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MENTAL HEALTH BROUGHT TO YOU BY © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 51

THERAPEUTIC COMMUNICATION TECHNIQUES Client-centered type of communication to build and help relationships with clients, families, and all relationships DO DON’T • Allow client to control the discussion • Ask “why” • Give recognition/validation • Ask too many questions • Active listening! • Give advice • Use open-ended questions • Give false reassurance • Change the conversation topic Don’t be a LOSER, be an active listener! • Give approval or disapproval • Use close-ended questions/statements l Lean forward toward the client o open posture EXAMPLES s sit squarely facing the client e establish eye contact “Don’t worry!” r relax & listen “I think you should _____” EXAMPLES “Don’t be silly” “That’s great!” “Is there something you would like to talk about?” “Tell me more about that” “So you are saying you haven’t been sleeping well?” “Tell me more about ______” THERAPEUTIC COMMUNICATION CAN BE BOTH... VERBAL COMMUNICATIONS & NON-VERBAL COMMUNICATIONS Words a person speaks You may say all the “right” things but deliver it poorly 35% • Facial expressions 65% • Eye contact • Posture • Movement • Appearance • Body language • Vocal cues (yawning, tone of voice, pitch of voice) © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 52

PERSONALITY DISORDERS CLUSTER PARANOID SCHIZOID SCHIZOTYPAL A ✹ Suspicious of others ✹ Indifferent ✹ Indifferent Odd or Eccentric ✹ Thinks everyone ✹ Seclusive ✹ Seclusive ✹ Detached ✹ Detached wants to harm them ✹ Doesn’t care for ✹ Doesn’t care for close relationships close relationships CLUSTER ANTISOCIAL BORDERLINE HISTRIONIC NARCISSISTIC B ✹ No care for others ✹ Unstable ✹ Seeks attention ✹ Egocentric Dramatic or ✹ Aggressive ✹ Manipulative to ✹ Center of attention AKA narcissus Emotional ✹ Manipulative ✹ Doesn’t follow self & others by being seductive ✹ Needs consistent ✹ Fear of neglect & flirtatious applause the rules CLUSTER AVOIDANT DEPENDENT OBSESSIVE C COMPULSIVE ✹ Anxious in social settings ✹ Extreme dependency Anxious or Insecure ✹ Avoids social interactions on someone ✹ Perfectionist but desires close relationships ✹ Searches urgently to ✹ Control issue ✹ Fear of abandonment find a new relationship when the other fails ✹ Rigid NURSING CARE Clients with TREATMENT a personality ✸ Safety is a priority disorder are at a Medications such as: ↑ risk for violence & • Antidepressants self-harm • Anxiolytics • Antipsychotics ✸ Develop a therapeutic relationship • Mood stabilizers ✸ Respect the client’s needs while still setting Therapies such as: limits and consistency • Psycho • Group ✸ Give the client choices to improve their • Cognitive feeling of control • Behavioral *For more information about psychiatric medications, see the Pharmacology Bundle © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 53

EATING DISORDERS ANOREXIA NERVOSA BULIMIA NERVOSA BINGE EATING ✸ ↓ Weight (BMI <18.5) ✸ Binge eating followed by purging ✸ Binge eating not followed ✸ Normal weight to overweight by purging ✸ ↓ Blood pressure from dehydration ✸ ↓ Heart rate & electrolyte imbalance (BMI 18.5 - 30) ✸ Tend to be overweight ✸ Teeth erosion ✸ ↓ Sexual development ✸ Bad breath ✸ Binging causes: ✸ May use laxatives and/or diuretics • Depression ✸ ↓ Subcutaneous tissue = Hypothermia • Hatred TREATMENT • Shame ✸ ↓ Period regularity Monitor client during and ✸ Amenorrhea (period may stop) after meals for acts of purging ✸ Refuses to eat ✸ Lanugo (thin hair to keep the body warm) ✸ Typically does not purge ✸ Restricts self from eating ✸ Fear of gaining weight ✸ Constipation (from dehydration) TREATMENT REFEEDING SYNDROME ☞ ↑ Weight slowly Potential complications when fluids, electrolytes, (2 -3 lbs a week) and carbohydrates are introduced too quickly to a malnourished client. Treatment should be done ☞ Monitor exercise slowly to avoid this syndrome. TREATMENT FOR ALL EATING DISORDERS Teach Maintain Have the client be a part Therapy coping skills trust of the decision making group, individual or family & the plan of care! © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 54

BIPOLAR DISORDER MOOD SWINGS: Depression to mania with periods of normalcy SWINGS FROM MANIC PHASE DEPRESSIVE PHASE • Periods of HIGH mood • Periods of LOW mood • Irritable & hyper • May require hospitalization SIGNS & SYMPTOMS SIGNS & SYMPTOMS ↓ Sleep Sad Delusions Low energy levels Restless Hallucinations Sleep disturbances: Flight of ideas Impulsive too much or too little sleep Conversation is all over Examples: maxing out credit cards, the place with rapid speech engaging in risky behavior For clients with mania, the nurse should Elevated activity offer energy & protein-dense foods that Grandiosity Leads to malnutrition are easily consumed on the go (finger foods!) Hyper mood & dehydration Leads to exhaustion HAMBURGERS • SANDWICHES FRUIT JUICES • GRANOLA BARS • SHAKES Poor judgment Manipulative behavior TREATMENT NURSING CONSIDERATIONS • Provide a safe environment FOR THE ACUTE PHASE Remove harmful objects from the room • Set limits on manipulative behavior • Provide finger foods & fluids • Re-channel energy for physical activity • ↓ Stimuli • Turn off or turn down the TV & music • Keep away from other clients if they are bothersome PHARMACOLOGY • Lithium carbonate • Anticonvulsants • Antidepressants See pharmacology section for more details • Antipsychotics • Antianxiety © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 55

SCHIZOPHRENIA SPECTRUM DISORDER OVERVIEW PHASES POSSIBLE CAUSES 1 PRE-MORBID Normal functioning. (not fully known) Symptoms have not become apparent yet. ↑ in the neurotransmitter DOPAMINE 2 PRODROMAL More tempered form of the disorder. Can be months to years for the disorder to Illicit substance (LSD & Marijuana) become obvious. Environmental 3 SCHIZOPHRENIA Positive symptoms are noticeable and apparent. (malnutrition, toxins, viruses during pregnancy) 4 RESIDUAL Periods of remission. Negative symptoms may remain, but S&S of the acute stage Genetics (family history) (positive symptoms) are gone. SIGNS & SYMPTOMS TREATMENT POSITIVE NEGATIVE • Medication - Antipsychotic medications Delusions Flattened/bland effect - Antidepressants Anxiety/agitation Lack of energy - Mood stabilizers (lithium) Reduced speech - Benzodiazepines Hallucinations Avolition Auditory *most common Lack of motivation *For more information about psychiatric medications, see the Jumbled speech Anhedonia Pharmacology Bundle Disorganized behavior Not capable of feeling joy or pleasure • Therapy Lack of social interaction • Exercise NURSING CONSIDERATIONS HOW TO ADDRESS HALLUCINATIONS? ☞ Try to establish trust with the client • Don’t address the hallucinations Example: ☞ Encourage compliance with the medications • Be compassionate “I don’t see spiders ☞ Promote self-care • Bring the conversation back to reality ☞ Encourage group activities • Do not argue with the client on the wall but ☞ Offer therapeutic communication • Provide safety for the client & the staff! I see you are scared” © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 56

TYPES OF DEPRESSION MAJOR DEPRESSIVE DISORDER (MDD) TREATMENT PHASES FOR MDD Has at least 5 of these symptoms ACUTE: 6 - 12 weeks every day for at least 2 weeks: Hospitalization & medications may be prescribed • Depressed mood • Not able to feel pleasure GOALS: • Too much or too little sleep • ↑ or ↓ motor activity • ↓ Depressive symptoms • Indecisiveness • Weight fluctuations • ↑ Functionality • Thoughts of death (suicide) • ↓ ability to think/concentrate (5% change within a month) CONTINUATION: 4 - 9 months Medication is continued FACTS GOALS: wipflolhTraraerretseflhaeeeitnctmhct! leewienyhntatt • Prevent relapse • MDD impairs the client’s normal functioning • MDD is not the same depression seen in bipolar disorder MAINTENANCE: 1+ year • MDD is not a mood swing, it’s constant Medication may be continued or be phased out GOALS: • Prevent relapse & further depressive episodes PREMENSTRUAL DYSPHORIC DISORDER (PMDD) SYMPTOMS • ↓ Energy • ↓ Concentration Depression that occurs during the luteal phase of the menstrual cycle. • Emotional • ↑ Eating SUBSTANCE INDUCED DEPRESSIVE DISORDER POSTPARTUM Depression associated with withdrawal or the use of alcohol and drugs. Depression that happens after a woman goes through childbirth. PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA) The woman may feel disconnected from the world. She may have a A more mild form of depression compared to MDD, fear of harming her newborn. although it can turn into MDD later in life. NURSING CONSIDERATIONS SEASONAL AFFECTIVE DISORDER (SAD) • Safety is a priority. Those struggling with Depression that occurs seasonally. depression have a higher suicide risk. Often occurs during the winter months when there is less sunshine. Initiate suicide precautions: TREATMENT: Light therapy - Remove sharp things - Keep medications out of reach TREATMENT ELECTROCONVULSIVE THERAPY (ECT) - Remove objects that may be used Used for clients who are unresponsive to other treatments. for strangulation (wires) ANTIDEPRESSANTS Transmits a brief electrical stimulation to the patient’s brain. • SSRIs • TCAs • Help the client identify coping methods • SNRIs • MAOIs • The client is asleep under anesthesia & teach alternatives if needed THE PROCEDURE• The client will not remember NON-PHARMACOLOGICAL • Provide local resources such as churches, THERAPIES and is unaware of the procedure local programs, community resources, etc. • Light therapy • Muscle relaxants may be given to • St. John’s wort • Encourage: ↓ seizure activity & ↓ risk for injury - Physical activity • Client may have memory loss, confusion, - Self-care - Supportive relationships & headache post-procedure Individual therapy, support groups, & peer support *For more information about antidepressants, see the psychiatric section in the Pharmacology Bundle 57 © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

DIFFERENT TYPES OF ANXIETY DISORDERS SYMPTOMS LEVELS OF ANXIETY NORMAL MODERATE SEVERE WORST MILD Thinking ability is Focus & problem solving PANIC impaired. Sharp focus are not possible. Normal/healthy & problem-solving can Feelings of doom Most extreme anxiety. amount of anxiety. still happen just at a may be felt. Unstable & not in Allows one to have sharp touch with reality. focus & problem solve. lower level. Dizziness Headache Pacing Nail-biting GI upset Yelling Tapping Headache Nausea Running Voice is shaky Sleeplessness Hallucinations Foot jitters Hyperventilation Separation Experiences extreme fear of anxiety when separated from someone Anxiety Disorder they are emotionally connected to. This is a normal part of infancy, Specific Phobia but not a normal part of adulthood. Social Anxiety Disorder Irrational fear of a particular object or situation. SOME EXAMPLES: (Social Phobia) ANXIETY DISORDERS • Monophobia - Fear of being alone Panic Disorder • Zoophobia - Fear of animals • Acrophobia - Fear of heights Agoraphobia Fear of social situations or presenting in front of groups. They fear embarrassment. Generalized Anxiety They may have symptoms (real or fake) to escape the situation. Disorder (GAD) Reoccurring panic attacks that last 15 - 30 minutes with physical manifestations. Extreme fear of certain places where the client feels unsafe or defenseless. Agora May even be too fearful of places to maintain employment. “opmeneaspnasce” Uncontrolled extreme worry for at least 6 months that causes impairment of functionality. OBSESSIVE COMPULSIVE DISORDERS Obsessive Compulsive OBSESSION: COMPULSION: Disorder (OCD) Recurrent thoughts Recurrent acts or behaviors This obsessiveness is usually because it decreases stress & helps deal with anxiety. Hoarding Disorder Compulsive desire to save items even if they have no value to the person. It may even lead to unsafe living environments. Body Dysmorphic Disorder Preoccupied with perceived flaws or imperfections in physical appearance that the client thinks they have. © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 58

SOMATIC SYMPTOM & RELATED DISORDERS (Somatoform Disorders) SOMATIC SYMPTOM DISORDER MANIFESTATIONS Somatization is psychological stress that presents • Consumed by physical manifestations through physical symptoms that can not be to the point it disrupts daily life explained by any pathology or diagnosis. • Seeks medical help from multiple places NURSING CONSIDERATIONS • Remission & exacerbations • Over-medicates with analgesic and • SAFETY is a priority Asses for symptoms or thoughts antianxiety medications of self-harm or suicide • ↑ Stress = ↑ somatic symptoms • Understand the somatic symptoms are real PHQ-15: to the client even though they are not real PATIENT HEALTH QUESTIONNAIRE 15 • Help the client verbalize their feelings while An assessment tool used to identify 15 limiting the amount of time talking about of the most common somatic symptoms their somatic symptoms • Assess coping mechanism & educate on alternative ways of coping CONVERSION DISORDER MANIFESTATIONS Sudden onset of neurological manifestations & MOTOR physical symptoms without a known neurological diagnosis. It can be related to a psychological con- Paralysis pseudoseizures flict/need beyond their conscious control. Pseudocyesis: NURSING CONSIDERATIONS Signs & symptoms of pregnancy without the presence of a fetus AKA false pregnancy. • Ensure SAFETY This may be present in a client who desires • Gain trust & rapport with the client to become pregnant • Assess coping mechanism SENSORY & educate on alternative ways of coping • Assess stress management methods Blindness • Encourage therapy such as: Deafness Sensations (burning/tingling) - Individual therapies Inability to smell/speak - Group therapies - Support groups MEDICATIONS The client may be prescribed antidepressants or anxiolytics POST TRAUMATIC STRESS DISORDER (PTSD) MANIFESTATIONS Mental health condition where exposure to a trau- Lasting longer than 1 month: matic event has occurred. • Anxiety NURSING CONSIDERATIONS • Detachment • Teach relaxation techniques • Nightmares of the event • Teach ways to ↓ anxiety MEDICATIONS • Support groups Antidepressants may be prescribed *For more information about antidepressants, see the psychiatric section in the Pharmacology Bundle © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 59

NEUROCOGNITIVE DISORDERS ONSET DELIRIUM Dementia & Alzheimer’s are NOT the same Dementia is a general term that refers to a SHORT TERM / SUDDEN CHANGE group of symptoms, not a specific disease. Impairment (hours - days) Dementia may advance to a major neurocognitive disorder such as Alzheimer’s disease. ALZHEIMER’S CONTINUOUS Decline of function (months - years) • Hospitalization • Genetics Family history (immediate family) RISK FACTORS • ICU delirium undscodeamaurellTsylweiiirhnntiauheggymirsnetchg!aaiesnuisse... • Polypharmacy • Head injury • Old age Traumatic brain injuries (TBI) & head trauma • Stroke • Advanced age • Surgery >65 have the highest risk • Restraints • Cardiovascular disease & lifestyle factors Inactivity, unhealthy diet, high cholesterol, obesity, & diabetes • Secondary to a medical condition (infection, electrolyte imbalance, substance abuse, etc.) Delirium is a medical emergency and STAGES OF ALZHEIMER’S DISEASE requires prompt diagnosis & treatment • Disorganization mild moderate severe • Most common to time & place MANIFESTATIONS • Happens mostly at night Early stage Middle Stage Late Stage • ↓ Memory • Anxiety & agitation Not noticeable to others Noticeable to others Requires full assistance • Delusional thinking • Memory lapse • Needs assistant • Ranges from lethargic to hypervigilance • Misplacing things • Forgetfulness • Difficulty focusing • Short term memory loss with all ADLs • Safety: prevent physical harm • Can still accomplish • Personality changes • Losing physical skills • Avoid restrains when possible own ADLs • Gets lost & wanders often • Remember physical needs • Unable to do some (walking, sitting, swallowing) (hygiene, food, water, sleep, etc.) ADLs & self-care • May result in (may be incontinent) death or coma • May be prescribed anti-anxiety/antipsychotic medications Caring for a client with Alzheimer’s is very complex! INTERVENTIONS • Help families in planning Communication for extended care • Speak slowly • Monitor nutrition, • Give one direction at a time weight, & fluids status • Don’t ask complex or • Maintain a quiet environment open-ended questions to ↓ stimuli • Ask simple, direct questions • Cholinesterase inhibitor may be • Face the client directly prescribed to improve quality of life but does NOT cure the disease. when speaking USES generic trade name donepezil Aricept Used in early & moderate stages of galantamine dementia & Alzheimer’s disease. May rivastigmine Razadyne also be used for Parkinson’s disease. Exelon CURE? Reversible if prompt treatment is initiated cure Irreversible © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 60

MOTHER BABY BROUGHT TO YOU BY © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 61

ABBREVIATIONS IUP/IUFD ...... Intrauterine pregnancy / intrauterine fetal demise NST ............... Non-stress test SAB ............... Spontaneous abortion CST ................ Contraction stress test TAB................ Therapeutic abortion BPP................ Biophysical profile LMP ............... Last menstrual period VBAC............. Vaginal birth after cesarean ROM.............. Rupture of membranes AFI................. Amniotic fluid index SROM............ Spontaneous rupture of membranes BUFA ............. Baby up for adoption AROM ........... Artificial rupture of membranes NPNC ............ No prenatal care PROM............ Prolonged rupture of membranes (>24 hours) PTL ................ Preterm labor PPROM ......... Preterm premature rupture of membranes BOA............... Born on arrival SVD ............... Spontaneous vaginal delivery BTL ................ Bilateral tubal ligation FHR ............... Fetal heart rate D&C / D&E ... Dilation & curettage / dilation & evacuation EFM............... Electronic fetal monitoring LPNC ............. Late prenatal care US.................. Ultrasound transducer (detects FHR) TIUP .............. Term intrauterine pregnancy FSE ................ Fetal scalp electrode (precise reading of FHR) VMI / VFI ...... Viable male infant / viable female infant IUPC .............. Intrauterine pressure catheter (strength of contractions) EDB ............... Estimated date of birth LTV ................ Long term variability EDC ............... Estimated date of confinement SVE................ Sterile vaginal exam EDD............... Estimated date of delivery MLE ............... Midline episiotomy PREGNANCY DURATION 40 weeks 38 weeks TRIMESTERS fetal age gestational age First Trimester 0 – 13 WEEKS This refers to the age of the Second Trimester 14 – 26 WEEKS The number of completed developing baby, counting Third Trimester 27 – 40 WEEKS weeks counting from the from the estimated date of 1st day of the last normal conception. The fetal age menstrual cycle (LMP). is usually 2 weeks less than the gestational age. PRENATAL TERMS Gravida / Gravidity Preterm A woman who is pregnant / the number of pregnancies Pregnancies that have reached 20 weeks but ended before 37 weeks Nulligravida Primigravida Multigravida Never been pregnant Pregnant for A woman who has the first time had 2+ pregnancies Term Parity Early Term: 37 – 38 6/7 Pregnancies that Full Term: 39 – 40 6/7 The number of pregnancies that have reach viability (20 have lasted between Late Term: 41 – 41 6/7 weeks of gestation) whether the fetus was born alive or not week 37 and week 42 Nullipara Primipara Multipara Postdate/Postterm 0 1 2+ A pregnancy that goes beyond 42 weeks Zero pregnancies One pregnancy Two or more beyond viability that has reached pregnancies that have reached (20 weeks) viability viability (20 weeks) (20 weeks) © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 62

GTPAL SCGATNPFAOL R VIDEO An acronym used to assess pregnancy outcomes G GRAVIDITY The number of pregnancies T TERM BIRTHS P PRE-TERM • Includes the present pregnancy • Includes miscarriages / abortions BIRTHS • Twins / triplets count as one A ABORTIONS / The number born at term MISCARRIAGES • > 37th week of gestation L LIVING • Includes alive or stillborn CHILDREN • Twins / triplets count as one PRACTICE QUESTION 1 The number of pregnancies delivered beginning with the 20th -36 6⁄7th weeks You are admitting a client to the mother-baby of gestation unit. Two hours ago she delivered a boy on her due date. She gives her obstetric history • Includes alive or stillborn as follows: she has a three-year-old daughter • Twins / triplets count as one who was delivered a week past her due date and last year she had a miscarriage at 8 weeks The number of pregnancies delivered gestation. How would you note this history before 20 weeks gestation using the GTPAL system? • Counts with gravidity A. 2-2-1-0-2 • Twins / triplets count as one B. 3-2-1-0-1 C. 3-2-1-0-2 The number of current living children D. 3-2-0-1-2 • Twin / triplets count individually © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. ANSWER KEY Q#1 is (D) 3-2-0-1-2 Q#2 is (C) 4-2-1-0-4 PRACTICE QUESTION 2 A prenatal client’s obstetric history indicates that she has been pregnant 3 times previously and that all her children from previous pregnancies are living. One was born at 39 weeks gestation, twins were born at 34 weeks gestation, & another child was born at 38 weeks gestation. She is currently 38 weeks pregnant. What is her gravidity & parity using the GTPAL system? A. 4-1-3-0-4 B. 4-1-2-0-3 C. 4-2-1-0-4 D. 4-2-2-0-4 63

PREGNANCY SIGNS & SYMPTOMS PRESUMPTIVE SUBJECTIVE NOT a definite diagnosis for pregnancy! Think p period absent (amenorrhea) “mom” These are changes felt by r really tired e enlarged breasts the woman and are subjective. Can be associated with other things. Why is quickening not a positive sign? s sore breasts u urination increased (urinary frequency) Quickening can be difficult to m movement perceived (quickening) distinguish from peristalsis or gas so it can not be a positive sign. e emesis & nausea PROBABLE OBJECTIVE “Tdhoicntokr” Pregnancy signs that the p positive (+) pregnancy test nurse or doctor can observe (high levels of the hormone: hCG) Why is a positive pregnancy test not a positive sign? r Returning of the fetus when uterus is pushed High levels of hCG can be associated with w/ fingers (ballottement) other conditions such as certain medications o objective or hydatidiform mole (molar pregnancy). b braxton hicks contractions a a softened cervix (Goodell's sign) b bluish color of the vulva, vagina, or cervix (Chadwick's sign) l lower uterine segment soft (Hegar's sign) e enlarged uterus POSITIVE OBJECTIVE Think Definite diagnosis for pregnancy! “Baby” Can only be f fetal movement palpated by a doctor or nurse attributed to a fetus e electronic device detects heart tones t the delivery of the baby u ultrasound detects baby s seeing visible movements © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 64

PREGNANCY PHYSIOLOGY HORMONES MUSCULOSKELETAL Prolactin: Allows for breast milk production • Lordosis: center of gravity shifts forward Estrogen: Growth of fetal organs & maternal tissues leading to inward curve of spine Progesterone & Relaxin: Relaxes smooth muscles hCG: Produced by placenta, prevents menstruation • Low back pain Oxytocin: Stimulates contractions at the start of labor • Carpal tunnel syndrome • Calf cramps RESPIRATORY • ↑ Basal metabolic rate (BMR) PITUITARY ↑ReOsp2 inraeteodrys • alkalosis (MILD) • ↓ FSH/LH due to ↑ Progesterone • • ↑ Prolactin • ↑ Oxytocin CARDIOVASCULAR • ↑ Cardiac output THYROID (↑ Heart rate + ↑ stroke volume) • ↑ Thyroxine • Blood pressure stays the same • May have moderate enlargement or a slight decrease q• ↑ in plasma volume of the thyroid gland (goiter) ThipsbBrelcesooheiouncodllcudarplmediranpensdsseosiidatucar!tee • ↑ Metabolism & ↑ appetite • Enlarges (May develop systolic murmurs) RENAL GASTROINTESTINAL • ↑ GFR from ↑ plasma volume • Pyrosis • Smooth muscle relaxation ↑ Progesterone = LOS to relax = ↑ heartburn of the uterus = ↑ risk of UTIs! • Constipation & hemorrhoids • ↑ Urgency, frequency ↑ Progesterone = ↓ gut motility & nocturia • Pica • EDEMA! Non-food cravings such as ice, clay, and laundry starch SKIN HEMATOLOGICAL • Striae Stretch marks (abdomen, breasts, hips, etc.) FIBRINOGEN Non-pregnant levels: 200-400 mg/dL Pregnant levels: up to 600 mg/dL • Chloasma - Mask of pregnancy Pregnant women are • ↑ White blood cells - Brownish hyperpigmentation of the skin HYPERCOAGULABLE • ↓ Platelets (increased risk for DVTs) RBC • Linea Nigra VOLUME “Pregnancy line” dark line that develops across your belly during pregnancy • Montgomery glands / Tubercles Small rough / nodular / pimple-like appearance of the areola (nipple) PLASMA VOLUME ANEMIA ANEMIA Plasma volume is greater than the amount of red blood cell (RBC) = hemodilution = physiological anemia © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 65

NAEGELE'S RULE Used for estimating the expected date of delivery (EDD) based on LMP (last menstrual period) – + +Date of Last Menstrual Period 3 Calendar Months 7 Days 1 Year REMEMBER: EXAMPLE 1st day of last period: September 2, 2015 How many days are Minus 3 calendar months: June 2, 2015 in each month? Plus 7 days: June 9, 2015 Plus 1 year: June 9, 2016 EDD \"30 days hath September, FACTS ABOUT NAEGELE'S RULE April, June & November. All the rest have 31, except q Bases calculation on a woman who February alone (28 days) \" has a 28-day cycle (most women vary) q The typical gestation period is 280 days (40 weeks) q First-time mothers usually have a slightly longer gestation period WHAT TO AVOID DURING PREGNANCY TERATOGENIC DRUGS TORCH INFECTIONS \"TERA-TOWAS\" TORCH infections are a group of infections that T Thalidomide cause fetal abnormalities. e epileptic medications (valproic acid, phenytoin) Pregnant women should r retinoid (vit A) avoid these infections! a ace inhibitors, ARBs T Third element (lithium) \"TORCH\" o oral contraceptives w warfarin (coumadin) T Toxoplasmosis a alcohol Parvo o Virus-B19 (fifth disease) s sulfonamides & sulfones r rubella c cytomegalovirus h herpes simplex virus © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 66

STAGES OF LABOR STAGE 1 Cervix DILATES from 0-10 cm Longest Latent (early) INTERVENTIONS q Promote comfort Stage - Warm shower, massage, or epidural q Cervix dilates: 1- 3 cm q Offer fluids & ice chips q Provide a quiet environment q Intensity: Mild q Encourage voiding every 1 - 2 hours q Contractions: 15 - 30 min Active q Encourage participation in care & keep informed q Cervix dilates: 4 - 7 cm q Instruct partner in effleurage (light stroking of the abdomen) q Intensity: Moderate q Encourage effective breathing patterns & rest between contractions q Contractions: 3 -5 min (30-60 sec in duration) L abor Transition actively q Cervix dilates: 8 - 10 cm transitioning q Intensity: Strong q Contractions: Every 2-3 min (60-90 sec in duration) >30 min = Retained placenta STAGE 2 The Baby is delivered STAGE 3 The placenta is delivered → Starts when cervix is fully dilated & effaced The PLACENTA is expelled (5 - 30 min after birth) → Ends after the baby is delivered SIGNS OF A PLACENTA DELIVERY DELIVERY MECHANICS pushing! q Lengthening umbilical cord \"Shiny Schultz\" q Provide ice chips & ointment for dry lips q Gush of blood Side of baby delivered 1st q Provide praise & encouragement to the mother q Monitor uterine contractions & mothers vital signs q Uterus changes from oval \"Dirty Duncan\" q Maintain privacy & encourage rest between to globular shape Side of mother delivered 1st contractions q Encourage effective breathing patterns & rest between contractions q Monitor for signs of birth (perineal bulging or visualization of fetal head) INTERVENTIONS q Assessing mothers vital signs INTERVENTIONS q Uterine status (fundal rubs every 15 minutes) q Provide warmth to the mother q Promote parental-neonatal attachment q Examine placenta & verify it's intact 1 vein - Should have 2 arteries & 1 vein STAGE 4 Recovery! q FIRM 2 arteries q Midline RECOVERY: first 1-4 hours after delivery of the placenta looks like a smiley face! q Assessing the fundus ✘ q Soft q Continue to monitor vital signs & temperature for infection q Boggy 2 \"A\" for Arteries q Administer IV fluids q Displaced 1 \"V\" for Vein q Monitor lochia discharge (lochia may be moderate in amount & red). 67 q Monitor for respiratory depression, vomiting, & aspiration if general anesthesia was used q Great time to watch for complications such as bleeding (postpartum hemorrhage) © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

TRUE VS. FALSE LABOR CONTRACTIONS FALSE LABOR TRUE LABOR • Irregular • Occur regularly • Stops with walking/position change ∙ Stronger • Felt in the back or the abdomen ∙ Longer ∙ Closer together above the umbilicus • Often stops with comfort measures • More intense with walking • Felt in lower back → radiating to the lower portion of the abdomen • Continue despite the use of comfort measures CERVIX • May be soft • Progressive change • NO significant change in.... ∙ Softening ∙ Effacement ∙ Effacement ∙ Dilation signaled by the ∙ Dilation appearance of bloody show • No bloody show ∙ Moves to an increasingly anterior position • In posterior position (baby's head facing mom's back) (baby's head facing mom's front of belly) FETUS • Presenting part is usually • Presenting parts become engaged in the pelvis not engaged in the pelvis • Increased ease of breathing (more room to breathe) • Presenting part presses downward & compresses the bladder = urinary frequency SIGNS OF LABOR Signs of Preceding Labor LABOR ☞ Lightening ☞ Increased vaginal discharge (bloody show) Moving the fetus, placenta, ☞ Return of urinary frequency  & the membranes out of the ☞ Cervical ripening uterus through the birth canal ☞ Rupture of membranes \"water breaking\" ☞ Persistent backache ☞ Stronger Braxton Hicks contractions ☞ Days preceding labor ∙ Surge of energy ∙ Weight loss (1- 3.5 pounds) from a fluid shift © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 68

FETAL HEART TONES EARLY DECELERATIONS MEMORY \"Mirror\" image of mom's contractions Normal TRICK fetal heart rate: (they don't technically come early) 120 - 160 BPM fetal heart rate Cause: q From head compression NORMAL! Intervention: q Continue to monitor q No intervention needed mom's contractions LATE DECELERATIONS MEMORY Literally comes late after mom's contraction TRICK NON-REASSURING fetal heart rate Cause: q Uteroplacental insufficiency mom's Intervention: contractions q D/C oxytocin q Position change q Oxygen (non-rebreather) q Hydration (IV fluids) q Elevate legs to correct the hypotension VARIABLE DECELERATIONS MEMORY *Variable: Looks \"V\" shaped TRICK NON-REASSURING fetal heart rate Cause: Side-lying or knee q Cord compression chest will relieve Intervention: pressure on cord q D/C Oxytocin mom's q Amnioinfusion contractions q Position change q Breathing techniques q Oxygen (non-rebreather) © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 69

VEAL CHOP A tool to help interpret fetal strips V → CVariable  Cord Decelerations Compression E → HEarly Head Decelerations Compression A → OAccelerations OK (normal fetal oxygenation) L → PLate Placental Decelerations Insufficiency ASSESSMENT OF UTERINE CONTRACTIONS Duration BEGINNING of the • Lasts 45 - 80 seconds contraction to the END • Should not exceed 90 seconds of that same contraction Only measured through external monitoring Frequency Number of contractions • 2 - 5 contractions every 20 minutes from the BEGINNING of • Should not be more FREQUENT one contraction to the BEGINNING of the next then every 2 minutes Only measured through external monitoring Intensity Strength of a • 25 - 50 mm Hg Mild - nose contraction • Should not exceed 80 mm HG Moderate - chin at its PEAK Can be palpated Strong - forehead TENSION in the uterine • Average: 10 mm HG muscle between contractions • Should not exceed 20 mm HG Resting (relaxation of the uterus = Soft = good Tone fetal oxygenation between Can be palpated Firm = not resting enough contractions) © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 70

PREECLAMPSIA OVERVIEW Overview of Hypertensive disorders during pregnancy 1st Trimester 2nd Trimester 3rd Trimester HAT IS HYPERTENSION 20 WEEKS SYSTOLIC > 140 W OR ? DIASTOLIC > 90 Triad Signs CHRONIC HTN: PREECLAMPSIA: HTN after 20 weeks gestation with systemic features Hypertension may be GESTATIONAL HTN: HTN after 20 weeks without systemic features abbreviated Before pregnancy \"HTN\" or before 20 weeks! SIGNS & SYMPTOMS PATHOLOGY RISK FACTORS \"PRE\" eclampsia Pathology q HX of preeclampsia in previous is not P Proteinuria plraoiocsttechnaeutsea pregnancies completely R rising BP known q Family history of preeclampsia >am3d5aavtgae=nerncAeaMdl A q 1st pregnancy E edema q Defective spiral q Obesity artery remodeling q Severe headache q Very young (<18) or very old (>35) q RUQ or epigastric pain q Systemic vasoconstriction q Visual disturbances & endothelial dysfunction q Medical conditions q ↓ Urine output q Hyperreflexia (Chronic HTN, renal disease, q Rapid weight gain diabetes, autoimmune disease) HELLP SYNDROME ECLAMPSIA (seizures activity or a coma) lifceo-tmhprleicaatteinoinng Variant of Immediate care: preeclampsia • Side-lying • Padded side rails with pillows/blankets H hemolysis • O2 • Suction if needed EL Elevated liver enzymes • Do not restrain • Do not leave LP low platelet count MAGNESIUM SULFATE TOXICITY! RX given to prevent seizures during & after labor. • RR <12 *Mag is excreted in urine *Remember: magnesium acts like a depressant • ↓ DTRs ↓UOP → ↑mag levels • UOP <30 mL/hr THERAPEUTIC RANGE: 4 – 7 mg/dL • EKG changes ANTIDOTE: calcium gluconate *because magnesium sulfate can cause respiratory depression © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 71

LABOR & BIRTH PROCESSES 5 P's 5 factors that affect the process of labor & birth Passenger Passageway Position Powers Psychology Fetus & Placenta The Birth Canal Position of the Mother Contractions Emotional Response Passenger Fetus & Placenta SIZE OF THE FETAL HEAD FETAL PRESENTATION FONTANELS ANTERIOR Refers to the part of the fetus that enters • Space between the bones of the pelvic inlet first through the birth canal during labor the skull allows for molding • Anterior (larger) 1 CEPHALIC CoMmomsotn - Diamond-shaped • Head first - Ossifies in 12-18 months • Presenting part: Occipital • Posterior (back of head/skull) - Triangle shaped - Closes 8 - 12 weeks MOLDING 2 BREECH • Change in the shape of the • Buttocks, feet, or both first • Presenting part: Sacrum fetal skull to \"mold\" & fit through the birth canal POSTERIOR 3 SHOULDER • Shoulders first • Presenting part: Scapula FETAL LIE Relation of the long axis (spine) of the fetus to the long axis (spine) of the mother LONGITUDINAL OR VERTICAL • The long axis of the fetus is parallel with the long axis of the mother • Longitudinal: cephalic or breech TRANSVERSE, HORIZONTAL, OR OBLIQUE • Long axis of the fetus is at a right angle to the long axis of the mother • Transverse: vaginal birth CANNOT occur in this position • Oblique: usually converts to a longitudinal or transverse lie during labor © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. CONTINUED → 72

LABOR & BIRTH PROCESSES Passenger CONTINUED FETAL ATTITUDE FETAL POSITION GENERAL FLEXION Head, foot, butt (closest to exit of uterus) • Back of the fetus is rounded so that FETAL STATION the chin is flexed on the chest, thighs are flexed on the abdomen, legs are • Where the baby's presenting part is located in the pelvis flexed at the knees • Measured in centimeters (cm) • Find the ischial spine = zero I'm (+) that I'm BIPARIETAL DIAMETER • Above the ischial spine is (-) MEMORY • 9.25 cm at term, the largest transverse TRICK getting this baby out diameter and an important indicator of fetal head size • Below the ischial spine is (+) -5 +4 / +5 = Birth is about to happen -4 SUBOCCIPITOBREGMATIC DIAMETER • Most critical & smallest of the ENGAGEMENT -3 anteroposterior diameters • Fetal station zero = baby is \"engaged\" -2 • Presenting parts have entered down into -1 the pelvis inlet & is at the ischial spine line (0) 0 +1 When does this happen? +2 • First-time moms: 38 weeks +3 • Already had babies: +4 +5 can happen when labor starts LW\"IGdmhrHooetpnThsteE\"hre'NisnbtIpoNaebtlGvhyies Passageway The Birth Canal: Rigid bony pelvis, soft tissue of cervix, pelvic floor, vagina & introitus TYPES OF PELVIS SOFT TISSUE GYNECOID LOWER UTERINE SEGMENT • Classic female type • Stretchy • Most common CERVIX ANDROID • Effaces (thins) & dilates (opens) • Resembling the male pelvis • After fetus descends into the vagina, the cervix is drawn upward and over the first portion ANTHROPOID • Oval-shaped PELVIC FLOOR MUSCLES • Wider anteroposterior diameter • Helps the fetus rotate anteriorly PLATYPELLOID VAGINA • The flat pelvis • Least common INTROITUS • External opening of the vagina © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 73

LABOR & BIRTH PROCESSES Position Position of the mother during birth UPRIGHT POSITION LITHOTOMY POSITION CoMmomsotn Frequent changes in Sitting on a birthing stool or cushion Supine position with buttocks on the table position helps with: \"ALL FOURS\" POSITION LATERAL POSITION • Relieving fatigue On all fours: putting your weight Laying on a side • Increasing comfort • Improving circulation on your hands & feet Powers Contractions: Primary & Secondary PRIMARY POWERS SECONDARY POWERS Involuntary uterine contractions Voluntary bearing-down efforts by the Signals the beginning of labor women once the cervix has dilated DILATION • Does not affect cervical dilation but helps with expulsion of infant once the cervix is fully dilated • Dilation of the cervix is the gradual enlargement or widening of the cervical • When the presenting part reaches the pelvic opening & canal once labor has begun floor, the contractions change in character & become expulsive. • Pressure from amniotic fluid can also meinascumred apply force to dilate • Laboring women start to feel an involuntary urge to push & she uses secondary powers to 0 - 10 cm aid in the expulsion of the fetus closed full dilation FERGUSON REFLEX • When the stretch receptors release oxytocin, it triggers the maternal urge to bear down EFFACEMENT Psychology Emotional Response • Shortening & thinning of the cervix during the first stage of labor is EXEP(F0RF-DAE1eCS0gS0EreE%MeDE)ofNinT% Anxiety can increase pain perception • Cervix normally: & the need for more medications 2 -3 cm long (analgesia & anesthesia) 1 cm thick • The cervix is \"pulled back / thinned out\" Things to consider: by a shortening of the uterine muscles SOCIAL PAST KNOWLEDGE SUPPORT EXPERIENCE © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 74

NEWBORN ASSESSMENT APGAR 7 --4160amgsogudrpeepsrosairtvteeivdereecspaurrseecsistaiotnion INITIAL GOALS 4 < 1ST PRIORITY = AIRWAY score 0 points 1 point 2 points Suction with bulb syringe / deep suction *Newborns are obligatory nose breathers A ACTIVITY Absent Flexed arms Active 2ND PRIORITY = WARMTH (Muscle tone) & legs Dry with a blanket or place in warmer P PULSE 0 < 100 > 100 CIRCULATORY SYSTEM G GRIMACE Minimal response Prompt • Blood flow from umbilical vessels & placenta stop at birth (Reflex irritability) Floppy to stimulation response to • Acrocyanosis: Blueness of hands & feet stimulation (normal during the first 24 hours of life) A APPEARANCE Blue / pale Pink body Pink • Closure of: (Skin color) all over Blue extremities q Ductus arteriosus (acrocyanosis) q Foramen ovale q Ductus venosus • Transient murmurs are normal R RESPIRATION No Slow Vigorous HEAD & irregular cry (Effort) breathing Caput Succedaneum: MEMORY • Edema (collection of fluid) TRICK VITAL SIGNS • Crosses the suture lines Like a Blood Pressure (bp) Systolic 60 -80 mmHg baseball cap (Not done routinely) Diastolic 40 - 50 mmHg Cephalohematoma: Heart Rate (hr) • Birth trauma (collection of blood) 110 - 160 bpm foarp1icfaTuallkpleumlsine • Does not cross the suture lines Respiratory rate (rr) can be 180 if crying temperature (t) (Axillary) can be 100 if sleeping Molding: Map Abnormal head shape 30 - 60 breaths/min that results from vommatiythTsheb,iesnoFerobiswnuitsbnlaoolgrnyrnimeinnlacglegrl.isdewoswh, enn. pressure (normal) 97.7 – 99.5°F (36.5 - 37.5°C) Fontanelles: Equal to the # of weeks gestation or higher Signs of Respiratory Distress Breathing pattern is IRREGULAR. Bulging = increase ICP or hydrocephalus Newborns are Abdominal breathers. Sunken = dehydration • Retractions • Nasal flaring • Grunting GENERAL To count breaths, place your UMBILICAL CORD 1 vein hand on their abdomen. 2 arteries CHARACTERISTICS Should have Count for a 2 arteries & 1 vein full minute! Should be dry, no odor & no drainage Length & Weight looks like a smiley face! expected 44 - 55 cm length 17 - 22 in expected 2,500 - 4,000 g ↓ weight 5 lb, 8 oz - 8 lb, 14 oz ↓ TEMP HEAT LOSS DUE TO: Head & Chest Circumference head 32 - 39 cm circumference 14 - 15 in *measure above eyebrows Evaporation: Convection: Conduction: Radiation: Moisture from Body heat to Body heat to a Body heat to a chest 30 - 36 cm skin & lungs cooler surface cooler object nearby cooler air in direct contact circumference 12 - 14 in *measure above nipple line © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 75

NEWBORN REFLEXES extend flex Babinski rooting moro reflex Tonic neck reflex reflex “Startle Reflex” reflex “Fencing” When the bottom of the When the baby's Can be triggered by a foot is stroked from the mouth is stroked, the sudden loud noise or When an infant is lying baby will turn its head unexpected movement. on its back, and quickly heel upward. The big and open the mouth. The infant will extend toe dorsiflexes (bends This helps the baby the arms with palms up turns their head to find the food source and then move the arms one side. The leg and back) and the other arm on that side will toes spread out. when feeding. back to the body extend, while the leg and are on the opposite Babinski = Big toe fans out side will flex. TYPES OF HEAT LOSS & PREVENTION EVAPORATION CONVECTION CONDUCTION RADIATION Moisture from Body heat to Body heat to a cooler Body heat to a skin & lungs cooler air surface in direct contact cooler object nearby prevention: prevention: prevention: prevention: Dry infant Keep bed away Warm stethoscope Keeping infant away immediately from open windows & other instruments from any cold objects after birth before use nearby © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 76

POSTPARTUM ASSESSMENT \"BUBBLES \" B BREASTS• May be sore after breastfeeding MASTITIS • Breastfeed every 2 - 3 hours (15 - 20 minutes each breast) Infection & inflammation of breast tissue • Position newborn \"tummy to mummy\" • Latch should be completely around the areola • Continue breastfeeding • Rest • Warm compress • Analgesics • Hydration • Wash hands! U UTERUS UTERINE ATONY SYMPTOMS INTERVENTIONS • Enlarged RISK FACTORS • Fundal massage • Retained placenta • Soft • Chorioamnionitis (infection) • Assist to void or use • Uterine fatigue • Boggy in-and-out catheter • Full bladder • Not midline • Poorly contracted uterus B BOWELSConstipation is common after HEMORRHOIDS INTERVENTIONS birth. Increasing FLUIDS & FIBER • May see blood in the stool may help! • Should begin to shrink • Tucks / witch hazel • Ice pack following birth • Squeeze bottle • Sitz Bath B BLADDER• Postpartum urinary retention is common • In-and-out catheterization may be needed • Bladder distention can cause a displaced & boggy uterus! SIGNS OF INFECTION • Foul smelling or purulent lochia L LOCHIA • Fever (>100.4 F ) • Abdominal tenderness \"Really Sore After\" • Tachycardia Rubra bright red Serosa pinkish/brown Alba whitish-yellow 1 - 3 days 4 - 10 days 10 - 14 days *Can last up to 6 weeks E EMOTIONAL STATUS• Postpartum depression (PPD) is common for women following childbirth • Crying • As the nurse ask about feelings of... • Irritable depression • hopelessness • self-harm • harm to the newborn • Sleep disturbances • Anxiety S SECTION (c-section incisions) / Episiotomy • Feelings of guilt • Promote proper wound healing • Report to the health care provider: pain • inflammation • surrounding skin is warm to touch © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 77

POSTPARTUM HEMORRHAGE Postpartum Hemorrhage is defined as: VAGINAL BIRTH: loss of >500 ml of blood CESAREAN BIRTH: loss of >1,000 ml of blood A change in hematocrit by 10% PATHOLOGY isLIoVfITtNehGneLcuIaGtlelAerTudUsRthEe SIGNS & SYMPTOMS RISK FACTORS overdistended uterus The uterus is like a q Hypotonia of the uterus q Multiple gestations BASKET WEAVE q Atony / boggy uterus q Polyhydramnios q Deviated to the right q Macrosomic fetus (> 8 lbs) OF MUSCLE FIBERS q Uncontrolled bleeding q Multifetal gestation that crimps off vessels protecting mom from hemorrhage. If the uterus is not doing this ute#r1inceauasteonoyf is crimping off, it causes bleeding! a full bladder DRUGS \"Oh My Hemorrhage\" This is a way to remember the order in which the drugs are used #1 #2 #3 Another medication Oxytocin Methergine Hemabate that can \"Pitocin\" \"Methylergonovine\" ACTION be used ACTION ACTION Hemabate is a Stimulates contraction prostaglandin! Misoprostol of the uterine Vasoconstriction Hemabate helps control given rectally smooth muscle blood pressure and ACTION CONTRAINDICATIONS muscle contractions Stimulates contraction Contraindicated in (uterine contractions). CONTRAINDICATIONS of the uterine people with hypertension Contraindicated in smooth muscle *Remember vasoconstriction people with asthma causes blood pressure to rise © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 78

PEDIATRICS BROUGHT TO YOU BY © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 79

PEDIATRIC MILESTONES INFANCY Birth 1 ye-ar fontanelle closure weight length teeth Anterior (larger) 6 months: Should be growing First teeth to → Diamond-shaped Should double ½ - 1 inch show are the → Closes in 12-18 months from birth weight every month lower Posterior 12 months: central incisors → Triangle shaped Should triple → Closes 8 - 12 weeks from birth weight (usually show around 10 months of age) motor skills language 2 • Raises head & chest Makes verbal months • Head control improving noise (coos) • Moves head side to side 4 • Should be smiling Babbling months (copies noises) • Begins to PLAY Rolls on the floor 6 Babbles months • Rolls from prone to supine (nonspecific) 8-9 • Holds & reaches for toys rhymes with four! Simple words months like “dada” • Head leads body when pulled to sit 10-12 months • Can sit up w/support • Stranger anxiety begins • Tripod sit • Sits without support • Crawling • Stands with pulling & holds onto object • Pincer Grasp • Object Permanence thtahstRiageathraotelbiszojtienuilclgttos f exist • Walking • Separation anxiety © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 80

PEDIATRIC MILESTONES TODDLER y1e-ar3s expressive language receptive language fine motor gross motor 15 months 18 months 24 months 30 months • Walks • Climbs stairs • Kicks a ball Think independently • Pulls toys Terrible Two's! • Able to stand on tiptoes • Climbs on & off furniture • Feeds self finger foods • Uses their hands a lot for: • Builds tower of 6-7 cubes reaching, grabbing, • Uses index finger releasing, stacking blocks • Right/left-handed to point • Turns book pages • Scribbles, paints, • Full pincer grasp • Removes shoes and socks & imitates strokes developed • Stacks four cubes • Turns doorknobs • Puts round pegs into holes • Understands • Understands “no” • Points to named body • Follows a series 100-150 words • Understands 200 words parts/pictures in books of 2 independent • Says: “what’s this?” commands • Follows commands • Listens to simple stories without gestures • Says: “my” & “mine” • Looks at adults when communicating • Repeats words • Vocab: 15-20 words • Vocab: 40-50 words • Vocab: • Babbles sentences 150-300 words • Uses names of familiar • Sentences of 2-3 words objects (ex. “want cookie\") • Use descriptive words: hungry, hot, cold signs of delay • Persistent tiptoe • Not walking • Does not: use two-word walking sentences, imitate • Not speaking 15 words actions, or follow basic • Does not develop a instructions mature walking pattern • Does not understand the function of common • Cannot push a toy household items with wheels © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 81

PEDIATRIC MILESTONES PRESCHOOL y3e-ar6s fine motor gross motor 3 years 4 years 5 years • Climbs well and runs easily • Throws ball overhead • May be able to: • Pedals tricycle • Skip • Walks up & down stairs • Kicks ball forward • Swim • Skate with alternating feet • Can bounce a ball back • Climb • Bends over without falling • Swing • Hops on one foot • Alternating feet going up & down steps • Undresses self • Uses scissors • Can draw a person and some letters • Copies circles • Copies capital letter • May dress/undress themselves • Tower of 9-10 • Draws circles, squares, & • Can use a fork, spoon, & knife • Holds a pencil • Mostly cares for own toileting needs • Screws and unscrews lids traces a cross or diamond • Turns book pages one at a time • Draws a person with 2-4 body parts • Laces shoes communication • Understands most sentences • Speaks in complete sentences • Most of the child’s speech • Understands physical relation can be understood signs of delay • Tells a story (in, on, under) • Explains how an item is used • Follows a 3-part command • 75% of speech understood by • Half of the conversation outside observers • Participates in long & detailed conversations understood by outside family • Stays on topic in conversation • Says: “why?” • Talks about past, future, • 3 or 4-word sentences • Knows the name of familiar animals and imaginary events • Talks about past • Vocab: 1,000 words • Knows at least one color • Answers questions that use • Says their name, \"why\" and “when” • Uses language to engage in age, & gender make-believe • Can count to 10 • Uses pronouns • Can count a few numbers • Says name & address and plurals • Vocab: 1,500 words • Recalls part of a story • Difficulty with stairs • Falls a lot while walking • Can't jump in place or ride a tricycle • Speech should be completely • Can’t build a 4+ block tower • Can’t stack 4 blocks intelligible, even if the child has • Extreme difficulty separating • Can’t throw a ball overhead articulation difficulties • Does not grasp crayon with from parents • Speech is generally grammatical correct • No make-believe play thumb and fingers • Can't copy a circle • Difficulty with scribbling • Vocab: 2,000 words • No short paragraphs • Can’t copy a circle • Doesn’t understand simple • Doesn’t say 3+ word sentences • Sad often • Can’t use the words “me” & “you” • Little interest in playing instructions • Ignores other children or doesn’t • Unclear speech & drooling with other kids • Little interest in other kids show interest in interactive games • Unable to separate from their parents • Still clings or cries if parents leave • Is extremely aggressive, fearful, passive, or timid. • Easy distracted (can't concentrate for 5 minutes) • Can not do ADLs by themselves (brush teeth, undress, wash & dry hands, etc.) • Rarely engages in fantasy play © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 82

PEDIATRIC MILESTONES PHYSIOLOGICAL CHANGES early 10-13 Middle 14-16 Late 17-20 Adolescence years Adolescence years Adolescence years • Pubic hair spread • Pubic hair becomes • Mature pubic hair laterally, begins to more coarse in texture distribution & curl, pigmentation & takes on adult coarseness increases distribution • Breast enlargement Male • Growth & • Testes, scrotum, & disappears enlargement of testes penis continue to grow & lengthening of the • Adult size & shape penis • The skin around the of testes, scrotum, scrotum darkens and penis • Lengthy look due to extremities growing • Glands penis develops • Scrotum skin faster than the trunk • May experience darkening breast enlargement • Voice changes female • First menstrual • Pubic hair becomes • Mature pubic hair period (average age coarse in texture distribution and is 12 years) coarseness • Amount of hair increases • Breasts bud and • Areola & papilla areola continue to enlarge (no separation separate from the of the breasts) contour of the breasts to form a secondary mound • Pubic hair begins to curl & spread over the mons pubis © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 83

PEDIATRIC CPR (<12 MONTHS) Cardiac arrest in infants usually PEDIATRIC VITAL SIGNS stems from respiratory etiology age Respirations Pulse Systolic BP ORDER OF EVENTS newborn 30 - 50 120 - 160 60 - 80 1 PULSE 6 mo - 1 yr 30 - 40 120 - 140 70 - 80 ✹ Check pulse no longer than 10 seconds 2 - 4 yr 20 - 30 100 - 110 80 - 95 Infant: Check brachial pulse child: Check carotid pulse 5 - 8 yr 14 - 20 90 - 100 90 - 100 8 - 12 yr 12 - 20 80 - 100 100 - 110 > 12 yr 12 -20 60 - 90 100 - 120 BREATHS/MIN BEATS/MIN 2 CALL FOR HELP ✹ Active the emergency response system / shout for nearby help ✹ Delegate someone else to call 911 / get the AED 3 CHEST COMPRESSIONS single rescuer 30:2 compression-to-breath ratio ✹ 2 minutes of CPR before retrieving the AED ✹ Rate of 100 - 120 compression/min Two rescuers 15:2 compression-to-breath ratio ✹ Using either 2 fingers or 2 thumbs on the sternum ✹ Depth: Infant: Equal to one-third of chest's anterior-posterior diameter Child: 2 inches ✹ Allow for recoil between compressions 2 - finger 2 - thumb compression encircling hand technique technique 4 CONTINUE UNTIL SIGNS OF HELP ARRIVE OR AED BECOMES AVAILABLE 84 © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

PIAGET'S STAGES OF COGNITIVE DEVELOPMENT Saying Piaget's cognitive Stages is Fun Sensorimotor Stage 0 - 2 years ✹ Development through our 5 senses Realizing that objects that ✹ Development through motor response are out of sight still exist ✹ OBJECT PERMANENCE is developed ✹ Egocentric 2 - 7 years ➥ Can only see the world from one's own point of view Preoperational Stage ✹ Symbolic thinking • Magical thinking ✹ Imagination • ANIMISM - thinks objects are alive ✹ Abstract thinking is still difficult • Plays pretend ✹ Asks a lot of questions (intuition) concrete operational Stage 7 - 11 years ✹ Develop concrete cognitive operations CONSERVATION ➥ Sorting blocks in a certain order Understanding that ✹ CONSERVATION is developed something stays the same ✹ Conductive reasoning (Mathematical advancements) in volume even though its shape changes. Formal Operational Stage > 11 years ✹ More rational, logical, organized, moral, and consistent thinking ✹ Hypothetical thinking - Can think outside the present ✹ Abstract concepts ➥ Love, hate, failures, successes ✹ Deductive reasoning © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 85

VARIATIONS IN PEDIATRIC ANATOMY & PHYSIOLOGY RESPIRATORY NORMAL EDEMA HEAD SIZE • Narrow airways ADU INFA NT • Head is the fastest growing part of • Newborns have ↓ alveoli than an adult an infant (large in proportion to the body!) LT • Thousands of alveoli grow each day • Head & neck muscles are not well for the first few months of life! developed • Floppy airways from less cartilage BRAIN & SPINAL CORD • Obligatory nose breathers • ↑ metabolic rate • Cranial bones not completely fused • ↑ O2 requirements • The brain is highly vascular EARS = ↑ risk for hemorrhage • Sutures & fontanels makes the skull ↑ RISK FOR EAR INFECTION • Eustachian tubes are flexible and allows for growth of the brain short, wide, & flat • The spine is very mobile = making drainage difficult = ↑ risk for cervical spin injury = harbors microorganisms IMMUNE SYSTEM CARDIOVASCULAR ↑ RISK FOR INFECTION • The transition from fetal • Immature immune systems circulation → normal circulation • ↓ inflammatory response at birth • Limited exposure to disease • Infants hearts are thinner (losing immunity from maternal and less compliant antibodies) SKIN NERVOUS SYSTEM • Epidermis is thinner • Myelinization is incomplete • Blood vessels are closer to the at birth surface - loses heat very easily! • Myelinization happens in cephalocaudal direction (head to tail) Cephalocaudal direction (head to tail) Head control before walking! KIDNEYS proximodistal • Kidneys are larger in relation to abdomen = less protection (inward outward) • GFR is slower • ↓ ability to concentrate urine & reabsorb = ↑ risk for dehydration 86 © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

SUDDEN INFANT DEATH SYNDROME (SIDS) Sudden death of a previously healthy infant younger than 1 year of age RISK FACTORS • Socioeconomic status THERE ARE • Lack of prenatal care • AGE: 1 - 6 months (↑ risk) • Genetic NO • Preterm • Bedding (can be smothered) • Sleep position • Room temp (cooler is better) SIGNS OR SYMPTOMS! • Sibling death • Nicotine exposure Sudden death Leading cause of death in infants EDUCATION / PREVENTION • Sleep in supine position • Bedding • Firm mattress • No toys, blankets, pillows, or stuffed animals • Avoid over bundling or overdressing the infant • Avoid smoking • No co-bedding (Infant should sleep separate from the parents) • Normal room temp • Encourage pacifier use ABCS OF 87 SAFE SLEEPING A alone B On their back C In a crib © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

NEURAL TUBE DEFECTS NORMAL SPINE Spina Bifida The neural tube closes: is a general term for a birth defect 3rd - 4th week of gestation typically diagnosed during pregnancy where the spinal column fails to close. Spina bifida means “split spine” CAUSES NOT KNOWN... BUT MANY FACTORS HINDER NORMAL CNS DEVELOPMENT • Drugs • Chemicals • Folic acid deficiency (Vitamin B9) • Malnutrition • Genetics • Diabetes • Obesity SPINA BIFIDA OCCULTA MIFLODREMST Defect of the vertebral Typically asymptomatic Does not need immediate body WITHOUT medical care if asymptomatic. protrusion of the May have dimpling, abnormal patches of If symptoms are present, spinal cord or meninges. hair, or discoloration near the client may get an MRI. the spine. MENINGOCELE Meninges herniate Surgical correction through a defect of the lesion Sac protruding in the vertebrae. from the spinal area. Usually minor or Most are covered no neurological deficits. with skin. MYELOMENINGOCELE SMEFVOOESRTRME Protrusion of The spinal cord often • Multiple surgical procedures the meninges, ends at the point • Paralysis cerebrospinal fluid, of the defect. • Bladder / bowel incontinence • Neurogenic bladder and spine. = • Meningitis (infection) • Hypoxia Skin may be Absent motor • Hemorrhage exposed as well. & sensory function • Freq. catheterization causes... beyond that point. ➥ Latex allergy ➥ UTIs / pyelonephritis ➥ Renal damage © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 88

BRONCHIOLITIS (RSV) PATHO BRONCHIOLITIS small airways in the lungs inflammation ✹ Viral illness usually caused by Respiratory syncytial virus (RSV) ✹ Very contagious ✹ Starts as an upper respiratory infection & moves into the chest SIGNS & SYMPTOMS INITIAL CONTINUED EMERGENT ✹ Upper respiratory symptoms ✹ Lower respiratory tract symptoms • Grunting • Nasal flaring • Nasal congestion • Tachypnea • Cyanosis • Runny nose • Cough • Hypoxia • Cough • Wheezing • Respiratory failure • Sneezing • Apneic episodes ✹ Fever TREATMENT ✹ Self-limited illness & supportive care ✹ Hydration ✹ Airway maintenance Increase fluid intake (oral or IV) • Oxygen (risk for dehydration) • Suctioning ✹ Hospitalization Saline nose drops & then suction the nares with a bulb syringe to remove the Only necessary if the child secretions before feeding or at bedtime has severe symptoms • Position the child at a 30 - 40° angle ✹ Use contact & standard caMnaobtsethmcohmainledargeend precautions during care © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 89

CAUSE REYES SYNDROME Rare disease affecting young children recovering from a viral illness (flu or chicken pox) Exact cause unknown Triggered due to the intake of salicylates or salicylate-containing products such as aspirin to treat a viral illness (Flu / Chickenpox) ENCEPHALOPATHY / CEREBRAL EDEMA SIGNS & SYMPTOMS ACUTE FATTY LIVER FAILURE \"CHILDS\" LABS C Confusion (changes in mental status) ↑ LIVER ENZYMES H Hyperreflexia ↑ AST I Irritability ↑ ALT L Lethargy D Diarrhea & vomiting S Seizures ✹ Early recognition & treatmentTREATMENT Educate on ✹ Education on prevention! products that contain ✹ Monitor fluid status ✹ Swelling of the brain occurs Salicylates: • Maintaining cerebral perfusion Aspirin • Managing & preventing increased ICP Alka-Seltzer • Seizure precautions Pepto-Bismol Kaopectate © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 90

INTUSSUSCEPTION PATHO ILEUM TELESCOPES INTO THE CECUM TELESCOPES ↓ OBSTRUCTION = PAIN ↓ COMPRESSION OF BLOOD VESSELS ↓ BLOOD FLOW DECREASES ↓ BOWEL ISCHEMIA ↓ RECTAL BLEEDING (CURRANT JELLY STOOLS!) ✹ Intermittent pain / cramping SIGNS & SYMPTOMS ✹ Child draws up their legs toward ✹ NOT COMPLETELY KNOWN the abdomen in severe pain THIS IS CAUSES ✹ May be due to a virus that while crying TINETLEEBSRECMCOIATPUTISNEENGTIS causes swelling ✹ Vomiting & diarrhea ✹ Condition child is born with • Diverticulum ✹ Currant-jelly stools (bloody) • Polyps ✹ Lethargy ✹ Sausage-shaped mass in the upper mid-abdomen TREATMENT ✹ May spontaneously be reduced Diagnostic / Treatment (Passage of normal, brown stools) AIR or BARIUM ENEMA ✹ IV fluids works to diagnose ✹ Antibiotics & also helps reduce ✹ Decompression via NG tube the intussusception ✹ Provide comfort & emotional support to the parents ✹ Monitor for signs of perforation & shock ✹ May need air or barium enema • Provide education to child & family about pre-op & post-op © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 91

HYPERTROPHIC PYLORIC STENOSIS NARROWING PATHO A hypertrophied pyloric muscle NORMAL HYPERTROPHIED PYLORUS MUSCLE causes narrowing of the pyloric canal vboemccoioMtAmninLtEegaKsTiASdnAwtesLhBopOaimOclcehSaiLtdcIleISheCwdahdwischhteon ↓ ↑PH & ↑HCO3 Thickness creates a narrow stomach outlet HYPERTROPHIC PYLORIC STENOSIS ↓ ↓ ↓ Increase in size Pylorus Narrowing Opening from the stomach into the small intestines SIGNS & SYMPTOMS ✹ Projectile vomiting ✹ Non-bilious emesis ✹ Olive-shape mass palpable in the right upper quadrant ✹ Infants will be hungry constantly despite regular feedings ✹ Weight loss ✹ DEHYDRATION! ↑ Hematocrit from hemoconcentration ↑ BUN ✹ Monitor ...TREATMENT Pyloromyotomy • I&O’s • Vomiting episodes & stools Cut the muscle of • Signs of dehydration & electrolyte imbalances the pylorus ✹ Obtain daily weights ↓ ✹ Provide comfort & emotional support Relieving the gastric to the parents outlet obstruction ✹ Educate about surgery 92 © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

PATHO Inflammation EPIGLOTTITIS of the WHAT IS THE EPIGLOTTIS? EPIGLOTTIS Piece of cartilage leading to an at the back of the tongue upper airway Function: obstruction Closes the entry to the trachea during swallowing.... AKA prevents aspiration CAUSES ✹ Most common cause: Haemophilus influenza type B HfiPabEllDvianScgicnidnciuadteeiotnnot ✹ Streptococcus pneumonia SIGNS & SYMPTOMS ✹ Tachycardia ✹ Drooling / dysphagia ✹ Sore throat ✹ High fever ✹ Tripod position ✹ Anxious / apprehensive / agitation ✹ Sitting forward with the neck ✹ Difficulty speaking ✹ Nasal flaring extended to breath - mouth open ✹ Stridor ✹ Retractions (chest) (Frog-like croak on inspiration) ✹ Nasal flaring ✹ Absent cough! ✹ Never leave the client Do not visualize the throat with a tongue blade. ✹ Asses oxygen status Take oral temperature or take throat culture. NURSING MANAGEMENT ✹ IV access Why? ✹ May need emergency intubation It can cause REFLEX LARYNGOSPASMS (cutting off the airway) ✹ Calm environment • Stay with parents • Don’t restrain the child ✹ NPO • Help to avoid crying ✹ Medications • Most comfortable position • Antibiotics • Antipyretics (usually tripod position) • Corticosteroids (decrease inflammation) ✹ Do not place them in supine position. It becomes harder to breathe. • IV Fluids © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 93

LARYNGOTRACHEOBRONCHITIS “CROUP” PATHO Inflammation of the LARYNGO TRACHEO BRONCHI ITIS larynx, trachea, & bronchi ↓ ↓ ↓↓ occur as a result of viral infection Larynx Trachea Bronchi Inflammation Most commonly caused by the Parainfluenza virus SIGNS & SYMPTOMS ✹ Inflammation & edema obstructs the airway Croup Vs. Epiglottitis 3 s’s Symptoms occur at night ONSET Sudden (at night) Rapid (within hours) FEVER Fluctuating High • Stridor COUGH Yes No • Subglottic swelling DYSPHAGIA No Yes Viral Bacterial (causes hoarseness in the voice) CAUSE • Seal-bark cough EMERGENCY Not typically Yes TREATMENT HOME CARE SEEK HELP Self-limiting When the child is indicating (Usually resolves on its own) respiratory distress ✹ Corticosteroids (↓ inflammation) ✹ Child is confused/restless ✹ Racemic epinephrine ✹ Blue lips/nails ✹ Humidified air ✹ ↑ respiration rate (steamy bathroom or mist humidifier) (breathing faster, but less air is going in) ✹ Encourage rest & fluid intake ✹ Retractions ✹ Calm environment for the child ✹ Nasal flaring ✹ Drooling/can’t swallow © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 94

FEVER MANAGEMENT NORMAL TEMP FEVER 97.5°F to 98.6°F > 100.4°F (38.0°C) 36.4°C to 37.0°C SIGNS & SYMPTOMS TREATMENT Do not administer aspirin (risk for Reye's Syndrome) ✹ Flushed skin ✹ Administer antipyretics (ibuprofen) Provide adequate fluids! ✹ Diaphoresis (sweating) ✹ Monitor for S&S of dehydration ✹ Chills Tepid water for 20-30 min. ✹ Restlessness & electrolyte imbalances Squeeze over back & body ✹ Lethargy ✹ Sponge bath ✹ Remove excess clothing & coverings to ↓ the temp ✹ Cool compress on the forehead Febrile Seizure WHAT IS IT? SIGNS & SYMPTOMS Seizures associated with a FEVER souhcrcaodhvimnidesatoapUeslbolelsielcisnuelpaigactnitytllioletuoyeptanrlssmy ✹ Rapid ↑ in core temperature Not related to: ✹ Child may be drowsy during • intracranial infection postictal period • metabolic imbalance • viral illness TREATMENT RISK FACTORS ✹ 6 months - 5 years ✹ NOT anticonvulsants therapy ✹ Rapidly developed fever ✹ HIGH fever ✹ Rectal Diazepam ✹ Family history of febrile seizures ✹ Certain vaccines ✹ Educate the parents to seek help if... • Last > 5 min • DTP & MMR • Repeated seizures © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 95

CYSTIC FIBROSIS (CF) ✹ Multisystem disorder of the EXOCRINE GLANDS CF is an with increased production of thick mucus Autosomal recessive ✹ Gene mutation (CFTR): prevents exocrine glands genetic disorder from properly functioning PATHO Dad is a Mom is a ✹ EXOCRINE GLANDS: Produce & transfer secretions carrier of carrier of (mucus, tears, sweat, & enzymes) via ducts CF gene CF gene ✹ ↑ viscosity of mucus = ↑ resistance to ciliary action ↓↓ = slowing the flow rate of mucus, leading to mucus plugging 2 mutated CF genes = Cystic Fibrosis DIAGNOSIS ✹ Ambry test CHEST PT ✹ Positive sweat sodium chloride test TREATMENT ✹ Genetic screen ✹ Drains airways of thick mucus to be coughed up ✹ Treatment of the mucus • Stimulates cough • Chest physiotherapy (PT) • Helps loosen mucus • Postural drainage • Results in deep breathing • Huff coughing • Builds up strength and endurance • Nebulizers Bronchodilators, mucolytics, of respiratory muscles anti-inflammatory drugs • Improves cardiovascular fitness ✹ Treat & prevent infection ✹ Done multiple times a day between • Wear a mask, hand washing, up-to-date on vaccines, 1-2 hour increments avoid those who are sick. • NOT done right before or after meals! ✹ Nutrition ✹ Causes vibrations & percussions ✹ Prevent GI blockage to break apart the mucus • Fluids & stool softeners (vests, manual vibration) ✹ ↑ protein, ↑ fat, ↑ calorie All Kids Eat Donuts • Fat soluble vitamin supplementation A, K, E, D ✹ Possible supplemental oral feeding or enteral feeding ✹ Pancreatic enzymes: • Pancrelipase or Pancreatin • Can swallow a capsules or sprinkle enzymes on foods that are acidic such as apple sauce! © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 96

MANIFESTATIONS OF CF RESPIRATORY NOSE & SINUSES • INFECTION: Thick mucus creates • Sinusitis a great environment for bacterial growth • Nasal polyps (snoring, stuffiness) • Pseudomonas • Staph. aureus PANCREAS • Pneumonia Pancreas secretes thick mucus • Bronchitis • Deficient in pancreatic enzymes: • Thick mucus = blocked airways (Protease, Amylase, Lipase) • Obstructive pulmonary disease • Weight loss (Emphysema) • Inadequate protein absorption • Clubbing • Deficiency of protein • Barrel-shape chest • Failure to thrive • Pneumothorax • Insulin deficiency • Strain on lungs = pulmonary hypertension • Hyperglycemia • CF-related diabetes CARDIOVASCULAR LIVER • Pulmonary hypertension • Bile duct blocked puts strain on the heart from THICK mucus • Right-sided heart failure • Gallstones • Biliary cirrhosis INTEGUMENTARY STOMACH & INTESTINES • Sweat glands produce • Fecal impaction ↑ chloride = salty skin • Rectal prolapse • Bowel obstruction • Salty sweat & salty tears • Intussusception which leads to • Back up of stool in intestine • Dehydration • Electrolyte imbalance • Constipation • Vomiting REPRODUCTIVE • Abdominal distention • Cramping BOYS • Anorexia • RLQ pain • Thick mucus blocks the BOTH • Meconium ileus in infants vas deferens = Infertility HAVE • Steatorrhea DELAYED • Frothy (bulky), fatty, GIRLS PUBERTY foul-smelling stools • Thick cervical mucus blocks sperm from penetrating = Infertility 97 © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal.

FETAL CIRCULATION IN UTERO FORAMEN OVALE How can blood be shunted Blood is SHUNTED from the right atrium from the right pressure difference! to the left atrium by the foramen Ovale atrium to the Blood flows from left atrium? high resistance Blood bypasses the lungs...why? to low resistance ↓It's already oxygenated blood from the placenta (mom) Lungs: High resistance SUPERIOR DUCTUS AORTA from all the fluid. So the VENA CAVA ARTERIOSUS blood does not want to RIGHT ATRIUM FORAMEN go in the lungs! OVALE ↓ Blood goes from the interior vena cava to the DUCTUS ARTERIOSUS right atrium as well as some deoxygenated blood coming from Blood is SHUNTED from the superior vena cava. the pulmonary artery into the aorta by So the blood is now MIXED RIGHT the ductus arteriosus ATRIUM ↓(oxygen-rich & oxygen-poor blood) ↓ Liver not fully INTERIOR AORTA functioning yet VENA CAVA Mixed blood is now in the DUCTUS VENOSUS LIVER aorta and being pushed out to oxygenate the fetus Umbilical vein is carrying DESCENDING oxygenated blood from the AORTA ↓ placenta. It passes the LIVER (Some blood will go to the liver) DUCTUS UMBILICAL BLOOD GOES but most will be SHUNTED VENOSUS ARTERIES BACK TO THE PLACENTA TO GET UMBILICAL OXYGENATED ↓to the inferior vena cava by VEIN AGAIN! the Ductus Venosus FROM PLACENTA → SHUNTS TO KNOW TO PLACENTA ← • Ductus venosus • Foramen ovale THE PLACENTA IS THE \"LIFELINE\" • Ductus arteriosus BETWEEN MOTHER & BABY The Placenta is like \"temporary lungs\" MEMORY A think AWAY TRICK for the fetus while in utero START 2 Umbilical Takes deoxygenated Arteries blood + waste AWAY from the baby back 1 Umbilical vein to the placenta Gives oxygen rich blood TO the baby © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 98

DEVELOPMENT DYSPLASIA OF THE HIPS (DDH) PATHO ✹ Abnormal development of the hip joint DISLOCATION No contact between femoral head & acetabulum ✹ A baby's bones are not ossified yet so they have the ability to dislocate SUBLUXATION Partial dislocation & relocate easily (acetabulum is not completely in contact with the hip joint) DYSPLASIA Hip joint doesn't have the proper shape to fit together correctly DIAGNOSIS ✹ Ultrasound for in utero Barlow ortolani ✹ X-ray for those older than 6 months Test Test ✹ Barlow test & Ortolani COMPLICATIONS RISK FACTORS ✹ FEMALE → more lax ligaments Listen for any noises during the exam. from maternal hormones There should be no \"clunks\" heard or felt. ✹ Breech positioning If \"clunks\" are felt or heard = a positive sign for DDH ✹ Oligohydramnios ✹ Avascular necrosis of the femoral head ✹ ↓ ROM ✹ Leg-length discrepancy ✹ Early osteoarthritis ✹ Femoral nerve palsy TREATMENT Early detection & treatment are crucial. The bones are not ossified Instructions in early infancy, so you want to manipulate them to grow properly. If for DDH is not treated early the bones will ossify and develop incorrectly. Pavlik Harness > 6 months ✹ Must wear the harness at all times! ✹ Pavlik harness: ✹ Do not adjust the straps or remove Stabilizes the hip by preventing hip extension harness until instructed by the HCP 4 months - 2 Years ✹ Change the diaper while the baby ✹ Closed reduction: • Requires general anesthesia where the hips will be is in the harness placed back into the acetabulum by the surgeon • Spica cast is worn after surgery to maintain reduction ✹ Check for redness, irritation or • After spica cast the child will wear a brace until acetabulum is fully normal breakdown 2-3 times per day > 2 Years or no improvements ✹ Place baby on their back to sleep with surgery or harness ✹ Place long knee socks and undershirt ✹ Open surgical reduction followed by casting to prevent rubbing of the harness © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 99

SCARLET FEVER PATHO ✹ Complication of group A streptococcal infection AKA Strep throat Scarlet Fever ✹ Not all children who have strep will develop scarlet fever think Strep! ✹ TRANSMISSION: Droplets & respiratory tract secretions. Transmission happens in close contact such as schools & daycares. SIGNS & SYMPTOMS Begins on the NECK & CHEST ✹ Onset: ABRUPT! and spreads outwards ✹ RED RASh! to THE EXTREMITIES! Rash is usually not Sandpaper-like rash seen on the palms ✹ Pharyngitis & soles of the feet ✹ Fever, body aches, chills ✹ Strawberry tongue S's of ✹ Tender cervical nodes Scarlet fever: ✹ Tonsils are red ✹ Exudate may be present Strawberry tongue Sandpaper rash Take antibiotics as directed.... COMPLICATIONS TREATMENT evFeinniisfhththeechmielddiacpaptieoanrs Most children can be cared for at home ✹ Rheumatic fever to be better! ✹ Glomerulonephritis ✹ Abscesses of the throat ✹ Antibiotics (Penicillin V) ✹ Pneumonia • Erythromycin for those allergic to Penicillin i&mptcroEoeramatrtaplmynlitedcnaitattogiaopnnrroeses!ivvseenrty ✹ Fluids & soft foods ✹ Provide comfort SPosoluuppsshsi,cieltesesa,s, ✹ Cool mist humidifier © 2021 NurseInTheMaking LLC. Sharing and distributing this copyrighted material without permission is illegal. 100