Week 11 Reproduction & Genitourinary/ High Risk NewbornsFunction

Genitourinary A&P for Children

the kidney is large in relation to the size of the abdomen until the child reaches adolescence. Therefore, kidneys of the child are less well protected from injury by the ribs and fat padding than they are in the adult.

Blood flow through kidneys (Children)

glomerular filtration rate (GFR) is slower in the infant and young toddler compared with the adult, increased risk of dehydration during times when fluid loss or decreased fluid intake occurs

Urinary Tract Anatomy- Female

the urethra is naturally shorter in all ages of females compared with males. Places them at increased risk for the entrance of bacteria into the bladder via the urethra. This risk is compounded by the physical proximity of the urethral opening to the rectum. The renal system usually reaches functional maturity at around 2 years of age, women at greater risk for UTIs during pregnancy and postpartum

High Risk Newborns

preterm newborns <37weeks or post-term newborns >42weeks. SGA/LGA, experiences breathing difficulties at birth, suffered excessive coldness or hypothermia, has an infection, born to mothers with high risk prenatal conditions.

The Preterm Infant

born before completion of 37 weeks gestation, organ systems are immature and lack adequate physiological reserves to function in the extrauterine environment, the lower the birth weight and gestational age, the lower chances of survival. Practical and ethical dimensions of resuscitation of extremely low-birth-weight infants (ELBW)

Common Physical Characteristics of Preterm Newborns

abnormal breathing patterns (apnea), body hair (lanugo), enlarged clitoris, less body fat, lower muscle tone and less activity, problems feeding due ot trouble sucking or coordinate swallowing and breathing, small scrotum that is smooth and has no rugae and undescended testicles, soft, flexible ear cartilage, thin, smooth, shiny skin that is often transparent (can see veins under skin)

Respiratory System Preterm Infant

one of the last systems to mature, therefore poses great risk for premature newborn. surfactant deficiency, unstable chest wall, immature respiratory control centres, small resp passages and inability to clear from these passages, resp rate: 30-60/minute, use of abdominal muscles

Cardiovascular System Preterm Infant

difficulty in making transition from intrauterine to extrauterine life. change from fetal to newborn circulation pattern, impact of low O2 level in circulating blood, increased incidence of congenital anomalies associated with prolonged fetal circulation, impaired regulation of BP, monitor for signs of hypovolemia and shock, hypotension, slow capillary refill, continued resp distress despite O2 and ventilation, murmurs

Gastrointestinal System Preterm Infant

small stomach, capacity. Lack neuromuscular coordination required to maintain suck, swallow, and breathing. Perinatal hypoxia causes shunting of blood away from gut to other organs (heart, lungs, brain), compromised metabolic function, intervention includes introduction of minimal enteral feeding to prepare newborn gut for future introduction of nutrients.

Renal System Preterm Infant

increased risk for fluid/electrolyte imbalance. Inability to concentrate urine and slow glomerular filtration rate.

Immune System Preterm Infant

increased susceptibility to infection. Impaired ability to manufacture antibodies to fight infection if exposed to pathogens during the birth process. Thin skin and fragile blood vessels provide limited protective barrier, prevention better than treatment.

Central Nervous System Preterm Infant

susceptibility to injury due to birth trauma, bleeding from fragile capillaries, impaired coagulation process, recurrent anoxic episodes and predisposition to hypoglycemia, increases the potential for long-term disability. High risk for heat loss (recognition and early management of cold stress is key). Susceptible to hypoglycemia. 

Nursing Assessment of Pain

assessed through monitoring of facial expressions, body movements and crying. Memories of pain, must have ongoing assessment of pain level. Allow parents to provide comfort measures.

Higher Risks for the Late Preterm Infant

thermoregulation, hypoglycemia, hyperbilirubinemia, respiratory distress, poor feeding and discharge delays

What is the Post Term Infant

newborn born beyond 42wks gestation, cause of extended pregnancy not well understood, however tends to be repetitive. ability of the placenta to provide adequate O2 and nutrients is compromised. As placenta loses its ability to nourish the fetus, the fetus uses stored nutrients to stay alive, thus wasting occurs (loss of muscle mass and SC fat)

Common Physical Characteristics of Post Term Infant

dry, cracked skin. long, thin extremities. creases that cover entire soles of the feet. Wide-eyed and alert, abundant hair on scalp, thin umbilical cord, limited vernix and lanugo, meconium stained skin.

Newborn Complications of the Post Term Infant

LGA or SGA, meconium aspiration/perinatal asphyxia, infectious morbidity, birth trauma, low apgar scores, perinatal mortality (intrauterine fetal demise and/or neonatal death), oligohydramnios, hypoglycemia, hypothermia, polycythemia

What is Small-for-Gestational Age

when they fall below the 10th percentile on a growth chart, some SGA newborns will be small but healthy, others will not meet the expected growth pattern (intrauterine growth restriction [IUGR]). Fetal growth dependent on genetic, placental, and maternal factors. Newborns who experience nutritional deficiencies in utero, and are born SGA, are at risk of cognitive deficits that can undermine their academic performance throughout life

Maternal Risk Factors SGA

smoking, hypertension, drug abuse, multiple gestation

Risks for baby SGA

hypothermia, infection, hypoglycemia, meconium aspiration, hyperbilirubinemia

Nursing Management SGA baby

weight, length, and head circumference measurements, serial blood glucose monitoring, vital sign monitoring, early and frequent oral feedings; IV infusion of dextrose 10%, monitoring feeding tolerance, sucking, swallowing, monitoring for S/S of polycythemia, anticipatory guidance

What is Large-for-Gestational Age

Newborns are LGA when they are above the 90th percentile on a growth chart and weigh more than 4000g. Due to size, vaginal birth may be difficult and result in birth injury.

Maternal Risk Factors for LGA

gestational diabetes (poorly controlled), post dates, maternal obesity

Risks of LGA baby

birth trauma, skull fractures, fractured clavicle, shoulder dystocia, nerve palsies, hypoglycemia, polycythemia, and hyperbilirubinemia

Nursing Management of LGA

vital sign monitoring, blood glucose level monitoring, initiation of oral feedings with IV glucose supplementation as needed, continued monitoring for S/S of polycythemia and hyperbilirubinemia, hydration, phototherapy for increased bilirubin levels

Hypothermia Newborn

newborn is more prone to develop hypothermia because of the large surface area per unit of body weight. Less SC fat, and reduced amount of brown fat, metabolism of brown fat. Metabolism of brown fat increases heat production (blood flowing through the brown fat becomes warm and heats the rest of the body)

S/S of Hypothermia

cool/cold to touch, cyanotic hands, feet, and tongue, shallow, slow resp rate, lethargic and hypotonic, feeds poorly, feeble cry, hypoglycemic

Nursing Management of Hypothermia Newborn

prevent cold stress, maintain neutral thermal environment, warm baby immediately after delivery, delay bath until temperature has stabilized, hourly temperature check within first hours of life, encourage feeding, keep temp of the room warm

Evaporation- Thermoregulation

loss of heat from infant by water evaporation (skin)

Conduction- Thermoregulation

contact with cold objects (touching)

Convection- Thermoregulation

loss of heat to the surrounding air

Radiation- Thermoregulation

loss of heat from infant to cooler surfaces

Fetal Monitoring- Extrernal Monitoring

may be used while membranes are still intact and cervix not yet dilated, but also can be used with ruptured membranes. Non-invasive assessment, measures approximate duration and frequency of contractions. May restrict the mother’s movements, provides a record of FHR, vulnerable to signal disruptions, cannot detect short term variability.

Internal Fetal Monitoring

indicated for women or fetuses considered high risk, involves placement of an electrode on the fetal presenting part to assess FHR. Requires 4 criteria, can accurately detect short term and long-term variability. Unaffected by maternal movement

4 criteria of Internal Fetal Monitoring

ruptured membranes, cervical dilation of at least 2cm, presenting fetal part low enough to identify correctly and allow placement of the scalp electrode, skilled practitioner to insert electrode

Baseline Fetal Heart Rate (FHR)

average FHR observed between contractions over a 10-min period, rounded to increments of 5bpm. Tachycardia- sustained baseline FHR >160 bpm for a duration of 10mins or longer. Bradycardia- sustained baseline FHR <110bpm for a duration of 10mins or longer.

Uterine Activity- Interpreting FHR Tracings

What is the frequency, duration, and intensity of contractions?

Labour Progress- Interpreting FHR Tracings

what is the stage of labour? What is the dilation, effacement, station, presentation, and position?

Baseline FHR- Interpreting FHR Tracings

What is the baseline FHR? Is tachycardia or bradycardia present?

Baseline Variability- Interpreting FHR Tracings

What is the variability of the FHR?

Periodic Changes in FHR- Interpreting FHR Tracings

Are there any FHR changes from the baseline, are accelerations present? Are any decelerations present?

Accelerations- Variability

increase in FHR of 15bpm about the FHR baseline that lasts for at least 15-30sec, sign of fetal well-being when they accompany fetal movement, may occur before, during, or after a contraction. Are defined as apparent, abrupt increases in the FHR above baseline.

Decelerations- Variability

decrease in FHR below the baseline FHR, further defined according to onset and duration (early, variable, late, prolonged)

Potential causes and Nursing Interventions of Accelerations

increased maternal activity, spontaneous fetal movement. monitor, no nsg interventions required

Early Decelerations

have a shape that is symmetrical, with a gradual decrease and return of FHR to baseline in association with a contraction. (head compression)

Late Decelerations

have a shape that is symmetrical, with a gradual decrease and return of FHR to baseline in association with a contraction. (disruption of O2 transfer)

Variable Decelerations

are an abrupt onset of decreased FHR below baseline that may occur with or after a contraction (umbilical cord compression)

Prolonged Decelerations

are >15bpm and lasts >2mins but <10mins from onset and return to baseline

Potential Causes of Prolonged Decelerations

placental insufficiency, uterine rupture, cord compression, entanglement or prolapse, maternal hypotension, cervical exam

Nursing Interventions of Prolonged Decelerations

if continued distress: intrauterine resuscitation is required, if no improvement: facilitate delivery of baby

Principles of Intrauterine Resuscitation

change maternal position, notify primary healthcare provider, if client is receiving oxytocin stop/decrease infusion if ordered. Administer IV fluid bolus if ordered, perform a vaginal exam to assess labor progression (may also relieve cord pressure). Administer O2 at 8-10L/min, modify breathing or pushing techniques, reduce maternal anxiety

Reassuring Patterns of FHR

normal baseline FHR, presence of short and long-term variability, presence of accelerations with fetal movement or contractions, early decelerations may be noted in active labor

Non-reassuring Patterns of FHR

abnormal baseline FHR, severe bradycardia or tachycardia, absence of variability, late decelerations, severe variable decelerations, prolonged decelerations

Expected Urine Output in Children

infants: >1ml/kg/hr, children: 0.5ml/kg/hr

Urine Culture and Sensitvity

obtaining a clean or sterile urine specimen is necessary for accurate urine culture results. Urine bag collection, urethral catheterization or suprapubic aspiration is used for obtaining a urine specimen from the neonate or young infant

Voiding Cystourethrogram

a urinary catheter must be inserted just prior to the voiding cystourethrogram, then contrast will be administered and pictures taken of the bladder and kidneys

CBC, Electrolytes, BUN, Creatinine

close monitoring of serum blood counts and electrolytes is a critical component of nursing care related to renal disorders

Urinary Tract Infection (UTI)

infection of the urinary tract, most commonly impacting the bladder. Occurs most often as a result of bacteria ascending to the bladder via the urethra. 

Nursing Assessment UTI

health hx, fever, nausea or vomiting, chills, abdomen, back or flank pain, lethargy, jaundice (in the neonate), poor feeding, urinary urgency or frequency, burning stinging with urination, foul-smelling urine, poor appetite, enuresis or incontinence in a previously toilet-trained child, blood in urine

Physical Examination UTI

in neonate/infant, observe for jaundice or increased resp rate, in infants and children, inspect perineal area for redness or irritation, observe the urine for visible blood, cloudiness, dark colour, sediment, mucus, or foul odour, note pallor, edema, or elevated BP, palpate the abdomen, note distended bladder, abdominal mass or tenderness, particularly in flank area

Eradicating Infection UTI

children <3months and those with dehydration, a toxic appearance or sepsis should be hospitalized for administration of IV antibiotics, administer oral/IV abx as prescribed, urge the client to complete entire course of abx at home even if feeling better

Promoting Comfort UTI

administer antipyretics such as acetaminophen or ibuprofen to reduce fever, a heating pad or warm compress may help relieve abdomen or flank pain, if client is afraid to urinate bc of burning (dysuria), encourage voiding in a warm sitz or tub bath

Preventing Recurrence of Infections

repeat urine culture after completion of abx course to ensure eradication of bacteria, monitor for complications such as Hemolytic Uremic Syndrome in children

Hemolytic Uremic Syndroe (HUS)

rare but srs disease that affects the kdineys and blood clotting functions of infected children. S/S include lethargy, blood in the urine, oliguria, petechiae and bruising, infection with HUS causes destruction of RBCs which can then cause kidney failure. HUS occurs as a complication of infection (E. coli), children will be treated with IV fluids, blood products and dialysis if kidney failure occurs

Endometritis Definition

infection of the endometrial layer of the uterus

Endometritis Therapeutic Management

oral abx, acetaminophen, and ibuprofen

Nursing Assessment Endometritis

fever, pain, lochia

Nursing Management Endometritis

encourage rest, medication adherence, monitor lochia

Wound Infection Definition

infection of a postpartum wound such as episiotomy or tear site

Wound Infection Therapeutic Management

oral abx, acetaminophen, ibuprofen

Nursing Assessment Wound Infection

fever, redness, swelling, pain, discharge, odor

Nursing Management Wound Infection

encourage rest, medication adherence, ice packs, cleansing wound site

Mastitis Definition

infection of CT in breast primarily in lactating or engorged women

Therapeutic Management Mastitis

oral abc, acetaminophen, ibuprofen

Nursing Assessment Mastitis

risk factors, flu-like symptoms, warm, red, tender, swollen breast, cracked or abraded nipple

Nursing Management Mastitis

breastfeeding or continued emptying of breast, medications, proper infant positioning at nipple, warm compresses, handwashing, supportive bra

Chlamydia Maternal and Fetal effects

maternal- postpartum endometritis, PROM, and preterm birth. Fetal- conjunctivitis which can lead to blindness, low birth weight and pneumonitis

Therapeutic Management Chlamydia

abx are usually used in treating this STI, CDC recommends annual screening of all sexually active clients aged 20-25yrs old, all high risk ppl

Nursing Assessment and Management Chlamydia

assess health history for significant risk factors, 70-80% are asymptomatic, awareness of symptoms with assessment, diagnosis made by urine testing or swab specimens

Gonorrhea Maternal and Fetal Effects

maternal- chorioamnionitis, preterm birth, PROM, fetal growth restriction, postpartum sepsis. Fetal effects- eye infection gonococcal opthalmia which can cause blindness

Therapeutic Management Gonorrhea

can be cured with the right treatment, dual therapy of cephalosporin and macrolide, in the form of 250mg Ceftriaxone injected IM and azithromycin PO as a first-line treatment

Nursing Assessment and Management Gonorrhea

50-90% of cisgender women are asymptomatic, sensitivity in addressing STIs

Genital Herpes

is a recurrent, lifelong viral infection that has the potential for transmission throughout the lifespan

Genital Herpes Maternal and Fetal Effects

maternal- spont abortion, intrauterine infection, preterm labour, PROM, fetal growth restriction. Fetal- birth anomalies, transplacental infection

Therapeutic Management Genital Herpes

no cure exists, but antiviral drug therapy helps reduce or suppress symptoms, shedding, and recurrent episodes (acyclovir PO), can be safely used during pregnancy

Nursing Assessment and Management Genital Herpes

the first or primary episode is usually the most severe, recurrence triggered by emotional stress, menses, and sex

Syphillis Maternal and Fetal Effects

maternal- spont abortion, preterm birth, stillbirth. fetal- congenital syphilis; multisystem organ failure, structual damage; mental retardation

Therapeutic Management Syphilis

effective treatment: benzathine penicillin G either IM or IV is the preferred drug of all stages of syphillis. Safe in pregancy, clients should be reevaluated at 3, 6, and 12 months after treatment for primary, seconday, or early latent syphilis with serologic testing

Nursing Management and Assessment Syphilis

assess for clinical manifestations and staging, address psychosocial aspects of STI

Human Papillomavirus HPV maternal and fetal effects

maternal- may cause dystocia if large lesions, fetal- none known

Therapeutic Management HPV

no treatment or cure, focuses heavily on prevention with the HPV vaccine (Gardasil) and education on the treatment of warts and lesions caused by HPV, vaccine recommended to those aged 9-26yrs old, IM

Nursing Assessment and Management HPV

complete health history, clinical manifestations, pap, warts diagnosed by inspection

HIV Maternal and fetal

maternal- fatigue, nausea, weight loss. fetal- transmission can occur transplacentally, during childbirth or through BM

An HIV pregnant woman can transmit HIV to her baby in 3 ways:

during preganncy, during vaginal childbirth, through breastfeeding

HIV Therapeutic Management

goals of drug therapy to decrease HIV viral load below the level of detection, restore the body’s ability to fight off pathogens, improve the client’s quality of life, reduce HIV morbidity and mortality

HIV Nursing management and assessment

providing education about drug therapy, promoting compliance, preventing HIV infection, providing care during pregnancy and childbirth

Diuretics

drugs that accelerate the rate of urine formation, result in the removal of sodium and water, mainstay of therapy for the treatment of hypertension and heart failure and for prevention of kidney damage during acute kidney injury

Some people should not use estrogen-containing hormonal birth control

age 35+ and smoke cigarettes, could possibly be pregnant, have had blood clots or stroke in the past, are being treated for breast cancer or have had it before, irregular or heavy periods, have liver disease, heart disease, get the type of migraine headaches that cause vision or hearing problems

Hormonal Birth Control

oral contraceptive, injectable contraceptive, transdermal patch, vaginal ring, emergency contraception