Test #3 Flashcards
What items do you need to know at an Intrapartum assessment?
Weight
Medical Hx
OB history
Allergies- Meds and Food
Date of last period (Due Date)
Blood Type
Substance Abuse - Smoking, Drinking also
LABS:
H&H, RH Factor, Rubella Status, GBS Status, Platelets
What do you need to assess for during an intrapartum assessment?
Vital Signs
All body systems
Fetal HR
Basic UA for ketones, protein and glucose
Psychological Assessment (Support, anxiety, knowledge)
What is Dilation?
The opening of the Cervix
0-10
What is effacement?
Thinning of the cervix
100%=Completely thinned
What is station?
Where the fetal head is in relation to the mothers ischial spine
What are the premonitory signs of labor?
LIghtening:
Fetus descends into pelvic inlet
Braxton Hicks:
Irregular, intermittent contractions that occur during pregnancy. Causes more discomfort closer to onset of labor
Cervical changes:
Cervix begins to soften and weaken (ripening)
Bloody Show:
Loss of cervical mucous plug, causes blood-tinge discharge
Rupture of membranes
Sudden burst of energy:
Known as nesting, usually occurs 24-48 hours before start of labor
Loss of 1-3 lbs
Diarrhea, indigestion, nausea, vomitting may occur prior to onset of labor
After your water breaks, how long do you have before you need to deliver the fetus?
24 hours
What do we do during a Domestic Abuse Assessment?
All women should be screened for domestic violence. This should be completed when the pt is alone.
Has anyone close to you ever threatened to harm you?
Have you ever been hit, kicked, slapped or chocked by someone close to you?
Has anyone including your partner ever forced you to have sex?
Are you afraid of your partner or anyone else?
*Can contact authorities in regards to BABY!
What is Asthma?
A chronic disorder characterized by:
Smooth muscle spasms
Bronchial edema
Tenacious Mucous
What are some contributing factors to asthma?
Genetics
Environmental (Extrinsic) factors
Intrinsic factors
What are some assessments for asthma?
Wheezing
Tachypnea
Retractions
Nasal Flaring
Paroxysmal, irritative and non-productive cough
Prolonged expiratory phase
What are some daily medications for Asthma?
Long Acting Beta 2 Agonists
Inhaled corticosteroids
Methylzanthines
Mast cell inhibitors
Leukotriene Receptor Antagonist
What are some quick release medications for Asthma?
Short acting beta 2 agonists
Corticosteroids
Anticholinergic
What do we know about immune systems in babies under 3 months old?
They have lower infection rate due to protection of maternal antibodies
What do we know about infections in 3-6 month babies?
Infection rates soar
What do we know about infection in toddler/preschool kids?
They have a high incidence of infection but they decrease steadily
By age 5 what happens when pertaining to infections?
Less frequent infection rate
Some mycoplasma pneumonias
Strep infections increase
Nursing care on admission focuses on providing orientation to the unit and obtaining overall physical assessments of mother and fetus… What all do you assess?
Maternal vital signs and FHR
Any recent symptoms
Perform vaginal exam to determine cervical dilation and state of membranes
Determine frequency and intensity of contractions
Review systems such as respiratory, cardiac and neurological
Assess woman’s understanding of labor process and identification of woman’s support system
What information do you need to get during admission to develop a clinical pathway for four stages of labor?
Prenatal information
Current assessments
Expected teachings
Nursing care expected for each stage
Expected activity level
Proposed comfort measures
Elimination and nutritional needs
Level of family involvement
What do you need to get for the initial Intrapartum assessment?
Current Meds/Herbals
FULL head to toe going through all body systems
Psychosocial and Knowledge assessment
Why do you want to know what the top of the skull looks like?
You will see the suture lines
MAIN THING: Pay attention to the anterior fontanele.
-That is going to tell you the position when checking mom
What is the first phase of Stage 1?
Latent BEST time to do education
What is the second phase of Stage 1?
Active Dilation between 4-6cm
Baby moves to the pelvis
Anxiety rises as contractions get stronger
Doing a lot of reassuring to the mom
Physiological changes: Inc BP, O2 demand Inc, Mild respiratory acidosis at time of birth, Edema may occur, keep bladder empty bc it can empede baby coming down, Gastric volume remain inc, WBC inc during labor
What is the third phase of stage 1?
Transition
Contractions worse
Dilated 7-10
Body tremors, inc feelings of anxiety, irritability, eager to complete birth process, need support at bedside
All women should be screen for Domestic Abuse, THIS HAS TO BE DONE ALONE, what are some of the questions you would ask?
Has anyone close to you eer threatened to harm you?
Have you evern been hit, kicked, slapped or choked by someone close to you?
Has anyone including your partner ever forced you to have sex?
Are you afraid of your partner or anyone else?
During the psychosocial assessment what do you need to find out?
Use assessment techniques to meet laboring client’s needs for information and support
Know their support system:
-Father or support person-What do their caretaker activities involve?
Pain/Anxiety: Observe for rapid breathing, nervous tremors, clenching of teeth, thrashing, crying or increased pulse and respirations.
What are some factors associated with a positive birth experience?
Motivation for the pregnancy
Attendance at child birth education class
A sense of competence or mastering
Self cnfidence and self esteem
Positive relationship with male
Maintaining control duing labor
Trust in medical and nursing staff
What are some nursing care items in the Latent phase of labor?
Establish rappor with woman and support person
Discuss expectations of labor and delivery
Provide for privacy
Discuss individual expression of pain and discomfort
Discuss pain management options and patient preferences
What are some comfort measures in the active phase of labor?
Assist patient to reduce anxiety
- may need a paper bag if patients lips are tingling (Hypervent)
- Provide information and enhance coping skills
- Teach about what to expect during the labor process
Promote relaxation techniques
Give instructions to woman’s support person
Administer pharmacologic agents as ordered by physician or certified nurse-midwife
Assist with placement of epidural
What are some nursing care items for the second stage of labor?
Provide as much privacy as possible
Encourage woman and support person to decide who should be present at delivery
Provide praisea nd encouragent of progress
Help woman find effective pushing pattern
Support woman’s attempts to rest between pushes
What are some nursing care items for the 3rd and 4th stages of labor?
Encourage womand and support person to hold and look at infant as much as possible
Teach woman care to be performed after baby is delivered
Provide woman with food and fluids as allowed
ENJOY BABY!
What are some things to remember when dealing with an adolescent mother?
It is unique and she has developmental needs as well as physical needs that must be addressed
Very young adolescnet has fewer coping mechanisms and less experience to draw on than older laboring mothers
- Crucial to have support peson
- Adolescnets have high risk for pregnancy and labor complications
What is precipitous birth?
One that occurs rapidly
Less than 3 hours from start of labor to delivery
What are some nursing care items when dealing with precipitous birth?
Remember mother may fear what is going to happen and feel that everything is out of control
Mother needs to assume comfortable position
PRIORITY=Safe birth
Stay with mom
-Delegate someone to call PCP
What does the nurse need to do to deliver fetus if the PCP is not present due to it being a precipitous birth?
Nurse scrubs his or her hands if time permits
Use preset pack if no time for sterile table
When infants head crowns, mother should pant
Gentle pressure is applied against fetus head to prevent it from popping out rapidly
Perineum is supported and head is born between contractions
Pull mucal cord from around baby’s neck
When the shoulders are being delivered you want to put downward pressure on the 1st and upward pressure on the 2nd
DOCUMENT:
assessments, actions you took, time you contacted PCP and when they arrived, time started pushing, time of delivery, when membrane ruptured and when placenta came out
During active labor what do you want to check the urine for?
Ketones
Glucose
Protein
What happens to the GI during labor?
Gastric emptying time is prolonged
Acidity of gastric contents increase by ~2.5x
Risk of aspiration, especially when narcotics or anesthesia are used
What are some nursing care items that deal with Fluid and Electrolytes during labor?
Ice chips or sips of clear fluids are usually allowed during early labor
Clear fluids are:
Tea with honey and lemon, broths, apple juice
Other items:
Lollipops, hard candy, and popcicle
Maintain I&O
Fluids provide hydration and calories
Ensure frequent emptying of the bladder
Offer the bedpan every 2 hours and/or assist to bathroom
Patient may have physiologic diarrhea that occurs with labor
Be wary of infusing IV glucose:
This can lead to hypoglycemia in the newborn
Prolonged labor:
LR which minimizes acidosis and electrolyte imbalance
Active Phase:
Monitor degree of bladder fullness and make sure they empty bladder.
Prevent dehydration and bladder distention
What happens to the respiratory status during labor?
O2 deman increases at onset of labor because of contractions
Anxiety and pain from contractions increase=hyperventillation
fall in PaCO2 results in respiratory alkalosis
PUSHING: PaCO2 levels may rise alo with blood lactate levels and respiratory acidosis occurs
4th STAGE: acid base returns to normal levels by 24 hours
What are some diagnostics/labs during labor?
For prolonged labor or signs of dehydration:
Serum Electrolytes, CBC and Urine ketones
What can the RN do during labor?
Monitor
Evaluate
Teach
What can the LPN do during labor?
Monitor and report to RN any abnormal findings
Reinforce teaching
What can an aide do during labor?
Vital signs
Report patient complaints
Provide ice chips, popcicles, etc
what are some sources of pain during labor?
Emotional tension, anxiety and fear
Uterine contractions
Perineal and uterocervial traction
What is the main goal during intrapartum?
To have a happy, comfortable, safe labor and delivery resulting in a healthy breathing, alert newborn
What are some items that promote comfort or help control anxiety?
Pregressive relaxation
Touch Relaxation
Effleurage
Postiioning
Backrubs/Massage
Warm bath/Whirlpool tub
Birthing ball
Aromatherapy/Music therapy
Duala
Nurse’s Behavior
What is the goal of pharmacologic pain relief?
Provide maximum pain relief with minimum risk to mother and fetus
What impacts pain relief and acheiving min risk for pt and baby?
All systemic drugs used in labor for pain relief cross placental barrier by simple diffusion
Drug action in body depends on rate at which substance is metabolized by liver
Fetus has inadequate ability to metabolize analgesic agent
What does the laboring mother need to know prior to getting pharmacological pain relief?
Type of medication being administered
Route of administration
Expected side effects of medication
Implications for fetus or newborn
Safety measures needed (ie: stay in bed with rails up)
What are some narcotics given during labor?
Narcotics
Demerol
Morphine Sulfate
Stadol
Nubain
Barbiturates- Seconal, Nembutal
Narcotiv Antagonists - Narcan
What are some considerations with the timing of medications during labor?
After a complete assessment:
- Analgesic agent generally administered when cervical change has occurred
- Pain medication given too early may prolong labor and depress fetus
Drugs may cause fetal respiratory depression at birth if given too late in labor
Maternal and fetal vital signs must be stable before systemic drugs may be administered
Assess mother and fetus and evaluate contraction pattern before administering prescribed medications
What do you need to do before laboring mother gets an epidural?
Informed consent
Lab values
Platelet count-If less than 100 CANNOT do
if they have been on anticoagulant they must be off for 24 hours before
Give 1 Liter bolus of fluid:
Lactated Ringers or Normal Saline (So they don’t bottom out BP)
Get up and go to the bathroom b/c they won’t be able to afterwards
Make sure they are in the right position:
- Sittin on side of bed slouched over
- Knees up to chest position
Must have pulse ox on
How do you test if the epidural is in the right space?
Push epinephrine in and if the Heart rate increase they are in a vein and need to re do
What do you need to do after an epidural on a laboring mother?
Lay on back
Put pillow under right hip
Monitor BP every 3 min for 15 min then every 15 min
If BP decreaes bolus fluids, if that doesn’t work call anestesiologist
If it still doesn’t go up then administer 5-10mg of Ephedrine
What is continuous epidural analgesia?
Continuous medications are administered through epidural
Provides good analgesia
Produces less nausea and provides greater ability to cough
May produce breakthrough pain, sedation, respiratory depression
Itching and hypotension are side effects
What is a sign of a spinal fluid leak and what do you do?
SEVERE headache
Give caffeine and fluids
if it doesn’t get better do a blood patch:
A small amount of the patient’s blood is injected into the epidural space near the site of the original puncture; the resulting blood clot then “patches” the meningeal leak
What is a spinal block and why are they used?
Local anesthetic agen injected directly into spinal canal
Level of anestesia dependent upon level of administration
May be administered higher for cesarean birth or lower for vaginal birth
Onset of anesthesia is immediate
Wears off in 2-3 hours
What are some side effects of spinal block?
Maternal hypotension:
Can lead to fetal hypoxia, requiring frequent BP monitoring for health changes
Indwelling cUrinary catheter usually nee due to decreased bladde sensation and tone
Woman’s legs must be protected from injury for 8-12 hours after birth of baby due to decreased movement and sensation
What are some complications that can arise from spinal block or epidural?
Maternal hypotension from hypovolemia or effects of anesthesia:
-Treat with bolus of crystalloid IV fluid and notify anethetist
Bladder distention
Inability to push during second stage of labor
Severe headache with spinal anesthesia
Elevated temperature with epidural anesthesia
Possible neurologic damage
What is a Pudendal Block?
Local anesthesia injected directly into pudendal nerve which produces anesthesia to lower vagina, vulva and perineum
Only produces pain relief at end of labor
Has no effect on fetus or progress of labor
May cause hematoma, perforation of rectum, trauma to sciatic nerve
What is local infiltration?
Local anesthesia injected into perineum prior to episiotomy
Provides pain relief only for episiotomy incision
There is no effect on maternal or fetal vital signs
Requires large amounts of local anesthetic agents
What do you document when laboring mother gets anesthesia of any form?
Always assess pain using a scale and define the scale
Record when and how medicine was given
Record non-pharmacological pain management techniques
evaluate effectiveness of intervention using the pain scale
What are some nursing care items when dealing with general anesthesia?
Assess when mother ate or drank last
Administer prescribed premedication such as antacid
Place wedge under mother’s right hip to displace uteerus and preven vena cava compression
Provide oxygen prior to start of surgery
Ensure IV access is established
Assiste anesthesiologist by applying cricoid pressure (pic) during placement of endotracheal tube
What are some major complications with anesthesia?
Fetal Depression:
If mother receives general anesthesia, infant may have respiratory depression
Method not advocated when infant is considered high risk
Uterine relaxation:
Most general anesthetic agents cause some uterine relaxation
Vomiting
Aspiration:
Agents may also cause vomiting and aspiration
What are some assessment finding that make you suspect Hydramnios (Excess amniotic fluid)?
This is caused by the fetus makes too much urine or does not swallow enough, amniotic fluid builds up
Fundal height disproportionately large for dates
Difficulty palpating fetus and auscultating FHR
Tense, tight abdomen on inspection
Large spaces between fetus and uterine wall on ultrasound
What are some Maternal conditions associated with Hydramnios?
Diabetes
Rh Sensitization
Large Placenta
What are some fetal conditions associated with Hydramnios?
Hydrops fetalis:
serious condition in which abnormal amounts of fluid build up in two or more body areas of a fetus or newborn
Malformation of fetal swallowing
Neural tube defects
Anencephaly
Cardiac anomalies
Twins
What are some maternal implications of hydramnios?
Shortness of breath
Greatly increased cesarean rate
Uterine dysfunction
Abruptio Placentae
Postpartum Hemorrhage
Preterm labor
What are some fetal-neonatal implications of hydramnios?
Malformations
Preterm birth
increased mortality rate
prolapsed cord
Malpresentation
What are some assessment findings that make you suspect Oligohydramnios?
Fundal height small for datesFetus easily palpated and outlined
Ftus no ballottable
Variable Decelerations:
Because less water to cushion
Reduced AFI (Amniotic Fluid Index) on ultrasound
What are some conditions associated with Oligohydramnios?
Postmaturity
IUGR secondary to placental insufficiency
Major renal malformations:
- Renal Agenesis
- Dysplastic Kidneys
- lower urinary tract ostructive lesions
What are some implications of oligohydramnios?
Dysfunctional labr with slow progress
Fetal Deformation defects:
- Adhesions
- Skin and skeletal abnormalities
- Pulmonary hypoplasia
- Dysmorphic faces
- Shor ubilical cord
Umbilical cord compression
Head compression
What do you need to do for Oligohydramnios?
Provide information and encourage questions
Evaluate EFM tracinfor variable decels or nonreassuring fetal status
rposition mother to relieve cord compression
Notify clinician of signs of cord compression
Evaluate Newborn:
- Anomalies
- Pulmonary Hypoplasia
- Postmaturity
What is PROM and what is done?
Premature rupture of Membranes occunig before 37 weeks gestation
Assciated with infection, previous hx of PROM, hydramnios and multiple pregnancies
PROM Nursing care focuses on prevention of infection
The fetus is monitored carefully
If term and labor does not start on it’s own labor augmentation may be started to have infant delivered before 24 hours of the ruptured membranes
Limit vaginal exams to dec inf risk
Change bed pads frequently
If very premature we may delay delivery:
- Give corticosteroids for lung development
- May have antibiotics to prevent infection
- Transfer while still pregnant to regional facility
What are some characteristics of hypertonic labor?
Can be caused by too much Pitocin
Increased contraction frequency (Closer than 2 min)
Decreased contracion intensity
Increased uterine resting tone (no uterine resting during in between)
Prolonged latent phase
Increased discomfort due to uterine muscle cell anoxia
Stress on coping abilities
What are some implications of hypertonic labor?
Prolonged labor resulting in:
- Maternal exhaustion
- Dehydration
- Increased incience of infection
Decreased uteroplacental flow=Nonreassuring fetal status
Prolonged pressure on fetal head reslting in:
- Excessive molding (Swelling from excessive pressure)
- Caput Succedaneum (Swelling all over skull)
- Cephalhematoma(Blood is accumulated & bruising on one side of head or other
What are some clinical therapies for hypertonic labor?
Bedrest and relaxation measures
Pharmacologic sedation
Low doses of oxytocin (Get the contractions stronger & further apart & to progress labor)
Amniotomy (Break water)
More effective labor pattern
What are some causes of hypotonic labor?
(contractions far apart and not progressing)
Fetal Macrosomia (BIG baby)
Multiple gestation
Hydramnios
Grand Multipariy (Several deliveries make uterus stretch so not as effective)
What are some implications of Hypotonic labor?
stress on coping abilities
Prolonged labor resulting in:
- Maternal Exhaustion
- Dehydration
- Increased incidence of infection
Postpartum heorrhage due to uterine atomy (Uterus not muscly)
Nonreassuring fetal status due to prolonged laor Pattern
Fetal sepsis from pathogens ascending from birth canal
What are some assessments for hypotonic therapy?
Maternal fever
Foul smelling amniotic fluid
Tachycardia
What areome clinical therapies for hypotonic labor?
Oxytocin infusion
Nipple stimulation
Amniotomy
IV fluids
Surgival birth, if needed
Provide emotional support
There are several types of Abruptio Placentae, What is Marginal?
Placenta separates at its edge
Blod passes between fetal membranes and uterine wall
Blood escapes vaginally
There are several types of Abruptio Placentae, what is central?
Placenta separates centrally
Blood trapped between placenta and uterine wall
Concealed bleeding
There are several types of Abruptio Placentae, what is Complete?
Total separation
Massive vaginal bleeding
What are some assessments of abruptio placentae?
Abdominal pain that doesn’t go away
Painful bleeding(May or may not see blood)
If internal bleed would see sign of shock:
decrease in blood pressure, rapid, weak, or absent pulse, irregular heart rate, confusion, cool, clammy skin, rapid and shallow breathing, anxiety, lightheadedness.
Fetus may have late decels
Decrease in variability (Move from tachycardia to brady)
Abdomen feels board like
What are some maternal implications of abruptio placentae?
Intrapartum hemorrhage
DIC
Hypofibrinogenemia
Ruptured uterus from over distention
Fatal hemorrhagic shock
Pospartum complication:
- Vascular spasm
- Intravascular clotting
- Hemorrhage
- Renal Failure
- Fatal shock
What are some fetal-neonatal implications of abruptio placentae?
Prematurity
Hypoxia
Anemia (Due to blood loss)
Brain damage
Fetal Demise
DELIVER NO MATTER WHAT!!
What are some nursing care items for abruptio placentae?
Maintain two large bore IV sites
Monitor fetus an uterine activty electronically
- Assess restine tone every 15 minutes
- Assess fetal status every 15 minutes
Monitor intake and output and urine specific gravity
Measure abdomial girth hourly as ordered
Review and evaluate diagnostic tests
Moniture for signs of DIC
Assess maternal cardiovascular status frequently
- Vitalsigns every 5-15 minutes
- Skin color and pulse quality hourly
- Measur CVP hourly as ordered
Prepare for cesarean as needed
Neonatal resuscitation as needed
Provide information and emotional support
(For fluids and blood products as ordered)
There are several categories of placenta previa (When the placenta is sitting on cervic and bleeds when cervix starts dilating), What is total placenta previa?
The internal OS is completely covered
There are several categories of placenta previa (When the placenta is sitting on cervic and bleeds when cervix starts dilating), What is Partial placenta previa?
They have NON PAINFUL bleeding
The internal OS is partially covered
There are several categories of placenta previa (When the placenta is sitting on cervic and bleeds when cervix starts dilating), What is marginal placenta previa?
The edge of the OS is covered
There are several categories of placenta previa (When the placenta is sitting on cervic and bleeds when cervix starts dilating), What is low lying placenta?
Implanted in lower segment in proximity to the OS
What is the complications of placenta previa?
Maternal psychologic stress
Transverse lie common
Changes in FHR
Fetal compromise (Hypoxia)
Cesarean birth
Neonatal Anemia
Do you want to do a digital exam on a mother with placenta previa?
Also picture of placenta previa on answer card
NO NO NO NO NO
What are some nursing care items for placenta previa?
NO VAGINAL EXAMS
Objectively and Subjectively assess blood loss, pain and uterine contractability
Continuous external monitoring of FHR and uterine actity - NO interal monitoring
Monitor aternal vital signs and I&O every 5-15 minutes with active hemorrhage
(We need to make sure the kidney’s are working)
Obtain/Evaluate labs
Maintain large bore IV access - Available whole blood setup
Verify familiy’s abiliy to copwith anxiety of unknown outcome
Provide information and emotional support
Anticipate cesarean delivery
What is placenta accreta and what can it cause?
Chorionic villi attach directly to myometrium of uterus
May result in maternal hemorrhage/failure of placenta to separate from uterus
May result in need for hystrectomy at time of birth
What is retained placenta?
Placenta not delivering more than 30 minutes after birth
Occurs in 1-100/200 vaginal births
If not expelled placenta must be manually removed
What are some conditions associated with Breech presentation?
Preterm birth
Placenta previa
Hydramnios
Multiple gestation
Uterine anomalies-IE. Bicornate uterus
Fetal Anomalies:
Anecephaly
Hydrocephaly
Most won’t be delivered vaginally
External Version: Turn baby in abdomen 36-38 weeks, if not successful then C-Section will be required
What are some implications of breech presentation?
Likely cesarean birth
Increased perinatal morbidity and mortality rates
Increased risk of prolapsed cord
Increased risk of cervical spinal cord injuries
Increasd rish of asphyxia and non-reassuring fetal status
What are some conditions associated with Transverse Lie?
Grand multiparity with lax musculature
Preterm fetus
Abnormal uterus
Excessive amniotic fluid
Placenta previa
Contracted pelvis
High risk of prolapsed cord
Cesarean birth
What is fetal Macrosomia?
Newborn weighing more than 4500g (9.9 lbs)
How do you identify fetal macrosomia?
Palpation of fetus in utero
Ultrasound of fetus
X-ray Pelvimetry
What are some managements for fetal macrosomia?
Cesarean birth performed if fetus is greater than 4500g
Continuous fetal monioring if labor is allowed to progress
Requires notification of physician for early decelerations, labor dysfunction or nonreassuring fetal status
What are some nursing care items for prolapsed cord?
Assess for nonreassuring fetal status
If a loop of cord is discovered, the examiner’s gloved fingers must remain in vagina to provide firm pressure on fetal head until provider arrives
Oxygen via face mask
Monitor FHR to determine if cord compression is adequately relieved
WOman assumes knee-chest position or bed is adjusted to Trendelenburg position
Transport to the operating room in this position
What are some risks for the fetus with fetal macrosomia?
Brachial plexus
Subdural hematoma
Broken clavical
What is the mother at risk for with fetal macrosomia?
Hemorrhage
What are some signs and symptoms of amniotic fluid embolism?
Dyspnea
Cyanosis
Frothy sputum
Chest pain
Tachycardia
hypotension
Mental confusion
Massive hemorrhage
Difficulty Breathing
What is amniotic fluid embolism?
Occurs when amniotic fluid — the fluid that surrounds a baby in the uterus during pregnancy — or fetal material, such as hair, enters the maternal bloodstream.
What are some implications related to amniotic fluid embolism?
Suden onset respatory distress
Acute Hemorrhage
Circulatory collapse
Cor Pulmonale
Hemorrhagic Shock
Coma and maternal death
Fetal death if birth not immediate
What are some interventions when a mother has amniotic fluid embolism?
Call ressucitation team
Give O2
Large bore IV access
May have to do CPR
Prepare for emergency C-Section
May administer blood
What are some nursing interventions with a multiple gestation mother?
Frequent assessment of feal heart tones of each fetus
Education of mother about signs and symptoms of preterm labor
Encouragement of mother to ret frequently prior to birth
Preparation of equipment needed to care for each individual newborn
Prolonged (Post term) pregnancy’s can result in an increased possibility of what?
Probable labor induction
Decreased perfusion to the placenta
Decreased amount of amniotic fluid and possible cord compression
Meconium aspiration
Macrosomia or a loss of fat and muscle mass resulting in small-for-gestational age (SGA) newborn
What are some interventions for intrauterine resuscitation?
Turn woman to left lateral position to treat hypotension
Begin or increase IV flow rate
Discontinue Pitocin or administer a toclytic agent to decrease contraction frequency/intensity
Administer oxygen
Perform vaginal exam toheck for dilation and cord prolapse
Notify Physician
Obtain additional information about fetus by fetal scalp blood sampling
What is some basic information about the respiratory system in peds? LOTS AND LOTS
Lung size is proportionate to body height
Alveoli develop from aprox 25 million - 300 million by age 3
Lung surface increases until 5-8 years
Actual lung growth continues into adolescence
Trachea size approximately tripled by adulthood
Tonsillar tissue is normally enlarged in early school children
Flexible larynx is more susceptible to spasm
Infants are nose breathers!!
Diaphram is a neonates major respiratory muscle
- Intercostal muscles are not well developed
- Retractions are more common in the infant than in older chilren and adults
Brief periods of apnea (10-15 secs) are common in neonate
- Respiratory pattern may also be irregular
- Respiratory rate is higher than an adult
Increased metabolic rate raises O2 need
Lack of surfactant
-Increases risk of Respiratory distress syndrome(RDS) prior to 34 weeks
Underdeveloped supporting carilage and smaller lower airways
-Predisposes child to increased risk of obstruction (Mucus, edema, foreign body)
Any factor that decreased the size of passage, increased airway resistance
-Hampers breathing and feeding
(Neonates airway is 50% smaller than adults)
What are some congenital anomalies regarding the respiratory system?
Choanal Atresia
Esophageal Atresia
tracheoesophageal Fistula
Diaphragmatic Hernia
What is choanal Atresia, what would you see and do?
Blockage of the posterior side of the nose
Noisy respirations
Cyanosis at rest
Difficulty breathing during feeding
Interventions:
- Listen to brath sounds holding the mouth closed and 1 nostril
- Pass msall catheter through each side
- Hold spoon under to see if it fogs
- Call PCP
- Give O2 STAT
- Raise HOB
What is esophgeal atresia and assessments?
Congenital malformation which the esophagus terminates before it reaches the stomach and or a fistula is present that forms an unnatural connection between the esophagus and the trachea
Assessments:
- Vomiting
- Abdominal distention
- Failure to pass suction catheter
- Excessive oral secretions, coughing and choking
- Food comes out as soon as you feed
What is tracheosophagal fistula and what are some assessments?
Fistula at the connectionbetween the trachea and esophagus
Assessments:
- Coughing
- Apnea
- cyanosis
- Frothy Saliva
At risk of aspiration of stomach contents
Interventions:
Suctioning every 5 min
Assess family (Therapeutic responses & keep family in loop)
What is a diaphragmatic hernia?
Portion of the intestines is in the thoracic cavity through abnormal opening in the diaphragm
LIFE THREATENING
What are some assessments of diaphragmatic hernia?
Abdominal organs in chest (by fetal ultrasonography).
Diminished or absent breath sounds on affected side.
Bowel sounds that may be heard over the chest.
Cardiac sounds that may be heard on the right side of the chest
Respiratory distress developing soon after birth—dyspnea, cyanosis, nasal flaring, tachypnea, retractions.
Scaphoid abdomen.
What are some therapeutic management of diaphragmatic hernia?
If diagnosed prenatally, mother moved to tertiary care center before delivery.
In utero surgery may be performed.
Neonatal emergency NG intubation with suction.
Ventilate with high-frequency ventilation. Manage acidosis with bicarbonate and ventilation.
ECMO.
Liquid ventilation.
Manage pulmonary hypertension; inhaled nitric oxide may be used.
Surgical reduction of hernia after physiologically stable; may wait 6-18 hr after birth.
Respiratory support and ECMO until lungs functioning after surgery. (McKinney 1077)
McKinney, Emily, Susan James, Sharon Murray, Kristine Nelson, Jean Ashwill. Maternal-Child Nursing, 4th Edition. W.B. Saunders Company, 2013. VitalBook file.
What are some interventions for diaphragmatic hernia?
Monitor intake and output. Document vomiting. Observe for respiratory distress. Provide routine postoperative care for GI surgery
Identify clinical findings and report immediately
Place child in semi-Fowler position on affected side with head of bed elevated.
Maintain patency of NG tube.
Monitor IV fluids.
Maintain mechanical ventilation, ECMO, chest tubes.
Assess oxygenation.
Do not use facemask or bag-valve-mask for ventilatory support because air can enter stomach and further impair respiratory function.
Provide minimal stimulation.
Provide routine postoperative care.
Monitor for signs of infection, respiratory distress, and feeding difficulties; report to physician.
Support family mourning loss of perfect child.
what is respiratory distress syndrome and what is it associated with?
Caused by insufficient surfactant
Surfactant prevents alveoli from collapsing with expiration
Each breath takes a log of energy and effort to inflate the alveoli
LACK OF CHEST EXPANSION CAN LEAD TO RESPIRATORY ACIDOSIS
Associated with:
- Preterm infants
- Infants of diabetic mothers
- Multifetal gestation
- Infant with difficulty deliveries
- C-Sections
What are some assessments of RDS?
Usully shows a progressive pattern
Respiratory rate increases
Nasal flaring, retractions and cyanosis
Expiratory grunt
Apical pulse incrases at first - Later becomes bradycardia
Abdominal seesaw pattern
Decreased breath sounds and rates may occur
Retractions:
- Subcostal and xiphoid
- Progressing to intercostal, supracostal and clavicula
Color Changes:
- Pink to circumoral pallor to circumoral cyanosis
- Acrocyanosis deepens (Could get so dark almost black)
Body Temperature Drops
-Avoid rapid rewarming-may bring on apneic spell (Stop breathing)
Incrase number of apneic spells
Tachypnea (80-100 breaths per minute)
May have a decrease in musce tone, decreased response to painful stimuli adn apneic spells
What is the goal with RDS?
NICU
Optimum oxygenation
Stabilization of vital signs
Correction of acid-base balance
What are some interventions for RDS?
Surfactant
Ox hood
- Start at 40% and wean down to 21% O2 with pulse ox at 94-98%
- Monitor continuously
CPAP, intubation, Ventilator
Blood gas monitoring
-Draw from femoral artery
Thermoregulation
-Put pad over liver
(Given via ET Tube)
What is bronchopulmonary dysplasia (BPD)?
Presisent lung disease following a premature birth
A complication of prolonged O2 therapy
Chronic Lung disease
What are some assessments for BPD?
Signs of tachypnea
Nasal flaring
Grunting
Retractions
Wheezing
Crackles
Irritability
Increased breathing workload
Cyanosis
Activity intolerance
How is BPD diagnosed?
Clinical manifestations
X-Ray abnormalities
Resp symptoms beyond 28 days of age, O2 suppement or mechanical ventilation
PROBLEMS SEEN AT BIRTH
What are some interventions for BPD?
O2 & drug therapy
Nutritional Support
What is Meconium aspiration syndrome?
In utero the fetus is stressed and meconium is expelled
What are some assessments of Meconium Aspiration syndrome?
If fluid has green specs or smells like BM
At birth:
Signs of distress like pallor, cyanosis, apnea, bradycardia, low apgar
-Skin, nails, cord may be stained with meconium
What are some interventions for meconium aspiration syndrome?
Suction ASAP
ECMO if severe
Home with monitor-If respiratory difficulties of hx prematurity
Teach parents to watch for respiratory distress
What is sudden infant death syndrome?
sudden and unexpected death of an apparently healthy infant youner than 2
Remains xplained after complete autopsy
Cause is unknown:
- Intrinsic and extrinsic risk factors commonly said
- Majority had 1 intrinsic and 2 extrinsic factors
What are some interventions for SIDS?
Prevention of extrinsic risk factors
Teaching is PRIORITY when it comes to newborns
Back to sleep
What is Cystic Fibrosis?
Genetic Disorder
Cuases mucus in the body to become sticky and thick
Glue like mucous builds up and causes problems in the organs, mainly lungs & pancrease
Children have serious breathing problems and lung disease
Also have problems with nutrition, digestion, growth and development
No cure & it gets worse over time
Most common lethal genetic disease in whites
What are some interventions & nursing care with cystic fibrosis?
Talk with parents about financial concerns and determine if financial assistance is needed
Changes in body image
Help parents create schedule for medication administration
-Pancrease meds at EVERY snack/meal
Teach respiratory therapy techniques; create schedule
Plan for exercise (Jogging, swimming, weight training)
-Makes them stronger and helps move mucous
Genetic testing
Teach diet high in protein and calories but low in fat
DO NOT GIVE ANTIHISTAMINE (Pseudafed, Benadryl)
What is asthma?
Chronic disorder characterized by:
- Smooth muscle spasms
- Bronchial Edema
- Tenacious mucous
Contributing Factors:
- Genetics
- Environmental/Extinsic factors
- Intrinsic issues
What are some assessments of asthma?
Wheezing
Tachypnea
Retractions
Nasal Flaring
Paroxymal, irritative and non-productive cough
Prolonged expiratory phase
What are some interventions for asthma?
Medications:
Daily Control
Quick Relief
What are some daily control medications for asthma?
Long acting beta 2 agonists
Inhaled corticosteroids
Mehtylzanthines
Mast cell inhibitors
Leukotriene receptor antagonist
What are some quick relief medications for asthma?
Short acting Beta 2 Agonists
Corticosteroids
Anticholinergics
What are some infectious conditions in peds?
Pertusis
Interventions: Immunize, promote rest and fluids, contact and droplet precautions, oxygenation
Tuberculosis
Person to person airborne droplet, maybe asymptomatic, symptoms same as adult
Influenza
Droplet directly or indirectly, rest and fluids, antipyretics, comfort
Pneumonia
Rest and fluids, antipyretics, analgesics, antibiotics if bacterial, Repositition every 2 hours so it doesn’t set up in the lungs (Even at home)
What is laryngotracheobronchitis?
Croup
Inflammation of the larynx, trachea and bronchi
What are some assessments for laryngotracheobronchitis (LTB)?
Irritability
Horseness
Inspiratory stridor
Respiratory distress
Low grade fever
Barking cough
Stridor
Cyanosis
Retractions
What is a treatment for LTB (Laryngotracheobronchitis)?
Epinephrine
UNLESS SEVERE: Can cause rebound effect
Oral Dexamethasone to open airway
Usually hospitalized
Give O2 and encourage rest/fluids
What is RSV (Respiratory Syncytial Virus)?
Acute viral infection
Involves bronchioles and aveoli
Most common for children under age of 2
-Usually Nov-Mar
Immunizations available
-Synagis: Monthly if high risk and over 2
Can be fatal for preterm infants an children with chronic illness
What are some assessments for RSV?
URI with serious nasal drainage that just gets worse
Cough, fever, RR >70
Decreased breath sounds
-apneic spells lead to respiratory acidosis
Increased respiratory rate
What are some diagnostics for RSV?
Nasal washing
Child’s age
Direct aspiration of nasalecretions
CXR & ABG
What are some interventions for RSV?
Maintain respiratory function
Hydration
Reduce anxiety and prepare for home care
Droplet precautions
-HIGHLY COMMUNICABLE: Can stay on crib and other surfaces for 6 hours and 1 hour on skin and paper
What is respiratory failure?
Occurs when the body can no longer maintain effective gas exchange
Hypoventilation results in hypoxemia and hypercapnia
When oxygen and carbon dioxide reach abnormal levels, hypoxia occurs and respiratory failure begins
Caponography: Tells what their carbon dioxide levels are
What are some assessments for MILD respiratory distress?
Body is attempting to compensate
Restlessness
Tachypnea
Tachycardia
Diaphoresis
What are some assessments of MODERATE respiratory distres?
Early decompensation
Nasal flaring
Retractions
grunting
wheezing
Anxiety, Irritability, mood changes, confusion
Hypertension
What are some assessments for SEVERE respiratory distress?
Respiratory Failure
Leading towards imminent event
Dyspnea
Bradycardia
Cyanosis
Stupor
Coma
What are some diagnostics and labs for respiratory disress?
Pulse Ox
AG
Sputum/throat/blood cultures
Radiology (CXR)
PFT
Bronchoscopy
Hematology
What is some pharmacology for respiratory distress?
Expectorants
Mucolytics (Humibid)
Bronchodilators
Antipyretics
Antibiotics
Corticosteroids
Oxygen
What are some interventions for respiratory distress?
RN MUST DO ASSESSMENT
Put in High Fowler’s
Bad Lung down
What is Epiglottitis?
LIFE THREATENING
Inflammation of epiglottis caused by bacterial invasion of the soft tissue of the larynx by streptococus, staphylococcus, or haemophilus influenza type B in unimmunized children
What are some assessments of Epiglottitis?
Suddenly Ill
High fever
sore throat
Four Classic Signs:
Dysphonia (Inability to talk)
Dysphagia (Difficulty swallowing)
Drooling
Distressed respiratory effort with inspiratory stridor
Sitting up and leaning forward - Sniffing or tripod
How is Epiglottitis diagnosed?
Clinical manifestations
Exam and observation are contraindicated until intubation and qualified personnel are available
What are some epiglottitis interventions and treatments?
DO NOT leave child unattended until intubated
NO cultures or things in mouth until intubation
Will stay intubated 1-2 days
Epinephrine and corticosteroids are NOT effective
Antibiotics- Rifampin Prophylaxis
Thrat cultures (MUST be intubated to obtain)
EPIGLOTTITIS MNEMONIC
CAPUT SUCCEEDAEUM MNEMONIC
EARLY AND LATE DECELERATIONS MNEMONIC
STAGES OF LABOR MNEMONICS
RESPIRATORY ACIDOSIS MNEMONIC
ANALGESIA VS ANESTHESIA MNEMONIC
ASTHMA MNEMONIC
ASTHMA MNEMONIC
RESPIRATORY DISTRESS SYNDROME MNEMONI
CYSTIC FIBROSIS MNEMONIC
HYPOXIA MNEMONIC
PITOCIN MNEMONIC
FETAL STATION MNEMONIC
FETAL STATION 2 MNEMONIC
APGAR MNEMONIC
FETAL HEART MONITOR MNEMONIC
VEAL CHOP MNEMONIC
LARYNGOTRACHEOBRONCHITIS MNEMONIC (LTB)
PLACENTA PREVIA AND ABRUPTIO
STAGES OF LABOR
