Families Final Flashcards
peds & OB
What is the normal HR range of the newborn baby?
110-160
What is caput succedaneum?
Swelling or edema of newborns head due to the vaginal birth canal crosses suture lines
what is bilirubin?
the yellow breakdown product of normal hemoglobin
What is cephalohematoma?
A small pool of blod collected between the periosteum of the skull bone and the skull bone itself, does not cross suture lines
Name 1 condition that can cause pathological jaundice. when does this type of jaundice present?
Maternal-fetal blood incompatibility, signs of jaundice and hyperbilirubinemia occur before 24 hours of life.
What is cyanosis found in the extremities, particularly the palms of the hands and the soles of the feet on the newborn?
Acrocyanosis
What is a common rash seen in full-term newborns, it usually appears in the first few days after birth and fades within a week?
Erythema Toxicum Neonatorum (ETN)
Name 3 s&s of newborn respiratory distress.
retractions, tachypnea, accessory muscle use, grunting, nasal flaring, cyanosis
What is colostrum?
occurs postpartum day 1-3 a nutrient -rich, thick, yellow, fluid produced by female mammals immediately after giving birth, its loaded with immune, growth and tissue repair factors.
How many wet diapers should a newborn have on day 7 of life?
6-8 wet diapers per day
Provide education for a non-breastfeeding mom of suppression of lactation
tight fitting sports bra, apply ice to breast, avoid breast stimulation, avoid heat, engorgement, lactation usually
What is postpartum depression
when a new mom feels guilt, anger, anxiety, hopelessness, loss of interest or pleasure in activities, mood swings, or panic attack, crying, irritability, or restlessness
longer than 2 weeks
What are treatment recommendations for breast engorgement?
Feed infant every 2 hours, use both breas at each feeding, wear a supportive bra, apply a cold compress after each feeding, gentle massage
Describe 3 types of lochia color
Lochia rubra- red (first 2-3 days or longer)
Lochia serosa- pink (day 3-10)
Lohia alba- white (continues until the cervix is closed)
What is the treatment for mastitis?
continue to breastfeed frequently, fully emptying the breast, ensure latch is effective, full course of antibiotics, increase fluid intake.
Name 4 causes of postpartum hemorrhage. Provide an example.
The 4 T’s: tone, trauma, tissue, thrombin
Uterine atony, Lacerations, retained placental fragments, disseminated intravascular coagulation
Name 3 risk factors for placental abruption.
Hypertension, cocaine use, trauma, cigarette smoking, chorioamnionitis
What is placental abruption?
this occurs when the placenta detaches from the inner wall of the womb before delivery. the condition can deprive the baby of oxygen and nutrients.
What is terbutaline?
a medication used as a tocolytic in preterm labor which has an adverse effect of cardiac complications and pulmonary edema.
Describe the third stage of labor
Delivery of the placenta
During what months can pregnant women start to experience quickening? And what is quickening?
4-5 months approximately 18 weeks.
quickening is the first feeling of the fetus moving
Name interventions during a postpartum hemorrhage
uterine/ fundal massage, call for help, vital signs, start 2 large bolus Ivs, insert urinary catheter, fluids (LR), draw labs, apply oxygen, weigh saturated pads/towels. prepare for pitocin infusion. emotional support, make sure the baby is safe (take to nursery)
2 possible findings for magnesium toxicity and its antidote.
decreased/ absent reflexes, respiratory depression, decreased output <30ml/hour, cardia arrhythmia
stop infusion
Antidote: calcium gluconate
If a pregnant or laboring patient is lying supine with a BP of 88/50, what could she be experiencing? what is one intervention?
vena cava syndrome, turn her on her side
A condition that occurs when there is too much amniotic fluid surrounding a developing fetus during pregnancy.
polyhydramnios
What medications can be used to treat gestational diabetes?
Metformin, insulin, and glyburide
A mother’s prenatal labs reveal that she has tested positive for hep B surface antigen. What information can you provide regarding vaccination for the newborn after birth?
Since the mom is positive that means she has the current infection that she can pass to the newborn, the newborn will receive the hep b vaccine and hep b immune globulin at birth (within 12 hours)
How does HBIG help a baby whose mom is positive for Hep B?
It provides temporary protection by giving antibodies to fight HBV
A mom is 38 weeks gestation and is experiencing tightness in her abdomen along with vaginal leaking. She is admitted into OB triage and is asking if she is in labor. What info can the nurse provide to Danielle about signs of true labor?
True labor leads to cervical dilation and effacement. Cervical dilation is the single most important indicator of the progression of TRUE labor.
After performing a vaginal exam, findings reveal that Danielle is 3cm/40%/-2. Explain these results to the client.
The cervix is 3 cm dilated, 40% effaced, and the presenting part is 2 cm ABOVE the level of the ischial spines.
Danielle is admitted into L&D and is started on Pitocin. After increasing the Pitocin, the fetal heart rate monitor reveals late deceleration. What does this indicate and what are 2 nursing interventions that can be done.
Late decelerations begin at the peak of the contraction and return to baseline after the contraction is over. This indicates poor placental perfusion or uteroplacental insufficiency or decreased blood flow. Turn off Pitocin, change mother’s position to increase perfusion.
After stopping the Pitocin, the fetal heart tones returned to normal, and Danielle entered the second stage of labor and delivered her baby. The baby’s weight is 9lb4oz. What is Danielle at risk for developing?
Due to her infant weighting over 9lbs, which T (out of the 4 T’s of PPH) would be the cause of her PPH?
Postpartum hemorrhage
Tone – Uterine Atony
Danielle spends 3 days on the postpartum unit and is preparing for discharge. What should her fundal, lochia, and breast assessment finding be, if she is experiencing no complications and has been effectively breastfeeding?
Fundus firm, midline, 3cm/fingerbreadths below the umbilicus. Lochia can be scant – moderate. Breast may start to feel engorged – full, heavy, tender, warm.
Danielle expresses two concerns before being discharged. The first concern is that her newborn’s eyes are occasionally crossing. The second concern is that her baby is not getting enough breast milk. What education can you provide to Danielle about monitoring soiled diapers during the first week of life?
It’s normal for a newborn’s eyes to wander or cross occasionally during the first few months of life. This is due to a lack of muscle control, but by the time a baby is 4–6 months old, the eyes usually straighten out.
Day 1, 2, 3 of life you can expect 1, 2, 3 wet/soiled diapers. By day 4 of life the breastfed baby should pass 3-4 light yellow stools per day that have a soft consistency. These stools are not foul smelling . By one week then infant should be having 6-8 soiled diapers per day.
Betzy Johnson is a 32-year-old G1P0 who is 29 weeks pregnant. Her blood type is O- and her prenatal labs are negative. She presents today for a routine prenatal visit and says to you “my baby seems to be more active at night, during the day he is not as active, and I am worried something is wrong”. What information can you give to her regarding kick counts and fetal activity?
To perform a kick count the client should sit down comfortably with feet up. For one hour, keep track of fetal movements or kicks. A normal kick count is 10 fetal movements in 1 hour. Vigorous activity generally provides reassurance of fetal well-being. Decrease or cessation of movement may signal a problem and may require further intervention
During the physical examination, Betzy mentions that her skin color has changed in certain areas on her body. Discuss with Betzy 3 areas that skin pigmentation can change due to increased estrogen and progesterone levels
Striae gravidarum - streaks or stretch marks on abdomen, thighs
Linea nigra – a narrow brown line from the umbilicus to pubis symphysis
Melasma - brown or gray-brown patches or freckle-like spots on the face, also known as “mask of pregnancy”
Betzy is now 39 weeks gestation and presents to triage with leaking of fluid which started one hour before presenting to the hospital. A nitrazine paper was used to confirm that the fluid is amniotic fluid and that her membranes have ruptured. After a vaginal exam, she is found to be 3cm dilated, 10% effaced, and -2 station. The nurse understands that after membranes have been ruptured there is an increased risk of developing which 2 complications?
Umbilical cord prolapse and chorioamnionitis
Betzy has progressed to 5cm/40%/-2 and is requesting an epidural for pain. In preparation for the epidural, what supplies should the nurse have available to counteract a common post epidural side effect?
IV access, Lactated Ringers IV fluid, prepare to bolus to counteract hypotension. The other side effect is itching – Benadryl or Nubain can be used
On the electronic fetal monitor there is moderate variability and occasional early decelerations. What does this indicate?
Variability is one of the most reliable indicators of fetal oxygenation and fetal well-being. Moderate variability is normal and shows fluctuations in fetal heart rate between 6 and 25 bpm.
Early decelerations occur with the contraction, mirroring the contraction peak. Early decelerations indicate fetal head compression which means labor is progressing into the second stage.
During the second stage of labor a student nurse is present. The family allows her to cut the umbilical cord. What education can the nurse give to the student nurse regarding the contents of the umbilical cord?
It has three blood vessels: one vein that carries food and oxygen from the placenta to your baby and two arteries that carry waste from your baby back to the placenta. A substance called Wharton’s jelly cushions and protects these blood vessels.
The infant has APGAR scores of 8/9, weight is average for gestational age, blood type is O+. What prescription order for the mother should the nurse anticipate to administer within 3 days after delivery.
Rhogam or Rho (D) Immune Globulin should be administered via IV push or IM injection within 72 hours (3 days) after delivery to a mother that is Rh negative with a newborn that is Rh positive.
During Betzy’s postpartum recovery the nurse performs a fundal assessment and finds that her fundus is firm but deviated to the right. What does this indicate and what is an appropriate intervention?
Bladder is full/distended. The goal is to empty the bladder – if the mother is stable and ambulatory, the nurse can assist her to the restroom. If the mother is unstable or non-ambulatory – use a bedpan. If the mother cannot void – straight catheter.
Betzy is bonding appropriately with her son and is anxious about breastfeeding. She is asking if her baby is receiving enough to eat and how we make that determination since we cannot see how much breastmilk is coming out during feeds. What education can you provide to her regarding monitoring for adequate intake?
During their hospital stay the infant will be weighed daily to ensure he doesn’t lose more than 10% of his body weight. Also, it is important to monitor dirty diapers. During the first 1, 2, 3 days of life he should have 1, 2, 3 voids and stools. These are the main indicators that the infant is getting sufficient intake
What conditions increase the risk of PPH
Conditions that distend the uterus beyond average capacity:
Multiple Gestation
Polyhydramnios
Large baby (>9lbs)
Presence of uterine myomas (fibroids)
VBAC assessment and management
review the medical record for evidence of previous uterine scars, history
VBAC Assessment and monitoring
assess: review medical record for evidence of previous uterine scars, history of uterine rupture, LGA fetus
monitor: FHR, Bleeding, signs of hypovolemic shock
monitor for uterine rupture: sudden severe pelvic pain, contractions that disappear from the monitor, decreased FHR/absent variability, vaginal bleeding, hypotension, tachycardia
Engorgement and treatment
engorgement: breast appear large and reddened with taut, shiny skin. breast are full hard and painful
treatment: this is a normal process due to increased vascularity and milk production
-continue breastfeeding q2-3 hours
-wear a supportive bra
-cold compress after feeding
-gentle massage
Oral contraceptive side effects
nausea, depression, weight gain, headache, breast tenderness, yeast infections, mild HTN, breakthrough bleeding
Oral contraceptives contraindications
-Hx. of thromboembolic disease
-family hx. of cerebral event
-family hx. of cardiovascular event
-migraine with aura
-smoker over age of 30
What is an oral contraceptive and what is it composed of?
they are composed of varying amounts of estrogen and progesterone.
Estrogen: suppressed FSH and LH to suppress ovulation
progesterone: decreases the permeability of cervical mucus, which limits sperm motility.
What can oral contraceptives decrease the incidence of
-Dysmenorrhea (pain during menstruation)
-iron deficiency
-benign breast disease
-pelvic inflammatory disease
-endometrial/ ovarian cancer
What is an emergency postcoital contraceptive?
-High-dose progestin-based pills (Plan B_
-needs to be taken within 72 hours
available over the counter for anyone (no prescription needed)
-insertion of copper IUD
-ulipristal acetate (ella)
pregnancy anatomic and physiologic changes
skin & hair: increased skin pigmentation caused by increased estrogen and progesterone
(striae gravidarum, linea nigra, melasma)
Musculoskeletal: increased estrogen and progesterone (softening of ligaments & joints, lordosis)
explain fetal activity monitoring through kick counts
kick counts focus on counting fetal movements keeping a record
-the client should feel at least 10 fetal movements in 1 hour
-vigorous activity generally provides reassurance of fetal well-being
-decrease or cessation of movement may signal a problem
What is variability?
fluctuations in baseline that are irregular in amplitude and frequency. Difference between the highest and lowest heartbeats shown on a strip
*one of the most reliable indicators of fetal oxygenation and fetal well-being.
(maybe absent, minimal, moderate, or marked)
Pre-eclampsia nursing care and expected findings
-monitor vital signs
-monitor urine output, and urine collection for labs
-labs: CBC, PLT, liver enzymes
-deep tendon reflexes
-monitor for weight gain
-monitor for edema
-neuro assessment
expected findings
-BP >140/90
- + proteinuria
- 1+ or 2+ upper edema
- >1lb weight gain (third trimester_
- >2lb weight gain (second trimester)
-patellar reflex 3+ or 4+
what do you treat pre-eclampsia with
magnesium sulfate
Information about magnesium sulfate and what you should monitor?
anticonvulsant
-CNS depressant
2-6 gram loading dose (followed by continuous infusion)
-therapeutic range is 5-8mg
Mag Toxicity
-decrease/ absent reflexes, respiratory depression, decreased output <30ml/hr
-cardiac arrhythmia -> stop infusion
-antidote: calcium gluconate
monitor
Blood pressure, respiratory rate, FHR, Intake/ output, LOC, patellar/ bicep reflex
Risk factors for abruptio placentae
maternal HTN, blunt trauma, cocaine, cigarette smoking, chorioamnionitis
What is vena cava syndrome
uterus compresses the vena cava when supine
decreases blood flow> maternal hypotension
Epidural anesthesia nursing care
positioning, monitor vital signs, urinary catheter, bed rest, frequent repositioning, IV fluid to counteract hypotension
Breast maternal postpartum assessment
Colostrum: present during first 1-3 days
Milk: production occurs on day 3-5
(prolactin)- milk production
(Oxytocin)- let down
whats mastitis?
Infection of gland or duct. Painful, red, elevated temp., flu-like symptoms
Newborn findings Molding
occurs to allow the skull to pass through the birth canal. resolves after a few days.
Newborn findings caput succedaneum
edema from pressure at birth that crosses the suture lines which resolves after a few days
Newborn findings cephalohematoma
collection of blood between the periosteum and the bones of the skull. caused by rupture of the capillary from pressure at birth. does not cross suture lines and can take weeks to resolve
Talk about hyperbilirubinemia and the different types of jaundice
the accumulation of excessive bilirubin resulting in jaundice
Physiologic jaundice- the benign, normal process of fetal RBCs breaking down
Pathologic jaundice- result of underlying disease appears before 24 hours of age EX: blood group incompatibility, infection, RBC disorder, blocked bile
Breastfeeding jaundice- occurs after the first week of life, for up to 12 weeks
Eriksons stages of cognitive development
Infants
Trust vs. Mistrust
-parent-infant bonding
-comfort through sucking
-
Eriksons stages of cognitive development
Toddlers
Autonomy vs shame/ doubt
-potty training
-accept regression during hospitalization
-encourage self-care behaviors
-reward appropriate behavior
Eriksons stages of cognitive development
preschoolers
Initiative vs guilt
-encourage parental involvement
-provide safe versions of medical equipment for play
-give clear explanations about illness- explain child is not responsible for illness
Eriksons stages of cognitive development
school age
industry vs inferiority
-provide gowns/covers and underwear
-explain treatments/ procedures
-encourage schoolwork
-encourage hobbies favorite activities
Eriksons stages of cognitive development
adolescents
Identify vs role confusion
-provide privacy
-interview separately from parents when possible
-encourage participation in care/decision-making
-encourage peer visitation
-provide information on sexuality
Growth and development across the stages
infancy, toddlerhood, pre-school, school-aged, adolescent
infancy: weight doubles 1st 5 months , triples within 1st year
Toddlerhood: at 2 yrs old 1/2 the height of an adult and can say mom and dad at 1 month
Pre-school age: 3-6 yr physical stance changes, physical and motor skill development, well-developed language skills
school-aged: 6-12 yrs old, rapid changes in height, weight, immunity, social development
Adolescent: 12yrs to 19yrs, the beginning of adulthood, sexual maturation, independence
Pediatric safety & caregiver education
toddlers, pre-schoolers, school-age, adolescents
safe sleep: place baby on back to sleep in crib without blankets or stuffed animals to reduce risk of SIDS, only breastmilk, avoid smoking, avoid overheating, room share but do not bed share
toddlers: 1-3 years ensure cleaning supplies and meds are stored out of reach to prevent poisoning
pre-schooler: 3-5 years explain rules no running out to the street, etc. Use car booster seats (rear-facing, middle back middle seat)
School-aged: 6-12 years old importance of safety with strangers
Adolescents: 12-18 years old educated about dangers of smoking/alcohol/drugs. peer pressure, safe driving
Pediatric pain management scale
FACES: 3 years and older, 0-5 pain rated using diagram of faces
FLAAC: 2 months to 7 years
Numeric scale: 5 years and older; pain rated on a sale of 0 to 10
Pediatric Medication Routes
Preferred method : Po, dont mix with formula sit infant up
NG/OG: assess patency and placemtn
IM: 90 degrees, may need to split dose if volume too large
Sub Q: 45 degrees
Optic: give drops before cream, lay on back and look up, cream inner to outer canthus before bed
Otic: <3 yrs: pull pinna down and back
>3 yrs: pull pinna up and back, lay on side with medicated ear up
always do least invasive to most invasive
Atrial Septal defect Pediatric explain it, expected findings, treatments, diagnostics, and nursing considerations
What is it? a hole between the atria, causing increased blood flow to the lungs ( O2 rich and O2 poor blood mix -> increased volume, left to right shunting
Expected findings: loud, harsh murmur with a fixed split-second heart sound, auscultated left upper sternal border
-heart failure due to atrial ventricular enlargement tires out heart muscle
-often asymptomatic
Treatments: Nonsurgical; closure during cardiac catheterization, diuretics for symptom management, low-dose aspirin 6 months after procedure to decrease risk of clotting Surgical: patch closure, cardiopulmonary bypass
Nursing Consideration: assess heart sounds( listen for murmurs & monitor for fatigue or respiratory issues), medication and post-procedure care (administer diuretics if prescribed & monitor for complications), Education (explain signs of complications and role of low-dose aspirin (prevents blood clots and heart failure & importance of follow up appointments)
Diagnostic: EKG/ECG
Ventricular septal defect Pediatric explain it, expected findings, treatments, diagnostics, and nursing considerations
VSD: hole between the ventricles > increasing blood flow to lungs, increased pulmonary blood flow. O2 rich blood from left too right
Expected findings: loud harsh turbulent murmur on left sternal border, increased blood flow leads to HF (S&S: fluid excess, poor feeding, inability to gain weight, cyanosis of fingers/ toes)
Nursing Care: Monitor for HF (assess resp. distress, check VS, O2, edema) provide medications (diuretics) Monitor nutrition status
Education: explain signs of worsening HF (edema, SOB, fatigue, tachycardia, tachypnea, importance f follow up appointment)
Treatment: VSD may spontaneously close in childhood. Nonsurgical: closure during catheterization, diuretics Surgical: pulmonary artery banding, complete repair with patch
Patent Ductus Arteriosus Pediatric explain it, expected findings, treatments, diagnostics, and nursing considerations
Explanation: open vessel after birth (between pulmonary artery and aorta), increases blood flow to the lungs, increases pulmonary blood flow
Expected findings: systolic murmur (machine HUM), widened pulse pressure, bounding pulses, rales
Treatment: indomethacin administration to promote closure, coils inserted during cardiac catheterization, diuretics(furosemide), give extra calories to prevent FTT (infants)
Nursing considerations: monitor VS & oxygenation, give indomethacin as prescribed , nutritional support, post procedure care
Coarctation of the aorta Pediatric explain it, expected findings, treatments, diagnostics, and nursing considerations
Explanation: narrowing of the aorta making it harder for blood to flow through the body
Expected findings: elevated BP, Bounding pulses in the upper extremities, decreased BP in lower extremities, weak or absent femoral pulse, HF in infants, dizziness, headaches, fainting, or nosebleeds in older children
Treatments: Nonsurgical; Infants & children: Balloon angioplasty, Adolescents: placement of stents Surgical; Repair of defect: recommended for infants less than 6 months of age
Nursing Consideration: Monitor VS, pulse checks(assess for bounding pulses ), check for skin temperature changes , monitor symptoms: Infants ( watch for signs of heart failure -resp. distress, poor feeding) Older children (monitor for dizziness, headaches, fainting, nosebleeds)
Tetralogy of fallot Pediatric explain it, expected findings, treatments, diagnostics, and nursing considerations
Explanation: A heart with 4 defects (VSD, saddling aorta, pulmonary stenosis, right ventricular hypertrophy). reduce blood flow to the lungs, causing O2 poor blood to circulate the body
Expected findings: cyanosis at birth , systolic murmur, “Tet” spells (episodes of acute cyanosis over first year of life
Treatments: Surgical: shunt placement (until primary repair), complete repair (within first year of life)
Rheumatic fever
Explanation: a recent upper respiratory infection often caused by Group A strep. fever is an early indicator, while cardiac symptoms such as murmur, a pericardial friction rub may indicate carditis.
Expected findings: chest pain, increased heart rate, presence of nontender subcutaneous nodules over bony prominences
Hallmark signs: joint involvement painful swelling in large joints (polyarthritis), pink nonpruritic macular rash (erythema marginatum) involuntary muscle movements (Sydenham chorea)Nursing Consideration: rest during acute phase, chorea is self limiting, eat a balanced diet, seek care for recurrent infections, possible valve surgery, insurance cardiologist follow-up can lead to a fib, can lead to embolism
*Diagnostic: JONES Criteria
Minor: fever/ Arthralgia
Major: JONES ( Joints (polyarthritis), carditis, Nodules (subcutaneous nodules), Erythema marginatum (rash), Sydenham’s chorea (involuntary movements)
Diagnostic test: GABHS Throat culture, *Elevated blood antistreptolysin O titer (blood anti titer O) most reliable
Labs: elevated CRP (inflammation), Elevated ESR
Kawasaki Disease explanation, nursing assessments, education, nursing considerations
Explanation: inflammation in the artery walls of body (including coronary arteries supplying blood to heart muscle)
Nursing Assessment: *Heart failure (edema, dysrhythmias, vitals, fever, red eyes, painful joints, oral mucus (strawberry tongue, red & inflamed, cracked lips), Skin (rash involving most of skin, red swollen hands & feet, desquamation)
Nursing Education: maintain follow up appointment, irritability can last 2 months, arthritic manifestations can last several weeks, skin manifestations are painless, ROM excersise in bathtub, *No live vax for 11 months, Notify HCP for any fever
-after discharge education: heart healthy diet, heart disease screening, blood pressure monitoring
Nursing consideration: monitor vital signs (fever/ cardiac function), assess for heart failure, track I/Os, daily weight, IV fluids and diet
Medication Considerations: IV Gamma Globulin: modulates immune response to prevent complications, aspirin: anti inflammatory, antiplatelet
Comfort Care: mouth -> avoid acidic foods, good oral hygiene, lip balm
rashes/desquamation -> skin care, minimize irritation, cool clothes, no hot baths or scented soaps, cluster care
Hemophilia explanation, labs, medications, nursing consideration, education, complications considerations
Explanation: X-linked recessive bleeding disorders characterized by clotting deficiencies. Type A: reduced factor VIII levels Type B: reduced factor IX levels
S&S: episodes of bleeding (epistaxis, hematuria) prolonged bleeding, easily bruised, joint pain
Labs: aPTT, normal platelets
Medications: DDAVP, VIII products, E-aminocaproic acid, corticosteroids
Nursing Considerations: control bleeding, minimize punctures
Education: proper oral care, limiting activities
Complications: Intracranial hemorrhage, airway obstruction, uncontrolled bleeding
Considerations: SubQ injections instead of IM, minimize skin punctures, monitor for blood, avoid aspirin, observe for any adverse effects, support joint care
Chemotherapy: Nursing Education
-steroid treatment can cause moon face, skin changes, and mood changes
-monitor for S&S of infection, skin breakdown & nutritional deficiencies
-*Notify treatment team if child develops a fever
-maintain good hygiene
-remember they are immunocompromised
-well balanced diet high protein, high calories
Tonsillect omy Education
Recovery is about 14 days
- diet should include bland foods, clear liquids (once gag reflex returns), soft foods. avoid citrus, highly seasoned foods, milk based foods, and red liquids (imitates blood)
-increase fluid intake, limit activity, analgesics for discomfort, clot/blood tinged mucus is normal
-avoid nose blowing, objects in mouth, throat clearing, coughing, and straws
-contact provider if any hemorrhage, s/s infection, difficulty breathing etc.
Bacterial epiglottitis Expected findings and nursing consideration
Expected findings: abscence of cough, *drooling and agitation, sitting upright with chin pointing out, mouth opened, and protruding tongue (tripod position), dysphonia, dysphagia, inspiratory stridor, suprasternal and substernal retractions, sore throat, very high fever, restlessness
*rapid progression of symptoms points to a diagnosis
FOUR D’S: drooling, dysphonia, dysphagia, distress with resp. effort
Nursing considerations: Protect airway (avoid throat cultures or tongue blades) prepare for intubation just incase, Provide humidified oxygen and monitor continuously with pulse oximetry. administer medications (corticosteroids and IV fluids as prescribed), antibiotics (start IV antibiotics, transition to oral antibiotics for a full 10-day course)
*droplet precaution for 24 hours after IV antibiotics are initiated
