NCLEX-RN Notes Core Review And Exam Prep

BASICS BASICS ■ Challenging, defensive, or disapproving responses ■ Direct probing and “how” and “why” questions ■ Interruptions, environmental noise, or extremes in temperature ■ Trite, common expressions (clichés) Leadership Leadership and Management Terms ■ Accountability: Answerable for actions/judgments regarding care ■ Autonomy: Nurse can make independent decision to decide/act ■ Case management: Coordination of interdisciplinary care for pt ■ Decentralized management: Staff participate in decision making ■ Performance appraisal: Evaluation of a nurse’s compliance (quality & quantity) with standards and roles within job description ■ Professional standards: Actions consistent with minimum safe professional conduct. Description of responsibilities. ANA, JCAHO, agency policy and procedure ■ Quality improvement: Activities to ↑achievement of ideal care ■ Responsibility: Duties and activities that nurse is hired to perform Leadership Styles ■ Autocratic: Complete control over decisions, goals, plan, and evaluation of outcomes; firm, insistent; often used in emergencies or when staff is inexperienced or new ■ Democratic: Participative; shares responsibilities; uses role to motivate staff to achieve communal goals (shared governance), encourages intercommunication and contributions; used to help staff grow in abilities; ↑motivation, ↑staff satisfaction ■ Laissez-faire: Nondirective; relinquishes control & direction to staff; best used with experienced, expert, mature staff who know roles Tasks That May Not Be Delegated to Unlicensed Nursing Personnel ■ Assessing, analyzing, and interpreting data ■ Identifying nursing diagnoses ■ Formulating a plan of care ■ Evaluating pt responses to nursing care and extent of outcome achievement ■ Screening and classifying pts to determine priority to receive intervention (triage) 18 19 ■ Giving/monitoring parenteral medications ■ Performing patient teaching ■ Performing professional procedures (e.g., sterile irrigations, insertion of urinary catheter, colostomy irrigation, tracheal suctioning) Leader and/or Manager Qualities Effective leaders and managers need to: ■ Understand human behavior Have insight into its relationship to beliefs, values, feelings; be sensitive to others’ feelings and problems ■ Use effective communication skills Be clear, concise, avoid ambiguity; use appropriate format (verbal, written, formal, informal); be aware of own nonverbal behavior; support staff in growth of skills ■ Use power appropriately Power attained through place in table of organization (positional); power attained through knowledge and experience or perceived by staff (professional); do not abuse ■ Respond to staff needs Listen attentively, attend to needs, provide positive feedback, avoid favoritism, set realistic expectations, avoid mixed messages, and treat staff with respect: Counsel privately; keep promises; avoid threats, superior attitude, criticism, or aggressive confrontation ■ Delegate appropriately Right person (competent subordinate), right task (is within scope of practice), right situation (nursing assistant should not perform a routine task on an acutely ill patient), right communication (clear instructions, validate understanding of instructions), right supervision (monitor actions, evaluate outcomes, review with subordinate); leader retains accountability ■ Provide opportunities for personal growth Aid less experienced nurse to ↑knowledge, experience, responsibility (e.g., mentor/preceptor, continuing education, staff education) ■ Use critical thinking and problem solving Process requires effective communication, assessment, planning, and participation of staff and evaluation of outcomes ■ Recognize conditions that are conducive to change Need is recognized by all staff and all have a stake in outcome; include all creatively in the process; focus on benefits; provide positive feedback; offer incentives ■ Process follows problem-solving process BASICS BASICS ■ Change is planned and introduced gradually ■ Change is initiated in a calm rather than chaotic atmosphere; best after a prior successful change ■ Resistance is recognized and addressed; causes of resistance: change is threatening; lack of understanding; disagreeing with purpose/approach, beliefs, and values; ↑in responsibility; habit; fear of failure Levels of Management ■ First-level: Supervises nonmanagerial staff; oversees day-to-day activities of a group (e.g.,Team Leader, Charge Nurse) ■ Middle-level: Supervises a group of first-level managers (e.g., Supervisor, Coordinator, Head Nurse) ■ Upper-level: Organizational executives; sets goals and strategic planning (e.g., VP for Nursing, Associate Director of Nursing) Staff Nurse Role ■ Function as role model regarding professional conduct ■ Receive report from nurse previously responsible for patient ■ Make rounds on all pts immediately after receiving report ■ Set priorities regarding pt needs: Immediate threat to survival (problems with breathing, VS, ↓LOC), requests for help (pain, toileting), urgent but not immediate needs (teaching) ■ Coordinate and/or perform care for assigned pts; use time-management skills; complete all care assigned ■ Delegate care to subordinates that is within their job description ■ Monitor care delegated; establish clear expectations; encourage communication; evaluate patient outcomes related to delegated tasks (nurse retains accountability for delegated tasks) ■ Give report to next nurse responsible for patient ■ Engage in quality improvement (QI) activities ■ Participate in intradepartmental and interdepartmental meetings Nurse Manager Role ■ Function as a role model regarding professional conduct ■ Set standards of performance; establish goals for the unit with the staff; mobilize staff and agency resources to attain goals ■ Support mutual trust; treat staff with respect; counsel privately ■ Empower staff: Support innovation, seek staff members’ opinions, promote professional environment and growth, reward growth ■ Perform pt rounds with multidisciplinary team 20 21 ■ Monitor nursing practice and achievement of standards ■ Design and implement a quality improvement (QI) program for the unit; engage staff in QI activities ■ Assist in staff development plan and orientation of new employees ■ Schedule staffing for the unit ■ Conduct regular staff meetings with all shifts ■ Evaluate performance of subordinates (performance appraisal) ■ Participate in intradepartmental and interdepartmental meetings Community Nursing ■ Community health nursing (public health nursing): Nursing care for a specific population living in the same geographic area, or groups having similar values, interests, and needs. Aims to develop a healthy environment in which to live ■ Public health functions: Community assessment, policy development, and facilitating access to resources. Cohesiveness is promoted by engaging community members in the problem-solving process and promoting empowerment through education, opportunities, and resources. Successful public health programs are congruent with that of the interests and goals of the community ■ Assessment of a community: ■ Structure (milieu): Geographical area, environment, housing, economy, water, and sanitation ■ Population: Age and sex distribution, density, growth trends, educational level, cultures and subcultures, religious groups ■ Social systems: Education, communication, transportation, wel- fare, and health care delivery systems; government and volunteer agencies ■ Community-based nursing: Nursing care delivered in the community while focused on a specific individual’s or family’s health care needs.The individual is viewed within the larger systems of family, community, culture, and society ■ Vulnerable populations: People at risk for illness (e.g., homeless, living in poverty, migrant workers, living in rural communities, pregnant adolescents, suicidal individuals, frail older adults) ■ Stigmatized groups: People viewed with disdain/disgrace (e.g., pts with dx of HIV positive, substance abuse, mental illness) ■ Settings in which nurses work: Homes, community health centers, clinics, industry, rehabilitation centers, schools, crisis intervention centers (phone lines), shelters, halfway houses, sheltered workshops, day care centers, forensic settings BASICS BASICS ■ Roles of nurses: Discharge planner, case manager, counselor, and epidemiologist, health promoter, case finder, caregiver, educator, researcher, consultant, advocate, role model, change agent ■ Hospice care: Palliative (relieve or ↓discomfort) and supportive care for dying persons and their caregivers. Experts in pain and symptom management. Focuses on preserving dignity and quality over quantity of life. Supports bereavement; usually during last 6mo of life ■ Respite care:Temporary care for homebound so that caregivers have relief from day-to-day responsibilities Patient Education Learning Domains Cognitive domain:Thinking, acquiring, comprehending, synthesizing, evaluating, storing, and recalling information. ■ Build on what pt knows. Present essential information first. Add information as pt asks questions. ■ Teaching strategies: Lecture, discussion, audiovisuals, printed material, computer-assisted and Web-based instruction. ■ Evaluation: Assess knowledge by verbal/written means. Affective domain: Addresses attitudes, feelings, beliefs, values. Takes time to internalize need-to-change behavior. ■ Understand own value system. Respect uniqueness of each pt. Help pt explore feelings. ■ Teaching strategies: Discussion, play, role modeling, panel discussion, groups, role-playing. ■ Evaluation: Evidence of behavior incorporated into lifestyle. Psychomotor domain: Addresses physical/motor skills. Requires dexterity and coordination to manipulate equipment. Ultimately performs a task with skill. ■ Achieve mastery of each step before moving on to next step. ■ Teaching strategies: Audiovisuals, pictures, demonstrations, models. ■ Evaluation: observation of performance of skill (return demonstration). Teaching and Learning—General Concepts ■ Education can prevent illness, promote or restore health, ↓complications, ↑independence and coping, ↑individual and family growth. Incorporate throughout health care delivery. ■ Environment should be conducive to learning: Private, quiet, well lit, comfortable, and lack distractions (close door/curtain, shut offTV). ■ Teaching process should follow format of Nursing Process. 22 23 ■ Both short- and long-term goals should be set to ↑motivation and allow for evaluation. Goals must be pt centered, specific, measurable, realistic, and have a time frame. ■ A variety of teaching strategies that use different senses should be used (written materials, videos, discussion, demonstration). ■ Teaching can be formal/informal, individualized, or within a group ■ Information should move from the simple to complex, from known to unknown, be appropriate for pt’s cognitive and developmental level. ■ Shorter more frequent sessions most effective (15–30min) ■ Learning is ↑with repetition, consistency, practice. ■ Evaluation and documentation are essential elements of teaching. Patient Factors That Influence Learning Culture, religion, ethnicity, and language: Commonalities and differences exist between cultures and among people from within the same culture. ■ Be culturally sensitive and nonjudgmental. ■ Avoid assumptions, biases, and stereotypes. Seek help from multicultural team. ■ Provide teaching in pt’s language. Use professional translator. Knowledge and experience: Can promote or deter learning. ■ Identify what patient already knows. Build on this foundation. ■ Explore concerns related to experiences. Correct misconceptions. Literacy:Years in school may not accurately reflect reading ability. ■ Assess ability to read and comprehend material (confusion, nervousness, excuses may indicate ↓ability to read). Use illustrations, models, videos/films, discussion. ■ Provide privacy. Developmental level: ■ Children: The younger the child the shorter the attention span. May regress developmentally when ill. Imagination can ↑fear and misconceptions.Toddlers and preschoolers are concrete thinkers; school-age children are capable of logical thinking. ■ Nursing: Identify developmental age to determine appropriate strategies and tools (dolls, puppet play, role playing, drawing, games, and books). Use direct, simple approach. Also direct teaching to parents. ■ Adolescents: Need to be similar to peers. Seeking autonomy. Focused on the present. ■ Nursing: Be open and honest about the illness. Respect opinions and need to be like peers. Support need for control. Learning must have immediate results. BASICS ■ Adults: Need to be self-sufficient and in control. ■ Nursing: Assess for readiness. Learning most effective when self- directed, built on prior knowledge and experience, and has a perceived benefit. ■ Older adults: Needs are highly variable. Functional changes, stress, fatigue, and chronic illness can ↓learning. Changes that may occur include slower cognition, slower reaction time, becoming overwhelmed with too much detail, and ↓ability to recall new information. ■ Nursing: Do not underestimate learning ability. ↓Pace of teaching to allow more time to process information and make decisions. Plan shorter, more frequent teaching sessions.Teach main points and avoid irrelevant details. Readiness to learn: Receptiveness to learning. ■ Patient has to recognize the need to learn and be physically and emotionally able to participate. ■ Depression, anxiety, anger, denial will interfere with readiness, motivation, and concentration. ■ Pain, acute/chronic illness, O2 deprivation, fatigue, weakness, and sensory impairment can interfere with learning. ■ Identify readiness (pt states misconceptions, asks questions, demon- strates health-seeking behaviors, is physically comfortable, and anxiety  mild). ■ Select teaching aids appropriate for pt’s sensory limitations. ■ Postpone teaching until pt is able to focus on learning; address factors that interfere with learning. Motivation: Drive that causes action. Essential to learning. ■ Personal desire to learn (intrinsic motivation, internal locus of control) such as feeling better after stopping smoking. ■ Desire to learn because of an external reward (extrinsic motivation, external locus of control) such as ↑salary. ■ Be sincere and nonjudgmental, ensure material is meaningful, make contractual agreement, and set short-term goals to ensure success. ■ Identify/praise progress (positive reinforcement), avoid criticism (negative reinforcement), allow for mistakes. ■ Use interactive strategies; do not let anxiety level climb past mild. ■ Assess for ↓motivation (distraction, changing subject). 24 BASICS 25 Basic Nursing Measures Body Mechanics ■ Maintain functional alignment: ↑Balance, movement, physiologic function; avoids stress on muscles, tendons, ligaments, bones, joints; avoid rotating or twisting body; use supportive devices. ■ ↑Balance by keeping wt within the center of gravity; avoid reaching. ■ ↑Stability by spreading feet apart to widen base of support. ■ Use large muscles of legs for power; avoids back muscle strain. ■ Flex knees and hold objects being lifted close to body; lowers center of gravity and keeps wt within base of support; ↑stability; ↓strain. ■ Raise bed to working ht; working closely to object being lifted or moved keeps object within center of gravity. ■ Use internal girdle to stabilize pelvis when lifting, pulling, stooping. ■ Use body wt as a force for pushing/pulling; lean forward and backward or rock on feet; ↓strain on back. ■ Pull, push, roll, slide rather than lift; face direction of movement. Fall Prevention ■ Assess for risk factors: History of falls, ↓sensory perception, weakness, ↓mobility, ↓LOC, ↑anxiety, confusion, ↓mental capacity, meds (diuretics, opioids, antihypertensives). ■ Orient to bed and room; teach use of ambulatory aids and call bell; answer call bell immediately. ■ Keep bed in lowest position unless receiving care. ■ Raise 3 of 4 side rails; raise 4 rails if it is patient’s preference or there is an order (4 raised rails are considered a restraint). ■ Lock wheels on all equipment and ensure that equipment is intact. ■ Keep call bell, bedside and overbed table, personal items in reach. ■ Keep floor dry and free of electric cords/obstacles; use night light. ■ Encourage use of grab bars, railings, rubber-soled shoes. ■ Stay with patient in bathroom/shower (need MD order for shower). ■ Teach fall-prevention techniques (e.g., rise slowly). ■ Use monitoring device to signal attempt to ambulate unassisted. BASICS BASICS Compression landmarks Compression method Compression rate and depth Compression/ventilation ratio Pulse check Defibrillation Rescue breathing Fire Safety ■ Stay calm; keep halls clear; do not use elevator; stay close to floor. ■ Know location and use of alarms and extinguishers. ■ Evacuate pts in immediate danger first and then ambulatory, those needing assistance, and finally bedbound pts. ■ Class A fire: Wood, textiles, paper trash; water extinguisher. ■ Class B fire: Oil, grease, paint, chemicals; dry powder and CO2 extin- guisher; water will spread fire; touching horn of CO2 extinguisher can freeze tissue. ■ Class C fire: Electrical wires, appliances, motors; dry powder and CO2 extinguisher. ■ RACE: Rescue pts in danger; Activate alarm; Contain fire (close doors/windows); Extinguish fire if small; Evacuate horizontally and then vertically. Cardiopulmonary Resuscitation (CPR)—Adult Assess for response Activate 911—1 rescuer Airway—breaths Tap and ask, “Are you OK?” Witnessed collapse with no response; unwitnessed event after 5 cycles of CPR Put on hard surface; head tilt-chin lift (lift- jaw thrust with spinal trauma); look, listen, feel for air; if not breathing, give 2–1 second breaths Center of chest; lower half of sternum (not over xiphoid) Heel of 1 hand, heel of 2nd hand on top (“hard and fast” allowing for chest recoil) Rate: Approximately 100/min; Depth: 11/2 to 2 inches 30:2 Carotid Sudden collapse: As soon as possible All others: After 5 cycles of CPR Pulse 60/min with no breathing: 10 to 12 breaths/min; 1 breath every 3–5 sec Pulse 60/min with no breathing: Continue CPR 26 27 BASICS Assess for extent of obstruction Mild: Can cough and make sounds; Severe: cannot cough, make sounds, or speak; difficulty breathing; pallor; cyanosis Victim is conscious Mild: Continue to monitor Severe: Abdominal thrusts until object Mild: Continue to monitor Severe: Deliver 5 back blows and 5 Victim becomes unresponsive Head tilt-chin lift; inspect mouth; remove object if present in pharynx; implement CPR but always inspect for object in pharynx before attempting 2 rescue breaths and remove if present; continue CPR Assess for extent of obstruction Mild: Can cough and make sounds; Severe: cannot cough, make sounds, or speak; difficulty breathing; pallor; cyanosis. Ask, “Are you choking?” If victim nods yes, initiate abdominal thrusts Abdominal thrusts Mild: Continue to monitor; Severe: Abdominal thrusts until object is expelled or victim becomes unresponsive Victim becomes unresponsive Head tilt-chin lift; inspect mouth; remove object if present in pharynx; implement steps in CPR for adult but always inspect mouth for object in pharynx before each 2 rescue breaths Foreign Body Airway Obstruction—Child and Infant Child: 1year–adolescent Infant: 1yr is expelled or victim unresponsive chest thrusts; repeat until object is expelled or victim unresponsive Foreign Body Airway Obstruction (FBAO)—Adult BASICS FACES Pain Rating Scale Alternate 0 coding Pain Management 012345 No hurt Hurts little bit 2 Hurts little more 4 Hurts even more 6 Hurts whole lot 8 Hurts worst 10 0 1 2 3 4 5 6 7 8 9 10 No Mild Moderate Severe Unbearable Pain Pain Pain Pain Pain Source: Wong-Baker FACES Pain Rating Scale. From Wong D. L., Hockenberry-Eaton, M., Willson D., Winkelstein M. L., Schwartz, P. Wong’s Essentials of Pediatric Nursing, 6th ed. St. Louis, MO, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission. 28 Pain nt Tool 29 Assessme P: Provokes/point. What causes the pain? Point to the pain? Q: Quality. Is it dull, achy, sharp, stabbing, pressuring, deep, etc.? R: Radiation/relief. Does it radiate? What makes it better/worse? S: Severity/S&S. Rate pain on 1–10 scale. What S&S are associated with the pain (dizziness, diaphoresis, dyspnea, abnormal VS)? T: Time/onset. When did it start? Is it constant or intermittent? How long does it last? Sudden or gradual onset? Frequency? Nursing Care ■ Assess pain: Use tools/scales ■ Provide comfort: Positioning, rest ■ Validate pt’s pain: Accept that pain exists ■ Relieve anxiety/fears: Answer questions, provide support ■ Teach relaxation techniques: Rhythmic breathing, guided imagery ■ Provide cutaneous stimulation: Backrub, heat and cold therapy ■ Decrease irritating stimuli: Bright lights, noise, ↑↓room temp ■ Use distraction (for mild pain): Soft music; encourage TV/reading ■ Provide pharmacologic relief: Administer meds as ordered ■ Evaluate pt response: Document; modify plan Restraints—Nursing Care ■ Physical or chemical intervention that ↓movement ■ Purpose: preventing falls, disrupting therapy, harming self/others ■ Physical restraints: Devices used to ↓movement (vest, mitt, wrist, elbow, belt, mummy) ■ Chemical restraints: Meds to calm disruptive/combative behavior that may cause harm to self/others ■ Nursing ■ Document behavior requiring need and failure of less invasive measures to protect pt; secure daily order ■ In emergency, notify MD and get order signed within 24hr ■ Ensure functional alignment before applying ■ Follow directions (correct size, snug but does not limit respirations or occlude circulation, apply vest with V opening in front, secure tails with slipknot to bed frame) ■ Pad under wrist or mitt restraints ■ Monitor respiratory and circulatory status routinely ■ Every 1–2hr remove restraint, assess skin, and provide care, perform ROM BASICS Type of Reaction BASICS Local skin reaction: Direct skin-to-latex contact Excessive exposure can lead to systemic reaction Systemic: Direct skin-to-latex contact Contact with equipment exposed to latex Visually Impaired Patient—Nursing Care ■ Knock on door, greet pt by name, identify self, and explain purpose ■ Do not touch until after pt understands your name and purpose ■ Approach in an unhurried manner and use clear, simple sentences ■ Stay within the pt’s field of vision ■ Orient to the room, location, and use of call bell ■ Provide a predictable environment; remove all hazards ■ ↓Noise and distraction in the environment; explain unusual noises ■ Ensure glasses are clean, accessible, and protected when stored ■ Inform of location of food on meal tray; use numbers on a clock ■ Ambulate pt by walking slightly in front while pt holds your arm. Never try to push or guide from behind. Inform of doors, steps ■ Make it clear to pt when the conversation is over or when leaving Hearing-Impaired Patient—Nursing Care ■ Greet pt by name, identify yourself and your purpose, ensure quiet ■ Use touch appropriately to alert pt that you are about to talk ■ Face pt directly; avoid turning away from pt while you are speaking; to facilitate lip reading, do not cover mouth with your hand ■ Talk in a normal tone at a moderate rate; speak clearly; articulate consonants carefully; do not overly articulate; do not yell ■ Use gestures and facial expression to convey message ■ Encourage use of hearing aid; facilitate repair of nonworking aids ■ Remove hearing aid when showering or washing the hair ■ Follow manufacturer’s directions to insert, remove, clean, and store aid Latex Allergy S&S Not life-threatening Erythema, pruritus, Popular, vesicular, scaling, or bleeding lesions; Life-threatening Angioedema Rhinitis or rhinorrhea, Conjunctivitis Bronchospasm 30 Nursing Actions Allergy wristband Label chart Use latex-free equipment (gloves, tape, dressings, syringes, antiembolism stockings, tubing, tourniquets, stetho- scopes, electrode pads, BP cuffs, any indwelling urinary catheters) Type of Reaction Powder particles exposed to latex may be inhaled or absorbed via skin, mucous membranes, or blood 31 LatexAllergy (Continue S&S Anaphylactic responses Circulatory collapse d) Nursing Actions Notify pharmacy so meds and mixed solutions are latex-free Ensure procedure rooms are latex-free and patient is first case of day Neutropenic Precautions ■ For individuals with compromised immune system ■ Use standard precautions, especially hand hygiene ■ Caregivers and visitors should be free of communicable illnesses ■ Private room if possible; keep room meticulously clean ■ Teach to avoid sources of potential infection (crowds, confined spaces such as airplanes, raw fruits/vegetables, flowers/plants) Sterile Asepsis ■ Check expiration date; ensure packages are dry, intact, and stain-free ■ Discard opened sterile solutions older than 24hr; criteria for medicated/antiseptic solutions may differ ■ Place cap on table with inner cap turned up; label with date, time, and initials; avoid touching bottle rim ■ Place sterile equipment inside the outer 1 inch of sterile field ■ Ensure that sterile objects touch only another sterile object ■ Open sterile packages away from sterile field ■ Keep sterile field in one’s line of vision ■ Position solution closest to patient; keep field dry and free of moisture ■ Don sterile gloves without contaminating sterile surfaces ■ Keep sterile gloved hands and equipment above level of waist ■ Avoid talking, coughing, sneezing around a sterile field ■ Discard sterile objects that become contaminated or if doubtful BASICS Standard Precautions:Tier 1 BASICS ■ Perform hand hygiene before and after care and when soiled; most important way to prevent infection ■ Use personal protective equipment (PPE) if touching, spilling, or splashing of blood or body fluids is likely; use gloves, gowns, mask, goggles, shields, aprons, head and foot protection ■ Discard disposable items in fluid-impermeable bag and contaminated items in Biohazard Red Bag ■ Do not recap used needles; dispose in sharps container ■ Hold linen away from body; place in impermeable bag in a covered hamper; do not let hampers overflow ■ Place lab specimens in a leak-proof transport bag without contaminating the outside; label with biohazard sticker and patient information ■ Institute procedure for accidental exposure: Wash area, report to supervisor, receive emergency care, seek referral for follow-up ■ Receive hepatitis B vaccine ■ Assign patient to private room if hygiene practices are unacceptable ■ Avoid eating, drinking, touching eyes, applying makeup in patient areas Transition-Based Precautions:Tier 2 AIRBORNE ■ Used for microorganisms that spread through air (droplet nuclei 5’m [e.g.,TB, measles, chicken pox]) ■ Private room; negative air pressure room; door closed; high-efficiency disposable mask (replace when moist) or particulate respirator (e.g., for TB); transport patient with mask, teach to dispose soiled tissues in fluid- impervious bag at bedside DROPLET ■ Used for microorganisms spread by large-particle droplets (droplet nuclei 5’m, (e.g., pneumonia [streptococcal, mycoplasmal, meningococcal], rubella, mumps, influenza, adenovirus) ■ Private room if available or cohort pts, mask when within 3ft of pt, door open, mask for pt when transporting, teach to dispose soiled tissues in fluid-impervious bag at bedside CONTACT ■ Used for organisms spread by direct or indirect contact; methicillin- resistant S. aureus (MRSA), vancomycin-resistant enterococcus (VRE), vancomycin intermediate-resistant S. aureus (VISA); enteric pathogens (e.g., E. coli, C. difficile), herpes simplex, pediculosis, hepatitis A and E, varicella zoster, respiratory syncytial virus ■ Private room or cohort pts; gowns, gloves over-gown cuffs; dedicate equipment 32 33 Nursing Care of Older Adults (65yr) Background DEMOGRAPHIC DATA ■ 70% rate themselves as healthy. Majority live in the community; increasingly more live in assisted living facilities. 5% in nursing homes. PHYSICAL CHANGES ■ Gradual ↓in physical abilities. Close vision impairment (presbyopia). ↓Hearing especially for high-pitched sounds. ↓Subcutaneous tissue. ↓Muscle strength. Impaired balance and coordination. ↓Immune response. One or more chronic health problems. PSYCHOSOCIAL ISSUES ■ Conflict is ego integrity vs. despair. Personality does not change but may become exaggerated. Adjusting to aging, ↓health, maintenance of quality of life, retirement, fixed income, death of spouse/friends, change in residence, own mortality. Reminiscing may become focused on bodily needs and comforts. Sexual expression (love, touching, sharing, intercourse) important and related to identity. COGNITIVE STATUS ■ IQ does not ↓. Mental acuity slows (↑time to learn, problem solve). Long-term memory better than short-term memory. REACTION TO ILLNESS/HOSPITALIZATION ■ Illness/recuperation longer. Secondary to ↓adaptive capacity. ↑Feelings of inadequacy and mortality. May ↑self-absorption, social isolation, frustration, anger, depression, especially if retirement goals are denied. Unfamiliar environment may cause confusion, anxiety. Chronic illness, pain, or impending death may cause dependence, hopelessness. May accept and prepare for death. ■ Nursing: Understand commonalities of aging but approach each person as unique. Avoid stereotyping because it denies uniqueness, ↓access to care, and impacts negatively on individual. Ensure access to health care and social services, especially in home. Critical illnesses deserve aggressive treatment if desired. BASICS Common Problems Associated With Aging BASICS BOWEL AND BLADDER INCONTINENCE ■ Not part of aging process. May be aggravated by ↓muscle tone of anal and urinary sphincters and prostatic hypertrophy. ■ Nursing: Ensure screening for UTI, bladder/prostate cancer. Assist with hygiene and skin care. Institute bowel or bladder retraining. ADVERSE DRUG EFFECTS ■ Multiple health problems require ↑prescriptions (polypharmacy) with ↓coordination among MDs. ↓Hepatic/renal function that results in accumulation, ↑paradoxic effects. ■ Nursing: ↑Coordination of health care. Identify unnecessary or excessive doses of meds. Assess for adverse/toxic effects. FALLS/ACCIDENTS ■ Secondary to sensory impairments (vision, hearing, touch), postural changes, ↓muscle strength and endurance, orthostatic hypotension, neurologic and cardiovascular decline. ■ Nursing: Assist with ambulation. Teach safety precautions (use grab bars, railings, and walker; rise slowly; keep feet apart for a wide base; give up driving when impairment jeopardizes safety). INFECTIONS ■ Increased secondary to ↓immune response. ■ Nursing:Teach preventive measures (handwashing, avoiding crowds, smoking cessation. Pneumococcal pneumonia vaccine, yearly flu vaccine. COGNITIVE IMPAIRMENT ■ Not part of aging process. Delirium is potentially reversible and is associated with acute illness. Dementia is a chronic, progressive, irreversible disorder. Sundowning syndrome is confusion after dark. ■ Nursing: SeeTAB 5—Mental Health Nursing for nursing care. ALCOHOL ABUSE ■ Secondary to depression, loneliness, lack of social support. ■ Nursing: Explore effective coping strategies. Refer to AA. RISK OF SUICIDE ■ Secondary to multiple losses (loved ones, health), lack of social support; 20% experience depression, feelings of hopelessness, and isolation. 34 35 ■ Nursing: Assess for suicide risk. Provide reality orientation, validation therapy, reminiscence. Support body image. Encourage psychological counseling; obtain order for antidepressant; referral to social service agency. SEXUAL RESPONSIVENESS/ERECTILE DYSFUNCTION ■ Sexual response takes longer; ↓estrogen and testosterone; chronic health problems; medications; unavailable partner; cognitive impairment. ■ Nursing: Provide privacy/dignity and nonjudgmental attitude, ↑verbalization of concerns, suggest lubricants, penile prostheses, meds to reduce erectile dysfunction. SEXUALLY TRANSMITTED INFECTIONS (STI) ■ Need for sexual expression continues. ↑Society recognition that sex is natural and acceptable even if single by choice or death of spouse. ■ Nursing: Maintain nonjudgmental attitude; teach about STI prevention. LEADING CAUSES OF DEATH ■ Heart disease, then cancer, stroke, lung disease, falls, diabetes, kidney and liver disease. Often have 1 or more chronic illnesses. ■ Nursing: Focus on health promotion. Encourage smoking cessation, ↑exercise, wt control, adequate nutrition. Provide screening programs to identify problems early and manage chronic conditions. Common Human Responses Vital Signs ■ Afebrile: Oral: 97.5–99.5F and rectal: 0.5–1.0F↑ than oral route ■ Hyperthermia: 99.5F; hypothermia: 97.5F PULSE ■ Normal: 60–100bpm ■ Tachycardia: 100bpm; bradycardia: 60bpm ■ Thready: Weak, feeble; bounding: forceful, full ■ Dysrhythmia: Irregular pattern ■ Pulse deficit: Difference between radial and apical rate RESPIRATIONS ■ Eupnea, normal: 12–20bpm ■ Tachypnea: 20bpm; bradypnea: 12bpm ■ Apnea: Absence of breathing TEMPERATURE BASICS BASICS ■ Hyperventilation: ↑Rate and depth ■ Kussmaul: Deep and rapid, associated with metabolic acidosis ■ Cheyne-Stokes: Rhythmic waxing and waning from very deep to very shallow and temporary apnea ■ Orthopnea: Upright position to breathe ■ Dyspnea: Difficulty breathing BLOOD PRESSURE ■ Normal: SBP 120 and DBP 80 ■ Prehypertension: SBP 120–139 or DBP 80–89 ■ Stage 1 hypertension: SBP 140–159 or DBP 90–99 ■ Stage 2 hypertension: SBP ≥160 or DBP ≥100 Fever ↑Temperature; low-grade fever 98.6 F–101F; high-grade fever 101 F S&S: Fatigue, weakness, flushed, dry skin ETIOLOGY: Bacterial, viral, or fungal infection, DVT, med side effects, tumor NURSING ■ Monitor VS and WBC; evaluate meds for possible drug-induced fever ■ Obtain diagnostic tests (sputum, blood, or urine for C&S, chest x-ray) ■ Perform focused assessments: ↓Breath sounds, crackles, rhonch; stiff neck; headache; photophobia; irritability; confusion; IV site, incisions and wounds for infection; legs for DVT (redness, warmth, swelling tenderness); urine for infection (burning on urination, cloudy, greenish/reddish color); GI S&S (diarrhea, N&V, abdominal discomfort) ■ Encourage coughing and deep breathing; ↑fluid intake ■ Antipyretics, tepid bath, hypothermia blanket ■ Change IV site if indicated Constipation ≤2 stools a wk and/or hard dry feces (obstipation). S&S: Distended abdomen, rectal pressure, back pain, straining at stool, anorexia, blood-streaked stools, ↓bowel sounds ETIOLOGY: Urge is ignored; ↓fluids, mobility, or fiber in diet; weak abdominal or pelvic floor muscles; med side effects (opioids, iron, MAO inhibitors); anal lesions; pregnancy; laxative or enema abuse; F&E imbalance; obstruction; child: stool-withholding behavior 36 37 NURSING ■ Assess stools for frequency, amount, color, consistency ■ ↑Fluid intake, ↑exercise and ↑fiber in diet, binding foods (rice, bananas) ■ Respond to urge; encourage sitting position and regular time each day ■ ↑Relaxation and privacy; give laxatives, cathartics, enemas as ordered Diarrhea Passage of fluid or unformed stool 3 a day S&S: Frequent loose stool; abdominal pain, cramps, flatus, N and V, fatigue, ↑bowel sounds, abdominal distention, anorexia; results in dehydration ETIOLOGY: Viral, bacterial, or parasitic gastroenteritis; contaminated food or water; spicy, greasy food; raw seafood; excessive roughage; lactose intolerance; AIDS; drug side effect; anxiety; inflammatory bowel disease (ulcerative colitis, Crohn’s disease); ingestion of heavy metals (lead, mercury); malabsorption syndrome NURSING ■ Assess stools for frequency, amount, color, consistency ■ Assess S&S of dehydration; ↑PO fluid intake ■ Assess perianal skin breakdown and provide skin care ■ Assess antibiotic, stool softeners, and opiate use ■ Ask about recent foreign travel and dietary intake ■ Obtain stool specimen (C&S, ova, and parasite) ■ Administer antibiotics, antidiarrheals, IV F & E as ordered ■ Contact precautions as indicated Hemorrhage Bleeding that compromises tissue/organ perfusion S&S: ↑Pulse, ↑respirations, ↓BP, narrowing pulse pressure; excessive blood loss; capillary refill 3sec; ↓peripheral pulses; cool, moist, pale, mottled, or cyanotic skin; thirst. Early CNS S&S: ↓LOC, anxiety, irritability, restlessness. Late CNS S&S: Confusion, lethargy, combativeness, coma ETIOLOGY: External: Surgical and traumatic wounds. Internal: blunt trauma, cancer, ruptured aneurysm, GI perforation, thrombolytic therapy NURSING ■ Apply direct pressure; reinforce dressing (removal may dislodge clot) ■ Monitor VS, I&O; lab results ■ Maintain airway; give O2 ■ Ensure #18 gauge IV access; Give IVF, blood or colloidal products BASICS BASICS Shock Acute circulatory collapse; ↓O2 to cells, tissues, and organs S&S: ↓BP; ↓urinary output; capillary refill 3sec; cool, pale, mottled, or cyanotic skin; change in mental status. Hypovolemic: ↓Peripheral pulses. Neurogenic: Tachycardia or bradycardia. Anaphylactic: Anxiety, throat tightness, stridor, tachypnea, diaphoresis, flushing, urticaria, coma. Septic: Fever, tachycardia, tachypnea ETIOLOGY: Hypovolemic: Blood loss, dehydration; Neurogenic: Spinal cord injury, anesthesia; Anaphylactic: Exposure to antigen; Septic: Infection, endo/exotoxin release NURSING ■ Emergency intervention: Establish airway; suction if needed; O2 via nonrebreather mask 10–15 L/min; supine position with legs elevated unless airway compromised, then low Fowler’s; ensure IV access with 18-gauge needle; prepare for code, intubation, central venous access, IVF, emergency meds; transfer to ICU ■ Ongoing assessments: ECG, hemodynamic monitoring, LOC, orientation, VS, pulse oximetry (may be unreliable due to ↓peripheral perfusion), I&O, and skin for color, temp, turgor, moistness ■ Specific to types—hypovolemic: Control bleeding if present, volume replacement with crystalloids, colloids, plasma expanders, and/or blood products; cardiogenic: vasopressors, cardiotonics, antidysrhythmics; anaphylactic: epinephrine, antihistamines, steroids; septic: volume replacement, antibiotics, vasopressors, antipyretics; neurogenic: ensure spinal stabilization, vasopressors Infection Entry and multiplication of a pathogen in tissue. Can be local or systemic or can progress from local to systemic. Example: UTIs can spread to kidneys and blood stream (urosepsis). Infection is accompanied by the inflammatory response S&S: Local: Erythema, edema, tenderness, heat, ↓function; purulent exudate; positive culture. S&S also depend on tissue involved. Systemic: ↑VS (T, P, R, BP); chills; diaphoresis; malaise; ↑WBCs; positive culture; occasionally headache, muscle/joint pain, changes in mental status ETIOLOGY: Invasion of bacterial, viral, or fungal pathogen NURSING ■ Assess VS, S&S of inflammation and infection ■ Obtain C&S before 1st dose of antibiotic if infection is suspected 38 39 ■ Avoid excess bed covers, change linen if diaphoretic ■ Promote rest and immobilization ■ Give O2, IVF, ↑po fluids, ↑protein, Vit C, and wound care as ordered ■ Transmission based precautions as indicated Inflammatory Response Local defensive vascular response to injury, infection, or allergen to protect and repair tissue; inflammatory response occurs with an infection SIGNS AND SYMPTOMS: Histamine, prostaglandin, bradykinin, and serotonin ↑vascular permeability, causing fluids, protein, and cells to move into interstitial tissue.This causes local edema, heat, redness. Histamine irritates and edema places pressure on nerve endings → pain. Edema and pain contribute ↓function. Exudate may be clear, plasmalike (serous), pink with RBCs, (sanguineous), or yellowish-green with WBCs and bacteria (purulent). Purulent exudate indicates infection ETIOLOGY: Local trauma, local infection NURSING ■ Assess for S&S of inflammation and wound characteristics ■ Provide wound care as ordered ■ Elevate area if possible to ↓edema. Immobilize area to ↓pain ■ Give antipyretics, anti-inflammatories, antibiotics as ordered ■ Apply ice (at time of injury to ↑vasoconstriction, which ↓pain/edema) or heat (after 24–48hr to ↑circulation and remove debris and localize inflammatory agents) if ordered Nausea and Vomiting Unpleasant wavelike sensation in throat and epigastrium (nausea). Ejection of GI contents through mouth (vomiting, emesis), which carries a risk of aspiration → atelectasis, pneumonia, asphyxiation S&S: Nausea, vomiting, ↑↓pulse, pallor, diaphoresis, bowel sounds↑ or high pitched, abdominal pain, S&S of F&E imbalance (e.g., hypokalemia, metabolic alkalosis) ETIOLOGY: Gastroenteritis, motion sickness, infection, pain, stress, med side effect, pregnancy, appendicitis, bowel obstruction, neurological causes (head trauma, vascular headache), ↑ICP NURSING ■ Maintain airway ■ ↑HOB or place in side-lying position; keep NPO ■ Assess emesis characteristics and note if vomiting is projectile BASICS BASICS ■ Assess hydration status, I&O, electrolytes, daily weight ■ Assess abdomen for distention and tenderness ■ Attempt to determine cause ■ Notify MD and obtain orders for alternate route for meds Orthostatic Hypotension ↓BP when rising from lying down to sitting or sitting to standing secondary to peripheral vasodilation without a compensatory ↑cardiac output. Also called postural hypotension. S&S: Lightheadedness, vertigo, weakness; cool, pale, diaphoretic skin ETIOLOGY: Older age, immobility, hypovolemia, anemia, dysrhythmias, med side effect (opioids, antihypertensives, diuretics) NURSING ■ Assess for ↑pulse and ↓BP when changing position ■ Rise slowly, “dangle” before standing, resume prior position if dizzy ■ Assist to bed, chair, or floor if falling; if ↓BP continues—assess for ↓LOC, neurologic status, cardiac status, S&S of dehydration 40 41 Prenatal Period: Fertilization to Start of Labor Signs of Pregnancy ■ Presumptive signs: Absence of menses (amenorrhea); 1st awareness of fetal movement (quickening) by 16–20wk ■ Probable signs: Softening of cervix (Goodell’s sign); bluish-purple mucous membranes of cervix, vagina, and vulva (Chadwick’s sign); softening of lower-uterine segment (Hegar’s sign); floating fetus rebounds against examiner’s fingers (ballottement) ■ Positive signs: Fetal heart sounds; fetal movement; ultrasound of fetus Prenatal Physiological Progression ■ Ovum expelled from graafian follicle (ovulation); then sperm unites with ovum (fertilization) in fallopian tube within 24hr ■ Fertilized ovum attaches to uterine endometrium (implantation) ■ Conceptus called embryo (first 8wk), then fetus ■ Trimesters: 1st (0–15wk); 2nd (16–27wk); 3rd (28–37/40wk) ■ Nägele’s Rule: Expected date of birth (EDB); add 7 days to 1st day of last menstruation, subtract 3mo, add 1yr ■ Cells differentiate wk 3–8 (organogenesis); negative influences (drugs, illness) may cause defects in embryo (teratogens) ■ Fetal heart audible with Doptone after 12wk ■ Fetal lungs produce pulmonary surfactants at 24–28wk ■ Deposits of brown fat begin at 28wk; most ↑wt in 3rd trimester ■ S&S of impending labor: ■ Fetal presenting part descends into true pelvis (lightening) ■ Cervix thins/shortens (effacement); external os opens (dilation) ■ Mild, irregular uterine contractions (preparatory contractions, formerly Braxton Hicks) ■ Energy spurt (nesting), usually 24–48hr before labor ■ Expulsion of mucous plug, usually 24–48hr before labor Prenatal Maternal Changes ENDOCRINE CHANGES ■ Placenta secretes human chorionic gonadotropin (hCG); used for pregnancy screening; has role in AM nausea ■ Progesterone and estrogen from corpus luteum in 1st trimester; from placenta in 2nd and 3rd trimesters ■ Thyroid, parathyroids, and pancreas ↑secretions; need for ↑insulin ■ Estro levels ↑; excess in maternal saliva may indicate preterm labor CHILDBEARING ■ Labor initiated by posterior pituitary oxytocin, ↓progesterone, ↑estrogen, ↑prostaglandins ■ Nursing: Obtain specimens for screening tests CIRCULATORY CHANGES ■ Cardiac output ↑30–50%; blood volume ↑50%, and RBCs ↑30% (physiological anemia); ↓Hct; WBCs ↑ to 12,000mm3 ■ Palpitations in 1st trimester are secondary to SNS stimulation and in 3rd trimester are secondary to ↑thoracic pressure ■ HR ↑10–15 beats/min and BP drops in latter half of pregnancy; HR may ↑40% with multiple fetuses ■ Supine hypotension syndrome (vena cava syndrome): weight of uterus on vena cava ↓venous return to heart and ↓placental blood flow; signs and symptoms include ↓BP, lightheadedness, and palpitations ■ Fibrinogen and other clotting factors ↑ ■ Varicose veins of legs, vulva, perianal area (hemorrhoids) due to pressure of uterus on pelvic blood vessels ■ Edema of extremities last 6wk secondary to circulatory stasis ■ Nursing: ■ Teach patient to ↑fluids, change positions slowly, elevate legs, wear antiembolism stockings, and avoid prolonged sitting. ■ For thrombophlebitis: maintain bedrest, anticoagulant as ordered RESPIRATORY CHANGES ■ O2 consumption ↑15% by 16–40wk ■ Nasal congestion and epistaxis 2o↑estrogen levels ■ Dyspnea 2o enlarged uterus pressing against diaphragm; subsides when lightening occurs around 38wk ■ Nursing: ■ Teach to balance rest/activity; avoid large meals ■ Suggest to blow nose gently and use saline nasal spray REPRODUCTIVE CHANGES ■ Amenorrhea; leukorrhea ■ ↑Vaginal acidity protects against bacterial invasion ■ Cervical/uterine changes: Goodell’s, Chadwick’s, and Hegar’s signs ■ Uterus in pelvic cavity at 12–14wk and then in abdominal cavity; to umbilicus at 22–24wk and almost xiphoid process at term ■ Breast changes: Fullness, tingling, soreness, darkening of areolae and nipples, nipples more erect, veins more prominent, reddish stretch marks; Montgomery’s follicles enlarge ■ Nursing: ■ Assess fundal height ■ Suggest side-lying, vaginal rear entry for intercourse ■ Tell patient not to douche and to use a supportive brassiere and cotton underpants 42 CHILDBEARING 43 GASTROINTESTINAL ■ Nausea without vomiting (morning sickness) and ↑salivation secondary to hormonal changes ■ Food cravings; eating substances not normally edible (pica) ■ Heartburn and gastric reflux secondary to delayed emptying of stomach and pressure of uterus ■ Flatulence secondary to ↓GI motility, air swallowing ■ Constipation secondary to ↓peristalsis, pressure of uterus, hemorrhoids ■ Nursing: ■ Teach to avoid gastric irritants, gas-forming foods, and antacids containing Na ■ Remain upright 1hr after meals ■ Small, frequent meals; dry crackers before arising ■ ↑Fiber, fluid, and walking ■ For hemorrhoids: Avoid straining at stool and prolonged sitting, warm sitz baths or ice packs, anesthetic ointments URINARY ■ Urinary frequency in early and late pregnancy secondary to enlarging uterus ■ Bladder capacity ↑ to 1500mL secondary to ↓bladder tone; may lead to stasis and infection ■ ↓Renal threshold may cause glycosuria and mild proteinuria ■ Nursing: ■ Teach to void q2h and on urge to prevent stasis ■ Assess for glycosuria secondary to DM and proteinuria 2o preeclampsia INTEGUMENTARY ■ Blotchy, brownish skin over cheeks, nose, and forehead (melasma, chloasma); pigmented line from symphysis pubis to top of fundus in midline (linea nigra) ■ Stretch marks over abdomen, thighs, breasts (striae gravidarum) secondary to adrenocorticosteroids during 2nd half of pregnancy ■ ↑Perspiration, oily skin, hirsutism, and acne vulgaris ■ Nursing: ■ Teach that changes are common and generally subside after birth ■ Striae slowly lighten MUSCULOSKELETAL ■ Softening of all ligaments and joints, particularly symphysis pubis and sacroiliac joints; backache 2o lordosis, and changes in center of gravity; leg cramps 2 hypocalcemia and pressure of uterus on pelvic nerves ■ Nursing: ■ Encourage intake of ↑calcium foods and perinatal vitamin ■ Teach body mechanics, avoid high-heeled shoes and lifting CHILDBEARING CHILDBEARING NUTRITIONAL NEEDS ■ 25–35lb gain: 2–5lb 1st trimester; 3/4lb per wk 2nd–3rd trimesters ■ Calories: ↑300cal/day to total of 2500cal/day ■ Protein: 60 grams/day, an increase of 14 grams/day above prepregnant level ■ CHO: Adequate to meet requirements; complex CHO preferred ■ Fats: 30% of daily caloric intake; 10% should be saturated ■ RDA vitamins and minerals attained in balanced diet and perinatal vitamin containing 400mcg folic acid; sodium is never completely restricted, avoid excess ■ Nursing: ■ Teach patient to have a well-balanced diet, avoid dieting ■ Teach patient to take a multivitamin with 400mcg folic acid daily before conception and during pregnancy to prevent neural tube defects Prenatal Health Promotion ■ Travel: Lap belt under abdomen and shoulder belt between breasts; stand/walk briefly q1h; airlines may restrict travel close to EDB ■ Smoking: Avoid to prevent spontaneous abortion, ↓birth wt, apnea in newborn ■ Employment: Avoid excessive standing or work that causes severe physical strain/fatigue ■ Alcohol: Avoid to prevent preterm birth, ↓birth wt, fetal alcohol effects (FAE), or fetal alcohol syndrome (FAS) ■ Illicit drugs: Avoid to prevent teratogenic effect, ↓birth wt, small for gestational age (SGA), fetal addiction, and dependency ■ Caffeine: ↑Risk of spontaneous abortion and intrauterine growth restriction; FDA recommends ≤ 2–3 servings (200–300mg) daily ■ Artificial sweeteners: Studies are inconclusive but moderation is recommended; mothers with PKU should avoid aspartame Tests Performed During Pregnancy HUMAN CHORIONIC GONADOTROPIN (HCG) ■ Tests for pregnancy ■ hCG is produced by cells covering the chorionic villi of placenta ■ Detectable 8 days after conception ■ ↓Or slowly elevating levels:Threatened abortion, ectopic pregnancy ■ ↑Levels: May indicate ectopic pregnancy, hydatidiform mole, Down syndrome 44 45 MATERNAL SERUM ALPHA-FETOPROTEIN (MS-AFP) SCREENING ■ Fetal protein used to screen for neural tube defects ■ Ranges identified for each wk of gestation ■ Peak concentrations at end of 1st trimester ■ 16–18wk optimum time for testing ■ ↑Levels: Risk of open neural tube defect ■ ↓Levels: Risk of Down syndrome ■ When ↓levels persist, ultrasonography for structural anomalies and amniocentesis for chromosomal analysis are done CHORIONIC VILLUS SAMPLING ■ Reflects fetal chromosomes, DNA, and enzymology ■ Placental tissue aspirated at 10–12wk ■ Earlier testing time than amniocentesis permits earlier decision regarding termination ■ Also ↓risk of 1st trimester spontaneous abortion and costs less than amniocentesis ■ Complications: Infection, preterm labor ■ Nursing: Obtain consent. Full bladder to serve as acoustic window. Assess VS and absence of uterine cramping. Provide emotional support.Teach spotting for 3 days is expected after transcervical route. Report flulike symptoms and vaginal discharge of blood, clots, tissue, or amniotic fluid; avoid sexual activity, lifting, or strenuous activity until spotting resolves. Ensure genetic counseling if appropriate BIOPHYSICAL PROFILE ■ Level II ultrasonography assesses FHR reactivity, fetal breathing movements and tone, amniotic fluid volume, gross body movement ■ Fetus status reflected numerically like Apgar score ■ Reflects CNS integrity; indicator of fetal crisis and demise ■ Done in response to nonreassuring NST and signs and symptoms of fetal compromise ■ Nursing: Same as ultrasonography; emotional support PERCUTANEOUS UMBILICAL BLOOD SAMPLINGS (PUBS) ■ Fetal cord blood assessed at 17wk. Identifies some maternal/fetal problems ■ Complications: Bleeding, infection, thrombosis, preterm labor ■ Nursing: Obtain consent; full bladder may be necessary; assess uterine activity, FHR, and reactivity; teach to take antibiotics and temp 2 times daily and report ↑temp FETAL ULTRASONOGRAPHY ■ Serial exams document progress, gestational age, placenta location, fetal position, and presentation CHILDBEARING ■ Assesses FHR and breathing movements, amniotic fluid index (AFI), and estimated birth wt ■ Visualizes multiple fetuses, maternal pelvic masses, gross fetal structural abnormalities, fetal demise ■ Nursing: Education based on findings. Provide emotional support ■ Transabdominal: Drink 1–2l fluid 1hr before test to fill bladder ■ Transvaginal: Empty bladder to ↓view of pelvic cavity AMNIOCENTESIS ■ Analysis of amniotic fluid ■ 14–17wk: Identifies chromosomal and biochemical disorders (e.g., Down syndrome, neural tube defects), fetal age, and gender. ↑Bilirubin signifies Rh disease, intra-amniotic infections ■ 35wk: Lecithin/sphingomyelin (L/S) ratio of 2:1; phosphatidyl glycerol (PG) is present and lamellar bodies of over 35,000 particles/μL indicate lung maturity ■ Complications: Preterm labor, amniotic fluid emboli, infection ■ 14–17wk: Ultrasound identifies fetal parts and pockets of amniotic fluid ■ Second half of pregnancy: Nonstress test to assess fetal well-being ■ Nursing: ■ Obtain consent ■ 14–17wk: Bladder must be full to raise uterus ■ Second half of pregnancy: Empty bladder to ↓confusion with uterus; hip roll to ↓hypotension; assess maternal VS, fetal cardiac activity. Mild cramping is common. Fluid leakage is usually self-limiting.Tell patient to avoid intercourse, heavy lifting, and strenuous activity for 24hr after test. Report ↑temp, persistent cramping, or vaginal discharge. Ensure genetic counseling if appropriate. Provide emotional support AMNIOTIC FLUID TESTS ■ Tests for amniotic fluid with ruptured membranes ■ Nitrazine test: Positive test tape dark blue or gray/green ■ Fern test: Fern pattern under microscope ■ Nursing: Dorsal lithotomy position; encourage coughing to ↑fluid expulsion; touch nitrazine tape to vaginal secretions; for fern test, use cotton-tipped applicator to collect secretions and draw over glass slide FETAL FIBRONECTIN (FFN) ■ Swab of vaginal/cervical secretions; 22–31wk; fFN leaks with amniotic sac separation; presence may predict labor onset ■ Nursing: Assist with dorsal recumbent or lithotomy position; sample collection is obtained like Pap smear 46 CHILDBEARING 47 NONSTRESS TEST (NST) ■ After 28wk; Doppler transducer records FHR in relation to movement; tocotransducer records fetal movement as changes in uterine pressure ■ Reactive NST: 2 accelerations (↑ of 15bpm for 15sec) in 20min and normal baseline FHR; predictive of fetal well-being ■ Nonreactive NST: Failure to meet reactive criteria over 40min; vibroacoustic stimulus for 1sec may be used to startle fetus and can be repeated 2 times ■ Inconclusive: Less than 2 accelerations in 20min; accelerations do not meet reactive criteria; inadequate quality recording for interpretation ■ Nursing: Left lateral position to ↓vena cava compression; transducer and tocodynamometer to abdomen; teach to press event button with fetal movement; observe fetal monitor CONTRACTION STRESS TEST (CST) ■ Contractions stimulated and fetal response monitored; done after nonreactive NST; identifies if fetus can withstand ↓O2 during stress of contraction ■ Negative: Normal baseline FHR, FHR accelerations with fetal movement, and no late decelerations with 3 contractions in 10min indicates healthy fetus; oxytocin discontinued; IV continued until uterine activity returns to prior status; fetus likely to survive labor if it occurs within 1wk with no maternal/fetal change ■ Positive: Late decelerations with 50% of contractions indicates fetal compromise; monitor mother/fetus; prepare for labor induction ■ Suspicious: Late decelerations with less than half the contractions ■ Nursing: Obtain consent; semi-Fowler’s with lateral tilt; Doppler transducer to abdomen; 30min baseline maternal VS and FHR; assist with stimulation; monitor IV and mother for signs and symptoms of preterm labor FETAL MOVEMENT COUNT ■ 28wk fetal movement counted by patient at same time daily; more testing indicated for ≤ 3 fetal movements ■ Nursing: Teach pt to assume a comfortable position; hands on abdomen; count movements for 1hr DOPPLER STUDIES (UMBILICAL VESSEL VELOCIMETRY) ■ Measures blood flow velocity and direction in uterine/fetal structures ■ ↓Umbilical vessel flow seen in IUGR, preeclampsia, eclampsia, and postterm ■ Nursing: Same as fetal ultrasonography CHILDBEARING Potential Problems During Pregnancy CHILDBEARING DISSEMINATED INTRAVASCULAR COAGULATION (DIC) ■ ↑Clotting in microcirculation; platelets and clotting factors become depleted → bleeding and thromboemboli in organs ■ S&S: Bleeding, petechiae, ecchymosis, purpura, occult blood, hematuria, hematemesis, shock; ↑PT and ↑PTT; ↓platelet count, Hct and fibrinogen levels; ↑risk for DIC in abruptio placentae ■ Nursing: Assess for signs and symptoms, VS changes, shock; give O2, heparin, coagulation FETAL DEMISE: FETAL DEATH IN UTERO (FDIU) ■ After 20th wk and before birth. Stillbirth: Birth of dead fetus 20wk gestation or wt ≤350gm ■ S&S of FDIU: No fetal movement/HR, ↓fundal ht; ↓fetal growth; may spontaneously go into labor within 2wk or may be induced ■ Nursing: Assess signs and symptoms; encourage expression of feelings; support grieving; support memories (seeing, holding, naming, memory box [pictures, blanket, clothing, ID bands, hair lock]); provide for privacy; ensure that family needs are met; refer to support group HYPEREMESIS GRAVIDARUM ■ Intractable N&V beyond 1st trimester causing F&E and nutritional imbalance ■ S&S: N&V, ↓wt, FVD, electrolyte and acid/base imbalances, ↑Hct, ketonuria ■ Nursing: Assess signs and symptoms; NPO until dehydration resolves and 48hr after vomiting stops; dry diet if tolerated, advance to small amounts of alternating fluids and solids; IV fluid replacement; antiemetics MULTIPLE GESTATION ■ Multiple fetuses 2o double ovulation, splitting of fertilized egg, or multiple in vitro implantations ■ S&S: Excessive fetal activity and uterine size, and ↑wt; multiple FHRs; palpation of 3–4 large fetal parts in uterus ■ Nursing: Assess VS, fetal growth, signs and symptoms of preterm labor; nonreassuring fetal signs; prepare for cesarean; give oxytocic meds postpartum to prevent hemorrhage because of atony 2o uterine over distention TROPHOBLASTIC DISEASE ■ Abnormal growth of tissue and ↑’hCG; hydatidiform mole ■ Risk factors include ovulation stimulation, early teens, ≥40yr ■ S&S: Uterus large for gestational age; no fetal HR, movement, or palpable parts; HTN, hyperemesis and passage of grapelike substance common; confirmed by ultrasonography; risk for hemorrhage, perforation, and infection 48 49 ■ Nursing: Assist with suction curettage; avoid induction due to risk of embolization; measurement of ’hCG for 1yr; avoid pregnancy for 1yr to allow assessments for signs and symptoms of choriocarcinoma ECTOPIC PREGNANCY ■ Implantation outside uterus; mid-fallopian tube most common site ■ S&S: Early signs may be obscure; spotting after 1–2 missed periods; sudden, knifelike right or left lower abdominal pain radiating to shoulder (tube rupture); rigid abdomen; signs and symptoms of shock with obscured hemorrhage ■ Nursing: Assess signs and symptoms, VS for shock, pain pattern, anxiety; give transfusions and pain meds; give RhoGAM to Rh negative patient if appropriate; prepare for repair/removal of tube INFECTIONS THAT ARE TERATOGENIC ■ Toxoplasmosis: Protozoal infection; can cause spontaneous abortion in early pregnancy; transmitted via feces of infected cats and raw meat. Nursing: Avoid cat litter; cook meat well ■ Rubella: Viral infection; teratogenic in 1st trimester; congenital defects in heart, ears, eyes, and brain. Nursing: Vaccination ≥3mo before pregnancy or after giving birth; avoid others with rubella ■ Cytomegalovirus (CMV): Viral infection acquired via respiratory or sexual route; fetus may contract infection through birth canal; can cause retardation, deafness, heart defects, and death of neonate. Nursing: Teach to avoid others with flulike infections during pregnancy ■ Genital herpes: Viral infection causing painful, draining vesicles on external genitalia, vagina, and cervix; fetal and neonatal risk are greater when first outbreak occurs during pregnancy; fatal or permanent CNS damage if neonate is infected during vaginal birth. Nursing: During active infection: Use contact precautions, prepare for cesarean birth, separate mother and neonate after birth ■ Human immunodeficiency virus (HIV): Viral infection; ↑transmission risk with advanced disease and prolonged ruptured membranes; antiviral therapy in 2nd and 3rd trimesters and neonate treatment for 6wk postbirth ↓transmission by 66%. Nursing: Encourage prenatal care, taking of all meds to ↓viral load, health promotion to ↓opportunistic infections; referrals for HIV counseling and teaching (especially if acquired via risky behavior) VENA CAVA SYNDROME (SUPINE HYPOTENSIVE SYNDROME) ■ Partial occlusion of vena cava by wt of uterus ■ S&S: ↑Pulse, ↓BP, N&V, diaphoresis, respiratory distress, nonreassuring fetal signs ■ Nursing: Position on left side to shift wt of fetus off inferior vena cava; monitor VS, FHR, and S&S of shock. Administer O2 CHILDBEARING HYPERTENSIVE DISORDERS Maternal BP ≥140/90. Risk factors include primipara ↓17yr and ↑35yr, multipara, DM, chronic HTN, multiple fetuses, trophoblastic or kidney disease, ↓nutrition, Rh incompatibility. Onset 12–24wk; subsides 6th wk postpartum. Only cure is birth of neonate Preeclampsia ■ S&S for mild: 140/90mm Hg or higher; 1 proteinuria; upper-body edema; progressive excessive ↑wt ■ S&S for severe: 2 resting BP readings 6hr apart ≥160/110; 3–4 proteinuria; mas