Final exam Block III part I

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Fall 2014 CAC Nursing program Psych, OB, Peds
updated 7 years ago by jenkarmata
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1

PED Erickson's Developmental theories (Assessment):

Trust vs. Mistrust (birth-1yrs)

Infants are developing trust, they cry to make their needs known. Mistrust develops w/inconsistent or inadequate meeting of needs. ***Children who do not have their needs met have no trust***

2

PED Erickson's Developmental theories (Assessment):

Autonomy vs Doubt (1-3yrs)

Increased ability to control self & environment, children gradually develop confidence, independence symbolized by "no" through repeated tries and & eventual success.

* If successful= Develops self confidence

* If criticized= Child learns shame and will doubt abilities

3

PED Erickson's Developmental theories (Assessment):

Initiative vs Guilt (3-6yrs)

Explores world, demonstrates initiative by planning & doing. Develops a conscience abilities.

*If successful= develops direction & purpose

*If criticized= leads to feelings of guilt & lack of purpose

4

PED Erickson's Developmental theories (Assessment):

Industry vs Inferiority (6-12yrs)

Develops new interests & involved in activities, learns to follow rules, learns to read, write math and social skills

If successful= develops confidence & enjoys learning

If compared to others= develops feelings of inadequacy

5

PED Erickson's Developmental theories (Assessment):

Identity vs role confusion (12-18yrs)

Rapid physical changes, preoccupation w/physical appearance, examines and redefines self, family, peers, community, experiments w/different roles, peer groups are important

If successful= develops confidence & self identity

If unable to establish meaning of self= develops role confusion

6

Psy therapeutic approaches: interpersonal (implementation):

Interpersonal

Emphasizes on relationships

7

Psy MAOIs (Planning)

Actions

Drugs that prevent the destruction of monoamines by inhibiting the action of MAOIs.

MAOIs prevent the breakdown of NE, serotonin & dopamine, thereby ↑ levels of these brain amines & resulting in ↑ mood.

* If not effective by itself, than another drug class added could improve effects.

8

Psy MAOIs (Planning):

Names of MAOIs

  • Phenelzine (Nardil)
  • tranylcypromine (Parnate)
  • selegline transdermal system (EMSAM)
9

MAOIs uses:

  1. Panic disorders
  2. Phobias
  3. GAD (general anxiety DO)
  4. OCD
  5. PTSD
  6. Bulimia
10

Psy MAOIs (Planning):

Foods-

AVOID FOODS ↑ IN TYRAMINE, SUCH AS:

  • Aged cheeses: cheddar, Swiss, blue cheese (stilton, gorgonzola, & camembert)
  • Cured Meets: dry-type summer sausages, pepperoni & salami
  • Fermented cabbage: sauerkraut & kimchee
  • Soy sauce

** They cause weight gain, HTN, glucose irregularities**

11

MAOIs: Important info

DO NOT TAKE WITH:

  • Barbiturates
  • TCAs
  • Antihistamines
  • CNS depressants
  • Antihypertensive
  • OTC cold medicines

WATCH FOR:

  1. Sweating
  2. Tremors
  3. ↑ temp
  4. ↑BP
  5. Bounding ♥ beat
12

Psy 2nd gen meds (analysis, implementation):

AKA atypical antipsychotics:

  1. Clorazil
  2. Risperdal
  3. Olanzapine (zyprexa)
  4. Seroquel
  5. Apripiprazole (Abilify)
  6. Clozapine causes agranulocytosis
13

You have a patient that has an order Nardil (MAOI) and the patient tells you that they also take anti HTN meds, barbiturates and OTC cold medicines.

Are those meds compatible?

No, Nardil is an MAOI and they are not compatible with anti HTN meds, barbiturates and OTC cold medicines.

14

Psy 2nd gen meds (analysis, implementation):

Permit more than just control, they allow for improvement of quality of life.

* Not used often as the 1st line of antipsychotics

* They produce minimal to no EPS or TD

* Improve cognitive defects of schizophrenia

** They cause weight gain, HTN, glucose irregularities**

15

Major depressive DO (Evaluation):

Definition

- Substantial pain & suffering

- Social & occupational disability

- Hx of one or more major depressive episodes and no hx of manic or hypomanic episodes

**Psychotic major depression is severe mood DO w/hallucinations and/or delusions**

16

Major depressive DO (Evaluation):

Outcomes:

  • Goals for safety
  • Name a person that the pt. will contact if self destructive thoughts occur.

Goals for vegetative or physical signs of depression:

  1. reports adequate sleep
  2. weight gain if there's loss or return to normal weight if there's a gain
  3. bowel activity
  4. return of sexual desire
17

Major depressive DO (Evaluation): Meds

TCA's

  • disapramine (Norpramin)
  • protiptyline (Vivactil)
  • amitriptyline (Elavil)
  • doxepin (Sinequan)

-This class is used for edogenous depression, reactive depression, & depression related to alcohol/cocaine withdrawal

18

TCA's uses and facts

-This class is used for edogenous depression, reactive depression, & depression related to alcohol/cocaine withdrawal.

WATCH FOR SIGNS OF:

  1. Sedation
  2. Orthostatic hypotension
  3. ↓ Sexual ability/desire
  4. Dry mouth
  5. Urinary retention
  6. Tachycardia
19

Major depressive DO (Evaluation): Meds

SSRIs

  • citalopram (Celexa
  • fluoxetine (Prozac)
  • sertraline (Zoloft)
  • Paxil
20

SSRIs: facts & uses

Uses: OCD, depression, anxiety

WATCH FOR:

  • Headache
  • Nausea
  • Lethargy
  • Fatigue
  • Insomnia
  • Sexual dysfunction
  • Weight gain

**DO NOT TAKE W/MAOIs OR ABRUPTLY STOP TAKING MEDICATIONS**

21

Major depressive DO (Evaluation): Meds

Atypical antidepressants

  • bupropion (Wellbutrin)
  • trazadone (Desyrel)
  • duloxetine (Cymbalta)
22

Major depressive DO (Evaluation):

Norepinephrine

Neurons that release it are called noradrenergic. They play a major role in regulating mood. Deficiencies usually involve depression whereas excess can indicate mania

23

Psy Effective verbal communication (Implementation)

Consists of words a person speaks- Effective communication consists of

  1. Silence
  2. Active listening
  3. Clarifying- clarifying techniques include:

i Paraphrasing

ii Restating

iii Reflecting

iiii Exploring

Assess for command hallucinations: If present, ask these questions:

- What are the voices telling you to do?

- Do you plan to follow the command?

- Do you believe the voices are real?

- Do you recognize the forces?

24

Psy suicide (implementation)

S

A

D

P

E

R

S

O

N

S

S = Sex + 1 point if male

A = Age +1 if 15-24, 25-40, or 65+

D = Depression + 2 if present

P = Previous attempts +1 if present

E = ETOH (alcohol) +1 if present

R = Rational thinking loss +1 if psychotic for

reason

S = Social support is lacking + 1, or loss

O = Organized plan + 1 if plan w/lethal weapon

N = No spouse, divorced/widowed, separated

or single +1

S = Sickness + 1 if severe or chronic

25

Interventions during crisis:

- Assess for suicidal ideations, take steps in making pt. feel safe & lower anxiety, listen carefully, make phone calls for babysitters, social worker, etc.,

- Assess support systems, identify need for social supports & mobilize first need first, plan interventions & follow up with pt. regularly.

26

Psy defense mechanisms (Assessment)

Healthy:

  • Altruism
  • Sublimation
  • Humor
  • Suppression
27

Psy defense mechanisms (Assessment)

Intermediate

  • Repression
  • Displacement
  • Reaction formation
  • Somatization
  • Undoing
  • Rationalization
28

Psy defense mechanisms (Assessment)

Immature

  • Passive aggressive
  • Acting out
  • Dissociation
  • Devaluation
  • Idealization
  • Splitting
  • Projection
  • Denial
29

Psy Anxiety levels (Assessment)

Mild

Heightened perception field. Alert, identifies the source of anxiety. Able to work. Slight discomfort, attention seeking behavior, restlessness, irritable, mild tension relieving behavior (foot tapping, lip chewing, fidgeting).

30

Psy Anxiety levels (Assessment)

Moderate

- Narrow perception field, grasps less of what's going on attentive if pointed out

- Able to perform but not at optimal level, better if guided by others

- Voice tremors, change in voice pitch, difficult concentrating, shakiness, somatic complaints, ↑ respirations, ↑ pulse rate, muscle tension.

- More extreme pacing, banging hands on table

31

Psy Anxiety levels (Assessment)

Severe

-Perceptual field is greatly reduced

-Person may focus one detail or many detail

-Difficulty noticing the environment, even when pointed out

-Learning & problem solving not an option at this time.

-Dazed & confused

-Behavior is automatic & trying to relax

-Severe somatic symptoms (HA, nausea, dizziness, insomnia), tremors, pounding ♥, hyperventilating & sense of dread

32

Psy Anxiety levels (Assessment)

Panic

Trippin really bad!

- Hallucinating

- Dilated pupils

- Irrational & illogical thinking

- Terror

- Unable to speak

- Trembling very much

- Sleepless

- Severe withdrawal

33

Psy Somatic symptom DO (Assessment)

Stress expressed as physical symptoms.

Not intentional or under conscious control

34

Psy Conversion DO (Assessment)

Symptoms or deficits that affect voluntary motor or sensory functions which suggest another medical condition. The dysfunction does not correspond to current scientific understanding.

Many show la belle indeference, which is an indifference towards symptoms

35

Psy Conversion DO (Assessment)

Common symptoms

  1. Involuntary movements
  2. Seizures
  3. Paralysis
  4. Abnormal gait
  5. Anesthesia
  6. Blindness & deafness

This DO is related to lower education & income levels. Child physical or sexual abuse has been found to be related.

36

Psy Cluster B: Borderline PD (evaluation)

Cluster B

- Instability of interpersonal relationships, self image

- Effects, marked impulsivity, difficulty controlling emotions, perceived abandonment, & feelings of emptiness.

37

Psy Personality DOs (Assessment)

Cluster A:

Odd, eccentric, paranoid, schizoid, schizotypal

38

Psy Personality DOs (Assessment)

Cluster B:

Dramatic, emotional erratic, antisocial, borderline, histrionic, narcissistic

39

Psy Personality DOs (Assessment)

Cluster C

Avoidant, OCD, dependent

40

Psy Anorexia nervosa (implementation)

- When admitted to acute care, usually in crisis state

- Suicidal ideation needs to be addressed immediately, along w/ weight

- Restoration program that allows for incremental wt. gain (goal is 90% of ideal body wt.)

41

Psy Anorexia nervosa (implementation): Clinical manifestations

  • Cachectic (severely underweight w/muscle wasting)
  • Lanugo may be present
  • Mottled cool extremities
  • ↓ BP/pulse/temp.
  • Prominent parotid glands (seen from hyper-stimulation from vomiting)
  • Severe electrolyte imbalance may be present may be present
42

Psy Anorexia nervosa (implementation): Treatment

Provide immediate stabilization (most likely hospitalization) for weight restoration, electrolyte imbalances & acute psychiatric symptoms (depression).

43

Refeeding syndrome

Overwhelming the system in attempts to replenish the patient resulting in cardiovascular collapse.

44

Psy Anorexia nervosa (implementation): Criteria

  • Wt. loss > 30% over 6mos
  • Rapid decline in weight
  • Inability to gain weight
  • Severe hypothermia <36°
  • HR < 40
  • Systolic BP <70 mmHg
  • Hypokalemia <3 mEq/L
  • ECG changes
45

Psy Mania (planning): Acute phase

-(0-2 months).- stabilize and maintain patient safety.

-Hospitalization is best option.

-Decrease physical activity, increase food and fluid intake, ensure 4-6 hrs of sleep, alleviate bladder and bowel problems, and meet self care needs. Seclusion and ECT may be an option

46

Psy Mania (planning):Continuation phase

-(2-6 months).- maintain med compliance, psycho educational teaching for family and patient is done.

-Referrals are made. Psychotherapy may be done during this time period.

47

Psy Mania (planning): Maintenance phase

- (6 months and over).- prevent relapse and limiting severity and duration of episodes.

-Medication may be lifetime. Encourage adherence to psychotherapy groups.

48

A client taking lithium carbonate (Eskalith) reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus & tremors. The lithium levis is checked as a part of the routine follow-up & the level is 3.0 mEq/L. The nurse knows that this level is:
1. Normal
2. Slightly above normal
3. Excessively below normal
4. Toxic

4- The therapeutic serum level of lithium is 0.6-1.2 mEq/L. A level of 3 mEq/L indicates toxicity.

49

A client receiving lithium carbonate (Eskalith) complains of loose, watery stools & difficulty walking. The nurse would expect the serum lithium level to be which of the following?
1. 0.7 mEq/L
2. 1.0 mEq/L
3. 1.2 mEq/L
4. 1.7 mEq/L

4- The therapeutic serum level of lithium ranges from 0.6-1.2mEq/L. Serum lithium levels above the therapeutic level will produce signs of toxicity.

50

A client who is taking lithium carbonate (Eskalith) is scheduled for surgery. The nurse informs the client that:
1. The medication will be discontinued several days before surgery & resumed by injection in the immediate postoperative period.
2. The medication is to be taken until the day of surgery & resumed by injection immediately postoperatively
3. The medication will be discontinued 1-2 days before surgery & resumed as soon as full oral intake is allowed.
4. The medication will be discontinued a week before the surgery & resumed 1 week postoperatively

3- The client who is on lithium carbonate must be off the medication for 1-2 days before a scheduled surgical procedure & can resume the medication when full oral intake is ordered after the surgery.

51

A client who is on lithium carbonate (Eskalith) will be discharged at the end of the week. In formulating a discharge teaching plan, the nurse will instruct the client that is most important to:
1. Avoid soy sauce, wine & aged cheese
2. Take medication only as prescribed because it can become addicting
3. Check w/the psychiatrist before using any over-the-counter medications or prescription medications
4. Have the lithium level checked every week

3- Lithium is the medication of choice to treat manic-depressive illness. Many OTC meds interact w/lithium & the client is instructed to avoid OTC medications while taking lithium, although lithium levels need to be monitored, it is not necessary to check these levels every week. A tyramine-free diet is associated w/ MAOIs

52

Q20. PSY 3.1d Psychotic DO: Catatonia

Extreme abnormal motor behavior, Position them in comfortable position

53

Q20. PSY 3.1d Psychotic DO: Catatonia (Implementation)

Outcomes ID:

PHASE I (ACUTE)- Goal

Overall goal PT safety and medical stabilization

54

Q20. PSY 3.1d Psychotic DO: Catatonia (Implementation)

PHASE II (MAINTENANCE)- Goal

Helping the PT to adhere to medication regimens, understand schizo, and participate in psycho educational activities for both PT and family

55

Q20. PSY 3.1d Psychotic DO: Catatonia (Implementation)

PHASE III (STABILIZATION)

  • Goals directed toward continual recovery
  • improvement in functioning
  • enhanced quality of life
56

OB 2.6 Normal pregnancy experience

Application Assessment Health promotion

Cardiovascular system

  • Total volume increase 40% - 50%
  • Increase cardiac output 305 - 50%
  • Blood pressure decrease
  • Heart size increases/elevates
  • Pulse increases
  • Increase WBCs
  • Increased venous pressure
  • Supine hypotension
57

OB 2.6 Normal pregnancy experience Respiratory:

  • Consumption increase 15%-20%
  • Diaphragm elevated
  • RR unchanged
  • Nasal congestion/epistaxis
58

OB 2.6 Normal pregnancy experience Renal:

  • Urinary frequency
  • Decreased bladder tone

-With increased capacity

  • Glomerular filtration increase – 50%
  • Renal threshold for glucose decreased
  • Dependent edema.
59

OB 2.6 Normal pregnancy experience GI:

  • Urinary frequency
  • Decreased bladder tone
  • With increased capacity
  • Glomerular filtration increase – 50%
  • Renal threshold for glucose decreased
  • Dependent edema
60

OB 2.6 Normal pregnancy experience Musculoskeletal:

  1. Waddle gait
  2. Lordosis
  3. Diastasis recti
61

OB 2.6 Normal pregnancy experience Integument:

  1. Chloasma( mask of pregnancy)
  2. Striae gravidarum
  3. Linea nigra
  4. Hot flashes
  5. Acne
62

Normal pregnancy experience Endocrine:

  • Decrease FSH
  • Increased progesterone, estrogen, prolactin
  • Increased oxytocin, hCG, human placental lactogen
  • Increased chorionic somatomammotropin
  • Increases maternal resistance to insulin
  • Hyperplasia of thyroid/increased vascularity
  • Increased cortisol
  • Increased maternal resistance to insulin
63

Normal pregnancy experience Reproductive:

  • Hegar’s sign- softening of the uterine segment
  • Goodell’s sign-softening of the cervix
  • Chadwick’s sign-bluing of vaginal mucosa and cervix
  • Ballottement-passive movement of the fetus
64

OB 3.1 Complicated pregnancy experience: Teratogens

  • Drugs, viruses, infections or other exposure that can cause embryonic/fetal developmental abnormality
  • Most vulnerable - first eight weeks of gestation
  • ETOH
  • Cocaine
  • ACE inhibitors
  • Anticonvulsants
  • Warfarin
  • Cigarettes
  • Caffeine
  • Hair dye
65

OB 2.6d Normal pregnancy experience: GI

Application Implementation Physiological integrity

  • Metabolism changes
  • Decreased peristalsis
  • Displacement of intestines
  • Ptyalism
  • Pyrosis
  • Liver
  • Cholestasia
  • Pruritis gravidarum
  • Cholecystitis/cholelithiasis
  • PICA (Not normal)
66

OB 2.7 Pregestational health issues

Analysis Assessment Physiological integrity

CARDIOVASCULAR DO: CHF

  • Edema, crackles, disorientation
  • Dyspnea, tachy, chest pain, cough

Later signs

  • Moist cough, pink frothy sputum, tachy, anxiety, cyanotic
67

OB 2.7 Pregestational health issues

Cardiac management pg. 172

  • Collaboration between obstetricians and other specialists
  • Discuss with mom estimations of maternal and fetal mortality, potential chronic morbidity, and interventions to minimize risk during pregnancy and delivery
  • Obtain lab tests to evaluate renal function and profusion (electrolytes = serum creatinine, proteins, and uric acid).
  • Monitoring of invasive hemodynamics: pulmonary caths, peripheral artery caths, and central venous pressure monitors
  • Drug therapy dependant on cardiac lesion
  • Vaginal delivery recommended for most patients with cardiac disease
  • Preterm delivery may be indicated for deteriorating mom or fetus status
68

OB 2.7 Pregestational health issues

Diabetes : DM Type 1 & 2 pg. 148

(self – management)

  • Self monitoring of blood glucose. Checking BG levels 4-8 x/day (before and after meals and bedtime. Most important parameter for determining metabolic control

TABLE 7-2 BLOOD GLUCOSE GOALS

AM fasting = <90 (from textbook)

PREMEAL = <105

1 HR POSTPRANDIAL = <140

MEAN BLOOD GLUCOSE = <100

69

OB 2.7 Pregestational health issues

Self monitoring of urine ketone. Done by testing first voided specimen for ketones. When BG levels >200 mg/dl during maternal illness and/or when glucose control is altered. Moderate to large amts of ketones indicate inadequate food intake and reported to HCP

  • Record keeping of BG levels, food intake, insulin, and activity of treatment regimen
  • Exercise is beneficial for glycemic control and overall well-being
  • Exercise 3x/wk for 20 mins. . Contraindicated to HTN and existing preeclampsia
  • Review S&S of hypoglycemia for prevention/management of episodes.
  • Have a carb food source with them at all times (ex: fruit juice, hard candy)
70

OB 2.7 Pregestational health issues; urine ketone medical mgnt

  • Medical nutrition therapy (MNT). Provides adequate nutrition, prevent diabetic ketoacidosis, and promote euglycemia (norm)
  • Achieving a HbA1C <7%
  • Management by multidisciplinary team
71

OB 2.7 Pregestational health issues

Gestational DM pg. 149

managed by HCP with consult and referral

Happening later in 2nd-3rd trimester (26th wk)

  • For most, GDM is controlled by diet and exercise
  • Up to 40% may need to be managed with insulin
  • DO NOT GIVE ORALS TO MOM = TERATOGENIC
  • CS recommended for birth weight >4500 g
  • Monitor moms wt after delivery for type 2 diabetes. About 1/3 will have recurrent GDM in subsequent pregnancies

managed by HCP with consult and referral

Happening later in 2nd-3rd trimester (26th wk)

  • For most, GDM is controlled by diet and exercise
  • Up to 40% may need to be managed with insulin
  • DO NOT GIVE ORALS TO MOM = TERATOGENIC
  • CS recommended for birth weight >4500 g
  • Monitor moms wt after delivery for type 2 diabetes. About 1/3 will have recurrent GDM in subsequent pregnancies
72

OB 2.7 Pregestational health issues

RESPIRATORY DISEASE: PULMONARY DO (ASTHMA) PG. 173

PULMONARY DO (FROM PPT)

  • Asthma most common
  • Risk for newborn
  • Hypoxia
  • Preterm birth, LBW
  • Medical Management
  • Aggressive tx (medications safe during pregnancy)
  • Nursing Actions
  • Assess cough, wheeze, etc
  • Monitor maternal O2 sat, fetal hypoxia
  • Teach – about disease, effects on baby, triggers/ avoiding triggers, monitor pulmonary function daily, and medication use
  • Asthma most common
  • Risk for newborn
  • Hypoxia
  • Preterm birth, LBW
  • Medical Management
  • Aggressive tx (medications safe during pregnancy)
  • Nursing Actions
  • Assess cough, wheeze, etc
  • Monitor maternal O2 sat, fetal hypoxia
  • Teach – about disease, effects on baby, triggers/ avoiding triggers, monitor pulmonary function daily, and medication use
73

OB 2.7 Pregestational health issues: Medical mgnt

RESPIRATORY DISEASE: PULMONARY DO (ASTHMA) PG. 173

PULMONARY DO (FROM PPT):

Monthly evaluation of pulmonary function

  • Serial US for fetal growth
  • Antepartal fetal testing for moderate-severe asthmatic women
  • Medications commonly used during pregnancy are safe and include: bronchodilators, anti-inflammatory agents (inhaled steroids, oral corticosteroids, allergy injections, and antihistamines).
74

OB 2.7 Pregestational health issues

ANEMIAS

  • Iron deficiency- BIG ONE. GIVE MOM IRON. Eat iron rich foods
  • Hemoglobin <10g/dL & hematocrit <30g/dL
  • Folic acid deficiency – 17-56 organs developing
  • in early pregnancy can cause NTD, cleft lip, & cleft palate
  • Monitor H & H

-Hemoglobin: below 10-11%

-Hematocrit: below 30%

  • Signs & symptoms

-fatigue

-pallor

-tachy

  • Sickle Cell
  • Thalassemia
  • Infertile

Medical Management: Iron supplementation

  • Supplement with 325 mg tid ferrous sulfate
  • Iron deficiency- BIG ONE. GIVE MOM IRON. Eat iron rich foods
  • Hemoglobin <10g/dL & hematocrit <30g/dL
  • Folic acid deficiency – 17-56 organs developing
  • in early pregnancy can cause NTD, cleft lip, & cleft palate
  • Monitor H & H

-Hemoglobin: below 10-11%

-Hematocrit: below 30%

  • Signs & symptoms

-fatigue

-pallor

-tachy

  • Sickle Cell
  • Thalassemia
  • Infertile

Medical Management: Iron supplementation

  • Supplement with 325 mg tid ferrous sulfate
75

OB 3.1f1 Preeclampsia/eclampsia; Magnesium sulfate

Analysis Planning Physiological integrity

Mag. Sulfate can be given to help prevent seizures in pt. with preeclampsia/eclampsia.

-loading dose: 2-4g given over 15-20 minutes.

-continuous infusion: 2g/hr in 100mL; infusion should continue for 24hrs post-delivery.

-measure mag. levels 4-6 hrs. after onset of treatment. Therapeutic level 5-8 mEq/L

-Antidote: calcium gluconate or calcium chloride 5-10 mEq given over 5-10 min.

Assess vitals, DTR, monitor I&O, maintain seizure precautions, and monitor FHR

Mag toxicity: decrease/loss in DTRs, respiratory depression, oliguria, SOB, chest pain, and EKG changes

76

OB 4.2 FHR monitoring

Comprehension Assessment Physiological integrity

Early =

Visual apparent decel. The nadir (lowest point) of decel happens at the same time at the peak of UC. In most cases, recovery looks like a mirror image. Caused by fetal head compression resulting in increased ICP. No management needed. They are benign.

77

OB 4.2 FHR monitoring Variable:

Decrease in baseline in an abrupt manner. Lasts b/w 15 sec – 2 minutes. Caused by umbilical cord compression. They sometimes have shoulders. U, W or V shaped. Managed with positioning, amnioinfusion, tocolytics and or delivery. Administer O2 @ 10 L/min to promote fetal oxygenation. Decrease Pitocin.

78

OB 4.2 FHR monitoring: Late

Occur after peak of UC. Can be a sign of fetal intolerance to labor. Uteroplacental insufficiency. Suppresion of fetal myocardium. Managed with tocolytics, delivery and/or positioning, DC Pitocin, IV bolus of fluids, SVE, notify physician.

79

OB 4.2 FHR monitoring: Prolonged

Gradual decline. Lasting more then 2 minutes but less than 10. Mechanical change in fetal O2, tachysystole, maternal hypotension, abruption placentae, cord compression and or prolapse. Change position, Discontinue Pitocin, assess hydration of mother, bolus IV of fluid helps with fetal oxygenation, O2 by mask @ 10 L/min, SVE (Sterile vag exam), notify Dr.

80

OB 3.3d Apply nursing process to the woman in labor: Labor process; Psyche

Application Planning Psychosocial integrity

  • Culture
  • Expectations
  • Support system
  • Type of support in labor
    1. Doula
    2. Husband
81

OB 5.1a Physiological changes in postpartum women

Comprehension Assessment Health promotion

  • Cardiovascular/Respiratory
  • Breast
  • Uterus
  • Bowel
  • Bladder
  • Lochia
  • Episiotomy
  • Homan’s sign
  • Emotions
  • Bonding
82

OB 1.8f Health – illness transitions related to alterations in female reproductive functioning: Pelvic organ prolapse

Analysis Evaluation Health promotion

Uterine Prolapse

  • Weakening of pelvic tissue Tx: Doughnut pessary
  • Cystoceles

Bulging of bladder into vagina Tx: Ring pessary w/support

Rectoceles

  • Bulging of rectum into the vagina Tx: Gellhorn pessary
83

OB 5.3a Postpartum complication: Hemorrhage

Application Implementation Physiological integrity

Early PPH = within first 24 hours after birth. Blood loss greater than 500 ml or if provider determines that loss is greater than normal. Cause by Uterine Atony, lacerations and hematomas.

Dx = 10% decrease in hematocrit, pad saturation q15min, boggy fundus after message, tachycardia, decrease in BP.

within first 24 hours after birth. Blood loss greater than 500 ml or if provider determines that loss is greater than normal. Cause by Uterine Atony, lacerations and hematomas.

Dx = 10% decrease in hematocrit, pad saturation q15min, boggy fundus after message, tachycardia, decrease in BP.

84

OB 5.3a Postpartum complication: Hemorrhage - Late PPH

after 24 hours post birth. Caused by hematomas, subinvolution and retained placental tissue.

85

Risk factors for PPH:

  • Macrosomia (Big Baby)
  • Polyhydramnios
  • Forceps or vacuum
  • Induced labor
  • Prolonged & precipitous labor
  • General anesthesia
  • Macrosomia (Big Baby)
  • Polyhydramnios
  • Forceps or vacuum
  • Induced labor
  • Prolonged & precipitous labor
  • General anesthesia
86

How to reduce complications:

  • Review prenatal and intrapartal records for anemia, long labor and any other risk factors
  • Assess for early signs of PPH
  • Good hand washing
  • Good diet, fluids activity and rest
  • Provide support
87

Uterine atony

Decreased tone of uterus. Unable to constrict and heal.

Soft boggy fundus, pad saturated q15min, slow and steady bleeding or sudden and massive, clots, pale clammy skin, anxiety and confusion, tachycardia, hypotension.

Oxytocin (20-40 units in 1000 ml @ 200 mU/min)

Methergine (IM or IV one dose, 200 mcg q2-4hrs, med increases BP, DO NOT GIVE IF BP ELEVATED.

Hemabate (Fever is a side effect, IM 250 mcg, no more than 2 mg)

IV fluids for volume, hysterectomy might be needed if all else fails. Review records, assess fundus, instruct to void or insert foley if needed, review Hgb and Hct levels. MESSAGE THE FUNDUS.

Lacerations = Common at cervix, vagina, labia and perineum. Common with macrosomia, operative delivery and precipitous labor.

Firm Uterus with a heavy bleed, with no clots, tachycardia and hypotension. Examine the location, sutures may be required, IV pain meds.

Review records, assess VS, blood loss, notify Dr., prepare for pelvic exam.

88

Hematomas

Blood in connective tissue of vagina or perineum from ruptured vessel. Pt. may not be diagnosed until hypovolemic shock. At risk: Episiotomy (major risk factor), forceps, and prolonged second stage.

Sever pain in vagina or perineum area, tachycardia, hypotension, heaviness or fullness of vagina and/or rectal pressure, swelling, discolored and tenderness, can accumulate up to 250 -500 ml.

Apply ice for first 24 hours, assess pain level, assess VS, review H&H.

89

Subinvolution of uterus

Uterus does not shrink or descend. At risk: Presecne of fibroids, endometriosis, retained placental tissue.

Uterus soft and larger than expected post partum, lochia heavy and in rubra stage, back pain.

Dilation and cutterage, Methergine for fibroids, ABX for endometriosis.

90

OB 5.6a7 Head to toe assessment of newborn: Integument

Comprehension Assessment Physiologic integrity

- Skin is pink with some acrocyanosis

- milia present on nose and chin

- lanugo on the back, shoulders and forehead

- peeling and cracking of skin normal for infants at 40 weeks

- Mongolian spots may be visible

- Hemangiomas (stork bites) They disappear within 1st year

- nevus flammeus (Port wine stain) they don’t disappear

- strawberry hemangioma, they resolve during childhood.

- Erythema toxicum (newborn rash) disappears by itself.

Not normal:

* Jaundice

* pallor all over

* green-yellow vernix = meconium passed.

* Ecchymosis = infection, sepsis

* Abundant lanugo = prematurity.

* Pilonidal dimple: small pit on sacral area, can become infected

91

Altruism

After your spouse dies you volunteer at church to keep busy

92

Repression

You cannot remember your father's funeral

93

Acting out

You get turned down for a promotion; you go to your office & punch a hole in the wall.

94

Humor

A woman trips & falls in front of lots of people, says "I haven't learned to walk yet."

95

Somatization

A student has a test & didn't study, skips class because of N/V

96

Undoing

You have feelings of dislike for someone so you buy them a gift

97

Devaluation

She is so dumb, she got that award because she is friends w/the boss

98

Reaction formation

You say you're not angry when you are

99

Projection

You get mad at your husband & ask, "why are you always so mad at me?"

100

Sublimation

Angry at her spouse, a woman cleans instead of yelling

101

Splitting

You think your best friend is worthless, because he missed a lunch date w/you.

102

Rationalization

I always study hard, this time I cheated...it's no big deal; everyone does it.

103

Idealization

Mary, meeting a man states, "he's the perfect man!"

104

Suppression

You are attracted to someone, but tell your friend you don't like the at all.

105

Dissociation

You are in a car accident & don't remember how you go to the ED

106

Displacement

You get angry at your sister and yell at your husband