Exam 4 Flashcards
(129 cards)
1
Q
Chronic HTN
A
SBP >140 or DBP >90.
Pts <20 wks OR hx HTN before pregnancy.
2
Q
Gestational HTN
A
SBP >140 or DBP >90.
>20 wks
Absence of proteinuria or symptomatic.
3
Q
Pre-eclampsia Definition and risk factors
A
SBP >140 or DBP >90.
>20 wks
Proteinuria w/ or w/o sx
OR s/s & lab abnormalities w/o proteinuria.
Risk Factors: Hx pre-eclampsia, multifetal gestation, chronic HTN, T1 or T2DM, renal disease, autoimmune disease, nulliparity, obesity, family hx, age > 35yrs, African American, IVF, previous adverse pregnancy outcome, >10yr pregnancy interval
4
Q
HELLP Syndrome Def and risk factors
A
Assoc w/ pre-eclamptic mothers .
Hemolysis (Breakdown RBCs)
Elevated Liver enzymes
Low Platelet Count
Increased risk for: Cerebral hemorrhage, retinal detachment, liver rupture, DIC, placental abruption, eclampsia, renal failure, pulmonary edema, maternal death
5
Q
Severe HTN/HTN Crisis;
- Definition
- Sx
A
SBP >160 and/or DBP >110 (repeat pressures) Thrombocytopenia (Plt <100) Impaired LFTs (RUQ pain, elevated LFTs) Renal insufficiency (Cr >1.1) Pulmonary edema HA unresponsive to tx Visual disturbances
6
Q
Pre-eclampsia Mgmt (Outpatient vs inpatient)
A
Outpatient: OB visits 1-2x/wk, quiet environment, intermittent bedrest, hydrate, take BP/wt daily, urine dipstick, fetal kick count
Inpatient: Freq assessments, bedrest, seizure precautions, Betamethasone
7
Q
Magnesium Sulfate;
- Indications
- Assessments
- S/s toxicity
A
Prevention/tx eclamptic seizures
Monitor mg levels
Assess DTRs, ankle clonus
Calcium Gluconate for mg toxicity
S/s toxicity: flushing, sweating, hypotension, cardiac/CNS depression
8
Q
Hydralazine (Apresoline);
- Indications
- Adverse effects
A
Improve perfusion to renal, uterine, cerebral areas
Reduce BP
D/c slowly to prevent rebound HTN
Adverse effects: palpitations, HA, tachycardia, anorexia, n/v/d
9
Q
Labetolol (Normodyne);
- Indications
- Adverse effects
A
Reduce BP, lowers BP w/o decreasing maternal HR, CO
Adverse effects: gastric pain, flatulence, constipation, dizziness, vertigo, fatigue
10
Q
Nifedipine (Procardia);
- Indications
- Adverse effects
A
Reduces BP, stops pre-term labor
Adverse effects: Dizziness, peripheral edema, angina, diarrhea, nasal congestion, cough
11
Q
Placental Abruption;
- Definition
- Causes, risks
A
MEDICAL EMERGENCY
- Early separation of placenta after 20w before birth
- Bleeding between decidua & placenta
- High mortality rate; fetal 40%, mother 5%
- Maternal vessels tear away from placenta & bleeding occurs between uterine lining & maternal side of placenta
- Blood accumulates & pushes uterine wall & placenta further apart
- Abruption continues, loss of placental function results in fetal hypoxia & eventually fetal death
Most causes: originate from maternal HTN & pre-eclampsia
Maternal risks: obstetric hemorrhage, blood transfusions, hysterectomy, DIC
12
Q
Placenta Previa;
- Definition
- Causes
A
“Afterbirth first”
- Placenta inserted wholly or partly into lower uterine segment, partially or completely covering internal cervical opening
- Risk for prenatal & postpartum hemorrhage
- Increased risk after multiple c-sections
-Caused by: uterine endometrial scarring or damage into upper segment, incites placental growing in unscarred lower segment
13
Q
Placenta Previa vs Placental Abruption;
- Onset
- Bleeding
- Pain/uterine tenderness
- FH tone
- Shock
- Delivery
A
Previa;
- Onset- 2nd trimester
- Bleeding- Mostly external, small to profuse amt, bright red
- Pain/uterine tenderness- Usually absent, uterus soft
- FH tone- Usually normal
- Shock- Not present unless excessive bleeding
- Delivery- May be delayed depending on size of fetus & amt of bleeding
Abruption;
- Onset- 3rd trimester
- Bleeding- Concealed, external dark hemorrhage, bloody amniotic fluid
- Pain/uterine tenderness- Usually present, irritable uterus
- FH tone- Irregular or absent
- Shock- Mod to severe depending on external hemorrhage
- Delivery- Immediate, by C-section
14
Q
Postpartum Body Changes
A
- Blood from uterus/placenta returns to central circulation
- Extracellular fluid moves into vascular compartments
- CO increases
- Diuresis & diaphoresis occur
- Increased risk for clots
- WBC remain elevated
- HCT low but stable
- Tachycardia/low BP early sign postpartum hemorrhage, infection, dehydration
- BP increase w/ HA is pre-eclampsia postpartum
- Diastis recti abdominis: left/right abd muscles most outward layer separate
- Lactogensis: onset milk secretion, triggered by delivery of placenta d/t decreased estrogen/progesterone w/ prolactin
- Breast tissue larger, firmer, more tender before milk arrives
15
Q
Postpartum Assessment
BUBBLE
A
Breasts Uterus Bowels Bladder Lochia (vaginal d/c after birth) Episiotomy/laceration/caesarean incision
16
Q
Breast assessment;
- Engorgement
- Mastitis
A
Inspect size, symmetry, engorgement, redness
Check nipples cracks, redness, bleeding, d/c
Palpate nodules, masses, areas warmth
Feeding challenges?
Manually express milk to assist w/ latching
Breast feeding women-Engorgement relived by: freq emptying, warm showers/compresses before feeding, cold showers/compresses between feedings
Non breast feeding women-Engorgement: Wear tight supportive bras, ice, avoid breast stimulation
S/s mastitis: flu like sx, tender, hot, painful areas, inflamed breast tissue, tenderness, cracked skin around nipple, breast distention w/ milk, hx clogged ducts/poor feeding
Mastitis tx: breast emptying, massage breasts before feeds, ABX, cold/warm compresses
17
Q
Uterus assessment
A
- HOB <30 degrees
- Fundal massage if boggy, should be midline/firm
- Empty bladder, can affect uterine location
- Quantified blood loss if still bleeding
- Fundus cont descend into pelvis approx 1cm or finger/day, should be nonpalpable by 14 days post partum
18
Q
Bowel assessment
A
Bowel sounds Return of bowel function Flatus Color/consistency of stool High fiber, fluids, ambulation
19
Q
Bladder assessment;
-S/s UTI
A
- Return of urination, within 6-8 hrs of delivery
- Approx 8 hours after delivery measure amt urine each void
- Minimum 150ml/void. Less = urine retention d/t decreased bladder tone post partum
- S/s UTI: freq urination, bladder spasm, cloudy urine, urgency, dysuria
- Bladder should be nonpalpable above pubis
20
Q
Lochia assessment;
-Types of Lochia
A
- Saturating one pad <1 hr, constant trickle, large lochia/clots could indicate serious complications
- How often pad changed?
- Color, flow, clots present
- Quantified blood loss
Lochia Rubra: Bright red bleeding/clots 1-3 days
Lochia Serosa: Pink/brown bleeding for 4-10 days
Lochia Alba: Whitish/yellow d/c for 10-14, could last up to 6 weeks
21
Q
Episiotomy;
- REEDA
- Interventions
A
Redness Edema Ecchymosis Discharge Approximation
- Redness normal
- Ice packs 12-24 hrs
- Sitz baths
- No d/c, wound edges approximated
- Kegel exercises, squeezing glutes w/ position changes
22
Q
Postpartum hemorrhage;
- Causes
- Assesments
- Mgmt
A
Causes:
- Grand multiparity
- Overdistention uterus
- Rapid, precipitous, prolonged labor
- Retained placenta
- Placenta previa or abruption
- Meds (Tocolytics, oxytocin)
- OR procedures (C-sec, vacuum extraction)
- Coagulation defects
Assessments:
- Risk factors
- Uterine tone, vaginal bleeding
Mgmt:
- Fundal massage w/ HOB down
- Measure quantified blood loss
- Admin uterotonic
- Start 2nd 18G IV
- Fluid admin
- Monitor s/s of shock; ER measures of DIC occurs
23
Q
Oxytocin
A
Begin or improve contractions during labor, reduce bleeding after childbirth
24
Q
Methergine
A
- Prevent or treat bleeding from the uterus after childbirth
- Contraindicated HTN/toxemia
- Monitor BP, HR, uterine response, change in vitals, freq periods of uterine relaxation, character/amt of vaginal bleeding
- NOT safe breastfeeding
- DONT use IV reg d/t increased risk severe HTN/stroke
25
Misoprostol (Cytotec)
Increases uterine tone, decreases PP bleeding
| Causes uterine contractions, induce labor
26
Carboprost
Treat bleeding after birth
| Enhances uterine tone
27
Subinvolution;
- Definition
- Causes
- Complications
Incomplete involution of uterus after birth
Causes: retained placental fragments, distended bladder, uterine myoma, infection
Complications: hemorrhage, pelvic peritonitis, salpingitis, abscess formation
28
Thromboembolism;
- Causes
- Screening/assessment
- Causes: Stasis, altered coagulation, localized vascular damage
- Homan's sign in calf
- Assess s/s thrombophlebitis
29
Puerpal Phases
Puerpal: During/relating to period of 6 wks after birth mother's reproductive organs return to original condition
Taking-in: 1-2 Days
- Dependent passive role
- Focus: rest, food, fluids
- Recount labor experience
- Spend time claiming newborn, common features
Taking-hold: Day 3-several wks
- Concerned about own health, baby's condition, her ability to care for baby
- Increased autonomy/independence by caring for self/baby
- Still requires assurance
Letting-go
- Assumes responsibility/care for baby w/ more confidence
- Relinquishes fantasy infant and accepts real one
30
Neonate Cold Stress;
- Definition
- Compensation
- Sx
- Newborns need higher environmental temp to maintain neural thermal environment
- Newborns tolerate narrower range of environmental temps, vulnerable to under heating and overheating
Compensation:
- Increase metabolic rate
- Increase flexion to maintain heat
- Increase peripheral vasoconstriction
- Increase glucose use
- Non-shivering thermogenesis- skin temp cool, metabolize "brown fat" to produce heat, converts chemical energy to heat, depleted fate stores leads to metabolic acidosis
Sx:
- Axillary temp < 36.5 C
- Cool skin temp, pale, mottled, acrocyanosis (blue skin)
- Lethargy, decreased muscle tone
- Irritability, weak cry or suck
- Poor feeding or intolerance
- Hypoglycemia
- Resp distress/hypoxia
- Poor wt gain
- Jaundice
31
Neonate Heat Loss;
- Factors
- Modes of heat loss
- Overheating
- Thin skin
- Cannot shiver
- Limited stores, glucose/glycogen/fat
- Large body surface r/t wt
- Lack subq tissue
- Cant conserve heat by position change
- Inability to communicate cold
Heat Loss:
1) Conduction- Transfer heat from one object to another w/ contact, ex metal scale
2) Convection- Flow of heat from body surface to cooler surrounding air or air circulating over body, ex drafty window
3) Evaporation- loss heat liquid converted to vapor
4) Radiation- loss body heat to colder, solid surface in proximity, ex next to cold window
Overheating: limited insulation and sweating ability, increases fluid loss, RR, metabolic rate
32
White fat vs Brown fat
White fat: Adipose tissue "bad fat."
Accumulated from excess calories or lack of exercise
Brown fat: "Good fat." Babies born with own fat, developed on fetus at 39 wks, only have it for 3-5 wks after birth
Burns calories and produces heat, on neck, chest, back, buttocks
33
Preterm Neonates;
- Complications
- Mgmt Nursery & NICU
Complications:
- Cold stress
- RDS
- Sepsis/infection
- Pain
- F&E imbalance
- Feeding difficulties
- Environmental overstimulation
- Hypoglycemia
- Hyperbilirubinemia
- Bronchopulmonary dysplasia
- Intracranial bleed
- Retinopathy of prematurity
- Necrotizing enterocolitis
- Cognitive delays
Mgmt Nursery 34-36w6d:
- VS q 4hrs
- Feeding q2 BF, q3 formula
- Blood sugar
- Neutral thermal environment
- Anticipatory guidance for parents
Mgmt NICU:
- Cont monitor VS, O2 sat
- Maintain hydration, assess for overload
- ABX for + blood cultures
- Cluster care
- Gavage (tube) and IV feedings
34
Premature Respiratory System
- Surfactant def resulting in RDS
- Unstable chest wall leading to atelectasis
- Immature resp control centers leading to apnea
- Inability to clear fluid leading to transient tachypnea
35
Premature F&E
- Most newborns after 34w feed normally
- Increased insensible water loss, Keratin keeps water in skin, developed 2-3 wks after delivery infants 30wk or more
- Difficulty maintaining fluid balance
- Kidneys DONT concentrate/dilute urine well, develop aat 35 wks, CANT regulate electrolytes
- Immature renal system, reduced ability to concentrate urine & slow GFR, risk fluid retention w/ subsequent F&E disturbances increases
- Limited ability to clear drugs from system = risk drug toxicity
36
Premature Risk for Infection
- Immature immune system; def IgG, transplacental transfer occurs at 34 wks
- Impaired ability to manufacture antibodies to fight infection if exposed to pathogens during birth
- Thin skin, fragile blood vessels limited protective barrier
- Lack passive antibodies from mom
- UA line, invasive procedures, do not cluster invasive procedures
- 3-10x > incidence of infections
- Feeding intolerance, early sign infection
- Monitor changes temp, tachycardia, tachypnea
37
Premature Overstimulation;
- Definition
- S/s
- Easily overstimulated
- Keep environment quiet, lights dimmed
- Environment caused stress
- O2 decreased
- Increase/decrease HR, RR
- BP instability
S/s:
- VS changes
- Cyanosis, pallor, mottling
- Flaring nares
- Sneezing, coughing, hiccupping
- Behavior changes
- Stiff, extended arms/legs
- Fisting of hands, splaying fingers
- Alert, worried expression
- Gaze aversion
- Regurgitation, gagging
- Yawning, fatigue
38
Premature Nutrition;
- Definition
- Readiness vs Nonreadiness Nipple feedings
- Working harder to breath = burning calories
- Lack coordination necessary for sufficient calorie and fluid intake to support growth, at risk malnutrition and wt loss
- Enteral feeds once resp system stabilizes
- DONT feed if baby not oxygenating, cause necrotic enterocolitis
- Enteral tube feedings conserve energy
- Gavage feedings used compromised newborns to allow rest. Use pacifier to train to suck then try bottle with tube feeds
Readiness for Nipple Feedings:
Rooting, sucking on gavage tubes/finger/pacifier, able tot tolerate holding, RR <60, presence of gag reflex
Nonreadiness: RR <60, No rooting, sucking, or gag reflex
39
Hyperbilirubinemia;
- Level
- Risk Factors
- Overproduction bilirubin from Hgb breakdown
- Serum bilirubin >5
- Jaundice
- Occurs from imbalance in rate of bilirubin production and bilirubin elimination
Risk Factors:
- Polycythemia (RBC)
- Fewer albumin sites after birth
- Liver immaturity
- Bruising, cephalohematoma
- Insufficient intake of milk
- Delayed BM
- Family ethnicity/background
- Intrauterine infections
- Maternal medication use
- Fetal-maternal blood group incompatibility
40
Increased ICP;
- Causes
- Interventions
- Result from head trauma, birth trauma, hydrocephalus, infection, brain tumors
- Measure head circumference in children <3 yrs; increases in circumference may indicate ICP
- Elevate HOB 15-30 degrees to facilitate venous return
- Minimize environmental stimuli/noise
- Have code cart available; resp/cardiovascular collapse
- Early intervention critical to prevent neuro damage/death
- Lumbar puncture to monitor spinal pressure
- ICP monitoring device placed in head to monitor pressure
41
Early signs of ICP
- HA
- Vomiting, projectile
- Blurred/double vision
- Dizziness
- Decreased HR, RR
- Increased BP, pulse pressure
- Pupil reaction time decreased/unequal
- Change in LOC, irritability
- Bulging, tense fontanel
- Wide sutures
- High pitched cry
42
Late signs of ICP
- Lowered LOC
- Decreased motor/sensory responses
- Bradycardia
- Irregular RR (Kussmals or Cheyne-Stokes)
- Decerebrate (outward flexion) or decorticate (toward the core) posturing
- Fixed/dilated pupils
43
Cushing's Triad
3 primary signs that indicate increase ICP:
- Increased SBP
- Decreased HR
- Decreased RR
44
Hydrocephalus;
- Definition
- Congenital
- Acquired
- Obstructive
- Nonobstructive
- Disorder of nervous system
- CSF accumulates w/in ventricular system & causes ventricles to enlarge/increase in ICP occurs
- Congenital present at birth d/t genetic/environmental influences during fetal involvement (drugs, alcohol)
- Acquired develops at time of birth, results from injury or disease
- Obstructive occurs when flow of CSF blocked
- Nonobstructive occurs when CSF blocked after it exits ventricles
45
VP Shunts
- Placed for hydrocephalus
- Shunt revision surgery needed as child ages
- Inserted into brain & go into abdomen, allows fluid to be removed from brain & collect in peritoneal space & absorbed by digestive system
- Small amts of hydrocephalus - endoscopic 3rd ventriculostomy, perfusion made in 3rd ventricle to allow CSF to leave ventricle & go into subarachnoid space
- Un-dx present with irritability, lethargy, poor feeding, vomiting, HA, altered mental status
- Infants: palpate fontanels may reveal wide, budging fontanels
- Tests include: Skull Xray, CT, MRI
- Infection in shunt common 1-2 months after placement
46
Ischemic Stroke;
- Definition
- Embolism
- Thrombosis
- TIA
- Causes: large artery thrombosis, small penetrating artery thrombosis, cardiogenic embolic, cryptogenic
- Causes wide variety of neuro deficits depending on location of lesion
- Sx appear contra-lateral below neck to location of stroke
- TPA administered within 3 hours of onset
- FAST: facial drooping, arm weakness, slurred speech, time to call 911
- Embolism: clot left part of body, develops in heart and travels to brain, which stops blood flow
- Thrombosis: Clot forms w/in artery wall in neck/brain, seen in pt's w/ HLD, atherosclerosis
- TIA (transient ischemic attack): "mini-stroke." S/s stroke occurs only for a few mins-hours then resolved. Warning sign of impending stroke may occur
47
Left Side Stroke Sx
"Logical"
- Paralysis/weakness right side of body
- Right visual field deficit
- Aphasia (Expressive-inability to express self, Receptive-inability to understand language/communicate, Global-both)
- Altered intellectual ability
- Slow, cautious behavior
48
Right Side Stroke Sx
"Creative Side"
- Paralysis, weakness on left side of body
- Left visual field deficit
- Increased distractibility
- Impulsive behavior
- Lack of awareness of deficits (neglect)
- Left side weakness (hemiplegia)
- Impairment in creativity, arts, music
- Confused on date, time, place
- Cannot recognize faces or person's name
- Loss of depth perception
- Trouble staying on topic when talking
- Trouble w/ maintaining proper grooming
- Emotionally: not thinking things through, impulsive
- Poor ability to make decisions/assessing spatial qualities/shapes
- Denial about limitations
- Not able to read nonverbal language/understand hidden meaning of things
- Very short attention span
49
TX Ischemic Stroke
TPA, Before giving it:
- CT Scan negative for hemorrhagic stroke
- SBP <185 and DBP ,<110
- No TIA
- No seizure at onset of stroke
- Not taking Warfarin
- No Heparin in last 48 hours
- No prior intracranial blood, neoplasm, aneurysm, AV malformation
- No major procedure in 14 days
- No stroke, head injury, intracranial surgery in last 3 months
- No GI bleed within 21 days
**Within 3 hours of sx onset, can be given 3-4.5 hrs in set criteria
50
Hemorrhagic Stroke;
- Definition
- Intracranial
- Subarachnoid
- TX
- SX
- Cause by IC or subarachnoid hemorrhage
- Caused by bleeding into brain tissue, ventricles, subarachnoid space
- IC hemorrhage; spontaneous rupture of small vessels accounts for 80% of hemorrhagic stroke, caused by uncontrolled HTN
- Subarachnoid hemorrhage results from ruptured IC aneurysm
- Increased ICP from sudden entry of blood into subarachnoid space compresses & injuries brain tissue
- SX: vomiting, early change in mental state, LOC, focal seizures
- CT to r/o bleed
- Lumbar puncture if no indication of increased ICP
- TX: Fresh frozen plasma and vitamin K, anticonvulsants, Craniotomy
51
Generalized Tonic Clonic
-AKA Grand Mal
-May experience AURA
-LOC
-Tonic phase: body stiffens, breathing stops
Clonic phase: recurrent jerking of extremities
-Usually lasts <3 mins
-At risk for status epilepticus
52
Absence Seizure
- Most common in Peds
- Staring like state
- Seems like child is daydreaming but can't snap out of it
- Can go unnoticed
- Child doesn't remember it
- Very short, lasts seconds
53
Febrile Seziure
- Age 3 months to 6 yrs
- Slight tendency to run in families
- Can be generalized, full body convulsion, <15 min, no more than one in 24 hr period
- Can be focused, one body part moves, <15 min, more than 1 in 24 hr period
- During seizure, place on side and keep trace of time
- Usually no seizure meds, Valium in hospital
54
Focal Awareness Seizure
- Old name is "Simple partial seizure"
- Starts in one area of brain and person remains alert and able to interact
- Brief lasting seconds to <2 mins
- Most common type, likely to occur in pts w/ head injuries, brain infections, strokes, tumors
- Fully awake, alert, able to recall events during seizure
- "Frozen" during, may not be able to respond to others
- After, person continues doing whatever they were doing before it started
55
Focal w/ Impaired Consciousness
- Temporal lobe most involved
- Aura can happen before starts
- Automatisms present; person performing action w/o knowing they are doing it, ex lip smacking, rubbing hands together
- Starts on one side of brain, person not aware of surroundings during
- Lasts 1-2 mins
- Temporal lobe- staring, daydreaming
- Most common in adults
- After- may be tired, confused, take 5-15 mins to feel normal
56
Status Epilepticus
MEDICAL EMERGENCY
- Seizure activity lasting >5 mins or 2 or more seizure in 5 min period w/o return to normal baseline
- Check BG, toxin levels, seizure med levels
- Treat w/ benzodiazepines
57
Phases of Seizures;
- Prodromal
- Ictal
- Postictal
1) Prodromal Phase; feeling/sensation can occur several hrs or days before seizure.
Sx: confusion, anxiety, irritability, HA, tremor, anger, mood disturbances
2) Ictal Phase; Actual Seizure.
Arm or leg stiffening, chewing, lip-smacking, confusion, difficulty breathing, distractedness, drooling, eye/head twitching, hearing loss, inability to move/speak, loss of bladder/bowel control, memory lapses, numbness, pale/flushed skin, pupil dilation, racing heart, sense of detachment, strange sounds, sweating, tremors, vision loss, blurring, flashing vision, walking/running
3) Post-ictal; Recovery Stage.
Some recover immediately, other may require mins or days. Depends on severity and type of seizure
58
Nrsg Mgmt Seizures
- Observe/record s/s, aura, time, when started/stopped
- Support pt's head, maintain airway, turn on left side
- DO NOT restrain, loosen constrictive clothing
- Rail padding, suction available, bed lowest position
59
Meningitis;
- Definition, sx
- 2 DX screening signs
- Tx
- Inflammation of meninges, which cover/protect brain
- Bacterial or viral
- Neisseria - dense communities, college, military
- Peak in winter/early spring
- HA (steady/throbbing), fever, neck stiffness (Nuchal rigidity)
-Kernig's sign:
Pt laying with thigh flexed on abdomen, leg cannot completely extend. When sign is b/l, meningeal irritation suspected
-Brudzinski's sign:
Pt's neck flexed, flexion of knees/hips produced. Lower extremity of one side is passively flexed, similar movement seen on opposite extremity. Better testing than Kernig's sign.
- CT, MRI, LP, Cultures and gram staining of CSF
- ABX that cross blood barrier (Penicillin G with Cephalosporin)
- Rest in quiet, dark room, fluids, hydration, pain mgmt
60
Pediatric Anomalies;
- Decreased pulmonary blood flow
- Increased pulmonary blood flow
- Obstructive Disorders
- Mixed Disorders
1) Disorders with decreased pulmonary blood flow; Tetralogy of Fallot, Tricuspid atresia, cyanosis
2) Disorders with increased pulmonary blood flow; PDA, ASD, VSD- heart failure
3) Obstructive Disorders: Coarctation of aorta, aortic stenosis, pulmonary stenosis
4) Mixed Disorders: Mixing of well oxygenated blood w/ poorly oxygenated blood, CO decreased, HF occurs
61
Ventricular Septal Defect;
- Patho
- SX
- TX/prevention
- Opening between R and L ventricular chambers of heart
- Spontaneous closure in 1/2 of children by 2 yrs old
- Sx: SOB, fast/hard breathing, paleness, failure to gain wt, fast HR, sweating while feeding, freq resp infections
- Prevention: Lasix, Digoxin, Vasotec
- Surgical closure via cardiac cath or open heart surgery
62
Tetralogy of Fallot;
- 4 Defects
- Patho
- Increased risk
- SX
- TX
4 heart defects;
1) Pulmonary stenosis
2) VSD
3) Overriding aorta
4) R ventricular hypertrophy
- Surgical intervention req in 1st yr of life
- Blood flow from R ventricle obstructed & slowed in pulm valve to pulm artery > decreased blood flow to lungs > decrease amt oxygenated blood returning to L atrium > increases pressure in R ventricle
```
Increased risk;
-Poor maternal nutrition
-Viral illness
-Alcoholism
-Age
-Family hx
-Presence of another syndrome
Actual cause: unknown
```
Sx;
- Cyanosis, SOB/rapid breathing, during feeding/exercise
- LOC, fainting
- Clubbing of fingers
- Poor wt gain
- Tiring easily
- Irritability
- Prolonged crying
- Heart murmur
Tx;
- Oxygen in safe range
- Prostaglandin keeps PDA open
- Surgical intervention
- Complete repair at 6 mons if O2 stable
- Closure of VSD
- Resection of muscle in right ventricle, enlarging pulm valve outflow
63
Patent Duct Arteriosus
- Failure of ductus arteriosus to close w/in 1st few wks of life
- Creates connection between aorta & pulm artery
Sx; Depends on size of PDA & amt of blood flow carried
-Infants may be asymptomatic, some s/s HF
64
Coarctation of the Aorta;
- Patho
- Sx
- Tx
- Narrowing aorta from L ventricle to rest of body
- Occurs near ductus arteriosus
- Blood flow impeded, causes pressure to increase
- BP increased in heart & upper portions of body, decreased in lower body
- May lead to HF
SX;
- Irritability & freq epistaxis
- Leg pain w/ activity, dizziness, fainting, HA, bounding pulse in upper w/ weak in lower
-TX; Cardiac cath or open heart surgery
65
CHF;
- Causes
- General sx
Causes;
- Overcirculation failure
- VSD, ASD, Abnormal heart valves (backflow, damage)
- AV malformations
- Anemia
- Pump failure- virus infection, drugs, electrical system damage, abnormal from birth
Sx;
- Lung congestion, rales/crackles
- Periorbital edema
- Lethargy
- Tachypnea
- Difficulty breathing, decreased sats
- Poor growth
- Excessive sweating
- Low BP
- Circumoral cyanosis
66
Right vs Left Sided CHF Sx
Right;
- Wt gain
- Fluid collection at sacrum, scrotum, eyelids
- Decreased urine output
- Hepatomegaly-distended vessels back up liver causing engorgement
Left;
- Tachypnea (worse w/ feeds, activity)
- Rales (fluid in alveoli, pulm edema)
- Hackling cough
- Retractions
- Fatigue
- Diaphoretic
- Anxious, irritable
- Poor growth, flattening curve
- Developmental delays
67
CHF Tx
Over Circulation;
- Surgery
- Meds, Diuretics, afterload reducers
- Nutritional supplements
- Low salt, low fat diet
- If improvement; this is called compensated HF
Pump Failure;
- Same meds as overload
- Meds to decrease BP
- Surgery to replace damaged heart valve
- Pacemaker
- Specialized heart cath; radiofrequency ablation
- Mechanical pump (LVAD) or ECMO
- Heart transplant
68
RSV:
- Definition
- Sx
- Tx
- Infection in resp system
- Can cause severe infection in some people, esp premies, older adults, infants, adults w/ heart/lung disease, or immunocompromised
- Upper resp systems, progresses rapidly over 1-2 days
Sx;
- Cough
- Coryza
- Wheezing/rales
- Low grade fever (<101 F)
- Decreased oral intake
-Dx through swabs
Tx;
- IV fluids tp prevent dehydration
- Oxygen
- Bronchodilators
- Anti-virals
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Cystic Fibrosis;
- Patho
- DX
- Disease of exocrine gland function involves multiple organ systems but mainly resp infections, pancreatic enzyme insufficiency
- Pulmonary involvement occurs in 90% of pts
- End-stage lung disease- principal of death
- Secretions in resp tract, pancreas, GI tract, sweat glands, other exocrine tissues are thickened, makes it difficult to clear
Dx;
- Clinical presentation
- Family hx
- Lab testing
- Quantitative sweat chloride test - measures amt of salt in person's sweat, higher in pts w/ CF. >60 chloride is positive
- CXR
- PFTs
- Stool fat/ enzyme analysis
- Barium enema
- Genetic testing
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Cystic Fibrosis Sx
- Meconium ileus
- Absence of pancreatic enzymes, impairing digestive activity
- Intestinal obstruction
- Chronic cough
- Pancreatic insufficiency, fat soluble vitamin def, malabsorption of fat/protein/carbs
- Steatorrhea, freq poorly formed, large, bulky, foul smelling greasy stools
- High electrolyte concentrations
- Sterility in males
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Cystic Fibrosis Tx
- CPT/oscillation 2-3x/day
- Neb tx
- O2
- Regular aerobic exercise
- Calorie needs-150% more
- Pancreatic enzymes before meals
- Diet high fat/protein/calories/vitamins
- Fat soluble vitamins - A,D,E,K
- Aerosol/neb tx
- Tobramycin bid x 2 months
- Pulmozyme qday before other tx
- Colistin bid q mouth
- Albuterol
- Hypertonic saline
- Clean nebulizer
- ABX, antifungals
- Culture
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Cholelithiasis vs Cholecystitis Definitions
Cholelithiasis:
- Most common disorder of biliary system
- Stones in the gallbladder
Cholecystitis:
- Inflammation of the gallbladder
- Associated with obstruction by stones or sludge
- May be acute or chronic
Cholelithiasis and cholecystitis usually occur together
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Cholelithiasis;
- Pathology
- 2 Types of Stones
- Risk Factors
- Cause of gallstones unknown
- Develops when balance that keeps cholesterol, bile salts, and calcium in solution is altered
- Causes include infection and disturbances in metabolism of cholesterol
2 types of stones;
1) Pigment (calcium): cannot be dissolved, must be surgically removed. Usually dark brown to black (too much bile)
2) Cholesterol – 75 % are this type. Solubility depends on bile acids and lecithin in bile. Yellow in color
Risk Factors:
- Gender
- Age
- Obesity
- Estrogen
- Ethnicity
- Familial tendency
- Rapid weight loss; fasting
- Cholesterol-lowering drugs
- Diabetes
- Sedentary lifestyle
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Cholecystitis;
| -Pathology
- Most commonly associated with obstruction caused by gall stones or sludge
- Bacteria ( e. coli, streptococci, salmonellae)
- Adhesions, Neoplasms
- Anesthesia, opioids
- Inflammation
- Major pathophysiologic condition
- Confined to mucous lining or entire wall of gall bladder
- Gallbladder is edematous and hyperemic during a acute attack.
- May be distended with bile or pus
- Cystic duct may become occluded.
-Acalculous cholecystitis is inflammation without obstruction
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Cholelithiasis vs Cholecystitis: Clinical Manifestations
Cholelithiasis:
- Sx depends on the stones being stationary/mobile and if obstruction is present
- Gallstones also may be silent , no pain and only mild gi symptoms, fullness and distention
- A stone is lodged in a duct- spasms may occur and cause pain
- Attach occurs 3 to 6hrs after a high fat meal or when lying down
- When total obstruction-symptoms relate to bile blockage
Cholecystitis:
- Indigestion to moderate to severe pain
- Pain in RUQ which may refer to right shoulder and scapula
- Fever and leukocytosis
- Nausea/vomiting
- Restlessness, Diaphoresis
- Murphy’s sign
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Lab Tests/Radiology - Inflammation
Laboratory tests:
- WBC with differential
- CRP (<1 Normal)
- ESR (0-15 M, 0-20 W)
- Serologic tests to detect specific antibodies or viruses
Radiographic studies:
- MRI
- CAT
- PET scans
- Colonoscopy
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WBC
NL values: 4,800 - 10,800/mm
Neutrophils: 50-70% -phagocytosis bands are immature neutrophils: 0-3%
Eosinophils: 0-4%- seen in allergic reactions
Basophils: 0-2% – increase with healing process
Lymphocytes:2 0-40% –assoc with viral infections
Monocytes: 4-8% assoc. with chronic inflammation
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Collaborative care:
- Cholelithiasis
- Acute Cholecystitis
Cholelithiasis will try dissolution therapy: dissolve cholesterol stones but more success w/ surgical therapy/ERCP
Cholecystitis acute focus:
- Rest, Pain mgmt
- ABX
- F&E balance (IV)
- Gastric decompression (npo with ng); If n/v is severe and then advance to clear then low fat diet
- Anticholinergics:↓ secretion, Counteract smooth muscle spasms
- Intracorporal and Extracorporeal lithotripsy (temporary)
- Laparoscopic or Incisional (open) cholecystectomy
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Gastritis:
- Acute, 2 types
- Chronic
- Inflammation of the gastric mucosa
- A common GI problem
- Acute gastritis: rapid onset of symptoms
1) Erosive- related to local irritants: ASA, NSAIDS, alcohol, dietary, and gastric radiation therapy. Other causes include bile reflux. Ingestion of strong acid or alkali may cause serious complications.
2) Non erosive: caused by an infection with Helicobacter pylori (H. Pylori)
-Chronic: prolonged inflammation due to benign or malignant ulcers of the stomach or by Helicobacter pylori. May also be associated with some autoimmune diseases, dietary factors, medications, alcohol, smoking, or chronic reflux of pancreatic secretions or bile.
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Clinical Manifestations - Gastritis:
- Acute
- Chronic
Acute:
- Anorexia
- rapid onset of epigastric pain
- n/v, hiccupping and dyspepsia
- May have bleeding – blood in vomit or melena
Chronic:
- Anorexia
- pyrosis-heartburn after eating
- belching
- sour taste in the mouth
- n/v
- intolerance of some foods
- May have vitamin deficiency d/t malabsorption of B12
- Some have no symptoms
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Mgmt of Gastritis:
- Acute
- Chronic
Acute:
- Refrain from alcohol and food until symptoms subside
- Mucosa is capable of repairing itself after an episode of acute gastritis
- If due to strong acid or alkali treatment to neutralize the agent, avoid emetics and lavage due to danger of perforation and damage to esophagus
- Supportive therapy- physical and emotional, pharmacological
Chronic:
- Modify diet, promote rest, reduce stress, avoid alcohol and NSAIDs
- Pharmacologic therapy
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RX Treatment: Gastritis
-Antacids
-Histamine -H2 receptor antagonists (H2 blockers);
Cimetidine, famotidine, ranitidine
-Proton pump inhibitors
Pantoprazole, omeprazole, Esomeprazole
*If H. pylori is +: treat with antibiotic (Amoxicillin, Clarithromycin or metronidazole) + PPI/and or Bismuth
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Nurse Mgmt/Interventions; Gastritis
- Reduce anxiety; use calm approach and explain all procedures and treatments/ dx testing
- Promote optimal nutrition; for acute gastritis, the patient should take no food or fluids by mouth. Introduce clear liquids and solid foods as prescribed.
- Evaluate and report symptoms. Discourage caffeinated beverages, alcohol, cigarette smoking.
- Promote fluid balance; monitor I&O, for signs of dehydration, electrolyte imbalance, and hemorrhage
- Measures to relieve pain: diet and medications
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GERD Clinical Manifestations
-HEARTBURN (pyrosis) / PAIN: burning sensation
located in lower substernal midline may radiate, generally in waves, upward to neck, jaw, back can last as long as 2 hours and is often worse after eating, commonly experienced with postural changes (bending, stooping, lying)
- Dyspepsia
- Dysphagia
- Regurgitation
- Extra esophageal symptoms: sore throat, chronic cough , wheezing and dental erosion
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GERD Medications
- Antacids - neutralize acid; 1 hr ac, or 2-3 hr pc
- Histamine-2 Receptor Antagonists - decrease gastric acid secretions Ranitidine(Zantac) Famotidine (Pepcid)
- Cholinergics – increases LES pressure/tone ( Urecholine); taken ac
- Proton Pump Inhibitors - Suppress secretions of gastric acid (Pantoprazole, Prilosec; Prevacid); taken ac
- Prokinetic agents –increase esophageal and stomach motility (Metoclopramide)
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GERD Lifestyle Changes
- Restrict diet to small, frequent feedings
- Eat slowly, chew thoroughly adds saliva
- Avoid offending foods, spices, fats, alcohol, caffeine, chocolate & citrus juices and carbonated beverages
- Avoid eating or drinking 2/3 hrs. before hs
- Increase HOB 6-8 inches (pillows or blocks)
- Lose weight
- Avoid tobacco, salicylates
- Avoid tight fitting clothes
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GER (Infants);
- Patho
- Sx
- Interventions
- Occurs frequently in the first year of life and usually resolves within 12-18 months
- Common in premature infants
- Pathophysiology of GER occurs during transient relaxation of the LES which occurs during
```
Clinical Manifestations:
-Swallowing
-Crying
-Other Valsalva maneuvers that increase intra abdominal pressure
-Delayed esophageal clearance and gastric emptying, hiatal hernia, increase acidic content , and neurological disease (could be contributing factors of reflux)
-Recurrent vomiting or regurgitation
-Weight loss or poor weight gain
Irritability in infants
-Chronic cough, wheezing , asthma, apnea
-Hoarseness / sore throat
-Heartburn
-Abdominal pain
-Dysphagia or feeding refusal
-Hematemesis
-Chronic sinusitis, otitis media
-Poor dentition (acid erosion)
```
Interventions:
-Keep the infant/child upright for 30 min. after feeding
S-maller more frequent feedings with nipple to control flow
-Burp infant more frequently
-Thickening formula with rice /cereal to keep formula down
-Elevate in bed 30 degrees
-Elevate 30 to 45 degrees after feeding
-Medications to decrease acid and stabilize pH
-Prokinetic agents
-Teach coping strategies –parental anxiety
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Diverticulosis vs Diverticulitis Sx
Diverticulosis:
- Most no symptoms
- Abdominal pain , bloating and flatulence
- Change in bowel habits
- Chronic constipation precedes development
Diverticulitis:
- Acute pain in LLQ
- Palpable abdominal mass
- Constipation
- nausea
- Systemic symptoms of infection
- Fever
- Increased CRP
- Leukocytosis
- Shift to left (^ neutrophils)
- Older adults: May be afebrile, have normal WBC, have little abdominal tenderness
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Medical Mgmt & Interventions: Diverticulitis
- Conservative Therapy – outpatient uncomplicated
- Clear liquid until inflammation subsides then High fiber diet, low fat
- Stool softeners and Anticholinergics (Bentyl)
- Oral antibiotics 7 to 10 days
- Hospitalization for severe symptoms/ acute
- IV fluids and antibiotics (broad spectrum)
- NG if vomiting, NPO to clear liquids
- Bed rest
- Analgesics
- CT guided percutaneous drainage for abscess
Nursing Interventions:
- Teaching the patient to increase fluids to 2 liters day
- Teaching diet to increase fiber and decrease fat
- Weight reduction for the obese patient
- Educate to increase physical activity (^ abd muscle tone)
- Discuss food triggers- nuts , popcorn
- Educate on factors that increase intraabdominal -pressure such as straining at stool, vomiting, bending, lifting, and wearing tight restrictive clothing
- Educate on medications and bulk laxatives
- With a patient that has a colostomy- teaching diet, care of ostomy and expectation
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UC vs Chron's Clinical Manifestations
UC:
- Diarrhea, 10-20 stools /day
- Blood, mucus and pus in stool
- Left lower quadrant cramping and pain
- Urgent need to defecate/tenesmus
- Anemia
- Fatigue
- Hypovolemia
- Nutritional impairment
- Anorexia
- Lab values- ^ ESR,^ WBC with shift
Chron's:
- Liquid to semi formed stool , no visible blood, 5 to 6 times per day
- Crampy abdominal pain, spasms, tenderness in RLQ
- Low grade fever -leukocytosis
- Steatorrhea (fatty diarrheal stools)
- Palpable RLQ mass
- Fatigue, malaise, weight loss
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IBD Collaborative Care
- Dietary Consult
- NPO for severe symptoms –TPN
- Elemental diet for less severe attacks such as vivonex or ensure-absorbed in jejunum
- Low fiber (low residue)
- Chronic UC – avoid milk products, pepper, caffeine, alcohol, smoking, raw vegetables and fruits
- Increase nutritional needs for fistulas in crohns
- If narrowing of small bowel in crohns– low roughage
- Need a high calorie, high protein, vitamins
- Small frequent meals
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IBD Complications
- Hemorrhage-UC
- Abscess formation
- Colonic distention leads to Toxic megacolon
- Malnutrition from malabsorption
- Fluid and electrolyte imbalance
- Bowel obstruction and strictures
- Bowel perforation leading to peritonitis
- Increase risk of colon cancer
- Arthritis and extraintestinal disorders
- Fistulas with crohns disease
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Osteoarthritis SX/Labs
- Localized
- Functional impairment
- Joint pain w/ activity
- Pain relief w/ rest
- Joint stiffness
- Crepitation in knee
Labs:
- DEXA scan: negative T score indicate osteoporosis (> - 2.5)
- Calcium 8.6 -10.2 mg/dL
- alkaline phosphatase 942-136 units/L
- vitamin D 29-32
- Thyroid testing (T4 &TSH)
- Testosterone
- Follicle stimulating hormone
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Osteoarthritis Collaborative Care/Teaching
- Nutritional/wt mgmt and counseling
- OT, PT
- Rest, joint protection, use of assistive devices
- Heat/cold applications
- Alternative therapies
- Pharm mgmt
- Reconstructive joint surgery
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Osteoporosis Clinical Manifestations/Tx
- Usually asymptomatic until fracture
- Back pin caused by fractures or collapsed vertebra
- Loss of ht over time
- "Dowager's hump"
- Stooped posture
TX:
- Calcium/Vitamin D
- Wt bearing exercise/freq ambulation
- Hazard free environment
- Use of assistive devices
- Screening with DEXA Scan
- STOP: smoking/decrease caffeine
- Pharm mgmt
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Casts:
- Nursing Care
- Pt teaching
- Ice
- Elevation of extremity
- Capillary refill
- Handling
- Skin color and temperature – compare extremities.
- Sensation/movement of casted extremity
- Drainage – mark and monitor
Pt teaching:
* Teach the patient to contact the health care provider for any of the following*
- Cast feels warm or hot or has an unusual smell
- Any drainage or blood that suddenly appears on the cast
- Any reports of new/increasing pain, burning, numbness, or tingling of the affected extremity
- Extremity changes color or temperature, or any swelling persists.
- Fever above 101.5° F (38.5° C) taken by mouth.
- Slipping of cast, inability to visualize toes or fingers
- Do not insert anything into the cast for the purpose of scratching, use cool air on blow dryer
- First 48 hrs elevation above the heart and cold therapy
- Showering and bathing with a cast
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Nursing Interventions - Fractures
- Anatomic realignment/reduction and immobilization
- Pain mgmt
- Prevention of infection with open fracture
- Prevention of complications
- Restoration of normal or near-normal function
- Splinting
- Casts
- Pins, rods, screws
- Traction
- Surgery – includes open or closed reductions
- “ORIF”
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Fat Embolism;
- SX
- TX
- A fat embolism is when fat from long bones enter circulation. Fat globules occlude small blood vessels that supply lung, brain and kidney
- Occurs with in 12-72 hrs post trauma or with ORIF of long bones or pelvis due to disruption of bone marrow
SX;
- decrease mental acuity: confusion and restlessness
- decrease BP
- Petechiae over neck and chest
- SOB and sometimes chest pain
- decrease O2 sat
- tachypnea and tachycardia
- fever
TX; oxygen for respiratory compromise, neuro checks, iv hydration, and corticosteroids, minimize movement of fracture
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Compartment Syndrome;
- SX
- TX
- See neuro changes first
- Pain out of proportion to type of injury
- throbbing and localized pain with passive stretch, -unable to distinguish sharp /dull
- pain unrelieved by analgesics
- Paresthesia: numbness and tingling ( nerve involvement)
- Pallor: dusky, cool to touch
- Paralysis: loss of function
- Pulslessness: diminished or absent peripheral pulses (late sign)
-Usually develops quickly-6 to 8 hrs after initial injury or fx repair and can take up to 48 hrs. damage is irreversible
TX:
- Extremity should not be elevated above heart level
- Elevation may raise venous pressure and slow arterial perfusion
- Remove ice therapy because cold will cause vasoconstriction
- Surgical decompression may be necessary- Fasciotomy
- Assess urine output because a possibility of muscle damage
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Scoliosis;
- Screening Test
- Types of Braces
- Boston Brace Instructions
-Standard screen test: Adam’s forward bend test
Types of Braces:
1) Charleston Bending Brace (“nighttime”)
2) Boston (TLSO)
3) Milwaukee (CTLSO)
Boston Brace Instructions:
- Wear cotton shirt under the brace for skin integrity and sweat
- Avoid powders
- Wear brace 23/24 hrs and remove for bathing per HCP
- Apply while lying flat in bed and log roll into brace
- Once front is placed- secure the Velcro tight
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Herniated Disc;
- Clinical Manifestations
- Post Op Instructions
- Pain in region of injury and/or in affected limb(s)
- Radicular pain / dermatomes
- Numbness, tingling, weakness
- Change in reflexes
- Lumbar- sciatica
- Cervical radiates to arms or shoulders
Post Op instructions:
- Comfort
- Neurovascular assessment (compare left to right and before and after surgery)
- Activity and position (walk or log roll)
- Prevention of complications
- Hematoma compresses nerve
- Infection
- Dural leak c/o headache
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Muscular Dystrophy (Duchenne's) Clinical Manifestations
- Hips thighs, pelvis and shoulders are affected first; then cardiac & resp
- As a child: late to walk, enlarged calves
- Fall often in pre school
- Difficulty climbing stairs/riding a tricycle
- Walk on toes or ball of feet, unsteady gait
- Between age 9 -13 lose their ability ambulate
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Parkinson's Disease:
- Clinical Manifestations
- Collaborative Care
- Pill rolling motion with fingers
- Tremors at rest
- Stooped posture
- Slow monotone speaking
- Decreased or absent arm swing
- Mask like expression
- Drooling
- Rigid limbs- resistant to PROM
- Slow shuffling gait
- Apathy
- Fatigue
- Pain
- Short term memory loss
- Feelings of depression
- Constipation
- Mood swings – cognitive impairment
Collaborative Care:
- Symptom relief
- Pharmacological mgt
- Ablation or deep brain stimulation
- Maintain independence (functional)
- Speech therapy, physical therapy
- Support groups
- Avoid complications –airway #1 priority
- Nutrition
- Exercise
- Safe environment
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3 Stages and Clinical Manifestations of Pertussis
Stage 1: Catarrhal stage and lasts 1 to 2 weeks
Coryza (runny nose), sneezing, rhinitis, low grade fever, mild occasional cough, highly contagious similar to URI
Stage 2: Paroxysmal stage – time varies from 1 to 6 weeks up to 10 weeks
- Paroxysm rapid cough followed by high pitch whoop when inhaling, vomiting and exhaustion after coughing. -Difficulty clearing secretions
- Infant increase frequency (10-30 x in a row) and periods of Apnea- red in the face, cyanosis and protrusion of tongue. infants <6 mths may not whoop. -Saliva, tears and mucus flow from the mouth, nose and eyes
Stage 3: Convalescent Stage lasts weeks to months
Susceptible to other infections gradually coughing less
For those >65 coughing can last from 2 weeks to 8 months and can lead to weight loss and can also turn into pneumonia
Infectious from beginning of catarrhal stage and remain infectious thru 3rd week after onset of paroxysmal or until after start of antibiotics for 5 days
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Pertussis Prevention/Vaccine/Risk Reduction
- DTAP basic immunization with 5 doses given from 2 months to 4-6 yrs
- Tdap booster instead of TD for anyone older than 11 and adults
- Tdap to pregnant women in the 3rd trimester (after 28 weeks)with every pregnancy (transplacental)
- Tdap to family members and care givers >19 yrs old once and make sure up to date
- Risk reduction: wash hands, hands away from eyes, mouth and nose, stay away 6 ft from anyone coughing or other respiratory signs
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Pertussis TX
- High humidity environment or oxygen (humidified 02 & vaporizer)
- Frequent suctioning and mobilize secretions
- Observe airway obstruction/ apnea monitoring
- Encourage fluids to thin secretions and hydration
- Reassure coughing spells can be very frightening
- Droplet precautions until 5 to7 days of antibiotics
-CDC recommends antimicrobial for tx and prophylaxis
> 1 month age – macrolides (azithromycin, erythromycin, clarithromycin, and Bactrim
< 1 month azithromycin
Hospitalization – infants usually under 6 months
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Phototherapy Nursing Mgmt
- Cover genitals and eyes
- Monitor temperature
- Frequent feedings
- Monitor I&Os
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Allergic Reaction Nursing Mgmt
If a patient is experiencing an allergic response:
- Exposure is removed
- Nurse assesses the patient for s/s of anaphylaxis
- Assess airway & breathing pattern are priority
- Vital signs
- Emergency response system is activated
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Rheumatoid Arthritis SX
- Chronic, systemic autoimmune disease
- Inflammation of connective tissue in diarthrodial (synovial) joints
- Most often affects small joints – hands and feet
- Larger peripheral joints: wrists, shoulders, knees, ankles, hips and jaw
- Periods of remission and exacerbation
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Difference between RA & Osteoarthritis
Osteoarthritis is caused by mechanical wear and tear on joints
Rheumatoid arthritis is an autoimmune disease in which the body's own immune system attacks the body's joints. It may begin any time in life.
111
Types/length of precautions for:
- Pertussis
- TB
- Bacterial Meningitis
Pertussis:
-Droplet, on precautions through completion of 5 days of therapy
TB:
-Airborne, for 14 days after starting effective treatment
Bacterial Meningitis:
-Droplet, until completed 24 hours of ABX
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Otitis Media;
- Risk Factors
- Clinical Manifestations
- "Watchful Waiting"
Risk Factors:
- Eustachian tube dysfunction
- Recurrent Respiratory infections
- First episode of AOM prior to 3 months old
- Family hx of middle ear disease
- Day care attendance
- Exposure to second hand smoke
- Immunodeficiency
- Poor living conditions or crowding in the home
- Craniofacial abnormalities such as cleft palate
- Poor nutrition
- Unvaccinated
- Bottle-feeding while supine
- Pacifier use
- Gastroesophageal reflux
Clinical Manifestations:
- Ear pain (otalgia)
- Irritability “fussy”
- Sleep disturbances
- Persistent crying in infants when lying
- Down (inconsolable)
- Fever (low grade or higher)
- Fluid draining from the ear
- Loss of appetite /poor feeding
- Diarrhea (especially in infants)
- Infants may pull their ears or roll their heads
"Watchful waiting"
-Observing child for 2–3 days to give your child's immune system time to fight off the infection rather than starting ABXs immediately
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Otitis Media Prevention
- Teach how to recognize upper respiratory tract
- Encourage early tx
- Discuss risk factors, and suggest changes the family can make such as avoiding exposure to secondhand smoke, weaning off the use of pacifiers, and avoiding supine feeding.
- Instruct the parents to avoid feeding an infant in the supine position or putting the infant to bed with a bottle, because doing so could cause reflux of nasopharyngeal flora.
- If appropriate, teach the child to promote Eustachian tube patency by performing Valsalva maneuver several times per day, especially during airplane travel.
- Encourage breast feeding- 6 to 12 months
- Hand washing
- Encourage routine vaccinations
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TB Clinical Manifestations & Vaccine
- Low grade fever
- Night sweats
- Fatigue
- Weight loss and anorexia
- Cough; nonproductive, mucopurulent, hemoptysis
- Lung sounds; diminished, crackles, rhonchi
Vaccine: BCG, not commonly used in US
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Latent vs Active TB
Latent:
-Doesn’t grow in the body. Doesn’t make a person sick or have symptoms. Can’t spread from person to person can advance to TB disease
Active:
-Active and grows in the body and makes a person sick and have symptoms. Can spread from person to person and can cause death if not treated
116
TB Prevention
- Early identification and treatment
- Exposed family members should be tested for TB
- Initiate isolation precautions immediately who are suspected , continue precautions until negative AFB
- INH used prophylactically for those at risk (daily dose for 6 to 12 months)
- Educate to prevent by covering mouth and not sharing eating utensils, good hand hygiene
- Yearly health care workers tested for tuberculin skin test
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Signs of Pregnancy:
- Presumptive
- Probable
- Diagnostic Test
Presumptive:
- Breast tenderness
- N/v
- Amenorrhea
- Breast enlargement
- Urinary frequency
- Fatigue
- Hyperpigmentation of the skin
- Fetal movements (quickening)
- Uterine enlargement (bloating sensation)
Probable:
- Braxton Hicks contractions
- Positive pregnancy test
- Abdominal enlargement
- Ballottement
- Goodell’s sign
- Chadwick’s sign
- Hegar’s sign
Diagnostic Tests:
- Ultrasound verification of embryo or fetus
- Fetal movement felt by experienced clinician
- Auscultation of fetal heart tones via Doppler
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Pregnancy Nutritional Needs
- Increase calorie intake by 300-500/day
- Increase consumption of foods rich in iron, folic acid, calcium and protein
- Increase consumption of fruits and vegetables
- Replace saturated fats with unsaturated ones
- Choose whole grains and high fiber foods
- Eat at least two servings of fish weekly, with one of them being an oily fish
- Consume at least 2 quarts of water daily
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Antenatal Testing:
- Chorionic Villus Sampling
- Nonstress test
- Oxytocin stress test
CVS:
Shows if baby has a chromosomal condition (+ or -)
Nonstress test:
- Baseline 110-160 bpm
- Moderate variability (6- 25 bpm)
- Two accelerations of 15 bpm above the baseline associated with fetal movement lasting 15 seconds (10x10 <32 weeks)
- Absence of decelerations
Oxytocin Stress Test:
- Negative test= no late decelerations
- Positive test= late decelerations with more than 50% of contractions
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Ectopic Pregnancy s/s & risk factors
S/s:
- 6-8 weeks after missed menses
* *Abdominal pain and fullness (often one side)
- Vaginal spotting/bleeding
- Low back pain
- S/S of Rupture (life threatening->hemorrhage->shock)
- Sudden, severe pain in the abdomen or pelvis
- Shoulder pain
- Weakness, dizziness, or fainting
- Unstable vital signs
Risk Factors:
- Previous ectopic
- Endometriosis
- PID, STIs
- Tubal, surgery
- Infertility
- SAB/IAB
- IUD fibroids
- Smoking
- Advanced maternal age
- ART
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True vs False labor s/s
True Labor:
- Regular contracts, become closer together; 4-6 minutes apart, lasting 30-60 seconds
- Contractions become stronger with time, vaginal pressure is usually felt
- Discomfort in the back and radiates around toward the lower, front of abdomen
- Contractions continue or augment w/ activity
- Patient teaching: Stay home until contractions are 5 minutes apart, last 45–60 seconds, and are strong that you can’t talk through—then go to the hospital or birthing center for evaluation
- Admit for labor and childbirth
False Labor:
-Irregular contractions, do not get closer together
-Contractions frequently weak, do not get stronger or alternating (strong one followed by weaker ones)
-Discomfort usually felt in the front, top of the abdomen (fundus)
-Contractions may stop or slow down w/ activity
-Drink fluids and walk around to see if there is any change in the intensity of the contractions; if the contractions diminish in intensity after either or both, stay home
-No Cervical change=False labor (Prodromal Labor/Braxton Hicks)
Discharge home, reinforce true labor signs
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Stages of Labor
First Stage= Effacement and Dilation (0-10cm)
Second Stage=Expulsion
Third Stage=Placental Delivery
Fourth Stage=Restorative
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Variability FHR;
- Absent
- Moderate
- Marked
Absent- no change detectable
Minimal: 0-5 bpm
Moderate: 6-25 bpm
Marked: >25 bpm
124
Variable Deceleration
- Abrupt and quick decrease > 15 beats below the baseline and last >15 sec
- Cause=Umbilical cord Compression
- No relationship with contractions
125
Early Deceleration
- Gradual decline mirroring the contraction
- Cause=fetal head compression
- Fetus okay, no intervention needed
126
Late Deceleration
- Decreased fetal heart after the peak of contraction
- Cause=Utero-placental insufficiency
- Results in decreased blood flow=>hypoxia
127
APGAR Score
```
Appearance (skin color)
Pulse (heart rate)
Grimace response (reflexes)
Activity (muscle tone)
Respiration (breathing rate and effort)
```
7 or above is normal
128
Epidural Nursing Responsibilities
- IV Bolus
- Assess CBC
- Contradicted: platelets less than 70,000
- Maternal VS with continuous O2 sat
- Monitor FHR and Uterine Activity (before and after procedure)
- Position Patient; upright, seated or side lying
- Oxygen and suction readily available
- Bladder assessment
-Monitor for side effects/adverse reactions;
Maternal hypotension, intravascular injection, “Spinal” Headache, inadequate or failed blockage, maternal fever, respiratory depression, N/V, fetal heart rate changes, pruritus, inability to void
129
Neonate signs of Respiratory Distress
- Bluish color of the skin and mucus membranes (cyanosis)
- Brief stop in breathing (apnea)
- Decreased urine output
- Nasal flaring
- Rapid breathing
- Shallow breathing
- SOB and grunting sounds while breathing
- Unusual breathing movement (such as drawing back of the chest muscles with breathing)
