Lecture 11 Maternal Newborn continued

LECTURE 11 MATERNAL NEWBORN continued FETAL MONITORING PATTERNS: • 7 that you should know but easy to remember • a) Low Fetal Heart Rate! = under 110! - BAD! do L I O N & if Pit was running, stop it • b) High Fetal Heart Rate! = over 160! - not a big deal, not a high priority! - document & take mom’s temperature! -> could be up because mom has a fever (so ! nothing wrong with baby) • c) Low Baseline Variability! = when the fetal heart rate stays the same & does ! not change (whether high, low, or in the middle)! - BAD! do L I O N • d) High Baseline Variability! = fetal heart rate is always changing! - good! document it • once a person is born, if their vital signs stay the same they are called stable BUT before you’re born, if your vital signs stay the same it’s bad! -> we don’t want to see the opposites happen • e) Late Decelerations! = heart rate slows down near the end or after a ! contraction! - BAD! do L I O N • f) Early Decelerations! = heart rate slows down before or at the ! beginning of a contraction! - normal, no big deal; document it • g) Variable Decelerations! - VERY BAD!!! this is what happens when you have ! prolapsed cord -> push, position! - this is the most unique one • 3 good ! 3 bad = all start w/ an L -> L I O N! 1 variable = push, position • What causes the different heart rates?! V = variable C = cord compression! E = early dec. H = head compression! A = acceleration O = it’s ok! L = late dec. P = placental insufficiency • What answer always wins in a tie??! - in OB = check fetal heart rate STAGE 2 of LABOUR = Delivery of the Baby: • all about order:! 1 = deliver head! 2 = suction the mouth first, then nose! 3 = check for nuchal cord (around the neck)! 4 = deliver the shoulders & the body • the baby MUST have an ID band on before it leaves the delivery area STAGE 3 of LABOUR = Delivery of the Placenta: • a) make sure it’s all there • b) check for 3 vessel cord! - 2 arteries! - 1 vein STAGE 4 of LABOUR = Recovery: • is the first 2 hours after delivery of the placenta • 4 Things you do 4 Times an hour in the 4th Stage: ! *** Q15! a) vitals signs! - assessing for S&S of shock (pressures down, ! rates up, pale, cold & clammy)! b) check the fundus! - if boggy -> massage! - if displaced -> catheterize! c) check the perineal pads! - to see how much she is bleeding! - if excessive -> will 100% saturate in 15 mins. or less (so if 98% saturated, she’s still ok)! d) roll her over! - check for bleeding underneath her! —> also lets you assess the perinanal area POSTPARTUM: • assessments -> usually 4-8 hrs. depending on PT stability • B = breasts! U = uterine fundus (want it firm, midline, height r/t ! to the bellybutton)! -> should be going down 1 cm per postpartum day! B = bladder! B = bowel! L = lochia (rubra, serosa, alba)! -> rubra = red; serosa = pink; alba = whitish yellowish! E = episiotomy! H = hemoglobin & hematocrit! E = extremity check ! -> check for thrombophlebitis (via bilateral calf ! circumference measuring)! -> Homan’s sign is not the best answer because you ! can have it w/o having thrombophlebitis & vice ! versa (not as reliable or valid)! A = affect (emotions)! D = discomforts! ** 3 big things tested in postpartum are the uterine ! fundus, lochia, & extremities Variations in the NEWBORN: • review all the normal’s • know difference between:! - caput succedaneum = c.s. -> crosses sutures! -> symmetrical! - cephalohematoma = bleeding • normal physiologic jaundice -> appears after 24 hrs. • pathologic jaundice -> baby comes out yellow ! OB MEDS: • don’t have to be an expert; just know general info what they are & a few main things about them! —> 6 main meds • Tocolytics = stops labour (threatening prematurity)! a) Terbutaline! - causes maternal tachycardia! b) Magnesium Sulphate! - watch for TOXICITY! - watch for hypermagnesemia (everything down)! -> heart rate down! -> BP down! -> hypo-reflexive (want to keep it +2)! -> resp. rate down (want at least 12 resps.)! -> LOC goes down! *** boards likes to test reflexes & resp rate most! - closely monitor the PT’s reflexes & resp. rate • Oxytocics = stimulate/start & strengthen labour! c) Pitocin! - can cause uterine hyper-stimulation (i.e. ! contractions longer than 90 seconds, closer than 2 ! mins. apart -> BAD!)! d) Methergine! - causes high BP (contracting -> vasoconstriction ! raises BP) • Fetal Lung Maturing meds:! e) Betamethasone - a steroid! i. mom gets it! ii. given IM! iii. given before baby is born! - can be repeated as long as baby is in utero! f) Survanta (Surfactant)! i. baby gets it! ii. given transtracheal (blown in through trachea)! iii. given after baby is born MEDICATION HELPS & HINTS • to help get basic facts down • What is Humulin 70/30?! = mix of N & R insulins! - 70 & 30 are percentages! -> 70 % is N! -> 30% is R • Can you mix insulins in the same syringe?! = YES! - when you draw it up go clear to cloudy, R to N ! (“RN’s draw up RN”)! - when talking about pressurizing the vials you inject ! air into N first, then R & draw up R, then draw up N • Injections:! —> will ask what needle to use for a particular injection! - IM = “I” looks like 1, pick the answer that has the 1’s ! in them (21 gauge…)! - SubQ = “S” looks like 5 HEPARIN vs. COUMADIN: • in the top 3 most commonly tested drugs! Route Onset Length of Use Antidote Lab Test that monitors HEPARIN IV or SubQ works immediately cannot be given for longer than 3 weeks (except Lovenox)! - body starts making heparin antibodies after 3 weeks which can be life-threatening Protamine sulphate PTT (partial thromboplastin time) can be given to pregnant women COUMADIN only PO takes a few days to a week to work can be given for the rest of your life Vit. K PT -> INR cannot be given to pregnant women • only major anti-psychotic that can be given to pregnant women = HALDOL K+ Wasting & K+ Sparing Diuretics: • probably the only questions you’ll get about diuretics is whether if wastes or spares K+ • any diuretic drug ending in “X” it waste’s K+! -> also Diuril! *** otherwise, it spares K+ Baclofen: • boards test muscle relaxants as a class • sore “back” -> if you’re on Baclofen, you’re on your back loafin’ • 2 side effects:! a) fatigue/drowsiness! b) muscle weakness • Patient teaching:! a) don’t drink! b) don’t drive! c) don’t operate heavy machinery • Flexeril -> the other muscle relaxant they test PEDIATRIC TEACHING • review of Piaget’s theory of cognitive development! -> won’t actually name Piaget but will ask questions ! on how you would teach children in order to test ! knowledge of the theory 4 Stages of Piaget (Cognition): • a) 0 - 2 years = SENSORY-MOTOR! - these kids are totally present oriented! -> don’t think about past or future! -> only sense what they are doing right now! - teaching: while/as you do it & teach them what you ! are doing (think present tense)! - teach verbally -> just tell them (don’t understand ! “play” yet)! - ex. when teaching a PT about a procedure, teach ! while doing it (won’t work to teach them ahead of ! time) -> no pre-op/post-op (except for the parents) • b) 3 - 6 years = PRE-OPERATIONS (think preschool)! - these kids are fantasy oriented! -> imaginative, illogical, thinking obeys no rules! -> “you can’t reason w/ a preschooler”! - understand past & future so you can teach them ! before & after ! -> BUT has to be shortly before or after (ex. the ! morning of, the day of, 2 hrs. before…)! -> don’t give them too much time to get ! imaginations going on something ! - teaching: what you are going to do (future tense)! - teaching through play! -> ex. the day of, teaching PT about lumbar puncture ! by playing w/ equipment/dolls • c) 7 - 11 years = CONCRETE OPERATIONAL! - these kids are rule oriented! -> can’t think abstractly yet, rigid! -> only one way of doing something! -> “my teacher said”, or “my parents said”! - will tell you you’re doing something wrong if it was ! different from the way a previous person did it (ex. ! wound dressings by different nurses)! - teaching: days ahead; what you’re going to do + skills! - teach via age appropriate reading & demonstration • d) 12 - 15 years = FORMAL OPERATIONAL! - can abstract think & think cause & effect! -> Hint: as soon as a kid hits 12 and they ask ! about teaching, it’s no longer a pediatric question ! and is an adult med-surge question (you teach ! them like an adult)! - ex. When’s the first age that a child can manage ! their own care? = 12! -> a 7 yr. old can do the skills related to their care ! but can’t manage; managing requires making ! decisions which require abstract thinking! -> it’s not the severity of the illness that determines ! who can manage it, it’s the age (ex. a 10 yr old w/ ! scraped knee vs. 13 yr old w/ renal dysfunction)! *** key word is manage (13 yr. old); skills = 7-11 7 PRINCIPLES of PSYCH • 1. Make sure you know which phase of the ! relationship you’re in ! - pre-interaction, introduction/orientation, working, termination • 2. Gift giving ! - NO GIFTS IN PSYCH (giving or receiving)! - ex. don’t accept flowers from a PT w/ schizophrenia ! because to you they might just be flowers but to ! them that might be a marriage proposal • 3. Don’t give advice! - ex. If the PT asks “What do you think I should do?” ! you reply w/ “What do you think you should do?”! - you can give advice in med-surge or paeds • 4. Don’t give guarantees • 5. Immediacy! - if a PT says something, the best answer is the ! one that keeps them talking! -> don’t pick answers that say “refer to social work” ! because that shuts off communication right then ! and there! -> Hint: it’s never wrong to get your PT to talk • f) Concreteness! - don’t use slang ! -> psych PT’s tend to take things literally! - if PT’s use made up words (neologism), those are ! not concrete so don’t use them • g) Empathy! - you have to know empathy!!! -> all about feelings! - the best psych answers are the answers that ! communicate to the PT that the nurse accepts the ! PT’s feelings as being valid, real, & worthy of action! - bad answers:! -> “don’t worry” (because it tells them not to feel)! -> “don’t feel”, “you shouldn’t feel…”, “I would feel”, ! “anybody would feel”, “nobody would feel”, “most ! people feel” Empathy Questions: • recognize that it’s an Empathy question! - always have a quote in the question & each of the ! answers is a quote (i.e. PT says; what would you say?) • put yourself in the client’s place! - you often have to read the feeling into the questions • ask yourself: If I say those words (in an answer) and I meant them, how would I be feeling after? • go and choose the answer that reflects that feeling (or anything close)! - DON’T choose the feeling that reflects the PT’s ! words! - empathy questions usually have a “sucker ! answer” (to sucker you into picking that one) & one ! of them is one that reflects/over-emphasizes what ! the PT said but ignores what the PT felt! -> you’re supposed to pick the answer that ! reflects what they felt (& ignores what is said)! * don’t mix this up