HESI Review

Erickson Psycho-Social Development 0-1 yr (Newborn) Trust vs. Mistrust 1-3 yrs (Toddler) Autonomy vs. Doubt and Shame Fear intrusive procedures - Security objects good (Blankies, stuffed animals) 3-6 yrs (Pre-school) Initiative vs. Guilt Fear mutilation Band-Aids good 6-12 yrs (School Age) Industry vs. Inferiority Games good, Peers important Fear loss of control of their bodies 12-19 yrs (Adolescent) Identity vs. Role Confusion Fear Body Image Distortion 20-35 yrs (Early Adulthood) Intimacy vs. Isolation 35-65 yrs (Middle Adulthood) Generativity vs. Stagnation Over 65 (Older Adulthood) Integrity vs. Despair Piaget Cognitive Development Sensorimotor Stage (0-2) Learns about reality and object permanence Preoperational Stage (2-7) Concrete thinking Concrete Operational Stage (7-11) Abstract thinking Formal Operational Stage (11-adult) Abstract and logical thinking Freud Psycho-Sexual Development Oral Stage (Birth -1 year) Self gratification, Id is in control and running wild Anal Stage (1-3) Control and pleasure wrt retention and pooping Toilet training in this stage Phallic Stage (3-6) Pleasure with genitals, Oedipus complex, SuperEgo develops Latency Stage (6-12) Sex urges channeled to culturally acceptable level, Growth of Ego Genital Stage (12 up) Gratification and satisfying sexual relations, Ego rules Kohlberg Moral Development Moral development is sequential but people do not aromatically go from one stage to the next as they mature Level 1 = Pre-conventional Reward vs. Punishment Orientation Level 2 = Conventional Morality Conforms to rules to please others Level 3 = Post- Conventional Rights, Principles and Conscience (Best for All is a concern) Bench Marks Birth wt doubles at 6 months and triples at 12 months Birth length increases by 50% at 12 months and doubles at 4 years Post fontanel closes by 8 wks Ant fontanel closes by 12-18 months Moro reflex disappears at 4 months Steady head control achieved at 4 months Turns over at 5-6 months Hand to hand transfers at 7 months Sits unsupported at 8 months Crawls at 10 months Walks at 10-12 months Cooing at 2 months Monosyllabic Babbling at 3-6 months, Links syllables 6-9 mo Mama, Dada + a few words at 9-12 months Throws a ball overhand at 18 months Daytime toilet training at 18 mo - 2 years 2-3 word sentences at 2 years 50% of adult Ht at 2 years Birth Length doubles at 4 years Uses scissors at 4 years Ties shoes at 5 years Girls growth spurt as early at 10 years Boys catch up ~ Age 14 Girls finish growing at ~15 Boys ~ 17

Nursing implications for toddlers (1-3 years) Temper tantrums are common and normal behavior Give simple brief instructions of procedures Forced separation from parents is their biggest threat Security or transitional objects should be encouraged Expect regression (bed wetting) Autonomy should be provided with choices

Nursing implications for the preschool child (3-6 years) Child stands erect with a more slender posture Thinking is egocentric & concrete A child learns sexual identity and masturbation is normal Imaginary playmates & fears are common Explain the child did not cause the illness and painful procedures are not punishments Therapeutic medical play with the equipment They need to be prepared for procedures and understand what is going to be fixed Pictures and dolls can be used

Nursing implications for the school age child (6-12) Maintaining school activities and social relationships with peers is important They learn by verbal explanations, pictures, books, and handling equipment Privacy & modesty are important and should be maintained

Nursing implications for the adolescent (12-19 years) They can problem solve & use abstract thinking Time when they form their own identity Rebelling against the family is common Teaching should include time with out the parents & if parents are present all questions should be

directed toward the adolescent The age for making own medical decisions ranges from 7-14 years The major concern is body changing and any procedure that will alter their appearances

Age Appropriate Toys Infants birth to 1 year (solitary play)

Mobiles Rattles Squeaking toys Picture books Balls Colored blocks

Toddlers (1-3 years) (parallel play) Boards and mallets Push-pull toys Toy phones Stuffed animals Story books with pictures

Preschoolers (3-6 years) (associative play) Coloring books Puzzles Cutting and pasting Dolls Building blocks Clay

School Age (6-12 years) (corporative play) Board & card games Hobbies and/or video games Puzzles

Immunizations (Hector Rayes did have pretty popular muscles varying high /school ) Hep B (3)

o Contraindicated in persons with anaphylaxis to backers yeast RV Rotovirus (3)

o IS a LIVE vaccine o Most common cause for diarrhea in infants & children

Dtap (diphtheria, tentanus, pertussis (5) o Administer separate site o Not given to kids past there 7th birthday o Contraindicated in kids with seizures or encephalopathy

HIB Hameophilus Influenza type B (4) o Protects against epiglotitis, bacterial meningitis, & septic arthritis o Given IM o No contraindications

PCN Pneumococal (4) o Used to protect against disease caused by bacteria, streptococcus

IPV Inactivated polio virus (4) o (OPV) Oral polio vaccine is a live vaccine that was given in 2000, OPV can not be given to kids

with HIV o IPV is a dead vaccine o Given sub-q or IM in a separate site o Contraindicated in people with an allergy to neomycin or streptomycin

MMR Measles, mumps, rubella (2) o Contraindicated in those allergic to eggs, neomycin, have immunodefiencies, or pregnant o Is a LIVE vaccine o Can be given to people with HIV & breast feeding mothers o Only injection Given Sub-q not IM o Child may develop a rash 2 weeks after administration

Varicella (2) o Protects against chicken-pox o Can not be given in children with HIV o Give MMR & varcella on the same day or within 30 days but in separate sites

Hep A (2) Tdap (x1 q 10 years , between 11-12) HPV (between 11-12) adminster the 2nd dose 1-2 months after the 1st & the 3rd dose 6 months after the

1st MCV4 Meningococcal (between 11-12) Influenza (IIV;LAIV) Flu- is given at 6 months of age then annually

o Is a LIVE vaccine o Contraindicated in persons with an allergy to eggs

The common cold is NOT an contraindication for immunizations Avoid Live Virus vaccines while taking prednisone (MMR, Flu, Varicella, RV Rotavirus, & Oral Polio Vaccine, Poliovirus the IPV is a dead vaccine) Hepatitis Hepatitis: -ends in a VOWEL, comes from the BOWEL (Hep A) Hepatitis B=Blood and Bodily fluids Hepatitis C is just like B

Immunization Chart Vaccines AGES Total

Amount HEP B Birth 1-2 months 6-18 months 3

RV ROTAVIRUS 2 months 4 months 6 months 3

Dtap 2 months 4 months 6 months 15-18 months 4-6 years 5

HIB 2 months 4 months 6 months 12-15 months 4

PCV13 PNEUMOCCAL

2 months 4 months 6 months 12-15 months 4

IPV INACTIVATED POLIO VIRUS

2 months 4 months 6-18 months 4-6 years 4

MMR 12-15 months 4-6 years 2

Varicella (VAR) 12-15 months 4-6 years 2

HEP A 12-23 < 6 months later 2

Immunization Side Effects T < 102, redness and soreness at injection site for 3 days give Tylenol and bike pedal legs (passively) for child.

Child Nutrition Assessment Nutrient Signs of Deficiency Food Sources Iron Anemia

Pale conjunctiva Pale skin color Atrophy of papillae on tongue Brittle, rigid, spoon like nails Thyroid edema

Iron-fortified formula Infant high-protein cereal Infant rice cereal Liver Beef Pork Eggs

Vitamin B2 (Riboflavin)

Redness & fissuring of eyelid coroners; burning itching, tearing eyes, photophobia

Magenta-colored tongue, glossitis Seborrheic dermatitis, delayed wound

healing

Prepared infant formula Liver Cows milk Cheddar cheese Some green leafy vegetables (broccoli, green

beans, spinach) Enriched cereals

Vitamin A (Retinol)

Dry, rough skin Dull, soft, cornea. Bitot spots Night blindness Defective tooth enamel Retarded growth Impaired bone formation Decreased thyroxine formation

Liver Sweet potatoes Carrots Spinach Peaches Apricots

Vitamin C (Ascorbic Acid)

Scurvy Receding, bleeding gums Dry rough skin, petechie Decreased wound healing Increase susceptibility to infection Irritability, anorexia, apprehension

Strawberries Oranges and orange juice Tomatoes Broccoli Cabbage Cauliflower Spinach

Vitamin B6 (Pyridoxine)

Scaly dermatitis Weight loss Anemia Irritability Convulsions Peripheral neuritis

Meats, liver chicken Cereals (wheat & corn) Yeast & Soybeans Peanuts Tuna Bananas

Communicable diseases in children 1. Rubella (measles)

Airborne precautions (private negative pressure room, need N95 mask) Children with Rubella = threat to unborn siblings (may require temporary isolation from Mom

during pregnancy) Contagious viral disease that can lead to neological problems Transmitted by direct contact with infected persons Symptoms

o Photophobia o Koplik spots on the buccal mucosa o Confluent rash that begins on the face and spreads downward

2. Varicella (chicken pox) CHICKEN POX Vesicular Rash (central to distal) dew drop on rose petal Airborne precautions

NORMAL CHILD VALUES ACCORING TO AGE **** Age Pulse Respirations Nursing Implications Newborn 1-11 months 1-3 years (toddler) 3-5 years (preschooler) 6-10 years (school age) 10-16 years (adolescent)

100-160 100-150 80-130 80-120 70-110 60-90 (HR in children increases with crying or if the child has a fever)

30-60 25-35 20-30 20-25 18-20 16-20

These ranges are averages only & vary with age, sex, and condition of the child. Always note whether the child is crying, febrile, or in some distress

Diarrhea and dehydration usually occurs in infants history of exposure to pathogens contaminated food or dietary changes

Signs and symptoms of dehydration poor skin turgor absence of tears dry mucous membranes weight loss of 5% to 15% depressed fontanelles decrease urinary output with increase specific gravity Loss or low potassium & sodium levels elevated hematocrit (HCT) & BUN

Nursing interventions do not take temperatures rectally check stools for pH, glucose, & blood oral rehydration solutions such as Pedialyte or Lytren children should not receive antidiarrheals (Imodium A-D) do not give the child grape juice, orange juice, apple juice, cola, or ginger ale. These solutions have high

osmolarity Signs and symptoms of shock

decrease blood pressure rapid weak pulse mottled to gray skin color changes in mental status

Fluids are given to a child with an increases respiratory rate to prevent dehydration & acid-base imbalances

Burns In children the greater central body surface area is concentrated in the head & trunk. Therefore a young

child is more likely to have more serious effects from burns to the head & trunk. Children have a greater fluid volume (proportionate to size) less effective cardiovascular responses to fluid volume shifts to estimate the percent of Burns and a child the Lund-Brower chart should be used to account for the

changing proportions of the child the Parkland formula is a commonly used guideline for calculating fluid replacement and maintenance

o 4 x Weight in kg x %BSA burned Then divided by 2 so half of the amount of fluid is given in the 1st 8 hours the rest is given over 16

Adequacy Of Fluid Replacement Is Determined By Evaluating Urine Output o Urine output for infants and children should be 1 to 2ml/kg/hr**** o Normal Specific Gravity Of Urine is 1.005 to 1.030 o SG is a measurement of hydration status

over hydration - will have a low specific gravity and means the urine is more dilute dehydration- will have a higher specific gravity and means their urine is more

concentrated Poisoning

use of IPECAC is no longer recommended by the AAOP induce vomiting is not recommended because it may cause more damage poison removal may require

o gastric lavage o activated charcoal o Naloxone HVL (Narcan)

Tylenol poisoning/overdose liver failure possible for about 4 days. Close observation required during this time-frame, as well as tx with Mucomyst.****

Respiratory disorders Signs of Respiratory Distress in Children *****

1. Cardinal Signs a. Restlessness b. Increased respiratory rate (tachypnea) c. Increased pulse rate (tachycardia) d. Diaphoresis

2. Other signs of respiratory distress a. Flaring nostrils Retractions b. Retractions Grunting c. Adventitious breath sounds (or absent breath sounds)

i. Discontinuous sounds 1. Fine Crackles- are soft, high pitched, & brief 2. Course Crackles (rales) - are louder, lower pitched, and longer

ii. Continuous Sounds 1. Wheezes- High pitched, (asthma is wheezing on EXPIRATION) become

concerned when the wheezing child stops wheezing 2. Ronchi- low pitched snoring sound

d. Use of accessory muscles, head bobbing e. Alterations in blood gasses: decreased PO2, elevated Pco2

Primary meds for ER for respiratory distress Sus-phrine (Epinephrine HCl) Theophylline (Theo-dur) Bronchodilators

Types of respiratory disorders in this unit Asthma Bronchiolitis (RSV) Cystic Fibrosis Otitis Media Epiglottitis Tonsillitis

1. Asthma- inflammatory reactive airway disease that is commonly chronic The airways become edematous the airways become congested with mucus the smooth muscle of the bronchi & bronchioles constrict air trapping occurs in the alveoli

Signs and symptoms Tight nonproductive cough Breath sounds: coarse expiratory wheezing, rales. Crackles Chest diameter enlarges Watch out if your wheezer stops wheezing. It could mean he is worsening. If the patient with as Asthma has intercostal retractions--be concerned

Treatments When using a bronchodilator (such as Albuterol, Singulair, Theophylline) inhaler inconjuction with a

glucocorticoid inhaler (Flovent, Qvar,) administer the bronchodilator first Theophylline increases the risk of digoxin toxicity and decreases the effects of lithium and Dilantin

INtal, an inhaler used to treat allergy induced asthma may cause bronchospasm, think INto the asthmatic lung

2. Cystic fibrosis (CF) Group B Strep (GBS) bacteria GBS is found in the vagina and/or lower intestines. It usually causes no symptoms and is not harmful to adults. If a pregnant woman has a positive GBS culture, she can transfer the bacteria to her baby during childbirth, increasing risk for CF

CF is an autosomal recessive disease that causes dysfunction of the exocrine glands provided to the child by each parent

Signs and symptoms o The first sign of cystic fibrosis may be meconium ileus at birth. Baby is inconsolable, do not eat,

not passing meconium. o Recurrent respiratory infections o pulmonary congestion o Steatorrhea excessive fatty greasy stools, foul-smelling and bulky stools o Diagnosed with a sweat test

Cystic Fibrosis give diet moderate to high fat, high in calories, high protein, moderate to low carbohydrates

Fat soluble vitamins ADEK. Aerosal bronchodilators, Skin Tastes Salty = Cystic Fibrosis Administer pancreatic enzymes with meals (Pancrease, Cotazyme-s)

3. Epiglottitis ** Caused by: H. influenza B Signs and symptoms

Child sits upright with chin out and tongue protruding (maybe Tripod position) Prepare for intubation or trach

Restlessness & high fever sore throat dysphagia -difficulty swallowing drooling with a muffled voice

DO NOT put anything into kids mouth, never examine the throat of a child with epiglottitis because of the risk of obstructing the airway completely

4. Otitis Media increases chances for conductive hearing loss later in life Signs and symptoms

o fever and pain o infant may be pulling at the ear o enlarged lymph nodes o discharge from the ear (if the drum is ruptured) o upper respiratory symptoms o vomiting diarrhea

Nursing Interventions o Pull pinna down and back for kids < 3 yrs. when instilling eardrops.dminister antibiotics is

prescribed o reduce body temperature (fever can go so high it places the child at risk for seizures)

Tepid baths Acetaminophen (Tylenol)

o position the child on the affected side o provide comfort with warm compress on the affected ear

5. Tonsillitis- Cause: usually Strep Important to know if this was caused by Strep because the patient is at greater risk for developing 1. Glomerulonephritis 2. Rheumatic heart disease/ Rheumatic fever Interventions

Get PT and PTT Pre-Op (ask about Hx of bleeding) No red liquids & no straws Post-op, Ice collar, soft foods Highest risk of hemorrhage = first 24 hrs and 5-10 days post-op (with sloughing of scabs)

Suspect Bleeding Post-Op if frequent o Swallowing o Vomiting blood o Clearing throat

No red liquids, no straws, use ice collar for pain and comfort, and only eat soft foods Highest risk of hemorrhage = first 24 hrs and 5-10 days post-op (with sloughing of scabs)

6. Bronchiolitis Cause Respiratory syncytial virus (RSV)

Isolate RSV patient with Contact Precautions Private room is best Use Mist Tent to provide O2 and Ribavirin Flood tent with O2 first and wipe down inside of tent periodically so you can see patient

No contact lenses or pregnant nurses in rooms where ribavirin is being administered by hoot, tent, etc Cardiovascular Disorders 1. Acyanotic = VSD (ventricular septal defect), ASD (atrial septal defect) , PDA (patent ductus arteriosus) Coarc of Aorta, AS Aortic Stenosis

left to right shunts or increase pulmonary blood flow obstructive defects

Has abnormal circulation however all blood entering the systemic circulation is oxygenated Antiprostaglandins cause closure of PDA (aorta - pulmonary artery)

Cyanotic = Tetralogy of Fallot, Truncus Arteriosis (one main vessel gets mixed blood), TVG (Transposition of Great Vessels) Polycythemia (increased amounts of hemoglobin) is common in Cyanotic disorders

right to left shunts or decrease pulmonary blood flow with mixed blood flow has abnormal circulation with unoxygenated blood entering the systemic circulation 3 Ts of Cyanotic Heart Disease (Tetralogy, Truncus, Transposition)

Cyanotic = Tetralogy of Fallot, Truncus Arteriosis (one main vessel gets mixed blood), TVG (Transposition of Great Vessels) Polycythemia (increased amounts of hemoglobin) is common in Cyanotic disorders

right to left shunts or decrease pulmonary blood flow mixed blood flow has abnormal circulation with unoxygenated blood entering the systemic circulation 3 Ts of Cyanotic Heart Disease (Tetralogy, Truncus, Transposition)

Tetralogy of Fallot Unoxygenated blood pumped into aorta, consists of 4 defects Pulmonary Stenosis VSD Overiding Aorta Right Ventricular Hypertrophy

TET Spells Hypoxic episodes that are relieved by squatting or knee chest position. They also can be treated with morphine. Congestive Heart Failure (CHF) can result

Use Digoxin Therapeutic range = 0.8-2.0 for kids********* Given on empty stomach one hour before meals or two hours after, do not mix digoxin with food or

formula You better pick do vitals before administering that dig. (apical pulse for one full minute). Signs and symptoms of early Digoxin toxicity

Nausea Vomiting other G.I. symptoms including anorexia, diarrhea, abdominal pain neurological signs including fatigue, muscle weakness, and drowsiness Hypokalemia- can increase digoxin toxicity

provide a diet low in sodium Aortic Stenosis- abnormal narrowing immediately before or after they aortic valve Ductus Arteriosus = Abnormal opening from the Aorta to the Pulmonary Artery Rheumatic Fever Cause: Group-a beta hemolytic strep infection

Most common cause of Acquired Heart Disease It Affects: the aortic and mitral valves

Signs and Symptoms Fever Chorea is part of this sickness (grimacing, sudden body movements, etc.) and it embarrasses kids. Elevated antistreptolysin O (ASO) & ESR to be elevated. Erythema Marginatum = Rash Chest pain, shortness of breath, (carditis) Tachycardia even during sleep Migatory large-joint pains

Treatment of Rheumatic Fever with Penicillin G = Prophylaxis for recurrence of RF Aspirin for anti-inflammatory and anticoagulant actions Kawasaki Disease

Coronary artery aneurysms due to the inflammation of blood vessels. Cause of the disease is unknown usually seen in children younger than five has three phases the acute, subacute, convalescent early treatment is essential to decrease chances of permanent or damage extreme irritability is seen in the child during the entire disease process

Acute Phase: high fever or for more than five days conjunctival redness with the strawberry tongue read swollen hands and feet

Subacute Phase pealing of the hands and feet

Convalescnet Phase starts when all the signs are gone and ends when lab values have returned to normal

Treatment administer intravenous immunoglobulin (IVIG) treat high fevers with acetaminophen and aspirin monitor cardiac status by documenting the childs

1. intake and output 2. daily weights

minimize skin discomfort with lotions and cool compresses initiate meticulous mouth care monitor the intake of clear liquids and soft foods

Neuromuscsular Disorders Down Syndrome

Trisomy or translocation of chromosome 21 Physical characteristics

o flat broad nasal bridge o inner epicanthal eye folds o upward outward slant of the eyes o protruding tongue o short neck o transverse Palmer crease (sinmian) o hyperexpendable and lacks joints (hypotonia)

Common associated problems o cardiac effects o respiratory infections o feeding difficulties o delay developmental skills o mental retardation o skeletal defects o altered immune function o endocrine dysfunction

Cerebral Palsy (CP) nonprogressive injury to the motor centers of the brain causing neuromuscular problems of spasticity or

dyskinsia (involuntary movements) Causes

1. anoxic injury before during or after birth 2. maternal infections 3. kernicterus 4. low birth weight (major risk factor)

Signs & Symptoms persistent neonatal reflexes (moro, tonic neck) after six months delayed developmental milestones and apparent early preference for one hand poor suck, tongue thrust, spasticity scissoring of legs (legs are extended and crossed over each other, & feet are plantar flexed)

Spina Bifida Meningocele- a sac that is present at some point along the spine that contains only meninges and spinal

fluid that has less neurologic involvement than a myelomeningocele Myelomeningocele is more severe than a meningocele because a sac contains spinal fluid, meninges,

and nerves. Every child with a history of spina bifida should be screened for latex allergy (mainly fruits)

o Fruits (and seeds) involved in this syndrome include banana, pineapple, avocado, chestnut, kiwi fruit, mango, passionfruit, fig, strawberry, soy, Potato, Tomato, Pineapple, Papaya, Eggplant, Melon, Wheat, and Cherimoya

Nursing interventions Keep the sac free from urine and stool cover the sac with moist sterile dressing Place the child in the Prone Position to keep pressure off the sac

Hydrocephalus- abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain causing An increase in intracranial pressure (ICP). **Signs and symptoms of increased ICP are the direct OPPOSITE from SHOCK ** Signs and symptoms of hydrocephalus or increased ICP (Cushings Triad)

1. Decreased pulse rate (bradycardia) 2. Decreased respiratory rate (Bradypnea) 3. Increased blood pressure (hypertension)

Signs and symptoms of Shock 1. Increased heart rate (tachycardia) 2. Increased respiratory rate (Tachypnea) 3. Decreased blood pressure (hypotension) Remember the O in shOck stands for Hypotension

Other symptoms of Hydrocephalus or increased ICP in CHILDREN 1. change in level of consciousness (LOC) = most important indicator of increased ICP 2. irritability 3. vomiting 4. headache on awakening 5. motor dysfunction 6. unequal pupil response 7. seizures 8. widened pulse pressure 9. Bossing sign (prominent forehead) 10. Even subtle changes in mood, behavior, restlessness, irritability, decline in academics, changes in

personality or confusion may indicate increased ICP 11. Watch for CSF leaks from nose or ears Leakage can lead to meningitis and mask intracranial injury

since usual increased ICP symptoms may be absent. Other symptoms of Hydrocephalus or increased ICP in INFANTS

1. irritability, lethargy 2. increased head circumference 3. bulging fontanels 4. widening suture lines 5. sunset eyes 6. high-pitched cry

Nursing interventions for Increased ICP 1. monitor for further signs of IICP 2. maintain seizure precautions 3. elevate head of bed

Treatment: Peritoneal Shunt

1. Shunt is inserted into ventricle 2. Tubing is tunneled through skin to peritoneum where it drains excess CSF

Postoperative Care 1. After the shunt is placed- bed position for the patient is FLAT, so that fluid does not reduce too rapidly. Only if you see S&S of increasing ICP does the head of the bed become elevated to 15-30 degrees

2. Assess for signs of shunt malfunction but DONT pump the shunt, that can put pressure on the ventricles a. Infants:

1. change in size, signs of bulging, tenseness in fontanels, & separation of suture lines 2. irritability, lethargy, or seizure activity 3. altered VS and feeding behavior

b. Older children: increased ICP 1. changes in LOC (#1 most important sign of IICP) 2. headache 3. changes in customary behavior (sleep or developmental capabilities)

Family Teaching 1. Teach to watch for signs of increased ICP 2. Note the child will outgrow the shunt and will need a revision, the child may shows signs of increased

ICP when he/she is beginning to outgrow it. Advise the pt to bring the child in when this occurs. 3. provide anticipatory guidance for potential problems with growth & development

Other signs of Shock Mental Status

o Early Shock- restless, hyperalert o Late Shock- decreased alertness, lethargy, coma

Skin Changes o Cool, clammy skin o Diaphoresis o Paleness

Fluid status Changes o Urine output decreases, or an imbalance between I&O occurs o Central venous pressure is abnormal o A urine specific gravity > 1.020 indicates hypovolemia

Shock- widespread serious reduction of tissue perfusion (lack of O2 & nutrients) Those at risk for the development of shock

1. very young & very old 2. post-MI clients 3. Clients with severe dysrhythmias 4. Clients with adrenocortical dysfunction 5. Persons with a recent history of hemorrhage or blood loss 6. Clients with Burns 7. Clients with massive overwhelming infections

Types of shock 1. Hypovolemic- related to blood loss (most common cause of shock) 2. Cardiogenic- related to ischemia or impairment in tissue perfusion from MI, serious arrhythmia, or

heart failure. All of these resulting in cardiac output. a. If cardiogenic shock occurs in the presence of Pulmonary edema (e.g. from pump failure)

position the client to reduce venous return. (HIGH FLOWLERs with LEGS DOWN) to decrease further venous return to the left ventricle.

3. Distributive- (Anaphylactic, Neurogenic, & Septic Shock) results from excessive vasodilation & the impaired distribution of blood flow

4. Obstructive- physical obstruction related to tamponade, emboli, compartment syndrome, that impedes the filling or outflow of blood resulting in reduced cardiac output

All types of shock can lead to systemic inflammatory response syndrome (SIRS) & result in multiple organ dysfunction syndrome (MODS)

Medical Treatments & nursing interventions for Shock

1. Oxygen & Ventilation corrects decreased tissue perfusion and restores cardiac output 2. Fluid Resuscitation (rapid infusion of volume-expanding fluids in: hypovolemic & anaphylactic shock) 3. Drug Therapy:

Drugs that increase cardiac Preload- blood products & crystalloids) Drugs that decrease preload (morphine, nitrates, diuretics) Drugs that increase Afterload (vasopressors, dopamine) Drugs that Decrease Afterload (nitroprusside, ACE-I, ARB) Drugs that decrease contractility (beta blockers, calcium channel blockers,) Drugs that Increase contractility (digoxin (lanoxin) dobutamine)

Seizures Nursing Interventions Maintain airway Nothing in the mouth, no padded tongue blades. That will cause more damage to the oral cavity Dont restrain Keep safe, support the head Turn head to the side

Maintain seizure precautions reduce environmental stimuli pad side rails or crib rails have suction equipment in oxygen quickly accessible table oral airway to the head of the bed

Treatment: Antivonvulsants- Phenobarbitol (Luminol), Phenytoin (Dilantin: Therapeutic Range = 10-20 Gingival Hyperplasia), Fosphenytoin (Cerebyx), Valproic Acid (Depakene), Carbamazepine (Tegritol)

Medication noncompliance is the most common cause of increased seizure activity Performing an EEG EEG, hold meds for 24-48 hrs prior, no caffine or cigarettes for 24 hrs prior, pt can eat, pt must stay awake night before

exam, pt may be asked to hyperventilate and watch a bright flashing light, after EEG, assess pt for seizures, pt's will be at increased risk.

Bacterial Meningitis bacterial inflammation of the meninges that cover the brain and spinal cord Place on droplet precautions Isolate for 24 hours implement seizure precautions elevate the head of the bed and position the patient on the side measure head circumference and I&O ** monitor hydration status and IV therapy- bacterial meningitis can lead to SIADH (over

production of ADH aka Vasopressin) causes you to retain too much water (fluid overload) in the body causes blood serum to become diluted causing Hponatremia *****

SIADH (increased amounts of ADH) signs & symptoms change in LOC, decreased deep tendon reflexes tachycardia n/v/a,

Signs and symptoms of Hyponatremia ** nausea muscle cramps

increased ICP muscular twitching convulsion

Causes Haemophilus influenza type B Streptococcus pneumoniae Neisseria meningitis

Signs and symptoms classic signs of increased intracranial pressure (hypertension, bradycardia, bradypnea) fever and chills neck stiffness-opisthotonus & photophobia Positive Kernigs sign (leg flex then leg pain on extension) Positive Brudzinski sign (neck flex =lower leg flex).

Diagnostic Lumbar Puncture of bacterial meningitis Shows increased WBC increase proteins increased ICP decreased glucose

Avoid further increasing of ICP by not suctioning coughing straining turning

Reye syndrome acute rapidly progressing encephalopathy and hepatic dysfunction Causes:

o viral infections such as influenza or chickenpox o aspirin use

Muscular Dystrophy Progressive muscle atrophy & weakness Duchenne muscular dystrophy is an X-linked recessive disease affecting primary males

A X-linked recessive chromosome disorder works by the mother being a carrier but only her sons may express the disease.

its rapidly progressing causing cardiac and respiratory complications and death by 25 years old X-linked Recessive Signs and symptoms Waddling gait hyper lordosis Gowers Sign = difficulty rising walks up legs (like Minors sign), fat pseudohypertrophy of calves.

Anticonvulsants Drugs/routes Indications Adverse Reactions Nursing Implications Phenobarbital (Lumunal) PO,IM,IV

Tonic-clonic & partial seizures

Is the longest acting of common barbiturates

Usually combined with other drugs

Drowsiness Nystagmus (uncontrolled movements of the

eyes) Ataxia (loss of full control of bodily

movements) Paradoxic excitement

Therapeutic levels: 15 to 40 mcg/ml Avoid rapid IV infusion Monitor BP during IV infusion

Phenytoin (Dilantin) PO, IV

Tonic-clonic & partial seizures

Gingival hyperplasia Nausea, anorexia Dermatitis Bone marrow depression Ataxia Nystagmus

Therapeutic levels: 10 to 20 mcg/mL Monitor any drug interactions Do not administer with milk Ensure meticulous oral hygiene Monitor CBC Report any rashes to HCP For IV infusion flush the line before &

after medication administration with normal saline only

Fosphenytoin Sodium (Cerebyx) IM, IV

Generalized convulsive status epilepticus

Prevention & treatment of seizures during neurosurgery

Short-term parenteral replacement for (Dilantin)

Rapid IV infusion can cause hypotension Severe: ataxia, CNS toxicity, confusion,

gingival hyperplasia, irritability, lupus, nervousness, nystagmus, paradoxic excitement,

Steven-Johnsons syndrome, toxic epidural necrosis

Prior to IV infusion, dilute in D5W or NS to administer

Infuse a rate of no more than 150mg PE/min

Valproic Acid (Depakene) PO

Absence seizures Myoclonic seizures

Hepatoxicity, especially in children under 2 Prolonged bleeding times GI disturbances

Therapeutic levels: 50-100mEq/ml Monitor liver function Potentiates Phenobarbital and

Dilantin, altering blood levels Carbamazepine (Tegretol) PO

Tonic-clonic, mixed seizures Drowsiness Ataxia

Hepatitis Agranulocytosis

Therapeutic levels: 6 to 12mcg/ml

Lamotrigine (Lamictal) PO

Partial seizures Tonic-clonic seizures Absence seizures

Dizziness Rash Headache Nausea

Withhold if rash develops Do not discontinue drug abruptly

Clonazepam (Klonopin) PO

Absence seizures Myoclonic seizures

Drowsiness Hyperactivity Agitation Increased Salvation

Therapeutic levels: 20-80mcg/ml Do not discontinue drug abruptly Monitor liver function, CBC, & renal function periodically

fvd V Dfv df D Sfdv Sdfv Sfv D Fv Dv Sd

Comparison Of Acute Glomerulonephritis & Nephrotic Syndrome Variables Acute Glomerulonephritis Nephrotic Syndrome Cause Follows Streptococcal Infection Usually Idiopathic Edema Mild, usually around the eyes Severe, generalized Blood Pressure Elevated Normal Urine Dark, tea-colored (hematuria) Dark, frothy yellow Protein in the urine Sight to moderate Massive amounts Blood Normal serum protein

Positive ASO titer Decreased serum protein Negative ASO titer

Medications Used in Renal Disorders Drugs/Route Indications Adverse Reactions Nursing Implications Bethanechol Chloride (Urecholine) PO, IM, IV

Cholinergic used to treat: Urinary retention Neurogenic Bladder Gastric reflux

Orthostatic hypotension Flushing Asthmatic reaction GI distress

Do not give IM or IV Monitor VS Preferably given on an empty stomach

Prednisone (Deltasone) PO

Adrenocorticosteriod used to treat: Immunosuppression (acts as antiiflammatory) Edema (promotes diuresis in nephrotic syndrome)

o Mood changes o Increased susceptibility to

infection o Cushingoid appearance (moon face & buffalo hump) o Acne o GI distress o Thrombocytopenia (low platelets) o Edema o Potassium loss o Growth failure in children

o In children, every other day administration is best to avoid growth failure when drug is taken long term o Discontinuing this drug requires tapering o Avoid Live Virus vaccines while taking prednisone (MMR, Flu, Varicella, RV Rotavirus, & Oral Polio Vaccine, Poliovirus the IPV is a dead vaccine)

o Oxybutynin (Ditropan) PO or Transdermal o Tolterodine (Detrol) PO

Genitourniary smooth-muscle relaxants (antispasmodics) used to treat:

Uninhibited neurogenic bladder

Reflux urogenic bladder Both are characterized

by voiding symptoms of urgency, frequency, nocturia & incontinence

o Increased susceptibility to UTI

o GI distress o Dry mouth o Vision changes o Dizziness o Chest pain o Drowsiness

o Administer orally: available in extended release forms

o Do not administer with other meds that have any other anticholinergic effects

o May exacerbate reflux esophagitis o Contraindicated in pt with untreated glaucoma

or any GI narrowing (GI obstruction may occur) o Safety for use in children has not been

established

Gastrointestinal Disorders 1. Cleft lip or Palate

initial surgery to close the cleft lip begins when 1. the child weighs 10 pounds or more 2. has a hemoglobin (HGB) of at least 10g/dl

Nursing implications Maintain proper airway Position on back or in infant seat to prevent trauma to suture line. Never lie the child prone While feeding, hold in upright position. Post-Op Place on side clean the suture site with sterile water after feedings-residual formula may impede healing and lead to

infection Protect the surgical site

maintain Logan Bow, Apply elbow restraints minimize crying

2. Esophageal Atresia with Tracheoesophageal Fistula (TEF) congenital anomalies in which the esophagus is not fully developed this is considered a clinical and surgical emergency

Nursing assessments 4 Cs of TEF in the newborn

1. choking 2. coughing 3. cyanosis 4. continuous drooling

excess salvation respiratory distress aspiration pneumonia

3. Pyloric stenosis narrowing of the pyloric canal, the sphincter hypertrophies to twice its normal size Nursing assessment

1. palpable Olive shaped mass in the upper right quadrant 2. mild vomiting (free from bile) that progresses to projectile 3. May spit up after feedings

Post-operative interventions 1. position the patient on the right side and semi-Fowler position after feedings 2. burp frequently to avoid stomach becoming distended and putting pressure on the surgical site

4. Intussusception telescoping of one part of the intestine and to another part usually the ileum into the colon

(ileocolic) partial or complete bowel obstruction occurs bowel vessels become trapped causing necrosis

Nursing assessment 1. Currant jelly stools (mixed with blood and mucus) 2. sausage shaped mass in the upper right quadrant while the lower quadrant is empty 3. common in kids with cystic fibrosis CF

Treatments 1. first attempt is a barium enema to hydrostatically reduce the telescoping of the intestines, if

successful in 2:3 cases. If not successful than surgical repair will be implemented a. resolution is obvious with the onset of a bowel movement

5. Congenital Aganglionic Megacolon AKA Hirschsprungs Disease absent autonomic parasympathetic ganglion cells in the distal portion of the colon and rectum causing:

1. absent peristalsis 2. fecal contents to accumulate above the aganglionic area of the bowel

Signs and Symptoms The initial sign is infants who fails the pass meconium within 24 hours of birth ribbon like stools and foul smelling stools a later seen in the older child

Signs of bowel perforation abdominal distention and vomiting irritability dyspnea and cyanosis

Diagnosis is made with rectal biopsy looking for absent ganglionic cells

Treatment before and after the procedure only axillary temperatures can be taken usually involves series of surgical procedures

i. a temporary colostomy will be applied ii. and later a reanastomsis and closure of the colostomy occurs

Hematologic Disorders LAB REVIEW ******

***Normal aPTT is within 30-40 seconds**(1.5-2.5X normal or control for heparin therapy 45-100 minutes) ****Normal PTT is within 60-70 Seconds* (1.5-2.5X normal or control for heparin therapy 90-175 minutes) Sed rate ESR: Males up to 15, females up to 20 rate is also increased during pregnancy, child up to 10, newborn put to 2. PT normal 11-12.5 seconds but just slightly lower in pregnancy (1.5-2X normal or control for Coumadin therapy 16.5-25) INR International normalized Ratio Normal: 0.8-1.1. Used to monitor anticoagulation therapy. INR Must be individualized

1. Iron Deficiency Anemia hemoglobin & RBC levels below normal range because of the body is an adequate supply, intake, or absorption of iron.

The need for iron is greater in children than adults because of accelerated growth Possible causes for iron deficiency anemia

inadequate stores during fetal development deficiency dietary intake chronic blood loss poor utilization of iron by the body

Nursing Assessment/ Signs & Symptoms pallor or paleness of mucous membranes tiredness and fatigue usually seen in infants 6 to 24 months old toddlers and female adolescent most affected overweight cows milk babies. Milk intake greater than 32 ounces a day low dietary intake of iron Lab Values

1. decreased hemoglobin Hgb 2. low serum iron level 3. elevated total iron binding capacity T IBC

Remember The Hemoglobin (Hgb) Norms Of The Following newborn 14 to 24 g/dL infant 10 to 17 g/dL child 9.5 to 15.5 g/dL

Nursing planning and interventions 1. support the childs need to limit activities 2. provide rest periods 3. administer oral iron (ferrous sulfate) as prescribed

Teach the family about administration of oral iron give on empty stomach-as tolerated because its better for absorption give with citrus juices such as vitamin C for increased absorption use dropper or straw to avoid discoloring teeth teach that stools will become tarry teach the iron can be fatal in severe overdoses. Keep away from other children do not give iron with any dairy products

Teach nutritional facts regarding iron limit milk intake to less than 32 ounces a day teach about dietary sources of iron

o meet o green leafy vegetables o fish o liver o whole grains o legumes o for infants: iron fortified cereals and formula

2. Sickle Cell Anemia inherited autosomal recessive disorder of hemoglobin (Hgb) known as HgbAS it occurs primarily in persons of African in eastern Mediterranean descent usually appears after six months Hemoglobin S (HgbS)- replaces all or part of the normal hemoglobin, which causes the red blood cells to sickle when oxygen is released into the tissues.

1. Sickle cells cannot flow through capillary beds 2. Dehydration promotes sickling 3. HgbS has a left their normal lifespan which leads to chronic anemia 4. tissue ischemia causes widespread pathologic changes in the spleen, liver, kidneys, bones, and

central nervous system. Signs and symptoms

frequent infections or nonfunctional spleen tiredness chronic hemolytic anemia delayed physical growth Vaso-occlusive crisis AKA Sickle Cell Crisis the classic signs are:

1. fever 2. severe abdominal pain 3. hand-foot syndrome (in infants) causing painful edematous hands and feet 4. arthralgia (joint pain) 5. leg ulcers (adolescents) 6. cerebovascular accidents (CVA, stoke) increased risk with dehydration

Hydration- is most important in the treatment of sickle cell disease because it promotes hemodilution and circulation of red blood cells through the blood vessels.

Nursing interventions for Sickle Cell Teach the family how to prevent sickle cell crisis (hypoxia)

keep the child from exercising strenuously keep the child away from high altitudes avoid letting the child become infected, and seek care at first signs of infection use prophylactic penicillin as prescribed keep the child well hydrated withhold fluids at night because enuresis is a complication of both the disease and treatment

Interventions for the hospitalized patient with a vaso-occlusive crisis/sickle cell crisis The two main interventions during a sickle cell crisis

1. Fluids: administer IV fluids and electrolytes as prescribed to increase hydration treat acidosis 2. Pain relief: administer analgesics

Do not give demerol to pts. with sickle cell crisis parenteral morphine for pain is given

use a warm compress for comfort (not ice) Administer blood products as prescribed Administer pneumococcal vaccine, meningococcal vaccine, Hib as prescribed. Administration of hep B

vaccine is prescribed because the child is at risk because of blood transfusion. Supplemental iron is not given to clients with sickle cell anemia. The anemia is not caused by iron

deficiency. Folic acid is given orally to stimulate red blood cell synthesis. Thrombocytopenia (low platelets > 150,000 Normal platelets 150,000- 400,000) ****

Can be seen in Sickle cell anemia, but most often seen in Aplastic Anemia Also seen in Hemophilia Signs and symptoms of Bleeding

Anemia- Deficiency of erythrocytes (RBC) causing a low Hematocrit (Hct) and a low Hemoglobin (Hgb) Normal Hgb (males: 14-18, females 12-16, pregnancy >11)

Children 1-6 years 9.5-14 6-18 years 10-15.5

Normal Hct (males: 42-52%, females 37-47%, pregnancy >33%) Children 1-6 years 30-40% Children 6-18 years 32-44%

Treatment of Sickle Cell with Rest & Hydration Hydroxyurea, for sickle cell any reports of GI symptoms immediately could be sign of toxicity

Acute Lymphocytic Leukemia (low WBC > 5,000) Normal WBC 5,000-10,000 *** Normal WBC in children

Signs and Symptoms of Lymphocytic Leukemia

Pallor, tiredness, weakness, and lethargy due to anemia Petechiae, bleeding, bruising, due to thrombocytopenia Infection, fever due to neutropenia bone joint pain due to leukemic infiltration of bone marrow enlarged lymph nodes; hepatosplenomegaly (enlargement of the liver and spleen) headache and vomiting with anorexia and weight loss lab data: bone marrow aspiration that reveals 80 to 90% immature blast cells

Nursing interventions Lymphocytic Leukemia recommend a private room reverse isolation is prescribed administer and monitor for side effects of chemotherapy have epinephrine oxygen readily available to treat anaphylaxis when administering L-asparaginase

3. Hemophilia- is an inherited bleeding disorder transmitted by an X-linked recessive chromosome (mother is a carrier, and her sons may express the disease)

Thrombocytopenia (low platelets) a normal individual has between 50 and 200% factor activity in blood. The hemophiliac has from 0% to 25% activity The affected individual usually is missing either factor VIII (most commonly in 75%) or factor IX

Signs & symptoms of Thrombocytopenia Easy or excessive bruising Superficial bleeding into the skin that appears as a rash of pinpoint-sized reddish-purple spots

(petechiae), usually on the lower legs Prolonged bleeding from cuts Spontaneous bleeding from your gums or nose (epistaxis) Blood in urine or stools Unusually heavy menstrual flows Profuse bleeding during surgery or after dental work

Place all Pt with Thrombocytopenia (including adults on anticoagulant therapy) on Bleeding Precautions o Soft bristled tooth brush o Electric razor only (no safety razors) o Handle gently, Limit contact sports o Rotate injection sites with small bore needles for blood thinners and avoid IM injections o Limit needle sticks, Use small bore needles, Maintain pressure for 5 minutes on venipuncture sites o No straining at stool - Check stools for occult blood (Stool softeners prn) o No salicylates, NSAIDs, or suppositories o Avoid blowing or picking nose o Do not change Vitamin K intake if on Coumadin Signs & Symptoms of Hemophilia

1. male child: first red flag may be prolonged bleeding at the umbilical cord or injection site of vitamin K, or following circumcision

2. prolonged bleeding with minor trauma 3. hemarthrosis (most frequent sight of bleeding) 4. spontaneous bleeding into muscles and tissues 5. loss of motion and joints 6. pain

lab values: 1. Prolonged PTT

****Normal PTT is within 60-70 Seconds* (1.5-2.5X normal or control for heparin therapy 90-175 minutes)

2. Factor assay is less than 25% Treatments of Hemophilia

administer fresh frozen plasma administer pain medication containing no aspirin follow blood precautions: risk for hepatitis Teach child and family home care

o teach to recognize early signs of bleeding into joints o teach local treatment for minor bleeding (pressure, splinting, ice) o teach administration of factor replacement o discuss dental hygiene: use only soft toothbrushes o provide protective care: give the child soft toys and use padded rails

Hesi Hint- inherited bleeding disorders (hemophilia and sickle cell anemia) are often used to test knowledge of genetic transmission patterns. Remember:

Autosomal recessive: both parents must be heterozygous, or carriers of the trait, for that disease to be expressed in their offspring. This means two copies of an abnormal gene must be present in order for the disease o trait to develop. Seen in: Cystic fibrosis, sickle cell anemia, PKU, Sickle Cell Anemia, Tay-Sachs, & Albinism,

Autosomal dominant, it means you only need to get the abnormal gene from one parent in order for you to inherit the disease. One of the parents may often have the disease. Seen in: Huntingtons, Marfans, Polydactyl, Achondroplasia, Polycystic Kidney Disease X-linked Recessive Trait- this trait is carried on the X chromosome, therefore; females can only be carriers and not have the gene & the mother usually passes the disease to her male offspring/son. Seen in: Hemophilia & Muscular Dystrophy

Other Associated Hemological Terms 1. Leukocytosis Increased WBC resulting from the inflammatory response,

Most commonly the result of infection parasitic infections or bone tumors strenuous exercise convulsions such as epilepsy emotional stress pregnancy and labor anesthesia or recent surgery epinephrine administration.

2. Lymphocytopenia- Decreased WBC resulting from Leukemia Hodgkins disease Corticosteroid use infections with HIV and other viral, bacterial, and fungal agents, malnutrition systemic lupus erythematosus, severe stress, intense or prolonged physical exercise (due to cortisol release), rheumatoid arthritis,

sarcoidosis iatrogenic (caused by other medical treatments) conditions. Chemotherapy or radiation

3. Thrombocytosis (or thrombocythemia) High platelets resulting from Reactive (Secondary)

Inflammation Surgery (which leads to an inflammatory state) Hyposplenism (decreased breakdown due to decreased function of the spleen) Splenectomy Asplenia (absence of normal spleen function) Iron deficiency anemia or hemorrhage Medications such as eltrombopag or romiplostim,

The vast majority of causes of thrombocytosis are acquired disorders, but in a few cases, they may be congenital, such as thrombocytosis due to congenital asplenia. Other causes include the following

Kawasaki disease Soft tissue sarcoma Osteosarcoma Dermatitis (rarely) Inflammatory bowel disease Rheumatoid arthritis Nephritis Nephrotic syndrome Bacterial diseases, including pneumonia, sepsis, meningitis, urinary tract infections, and septic

arthritis.[6] 4. Thrombocytopenia and thrombopenia Low Platelets resulting from Decreased production

Vitamin B12 or folic acid deficiency Leukemia or myelodysplastic syndrome Decreased production of thrombopoietin by the liver in liver failure Sepsis, systemic viral or bacterial infection Dengue fever can cause thrombocytopenia by direct infection of bone marrow megakaryocytes, as well

as immunological shortened platelet survival. Hereditary syndromes

Congenital amegakaryocytic thrombocytopenia Thrombocytopenia absent radius syndrome Fanconi anemia Bernard-Soulier syndrome, associated with large platelets May-Hegglin anomaly, the combination of thrombocytopenia, pale-blue leuckocyte inclusions,

and giant platelets Grey platelet syndrome Alport syndrome WiskottAldrich syndrome

Increased destruction Systemic lupus erythematosus Post-transfusion purpura Neonatal alloimmune thrombocytopenia Splenic sequestration of platelets due to hypersplenism HIV-associated thrombocytopenia[4] Gaucher's disease

Medication-induced

5. Polycythemia (also known as polycythaemia or polyglobulia) High RBC caused by chronically low oxygen levels malignancy. Being over-transfused

Metabolic & Endocrine Disorders 1. Congenital hypothyroidism

low levels of T4 (thyroxine) high levels of TSH thyroid stimulating hormone Synthroid: tx of hypothyroidism..may take several weeks to take effect...notify doctor of chest pain..take in the AM on empty stomach..could cause hyperthyroidism.

2. PKU Phenylketonuria *****

Autosomal Recessive Diseases in which the body cannot metabolize the essential amino acid phenylalanine

Guthrie Test Tests for PKU, at birth & again at 3 weeks o baby should have eaten source of protein first o positive test if serum phenylalanine level of 4mg/dl

No phenylalanine with a kid positive for PKU (no meat, no dairy, eggs, Aspartame (NutraSweet) has phenylalanine in it and should not be given to PKU patient)

o infants require special formula Lofenalac, Phenex-1 o infants require phenyl free milk substitutes after two years of age o No foods low in phenylalanine (vegetables, fruits, juices, cereals, breads, and starches o the diet must be maintained until at least brain growth is complete around ages 6 to 8

The buildup of serum phenylalanine leads to CNS damage Leads to MR early detection for PKU and hypothyroidism is essential for preventing cognitive impairments.

3.Insulin-Dependent diabetes mellitus or type I (IDDM) metabolic disorder in which the insulin producing cells of the pancreas are not functioning as a result of

some and so diabetes can cause altered metabolism of carbohydrates, proteins, and fats treatment includes insulin replacement, dietary management, and exercise fasting blood sugar greater than 120 mg/dL is a diagnosis of diabetes

Hyperglycemia is caused by: too much food, too little insulin, too little diabetes meds, illness or stress. Onset: start slow

Signs & Symptoms of Hyperglycemia (3Ps with varying weight situations) Polydipsia Polyuria Polyphagia weakness weight loss syncope blurred vision

Nursing Actions: encourage water intake check glucose regularly assess for ketoacidosis- when a child is in ketoacidosis administer regular insulin IV in normal saline administer insulin

Hypoglycemia- is caused by to little food, to much insulin or diabetic medicine, or to much activity Onset: is sudden and can progress to insulin shock Signs & Symptoms include (Tiredness TLC)

Tachycardia/tremors Irritability/anxiety Restlessness Extreme headache Depression Nausea Sweating Slurred Speech TLC

Tingling Lethergy Confusion

Nursing Actions Treat with complex carbs

o Grahm crackers & peanut butter o 12 cup OJ o 1 cup milk o Hard candies NO chocolate

Recheck glucose in 20 minutes Diabetic ketoacidosis (DKA)= Occurs when the body is breaking down fat instead of sugar for energy. Fats leave ketones (acids) that cause pH to decrease.

DKA is rare in diabetes mellitus type II because there is enough insulin to prevent breakdown of fats. Kussmauls breathing (Deep Rapid RR) is present during DKA Serum acetone and serum ketones rise in DKA. As you treat the acidosis and dehydration expect the

potassium to drop rapidly, so be ready, with potassium replacement. However, NEVER give potassium K+ IV Push Fluids are the most important intervention DKA, so get normal saline running first then infuse with

regular insulin IV While treating DKA, bringing the glucose down too far and too fast can result in increased

intracranial pressure d/t water being pulled into the CSF. When drawing up Insulin Remember:

Draw Regular (Clear) insulin into syringe first when mixing insulins (Nichole Richey RN) Put Air into NPH first, then air into regular, draw up regular first RN) then draw up NPH

Insulin Rotate Injection Sites (Rotate in 1 region, then move to new region) Rapid Acting Insulins Lispro (Humalog), Aspart (Novolog) O: 5-15 min, P: .75-1.5 hrs Short Acting Insulin Regular (human) O: 30-60 min, P: 2-3 hrs (IV Okay) Intermediate Acting Insulin Isophane Insulin (NPH) O: 1-2 hrs, P: 6-12 hrs Long Acting Insulin Insulin Glargine (Lantus) O: 1.1 hr, P: 14-20 hrs (Dont Mix) Oral Hypoglycemics decrease glucose levels by stimulating insulin production by beta cells of pancreas, increasing insulin sensitivity and decreasing hepatic glucose production Glyburide, Metformin (Glucophage), Avandia, Actos Acarbose blunts sugar levels after meals

Insulin type Name Onset Peak action Duration Nursing implications Rapid acting Lispro (Humalog)

Aspart (NovoLog) Glulisine (Apidea)

0.5-1hour 5-15 minutes 25 minutes

2-4 hours 0.75-1.5 hours 1 hour

4 hours 3-5 hours 2-3 hpurs

Give within 15 minutes of a meal (Humalog and NovoLog)

Short acting Regular insulin (clear) (Humlin R, Novolin R)

30 to 60 minutes 2 to 3 hours 5 to 7 hours Regular insulin may be given IV

Intermediate acting Isophane insulin (NPH) (cloudy) Humulin N, Novolin N

1 to 2 hours 6 to 12 hours 18 to 28 hours Cannot be given IV Mixtures combine rapid acting regular insulin with intermediate acting NPH insulin in a 30% regular with 70% NPH proportion or at 50-50 combination

Long acting Glargine (Lantus) Detemir (Levemir)

48 hours 1.1 hours

14 to 20 hours five hours (some sources say there is no peak)

24 hours Not to be given IV Recommended: give one

dose subcutaneously at bed time

In some cases its given 2x/day

Acts as basal insulin Caution: solution is clear,

but the bottle shape is distinctively different from regular insulin.

Do not shake solution Do not mix other insulins

with Lantus. Use cautiously if patient is

NPO

Premix Humalog 75/25 NPH (25% Lispro/ 75% Humulin N) Human 70/30 (30% regular/ 70% NPH NovoLog 70/30 (30% Aspart/ 70% NPH) Humalog 50-50

For all premixes: offer when food is readily available

Skeletal disorders 1. Fractures- are described by the type and extent of the break

Fractures are caused by a direct blow, Cushing force, a sudden twisting motion, or disease such as cancer or osteoporosis.

Fractures are classified by the following: 1. Complete fracture- a break across the entire cross-section of the bone, dividing it into distinct

fragments; often displaced. 2. Incomplete fracture- a fracture that occurs through only one cortex (part) of the bone, is usually

nondisplaced 3. Close fracture- no break in the skin 4. Open fracture/compound- broken bone protrudes through the skin or mucous membranes.

Making this fracture more prone to infection. Bleeding is part of the circulation assessment of the ABCDs in an emergent situation. Therefore, if airway and breathing are accounted for, a compound fracture requires assessment before Glasgow coma scale and a neuro check (D=disability, or neuro check)

5 Types of fractures 1. Greenstick- Is an incomplete fracture in which one side of a bone is broken, but the other side is

bent (flexed) but intact. 2. Transverse- A break that occurs straight across (90-degree angle) the bone shaft 3. Oblique- break that occurs at a 45-degree-angle across the bone 4. Spiral- fracture line results from twisting force it forms a spiral encircling the bone

a. Spiral fractures or infant fractures may be related to child abuse 5. Comminuted- a break that consists of more than three fragments that may be splintered or

crushed. (Least common in children) Intracapsular fracture- occurs in the neck of the femur and heels with greater difficulty than an extracapsular

Fracture (occurs below the neck of the femur) because the blood supply enters the femur below the neck of the femur, there is greater likelihood that necrosis will occur because the fracture is cut off from the blood supply

Signs and Symptoms of a Fracture Pain, swelling, tenderness Deformity, loss of functional ability Discoloration, bleeding at the site through an open wound Crepitus: crackling sound between two broken bones ** SIGNS of a Fractured hip: EXTERNAL ROTATION, SHORTENING, ADDUCTION

Nursing Interventions Frequent neurovascular assessment distal to the injury (skin color, temperature, sensation, capillary

refill, mobility, pain, swelling (elevate to prevent swelling) and pulses should be assessed.) Assess the 5Ps of neurovascular functioning

1. Pain 2. Paresthesia 3. Pulses: check pulses distal to the injury to assess circulation 4. Pallor 5. Paralysis- check for nerve or movement impairments, compare with uninjured extremity

Report abnormal assessment findings promptly Observe client use of assistive devices 1. Crutches- there should be to a three finger widths between the axilla and top of the crutch.

a. A three-point gait is common. The client advances both crutches and the impaired Leg at the same time. The client then swings the uninvolved leg ahead to the crutches.

b. Remember the phrase step up when picturing a person going up stairs with crutches. The good leg goes up first, followed by the crutches and the bad leg. The opposite happens going down. The crutches go first, followed by the good leg.

2. Cane- is placed on the unaffected side

a. the top of the cane should be at the level of the greater trochanter b. Remember: COAL (cane walking): C Cane O- Opposite A- Affected L- Leg

3. Walker- strength of upper extremity & unaffected leg is assessed & improved with exercise so that upper body is strong enough to use the walker. The pt Lifts & advances the Walker and steps forward.

2 major complications of a fracture 1. Compartment Syndrome which may cause Permanent damage to nerves and vessels

Compartment syndrome is an emergency situation. Paresthesias and increased pain are classic symptoms. Neuromuscular damage is irreversible 4-6 hours after onset.

2. Fat embolism - a syndrome in which fat globules migrate into the bloodstream and combine with platelets to form emboli.

Its greatest occurrence is in the first 36 hours after a fracture People more likely to develop a fat embolism

o people with multiple fractures o fractures of long bones o fractures of the pelvis

Signs and symptoms of a fat embolism 1. Number 1 symptom is confusion due to hypoxemia (check blood gases for Po2) 2. Petechiae 3. respiratory distress 4. restlessness or irritability 5. fever

If a fat embolism is suspected- notify the physician stat, draw blood gases, administer O2, and assist with endotracheal intubation. Treatment for a Fat embolism is Heparin Administration

Traction Maintain traction if prescribed. Always document the

1. bed position 2. type of traction 3. weights 4. pulleys 5. pins & pin sites- can be source of infection, monitor for signs and symptoms and cleanse and dress

pin sites as prescribed 6. adhesive strips or ace wraps 7. splints 8. casts

Types of Traction 1. skin traction: force is applied to the skin

a. skin traction for a fracture reduction should not be removed unless a healthcare provider prescribes its removal.

b. Buck traction- lower extremities, keeps legs extended no hip flexion c. Dunlop- two lines of pull on the lower extremity 1 perpendicular & 1 longitudinal d. Bryant- both lower extremities flex and 90 at the hip (is really use because extreme elevation of

the lower extremities causes decrease peripheral circulation) 2. Skeletal traction: pain or wire applies pull directly to the distal bone fragment

a. 90 traction- 90 flexion of hip and knee, lower extremity is in a boot cast; & can also be used on the upper extremities

b. Questions about a halo traction? Remember safety first, have a screwdriver nearby.

Nursing Interventions for a child in traction 1. maintain child and proper body alignment: restrain if necessary 2. monitor for problems of immobility 3. prepare child for Application 4. provide routine cast care following application: petal cast edges Teach home cast care to the child & family

teach neurovascular assessments including the 5 Ps teach child not to get the cast wet teach the child not to place anything under the cast such as small objects, toys, food, or something to

help scratch such as a wire hanger Other Hints for Traction and/or fractures Always deal with actual problems or harm before potential problems Always select a patient focused answer. An answer option that states "reassess in 15 minutes" is probably wrong (unless you already completed A nursing intervention such as gave OJ to a hypoglycemic client, then you need to recheck sugar.) Developmental Dysplasia of the Hip

abnormal development of the femoral head in the acetabulum conservative treatment consists of splinting, surgical intervention is necessary of splinting is not

successful. Nursing Assessment for Signs & Symptoms Infant:

Positive Ortolanic Sign (clicking with abduction) unequal folds of the skin on the buttocks and thigh limited abduction of affected hip unequal leg lengths

Older child limp unaffected side Trendelenburg sign

Nursing interventions apply abduction device or splint (Pavlik harness: Frejka or Von Rosen splint) therapy involves positioning legs in the flexed abducted position teach application and removal of the device (worn 24 hours a day) teach skin care and bathing (physician may allow parents to remove the device for bathing)

Scoliosis lateral curvature of the spine, if severe it can cause respiratory compromise. Surgical correction by spinal fusion may be required if conservative treatment is an effective.

Nursing assessment for signs and symptoms occurs most commonly in adolescent females 10 to 15 years old elevated shoulder or hip head in hips not aligned while child is bending forward, a rib hump is apparent (ask the child to bend forward from the hips with

the arms hanging free, and examine the child for curvature of the spine, rib hump, and hip asymmetry) Nursing Interventions

prepare the child and family for conservative treatment such as the use of a brace o teach the application of the brace (Boston, Wilmington, or Milwaukee are most common) o instruct to wear it 23 hours a day o instruct to a T-shirt under the brace to decrease skin irritation o Lotions and powders are not applied to the skin under the brace o instruct to check skin for areas of irritation or skin breakdown

a brace does not correct the spines curve in a child with scoliosis: it only stops or slows the progression

Juvenile Arthritis (JA) or juvenile idiopathic arthritis (JIA) chronic inflammatory disorder of the joint synovium

Nursing Assessment for Signs and Symptoms 1. joint swelling and stiffness (usually of large joints) 2. painful joints 3. generalized symptoms: fever, malaise, and rash 4. periods of exacerbations and remissions 5. varying in severity from mild and self-limited or severe and disabling 6. lab data: latex fixation test (usually negative) and elevated ESR

Nursing interventions plan homecare prescribed exercise splinting and activity assist in identifying adaptations a routine (Velcro fasteners,& frequent rest periods throughout the day) encourage periodic eye exams for early detection of iridocyclitis so as to prevent vision loss encourage the family to allow childs independence

Medication intervention 1. nonsteroidal anti-inflammatory drugs (NSAIDS)

o aspirin o Tolmetin Sodium o Ibuprofen o Naproxen

2. Antirheumatic drugs 3. Corticosteroids (prednisone)- are used in the short term in low doses during exacerbations only. Long- term use is avoided because of side effects and their adverse effects on growth. 4. Cytotoxic drugs (Cyclophosphamide, methotrexate)

Maternity Review Ovulation- usually occurs 14 days before the onset of menstrual flow Last Menstrual Period (LMP)- The date of the first day of the last menstrual bleeding, used for EDB-estimated date of birth & EDD estimate delivery/due date NAGELS RULE- LMP Subtract 3 Months & ADD 7 days and Add 1 Year Take 400mcg FOLIC ACID within or before the first trimester to prevent nurotube defects

They are decreased by 70% if taken regularly Sources of FOLIC ACID- Leafy greens, whole grains, OJ

Amniotic fluid = 800-1200 mL (< 300 mL = Oligohydramnios = fetal kidney problems) Oligohydramnios- Having less than 300ml of amniotic fluid, is never good & can be associated With fetal renal abnormalities Polyhydramnios Having more than 2L of amniotic fluid, may not ALWAYS be a bad thing, it Can be managed on an outpatient basis, but also can be associated with GI malformations UMBILICAL CORD- Has 3 Vessels (Vein carries oxygenated blood to fetus (opposite of normal)

2 ARTERIES- carry unoxygenated blood back to the placenta 1 VEIN- Carries oxygenated blood to the fetus

o Whartons Jelly- Connective tissue that prevents compression of the blood vessels & ensures continued nourishment of the fetus

PLACENTA- Specialized organ that forms maternal-fetal gas & nutrient exchange, begins to Form at implantation FUNCTIONS:

1. Endocrine Gland- Produces hormones necessary to maintain pregnancy a. Human Chorionic Gonadotopin (hCG)- is a protein hormone that can be detected

in the maternal serum by 8-10 days after conception, just shortly after implantation. Basis for a pregnancy test

i. HCG- Preserves the function of the ovarian courpus luteum, ensuring the continued supply of estrogen & progesterone to maintain pregnancy

ii. The amount of hCG- Reaches a PEAK level at 50-70 days then begins to DECREASE

2. Metabolic Function- of blood & gas exchange 3. Nutrient/excretion 4. Storage

Fetal Maturation/Circulation The cardiovascular system is first to begin to function HEART BEATS by the end of the 3rd Week NASIDS- should be AVOIDED because they can cause a premature closure of the Ductus Arteriosus,

which may lead to pulmonary vasculature abnormalities & pulmonary HTN Pregnancy Trimesters

1st Trimester Conception-13 Weeks 2nd Trimester 14 weeks through 26 weeks 3rd Trimester 27-40 weeks

Fetal & Maternal Changes 8 weeks A. Fetal Development

1. Development is rapid 2. Heart begins to pump blood

B. Maternal Changes 1. Nausea persists to 12 weeks 2. Hegar sign (softening of the isthmus of cervix AKA lower uterine segment) 3. Goodell sign (Softening of the cervical tip) 4. Chadwick sign (bluing of vagina, & a violet-bluish mucosa & cervix appears as early as 4 weeks)

5. Leukorrhea- White or grey muciod discharge with a musty odor 12 Week A. Fetal Development

1. Heart is discernible by ultrasound 2. Sex is determinable 3. Kidneys produce urine

B. Maternal Changes 1. Braxton Hicks Contractions 2. Chance for UTI increases 3. WEIGHT GAIN is 2-4 Pounds during the First Trimester, then 1 pound a week thereafter 4. Placenta is fully functioning & produces hormones

a. Teach UTI prevention- Pt increase fluid intake to 3/L day &Void Q2h while awake & after sex b. Increase caloric intake by 300 calories/day, weight gain of 25-35 lbs total is normal

16 Weeks A. Fetal Development

1. Meconium in bowel, & anus opens 2. Respiratory Bronchioles appear

B. Maternal Changes 1. Quickening (the mothers 1st perception of fetal movement, occurs between weeks 16-20) 2. Colostrum can be expressed as early as 16 weeks 3. Cholesterol Increases from 16-32 weeks and remains high til birth 4. INSULIN RESISTANCE begins as early as 14-16 weeks 5. Weight gain of about 1 pound/week in the second & third trimester

20 Weeks A. Fetal Development

1. Vernix & Lanugo (fine hair ) covers & protects the body 2. Fetus sleeps, sucks, & kicks

B. Maternal Changes 1. Fundus reaches umbilicus 2. Areolae darken 3. Postural HYPOTENSION may occur 4. Nasal stuffiness, leg cramps, varicose veins, constipation develops

24 Weeks A. Fetal Development

1. sweat glands forming 2. blood formation increases in bone marrow & decreases in the liver 3. Can begin to HEAR

B. Maternal Changes 1. Uterus reaches umbilicus 2. DIASTOLIC BP gradually increases at 24-32 weeks, AFTER having Decreased Diastolic BP in the

first trimester. Systolic BP- remains the same during the entire pregnancy 28 Weeks A. Fetal Development

1. Fetus can breathe, swallow, & regulate temp 2. Surfactant forms in the lungs

B. Maternal Changes 1. Fundus is halfway between umbilicus & xiphoid process 2. Thoracic breathing replaces Abdominal breathing 3. Heart burn & hemorrhoids may develop

32 Weeks A. Fetal Development

1. Brown fat deposits develop under the skin

2. Fetus begins storing iron, calcium, & phosphorus B. Maternal Changes

1. Fundus reaches xiphoid process 2. urinary frequency returns Along with swollen ankles, sleeping problems &/or Dyspnea may occur

36-40 Weeks A. Fetal Development

1. Fetus occupies the entire uterus so activity is restricted 2. Maternal Antibodies are transferred to the fetus & provide infant immunity for approx 6 months

B. Maternal Changes 1. Lightening occurs- fundal height drops as the fetus begins to descend & engage in the pelvis 2. Backaches increase & Braxton Hicks Contractions intensify

Physiologic Changes During Pregnancy 1. Reproductive System Changes

1. Amenorrhea 2. Brest Changes- They enlarge & become nodular as the glands increase in size & number

2. Cardiovascular Changes ** 1. Between 14-20 weeks gestation the heart rate increases about 10-15 beats/min remains until term 2. There is a more audible splitting of S1 & S2 & S3 may be readily heard after 20 weeks 3. BLOOD PRESSURE:

a. Diastolic BP begins to decrease in the first trimester, & continues to drop until 24-32 weeks, then gradually increases by term

b. Systolic BP usually remains the same but may decrease slightly as pregnancy advances c. MAP readings are slightly higher in pregnant women d. Maternal position affects BP readings, Brachial BP is higher when a woman is sitting

than when she is lying in the lateral recumbent position e. Position of the arm also makes a difference: if the arm is ABOVE the heart, the reading

will be LOWER than the actual reading, if below the heart, the reading will be higher f. Supine Hypotensive Syndrome- Some degree of compression on the Vena Cava occurs

in all women who lie flat on their backs during the second half of pregnancy. As a result some women experience a decrease in systolic BP decrease more than 30mmHg, after 4-5 minutes of reflex bradycardia, cardiac output is reduced by half, & the woman feels faint.

i. Teach the woman- that a left side-lying position relieves this Hypotension & increases perfusion to the uterus, placenta, & fetus

4. Compression of the iliac veins & inferior vena cava by the uterus causes increased venous pressure & reduced blood flow in the legs (except when the woman is in the lateral position) This contributes to dependent edema, varicose veins, & hemorrhoids

5. Blood Volume Increases by approximately 1500 ml, or 40-45% above non-pregnancy levels a. The increase consists of 1000ml of plasma plus 450ml red blood cells (RBC)

i. The state of hemodilution occurs & is termed Physiologic Anemia. This happens because the plasma increase exceeds the increase in RBC production, a decrease in the normal hemoglobin (HGB) (12-16 g/dl in non-pregnant) & hematocrit (HCT) (37-47% in non-pregnant) values occurs.

1. A Hemoglobin Value Below 11 g/dl & Hematocrit below 33% are considered Abnormal & is often due to iron deficiency anemia

a. Foods High in Iron: fish, red meat, cereal, yellow veggies, green leafy veggies, citrus fruits, egg yolks, & dried fruits

b. Blood volume starts to increase by the 10-12th week of pregnancy, & decreases by term 6. Total WBC Increases during the second trimester & peeks during the 3rd 7. Cardiac Output (CO) Increases from 30%-50% over the non-pregnant rate by the 32nd week

a. The elevated CO is caused by an increase in stroke volume & HR & occurs in response to increased tissue demands for oxygen

b. CO is Higher when the woman is in the lateral recumbent position than supine

8. Coagulation Times Are Decreased, resulting in increased clot formation & thrombus 3. Respiratory Changes

a. The upper respiratory tract becomes more vascular in response to elevated levels of estrogen a. As the capillaries become engorged edema occurs in the nose, pharynx, larynx, trachea, &

bronchi. This congestion gives rise to nasal & sinus stuffiness, epistaxis (nosebleed), or URI. b. Increased vascularity of the URT also causes tympanic membranes to swell, resulting in impaired

hearing, earaches, or a sense of fullness in the ears. c. Basal Metabolic Rate (BMR) Which is the rate at which the body uses energy while at rest to keep

vital functions going, such as breathing and keeping warm, is INCREASED during pregnancy. d. Acid-Base Balance- By about the 10th week of pregnancy there is a Decrease of about 5 mmHg in

the partial pressure of Carbon dioxide (Pco2) e. Progesterone- may be responsible for increasing the sensitivity of the respiratory center receptors

so, tidal volume is increased, Pco2 is Decreased, & PH is slightly Increased a. These alterations indicate pregnancy is a state of compensatory Respiratory Alkalosis

4. Renal Changes a. Urinary Frequency- caused by an increased progesterone, increased glomerular filtration, & crowded

bladder b. Increased cardiac output increases renal blood flow in the 1st trimester c. Bladder tone reduced by effects of progesterone on smooth muscle

5. Skin Changes a. Chloasma (Facial Melasma)- a patchy brown discoloration, that usually appears on the face b. Linea Nigra- Is a pigmented line extending from the symphysis pubis (pubic bone) to the top of the

fundus (navel) c. Striae Gravidarum- stretch marks d. Angiomas (Vascular Spiders) that indicate increased circulation e. Palmar erythema- Pinkish-red diffuse mottling or blotches over the palmer surface of the hands

Antepartum Care G/P

Gravida- The TOTAL number of times a woman has been pregnant Parity- Number of pregnancies (not kids) that have reached viability (pass 20 weeks)

o G2P1- Pregnant twice but only gave birth once GTPAL

Gravida- Total number of times a woman has been pregnant Term- Total number of pregnancies that have passed 37 weeks Preterm- Total number of pregnancies that passed viability (20 weeks) but ends before completion of

37 weeks Abortion- How many voluntary or involuntary number of pregnancies that did not reach 20 weeks Living- How many living children the woman currently has

Normal Vital Signs for the Pregnant Woman BP- systolic should rise no more than 30 mmHg, and 15 mm Hg Diastolic

o Systolic Average 90-140 mm Hg o Diastolic Average 60-90 mm Hg

HR- 60-90 BPM RR- 16-24 Breaths/Min Temp- 97-100 degrees F (F-32 X 5/9= C) 97 F = 36.1 C

o Convert Celsius to Fahrenheit (C x 9/5 + 32 = F) 37.8 C = 100 F Teach Position Changes

The Knee-Chest Position- provides optimum fetal & placental perfusion, but the IDEAL position for the mother, which supports fetal, maternal, & placental perfusion, is the SIDE-LYING

Teach Proper Nutrition Symptoms of Malnutrition:

1. Glossitis (inflammation of the tongue) 2. Cracked Lips 3. Dry, Brittle Hair

Obesity- Woman over 200 lbs are at risk for diabetes, HTN, infections, & Macrosomia Macrosomia- Large baby over 4500 kg or 9.5 lbs Underweight- Woman under 100 lbs are at risk for low birth weight babies, IUGR, & preterm labor

Nutritional Plans Increase calories by 300 above basal & activity needs Increase Protein by 30g/day

o Milk, meat, eggs, cheese Increase intake of Iron & Folic Acid Increase Intake of Vitamin A, C & Calcium

o Calcium is needed for fetal bone & tooth development, recommended intake of 1500mg/day Drink 8-10 glasses of fluid a day or 3L, 4-6 glasses should be water: WATER

o Maintains body temp o Hydrates uterus

Limit caffeine intake to less than 200mg (12 oz daily) Aspartame (Equal) or Sucralose (Splenda) have NOT been found to have adverse effects Sodium HAS NO RESTRICTIONS- But makes you retain water

Phenylketonuria (PKU)- Is a RECESSIVE Hereditary disease that results in a defect in the metabolism of the Amino Acid Phenylalanine caused by the lack of an enzyme called phenylalanine hydroxylase, that is

Necessary for the conversion of the amino acid Phenylalanine into Tyrosine. If not treated it can cause brain damage & mental retardation

Women with PKU CAN NOT eat ANYTHING with Phenylalanine, which is found in the following:

o Diet Soda, Bread, Nuts, Milk, Sugar, Some fruits & Veggies A Routine Physical Assessment and initial Labs

1. CBC- Can determine Iron deficiency which could indicate anemia 2. Blood Type & Screen- Done to determine if the MOTHER is (Rh-) if she is, she will need an injection

of ROGRAM at 28 weeks. This is because the mother can develop antibodies to a Rh+ fetus and her body will attack the fetus as if it was a foreign substance & kill it

3. Rubella Status- Will effect the growing fetus, the mother will need a vaccine postpartum if not up to date

4. RPR- Can diagnose syphilis Assess Fetal Well-Being and Heart Rate

Fetal well-being is determined by assessing fundal height, fetal heart tones & rate, fetal movements, & uterine activity (contractions). Changes in Fetal Heart Rate (FHR) are the FIRST & MOST IMPORTANT indicators of compromised blood flow to the fetus, & these changes require action.

FHR Can be detected by using a Doppler between 10-12 weeks gestation FHR can be detected by using a fetoscope between 10-20 weeks gestation ***NORMAL FETAL HEART RATE IS- 110 to 160 bpm*******

***FHR is best heard (Point of Maximum Intensity OMI) through the fetal BACK *** Possible Indicators of Preeclampsia & Eclampsia Are:

1. Visual Disturbances 7. Changes in fetal movement or increase in FHR 2. Swelling of the face, fingers, or Sacrum 8. Infection: Possible Indicators Include 3. Severe Continuous Headaches 1. Chills 4. Persistent Vomiting 2. Temp over 100.4 Degrees Fahrenheit 5. Epigastric Pain 3. Dysuria (painful or difficult urination)

6. Fluid discharge or bleeding from the vagina 4. Abdominal Pain Fetal & Maternal Assessment A. Maternal Risk Factors

1. Age: Under 17 or Over 34 2. High Parity >5 3. Pregnancy (3 months since last delivery) 4. Hypertension or presence of or history of Preeclampsia 5. Anemia, History of Hemorrhage, or current Hemorrhage 6. Multiple Gestations 7. Rh Incompatibility 8. History of Dystocia (e.g. shoulder dystocia) or previous operative delivery 9. A height of 5 feet or less 10. Malnutrition or Obesity 11. Current medical disease/condition 12. History of family violence or lack of support

SCREENING TESTS (NOT DIAGNOSTIC TESTS) 1. Ultrasonography

a. Used in the First Trimester to Determine 1. Gestational Age: Best indicator in the 1st trimester, very accurate second to Negals rule 2. Number of fetuses 3. Presence of fetal cardiac movement & rhythm 4. Uterine abnormalities

b. Used in the Second & Third Trimester to Determine 1. Fetal viability & gestational age (not as accurate) 2. Size-date discrepancies 3. Amniotic Fluid volume 4. Placental location & maturity 5. Uterine abnormalities & anomalies 6. Results of amniocentesis

c. Findings 1. Fetal heart activity is apparent as early as 6-7 weeks gestation 2. Serial ultrasound measurements are needed to determine & true Intrauterine growth

restriction (IUGR) *A Single ultrasound exam is NOT useful in determining IUGR 3. Serial evaluation of biparietal diameter & limb length can differentiate between wrong

dates d. Nursing Care

1. Instruct the pt to drink 3-4 glasses of water and NOT URINATE, the bladder must be FULL during the exam for the uterus to be supported for imaging. (A full bladder is NOT NEEDED if the ultrasound is done transvaginally instead of abdominally)

2. Chorionic Villi Sampling (CVS) -Removal of a small piece of villi during the period of 8-12 weeks under ultrasound guidance a. Findings

1. The test determines genetic diagnosis early in the first trimester & The results are obtained in 1 week b. Nursing Care

1. Place the pt in the lithotomy position using stirrups & Warn of sharp pain upon catheter insertion c. Complications of Chorionic Villi Sampling

1. Spontaneous Abortion (5%) 2. Controversy regarding fetal abnormalities (limb)

3. Amniocentesis- Is a positive Diagnostic TEST its the Removal of Amniotic fluid sample from the uterus A. Its used to determine:

1. Fetal Genetic diagnosis (usually in the first trimester) 2. Fetal Lung Maturity (in the LAST trimester)

3. Fetal well-being B. This is performed ONLY when uterus rises above the symphysis (between 12-13 weeks) & amniotic fluid Has formed. C. Usually takes 10 days- 2 wee