Week 4; High Risk OB Flashcards
(131 cards)
1
Q
The current status of a woman’s labor is determined by the:
A
- contraction pattern (frequency, duration, and intensity),
- status of the amniotic membranes (ruptured or intact)
- the cervical exam (dilation, effacement, and fetal station)
2
Q
Adolescent during labor and delivery
A
-Adolescent who has not had prenatal care requires close observation during labor
-Risk for pregnancy and labor complications
-Alert for physiologic complications of labor
-Support role of nurse depends on young woman’s support system during labor
-Trusting relationship, nurturing rapport, respect for expectant adolescent
-The younger the adolescent, the less she may be able to participate actively in labor and delivery process, even if she has taken prenatal classes
-Very young adolescents have fewer coping mechanisms, less experience to draw on
Incomplete cognitive development → fewer problem-solving capabilities
-Ego integrity may be more threatened by experience of labor
3
Q
Labor and delivery over age 35
A
-Respond to stresses of labor similarly to younger women
-Risk of maternal death higher for women over age 35
-Even higher for women over age 40
-More likely to have chronic medical condition that can complicate pregnancy
-Higher rates of miscarriage, stillbirth, preterm birth, low birth weight, perinatal morbidity and mortality
-Risk of pregnancy complications higher in women over age 35 with chronic condition such as diabetes or hypertension or who are in poor general health
-Risks much lower than previously believed for physically fit without preexisting medical conditions
4
Q
Dysfunctional labor
A
Does not result in normal progression
Problems with: powers of labor, the passenger, the passage, the psyche, abnormal Labor duration, also can be a combo of these
5
Q
Problems of the powers of labor
A
Ineffective Contractions, ineffective maternal pushing
6
Q
Problems with the passenger
A
Fetal size, Abnormal presentation or position, multifetal pregnancy
7
Q
Problems with the Passage
A
Pelvis, maternal soft tissue obstructions
8
Q
Problem with the Psyche
A
Stress, pain, fear
9
Q
Abnormal duration
A
abnormally long or abnormally short
10
Q
Ineffective contractions possible causes:
A
Maternal fatigue, maternal inactivity, fluid and electrolyte imbalance, hypoglycemia, excessive analgesia or anesthesia, maternal catecholamines secreted in response to stress, disproportion of maternal pelvis and fetal presenting part, uterine overdistention such as with multiple gestation or hydramnios (excess volume of amniotic fluid)
11
Q
Two patterns of ineffective uterine contractions are:
A
labor dystocia and tachysystole
12
Q
Labor dystocia –
A
difficult labor, failure to progress
13
Q
Tachysystole –
A
more than 5 contractions in 10 minutes
14
Q
Other concerns with contractions:
A
lasting 2 minutes or longer, less than 2 minute resting time between or failure of uterus to return to resting tone in between
15
Q
ineffective Maternal pushing possible causes:
A
Use of non physiological pushing techniques and positions, maternal exhaustion, decreased or absent urge to push, analgesia or anesthesia that suppresses woman’s urge to push, psychological unreadiness to “let go” of baby
16
Q
Labor dystocia interventions
A
-Depends on cause
-No limit to duration of the second stage of labor as long as the woman and fetus are stable with normal VS and FHR patterns.
-Changing positions: Upright positions such as squatting add gravity; semi-sitting, side-lying and pushing while sitting on the toile are other options.
-Sometimes allowing woman who is exhausted to rest and push with every other contraction.
-IV fluids
-Pain management – epidural block may reduce effectiveness of contractions. Epidural analgesia – pain control without major loss of sensation – may lose feel of urge to push
-Therapeutic communication, calming
-Education on fetal descent may decrease fear of process
-Oxytocin and amniotomy (intentional rupture of the amniotic sac) to promote labor
-Decision to order uterine stimulant or relaxant is very individualized and based on each woman’s labor pattern
17
Q
Management of tachysystole may include
A
Tocolytic drugs to reduce uterine resting tone and improve placental blood flow.
18
Q
Problems with the passenger; fetal size
A
Macrosomia, shoulder dystocia, rotation abnormalities - occiput transverse or occiput posterior, abnormal fetal presentation or position, multifetal pregnancy – overextension of uterus
19
Q
Macrosomia –
A
infant weighs more than 8 lb. 13 ounces
20
Q
Shoulder dystocia –
A
delayed or difficult birth of the shoulders, urgent because cord may be compressed
21
Q
Problems with the passenger interventions
A
Depend on the problem
-Positioning to promote vaginal delivery
-Shoulder dystocia – “turtle sign” when head is born it retracts against perineum – team prepares for emergency surgical delivery because cord can be compressed between fetal body and pelvis
-External Cephalic version – also called “manual version” – when attempts are made to manually move fetus in breech positon to cephalic presentation. If can’t be moved C-section usually performed to prevent complications.
-Surgical Delivery/Cesarean birth if vaginal birth is not possible or is inadvisable
22
Q
Problems with passage
A
-Variations of maternal bony pelvis or soft tissue problems that inhibit fetal descent; examples: small pelvis or soft tissue blockage
-A full bladder can also cause a soft tissue obstruction; assess for full bladder
-Encourage to void every 1-2 hours
Catheter – intermittent or Foley insertion
23
Q
Problems of the psyche
A
-Stress; secretion of catecholamines (epinephrine and norepinephrine) by adrenal glands stimulates uterine beta receptors which inhibit uterine contractions. Increased glucose consumption reduces energy supply. Catecholamines also divert blood from uterus to skeletal muscles. Pain perception increased and pain tolerance is decreased
24
Q
Abnormal labor duration
A
Prolonged or precipitous
25
Possible problems that cause abnormal labor duration
Maternal infection, neonatal infection, maternal exhaustion, higher levels of anxiety and fear during subsequent labor
26
Nursing measures for prolonged labor
-Include promotion of comfort, conservation of energy, emotional support position changes and assessments for infection
-Nursing care for fetus includes observation for signs of intrauterine infection and compromise fetal oxygenation
27
Precipitous labor
-Birth occurs within 3 hours of onset of labor
-Intense contractions often begin abruptly rather than gradually
-Precipitous birth is also when a birth occurs after a labor of any length when a trained attendant is not present to assist
-Several conditions can be associated – placental abruption, fetal meconium, infection, maternal cocaine use, postpartum hemorrhage and low Apgar scores for infant
28
Nursing measures for precipitous birth
-Promotion of comfort
-Conservation of energy
-Emotional support
-Position changes that favor normal progress
-Assessment for infection
-Nursing care for fetus includes observation for signs of intrauterine infection and compromise fetal oxygenation
29
Intrauterine Infection mnemonic
Triple I- intrauterine inflammation, infection or both
30
Application of the Nursing Process: Intrauterine Infection
-Assessment – every 2-4 hours in normal labor and every 2 hours after membranes rupture
-Identification of patient problems
-Reduce risk of infection
-Keep area clean
-Good handwashing, use PPE
-Fewest vaginal exams possible
-Keep underpads as dry as possible
-Wash perineum, front to back, keep as clean as possible
-Evaluation
31
Intrauterine infxn s/s
--Fever greater than 102.2F or 100.4 on 2 readings, 30 min. apart
-Fetal tachycardia – greater than 160 bpm
-Elevated WBC – greater than 15,000
-Purulent fluid coming from cervical os
-Cloudy, yellowish, thick discharge confirmed visually on sterile speculum exam and coming from cervical canal
-Biochemical or microbiologic amniotic fluid results
32
Assessment for signs of maternal exhaustion
-Verbal expression of tiredness, fatigue
-Verbal expression of frustration, “I can’t do this any more”
-Ineffective use of coping skills – stops using breathing techniques
-Changes in pulse, respiration and BP
33
Maternal exhaustion interventions
-Conserving maternal energy by taking breaks
-Position of comfort
-Maintain comfortable temperature
-Soothing back rub
-Maintain IV fluids
-Assess for dehydrations
-Promoting coping skills
34
PROM Etiology
infection, abnormalities, overdistention of uterus, stress, diabetes, poor nutrition
35
PROM complications
Risk for infection to mother or infant; organisms that cause Triple I weaken the amniotic membrane leading to rupture.
36
PROM therapeutic management
Determining time of membrane rupture, maternal antibiotics
37
Determining true membrane rupture; mistaken conditions and how to differentiate
Urinary incontinence, vaginal discharge, loss of mucus plug
-Sterile speculum exam to look for a pool of fluid near cervix and estimate dilation and effacement
pH to verify liquid is amniotic (approx. 7-7.5)
-Transvaginal ultrasound
38
Pre term labor risk factors
Obesity, fibroids or other abnormalities, uterine over distention, fetal conditions, poor nutrition, younger than 18 or over 40, smoking more than 10 cigs per day, substance abuse, domestic violence, lower socioeconomic group
39
Preterm labor s/s
-More subtle than those of labor at term
-Contractions that may or may not be painful
-Cramps similar to menstrual cramps
-Constant low backache
-Sensation of pelvic pressure
-Pain or discomfort tor pressure in vagina or thighs
-Change in vaginal discharge or spotting
-Sense of “just feeling bad”
40
Prevent preterm birth through:
Prenatal care, assessment of risk factors, nutrition, education for women and partners, delaying depends on early identification and seeking treatment
41
Preterm labor therapeutic management
Predicting, identifying, stopping, identifying and treating infections, identifying other causes, limiting activity, hydration
42
Assessment of fetal position is determined in following ways:
Inspection, palpation of woman's abdomen, vaginal examination, ultrasound, auscultation of fetal heart rate
43
Electronic monitoring of fetal heart rate
Produces continuous tracing of FHR, indications include: hx of stillbirth at ≥38 weeks of gestation, presence of complication of pregnancy, induction of labor, preterm labor, decreased fetal movement, meconium staining of amniotic fluid, maternal fever, trial of labor following previous cesarean birth
44
Electronic monitoring of fetal heart rate; Methods of electronic monitoring
Ultrasound, telemetry system (some models can be worn in tub, can be submerged in water), internal monitoring with internal spiral electrode (membranes must be ruptured, cervix at least 2 cm dilated, more effective, provides more accurate fetal tracing, can injure fetus)
45
Normal FHR ranges
110–160 bpm
46
Fetal tachycardia:
sustained rate of ≥161 bpm
47
Fetal bradycardia:
rate of <110 bpm during ≥10-minute period
48
Early deceleration:
onset of uterine contraction
49
Late deceleration:
caused by uteroplacental insufficiency
50
Responses to electronic monitoring:
Some women react positively, reassurance that baby is okay, helps identify problems in labor, some women ambivalent or negative, may believe monitoring is interfering with natural process, may resent time could be otherwise spent providing nursing care, anxiety produced by equipment, wires, sounds, discomfort of lying in one position, fear of injury to baby
51
Accelerating fetal lung maturity
Single course of corticosteroids (Bexamethasone and Dexamethasone.) Accelerates lung maturity and reduce severity of respiratory distress syndrome. Contraindicated in Triple I
52
Postterm pregnancy
-Late-term pregnancy is defined as period between 41 0/7 and 41 6/7
-Post-term pregnancy is defined as one longer than 42 0/7
-Most women in US who receive prenatal care are induced before 42 weeks.
53
Post term pregnancy complications
-Insufficiency of placental function secondary to aging and infarction reduces transfer of oxygen
-Meconium aspiration syndrome – respiratory distress
-General complications related to large fetus such as dysfunctional labor
54
Therapeutic management of post term pregnancy
Determine gestation, induction, nursing considerations, supporting fatigue, nursing care related to procedure
55
Chorioamnionitis
Common cause of preterm birth and may cause adverse neonatal outcomes, including neurodevelopmental sequelae. Chorioamnionitis has been marked to a heterogeneous setting of conditions characterized by infection or inflammation or both, followed by a great variety in clinical practice for mothers and their newborns.
56
Intrapartum emergencies
Placental abnormalities, prolapsed umbilical cord, uterine rupture, uterine inversion – turning inside out after birth, anaphylactoid syndrome (amniotic fluid embolism), trauma
57
Prolapsed umbilical cord
Umbilical cord slips down after the membranes rupture subjecting it to compression between fetus and pelvis
58
Prolapsed umbilical cord causes
Fetus remains at high station, preterm fetus or small fetus, breech, hydramnios – large amount of fluid
59
Signs of prolapse
Occult (hidden): In front of fetal head
Complete cord prolapse – protruding from vagina
60
Prolapsed cord management
C- section – almost always unless vaginal can be done quicker
-Need to relieve pressure on cord to improve umbilical flow
-Interventions should not delay the prompt delivery
61
Prolapsed cord nursing considerations
-Position woman’s hips higher than her head to shift the fetal presenting part toward diaphragm
-Knee chest or Trendelenburg position
-Hips elevated with pillows with side-lying position maintained.
-Maintain vaginal elevation
-Avoid or minimize manual palpation or handling of the cord as much as possible
-Ultrasound to confirm presence of fetal heart activity
-Oxygen at 8-10 L/min by face mask
62
Uterine rupture
Tear in the wall of the uterus because uterus cannot withstand the pressure
63
Uterine rupture risk factors
Previous surgery, high parity, excessively strong contractions
64
Uterine rupture s/s
Vary upon degree of rupture, may or may not interfere with delivery, abdominal pain, chest or shoulder pain, pain between scapulae, pain on inspiration due to irritation of diaphragm, hypovolemic shock
65
Signs of Impaired fetal oxygenation
Cessation of contractions, palpation of fetus outside uterus, if rupture is incomplete, blood loss is slower and other signs may be delayed
66
Uterine rupture therapeutic management
Stabilization, repair of tear, hysterectomy, blood and blood products
67
Uterine inversion
Uterus completely or partly turns inside; uncommon but potentially fatal. No single cause
68
Uterine inversion s/s
Uterus is absent from the abdomen or there is a depression in the fundal area, interior of uterus seen through cervix or protruding into vagina
69
Uterine inversion management
physician repositions, anesthesia may be required, blood ordered immediately
70
Uterine inversion nursing considerations
Assessing and maintaining blood volume, correcting shock, transfer to ICU, assess fundus if hysterectomy not required, observe for falling BP, tachycardia associated with shock, central venous pressure monitoring, blood gases and other labs
Indwelling catheter, I&O, NPO until stable, uterine inversion does not usually recur in current postpartum period
71
Trauma in pregnancy
Similar to non-pregnant woman, ABC’s, CPR if needed, controlling bleeding, evaluation of uterus and fetus even after minor trauma, mother may be discharged after evaluation and told to monitor kick counts (10 in 2 hours), any changes such as pain, bleeding, MD will give parameters regarding when to call MD or return to E.D.
72
Postpartum hemorrhage
Leading cause of Maternal Mortality in the U.S.
73
Early and late causes of postpartum hemorrhage:
Hematomas
Placenta acreta – abnormal adherence of placenta to the uterine wall
Uterine inversion – fundus collapses into the endometrial cavity turning the uterus partially or completely inside out - EMERGENCY
Uterine atony – lack of muscle tone, failure of fibers to contract
74
Predisposing factors for PP hemorrhage:
over distention, large infant or hydramnios, multiparity, obesity, retention of placenta
75
PP hemorrhage parameters
To be diagnosed: >500 ml for vaginal delivery, >1000 ml Caesarian delivery, or 10% drop in H&H
76
PP hemorrhage s/s
Uterine fundus difficult to locate, soft or boggy feel, uterus firm when massaged but loses tone when massage stopped, fundus located above expected level, excessive lochia or clots
77
Managment of atony
-IV infusion of dilute oxytocin during stage 3 of labor
-Assessments and massage fundus
-Firm gentle pressure on fundus in direction of vagina
-Do not push on uterus that is not contracted – could cause inversion, massive hemorrhage and shock
-Catheterization
-MD may order methergine (oxytocic) or Pitocin. if oxytocin ineffective
-MD may use bimanual compression of uterus
-Laparotomy may be necessary to identify source of bleeding
78
PP hemorrhage; trauma: predisposing factors
large infant, use of forceps or extractors, birth occurred rapidly, lacerations to perineum, vagina, cervix and area around urethral meatus, hematomas
79
Hemorrhage management
Surgical repair, comfort measures, pain management, large hematomas may require incision and evacuation
80
Late postpartum hemorrhage occurs d/t
Subinvolution, retained placental fragments and infection, hematoma
81
Subinvolution –
delayed return of uterus to non pregnant size and consistency
82
Late PP hemorrhage s/s
Prolonged discharge of lochia, irregular or excessive bleeding, pelvic pain, backache, fatigue, on palpation, uterus feels larger and softer than normal for that period of time following birth
83
Management of late PP hemorrhage
-Control excessive bleeding
-Pharmacologic intervention – oxytocin
-Dilation and curettage (D&C) – stretching of the cervical os to permit suctioning or scraping of the walls of the uterus
-Antibiotics
-Subinvolution may not be noticed until mother is at home
-Teaching how to recognize and report any deviation form expected
84
Hypovolemic shock review
-Abnormally decreased volume of circulating fluid causing peripheral circulatory failure
-Endangers vital organs
-Brain, heart, kidneys are particularly vulnerable
-Tachycardia is an early sign of compensation for excessive blood loss
-Tachycardia, tachypnea, BP normal initially, decrease or narrowing in pulse pressure (difference between systolic and diastolic) elevated BP can occur initially until compensatory mechanisms fail
-Acidosis with vasodilation and decreased BP, increased bleeding, decreased circulating volume, and subsequent organ death
85
Hypovolemic shock nursing considerations
-Assess for signs: uterus does not contract, gush or slow steady trickle of blood, severe perineal or rectal pain and tachycardia
-Monitor bleeding and pads (1 peripad per 15 minutes)
-Immediate care
-Treatment for cause
-IV Fluids and blood transfusion
86
Venous stasis –
pronounced when pregnant woman stands for long periods, pooling of blood, prolonged time in stirrups can also cause venous stasis
87
Hypercoagulation pregnancy
is characterized by changes in the coagulation and fibrinolytic systems, factors cause increased clot formation
88
Blood vessel injury –
may occur especially at birth, c-section increases risk, ages 35 and older doubles risk, history of thromboembolic disease or smoking increases risk
89
Puerperal Infection
Bacterial infection after childbirth; temperature of 38°C (100.4°F) or higher after the first 24 hours and occurring on at least 2 of the first 10 days following childbirth, effect of normal anatomy and physiology of infection. Infection can be carried via the blood or lymphatics to other areas causing septicemia
90
Puerperal Infection risk factors
Acidity of vagina is reduced during labor and an alkaline environment encourage growth of bacteria, tissue trauma
91
Endometriosis
Infection of inner lining of the uterus (1-3% risk)
92
Endometriosis s/s
fever, chills, malaise, abdominal pain and cramping, purulent and foul smelling lochia
93
Management of endometriosis
Therapeutic management: antibiotics, nursing considerations, fowlers position promotes drainage, pain medication, VS, antibiotics, warm blankets, cool compresses, cold or warm drinks, heating pad, maintain hydration
94
Complications of endometriosis
may affect other areas such as fallopian tubes or form pelvic abscess
95
Nursing interventions: puerperal or endometritis
Fowlers position promotes drainage, clean pads, peri-care, pain medication, VS – monitor temp, antibiotics, comfort measures: warm blankets, cool compresses, cold or warm drinks, heating pad, maintain hydration
96
Mastitis
Infection of the breast that occurs most often 2 to 4 weeks after childbirth, usually effects only one breast; staph aureus, E.coli, and MRSA most common. Organism enters through crack or blister, sore nipple from breast feeding. Engorgement may precede mastitis – skipped feedings
97
Mastitis s/s
flu-like symptoms, fever, chills, malaise, headache, pain or local lump in breast, redness, heat, inflammation, and enlarged axillary lymph node
98
Mastitis management
Antibiotics, application of moist heat or ice packs, breast support, bed rest, positioning infant correctly and avoiding nipple trauma, analgesics, continue to breast feed from both breasts, teach before discharge because this usually occurs after discharge, nursing pad should NOT have plastic layer, breast should be completely empty at each feeding to prevent stasis of mild, increase fluid intake
99
Wound infection (cesarean surgical incision, episiotomies, and lacerations) s/s:
Edema, warmth, redness, tenderness, and pain. Edges of the wound may pull apart and seropurulent drainage may be present. If untreated, may develop generalized signs including fever and malaise. Necrotizing fasciitis is rare but can occur at any incision site
100
Fran delivered a 9 lb, 10 oz. baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch diameter puddle of blood. What is your first action?
Call for help
Assess the fundus for firmness
Take her blood pressure
Check the perineum for lacerations
ANS: B
Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first assess for firmness and massage the fundus as indicated. The first action should be to assess the fundus. Assessing blood pressure is an important assessment with a bleeding patient, but the top priority is to control the bleeding. This is done by first assessing the fundus for firmness. If bleeding continues in the presence of a firm fundus, lacerations may be the cause.
101
Preterm infants –
Born before 37 weeks. The work Preterm is sometimes confused with low birth weight (LBW)
102
Fetal Growth restriction –
some can be full term but failed to grow normally
103
Late preterm infants
Infants born between 34 0/7 and 36 6/7 weeks of gestation, usually look full term but physiologically immature
104
Late preterm infants are at risk for
Respiratory disorders, problems with temperature maintenance, hypoglycemia, hyperbilirubinemia, feeding difficulties, acidosis, infections, long term neuro problems
105
Assessment and care of common problems with late preterm infants
Thermoregulation; Check temp every 3-4 hours for first 24 hours
Kangaroo Care
Feedings – immature sucking and swallowing reflexes
Two key breastfeeding elements to be assessed and supported:
1. protecting mother’s milk supply
2. Ensure infant is gaining weight
106
Positioning late preterm
-Side-lying and prone facilitate drainage of respiratory secretions and regurgitate feedings
-Prone and sidelying NOT recommended for normal newborn infants because they are associated with SIDS
-In preterm, the prone position increases oxygenation, enhances respiration, improves lung mechanics, and reduces energy expenditure.
-Supine position is begun as soon as infant can tolerate it and before discharge.
-Important to explain to parents
107
Discharge of late preterm infants
-Late preterm may be discharged at same time as full term infants.
-Not earlier than 48 hours
-Ensure feeding adequately and normal vs before discharge
-Teaching about keeping warm
-Teach signs of over stimulation
-Car seat – conduct before discharge, infant can tolerate sitting in a care without bradycardia, apnea or decreased oxygen sat
-SiGns of common complications such as jaundice or dehydration
-Follow up visit with MD/NP
108
Preterm
Born before the beginning of the 38th week of gestation
109
Characteristics of preterm infant
-Often appear frail and weak
-Less developed muscles
-Limp extremities
-Lack subcutaneous fat which may make skin appear red and translucent
-Plantar creases are absent in infants younger than 32 weeks gestation
-Vernix caseosa and Lanugo may be abundant
-Little excess energy
-Easily exhausted by noise and routine activities
-Feeble cry
-Lower oxygenation and stress-related behavior
-Females have large, non-separated labia and males undescended testes
110
Problems with respiration with preterm infants
-Normal is 30-60 respiration per minute
-Very rapid respiratory rate can interfere with feeding in premature infants
111
Periodic breathing –
cessation of 5-10 seconds followed by 10-15 seconds of rapid respirations. -No change in color or heart rate
112
Apneic spells –
absence of breathing more than 20 seconds, cyanosis, pallor, bradycardia, or hypotonia
113
Nursing interventions with preterm infant
-Working with respiratory equipment – nasal cannula, oxygen hood, cpap
-Positioning the infant – side-lying and prone facilitate (face down) drainage
-Supine to prevent Sudden infant death syndrome (SIDS) – get ready for home
-Suctioning secretions
-Maintaining hydration
114
Problems with thermoregulation in the preterm infant; nursing interventions
Neutral thermal environment – prevents need for increased oxygen
NTE varies according to gestational age (charts are used for regulation)
Incubators are used for those who do not need to be under radiant warmers
Weaning to open crib – each nicu has own protocol
Kangaroo Care – Skin to skin contact between sable preterm infant and parent, found safe even if intubated
Infant wears diaper and hat, placed in upright position
115
Preterm infants; issues with fluid and electrolytes
-Typically weigh diapers (wet diaper weight subtracted from dry)
-Check specific gravity of urine
-Weight
-Signs of dehydration or overhydration
Dehydration – low urine output ,1 ml/kg/hr, specific gravity >1.012, wt. loss, sunken anterior fontanel, dry skin and mucous membranes, poor tissue turgor
Overhydration – output >3 ml/kg/hr, specific gravity <1.005, edema, weight gain, bulging fontanels, moist breath sounds
116
Gavage feeding
Used for pre-term neonates who lack or have a poorly coordinated suck and swallow reflex, who are ill, or are ventilator dependent. Administered via nasogastric or orogastric route by intermittent bolus or continuous drip
Advantages – fewer days on TPN, Weight gain
TPN used when situation does not allow feeding through NG/OG tube
Calculations must take into consideration weight, postnatal age, calculations important
117
Nursing interventions for fluid and electrolyte imbalance
Careful IV fluid administration, assess IV site every hour, assess central lines or umbilical lines for infection and position changes, blood transfusions may be needed
118
Pain in the infant; assessment
changes in VS, “Cry face”, rigidity of extremities, flailing, eyes squeezed shut, furrowing of brow, high pitched cry, changes in sleep-wake pattern
119
Pain in the infant; interventions
Containment such as swaddling, positioning devices. Reduce handling before a painful procedure, nonnutritive sucking pacifier, sucrose on pacifier, talking soft, rocking. Speak with primary care provider for pain medication or topical anesthesia for procedures
120
Pre term infant respiratory distress syndrome
Caused by insufficient production of surfactant in the lungs, lungs become noncompliant or “stiff." Occurs most often in preterm infants under 28 weeks gestation
121
Respiratory distress syndrome s/s
Can begin first hours after birth: tachypnea, bradycardia, nasal flaring, cyanosis, retractions of accessory muscles, audible grunting on expiration, breath sounds diminished, crackles present
122
Therapeutic management and nursing considerations for RDS
Surfactant instilled into trachea shortly after birth or as soon as signs of RDS, oxygen, continuous cpap or mechanical ventilation, correction of acidosis, antibiotics, monitor glucose, monitor labs – abnormal blood gases
123
Bronchopulmonary dysplasia
Chronic condition, AKA Chronic Lung Disease
-Prolonged dependences on supplemental oxygen
-Damage to the infant’s lungs requires prolonged dependence on supplemental oxygen.
-Therapeutic management: steroids, antibiotics, and diuretics
124
Retinopathy of prematurity
Injury to the blood vessels in the eye may result in visual impairment or blindness in preterm infants.
Exact cause is unknown; high level of oxygen is a risk factor.
Nursing considerations – check pulse ox, oxygen titrated to keep within prescribed levels
125
Necrotizing enterocolitis
Serious inflammatory condition of the intestinal tract that may lead to cellular death of areas of intestinal mucosa. Can be caused by previous hypoxia of the intestines, feedings tat are too early or increased too fast
Manifestations: increased abdominal girth, decreased or absent bowel sounds, vomiting, bile-stained residuals or emesis, abdominal tenderness or discoloration, signs of infection
Therapeutic management: probiotics, antibiotics, gastric suction, surgery
Nursing considerations: assessment, vs, measure abdominal girth, encourage breastfeeding
126
Post term infants
Born after the 42nd week of gestation.
Placental functioning may decrease when pregnancy delayed, decreased amniotic fluid, compression of umbilical cord may occur, may have decreased oxygenation and nutrients (post-maturity syndrome).
Therapeutic management – prevention and symptomatic treatment: C-Section if needed, temperature regulation, hypoglycemia, may need early and more frequent feeding to help compensate for period of poor nutrition before birth
127
Small for gestational age (SGA) causes:
congenital abnormalities, infections, poor placental function, illness in mother, smoking, drug or alcohol abuse or severe maternal malnutrition
128
SGA poses risk for
Polycythemia, inadequate thermoregulation, hypoglycemia, meconium aspiration
129
SGA appearance
Low weight, smaller head circumference, body proportionate and normally developed, may appear long thin and wasted with dry, loose skin
Generally “catch up” in first 2 years
130
SGA management
Adapted to meet specific problems, accurate measurements, hypoglycemia, caloric needs greater because liver is small and has inadequate stores of glycogen, temperature regulation, respiratory support
131
Large for gestational age (LGA)
Greater than 8 lb 13 oz. Born to multiparas, mothers who are obese, Mothers who are diabetic
Nursing considerations: delivery problems, C-Section may be necessary
Assess for injuries – fractures of clavicle or skull, injury to facial nerve, subdural hematoma, bruising
Assess Complications: hypoglycemia, polycythemia
Treatment is geared to the presenting problem
