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all in one postpartum

The postpartum period or puerperium. 3 to 6 weeks after delivery Retrogressive and Progressive changes Begins with the delivery of the placenta and ends with resumption of menses.
Involution 3 Processes Contraction Catabolism Regeneration
Normal, Spontaneous, Vaginal Delivery (NSVD): postpartum assessment same as cesarian section VS Breasts. Uterus. Bladder. Lochia. Perineum. Lower extremities. Other systems.
Vital Signs: Normal Vaginal Spontaneous Delivery Temperature may be elevated for up to 24 hours with no other symptoms. Blood Pressure should remain stable. Pulse: bradycardia is common. Respirations: normal respiratory rate is common. Pain
Postpartum Assessment Con’t Breasts: Breasts should be examined for engorgement (firm and tender). If mother is not breastfeeding, wear supportive or sports bra. If mother is breastfeeding, reassurance may be needed. Nurse baby, apply heat
Postpartum Assessment Con’t Uterus: The fundus should be assessed after the woman has emptied her bladder. The fundus should remain firm after delivery.It should be assessed for consistency and location with each postpartum assessment. The fundus is usually +/- 1 to 2 cm above or below the umbilicus for the first 12 hours; It should be midline.
Postpartum Assessment Con’t Bladder: Uterus is displaced upward and laterally. Increased lochia. May urinate in small amounts. Should void 300 to 400 ml. Urinary retention and overdistention of the bladder may cause UTI and postpartal hemorrhage. daily output of up to 3 L common.
Postpartum Assessment Con’t Bowels: Assess for active bowel sounds, abdominal distention, signs of constipation. Usually first bowel movement is in the 2nd-3rd day. Encourage adequate fluid intake, progressive exercise and dietary fiber to facilitate soft stools.
Postpartum Assessment Con’t Lochia: post delivery uterine discharge. Characterized by its appearance and contents. Assessed in conjunction with fundal check, noting: Color. Amount. Odor. Presence of clots.
Lochia Characteristics Lochia rubra: Blood content; bright red colored for the for 1-3 days. Lochia serosa: Pink to brown discharge day 4 – 10 days. Lochia alba:  Slightly yellow to white discharge which lasts from 11days to 21 days (may last 6 weeks).
Lochia Volume Heavy is saturating a pad every 1 hours. Moderate is less than a 4 - 6 inch stain on the pad. Light is less than a 1 - 4 inch stain. Scant is less than a 1 inch stain. Excessive is saturation of a peripad pad within 15 minutes.
Lochia Assessment Con’t Report to provider if: Foul smelling, bright red discharge. Clots are passed. Pad is saturated in less than one hour.
Check the episiotomy for REEDA: Redness. Edema. Ecchymosis. Discharge. Approximation.
Teach peri-care: Cleanses. Provides comfort. Prevents infection Teach the mother peri-care by using a peri-bottle and squirting warm water over the perineum after each voiding or bowel movement.
Episiotomy Con’t Comfort Measures: Ice pack. Topical medications: Dermoplast. Epifoam. Tucks pads. Sitz bath.  Dry heat, heat lamp. Oral analgesics.
Postpartum Assessment Con’t Lower Extremities Lower extremities are examined for varicosities and signs and symptoms of thrombophlebitis. Indications include localized areas of redness, heat, edema, and tenderness. check for Homans sign
Cardiovascular System Assessment Blood clotting factors are higher the postpartum patient is at increased risk for clot formation. Leukocytosis Chills thought to be related to the sudden release of pressure on the pelvic nerve can develop.
Cardiovascular System Assessment blood volume Hypervolemia allows for blood loss during delivery. Up to 500 ml for vaginal birth and 1000 ml for cesarean birth.
Neurological System Changes After childbirth neurological discomfort and fatigue are common. Severe headaches are not common and maybe post puncture from regional anesthesia. Watch for severe headache accompanied by blurred vision, proteinuria
Endocrine Changes Placental hormones decrease. Ovulation resumes: Breastfeeding delays ovulation. Nonnursing: menses resume 6 to 8 weeks Endocrine glands return to normal
Musculoskeletal System Changes Abdominal muscle tone returns to normal. 6 weeks May have hip and joint pain Reassurance and told temorary Exercise per provider’s guidance
Integumentary System Changes Chloasma (mask of pregnancy) disappears. Striae fade. Hyperpigmentation of the skin fade after delivery but fade. Hair loss Begins 4 – 20weeks Regrown 4 -6 months
Immune System Changes The need for a rubella vaccination or for RhoGAM for prevention of Rh isoimmunization should be determined and given prior to discharge. Must consent and be counseled to avoid pregnancy for at least 28 days.
Cesarean Delivery Normal postpartum assessment along with postoperative assessment. In addition, assess the following: Pain:Level, PCA, Opioids and / or other medications Respirations:Incentive spirometer use, Ambulate according to protocols Abdomen: Auscultate bowel sounds; Keep NPO until return, Observe dressing, Be gentle doing assessment of fundus.
Cesarean Delivery Assessment Con’t Intake and Output: IV fluids. Monitor foley drainage. Dietary changes according to protocol. Simethecone for decreasing flatulence.
Postpartum Psychosocial Adaptations Important to assess the woman’s ability to meet her own needs and those of her infant. mother may feel the entirety of the baby through a process called fingertipping
Psychosocial Adaptations Con’t Rubin’s Psychological Changes of the Puerperium Phase 1: Taking In.2days, focus on mothers needs Phase 2: Taking Hold.may occur right after birth,teach mother her role as caretaker Phase 3: Letting Go.mom knows her role as caretaker continues throughout discharge
Psychosocial Adaptations Con’t Mother must be taught: Take care of herself. Use good hand washing. Breast care. Incision/episiotomy care. REST.
Postpartum Danger Signs Passive reactions, either verbal or nonverbal. Hostile reactions. Disappointment over the sex of the baby. Lack of eye contact. Non-supportive interaction between parents.
Psychosocial Adaptations Postpartum Blues Mild depression. Affects 60 – 80% of mothers in U.S. Self-limiting. May benefit for empathy and support Does not affect the mothers ability to care for the infant.
Psychosocial Adaptations Postpartum Depression/Postpartum Psychosis Postpartum blues is not the same as postpartum depression and postpartum psychosis. Moderate to Severe disturbances in the interactions with baby Prodominent feature is rejection of the infant Disinterest or annoyance with care demands May lead to killing family members (rare) Doesn’t share thoughts because of embarrassment
Psychosocial Adaptations Medical Management & Nurse Interventions Pharmacological intervention Antidepressants Anxiolytic ECT Hospitalization Anticipatory guidance Offer therapeutic interventions Provide referrals
Family Adaptation Mother: Primary caregiver to the infant. Loss of freedom. Must be sensitive to concerns. Father: Must be engrossed in child’s life to develop a bond. Eager to help, but may lack confidence. Must be included in teaching.
Family Adaptation Con’t Siblings: Depends on developmental level. Toddler: Infant is competition. May have sleep problems. Regression. Preschooler: look more than touch. School age: easily adapts. All need attention and reassurance. Sibling classes may help.
During the Postpartum Period if the fundus is not firm, and massaging and breast feeding does not increase the muscle tone prepare to give an oxytocic medication. Most common:Pitocin,Methergine,Usually administered IV. Potential side effects include: Increased blood pressure. Bradycardia. Headache. Nausea. Vertigo.  
Discharge Criteria: No complications. Normal assessments. Immunizations given if needed. Discharge teaching given. Demonstration of readiness to take care of self and baby is evident. Support person is available
Discharge Teaching Planning begins at confirmation of pregnancy.
Reportable Signs and Symptoms Fever. Localized redness, swelling or pain in either breast that is not relieved by support or analgesics. Persistent abdominal tenderness. Feeling of pelvic fullness or pressure. Persistent perineal pain.
Reportable Signs and Symptoms cont. Frequency, urgency or burning on urination. Abnormal change in character of lochia. Localized tenderness, redness, swelling or warmth of the legs. Swelling of, redness in, drainage from, or separation of an abdominal incision.
drugs you may need to know vitamin k given to baby (aqua mephyton) IM erythromycin (ilotycin) prevents gonorhea infection methylergonovine meleate (methergine) controle bleeding PP simethicone(mylicon) antiflatulant ibuprofen used as NSAID
Postpartum Hemorrhage Definition: blood loss greater than 500 ml after vaginal birth, or 1000 ml after cesarean birth. Two Types: Early postpartum hemorrhage.  Late postpartum hemorrhage. note: A more measurable definition is a decrease in hematocrit of 10 percent or more since admission.
Early Postpartum Hemorrhage Hemorrhage that occurs within 24 hours of delivery. The two causes are: Uterine Atony. Trauma.
Uterine Atony Refers to the lack of muscle tone that results in failure of the uterine muscle fibers to contract firmly around blood vessels when the placenta separates.
Uterine Atony Predisposing Factors Over-distension of the uterus Intrapartum factors Augmented labor with oxytocin DIC Multiparity
Uterine Atony Clinical Signs Uterus is difficult to palpate, Boggy (soft) The fundal height is high Excessive lochia
Uterine Atony Therapeutic Management Massage the fundus until it is firm Assist mother to urinate if full bladder Rapid IV infusion of oxytocin (Pitocin)
Uterine Atony Pharmacological Measures oxytocin (Pitocin) methylergonovine (Methergine) prostaglandin (Hemabate, Prostin) misoprostol (Cytotec
Uterine Atony Surgical Management If all other measures are ineffective: Exploration Ligation Hysterectomy
Priority assessments include: vital signs every 15 minutes Uterine Atony Assess consistency & location of fundus. Ensure patient does not have full bladder when doing assessment. When inspecting blood loss, ask the woman to turn on side because blood that pools under her is not visible when checking pads from front.
Early Postpartum Hemorrhage Trauma Predisposing Factors: Uterine atony Induction and augmentation of labor Assistive devices
Trauma common types Lacerations:Bleeding from lacerations often is bright red Hematomas:usually on the vulva or inside the vagina.
Trauma Nursing Management Assess q15 minutes for 1 hour Then q30 minutes for 2 hours Then hourly for next 4 hours Count number of pads Weigh wet pads Quantify amount of blood
Medical Treatments Early Hemorrhage Small hematomas usually resolve without treatment. Large hematomas may require incision and drainage of the clots. Bleeding vessel is ligated or area packed with a hemostatic material to stop bleeding. Surgical Asepsis is required
Late Postpartum Hemorrhage AKA Secondary Postpartum Hemorrhage Typically it occurs without warning 6 days to 6 weeks days after delivery. Occurs after discharge
Late Postpartum Hemorrhage Most Common Causes Subinvolution Retained placenta. Pelvic infection.
Late Postpartum Hemorrhage Predisposing Risk Factors Attempts to deliver the placenta before it separates from the uterine wall. Manual removal of the placenta. Placenta accrete.  Previous cesarean births Uterine leiomyomas
Subinvolution of the Uterus Signs and Symptoms Prolonged discharge of lochia. Irregular or excessive uterine bleeding. Pelvic pain or feelings of pelvic heaviness. Backache, fatigue and persistent malaise.
Late Postpartum Hemorrhage Therapeutic Management Oxytocin, Methergine, and prostaglandins are the most commonly used pharmacologic measures. Dilation and curettage may be necessary to remove fragments if bleeding continues or recurs. Antibiotics Ultrasound to ID retain materials
Late Postpartum Hemorrhage Nursing Interventions Assess frequently for a resumption of bleeding Allow rest periods Assist in getting out of bed Encourage intake of foods high in iron. If problems arise, act to minimize hemorrhaging
Late Postpartum Hemorrhage Patient Education: Teach mother and family how to assess for condition. how to locate and palpate the fundus and estimate fundal height. Explain changes of lochia from rubra to serosa and then to alba. Report deviation from expected pattern or duration of lochia.
Hypovolemic Shock Signs and symptoms may be Excessive blood loss Tachycardia.   Increased respiratory rate. Decreased blood pressure. Skin and mucous membranes become pale, cold and clammy. Anxiety, confusion, restlessness and lethargy. Urinary output decreased.
Three Major Causes of Thrombosis are: Venous Stasis. Hypercoagulation. Blood Vessel Injury
Thromboembolic Disorders Predisposing Factors Varicose veins. Obesity. History of thrombophlebitis. Use of oral contraceptives before pregnancy. Smoking. Women older than 35 years or who have had more than three pregnancies are also at increased risk.
Superficial Venous Thrombosis (SVT) Clinical Signs and Symptoms Swelling of the involved extremity. Redness, tenderness and warmth. An enlarged, hardened, cordlike vein may be palpated. The woman may experience pain when walking. Often there are no signs at all.
Superficial Venous Thrombosis (SVT) Therapeutic Management Analgesics, rest, and elastic support. Elevation of the lower extremity improves venous return. Warm packs may be applied to promote healing. Woman should avoid standing for long periods
Deep Vein Thrombosis (DVT) Clinical Signs and Symptoms Swelling of the leg. Erythema, heat or tenderness. Pedal edema. also: Positive Homan’s Sign: dorsiflexion of the foot causes pain. Affected leg may become pale and cool to the touch with decreased peripheral pulses. Pain on ambulation. Chills, general malaise. Absent signs in 75%
DVT Diagnosis Is made using: Ultrasonography with vein compression. Doppler flow analysis. MRI may be used for pelvic veins.
Preventing thrombus formation: Identifying high risk Ambulate or Range of Motion Antiembolism stockings or sequential compression devises Lifestyle changes
Initial Treatment when a DVT occurs includes: Gradual ambulation. Avoid sitting with the legs dependent. Anticoagulant therapy Analgesics to control pain. Antibiotic therapy to prevent or control infection. Continuous moist heat for pain relief and increase circulation.
DVT Therapeutic Management Heparin During the postpartum period, heparin can be changed to warfarin (Coumadin) therapy and may be continued for 6 weeks to 6 months
Thromboembolic Disorders Nursing Management Palpate pedal pulses Monitor for signs of bleeding Be alert for signs of hemorrhage such as Monitor for pulmonary embolism
Nursing Management Con’t Instruct the woman in measures to prevent excessive anticoagulation. Explain the need for repeated labs to regulate the dose of the anticoagulants.
Question: Name two risk factors for thrombosis common in pregnancy? Answer: Increased clotting factors and venous stasis
Question: What are signs and symptoms of a pulmonary embolism? Answer: Sudden chest pain, dyspnea, decreased LOC
Puerperal Infections Bacterial infection after childbirth. Sites of infection Endometritis Metritis Wound Infections Episiotomy. Lacerations. Surgical incision. Mastitis Urinary tract infections Septic pelvic thrombophlebitis
Puerperal Infection Signs and Symptoms Temperature of 38C (100.4 F) or higher after the first 24 hours.  Localized redness, edema, and pain. Fever, malaise, achiness and loss of appetite.
Puerperal Infection Predisposing Risk Factors Childbirth, Breastfeeding, Cesarean birth, Use of forceps or vacuum extractor, Prolonged rupture of membranes, Urinary catheterization, Repeated vaginal examinations during labor, Retained fragments of placenta, Anemia, Poor nutritional state.
Endometritis: An infection of the uterine lining, often at the site of the placenta. Occurs in 1% to 3% of vaginal births and 5% to 20% of cesarean births. Caused by organisms that are usually found in group B streptococci, enterococci and klebsiella pneumonia.
Endometritis Signs and Symptoms Usually temperature occurs within 36 hours after delivery and include the following: Chills, malaise, lethargy and anorexia. Uterine tenderness. Abdominal pain and cramping. Foul-smelling lochia. Leukocytosis after the first day that is not decreasing.
Endometritis Therapeutic Management: Complications: major risk of endometritis is that the infection may spread to the nearby organs. Culture and sensitivity of the uterine cavity. IV Antibiotics usually clindamycin plus gentamicin are often used until the woman has been afebrile for 48 hours. Analgesics such as antipyretics for fever. clindamycin gentamicin
Endometritis Nursing Interventions Patient Education: teach woman usual progression of lochia to include color and smell. Keep patient in Fowler's position to facilitate drainage of infected lochia. Analgesics for pain and cramping and antibiotics as ordered.
Endometritis Nursing Interventions cont. Observe patient for: Spread of infection. Absent bowel sounds. Abdominal distention. Nausea or vomiting. Increasing abdominal pain.
Wound Infection Most commonly occurs in cesarean surgical incisions, episiotomies or lacerations. Signs and Symptoms include: Inflammation (redness, edema, warmth, pain). Separation of suture line. Purulent drainage. Fever and malaise.
Wound Infection Therapeutic Management Draining the affected area as needed. Culture and sensitivity of wound exudates. Broad-spectrum antibiotics may be ordered. Analgesics.
Wound Infection Nursing Interventions Aseptic/sterile technique for all wound care. Teach proper perineal hygiene. Sitz baths for perineal infection. Teach the patient to report fever or increased pain.
Urinary Tract Infections Signs and Symptoms typically begin on the first or second postpartum day. They include: Dysuria, urgent and frequent urination. Suprapubic pain. Low-grade fever. Chills, spiking fever, flank pain and nausea and vomiting all occur if the infection has progressed to the upper urinary tract. 
Urinary Tract Therapeutic Management Clean-catch or catheterized urine for culture and sensitivity. Broad-spectrum IV antibiotics. Increased fluid intake 3000ml fluid each day.
Urinary Tract Nursing Interventions Teach patient which foods increase acidity of urine, such as apricot, cranberry juice, plum and prune. Teach mother to include measures to prevent UTI such as proper perineal care and urinating frequently. +fluid finish medication regime
Question: What are the most likely sites for postpartum infections? Answer: Laceration, Uterus, Urinary tract, Breast
Question: Name three nursing interventions to teach UTI prevention. Answer: Teach perineal hygiene, encourage increased fluid intake, teach to increase acidity with foods (apricots, cranberry, plums, prunes)
Postpartum Depression: Most common It occurs in 19% of woman usually developing between the first 3 months postpartum Hormonal fluctuations Personal or family history of depression or mental illness. Marital dysfunction or lack of support. (external social factor)
Postpartum Depression Signs and Symptoms Lack of enjoyment in life and food. Disinterest in others including the newborn; unable to feel pleasure or love. Feelings of inadequacy, unworthiness, guilt, shame and inability to cope. Loss of mental concentration and inability to make decisions.
Postpartum Depression’s Impact on the Family Postpartum depression impacts and creates strain for the entire family. Communication is impaired. Infants of depressed mothers are at risk for later cognitive and behavioral problems.
Postpartum Depression Nursing Care All women should be assessed for depression during pregnancy, at the birth facility and during follow-up visits. When mothers bring infants into the clinic for newborn visits, assess the new mother’s emotional state and provide referrals if necessary.
Bipolar disorder: a disorder characterized by periods of depression and hypomanic episodes. Periods of irritability, hyperactivity, euphoria Need to be assessed for risk of suicide or harming infant Treatment is with medications and psychotherapy
Postpartum Psychosis Occurs in 1 to 2 out of 1000 postpartum women. It generally surfaces within 3 months of delivery. Suicide and infanticide are possible, especially during depressive episodes.
Postpartum Psychosis Signs and Symptoms Sleep disturbances Hallucinations and delusions which increases risk that mother will kill herself or baby. Tearfulness. guilt and feelings of worthlessness. Lack of appetite. An excessive concern with the baby health. Withdrawn.
Postpartum Psychosis Assessment and Management: Beyond the scope of nursing. Once signs are symptoms are recognized, the woman requires immediate medical attention and hospitalization. Postpartum psychosis is a medical emergency!
Question: What might the infant and mother be at risk for if the mother is suffering from major depression? Answer: Death
Question: What are the three types of mood disorders related to the postpartum period? Answer: Postpartum Blues, Postpartum Depression, Postpartum Psychosis
molding changes in head and shape to allow passage through birth canal Resolves gradually within days
Suture Lines & Fontanels Overriding suture lines: due to molding Bulging fontanels: may indicate increased intracranial pressure
Caput Succedaneum Localized edema that crosses suture lines Results from pressure against mother’s cervix or use of vacuum extractor
Cephalohematoma Caused by bleeding between periosteum and skull Does not cross the suture line Infant at greater risk for jaundice due to break down of RBCs
Vernix Provides protective covering for fetal skin in utero Common in pre-term/post-term infants
Lanugo Fine hair that covers fetus in utero Covers shoulders, upper back, forehead, sides of face
Milia White cysts, 1-2mm Distending sebaceous glands “Baby acne”
Stools of infant Meconium Stool: First stools; tarry dark green/black Transitional Stool: Loose, green/brown; 2nd-3rd day Breast Milk Stool: Soft, seedy, mustard yellow Formula Stool: Solid, pale yellow/light brown, odorous
Genitourinary of infant Urine First void by 24 hours Frequency Genitalia Female: swollen, white discharge, pseudomenstration Male: Scrotum: palpate testicles, observe skin, meatus location
Assessment of Neurological System Rooting: stimulated by touching the side of the newborn's cheek near the mouth. Infant turns head toward that side and opens the lips.
Sucking: stimulated by placing a nipple or gloved finger into the infant's mouth. Suck reflex is assessed for presence and strength.
Moro reflex (startle reflex): 1)Occurs when the infant’s head and truck are allowed to drop back 30 degrees when the infant is in a slightly raised position. 2)Infant’s arms and legs extend and abduct, with the fingers fanning open and thumbs and forefingers forming a C position.
Tonic Neck Reflex: in a supine position, the infant's head is quickly turned to one side, arm and leg will extend on that side, and opposite arm and leg will reflex; posture resembles a fencing position.
Palmar grasping reflex: occurs when the infant’s palm is touched near the base of the fingers. Hand closes into a tight fist.
Babinski: 1)Elicited by stroking the lateral sole of the infant’s foot from the heel forward and across the ball of the foot. 2)Causes the toes to flare outward with dorsiflexion of big toe.
Dance or stepping reflex: 1)Occurs when infants are held uprights with their feet touching a solid surface. 2)They lift one foot and then the other, giving the appearance that they are trying to walk.
Breastfeeding Colostrum: (a)A thick yellow substance high in protein, minerals, fat soluble vitamins and immunoglobulins, which transfers some immunity to the infant. (b)Its laxative effect speeds the passage of meconium.
Breastfeeding Transitional milk: (a)Appears as the milk changes from colostrums to mature milk. (b)Immunoglobulins and protein decrease, whereas lactose, fat, and calories increase.
Breastfeeding Mature milk: (a)Established by two weeks after delivery. (b)Bluish in color and not as thick as colostrum.
warmth for the baby when baby is born make sure to dry baby off immediatley. keep away from cool objects and window. the mother is the best source of warmth for the baby.
Question: Name the three stages of breast milk production Colostrum, Transitional milk, Mature milk
Question: Name four methods of heat loss Evaporation, Convection, Conduction, Radiation
Question: How is bonding facilitated? Eye to eye contact, touching, verbal behavior
after baby is stable Erythromycin 0.5% Apply 1 to 2 cm ribbon to the lower conjunctival sac of each eye within hour after birth. One dose of vitamin K IM within the first hour after birth prevents bleeding problems
Hyperbilirubinemia There are two types of jaundice: Physiologic Jaundice (also called nonpathological or developmental jaundice). Pathologic Jaundice.
Physiologic Jaundice Appears on the second or third day after birth (considered normal in term newborns) Immature liver function causes bilirubin levels to rise from birth, peaks between 2nd – 4th days after birth at 5-6 mg/dl fall to normal levels (1.0 mg/dl) by 5-7 days  Jaundice becomes visible when it reaches 5 to 7 mg/dl.
Pathologic Jaundice Appears during the first 24 hours after birth Total Serum Bilirubin (TSB) rises and falls by age of infant indicating degree of risk High risk if TSB greater than 8 mg/dL at 24 hours old Clinical jaundice that lasts more than 2 weeks in a full term infant.
Pathologic Jaundice Most commonly a result of: Abnormalities causing excessive destruction of erythrocytes. Incompatibilities between mother’s and infant’s blood types. Infection. Metabolic disorders.
Breastfeeding Associated Jaundice Most common cause of jaundice inadequate intake. Levels usually peak at 5-10 mg/dl and fall gradually over several months
Pathologic jaundice may lead to kernicterus (acute bilirubin encephalopathy). may lead to: Cerebral palsy Cognitive impairment Hearing loss and/or More subtle neurologic and developmental problems.
Factors that Increase Hyperbilirubinemia Hemolysis of excessive erythrocytes. Short red blood cell life. Liver immaturity. Lack of intestinal flora. Delayed feeding. Trauma resulting in bruising or cephalohematoma. Cold stress or asphyxia.
Common Risk Factors for Hyperbilirubinemia Prematurity. Cephalo-hematoma. Bruising. Delayed or poor intake. Cold Stress. Rh or ABO incompatibility. Polycythemia. Sepsis/infection. Sibling with jaundice.
Common Risk Factors for Hyperbilirubinemia cont. Asphyxia. Male gender Maternal diabetes or pre-eclampsia Breastfeeding Asian, Native American or Eskimo heritage.
Assessment for jaundice in infant Blanch the infant’s skin on the nose or sternum to check for jaundice Determine how far down the body the jaundice extends.
Therapeutic Management jaundice Phototherapy- exposing infant to fluorescent lights Exchange Transfusion Infants with hyperbilirubinemia risk factors (such as premature infants) may need treatment at lower TSB levels
Nursing Interventions jaundice Maintain a neutral thermal environment. Undress newborn down to diaper Turn frequently Check temp q2-4 hrs Dress newborn when removing from lights Provide optimal nutrition.
Nursing Interventions cont. jaundice Protect the eyes. Enhance response to therapy. Ensure proper placement and distance of light source Avoid creams
Nursing Interventions cont jaundice Detect complications. lethargy Increased muscle tone Decreased Moro reflex Poor feeding High pitched cry, irritability, opisthonos and seizures Note changes in skin Parent Teaching
Question: Name three nursing interventions for infants undergoing treatment for physiologic jaundice. Maintain a neutral thermal environment, administer phototherapy, provide optimal nutrition, detect complications and teach parents.
Acrocyanosis Hands and feet may appear slightly blue. common during the first day
Harlequin Color Change Deep red color over half of body with pallor on the other half of the body. Cause is vasomotor instability. Usually transient and benign.
Cutis Marmorata (Mottling) Lacelike red or blue pattern. May occur when infant is cold. If persistent it may indicate a chromosomal abnormality.
Milia Pearly white pinpoint papules on face and nose of newborn. Disappear within a few weeks without treatment. Educate parents not to attempt to "squeeze out" the white material because infection can occur.
Erythema Toxicum Benign rash of unknown cause in newborns, blotchy red areas that may have white or yellow papules or vesicles in the center. Harmless condition commonly called newborn rash or fleabite rash and resembles small bites or acne.
Erythema Toxicum area and cont. Rash appears during the first 24 to 48 hours after birth, although occasionally not until 1 to 2 weeks. Most common over the face, back, shoulders, and chest.
Erythema Toxicum Cont Does not result from infection but should be differentiated from a pustular rash cause by staph infection or vesicles from herpes simplex. Cause is unknown, but it occurs in 50% of full-term infants and disappears within hours or up to 10 days.
Mongolian Spots Bluish black marks that resemble bruises. Usually occur in the sacral area. Frequently in newborns with dark skin.
Nevus Simplex “Stork bite” Flat, pink, or reddish discoloration. Usually on face or neck. Color blanches. Disappear by 2 years of age.
Nevus Flammeus Known as port wine stain Permanent, flat, dark, reddish-purple mark. Varies in size and location. Can be removed by laser surgery. Lesions on forehead and upper eye may be associated with Sturge-Weber syndrome(nuerologic condition that may involve problems).
Nevus Vasculosus Known as strawberry hemangioma. Enlarged capillaries in the outer layer of skin. Dark red and raised with a rough surface. May grow quickly for 5-6 months. Will disappear without treatment by school age.
Café-au-lait Permanent light brown spots Usually benign Six or more spots or spots larger than 0.5 cm are associated with neurofibromatosis, a genetic condition of neural tissue.
Bruises May occur on any part of the body. Bruising on the face or head may be from forceps or vacuum assisted delivery or if there was a tight nuchal cord. Document size, color, and location
Petechiae Pinpoint bruises that resemble a rash. Increased intravascular pressure. May indicate infection or a low platelet count.
Question: Mongolian spots can be mistaken for what condition? Answer: Child abuse
Question: How long does erythema toxicum last? Answer: Hours to 10 days
Circumcision Most common surgical procedure performed on males. Reasons for circumcision. AAP states benefits outweigh the risks Benefits are not enough to be a routine recommendation Reduces penile cancer, UTIs in early life, HIV infection and transmission of other STDs. Religious, cultural or social reasons.
Reasons for rejecting circumcision. Pain and risk of surgery Considered cosmetic and unnecessary Fear of complication although uncommon Lack of insurance coverage Cultural reasons
Pain Relief circumsicion procedure Acetaminophen may be given before and after procedure per the institutions SOP ACOG and the AAP recommend local anesthesia. Non-pharmacologic methods also decrease stress. Pacifier Oral sucrose Visual and auditory calming methods
Methods of circumsiscion Both methods: foreskin is first separated from the glans with a probe and incised to expose the glans. Gomco clamp. Plastibell.
Nursing Considerations Before the circumciscion Assist in decision making. Verify signed consent. NPO 2-4 hours before. Bulb syringe for secretions. Ensure infant has received Vit. K
Nursing Considerations Before the Procedure cont. Place a light blanket under infant to pad the circumcision board Position the heat lamp or radiant warmer to avoid cold stress.
Nursing Considerations After the Procedure Hold and soothe infant or give to parents. Gentle pressure for bleeding. Notify physician if excessive bleeding occurs Note first void (should be between 6-8 hours.)
Parent Teaching circumscision Squeeze warm water over penis to clean. Yellow crust on glans is normal. Apply petroleum jelly (if Gomco procedure).
Parent Teaching circumscision cont. Notify physician of signs of infection, excessive bleeding or swelling, if the plastibell slips onto the shaft or hasn’t come off by 5-8 days or if the baby hasn’t voided within 8 hours.
Question: For what reason should a parent contact a nurse or provider following a circumcision? If the plastic ring has not fallen off in 8 days. Any unusual swelling or bleeding. If the plastic ring has slipped onto the shaft of the penis (this is an emergency). No voiding within 8 hours after a circumcision.
Gestational Age Classifications Preterm: less than 38 weeks. Term: 38-42 weeks. Post-term: beyond 42 weeks.
Ballard Scoring System Gives a score to each assessment area with the total score determining the gestational age of the infant. can estimate age to within two weeks
Gestational Age The estimated age can be compared with the newborn’s weight, length, and head circumference to determine whether the neonate is large, average or small in size
Birth Weight low birth weight Low birth weight (LBW): weight is 2500 g (5 lb 8 oz) or less at birth and of any gestational age (not to be confused with preterm).
very low birth weight Very low birth weight (VLBW): weight is 1500g (3lb, 5 oz) or less at birth.
extremely low birth weight Extremely low birth weight (ELBW): weight is 1000g (2 lb 3 oz) or less at birth.
Question: What is the difference between a low birth weight baby and a small for gestational age (SGA) baby? A low birth weight baby is any newborn regardless or gestational age that weights <2500 g and a SGA baby is below the 10% of the average weight of newborns born at the same gestational age
Handicaps of Preterm Newborn: Inadequate Respiratory Function Respiratory Distress Syndrome: Symptoms of respiratory distress may begin within the first hours after birth. Symptoms include tachypnea, tachycardia, nasal flaring, cyanosis, xiphoid and intercostal retractions and grunting.
Gestational Age Small for gestational age (SGA): size is below the 10th percentile. Appropriate for gestational age (AGA): infant whose size is AGA falls between the 10th and 90th percentiles. Large for gestational age (LGA): size is above the 90th percentile.
Inadequate Respiratory Function Cause Inadequate amounts of surfactant. Poorly developed cough reflex and narrow respiratory passages. Apneic spells. Weak chest wall muscles.
Inadequate respiratory function Nursing interventions include: Frequent assessment Repositioning to mobilize secretions* Oxygen administration Mechanical ventilation Suction
Thermoregulation Heat Loss Thin skin and superficial vessels Lack of brown fat Larger head and greater body surface area Temp control center of the brain is immature Limp, extended body posture (increases BSA exposed to air)
Signs of Inadequate Thermoregulation Decreased skin temperature. Signs of respiratory difficulty. Signs of hypoglycemia. Mottled skin. Lethargy, irritability or weak cry or suck. Decreased muscle tone Poor weight gain
Heat Loss Nursing Interventions Place infant in radiant warmer or incubator. Monitor infant's skin temperature using a skin probe to maintain optimum levels. Avoid forms of heat loss. Warmed oxygen. Maintain fully dressed when weanning to open crib.
Question: Name three signs and symptoms of RDS? Answer: Tachypnea Tachycardia Nasal flaring Cyanosis Xiphoid and intercostal retractions Grunting.
Question: Why are premature infants at increased risk for RDS? Answer: Inadequate amounts of surfactant. Poorly developed cough reflex and narrow respiratory passages. Apneic spells. Weak chest wall muscles.
Question: Name three signs of inadequate thermoregulation Answer: Decreased skin temperature. Signs of respiratory difficulty. Signs of hypoglycemia. Mottled skin. Lethargy, irritability or weak cry or suck. Decreased muscle tone Poor weight gain
Problems with Fluid and Electrolyte Balance Preterm infants lose fluid very easily Skin has little protective subcutaneous white fat and is more permeable than a term infant’s skin. Kidney development incomplete. Electrolyte regulation imbalance (NA, K CA).
Problems with F & E Con’t Nursing Interventions: I & O. Urine specific gravity. Daily weights, (sometimes bid). Signs of dehydration or fluid overload must be carefully monitored by the nurse
Problems with infection Incidence of infection is 3 to 10 times greater. Maternal infection and immature immune system predispose infant to sepsis.   Multiple invasive procedures increase risk
Problems with infection Treatment includes: IV antibiotics. Maintenance of warmth. Nutrition. Meticulous handwashing
Problems with Digestion Born before full accumulation of nutrient stores GI tract does not absorb nutrients well Lack reservoirs of calcium, iron and other nutrients Have minimal fat stores and glucose reserves which increases risk for hypoglycemia
Question: What predisposes premature newborns to fluid and electrolyte imbalances? Answer: Increased fluid loss and imature kidneys
Question: Why are premature newborns more susceptible to infection? Answer: Immature immune system and increased need for invasive procedures
Question: Name three reasons why the premature newborn struggles to obtain adequate nutrition Immature GI tract Decreased accumulated nutrient, fat and glucose reserves Insufficient bile acids and pancreatic lipase Lactase deficiency Small stomach Difficulty coordinating sucking, swallowing and breathing Missing gag reflex Easily tired
Common Complications of Preterm Infants Bronchopulmonary Dysplasia (BPD) Periventricular-Intraventricular Hemorrhage (PIVH) Retinopathy of Prematurity (ROP) Necrotizing Enterocolitis (NEC)
Bronchopulmonary Dysplasia Chronic condition occurring most often in infants weighing less than 1500 g at birth. It is associated with a mortality rate of 10% to 25%. Infants continue to require oxygen, positive pressure ventilation of continuous positive airway pressure at 36 weeks’ gestation
Bronchopulmonary Dysplasia Pathophysiology BPD results from a combination of factors. High levels of oxygen, oxygen-free radicals, and high positive-pressure ventilation that damage bronchial epithelium and interfere with alveolar development.
BPD Pathophysiology cont. The result is: Inflammation. Atelectasis. Edema. Airway hyperreactivity with loss of cilia, thickening of the walls of the alveoli, and fibrotic changes.
Bronchopulmonary Dysplasia Manifestations increased need for ventilation or an inability to be weaned from the ventilation and oxygen. Other signs include: Tachycardia. Tachypnea. Retractions.
BPD manifestations cont. Rales. Wheezing. Respiratory acidosis. Increased secretions. Bronchospasm. Characteristic changes in the lungs on chest X-ray. Pulmonary edema
Bronchopulmonary Dysplasia Therapeutic Management Prevention includes: Use of maternal steroids to reduce prematurity and RDS. Minimizing exposure to oxygen. Avoidance of fluid overload. Increased nutrition.
Bronchopulmonary Dysplasia Treatment Gradual decreases inamount of oxygen, bronchodilators, antibiotics as necessary. Diuretics are given/fluids restricted, infants prone to fluid overload. Increased calories and protein are important. Infant may go home on long-term oxygen therapy.
Periventricular-Intraventricular Hemorrhage Most common in infants <32 weeks or < 1500 grams. Less frequent and severe if mother received steroids prior to delivery. Caused by ruptured blood vessels in the germinal matrix around ventricles of brain. Graded on 1-4 scale. May result in nuerologic abnormalities and developmental delays
PIVH Signs include: Lethargy, poor muscle tone Apnea or cyanosis Full or bulging fontanels A drop in hematocrit Abnormal eye positions or seizures
PIVH: Nursing Interventions Avoiding situations which increase cerebral blood flow and blood pressure. Handling is kept to a minimum Pain and environmental stressors are reduced. Daily head circumference and observation for changes in neurological status which may be subtle.
Retinopathy of Prematurity Infants of less than 29 weeks 1000 g or less. Check pulse oximetry frequently. Treatment: Consult with an ophthalmologist. Possible laser photocoagulation surgery. Cryotherapy. Reattachment of the retina.
Necrotizing Enterocolitis A serious inflammatory condition of the intestinal tract that may lead to cellular death or areas of intestinal mucosa Incidence higher in infants that have been fed Ilium/proximal colon are most affected Mortality rate 10-30% survivors have long term GI issues.   During asphyxia blood is diverted from the GI tract to vital organs. Less common in breastfed infants
Necrotizing Enterocolitis Signs Abdominal distention. Increased gastric residuals. Decreased or absent bowel sounds. Loops of bowel seen through abdominal wall Vomiting. Bile-stained emesis or residuals.
Necrotizing Enterocolitis Signs cont. Occult blood in stools. Abdominal tenderness. Signs of infection. Respiratory distress, bradycardia, temperature instability, lethargy, hypotension and shock may also be present.
Necrotizing Enterocolitis Treatment Antibiotics. Parenteral nutrition to rest the bowel. NPO. Continuous or intermittent gastric suction. May need to surgically remove necrotic bowel and place an ostomy.
Necrotizing Enterocolitis Nursing Interventions Measure abdominal girth daily. Manage IV fluids and parental nutrition. Strict I&O. Encourage mothers to provide breast milk Position infant on the side to minimize effects of pressure on the diaphragm from distended intestines.
QUESTION: Name four common complications of the preterm newborn. Bronchopulmonary Dysplasia (BPD) Periventricular-Intraventricular Hemorrhage (PIVH) Retinopathy of Prematurity (ROP) Necrotizing Enterocolitis (NEC)
Nutrition: Parenteral or gavage feedings. Need special formulas or fortified breast milk. 22-24 kcal/oz
Assess how well infant tolerates feedings: Check residual volume before tube feeding or refer to SOP for continuos feeding Excessive residual may indicate need to change type or amount of formula The next feeding may be reduced by the amount of the residual.
Readiness for Feeding Intact gag reflex. Coordination of sucking, swallowing, and breathing is complex. Oral feedings usually start at 32-34 wks. Frequent choking, gagging, cyanosis = inability to advance. Assess respiratory rate tachypnea could lead to aspiration.
Facilitating Breastfeeding Breast milk Stimulates immune and GI system maturity More easily digested Support and encourage breastfeeding mothers Patient teaching Breast pump for 10-15 min 8x a day to maintain lactation
QUESTION: At what gestational age do infants have the ability to suck and swallow? ANSWER: 32-34 weeks
QUESTION: What respiratory rate is the safe upper limit for oral feedings? ANSWER: 60
Potential parent responses to a preterm infant: Emotionally traumatic to parents. Difficulty developing feelings of attachment. Delayed attachment. Loss of parental role due to extended hospitalization and separation.
Parenting Nursing Interventions If possible plan NICU visit before preterm delivery. Allow parents to see and touch newborn even if only briefly to initiate bonding. Prepare parents for what they will see. Allow support person to watch initial NICU care if possible Take mother to NICU as soon as possible
Parenting Nursing Interventions Allow parents to vent their feelings and concerns. Involve in all aspects of infant care as soon as possible. Encourage Kangaroo care.
Advantages of Kangaroo care skin to skin for the preterm infant Improved infant growth Decreased length of hospital stay Less crying Fewer pain responses Fewer infections Infant must have stable vital signs and will need continued monitoring for response to KC.
Parenting Collaborate with other disciplines. Discuss home care with parents. Assist parents in planning how to integrate new infant into family. Refer to support group if possible.
Question: What are the benefits of Kangaroo care? Answer: Improved infant growth Decreased length of hospital stay Less crying Fewer pain responses Fewer infections
The Post-term Newborn Many post dates infants are of normal size or are LGA. Approximately 20% are affected with “post-maturity syndrome.” In these cases placental function has decreased as the pregnancy is prolonged
Post-mature Newborn Physical Characteristics: Thin with loose skin. Unusually alert and wide-eyed. Little or no vernix and lanugo. Skin is wrinkled, cracked and peeling. Abundant hair and long nails.
Problems with Post Maturity Asphyxia. Meconium aspiration. Poor nutrition status due to depleted reserves. Higher perinatal mortality rate. Risk for low temperature. Polycythemia and jaundice
Postterm Nursing Care Thorough assessment for injuries. Observe infant for: Respiratory distress. Hypoglycemia. Hypothermia. Jaundice.
Question: What should the nurse observe for in the post term newborn? Answer: Respiratory distress. Hypoglycemia. Hypothermia. Jaundice.
Hydrocephalus Caused by imbalance in production and absorption of CSF in ventricles of the brain Pathophysiology: Congenital or acquired Classified as non-communicating or communicating
Hydrocephalus Pathophysiology Con’t Often associated with myelomeningocele. May result from preexisting developmental defect, intracranial hemorrhage, infection, or a space occupying lesion.
Arnold-Chiari Malformation Congenital anomaly in which the cerebellum and medulla oblongata extend down through the foramen magnum
Hydrocephalus Assessment in Infants Head enlarged Fontanel full or bulging Neurologic signs present and progressive. For eg. Setting-sun sign
Hydrocephalus in older children Lesions produce other neurologic signs through pressure on adjacent structures before causing CSF obstruction Signs and Symptoms related to the focal lesion
Hydrocephalus Diagnostic Evaluation Factors: Time of onset Presence of preexisting lesions Diagnostic tools: CT MRI
Hydrocephalus Therapeutic Management Treatment directed toward: Relief of hydrocephalus Treatment of complications Management of problems related to psychomotor development
Hydrocephalus Therapeutic Management cont. Surgery: Direct removal of an obstruction (such as tumor) Placement of a ventriculo-peritoneal shunt
Hydrocephalus Preoperative Care Observe for signs of increasing ICP Measure head circumference daily Gently palpate fontanels and suture lines Observe for irritability, lethargy, seizure activity, altered vital signs or feeding behavior Maintain adequate nutrition
Postoperative Nursing Care Hydrocephalus Position on un-operated side Keep flat Monitor for increased ICP, abdominal distention, or signs of infection Assess pain and provide relief Monitor I&Os
Question: What are the two classifications for hydrocephalus? Answer: Communicating and noncommunicating hydrocephalus
Neural Tube Defects Abnormalities derived from the embryonic neural tube Failure of neural tube closure produces defects of varying degrees.
Spina Bifida Midline defect involving failure of the bony spine to close Categorized into two types: Spina Bifida Occulta Spina Bifida Cystica
Spina Bifida Occulta Not externally visible May be a dimple on the back, which may have a tuft of hair over it Failure of the vertebral arch to close, usually without other anomalies.
Spina Bifida Cystica Visible defect with external saclike protrusion. Two major forms:  Meningocele: encases meninges and spinal fluid. Spinal cord not involved. Meningomyelocele: contains meninges, nerve roots, spinal cord, and spinal fluid.
Neural Tube Defects Diagnostic Evaluation MRI Ultrasound CT Myelography Prenatal detection by elevated AFP, fetal ultrasound & CVS
Neural Tube Defects Therapeutic Management Initial Care: Prevention of infection Surgery Neurologic assessment, including observation for associated anomalies Dealing with impact of anomaly on the family
Neural Tube Defects Therapeutic Management Initial Care Continued Early closure of the defect Identify other complications associated with this abnormality Assess for any sequelae associated to diagnosis
Neural Tube Defects Nursing Considerations Note position and covering of the defect at birth. Observe movement below the defect. Examine for a relaxed anus and dribbling of stool and urine.
Neural Tube Defects Nursing Considerations cont. Care of the sac. Positioning. Diapering. Meticulous skin care.
Neural Tube Defects Nursing Considerations Con’t Postoperative nursing care. Latex-free environment. Family support and education.
Question: Name two types of spina bifida cystica. Answer: Meningocele and myelomeningocele.
Cleft Lip and Cleft Palate Facial malformations that occur during embryonic development Most common congenital deformities of the head and neck Occur together or separately, on one or both sides
CL / CP Therapeutic Management Early neonatal repair Speech impairment Long-term follow-up
CL / CP Feeding Considerations Con’t Feed in upright position Feed slowly Wash away milk curds ESSR feeding
Postoperative Care Cleft Lip Protect operative site  Prevent infant from sucking and crying Elbow restraints Position on back or side
Postoperative Care Cleft Lip Prevent infection/scarring Pain relief Clear liquids Gentle aspiration
Post-op Care Cleft Palate May lie on abdomen Feeding Oral packing Elbow restraints
Parent Education CL / CP Diet and feeding techniques Prevent infections Regular follow-up Psychosocial support. Refer to support groups.
Question: What is the difference between cleft lip and cleft palate? Cleft Lip (CL): Minor notching of the lip or complete separation through the lip and into floor of nose. Cleft Palate (CP): Midline fissure of the palate that result from failure of the two sides to fuse.
Congenital Clubfoot A complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus and ankle equinus.
Congenital Clubfoot Types Talipes varus: inversion or bending inward Talipes valgus: eversion or bending outward Talipes equines: plantar flexion, toes lower than heel Talipes calcaneus: dorsiflexion, toes higher than heel
Congenital Clubfoot Talipes equinovarus *Child walks on his toes and the outer edges of his feet. Incidence is 1 to 2 per 1000 live births. Boys 2x as often as girls. Bilateral clubfeet occur in 50% of the cases. Incidence
Classification Positional syndromic- Associated with other anomalies such as myelomeningocele. Congenital or idiopathic.
Congenital Clubfoot Therapeutic Management Goal of treatment is to achieve a painless, plantigrade, stable foot Treatment involves three stages: Correction of deformity Maintenance of the correction Follow-up
Congenital Clubfoot Therapeutic Mgmt Con’t Serial casting Manipulation and casting repeated frequently Surgical intervention
Congenital Clubfoot Nursing Considerations Same as for any child with a cast Observation of skin for breakdown Assess for compromised circulation Parent teaching
Developmental Hip Dysplasia Describes a spectrum of disorders related to abnormal development of the hip that may develop at any time during fetal life, infancy, or childhood.
Three Degrees of DHD Acetabular dysplasia (or preluxation) Subluxation Dislocation
Diagnostic Evaluation Often not detected at birth Ortolani or Barlow tests Other signs Shortening of the affected limb One buttock appears higher than the other Asymmetry of gluteal and thigh folds
Therapeutic Management Developmental Hip Dysplasia Treatment begun as soon as the condition is recognized Treatment varies with age of child and extent of dysplasia Newborn to 6 months 6-18 months Older children
Nursing Considerations Developmental Hip Dysplasia Parent teaching Pavlik harness Cast Skin care Nurturing Age-group appropriate activities
True or False: Developmental Hip Dysplasia is often not detected at the initial examination after birth. True
Phenylketonuria (PKU) A genetic disorder that causes central nervous system damage from toxic levels of the amino acid phenylalanine in the blood All newborns are screened for this condition (U.S.) Incidence: the U.S. is 1 in 15,000 live births Highest in Northern European ancestry; American Indians and Alaskan Natives.
Phenylketonuria (PKU) Causes: A deficiency of the liver enzyme phenylalanine hydrolase, which is needed to convert phenylalanine to tyrosine It is an autosomal recessive disorder
Phenylketonuria (PKU) Signs and Symptoms: Digestive problems, feeding difficulties Failure to thrive (growth failure) Vomiting, and later progress to seizures Musty odor in urine and severe intellectual disability
Phenylketonuria (PKU) Signs and Symptoms in the Older Child Eczema Hypertonia Hyperactive behavior Intellectual disability Hypopigmented hair, skin, and irises Commonly bizarre and schizoid behavior
Therapeutic Management Phenylketonuria (PKU) Further evaluations for positive tests Low-phenylalanine diet Special formula for infants Diet is primarily fruits, vegetables, and starches with a phenylalanine-free protein supplement Small amounts of phenylalanine are allowed
Phenylketonuria (PKU) Nursing Considerations Ensure newborns are screened for PKU at the appropriate time Assist parents in regulating the diet to meet infant’s changing phenylalanine needs
Why is early detection of PKU crucial? Phenylalanine accumulates in the blood and causes severe mental retardation if not treated early.
Down Syndrome (Trisomy 21) Most common chromosomal abnormality of a generalized syndrome. Incidence: 1 in every 800 to 1000 live births. Occurs slightly more often in white than blacks
Down Syndrome Etiology Statistically greater risk when maternal age > 35 Increase in congenital abnormalities when paternal age > 55 There are three phenotypes: Trisomy 21 (nonfamilial trisomy 21) Translocation of chromosomes 15 and 21 or 22 Mosaicism
Trisomy 21: Attributable to an extra chromosome 21 Occurs in about 95% of all cases of Down Syndrome
Translocation of chromosome 15 and 21 or 22: This type of genetic aberration is usually hereditary Not associated with advance parental age Occurs in about 3% to 4% of cases
Mosaicism: Refers to cells with both normal and abnormal chromosomes The degree of physical and cognitive impairment is related to the percentage of cells with the abnormal chromosome makeup Occurs in 1% to 2% of cases.
Diagnostic Evaluation Down Syndrome Alpha-fetoprotein (AFP) screening   Multiple Marker screening Chorionic villus sampling Amniocentesis Nuchal translucency
Clinical Manifestations Down Syndrome Head: Separated sagittal suture Brachycephaly Skull rounded and small Flat occiput Enlarged anterior fontanel Face: flat profile
Clinical Manifestations Down Syndrome cont. Eyes: Oblique palpebral fissures (upward, outward slant) Inner epicanthal folds Speckling of iris Short, sparse eyelashes Nose: small, depressed nasal bridge (saddle nose
Clinical Manifestations Down Syndrome cont. Mouth: High, arched, narrow palate Protruding tongue that may be fissured at lip and furrowed on surface Hypoplastic mandible Downward curve (especially when crying) Mouth kept open
Clinical Manifestations Down Syndrome cont. Hands: Broad, short stubby fingers Incurved little finger Transverse palmar crease Increased ulnar loops on fingers Chest: Shortened rib cage Twelfth rib anomaly
Clinical Manifestations Down Syndrome cont. Feet: Wide space between big and second toes Plantar crease between big and second toes Broad, stubby, and short Musculoskeletal: Short stature Hyperflexibility, muscle weakness Hypotonia
Clinical Manifestations Down Syndrome cont. Reduced birth weight Abdomen: Protruding, muscles lax and flabby Diastasis recti Umbilical hernia
Clinical Manifestations Down Syndrome cont. Other problems: Congenital heart malformation (septal defects) Respiratory tract infections Dysfunction of immune system Thyroid dysfunction (congenital hypothyroidism) Increased incidence of leukemia
Nursing Considerations Down Syndrome Family support and education Allow parents to express concerns Assist in preventing problems Involve parents in infant care to promote bonding Involve siblings in infant care, include them in discussions Refer parents to others for help or advice
What is Trisomy 21? Three number 21 chromosomes instead of the normal two.
Hemolytic Disease of the Newborn Causes: Incompatibility between blood of mother and fetus. Rh incompatibility. ABO incompatibility
Therapeutic Management Hemolytic Disease Focus is prevention of Kernicterus Diagnostic Evaluation Diagnosis is determined by history and diagnostic tests Indirect Coombs test in mother Direct Coombs test in infant Aminocentesis/ultrasonography Transcutaneous and serum/bilirubin levels
Question: What is the primary aim of therapeutic management? Answer: Prevention of isoimmunization, also with the focus on prevention of kernicterus.
Periventricular-Intraventricular Hemorrhage Defined as bleeding around and into the ventricles of the brain. Pathophysiology: Occurs most often in infants of less than 32 weeks or weight less than 1500g. First few days (3), are the most common time for hemorrhage to occur. Results from rupture of the fragile blood vessels around the ventricles.
Pathophysiology The amount of bleeding varies. IVH is often described in four grades: Grade I - bleeding occurs just in the germinal matrix. Grade II - bleeding also occurs inside the ventricles. Grade III - ventricles are enlarged by the blood. Grade IV - there is bleeding into the brain tissues around the ventricles
Pathophysiology IVH Most often associated with: Hypoxic injury to the vessels Increased or decreased blood pressure Increased or fluctuating cerebral blood blow. Rapid blood volume expansion Hypercarbia Anemia Hypoglycemia
Manifestations IVH Signs include: Lethargy Poor muscle tone Deterioration of respiratory status with cyanosis or apnea Drop in hematocrit levels Decreased reflexes Full or bulging fontanelles Seizures
Therapeutic Management Ultrasonography on preterm infants Treatment is supportive Maintain respiratory function Handle other complications Hydrocephalus may develop Lumbar taps Ventriculoperitoneal shunt
Care may increase cerebral blood flow and blood pressure Be alert for early signs of PIVH Care includes: Head circumference Observation Minimal handling Reduced environmental stressors HOB elevated 30 degrees Parental support and teaching
What are the signs of PIVH? Signs include poor muscle tone, lethargy, respiratory distress, cyanosis, apnea, decreased reflexes, full or bulging fontanelles and seizures.
Infant of Diabetic Mother (IDM) Risks: Neonatal mortality 5 x more likely Congenital anomalies: 3 X more likely Most frequent anomalies are: Cardiac Urinary tract Gastrointestinal Neural tube defects Caudal regression syndrome Cardiomegaly is common and may lead to heart failure
Infant of Diabetic Mother (IDM) Risks (cont.) The incidence of anomalies is less if blood glucose levels remain within normal limits, especially before conception and in the early weeks of gestation
Manifestations Infant of Diabetic Mother (IDM) Macrosomic: 4000-4500g or 8lb13 oz-9 lb 15 oz: 50% gestational 40% pregestational Fetal pancreas secretes large amounts of insulin Hypoglycemia Risk for injury during birth Higher risk of asphyxia and RDS
Other complications: Manifestations Infant of Diabetic Mother (IDM) Hypocalcemia Low magnesium levels Polycythemia with hyperbilirubinemia Increased likelihood of premature delivery
Therapeutic Management Infant of Diabetic Mother (IDM) Includes controlling the mother’s diabetes throughout the pregnancy to decrease complications Be prepared for shoulder dystocia or cephalopelvic disproportion and C- Section
Nursing Considerations Assessment: Infant of Diabetic Mother (IDM) Signs of complications, trauma, and congenital anomalies at delivery and during transition Respiratory problems Hypoglycemia Rapid respirations, low temp and poor muscle tone
Nursing Considerations Infant of Diabetic Mother (IDM) Interventions: Monitor glucose levels ( 40-45mg/dl) Feed infant early Parental support
Why is the infant of a diabetic mother often hypoglycemic after delivery? Due to the abrupt loss of maternal glucose and the overproduction of insulin by the infant.
Created by: grayman94