Health and Illness Exam 3

Postpartum period

6-8 weeks after birth

Vitals indicating hemmorage

• Decreased blood pressure (orthostatic hypotension is normal)

• Increased HR

• Saturating a pad in 15 min

Postpartum neuropathy

Loss of sensation in lower limbs usually r/t positioning of the legs after birth 

Hormone changes in the postpartum period

• Estrogen - drops and can cause diuresis, breast engorgement, sweating

• Progesterone - drops causing increased muscle tone in body

• Placental enzyme insulinase - results in reduction of blood glucose

• Low estrogen and progesterone trigger anterior pituitary to produce prolactin 

• Oxytocin coordinates and strengthens uterine contractions to prevent hemorrhage (breastfeeding triggers release)

• Thyroid levels return to normal after 3 mo, postpartum thyroiditis is a concern 

Cardiovascular and hematological systems postpartum

• CO declines to prelabor levels within 1-2 hours postpartum

• CO returns to prepregnancy levels within a few weeks

• Varicosities resolve within 6 weeks

• Blood volume returns to normal 6 weeks postpartum

• Hypovolemic shock usually does not occur r/t normal blood loss (300-500mL) r/t expanded blood volume during pregnancy

• Coagulation factors rise after birth and put pt at risk for DVT

GI and GU systems postpartum

• constipation(hemorrhoids, pain from incisions, dehydration) use stool softener especially if opioid pain management in use 

• Mild proteinuria on day 1 and 2 and may last up to 6 weeks

• Encourage voiding right after birth (needs to be within 6-8 hours) and should measure 150mL AT LEAST

• Urinary retention may occur causing displacement of the uterus but postpartum diuresis usually occurs within 12 hours after birth (>3,000 mL/day)

Fundus postpartum

• Should be firm (instruct pt to empty bladder, perform fundal massage)

• Located between symphysis pubis and umbilicus immediately postpartum

• Rises to at or below umbilicus 12 hours pp

• Decreases in size by about 1-2 cm per day and should return between symphysis pubis and umbilicus by end of first week

• At around 2 weeks it should be within the pelvis and not palpable

Documentation of lochia

Scant- 2.5 cm

Light - 10 cm

Moderate - 15cm

Heavy - saturated within 2 hours (similar to a heavy period up to 2 hours after birth)

• flow may increase with standing and breastfeeding

Lactational amenorrhea

Suppression of ovulation during breastfeeding r/t prolactin

If breastfeeding, approx 6 months to first ovulation but depends on breastfeeding frequency, length of feeding, and infants suck

If not breastfeeding, approx 7-9 weeks (45-94 days) s/p birth ovulation begins and menses within 12 weeks

Hyperlactation vs hypolacation

Hyperlactation: excess mammary glandular tissue growth, overstimulation of the breasts or nipples

Hypolactation: having DM, PCOS or thyroid disorders.

Manifestations of PP depression 

• fatigue

• insomnia

• flat affect 

• lack of appetite

• headache

• anxiety, anger, sadness

Frequencies of vital signs after labor

• Blood pressure every 15 min for the 2 hours

• Temperature every 4 hours for the first 8 hours and then at least every 8 hours

• If temp is elevated after first 24 hours - infection is possible

Assessing fundus nursing interventions

• position patient supine with knees slightly flexed so fundal height is not influenced by positioning

• Assess q8 hours

• Cup one hand above the symphysis pubis and the other hand on the fundus to support and palpate the uterus and massage in a circular motion.

• Observe lochia flow as fundus is palpated 

• Fundus may be deviated to the right if the bladder is full. It should be firm and midline after birth.

Engorgement vs mastitis

Engorgement: fullness of breast tissue

• will resolve on own, wear supportive bra, cold packs (15 on, 45 off) or cabbage leaves

• empty each breast after feedings, using a pump if needed

• take a warm shower or apply warm compress before breastfeeding

Mastitis: infection in a milk duct

• flu like symptoms

Behaviors indicating parent-newborn bonding

• holds newborn face to face

• assigns meaning to newborn behavior and views positively

• Names the newborn

• touches and maintaines proximity

• responds to cries

Behaviors that indicate impaired sense of parents bonding

• apathy when newborn cries

• disgust when newborn voids, stools or spits up

• turns away

• does not include newborn in family context

• perceives newborn as incorporative

Nutrition education for postpartum patients

• non lactating patients should consume 1,800-2,200 cal/day

• lactating patients should add 450-500 calories onto pre pregnancy diet

• Continue prenatal vitamins until 6 weeks s/p birth

Immediate care for newborn

• Suction mouth, then nose after cutting umbilical cord to establish respiratory function (suction at the side of the mouth)

• Obligatory nose breathing is expected

• Rub back and tap feet to stimulate breathing, apply O2 as needed

• Check central skin color

• Dry off quickly, provide a warm surface and cover

Normal vitals for a newborn

Done in the following order: 

RR: 30-60 (2x adult)

• short periods of apnea <15 seconds are OK

HR: 120-160 (can be as low as 80 during sleep) use apical for 1 full min (2x adult)

B/P: 60-80/40-50 (1/2 of adult)

• can be done in all four extremities

Temp: 97.6-99.6

Newborn reflexes

Rooting - stroking cheek or edge of mouth causes newborn to turn head to that side and start to suck

Moro (startle) - allow head and trunk of newborn in a sitting position to fall backward at an angle of 30 degrees. The newborn should extend and then abdult the arms, elbows and fingers to form a C

Palmar grasp - Place fingers in newborns hand, the hand should close around the fingers

Babinski - stroking outer edge of foot causes newborns toes to fan upward and out

Plantar - place finger at base of newborns toes, the newborn should curl toes downward

Lanugo vs vernix

Lanugo: excess hair

Vernix: cheesy coating on newborn's skin, providing protection from amniotic fluid and aiding in thermoregulation.

Assessment of umbilical cord

• 3 vessels

• two arteries, one vein

Elimination assessment in the newborn 

• First void by 24 hours

• Should void 6 or more times per day

• Meconium stool 24-48 hours 

Newborn medications + vaccines

• Hep B vaccine

• Erythromycin eye ointment (inner to outer canthus in lower conjunctival sac)

• Vitamin K injection to prevent hemorrhage in vastus lateralis

• Don’t give vitamin K and hep B vaccine in same thigh

Umbilical cord and circ care

• Remove clamp (clamp prevents hemorrhage) when dry at about 24 hours

• Stump will fall off around 2 weeks of age

• Clean the cord with water

• Fold the diaper down and away from the umbilical stump

• Don’t bathe by submersion until cord has fallen off

• For circumcised babies, apply diaper loosely and change q4 hours and apply petroleum jelly

Bathing the newborn 

• first bath should be delayed for 8-24 hours

• Bathe every other day

• Use a mild soap only PRN

• Do not give baby boys baths until circumcision is healed, but you can trickle warm water over the penis

• Do not wash off yellowish mucus on glans of circumcised babies

Hypoglycemia in the newborn

• can be r/t cold stress

• s/s: jittery, hypotonia, unstable VS, weak or high pitched cry, poor feeding, apnea, respiratory distress, low temp, seizures

• Blood glucose 40-45 mg or less = hypoglycemia

• Take sample on outer heel edges

Newborn screenings

• PKU sample taken at 24 hours, then another in 10-14 days

• Congenital heart disease screening at 24 hours and 48 hours, tests oximetry and BPs on arm and foot x3 tests an hour apart (less than 3% difference between arm and leg is passing) 

• Hearing screening by 1 mo

• Vision: newborn should be able to focus on objects 8-12 inches from face

Types of jaundice 

• Assess skin and sclera 

• Pathological : Over 10 days or very high bilirubin 

• Physiological: less than 24 hours

• Kernicterus is a serious condition resulting from excessive bilirubin levels that can lead to permanent neurological damage.

Cold stress in newborns

• newborns have a large surface area to weight ratio and reduced metabolism

• newborn keeps warm by metabolizing brown fat

• becoming chilled quickly uses up brown fat and can increase oxygen demand and cause hypoglycemia

• check temperature axillary

• Temp stabilizes within 12 hours after birth if chilling is prevented

• S/s include: mottling, skin pallor, tachypnea

Individuals with disabilities act

• free public education for kids with disabilities

• requires IEP

• adaptations, modifications for classrooms

• address behavior issues

• transition to adulthood

Characteristics of ASD

• Decreased communication in social situations

• abnormal communicative behaviors and body languages

• Repetitive motor or speech patterns (flapping hands, rocking body)

• Insistence on routine

• Typically appears in first 3 years at puberty

• Lacks empathy/trouble showing feelings

• Lacks cooperation  

• Language delay

• Self care deficits

• Head banging, hand biting 

• Depression - flat affect 

• Withdrawal

• Disregards social norms 

• Poor eye contact 

Medication tx for ASD

• 2nd generation antipsychotics

• SSRIs

• Stimulants (for hyperactivity and impulsivity)

• Naltrexone (off label use)

Characteristics of ADD

• Impulsivity 

• Inattention, hyperactivity or combined

Inattention

• unable to concentrate, easily distracted, short attention span

• Unable to follow instructions

• Difficulty with organization

Hyperactivity:

• unable to sit still

• fidgeting

• excessive physical movement, talking, interrupting

Impulsivity:

• acting without thinking

• lack of regard for consequences

• no sense of danger, frequent injuries. 

Medication tx for ADD

• Ritalin (increase dopamine and attention)

• Adderall

• Atomoxetine (SSRIs)

• Clonidine (alpha 2 adrenergic agonist)

• Guanfacine (alpha 2 adrenergic agonist)

Neurodevelopmental disorders

Disorders that affect the development of the brain and nervous system, impacting behavior, memory, and learning. Examples include autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD).

• often have onset in developmental period

• impairments of personal, social, academic or occupational functioning

• Harder to dx in younger children

• Often improve as the patient gets older but can persist into adulthood 

More s/s of ADD

• behaviors at home and at school

• often found before age 12

• Low frustration tolerance

• temper outbursts

• poor school performance

• low self esteem

• difficulty taking turns

• poor social boundaries

• intrusive behaviors

• disorganized

• Easily bored

• Not task oriented

Intellectual developmental disorder

A type of neurodevelopmental disorder

Severe deficits in three major areas of functioning

According to DSM-5-TR:

• intellectual - mental capacity, learning, reasoning, problem solving

• social - work, social activities, relationships

• daily functioning - ADLs

Noted during child development

Examples include

• Down Syndrome

• Fragile X syndrome

• PKU

Etiology of neurodevelopmental disorders

Combination of genetic, and environmental factors

• Before birth (genetic conditions), insufficient dietary iodine, postnatal infections (rubella, HIV)

• During birth (delivery complications)

• Childhood head injury or infection

• Exposure to toxins such as alcohol or heavy metals

• Oxidative stress: balance of free radicals and antioxidant defenses is disturbed, which in a developing brain can result in impairment

Comorbidities in neurodevelopmental disorders

Conditions that often occur alongside neurodevelopmental disorders, such as anxiety, depression, or learning disabilities.

For example, in patients with ASD:

• ADHD

• Epilepsy

• Psychiatric/behavioral concerns

• GI disorders

Are common comorbidities, especially in ASD folks with intellectual disability

In patients with ADHD:

• substance use disorders

• sleep disorders

• anxiety disorders

Types of neurodevelopmental disorders

1. Learning disorders - a deficiency that involves the way someone brain receives, processes, retains and responds to information (ie dyslexia). Often comorbid with ADHD population

2. Motor disorders - Tic disorders (vocal and motor),repetitive movement (rocking, grinding teeth) - often comorbid with ADHD, depression and OCD

3. Attention-Deficit/Hyperactivity Disorder - inattention, impulsivity - often comorbid with learning disorders

4. Autism Spectrum Disorders - deficits in social interaction + communications, repetitive and restricted patterns of behavior, interests or activities

5. Communication Disorders - language difficulties, vocabulary skill decificany, speech problems (stuttering, ect) - often comorbid with hearing impairment, intellectual disabilities, developmental disabilities ASD, ADHD, TBI

6. Intellectual Disabilities - deficits in intellectual and adaptive functioning (down syndrome, fragile X syndrome) - often comorbid with increased aging, alzheimer’s (DS)

Identifiable risk factors for neurodevelopmental disorders

ADHD

• low birth weight

• tobacco and alcohol use of mom

ASD:

• De novo gene mutations

• Family history 

• advanced parental age (combined with genetic factors) 

• very low birth weight (combined with genetic factors) 

• More common in boys than girls

Nursing interventions for ASD

• Refer to early intervention programs at school

• Educate parents to provide structure and consistent expectations

• Utilize behavior reward system

• PT, OT and ST as needed

• Short, concise and developmentally appropriate communication

Nursing interventions for ADHD

• Refer for family therapy to improve communication and coping skills.

• Use cognitive behavior therapy to improve behavior patterns and develop problem-solving skills.

• Music or art therapy school program.

• Pharmacological intervention with stimulant medication, such as methylphenidate, to treat unresolved signs of restlessness and distractibility

• Provide short and clear explanations 

Pathophysiology of gene mutations

• permanent change in the DNA sequence

• Can affect a single DNA base pair or large segments of a chromosome

• Changes the type/amount of protein made causing it to work incorrectly or not at all

• Can be neutral, harmful or beneficial (evolution vs genetic disorders)

Genogram/Pedigree

A graphical representation that displays family relationships and medical history, often used in nursing to assess genetic risks and patterns of illnesses.

• uses at least 3 generations

• Looks for inherited genetic disorders rather than acquired (from replication errors or damage to DNA from toxins and is more individual)

Katrotype

Diagram of all the chromosomes in a person’s cells, arranged in pairs and ordered by size, shape and number

• sample taken from blood, amniotic fluid, ect 

• 22 pairs of autosomes

• 1 pair of sex chromosomes (XX female, XY male) 

Genetic component of cystic fibrosis

Hereditary disorder acquired from two parents having mutations in the CFTR gene

• Must inherit two copies of mutated (recessive) gene

• White americans more likely to have

• Faulty CFTR protein changes how much salt moves in/out of cells

• Causes thick and sticky mucus and increases amount of salt in sweat

• Affected organs include: lungs, liver, small intestine, reproductive system

Symptoms of CF

• Thick mucus - can block and damage airways of lungs

• Persistent cough (dry)

• Exercise intolerance

• Repeat lung infection

• Inflamed nasal passages

• Recurrent sinusitis

• Clubbing of fingers, and toes, barrel chest r/t poor oxygenation

• Fever, night sweats

• Salty skin and extra salty sweat, tears, saliva (high Na and Cl)

• Slow growth and shorter height

• Can also clog digestive system

• Bulky, frothy, greasy stools full of lipids

• Meconium ileus in infants

Complications of CF

• Bronchiectasis

• Chronic infections

• Hemoptysis

• Pneumothorax

• Exacerbations

• Nutritional deficiencies especially fat soluble vitamins (ADEK)

• DM related to pancreas damage

• Liver disease

• Infertility - especially in men

• Osteoporosis

• Electrolyte imbalance

• Dehydration

• Mental health concerns 

Diagnostic testing and criteria for CF

• Heel prick on card to test for immunoreactive trypsinogen as a newborn screening 

• Sweat test for high levels of chloride (ensure child is well hydrated) (can be done as soon as 48 hours s/p birth)

• CFTR gene analysis 

Interventions for CF

• Airway clearance therapy (ACT) such as manual chest physiotherapy (2x per day, not after meals) 

• Aerosol therapy (bronchodilators) admin before ACT

• Encourage aerobic exercise 

• Oxygen as prescribed 

• High protein, high calorie diet

• Admin pancreatic enzymes within 30 min of eating a meal or snack

• Adding salt to foods during hot months 

• Antibiotics for lung infection 

• Stay up to date on immunizations 

• Good dental hygiene

• Have child rest prior to meals