleviate stress and fears: explain procedure, distraction, ask parent to stay and participate in care and explain what's going on. Pain management for children - both pharm and non- pharm management -Non-Pharm methods- music and distraction, relaxation, holding hand, cuddling, reassurance, baby's (non-nutritive suckling, cuddling, sugar water), play, toys, draw pictures *Manage as you would an adult. Pain scales- Faces and FLACC are preferred. Believe the child's report. *For children 10-12 years old can use the numerical pain scale *ALWAYS treat pain to validated level of response. Chart pain, intervention and response. -Pharm- Morphine is the primary pain med for peds. Erikson's theory -Trust vs. mistrust (birth-1year) -Autonomy vs shame and doubt (1-3 years)- toddlers learning to be different, moving quickly away from parent, doing things themselves [balance independence and self-sufficiency] -Initiative vs guilt (3-6 years) exploring everything, mimic things you do. [wanting to be independent and needing to stay attached to parents] -Industry vs. inferiority (6-12 years)- mastery; star baseball player; frustrated [sense of confidence through mastery of tasks] -Identity vs. role confusion (12-18 years) - teenagers are struggling to find who they are, family is important if they are given positive reinforcement, if they don't get reaffirmation they look for it elsewhere. Discipline and limit setting - what is appropriate. Know families - and how they cope with stress - how do children cope with stress? *Discipline is for- Safety and education with positive reinforcement; to make good choices, aggressiveness with toddlers because they don't remember: Withholding, time out, rationalizing, distractions -Harmful disciplines - Corporal punishment (okay to hit, slap or harm), Isolation (in some cases), (demoralizing) screaming/verbal abuse, neglect - passive aggression. -Authoritarian- dictator -Authoritative/democratic-is most effective **Beneficial - Time out (without isolation) redirection, distraction, positive reinforcement, modeling preferred /desired behavior, removal of privileges, natural consequences of actions. Coping with Stress Positive - Child begins to expand their world when parents are absent. =Healthcare providers can see the child adapt. -If parents are gone too long. abandonment can set in. **Stress helps them learn how to cope. -Long term stress (not good), however display itself in physical manifestation. Medication administration to children *Oral meds- measure correctly, don't use spoon or cup, no ASA for children except for Kawasaki's. Uncooperative use syringe. Do not mix in formula. Mix in food. Make sure getting correct dose. *IM/SubQ- know equipment and sites. Best site vastus lateralis for babies and toddlers. Vaccines in deltoids (preschool/school aged). Ventral gluteal- choice, no major vessels, easy landmarks, less pain. PCN (oil based) *IV meds- 24g IV (shorter catheter), 22g when older, 5/8 needle-1 in. Check for infiltration frequently because of movement. Use plastic domes (cups) over the site, tape, wrap in gauze, immobilizers, use tegaderm to view sites, use restraints if necessary and lots of tape Otic Meds (Ear drops)- up and back at age 3, otherwise down and back < 3 years *Trach for child- less than 5 seconds on suction. One pass. Ensure Tubing is half the size of trach (prevent edema or trauma). What is the role of the child life specialist? -Is an expert in child development and therapeutic play -She can assist in diversion activities during procedures, arrange for therapeutic play, or simply let the child take time to play. Neurological - seizures and LOC - using Glasgow coma Score of 1-15 Score of 9-15 (unaltered state of consciousness) Score of 8-4 (state of coma) Score of 3 or below (deep coma) Glasgow Coma Scale assesses: Eye opening- pupil dilation Verbal Response- answer questions Motor Response- move when asked -Neuro exams include hand strength, limb strength, and ability to follow commands, ability to move eyes in equal and uniform fashion, deep pain stimulus response, symmetrical and coordinated movement, clear, speech. Autism *Multi-spectrum process- from savants to non- functional; Early intervention- realistic goals; productive individual -Unable to engage in social communication (poor eye contact) -Communication impairment (no language use or major errors in speech) -Restrictive and repetitive behaviors (playing w/ toys in unusual way, preoccupied w/ parts of toy instead of just playing w/ it, following strict routine) Acute Laryngotracheobronchitis LTB/Croup -is an acute inflammation of the larynx, trachea and bronchi Fever, severe dyspnea, difficulty in inspiratory phase, later on difficulty in expiratory phase, hoarseness of voice, chest retraction, cyanosis, cough with exudates. Treatment: 1. Humidified oxygen. 2. Patent airway e.g: tracheotomy. 3. Antibiotics. 4. Increase fluid intake (parenteral). Responsibility of the nurse: 1- Observe the child for any indication of increase fatigue or respiratory distress. 2- Reporting to the physician the occurrence of increase restlessness (R.R,P.R, Temp, dyspnea, chest retraction). Respiratory - croup syndromes Stridor; trachea get edematous because it's dry. Sounds like a seal (seal bark), moist steam (humidifier); evening or at night time take kid outside. **Viral, some is transient. Larynx can become inflamed and swollen. Narrow airway diameter so children more susceptible. Poor tissue perfusion. Management of Croup nebulization, oxygen tent, corticosteroids, if necessary use antibiotics, monitoring, artificial airway in emergency. -Use cool night air, cool air from the refrigerator or freezer, or a steamy bathroom (from running a hot shower) to assist in rearing the child's breathing. With any respiratory compromise, elevate HOB to ease breathing. Why do children have more Respiratory infections? *Shorter softer airway, short Eustachian tubes, soft epiglottis & trachea, larger tonsils; exposed to more bugs (germs), doesn't have a very good immune system, puts everything in mouth. *Children are oral, poor at hygiene, and not fully developed tissues to manage the illness. Intercostal muscles weak, abdominal breathers when little. Infants are obligate nose breathers. **ABC'S trump all!! Maintain the Airway first epiglottis is longer and flaccid and greater risk to child's airway. Cardiac Cath stuff to know: Pre Procedure- teach child and family about the disease, its cause, and treatment. NPO. -Answer questions child or family has, explain the risk of bleeding, infection, thrombus, arrhythmias, perforation, stroke, and even death. Post Procedure- **Lie flat. Monitor vitals (HR, RR, BP), distal pulse, restrain, maintain IV therapy (dehydration), and Monitor bleeding of the site and apply pressure above site if bleeding. -Note: place dressing on top to reinforce, do not remove dressing MD applied. Monitor pain and administer pain meds as prescribed. May need to add sedation if too rambunctious. CHF (kid) -fluid restriction is not used w/ peds except in severe cases, poor feeding and growth, SOB, excessive sweating, bulging fontanelles -May be prescribed diuretics (Lasix), digoxin, vasodilators (captopril); All three may be used depending on the case -Vigilant surveillance of vital sign and bleeding. If bleeding is severe the patient must be attended with pressure held to the site while another nurse contacts the physician and calls for immediate assistance. Digoxin (Cardiac Drugs) -strengthens the heart; better pump; control and slow certain irregular or fast heartbeats. -S/E: drowsiness, upset stomach, Digoxin toxicity; slow HR, dizzy, pale color, weakness, clammy, loss of appetite, blurred vision, or halos around objects -Monitor for signs of dig toxicity. Lasix (Cardiac Drugs) -used to reduce edema in both acute and chronic cardiovascular, pulmonary, and kidney diseases; fluid overload, high BP. -S/E: dry mouth, increase thirst, h/a, skin sensitive to the sun, N/V -Increased risk for blood clots, hypotension, dehydration, hypokalemia monitor electrolytes, monitor and replace K in diet. Steroids help control inflammation and swelling in the body; pain and discomfort -S/E: adrenal suppression, elevated pressure in eyes, increased BP, mood swings, weight gain, fat deposits in abdomen and face. Long term-cataracts, high blood sugar, and increased risk for infections, thinning bones, and thin skin, bruise easily. Inhaled- oral thrush, hoarseness. Hypothyroidism S/Sxs- Hair loss, apathy, lethargy, dry skin, muscle aches & weakness, constipation, intolerance to cold, receding hairline, dull blank expression, extreme fatigue, thick tongue (slow speech), anorexia, brittle nails & hair, menstrual disturbances. Late manifestations: subnormal temp., bradycardia, weight gain, decreased LOC, thickened skin, cardiac complications. -thyroid gland underactive -not enough thyroid hormone secreted -can lead to goiter if untreated -thyroid hormone controls metabolism rate. ** Low T3 and T4, high TSH -Treatment w/ levothyroxine Hyperthyroidism S/Sxs Finger clubbing, tremors, increased diarrhea, Amenorrhea, intolerance to heat, fine straight hair, bulging eyes, facial flushing, enlarged thyroid, tachycardia, increased systolic BP, breast enlargement, weight loss, muscle wasting, localized edema. Graves' (hyperthyroidism) -overstimulation of thyroid w/ excess production of thyroid hormone [autoimmune] **Low TSH, high T3 and T4 -Treatment w/ methimazole Diabetes - thorough education of disease, manage insulin and glucose, diet and activity, let child self-medicate. **Manage insulin, diet, & activities (is the focus DM1) Hyperglycemia - polyuria, polyphagia, polydipsia, slurred speech, fatigue, blurred vision, ketones in blood and urine, fruity breath. Hypoglycemia - shakiness, pale, sweaty, hunger, palpitations, loss of consciousness. [[Note: DM- Airway, shock, infection, fluids, pain, drugs (versed, morphine)- Key for DM is let child self-medicated and learn.]] Diarrhea - rehydrate (severely - IV therapy, PO if possible), avoid soda, caffeine, sweet juices and milk; pedialyte or anything w/ electrolytes, monitor I & O, do not stop diarrhea in order to get rid of the cause (if not long term) -Do not use anti-diarrheal, do not restrict dieting. Dehydration - Children that become dehydrated may suffer long term organ damage; encourage fluids - PO or IV. -Watch the titration however, it may cause problems if we run fluids too rapidly. -We do not restrict fluids, keep track of what they are drinking - milk may thicken secretions - fruit juice may induce diarrhea, soda/pop -May also induce diarrhea or cramping. Constipation -idiopathic or functional constipation -Symptoms associated with constipation are poor appetite, straining w/ stools, hard, sometimes bloody stools, tenderness (colon/small bowels), and rectal fissures. -Diagnosis: based on symptoms, abdominal radiography & barium enema -Manage by focusing on dietary intake (regular diet w/all nutrients), add fresh fruits and fibers, adequate fluids, limit dairy and keeping bowel sort of empty, stool softener at HS. Or, suppositories, enemas, Go LTYELY for chronic constipation. Renal - concern failure Renal disease causes chronic electrolyte imbalance, fluid retention, profound fatigue, foamy urine, low GFR, high creatinine. **In late stage, fluid sodium retention, poor color, poor decision making, brain fog. Kids More prone to UTI -*Children have unique challenges avoiding UTI's due to their frequent interest in handling their genitals with unclean hands (hand hygiene), as well as having short urinary tracts in girls. *Signs/Symptoms of UTI in children: Neonate -are failure to thrive, jaundice, fever or hypothermia, poor feeding, or vomiting. Infant -usually is a poor feeder, has fever, strong- smelling urine, vomiting, and diarrhea. Preschooler -often presents with anorexia and sleepiness along with vomiting, diarrhea, abdominal pain, fever, strong-smelling urine, enuresis, dysuria, urgency, or frequency. School-age child- has new enuresis, strong-smelling urine, urgency, or flank pain and some changes of personality. Adolescents-often experience fatigue and flank pain. Visual inspection of external genitalia for irritation, pinworms, sexual abuse, trauma, or vaginitis is important. Difference between sprains/ fractures -Sprains are soft tissue injuries (ligaments and tendon; occur after puberty after growth plates of epiphysis is closed) -Fractures occur when the bone undergoes more stress than it can absorb (Open or closed). Most common causes; falls, MVA, & bicycle accidents. Rest, Ice, Compression and Elevation are standards of care for sprains. R: Rest, allows to heal I: Ice for first 48 hours at 15 min. intervals to decrease swelling C: Compress, ace wraps E: Elevation, early motion; helps keep full ROM Other therapies for sprains and broken bones *Crutches or braces may be used as adjunctive therapy. If no weight bearing is ordered, patient should be fit for crutches. -Casts; don't stick anything down into cast, or make indents in casts. Complications; compartment syndrome, cast syndrome (compressing) -Nursing Considerations; skin, perfusion, sensation and movement, emotional effect of child, respiratory management, & pain management. Immunocompromised or suppressed children - what are the risks? How do we prevent risks? **No aspirin to any child under the age of 18, with a viral illness. -Reye's syndrome thought to be driven by the use of aspirin in a child who has, or has recently had a febrile illness. -**Aspirin used only when benefit outweighs risk (some rheumatologist's and cardiologist's will use aspirin in children if their condition warrants it). -Best possible infection control **Handwashing Sickle cell anemia -genetics, crescent shaped RBCs, sickling in joints. -Causes: Poor O2, severe pain, weakness -Risks: Infections and dehydration -Tx: O2, fluids (IV), Abx, pain meds. Sickle Cell Crisis Vaso-occlusive sickle cell crisis is caused atypical sickle-shaped RBCs Symptoms of extreme pain in abdomen & joints Lack of circulation and perfusion cause anoxia to tissues, great pain, and anxiety. Hydration and pain control are the focus of nursing intervention. **May need blood transfusion if severe Iron Deficiency anemia -occurs in adolescents & toddlers -Adolescents- muscle growth, menses, poor diet (fast foods) -Toddlers- Milk, Ca+ impedes iron absorption -TX: Diet, vitamin C, iron foods, iron supplement (NO iron supplement with milk; constipation, and stains teeth). Hemophilia -bleeding disorder caused by congenital X-linked deficiency of either clotting factor VIII or IX (pt. cannot clot; bleed out) -S/Sx: Hemiarthrosis (blood in joint), discovered at circumcision or tooth extraction (bleeding), long term; mobility limitations, bony changes, and crippling deformities -Tx: Identify deficient factors and administer the proper replacement factors, prompt tx for bleeding episodes. Managing blood administration *Consent, type and cross, -needle 20 gauge (smallest), -Vitals before and after transfusion, -double check blood with another nurse, -reaction to blood (Benadryl), -Administer unit within 4 hours (no longer than 30 min on the unit). -Run with NaCl and special filter closest to the hub of the IV -Document clearly -Stay w/the pt. for first 15 min of blood starts running, if reaction is going to happen will likely happen during this time. Curative Care; Cancer -Treat the cancer with drugs/radiation or surgery -Surgery- Remove tumors, surgical complications. Palliative Care; Cancer -Hospice; comfort care, pain management, help with ADL's, parental support & education for the family. -Management- Infection control issue, hand wash, contact precautions. Chemo therapy has risks and side effects -Chemo Therapy- N/V, loss of hair, loss of appetite, weakness, lethargy -Nursing management: Infection control issues; isolation from others who are sick, handwashing. Grieving families - stages of grieve and how do we respond to family needs? Kübler-Ross: -Denial and isolation- feelings of numbness, disbelief and shock *Remind the family to slow down "take it easy", pay attention to safety measures, & retain healthy habits -Anger- developed awareness to impending death, upset, and guilt. *Give spiritual care; Chaplain, family's personal clergy. Prayer, meditation, spiritual text, making self-available to family. Physical exercise, journaling, drawing, therapeutic play. Bargaining- Bargain with self or God. Reinforce child's illness is no one's fault -Depression- profound sadness, excessive worry, insomnia *Get extra help from hospital social worker, physician, social worker or professional counselor -Acceptance- emotional adjustment to child's death *Continue to offer support and encouragement. Offer community resources for continued grief. Pre and post-operative care of the child *Pre-OP - NPO if necessary, explain what is going to happen Post-Surgical-Pain management*, checking incision, check for bleeding (excessive swallowing for tonsillectomy), and monitor vitals, proper diet is in place, proper activity level. [[(From Lecture): Do a Head to toe; airway, dressings, distal pulses, ROM, if bed ridden check for circulation issues (SCDs), Check I&O, activity, check IV site to make sure patent; not infiltrated. Tonsillectomy-lie to one side or semi- fowlers 30°, evaluate drainage. No red stuff to eat/drink. Appendectomy-look for abd distention, check for pain, I&O, bowel sounds. Know what the pts. orders are*]]. Hand hygiene is paramount to prevent the spread of disease. -This is particularly important in an immunosuppressed child who is a surgical patient. Forms of child abuse Physical, Sexual, Verbal, Neglect -Difficult to pin point -The nurse looks for repeated admissions or office visits for unexplained physical injury. -Spiral fractures is a main sign indicating child abuse suspicious bruising, welts, or burns, new or healing lacerations -fear of going home -retinal hemorrhage (SIDS; babies) -hunger, clothing unsuited for weather (neglect) [*The nurse observes the child for signs of fear of the adult care-giver, inability to answer questions without looking to the adult for approval, a child with little reaction to pain, poor eye contact, or injury inconsistent with the story given for reason of injury.] -To report child abuse the nurse can call local law enforcement agency and/or follow institution policy. NURSE MUST REPORT Burns care: Priorities and assessment of burn management *Airway, Breathing, Circulation (establish vascular access), disability, fluids (LR), infection control, tetanus, wound care and dressing selection* -1st degree burn: superficial, erythematous and painful, involve intact epidermis w/o blistering, no fluid loss, only outer epidermis layer, heals w/o scarring in 4-5 days (<10% according to 9s) -2nd degree burn: superficial partial thickness or deep partial thickness, partial destruction of dermis, red painful w/ blister, weeping/moist appearance, heal w/ min. scarring 7-10 days (10-20% according to 9s) 2nd degree that involve >50% of dermis, destroy nerve fibers so less painful, white pale appearance 2-3 wks. to heal, hard to distinguish between this and 3rd degree, at risk for fluid volume loss, skin grafting necessary (>20% according to 9s) -3rd degree burns: full thickness, white, waxy or leathery, no blanching or bleeding, may be black in color (eschar), less painful from nerve damage, referred to burn center, skin grafting necessary, risk for infection and fluid loss, take several weeks to heal. Rule of 9's for burn evaluation. Body surface is divided in area representing areas of 9% determined by Total Body Surface Area. – Child: Face 18%, chest 18%, back 18%, genitals 1%, each leg 13.5%, each arm is 9 -TX: manage pain, cover to prevent infection, replace fluid loss, adequate nutrition, -*In the immediate aftermath, the burn should be cooled with saline soaked cool cloths. -No oil/butter should be rubbed on the burn as it will continue to burn the skin -Ice should never be used on a burn. Types of Burn: Thermal (hot liquid/grease 80% of burns hospitalized), Chemical, Radiation (sun), and Electrical. -Management is focused on pain control and infection prevention. Other Skin Issues: Chicken pox would be deferred unless emergent with diagnosis being done preliminarily over the phone to prevent spread. **Hallmark chicken pox- spots are the size of a pencil eraser (roughly) and pink, become vesicular, and crust over with scabs as they heal. Measles are characterized by Koplik's spots in the oral cavity (hallmark signs) [Show More]

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