advanced client centered care ii day 2 (1).ppt

7/26/2019 Advanced Client Centered Care II Day 2 (1).ppt

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Perry S RN, MSN

Maternal/Child


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Learning Outcomes

1. Describe the beginning of labor and

variables that affect labor and birth.

2. List the stages and mechanisms of

labor and important nursinginterventions for each stage.

3. Identify nursing diagnoses and nursing

interventions to assist the client inlabor.


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Learning Outcomes

4. Describe the role of the LPN/LVN in

preparing the mother for birth and in

providing infant care.

5. Identify causes of high-risk labor andappropriate nursing interventions for them.


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Care of the Patient in Labor

Components of Labor

Signs of impending labor Lighteningdescent of the fetus into the

pelvis Braxton Hicks contractionsirregular

painless contractions

Cervical changeseffacement and dilatation

Bloody showpassage of the mucousplug

Ruptured membranes

Sudden burst of energy


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Figure 53.18 Birthing suite.

Birthing Suite


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The 5 Ps of Labor

Passage

Maternal pelvis

Passenger

Lie, Size, Presentation, Attitude

Power

Position

Maternal

Psyche


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Passage

Size and shape of maternal pelvis

See page 1459 in Ramont, figure 53-1

Cephalopelvic disproportion fetal head

larger than maternal pelvis Stationis the relationship between the

maternal ischial spines and fetus

See page 1460 in Ramont figure 53-2 Station 0 is when the fetal head reaches

the ischial spines, fully engaged

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Passenger

Size: Fetal head largest part, molding,anterior and occipital fontanels used todetermine the position of the fetus See inRamont page 1460 figure 53-3

Fetal attitude: Degree of flexion of the fetalhead and limbs to the trunk

Fetal Lie: the relationship of the long axis

of the fetus to long axis of mother. Fetal presentation: Fetus body part that is

closest to cervix

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Passenger

Vertex area between anterior and

posterior or the occiput presents first

Brow forehead or brow presents

Face

Complete breech: Buttocks presents

first, hips and knees flexed on abdomen

Frank Breech: Buttocks presents first

but the knees are extended with feet

close to head

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Passenger

Fetal position is the relationship of the

presenting part to the four quadrants of

the maternal pelvis.

See Ramont page 1462 figure 53-7

See Ramont page 1462, table 53-2

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Primary Powers

Involuntary muscle contractions of themyometrium

Contractions due to shortening of musclefibers

Frequency: is the beginning of onecontraction to the onset of the nextcontraction

Duration: beginning of contraction to the

end of the contraction Intensity is the strength of the contraction

at its highest point

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Secondary Power

Pushing of the fetus through the birth

canal

Fergusons reflex is the desire to push,

abdominal contraction initiated by

stretching of pelvic soft tissues.

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Position

Position of mother during labor

Back = frequent contraction of low

intensity

Side = less frequent contraction but of

higher intensity

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Psyche

Mothers emotional state

Fear and anxiety cause release of

epinephrine and norepinephrine which

causes blood vessels to constrict whichdecreasesthe effectiveness of

contractions and makes labor more

painful

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Figure 53.2 Measuring the station of the fetal head while it is descending. In

this view, the station is -2/-3.

Station of the Fetal Head


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Figure 53.5 A. Fetal attitude. The relationship of body parts of this fetus is

normal. The head is flexed forward, with the chin almost resting on the chest.

The arms and legs are flexed.

Normal Fetal Attitude


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Figure 53.5 (continued) B. Frank breech presentation.

Breech Fetal Position


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Stages of Labor

First Stage of Labor

Latent Phase

Active Phase

Transition Phase

Second Stage of Labor

Third Stage of Labor

Fourth Stage of Labor


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Figure 53.9 Contraction patterns in first, second, and third stages of

labor. Primigravidas may be 100% effaced before labor begins.


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Figure 53.11 Effacement and dilatation of the cervix in the primigravida. A. Beginning of

labor. There is no cervical effacement or dilatation. The fetal head is cushioned by

amniotic fluid.

Effacement and Dilation

Beginning of Labor


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Beginning Cervical Effacement

and Dilatation

Figure 53.11 (continued) Effacement and dilatation of the cervix in the primigravida.

B. Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid

collects below the fetal head.


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Mid-Cervical Effacement and

Early Dilatation


C. Cervix about one-half effaced and slightly dilated. The increasing amount of amniotic

fluid exerts hydrostatic pressure..


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Complete Effacement and

Dilatation


D. Complete effacement and dilatation.


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Figure 53.13 The two most common types of episiotomy are

midline and mediolateral.


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Mechanism of Labor

Engagement

Descent

Flexion

Internal rotation

Extension

Restitution/External rotation

Expulsion (lateral flexion)


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Assessments

Ask about

contractions

Ask if membranes

ruptured V.S.

Labs, urine dipstick

for glucose and

protein FHR

Monitor contractions

Vaginal exams

Nitrazine test

Signs of PIH


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animation labor and birth
http://www.youtube.com/watch?v=B84MewU8h7Yhttp://www.youtube.com/watch?v=B84MewU8h7Y


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Non Pharmacologic Comfort

Measures

Emotional Support

Informational Support

Physical Comfort Behaviors

First Stage

Second Stage

Advocacy Support


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Drugs Used in Labor

Management

Narcotic/Analgesics

Sedatives

Anesthetics

Local

Pudendal

Spinal/Epidural

Pudendal Block

. Pudendal block by transvaginal approach

Figure 53 17 (continued) A Schematic diagram showing pain path and sites of


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Figure 53.17 (continued) A. Schematic diagram showing pain path and sites of

interruption. A. Paracervical block (sensory pathways and site of interruption in

relation to fetus). B. Pudendal block by transvaginal approach. C. The lumbar

epidural block. The epidural space is located between the dura and the vertebra.


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Medical Interventions

for Labor Complications

Induction

Prostaglandins

Artificial Rupture of Membranes (AROM)

Pitocin (Oxytocin)

Forceps/Vacuum

Dilation and Curettage

Cesarean Section Emergent


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Artificial Rupture of Membranes

(AROM)


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Preterm Labor

20-37 weeks contractions with cervical

changes

Tocolytic for preterm see page 1474 in

Ramont table 53-6

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Induction of Labor

Prostaglandins (PGE 1) Softens cervix

Artificial rupture of membranes (ARM)

Pitocin (oxytocin)

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Precipitous Birth

Last < 3hours

Increased risk of ruptured uterus,

cervical and vaginal lacerations,

hemorrhage, fetal distress, and fetalcerebral trauma

Ramont page 1477 box 53-3

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Figure 53.21 Cord prolapse through the introitus. The prolapse of an

umbilical cord creates an emergency situation requiring birth by cesarean

section.

Cord Prolapse


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Cesarean Delivery

When labor does not progress normally

(dystocia), the nurse must be prepared

to assist with a cesarean birth.

Surgical birth is performed for a varietyof reasons, including:

Placenta previa, abruptio placentae, CPD,

fetal distress, breech presentation,

pregnancy-induced hypertension, multiple

pregnancy, and previous cesarean birth.


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POST PARTUM PERIOD


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Postpartum Period

Past placenta delivery to 6 weeks after

delivery

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Learning Outcomes

1. Describe the physical changes that

occur after a woman has delivered a

baby and placenta.

2. Identify psychological changes in thepostpartum woman.

3. Describe important aspects of support

for the postpartum woman.


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Learning Outcomes

4. Explain nursing interventions to use

when providing nursing care for a

postpartum woman.

5. Discuss methods of providing painrelief for the postpartum woman.

6. Identify crucial areas of client teaching

for the postpartum woman.


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Learning Outcomes

7. Describe important factors in self-care for

women after discharge.

8. Discuss client teaching about postpartum

emergencies.

9. Identify adaptations in postpartum care for

women after cesarean section.


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Learning Outcomes

10. Discuss important nursing

considerations regarding the new

family.

11. Discuss nursing care and teachingrelated to breastfeeding.


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Physiologic/Anatomic Changes of the

Postpartum Client

Breasts

Breast feeding vs. Non breast feeding

Cardiovascular system

Normal blood loss effect

Abdomen

Gastrointestinal System

Urinary System

Natural diuresis


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Physiologic/Anatomic Changes of the

Postpartum Client

Uterus Involution

Lochia

Types/Amount Cervix

Vagina

Perineum Intact

Lacerated/Episiotomy


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Involution

Figure 54.1 Involutionof the uterus. A. Immediately after delivery of the placenta, the

top of the fundus is in the midline and about halfway between the symphysis pubis and

the umbilicus. B. About 6 to 12 hours after birth, the fundus is at the level of the

umbilicus. The height of the fundus then decreases about one fingerbreadth (about 1 cm)

each day.


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Medications for the Post Partum Client

Analgesics

Narcotics

Salicylates

Anti inflammatory agents

Prostaglandins


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Postpartum Nursing Responsibilities

Breasts

Uterus

Bowel

Bladder

Lochia

Episiotomy/Incision


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Psychological Changes

Takinginstage: 1-2 days pastdelivery; recalls birth experience, relies

on others for care

Takingholdstage: 3rdday, control of

herself and infant

Lettinggostage: letting go of the

perfect pregnancy, perfect transition and

perfect baby. Desire to social interactionAttachment: Bond to infant

Negative feelings: negative, baby blues,

post-partum depression 55

Care of the Postpartum


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Care of the Postpartum

Woman

Vital signs should be assessed every 15

minutes in the first hour after birth.

When vital signs are stable, the time

interval can be lengthened.

Pain with dorsiflexion (Homans sign) is

an indication of an inflamed vessel in the

leg.


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Fundal Massage

Fundal massage is done to prevent or

correct uterine atony and remove clots

from the uterus in order to evaluate

uterine bleeding and preventhemorrhage.

A fundus requiring massage will be soft

and can be felt above the umbilicus.


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Fundal Massage

Figure 54.15 Nurse positioning hands to remove clots from uterus. Note that

lower hand supports the uterus.


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Hemorrhage

Life-threatening hemorrhaging can occur

in the postpartum woman hours or even

days after delivery.

A low blood pressure may indicatehemorrhage.

Tachycardia associated with

hypotension may indicate hemorrhage.


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Care After Cesarean


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Care After Cesarean

Delivery It is very important that adequate pain

relief be provided following a cesarean

section.

If the woman is receiving medication viaa PCA pump, she should be instructed

to push the button when she needs the

medication, and to notify the nurse if

pain relief is not adequate.

Care After Cesarean


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Care After Cesarean

DeliveryAn indwelling urinary catheter may be in

place. Measure intake and output,

checking for signs of blood.

Instruct the woman to keep the incisionclean until healing is complete.

Once the dressing is removed, the

woman may shower without any specialprecautions.


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Care After Cesarean Delivery

Instruct her to allow the incision to dry

completely after washing and to apply a

small dressing if desired.

If Steri-Strips have been applied to theincision, they will not be harmed by the

shower and will come off in about 1 week.

Teach the woman who has had a cesareansection that it is important not to overdo

activity for 4 to 6 weeks.


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Listening Skills

Listening is one of the most important

skills a postpartum nurse needs to learn.

It can make the difference between a

positive and a negative postpartumexperience.


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Client Teaching

Mother and baby care and education

should begin as soon as the mother and

baby are stable.

A womans choice regarding care ofherself and her infant must be

recognized as a very important element

in her care.


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Client Teaching

Instruct the client about expected

progression of lochiafrom red to dark

brown, to pale yellow or white.

Instruct the client to report anydeviations from this pattern.

Instruct the client regarding ways to

prevent perineal infection, such asfrequent pad changes, avoiding

tampons, and using a peri bottle after

voiding.


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Client Teaching

Instruct the client about expected

progression of lochiafrom red to dark

brown, to pale yellow or white.

Instruct the client to report anydeviations from this pattern.

Instruct the client regarding ways to

prevent perineal infection, such asfrequent pad changes, avoiding

tampons, and using a peri bottle after

voiding.


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Client Teaching

The teenage mother may require a

different approach to teaching. Hands-

on education with client return

demonstration is often most effective. The postpartum woman should be

instructed not to have intercourse until

she has seen her obstetrician or midwife

for a follow-up visit and has been told

that she may resume intercourse.


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Client Teaching

Instruct all postpartum women, whether

lactating or not, that absence of a

menstrual period does not mean they

are infertile. Encourage the woman to simplify

routines for this period of time and not to

make any major changes.


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Client Teaching

Instruct the woman in the signs of

postpartum emergencies in her infant

and herself and tell her to call the

pediatrician or obstetrician if any occur.


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THE NEONATE


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Learning Outcomes

1. Identify physiologic adaptations of theneonate.

2. Describe the use and method of

obtaining an Apgar score.3. List aspects of delivery room care and

nursing interventions for the neonate.

4. Explain nursery care of the neonate.


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Learning Outcomes

5. List differences that identify thegestational age of the neonate.

6. Describe the physical characteristics of

the neonate.7. Explain proper hygiene methods in

caring for a newborn.

8. Compare and contrast two methods ofproviding neonatal nutrition.


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Learning Outcomes

9. Identify common procedures in care of the

newborn.

10. Provide discharge teaching to parents of a

newborn.


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Neonatal Period

The neonateis the infant from deliverythrough the first month of life.

Initial care revolves around meeting the

basic biologic needs and helping thenewborn adjust to life outside the womb.

Most infants are born without

complications, and require routine care.

Foundations of Neonate


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Foundations of Neonate

CareAn understanding of the physiologic

adaptation to life outside the uterus

guides the nurses actions when setting

priorities in the care of the newborn. They involve:

Airway.

Breathing. Circulation.

Thermoregulation.

Figure 51.4 Fetal circulation. Blood leaves the placenta and enters the fetus through the umbilical vein. After circulating

through the fetus, the blood returns to the placenta through the umbilical arteries. The ductus venosus, the foramen

ovale and the ductus arteriosus allow the blood to bypass the fetal liver and lungs


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ovale, and the ductus arteriosus allow the blood to bypass the fetal liver and lungs.

I iti l N b A t


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Initial Newborn Assessment

Apgar Scoring A ppearance (Color)

P ulse (Heart rate)

G rimace (Reflex)

A ctivity (Muscle tone)

R espiratory Effort

APGAR
http://www.youtube.com/watch?v=zY87wohJl9Ihttp://www.youtube.com/watch?v=zY87wohJl9I


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APGAR score

Newborn Assessment
http://www.youtube.com/watch?v=zY87wohJl9Ihttp://www.youtube.com/watch?v=zY87wohJl9I


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Characteristics of the


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Characteristics of the

Newborn Skin

Acrocyanosis

Ecchymosis

Petechiae Lanuago


Mongolian spots Milia

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Characteristics of the Newborn


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Characteristics of the Newborn

Head

Molding Caput succedaneum edema of scalp crossing

suture lines

Cephalhematoma accumulation of blood

between the periosterum and skull bones, doesnot cross suture lines.


Strabismus lack of eye coordination see page1542 figure 56-13

Epsteins earls= small cyst on the palate

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R fl


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Reflexes

Rooting reflex ; Sucking reflex

Palmar grasp reflex:

Plantar reflex: last 8 months, foot touched

and toes curl under Babinski reflex: big toe dorsiflexs and other

toes flare

Stepping reflex

Tonic neck reflex Moro or startle reflex

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H i C


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Hygiene Care

Bathing: once temperature stable, nobath tub until cord falls off

Change diaper every 2 hours or more

frequently if needed Perineal care with each diaper change

Eye care eye ointment to prevent

ophthalmia neonatorum Umbilical cord care: with each diaper

change

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Newborn Assessment -


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Figure 56.21 Neonatal measurements are taken immediately after birth. For

height, it is often helpful to have two staff members work together to ensure the

accuracy of the measurement from crown to heel.

Taking Measurements

Newborn Assessment -


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Taking Measurements Head circumference

is a measurement of

a childs head

around its largestarea.

measures the

distance from above

the eyebrows and

pinas and around the

occiput.

C t f N b A t


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Components of Newborn Assessment

Body size andshape

Skin Characteristics

Reflexes

Nutritional needs

Temperature

Elimination

Rest/Activity

Bonding

N rser Care


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Nursery Care

Safety in the newborn nursery involvesprotecting the newborn from injury and

abduction.

Routine care of the neonate involvessponge baths, feeding, cord care,

circumcision care, and diapering in a

warm, calm environment.

The neonate should only be transported

in a bassinet, not held in the arms.

Umbilical Cord Alarm


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Figure 56.5 B. Umbilical alarm attached to newborn infant.

Umbilical Cord Alarm

Common Neonate


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Medications 1.0% tetracycline or 0.5% erythromycin

ophthalmic ointment (to prevent eye

inflammation and infection)

Vit. K. AquaMEPHYTON IM (to preventhemorrhagic disorders)

Hepatitis B immunization may be

administered in the newborn nurserywith parental consent.

Promotion of Optimum Health for the


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p

Newborn

Nutrition Breast

Formula

Sleep/Rest/Exercise Safety/Bonding

Family Structure/Support

Impact on Family Healthy vs. Abnormality

Breastfeeding


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Breastfeeding

When

Why

How

How

often

How

much

Neonate Nutrition


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Neonate Nutrition

A full-term infant needs 50 to 55 kcal/lb(110 to 120 kcal/kg) that equals 20 oz

(600 mL) of breast milk or formula per

day.At birth, the newborns stomach will hold

20 mL, or slightly less than an ounce.

Neonatal Nutrition


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Neonatal Nutrition

The infant will need to be fed every 2 to4 hours to meet nutritional needs.

The American Academy of Pediatrics

recommends breast milk for the firstyear of life.

It is important for parents to receive

information regarding the benefits ofboth breastfeeding and bottle-feeding.

Sleep


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Sleep

The neonate generally sleeps forapproximately 20 to 22 hours a day.

The newborn likes the security and

warmth offered by swaddling. The infant should be placed on his or

her back for sleeping.

All objects including stuffed animals,pillows and blankets should be removed

from the crib to prevent suffocation.

Neonatal Screening Tests


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Neonatal Screening Tests

Accomplished through heel sticks forblood draw to test for:

Hypoglycemia

Phenylketonuria Bilirubin

Heel Stick


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Figure 56.19 A. Potential puncture sites for heel sticks. Avoid shaded areas to

prevent injury to arteries and nerves in the foot.

Heel Stick

Newborn Jaundice


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Newborn Jaundice

Physiologic Occurs after the first 24 hours

Increased RBC during development

Improve O2 transport

Immature liver development

Inability to handle the breakdown process

Bilirubin held in the blood stream

Newborn Jaundice


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Newborn Jaundice

Pathologic Occurs priorto the first 24 hrs

ABO/Rh incompatibility

Treatment

Exchange transfusion

Phototherapy

F/U bilirubin

Phototherapy


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Phototherapy

Phototherapy


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Phototherapy

How does it work?

Bilirubin in the baby's body is changed

into another form that can be more

easily excreted in the stool and urine.

When do they have to use photo therapy?

When serum bilirubin is greater than 8mg/dl at 24 hours of life

Discharge Teaching


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Discharge Teaching

Any time care is provided in thepresence of the mother, and/or

significant others, teaching should be

provided regarding the care that isgiven, the reasons for the care, and

whether the parents should do the same

care at home.

The LPN/LVN assists the RN by

teaching parents about routine newborn

care.

Discharge Teaching


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Discharge Teaching Topics that require client teaching prior to discharge

include the following:

Nutrition

Elimination

Diapering

Hygiene

Placing infant on back to sleep

Discharge Teaching


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Discharge Teaching

Topics that require client teaching prior todischarge include the following:

Perineal care

Circumcision care Umbilical cord care

Safety


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