Study Guide 3
Study Guide 3 NSG 330
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This 24 page Study Guide was uploaded by Brieanna Phipps on Thursday March 24, 2016. The Study Guide belongs to NSG 330 at University of North Carolina - Wilmington taught by Dr. Goff in Spring 2016. Since its upload, it has received 31 views. For similar materials see Maternal Infant in Nursing and Health Sciences at University of North Carolina - Wilmington.
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Date Created: 03/24/16
NSG 330 MaternalInfant Nursing Exam III Study Guide Fall 2015 Module 6: Nursing Care: Normal Postpartum PPT 1(Chapters 20, 21, 22): 1. Interpret postpartum lab findings, such as Hgb, Hct, WBC, urinalysis, and Rh factor. Recognize deviations and nursing care. SLIDE: 6, BOOK: p. 478 increases HCT, hbg, wbcs, and coagulation factors rbc volume normal 68wk pp stroke volume, CO, systemic vascular resistance remain elevated for about 612 weeks PP. BUN increases Hematocrit and Hgb: in women with an average blood loss during birth, the hematocrit level drops moderately for 3 to 4 days, then begins to increase, and reaches nonpregnant levels by 8 weeks PP. The PP hematocrit can be lower than normal if the blood loss was increased or if the hypervolemia of pregnancy was less than normal. WBC: Normal leukocytosis of pregnancy averages approximately 12,000. During the first 47 days after birth, values between 20,000 and 25,000 are common. Leukocytosis can obscure the diagnosis of acute infection. Urinalysis (p. 476urine components): The renal glycosuria induced by pregnancy disappears by 1 week PP but lactosuria can occur in lactating women. The blood urea nitrogen increases during the puerperium (fourth trimester of pregnancy) as autolysis of the uterus occurs. Plasma creatinine levels return to normal by 6 weeks PP. Pregnancy associated proteinuria resolves by 6 weeks after birth. Ketonuria can occur in women with uncomplicated birth or after a prolonged labor with dehydration. Rh factor (p. 493): Injection of Rh immune globulin (a solution of gamma globulin that contains Rh antibodies) within 72 hours after birth prevents sensitization in the Rh negative woman who has had a fetomaternal transfusion of Rhpositive fetal RBCs. Rh immune globulin promotes lysis of fetal Rhpositive blood cells before the mother forms her own antibodies against them. (300mcg 1 vial) is usually sufficient to prevent 1 maternal sensitization. The dosage needed should be determined by performing a KleihauerBetke test. If more than 30 ml of fetal blood is in the maternal circulation, the dosage of Rh must be increased. 2. Describe normal vital signs (BOOK p. 478 CHART) and other postpartum assessment findings (including normal urine output BOOK p. 476 (under fluid loss)), deviations from normal and appropriate nursing interventions. SLIDES: 89,BOOK: READ CH. 20! stable BP, increased respirations, decreased pulse temp less than 100.4F, 38C Urine output: 3000 ml or more each day during the first 2 to 3 days is common. Postpartum Assessment: slides 1029, BOOK CH. 20 [BUBBLE HE] Breasts Uterus Bowels Bladder Lochia Episiotomy/Laceration/Csection Incision Homan’s/Hemorrhoids Emotional Breasts: Nipples Areola Fullness Tenderness Engorgement can be very painful: o Occurs 24 to 48 hours PP o Vasocongestion: temporary congestion of veins and lymphatics; milk present o Swollen, firm, tender, and warm to touch o Breast binder or bra, fresh cabbage leaves, ice packs, mild analgesia 2 Uterus: Involution (the process)—reduction in size of uterus and return to nonpregnant state (goes from 2lbs back to 2oz) Autolysis (the specific process)—destruction of excess hypertrophied uterine tissue, comes out in lochia Afterpains—mostly in multigravidas (the uterus is still contracting because she had more babies, twins, etc) Uterine atony—relaxation of uterus, within 12 hours PP the fundas should be approximately 1cm above the umbilicus. o Nursing Priorities of Uterine Atony: Massage fundus until firm & express clots present Check for bladder distention If necessary, check standard orders or notify primary health care provider for oxytocic order Check amount and character of lochia and change pad Increase frequency of PP assessments Document all findings, actions, and responses Bowels: Spontaneous may be delayed: pain, decreased muscle tone, dehydration Stool softeners Dulcolax suppository PRN or enema if no bowel movement in 48 hours Anusol cream for hemorrhoids PRN Encourage Kegal exercises Bladder: Postpartal diuresis May have decreased urge to void Full bladder displaces uterus & decreases its tone, & can lead to bladder infection and inadequate voiding With adequate emptying, tone usually restored 5 to 10 days PP Lochia: Lochia Rubra red (within first day or two) Lochia Serosa pinkish/brown (third or fourth day) Lochia Alba even less of those colors (about 10 days PP) Scant until oxytocic wears off Smaller amount after C/S (they suction it out) Persistent rubra: retained placental fragments Increases with ambulation & breastfeeding (warn her of that during her first time up, she may have a gush) 3 First menstrual flow is usually heavier than usual. Returns within 34 cycles Epis/Lacerations/CS Incision: Redness Edema Ecchymosis Discharge/Drainage Approximation Homan’s: Check Homans’ sign if protocol Assess number, size, and character of hemorrhoids Assess level of hemorrhoidal (or perineal) pain Self Care for Epis/Lac/Hemorrhoids: o Perineal Cleansing o Ice Packs o Squeeze Bottle o Sitz Bath o Dry Heat o Topical Applications Epidural or Spinal Assessment: o Raise legs extended at knees off bed o Flex knees, place feet flat on bed o Raise buttocks well off bed o Numbness, tingling, prickly totally gone o General: awake, alert, oriented 4 o Respiratory rate within normal limits o O2 sat at least 95% Postanesthesia Recovery (PAR) every 15 minutes: o Activity o Respirations o Blood Pressure o Level of Consciousness (LOC) o Color Emotional: Commitment, attachment, preparation (pregnancy) Acquaintance, learning, physical restoration (first 26 weeks PP) Moving toward a new normal (2 weeks to 4 months) Achievement of maternal identity Urine output: 3000 ml or more each day during the first 2 to 3 days is common. 3. Recognize adaptive and maladaptive parentinfant interaction. SLIDES: 3040, BOOK CH. 22 CHARTS PG. 503 Attachment and bonding are very similar terms a specific enduring tie to another person. Mutuality what does the baby do, when the baby reacts the parent will react too. Acquaintance learning what that baby is actually like (talking, touching, and exploring to become acquainted with their infant). Claiming process looking for the likeness of them or other family members (her eyes, dad’s nose, fred’s ears), “differences”, and “uniqueness”, when they are checking all the fingers and toes, etc as well. Touch May be very careful at first using only fingertips and then will start touching baby with palm of hand. Voice baby’s have heard things when they were in utero, music effects how much they move in utero. Entrainment with adult speech, if you talk quickly then the infant will move more quickly. (dancing in tune) Biorhythmicity The infant being in tune with the mother’s natural rhythms. The sleep cycle, feeding cycle, etc. Reciprocity The behavioral cues the infants provide to the parents and then the parents respond. (When the baby cries and mother picks baby up) 5 Synchrony what is the fit between the baby’s cues and the parent responses, and how they fit together. Ex: you can start telling what type of cry your baby has, sharing a smile. Engrossment specifically addressed when talking about dads, his absorption, preoccupation and interest in the infant. Facilitating: Inhibiting: Looks, gazes, en face position, eye Turns away, ignores, avoids, refuses contact, hovers, pays attention to hold Identifies and claims Fails to identify Touches, talks Limited or no touch Smiles Frowns Positive attitude Negative attitude Views infant as ugly Module 7 Postpartum Complications PPT 2 (Chapter 33) 4. Postpartum hemorrhage: compare/contrast likely causes (uterine atony, lacerations, hematoma, retained placental fragments), describe nursing assessment and nursing care for each. BOOK: Ch. 33, SLIDES 27, 1116 1. Uterine Atony: overdistented uterus (boggy), relaxed. The greatest risk for early PP hemorrhage is during the first hour after birth! Causes: high parity, polyhydramnios, fetal macrosomia, multiple gestation, traumatic birth, use of halogenated anesthetic, mag sulfate, rapid or prolonged labor, PIH, chorioamnionitis, use of oxytoxin for labor induction or augmentation, and uterine atony in previous pregnancy. Management of Uterine Atony: Fundal massage until uterus is contracted – FIRST THING Assess for bladder distension (THEN SUSPECT BLADDER IS FULL) IV oxytocin (pitocin) – works quickly but if you stop pitocin, it stops working. Methergine IM or po Prostaglandin IM 2. Lacerations: if bright, red bleeding continues despite a firm, contracted uterine fundas. This bleeding can be a slow trickle, an oozing, or frank hemorrhage. If it is more 6 bright red it could indicate a deeper laceration (arterial) and if darker blood (venous and more superficial). Causes: Nulliparity, Epidural anesthesia, Precipitous childbirth, Macrosomia, Forceps or vacuumassisted birth Management: Sutured immediately after birth Analgesia for pain and hot/cold applications as necessary. Increased fiber in the diet and increased intake of fluids is emphasized to reduce the risk of constipation. Stool softeners may be used to reestablish bowel habits without straining and putting stress on suture lines. 3. Hematoma: Result of injury to a blood vessel from birth trauma, vulvar hematomas are the most common. Risk Factors: Prolonged second stage of labor PIH Precipitous labor Macrosomia Forceps or vacuumassisted birth Vulvar varicosities Signs/Symptoms: Perineal pain (the MOST COMMON S&S), out of proportion to observed trauma Rectal pressure Difficulty voiding Bulging mass of the perineum Management: Close observation Cold therapy Ligation of bleeding vessel Evacuation Fluids and/or blood replacement may be necessary 4. Retained Placental Fragments—Subinvolution of the Uterus: Delay in normal involution Causes: Retained placental tissue/fragments and infection 7 Signs/symptoms: Postpartum fundal height is greater than expected (should be 1cm below the umbilicus each day) Leukorrhea, backache, and foul odor, if infection is a cause Lochia fails to progress from rubra, to serosa, to alba normally Lochia rubra may persist longer than 2 weeks Spontaneous hemorrhage Management: Oral oxytocin (methergine) Antibiotics if infection D&C dilatation and curettage 5. Pitocin, Methergine, Hemabate, Cytotec: explain action, contraindications, route, potential side effects (BOOK p. 807 CHART) handout from Dr Goff. 8 6. Placenta accreta, increta, percreta: definitions and risks (SLIDE 8, BOOK p. 804) Placenta accreta Slight penetration of (myometriummiddle layer of uterine wall)(most common, incidence increasing in Csections) Placenta increta Deep penetration of myometrium Placenta percreta Perforation of uterus Risks: maternal hemorrhage and failure of the placenta to detach. Hysterectomy may be indicated for all three types if bleeding is uncontrolled. 7. Uterine inversion: contributing factors and potential complications (SLIDES 910, BOOK p. 804805) Prolapse of uterine fundus down through cervix, "turning insideout" of uterus after birth, rare, but lifethreatening. Results in hemorrhage and shock. The uterus is not palpable abdominally. THE UMBILICAL CORD SHOULD NOT BE PULLED UNLESS THERE ARE CLEAR SIGNS OF PLACENTAL SEPARATION. Contributing factors: abnormal adherence of placenta, uterine abnormalities, protracted labor, uterine relaxation secondary to anesthesia, excess traction on umbilical cord or vigorous manual removal of the placenta. 8. covered above 9. Urinary tract infection: nursing assessment (BOOK p. 813, SLIDES 2324) Increased risk due to: Postpartal diuresis Increased bladder capacity Decreased bladder sensitivity from stretching or trauma General or regional anesthesia Contamination from catheterization Frequent pelvic exams S&S: Dysuria Frequency and urgency Low grade fever Urinary retention Hematuria 9 Pyuria Costovertebral angle tenderness or flank pain may indicate upper UTI Monitor for overdistention, encourage frequent emptying Ecoli is most common causative organism for cystitis and pyelonephritis that develops PP 10. Endometritis & Mastitis: signs/symptoms, medical treatment, nursing assessment and care. (SLIDES: 1718, 2528) Endometritis: most common PP infection! BOOK P. 813 Inflammation of endometrium Aerobic and anerobic organisms can cause PP uterine infection. Sign/symptoms: scant or profuse, bloody, and foulsmelling lochia; uterine tenderness; fever (greater than 100.4), chills, anorexia, nausea, fatigue, lethargy, and pelvic pain. Treatment: IV broadspectrum antibiotic therapy (cephalosporins, penicillins, clindamycin, gentamicin). Supportive care, hydration, rest, and pain relief. Therapy usually discontinued after 24 hours of no symptoms. Nursing Assessment: lochia, vital signs, and changes in woman’s conditon. Mastitis: BOOK P. 812 Causative organisms: staph aureus, Ecoli, strept., Candida albicans can lead to yeast infection of the breast S/S's: nipple pain; shooting pain through breast during and between feedings; localized pain, redness, and tenderness; fever; general malaise Often a result of invasion of bacteria to traumatized nipples Other contributing factors: poor drainage of milk, lowered maternal defenses due to fatigue or stress, poor hygiene practices, tight clothing, missed feedings. Treatment: Rest, fluids, frequent breastfeeding, local application of heat and cold Teach prevention of nipple trauma and milk stasis 10 11. Thromboembolitic disease: types, signs/symptoms, prevention, treatment (SLIDES 2932, BOOK P. 811) Deep vein thrombosis > pulmonary embolism 1.Superficial venous disease THE MOST FREQUENT FORM OF DISEASE PP. Involvement of the superficial saphenous venous system. 2.Deep vein thrombosis more common during pregnancy, occurs most often in lower extremities; involvement varies but can extend from the foot to the iliofemoral region. 3. A pulmonary embolism a complication of the DVT, occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs. EARLY AMBULATION HELPS!! Predisposing factors: Obesity Increased maternal age High parity Anesthesia and surgery Previous history of venous thrombosis Maternal anemia Hypothermia Heart disease Endometritis Varicosities Signs/Symptoms: Edema Lowgrade fever Homan's sign positive Decreased peripheral pulses Prevention: early ambulation, avoid kneegatch, avoid stirrups for long period of time, leg exercises if on bedrest (will need elastic stockings), avoid prolonged sitting or standing, avoid crossing legs Treatment: heparin IV (35 days), then oral warfarin for about 3 months, monitor for signs of pulmonary embolism. If she had a PE she would continue the IV heparin and then get into the warfarin eventually but the heparin would be taken for a w ile. 11 The BEST way to diagnose? ULTRASOUND, VENOGRAPHY IS INVASIVE. Module 8: Healthy Newborn PPT 3 (Chapters 23 and 24): 12. Calculate newborn weight from grams to pounds, interpret if in normal range, and determine normal weight loss after delivery. BOOK p. 553 *******1lb= 453.6grams.******* •Weight 25004000g (term), 5.58.8lbs <2500g (preterm, small for gestational age, rubella syndrome) >4000g (large for gestational age, maternal diabetes, heredity—normal for these parents) Normal weight loss after delivery: 10% or less in first 35 days Weight loss more than 1015% (growth failure, dehydration); assess breastfeeding success! 13. Distinguish major newborn reflexes. (slide 3843) (ATI page 273274 CHART) BOOK 541544 charts and pictures MORO reflex by striking a flat surface the newborn is lying on, or allowing the head and trunk of the newborn in a semisitting position to fall backward to an angle of at least 30 degrees. Arms and legs symmetrically extend and then abduct while fingers spread to form a “C”. (checks nervous system response) 12 STEPPING reflex Elicited by holding the newborn upright with feet touching a flat surface. The newborn responds with stepping movements. TONIC NECK reflex (fencer position) the newborn extends arm and leg on the side when head is turned to that side with flexion of arm and leg of opposite side. BABINSKI reflex Elicited by stroking outer edge of sole of the foot, moving up toward toes. Toes will fan upward and out. 13 TRUNK INCURVATION reflex trunk will go toward the side you stimulate. 14. Calculate Apgar Score and recognize normal. (slide 13) normal is 710. (ati page 267) 14 15. Interpret newborn vital signs, blood glucose levels, O2 saturation, GBS, Coombs test, head, chest, and length measurements, weight, hemoglobin, Rh factor, and bilirubin. Recognize deviations from normal and appropriate nursing care. (ati p. 274, slides 14,16,22) • Respiratory Rate: 30 to 60 breaths/minute • Heart Rate: 100 to 160 beats/minute; up to 180: active & crying; 80: sleeping • Temperature: drops to 35.6 degrees C (96.1 F) • Temperature stabilized by 810 hrs of age (>37.0 C) (98.6 F) • Blood Pressure: 6080systolic/4050diastolic: term infants at birth • Weight 25004000 g (term) (5.51lbs8.82lbs) • Length: 4555 cm (17.7 in21.7 in) • Glucose level 4060mg/dL • Hemoglobin 1424 g/dL • Billirubin 06 mg/dL on day 1, 8mg/dL or less on day 2, 12mg/dL or less on day 3 • Head: one fourth of infant total length Occipital Frontal Circumference (OFC): 32 to 36.8 cm (12.614.5in) • Chest Circumference 3033 cm (1213 in) 23cm less than head circumference. • Coombs test is a screening tool for Rh incompatibility. It can also detect other antibodies that may place the fetus at risk for incompatibility with maternal antigens. (p 647) • Coombs test (to determine whether jaundice is due to Rh or ABO incompatibility • Indirect Coomb’s: measures amount of Rh+ antibodies in the mother’s blood • Direct Coomb’s: reveals presence of antibody coated (sensitized) Rh+ RBC’s in the newborn • PO2 after birth (pg 551 book) • Target S1 min 6065% • 2 min 6570% 15 • 3 min 7075% • 4 min 7580% • 5 min 8085% • 10 min 8595% • GBS(pg 866 book) infection leading cause of neonatal morbidity and mortality in the US. The practice of giving prophylactic antibiotics to women in labor who are GBS positive has significantly reduced the incidence and severity of early onset GBS infection in the newborn. Early onset Group Beta Streptococcus infection usually occurs in the first 7 days of life but most commonly manifests in the first 24 hours of birth. Risk factors include low birth weight, preterm labor, rupture of membranes of more than 18 hours, maternal fever, previous GBS infant, maternal GBS bacteriuria, use of intrauterine fetal monitor, maternal age less than 20, and Hispanic or African American. 16. Differentiate normal variations in the newborn and those that need to be referred to Pediatrician. (p 531532 book, ati p275 and 286) page 556 nsg dx GI problems the time, color, and character of the infant’s first stool should be noted. Failure to pass meconium can indicate bowel obstruction related to conditions such as an inborn error of metabolism. Jaundice yellow color of skin and sclera caused by elevated serum levels of unconjugated bilirubin. The liver is responsible for the conjugation of bilirubin. Airway obstruction related to mucus mouth and nose are suctioned with bulb and gentle percussion of the chest can help loosen secretion. Hypothermia monitor for an auxiliary temp of less than 36.5C or 97.7F. If temp is unstable, place the newborn in a radiant warmer, and maintain skin temp at approx. 97.7F. (Assess temp every hour until stable) Exams performed under a warmer. Inadequate oxygen supply related to obstructed airway, poorly functioning cardiopulmonary system, or hypothermia. (monitor respirations and skin color for cyanosis. Admin O2 and prepare for resuscitation if needed. Cold Stress can lead to hypoxia, acidosis, and hypoglycemia. Newborns with respiratory distress are higher risk for hypothermia. (monitor for cyanotic trunk, depressed respirations) Warm slowly over 24 hours. MODES OF HEAT LOSS 16 Convection-the flow of heat to cooler ambient air (swaddle helps) (room temp) Radiation-body surface to cooler solid surface not in direct contact but in relative proximity with windows and avoid air drafts. Evaporation-liquid converts to vapor (DRY baby off) Conduction- from body surface to cooler surface in direct contact. (warmed table or crib) Hypoglycemia occurs in first few hours of life secondary to the use of energy to establish respirations and maintain body heat. Newborns of mothers who have diabetes, are small or large, are less than 37 weeks gestation, or greater than 42 weeks are at risk for hypoglycemia and should have blood glucose checked within 2 hours of life. (monitor for jitteriness, twitching, a weak high pitched cry, irregular respirations, cyanosis, lethargy, eye rolling, seizures) Give formula or breast feed to elevate glucose level. Hemorrhage due to improper cord care of placement of clamp. (ensure clamp is tight, if seepage of blood is noted, a second clamp should be placed.) notify HCP if bleeding continues) 17. Describe stages of transition to extrauterine life, such as first period of reactivity. (slides 57) (ati p280) First Stage: 0 to 30 minutes; first period of reactivity the newborn is alert, exhibits exploring activity, makes sucking sounds, and has a rapid heart rate and respiratory rate. Heart rate may be as high as 160 to 180/min, but will stabilize at a baseline of 100 to 120/min during a period that lasts 1530 min after birth. bowel sounds absent. (grunting, flaring, chest retractionnot a lot) Second Stage: 30 minutes to 2 hours; period of decreased responsiveness. (period of relative inactivity) the newborn will become quiet and begin to rest and sleep. The heart rate and respirations will decrease, and this period will last from 30min2hr after birth. (color should be pink and bowel sounds audible) Third Stage: 2 to 8 hours; 2nd period of reactivity The newborn reawakens, becomes responsive again, and often gags and chokes on mucus that has accumulated in his mouth. This period is 28hrs after birth and may last 10 mins to several hours. (pass meconium in first 24 hours) increase muscle tone and good color. 17 Module 9: High Risk Newborn :(Chapter 34): PPT 4 (chpt 27 ati) 18. Preterm infant A. Vital signs (KNOW NORMAL RANGES PER DR GOFF) look above B. Physiologic functions and Nursing diagnoses BOOK: P. 817822 cardiovascular – slow cap refill, hypovolemia, accurate bp helps make a diagnosis. limited stores of brown fat which generate heat to maintain body temp NURSING DIAGNOSIS Ineffective Thermoregulation r/t immature temperature regulation and minimal subcutaneous fat stores. Risk for infection related to immature immune system Risk for imbalanced nutrition : less than body requirements r/t inability to ingest nutrients secondary to immaturity Risk for deficient fluid volume/excess fluid volume related to immature physiology C. Priorities of care (O2, etc.) page 823833 physical care incubator or radiant warmer to control body temp, oxygen admin, electronic monitoring, parenteral fluids to help support nutrition and maintain normal AGB, blood work. Respiratory Care oxygen sat less than 92% (see E) Nutritional Care(see G) Skin CareNeonatal Skin Condition Score to minimize breakdown Environmental concernsNoises in NICU can damage infant hearing and other machines can alter infant vision. Developmental Care plan care and interventions based off infants behavior. D. Potential complications of O2 therapy pneumothorax and pulmonary interstitial emphysema (free air that accumulates in interstitial tissue are decreased) E. Stimulation when having respiratory difficulty PEEP and CPAP 18 change babies position to side lying or prone then move to various types of O2 therapies such as nasal canula (helps with low flow amounts of O2) Hood Therapy ( used to admin O2 to infants that do not require mechanical pressure support, CPAP (infuses air under a preset pressure by means of nasal prongs or face mask), Mechanical Ventilation (must be implemented if other therapies cannot correct abnormal oxygenation. used for infants with apnea with bradycardia, ineffective respiratory effort, shock, asphyxia, infection, meconium aspiration syndrome, or RDS. Nitric Oxide Therapy delivered as a gas for pulmonary hypertension, ECMO (Extracorporeal Membrane Oxygenation) for severe cardiac of respiratory failure, Partial liquid vent(for severe RDS). F. Apnea vs. periodic breathing Apnea is a 20 second or greater cessation of respiration, or a shorter pause accompanied by bradycardia, cyanosis, or hypotonia. Periodic breathing is a respiratory pattern commonly seen in preterm infants. Such infants exhibit 510 second respiratory pauses followed by 1015 seconds of compensatory rapid respirations. G. Nutritional care (Chpt 25 book) slides 2535 preterm baby 120150 cal/kg/day 34 gm/kg/day protein Supplemental vitamins, vitamin E and calcium May give preterm formula (24 kcal/oz) Can fortify breast milk to 24 kcal/oz Beginning with intravenous feedings, then advancing to gavage feedings Asphyxiation with a potential for necrotizing enterocolitis (NEC) Weak or absent suck, swallow, and gag reflexes, small stomach capacity, weak abdominal muscles (NOT ABLE TO EAT) Cannot always provide enteral feedings to infants Lack of coordinated suck Inability to suck because of a congenital anomaly Respiratory distress requiring aggressive ventilator support Parenteral Fluids Given intravenously to infants who are unable to obtain sufficient fluids or calories by enteral feeding Oral feeding If bottle feeding, infant may require special nipple (preemie nipple, pigeon nipple) (FAT TIP) FLUID REQUIREMENTS 19 120150 ml/kg/day by the 3rd day Output: 13 ml/kg/hr Signs of dehydration: Less than 1ml/kg/hr Urine specific gravity >1.015 Weight loss Dry skin, mucous membranes Sunken anterior fontanelle 19. Gestational maturity using New Ballard Score—compare preterm to full term (see page 554555) Maturational Assessment of Gestational Age 20 20. SGA: nursing actions (slides 4,69) book p844 SGA: less than 10th percentile IUGR 5 times greater risk of perinatal asphyxia 8 times greater risk of perinatal mortality Causes Malnutrition Vascular complications (PIH, advanced DM) Maternal disease (heart disease, substance abuse, sickle cell anemia, or AIDS) Environmental factors Maternal factors (grand multiparity, lack of prenatal care, smoking, low SES) Placental factors Fetal factors (TORCH, congenital malformations) Detection antenatally is key 21 Complications of SGA Asphyxia Hypoglycemia Polycythemia Heat loss Nursing Actions: Maintaining a clear airway, prevent cold stress, treat hypoglycemia with feedings, an external heat source to keep adequate body temp, and nursing support of parents. 21. Postterm infant: physical characteristics: (BOOK P. 565) Postterm (post date): greater than 42 weeks Physical characteristics: Little if any vernix caseosa (if they have any it will be stained deep yellow or green usually indicative of meconium in the amniotic fluid) Absence of lanugo Abundant scalp hair Long fingernails The skin is often cracked, parchmentlike, and desquamating. A common finding in postmature infants is a wasted physical appearance that reflects intrauterine deprivation. Depletion of subcutaneous fat gives them a thin, elongated appearance. 22. RDS: (RESPIRATORY DISTRESS SYMDROME) types of babies at risk, symptoms, diagnosis, medical treatment, nursing assessment and interventions (SLIDES 1518, BOOK P.836) #1 problem in preterm infants, weighing less than 1500g (3.3lbs) is about 45% Diagnosis: ***Xray revealing diffuse pattern of haziness areas resembling ground glass Blood studies revealing respiratory acidosis. Cultures to ruleout sepsis as a cause (E. coli, GBS) o Sepsis: toxins/microorganisms in the blood or tissues. 22 S&S of distress: flaring of nares, expiratory grunt, chest retractions (caving in and then coming back out), apneic spells, cyanosis, seesaw breathing (when chest rises, the abdomen retracts, when the abdomen comes out, the chest goes down) As distress continues, may develop cyanosis, pale gray skin color, apnea, bradycardia, heart failure Some babies even when they are normal size can be lying in their crib and then have difficulty breathing, the best thing to do is PUT THEM OVER TO THEIR SIDE OR STIMULATING THEM!! Show the parents as well. Retractions: Silvermananderson is an index that is observing the level or retractions. An index of respiratory distress. Treatment: Surfactant replacement best within the first 8 hours after birth after confirming the diagnosis. Oxygen administration with PEEP or CPAP to prevent alveolar collapse, pulse ox, arterial blood gases. Ventilation Sidelying or prone position: more efficient use of respiratory muscles, resulting in decreased respiratory effort, and better oxygenation and lung compliance Corticosteroids to the mother when the baby is in utero are best used at 3032 weeks. PEEP: positive end expiratory pressure; allows the baby to breath spontaneously but it adds mechanical cycled respirations and pressure CPAP: continuous positive airway pressure; not allowed to do his own breathing, totally mechanical, used when the electrolytes and everything are all messed up. You can use the CPAP by hood or nasal cannula, if the baby is on low flow he can actually do this at home. On their back is important Work of breathing: how much work they have to do to take a breath and let it out. That can create a lot of exhaustion as a result. Nursing Interventions: Clustering care to minimize stimulation Parenteral fluids to support nutrition and maintain normal ABG levels and acidbase balance Possible IV access to facilitate the administration of antibiotic therapy Monitor ABG, blood pH, blood glucose, electrolytes, status of blood cultures 23. LGA (larger than gestational age) and Macrosomia; possible complications, nursing actions (SLIDES 45, BOOK P. 845) 23 LGA: greater than 90 percentile, weighing >4000g (8.8lb) Possible Complications: Increased cesarean delivery rate Hypoglycemia Polycythemia: increased erythrocytes (RBC) from transfusions, from hypovolemia. decreases circulation, increases the blood viscosity, increases the chance of a higher bilirubin level. Birth trauma: fracture (clavicle), bruising 24
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