Midterm Prep Flashcards
What is the acronym for a post-partum assessment and what does each letter stand for?
BUBBLERS Breasts Uterus Bladder Bowels Lochia Episiotomy (lacerations or perineum) Reaction (emotions) Signs (homan's, vitals, pain)
What should be assessed about the breasts during a post-partum assessment?
-if the mother is breast of formula feeding
-if breastfeeding assess
nipples (soreness, bruising, blisters, inverted nipples), breasts (softness, filing, full, engorged//anticipate milk to come in at 3 days)
for signs of mastitis (red mark or streak, warmth, fever, firm lump in breast)
-if not breastfeeding assess
comfort
avoid stimulation of the nipples
still need to assess breasts
What is mastitis and what are symptoms of it?
mastitis occurs when a milk duct in the breast becomes plugged
signs may include: red mark or streak, warm/hot area on breast, fever, firm lump in breast
what needs to be assessed about the uterus on a postpartum assessment?
- assessing involution (the contraction of the uterus)
- should decrease to the size of non-pregnant state within several days postpartum
- should be palpated to feel size and firmness
- assess pain - shouldn’t be super painful when palpated. this could indicate infection
- a boggy uterus indicates that contraction has not occurred. this can be a result of the bladder impeding it’s ability to contract, clots or pieces of membrane being in the uterus, or because the uterus is stretched/tired (this is usually in a mom who has just had multiples, has had more than 3 births, or had a large volume of amniotic fluid)
- anticipate uterus shrinks by 1cm per day post-partum
- need to note height of uterus, firmness, positions
what can aid the uterus in contracting postpartum and why is this important?
- contraction of the uterus helps to seal off where placenta attached and can help to prevent postpartum hemorrhage
- fundal massage immediately following birth and when mother arrives on postpartum unit can aid in contraction
- emptying bladder can help make space for uterus to contract
- breastfeeding can help uterus to contract because of oxytocin
- giving oxytocin (usually started when anterior shoulder is delivered)
what should be assessed in a postpartum woman who has had a cesarean delivery or a tubal ligation?
- palpate abdomen to assess involution (palpate fundus)
- check peripads
- assess pain (naproxen commonly given for pain
what should be assessed about a postpartum woman’s abdomen?
- fundal height
- firmness of the uterus
- position of the uterus
- any incisions
- musculature
what are afterpains?
pains caused by involution contraction
- more common after 2nd or later deliveries than for 1st time moms
- occur often during breastfeeding because of oxytocin causing contractions
- painful during contractions but should not be painful on palpation - this could indicate infection
what is diastasis recti abdominus and how is it assessed for?
- the separation of the rectus abdominus muscle
- should be assessed by visualizing and
- can be improved using the Tupler Technique
what are some of the normal developmental markers of a 2 month old?
weight of 4-6.5kg has a strong suck and gag reflex may lift head and hold object plays with fingers follows objects begins to smile
how are the fluid requirements for infants calculated?
100 ml/kg for first 10 kg
50 ml/kg for the next 10 kg
20 ml/kg for anything over 20kg
what are the anatomical and physical differences in the airways of infants?
- infant is 4mm in diameter (5x less than the size of an adults)
- during first 5 years airway increases in length but not diameter
- infants are obligate nose breathers until 4 weeks of age
- bronchioles are fewer in number and don’t increase until about 8 years of age
- infants have a higher metabolic rate which uses more oxygen
what is a major way that uncontrolled asthma can disrupt normal development?
causing a child to miss school
what is asthma
- a chronic inflammatory disease of the lungs that makes it difficult to breath
- cannot be cured but can be managed
- inflammation of the airway occurs and an increase in mucus production
- constriction of bronchial smooth muscle causes spasm
what age does asthma generally develop prior to?
the age of 6
can children grow out of asthma?
-yes, but it may reappear in adulthood
what is the operational diagnostic criteria for 1-5 year olds?
recurrent asthma-like symptoms or exacerbations with documentation of:
- airflow obstruction
- reversibility of airflow obstruction
- no clinical evidence of an alternative diagnosis
what are factors that increase the risk of developing asthma?
- family history of allergy or allergic disorders
- passive smoke exposure
- indoor air contaminants
- outdoor air pollutants
- recurrent viral infections
- low birth weight and respiratory distress syndrome
- obesity
what are the two factors that provoke asthma?
triggers (cause tightening of airways // bronchoconstriction)
inducers (cause inflammation of airways)
what are asthma triggers?
- things that when someone with asthma are exposed to, leads to exacerbation
- they DO NOT cause inflammation and therefore don’t cause asthma
what are some asthma triggers?
Indoor Air Trigger Strong fumes Scents Dust Mold Emotional upsets Smoke, 2nd and 3rd hand Cold Pets – often people will be told to get rid of pet, but this can cause emotional stress
Additional Triggers
Exercise
Aggravating conditions: rhinitis, GERD
o Post nasal drip can trigger coughing and drainage can settle into bronchioles
o May be more susceptible to pneumonia developing quickly
Menstrual cycle
what are asthma inducers?
- they are things that cause inflammation and airway hyper-responsiveness
- things like allergens and respiratory viral infections
what is meant by persistent asthma?
-symptoms that occur at least twice a week during the day and twice a month during the night
For children 6 years and older what are common medications for asthma?
for intermittent: short acting beta-agonist (bronchodilator)
for persistent: low dose inhaled corticosteroid and a long acting beta-agonist if needed
in more serious cases may introduce leukotriene receptor and systemic corticosteroid
for children between 1 and 5, what are common medications for asthma?
for mild exacerbations: short acting beta-agonists
for moderate to severe exacerbations: a short acting beta-agonist and a corticosteroid
what are the goals of asthma management?
- control symptoms so that there is no sleep disruption, missed school, need to visit ER
- be able to maintain normal activities, have near normal lung function and avoid side effects of medications
what is ventolin?
a bronchodilator used for prevention and relief of bronchospasm in those with asthma
why use a spacer for inhalers?
to make it easier for someone to take in the dose (hard to do if you have small lungs or impaired capacity so spacer hold the dose while you take it in over a few breaths)
- less coordination is required
- oropharyngeal deposition is decreased
- more drug is deposited in lungs!
why are inhaled medications used for asthma and generally prefered over oral?
- have a rapid onset of action
- less drug can be used
- often better tolerated with less side effects
- useful for acute symptoms treatment
- if someone is having trouble breathing, swallowing is probably really difficult
what is flovent
a corticosteroid
used to reduce inflammation and swelling
used for long-term control of asthma (not used for rescue)
-side effects can be a sore throat, hoarseness, thrush
what is methyprednisone
- an anti-inflammatory, immunosuppressant agent used to treat allergic, inflammatory, and autoimmune disorders
- usually given IV if quick onset needed (not given orally if you are having trouble breathing)
what is RSV
respiratory syncytial virus
- most common cause of lower respiratory tract infection in children worldwide
- virtually all children have had it by age of 3
- leading cause of pneumonia and bronchiolitis in infants
- may play a role in pathogenesis of asthma
what are symptoms of RSV?
- runny nose (rhinorrhea)
- wheezing and coughing
- irritability and restlessness
- low grade fever (but can get high temp)
- nasal flaring and retractions
- enlarged liver and spleen
how is RSV managed?
- hydration
- relief of symptoms (like giving bronchodilator)
- antiviral medication (ribavirin)
- oxygen therapy
- treatment of other infections
- humidity
what is para influenza?
- causes many pediatric respiratory infections, including upper respiratory tract infections, croup (laryngotracheobronchitis), bronchiolitis, pneumonia
- this virus is the major cause of croup
- virus that colonizes nose and nasopharynx then invades epithelium causing cell damage, edema, and loss of cilia
- fibrinous exudate develops with downward spread of cell damage and edema causing airway obstruction and laryngeal muscle spasm
what are symptoms of para influenza?
- low-grade fever
- nasal congestion
- sneezing
- sore throat
- cough (barking)
- inspiratory stridor
what is hemophilus influenza b?
- a bacterial infection that affects several body tissues and organs
- can cause meningitis and severe throat and/or lung infections
- 1 in 20 children who get it will die and 20-50% will suffer deafness and/or permanent brain damage
what are symptoms of hemophilus influenza b?
- meningitis
- fever
- stiff neck
- drowsiness
- extreme irritability
- sudden vomiting
- symptoms at a site of infection (can be skin or joint for example)
how can hemophilus influenza b be prevented?
vaccination
what is pertussis?
- a highly contagious bacterial infection
- affects respiratory system and produces coughing spasms that usually end in a high-pitched sounding deep inspiration (which is why it is called whooping cough)
- causes very thick sputum
how is pertussis diagnosed?
- a culture of secretions from mouth and nose
- a throat swab culture
- a CBC (usually elevated WBC and large number of lymphocytes)
- serologic (blood) test for Bordetella pertussis
- immunological tests
how can pertussis be prevented?
-vaccination
how is pertussis treated?
- if diagnosed very early, erythromycin may be used, but usually patients are only diagnosed after period of time when this would be effective
- oxygen tent with high humidity
- IV fluid
- suctioning of secretions
should cough suppressants be used in those with pertussis?
NO! cough suppressants can cause airway obstructions as secretions build
-secretions are often very thick and young patients may even need NG tube feeding because of how much it can impair swallowing
what is prevnar pneumococcal conjugate
- a bacterial infection spread by nasal droplets
- it is the leading cause of pneumonia and acute middle ear infections as well as childhood meningitis
- approximately 15 children under the age of 5 die in Canada each year because of this disease
what is the difference between active and passive immunization?
active is immunization with the bacteria/virus (even an inactivated form) that triggers an immune response
passive is protection against certain infections that is created by administration of antibodies derived from humans or animals
what is immune globulin?
- it is obtained from human plasma
- contains mainly IgG and small amounts of IgA and IgM
- contains antibodies that protect from disease
What are the BMI ranges and corresponding recommended weight gains for women during pregnancy?
<18.5 12.5-18kg//28-40lb
18.5-24.9 11.5-16kg//25-35lb
25-29.9 7-11.5kg//15-25lb
>30 5-9kg//11-20lb
for a woman with a normal BMI, approximately how much weight should be gained each trimester?
1st - 6lbs
2nd - 12lbs
3rd - 12 lbs
what does VEAL CHOP stand for and when is it used?
used to assess fetal heartrate
when written one acronym beside the other gives the type of rate changes and the causes
Variable decelerations
Early decelerations
Accelerations
Late Decelerations
Cord compression
Head compression
Okay
Placental and uterine insufficiency
what are normal fetal heart rate features?
- rate between 110 and 160
- moderate variability
- accelerations present
- decelerations absent, early or variable ones that are occasional and uncomplimented
what are features of fetal assessment that are abnormal or atypical?
- bradycardia less than 110
- tachycardia greater than 160
- absent, minimal or marked variability
- recurrent late decelerations
- complicated or repetitive variable decelerations
if you notice a fetal heart rate monitoring strip has concerning features, what are your steps?
- reposition mother (repeatedly)
- decrease or discontinue oxytocin
- correct hypotension if present
- give oxygen
- administer IV fluids as needed
- nitroglycerine if uterine hyperstimulation and bradycardia are occuring (relaxes smooth muscle and uterus is smooth muscle)
- perform vaginal exam to assess progress and rule out prolapse
- give support and explain what is going on
- notify other staff, attending physician, on-call physician, etc
- document
what should be done if you notice a fetus develops atypical deceleration patterns?
- notify healthcare provider to obtain further orders
- document orders and interventions
- document interventions effect on FHR pattern
- reduce or d/c oxytocin as dictated by facility protocol if it is being given
- provide reassurance
- provide additional interventions based on type of atypical decelerations
what are additional interventions for late decelerations of fetal heart rate?
- turning mother onto left side to increase placental perfusion
- administer oxygen to increase fetal oxygenation
- increase IV fluid rate to provide more intravascular volume
- assess mother for underlying contributing causes
what are additional interventions for variable decelerations of fetal heart rate?
- change clients position to try and relieve compression on the cord
- give oxygen and IV fluid as ordered
what are the care priorities during the first stage of labor?
- provide privacy
- encourage positions changes
- provide comfort measures
- give/support intake of clear fluids
- encourage
- provide education about procedures/drugs/options as appropriate
- support elimination needs (assess bladder for distension, encourage voiding q2h, test urine specimens for ketones, glucose, and protein
what are the care priorities during the second stage of labour?
- help woman find effective pushing pattern
- monitor fetal heart rate q5 minutes when pushing
- note EFM pattern, response to contractions, and variability
- support attempts to rest between pushes
- get assistance
- set up for delivery (infant warmer, oxygen and neonatal resuscitation equipment etc)
- administer syntocin 5 units IV or 10 units IM after anterior shoulder delivered
- note time of actual birth
when testing for ketones during labor, what may their presence indicate?
that glucose is needed by patient
what are the care priorities during 3rd stage of labour?
care of mom:
- place hand on fundus
- take vital signs
- monitor signs of separation of placenta (cord gets longer, may be a gush of blood, uterus rises)
- promote bonding
- assess placenta after delivery for intactness and general appearance
for baby:
- maintain respirations
- promote warmth
- prevent infection
- take cord blood sample
- clamp cord
- do APGAR score at 1, 5, and 10 minutes
what should be noted about umbilical cord after delivery of infant?
- how many vessels (normally there are two arteries and 1 vein)
what is involved in care during the fourth stage of labour?
- this is up to four hours after delivery of placenta
- monitor mom and infant to make sure they are stabilized before transfer onto the postpartum unit
- do assessments q15min for first hour or until stable if that takes longer
- assess vitals, fundus, bleeding, perineum
- encourage and support breastfeeding and bonding
- provide maternal nutrition
- support mom taking a shower and elimination (urine and BM ideally as soon s possible but BM sometimes takes a while)
what are the five categories of labour support?
- physical
- emotional
- instructional/informational
- advocacy
- partner/coach care
what are the goals of supportive care during labour?
- provide safe environment for mum and baby
- empowerment
- promote maternal coping
- support mother and family through labour and birth
- offer reassurance and information
- offer care in cultural context
what are the factors that affect perception of pain during labour?
- knowledge and childbirth preparation
- past experience
- responses of others
- physical and emotional state
- sociocultural factors
- effectiveness of pain management
what is the goal of labour support?
- promote relaxation
- conserve energy
- maximize oxygen to mum and babe
- maintain presentness
what is the difference between pain and suffering?
pain is a physical sensation
suffering is and emotional reaction and comes with exhaustion, feeling unsupported, helpless, out of control
what are forms of child birth preparation?
- prenatal classes
- independent study
- previous experience
- stories of others
- birth plans
what are the three Rs related to labour?
relaxation
rhythm
ritual
what are some mental activities that can be used to manage pain?
- imagery
- distraction
- hypnosis
- non-focused awareness
what are some non-pharmacological pain management strategies?
- mental techniques
- breathing techniques
- water/hydrotherapy
- hot/cold therapy
- positioning/repositioning
- use of birthing ball
- acupuncture
- acupressure
- aromatherapy
- TENS
- sterile water injections
- keeping a calm/comfortable environment
what is the goal of pharmacological pain relief during labour?
-to provide maximum relief with minimal risk to mother and fetus
what are some one minute comfort measures that can be done during labour?
- Role modeling, helping woman through contraction, give feedback. Partner to do same thing
- Watch couple/woman through a contraction, give feedback and suggestions
- Eye contract and soothing words throughout a contraction (as culturally appropriate)
- Visualization guided imagery during contractions
- Reassurance, encouragement, praise
- Take charge routine, when a woman is agitated or discouraged
- Talk her through the contraction, “conducting” her breathing in rhythm with hand or head movements. Have partner continue this
- Hand, foot, back massage
- Cold packs, hot packs, warm blankets
- Acupressure (role modelling)
- Reassuring touch (holding, patting hand, stroking cheek.
what are the priority needs of the newborn?
- Initiation and maintenance of respirations
- Establishment of extrauterine circulation
- Control of body temperature
- Adequate nutrition intake
- Establishment of waste elimination
- Prevention of infection
- Establishment of an infant-parent relationship
- Developmental care which balances physiological and neurodevelopmental needs
- Baby has to start doing things themselves
what are the adaptations that occur in a newborn related to respirations?
- while still in-utero, production of lung fluid decreases 2-4 days before labour in term infant
- during birth fetal chest is compressed and squeezes fluid out
- baby’s first breath is a inspiratory gasp triggered by pressure changes and increased pCO2 and decrease in pH and pO2
how much lung fluid remains in the air passage of a full term infant?
80-100mL remain in passage of a full term infant
immediately after birth, what should be assessed about newborn?
- ABCs
- rapid assessment (breathing or crying)
- muscle tone
- term infant?
- meconium present in amniotic fluid?
- APGAR score
what is involved in APGAR scoring?
HR Colour Respirations Muscle Tone Reflex irritability
score of 2 if things are normal, 1 if things are maybe not quite normal, 0 if there may be cause for concern
what words are used in the APGAR acronym and what are their meanings?
Appearance (colour) Pulse (heart rate) Grimace (refers to reflex - baby will make face if you do tangental foot slap) Activity (muscle tone) Respirations
what heart rate would get a score of 0 in APGAR scoring?
absent
what respiration rate would get a score of 0 in APGAR scoring?
absent
what kind of muscle tone would get a 0 in APGAR scoring?
flaccid tone (no flexion)
what reflex irritability would get a 0 in APGAR scoring?
no response
note, vigorous cry is a 2
what colour would get a score of 0 in APGAR scoring?
pale, blue
note this is often where some points are lost for even very healthy infants
what is normal venous and arterial cord blood values?
venous: 7.30-7.35
arterial: 7.24-7.29
what are normal pO2 values for venous and arterial cord blood?
venous: 28-32mmHg
arterial: 12-20mmHg
when cord blood gases are taken, which blood is anticipated to be oxygenated and which de-oxygenated?
opposite of in adults!
venous is oxygenated
arterial is deoxygenated
- the arteries attach to baby’s arteries - but because fetal circulation is different, this is actually the deoxygenated blood
- the blood from the cord vein is coming from the placenta, is oxygenated and goes through right atrium before circulating through arteries in fetus
how many vessels and of what type are in a normal cord?
2 arteries and 1 vein
what are some signs of neonatal respiratory distress?
- tachypnea
- apnea
- cyanosis
- grunting or cooing (done because infant trying to keep peak respiratory pressure to get more oxygen)
- nasal flaring
- retractions/indrawing
- poor feeding
- accessory muscle use
what needs to be done before the rectal temperature of a newborn is taken and why?
inspect the anus because it may not be patent (may have membrane or child may have been born without anus all together)
what is the normal temperature range for a newborn?
36.5-37.5 regardless of how it is taken!
how quickly can an infant loose heat?
0.2-1.0 degree Celsius per minute
what does BAT stand for?
brown adipose tissue
why are newborns at risk for hypothermia?
- amniotic fluid evaporation
- BAT is their main form of thermogenesis - they don’t shiver
- just came out, not used to making their own heat
when does brown adipose tissue appear in fetus?
between 26 and 30 weeks
what are risk factors for a newborn for altered thermoregulation
- first 8-12 hours are highest risk
- being premature
- being small for gestational age
- having CNS problems
- having had prolonged resuscitation efforts
- sepsis
what are signs of cold stress in a newborn?
vasoconstriction (acrocyonosis aka blue hands and feet or cyanosis or poor pallor)
tachypnea
tachycardia
fussiness/hyperactivity/irritability
what are ways to prevent cold stress in neonates?
Area for deliver between 23 and 25 degrees
Dry quickly (**head) – remove wet linens, hat
Use prewarmed plankets
Skin-to skin contact with mother
If needed, provide radiant warmer heat; do not block heat
Keep away from drafts, air conditioning vents, cold windows
Warm items – scales, stethoscope
Be aware of hyperthermia too
why are infants at risk of hypoglycemia?
- glucose is main source of energy for brain cells
- babies aren’t used to taking in food orally - used to having it continuously supplied
how long after birth do healthy babies typically take to start responding to low blood glucose?
-1 hour after delivery
what are risk factors for hypoglycemia in a neonate?
- small for gestational age because they have low glycogen stores
- large for gestational age because they produce more insulin
- being born to a diabetic mother because mom has had higher blood glucose and child produced more insulin before birth (also often LGA - though can be SGA too)
- premature birth because they don’t have fat and extra weight to stay warm, they may have under developed organs, don’t have glycogen stores, and may be using more glucose
- sick or stressed or cold - may be using/needing more glucose
what are symptoms of hypoglycemia in a newborn?
Jitteriness or tremor Apathy Cyanosis Convulsions Apneic spells or tachypnea Weak or high pitched cry Limpness or lethargy Difficulty in feeding -poor suck, refusal to feed Eye rolling Sweating, sudden pallor hypothermia and cardiac arrest (less common) *Above are in order of frequency*
how is hypoglycemia treated in a newborn?
- if child is asymptomatic: feeding frequency increased and possible supplementation if that doesn’t resolve issue in about an hour
- if child is symptomatic of BGM is less than 2mmol/L IV glucose infusion given
what medications are given at birth and why?
vitamin K - to prevent hemorrhagic disease of the newborn
erythromyocin ointment to prevent ophthamal neonatorum
what is the first period of reactivity?
refers to just after baby is born, it is a period where baby is awake and active
lasts about 30 minutes
baby is hungry and ideally breast feeding starts here
what is the inactivity to sleep phase?
occurs about 30-120 minutes after a baby is born
baby will be tired, show no interest in scuking, and be difficult to rouse if sleeping
lasts up to 2 hours
what is the second period of reactivity?
it is the third typical period seen in newborn behavior (after an initial period of activity and then sleep, baby becomes active again)
lasts 4-6 hours
normally meconium stool is passed
what is average head circumference for a newborn?
32-38cm
larger than chest by about 2 cm
what is average chest circumference for a newborn?
30-36 cm
what is average length for a newborn?
46-56 cm
what general newborn care should be given?
Vital sign q1h x 4, q4h x 24 - 48 hours , then BID.
“Head to toe” assessment BID
Weight at birth, then prior to d/c
• OD if <2500 grams or >10 % drop in birth weight.
Intake & output – monitor feeds, diapers.
Cord care – air dry, falls off 5 - 15 days, risk for infection.
Metabolic/Bilirubin screen after 24 hours (TCB if term)
• TCB less invasive
Facilitate family’s efforts to care NB
what should be done to care for cord of newborn?
- air dry
- inspect for pus/discharge
- should have fallen off by 15 days
- keep it dry
what are typical findings about the anterior fontanelle in a newborn?
varies from 1-4cm in any direction
diamond shape
when does anterior fontanelle typically close?
between 9 and 18 months
what are typical findings about the posterior fontanelle in a newborn
should be less than 1 cm
triangular shape
when does the posterior fontanelle typically close
within 8 weeks
How much weight should and 2-6 month infant gain easy week?
120-140 grams per week
How long after birth does rubra lochia typically continue?
- 1-3 days
- it is the dark red, musty and stale smelling discharge
What size clot noted in lochia should be followed up with a health care practitioner?
Greater than a loonie size
Or if tissue is present
What kind of lochia is serosa and how long does it persist?
- pinkish brown discharge
- typically lasts from day 3-10 postpartum (about 7 days)
What is Alba lochia and how long does it persist?
- yellow or white discharge that can last up to 6 weeks postpartum
- typically day 10-24
