Advanced Client Centered Care II Day 2 (1).ppt
Transcript of Advanced Client Centered Care II Day 2 (1).ppt
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Perry S RN, MSN
Maternal/Child
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Learning Outcomes
1. Describe the beginning of labor and
variables that affect labor and birth.
2. List the stages and mechanisms of
labor and important nursinginterventions for each stage.
3. Identify nursing diagnoses and nursing
interventions to assist the client inlabor.
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Learning Outcomes
4. Describe the role of the LPN/LVN in
preparing the mother for birth and in
providing infant care.
5. Identify causes of high-risk labor andappropriate nursing interventions for them.
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Care of the Patient in Labor
Components of Labor
Signs of impending labor Lighteningdescent of the fetus into the
pelvis Braxton Hicks contractionsirregular
painless contractions
Cervical changeseffacement and dilatation
Bloody showpassage of the mucousplug
Ruptured membranes
Sudden burst of energy
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Figure 53.18 Birthing suite.
Birthing Suite
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The 5 Ps of Labor
Passage
Maternal pelvis
Passenger
Lie, Size, Presentation, Attitude
Power
Position
Maternal
Psyche
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Passage
Size and shape of maternal pelvis
See page 1459 in Ramont, figure 53-1
Cephalopelvic disproportion fetal head
larger than maternal pelvis Stationis the relationship between the
maternal ischial spines and fetus
See page 1460 in Ramont figure 53-2 Station 0 is when the fetal head reaches
the ischial spines, fully engaged
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Passenger
Size: Fetal head largest part, molding,anterior and occipital fontanels used todetermine the position of the fetus See inRamont page 1460 figure 53-3
Fetal attitude: Degree of flexion of the fetalhead and limbs to the trunk
Fetal Lie: the relationship of the long axis
of the fetus to long axis of mother. Fetal presentation: Fetus body part that is
closest to cervix
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Passenger
Vertex area between anterior and
posterior or the occiput presents first
Brow forehead or brow presents
Face
Complete breech: Buttocks presents
first, hips and knees flexed on abdomen
Frank Breech: Buttocks presents first
but the knees are extended with feet
close to head
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Passenger
Fetal position is the relationship of the
presenting part to the four quadrants of
the maternal pelvis.
See Ramont page 1462 figure 53-7
See Ramont page 1462, table 53-2
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Primary Powers
Involuntary muscle contractions of themyometrium
Contractions due to shortening of musclefibers
Frequency: is the beginning of onecontraction to the onset of the nextcontraction
Duration: beginning of contraction to the
end of the contraction Intensity is the strength of the contraction
at its highest point
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Secondary Power
Pushing of the fetus through the birth
canal
Fergusons reflex is the desire to push,
abdominal contraction initiated by
stretching of pelvic soft tissues.
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Position
Position of mother during labor
Back = frequent contraction of low
intensity
Side = less frequent contraction but of
higher intensity
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Psyche
Mothers emotional state
Fear and anxiety cause release of
epinephrine and norepinephrine which
causes blood vessels to constrict whichdecreasesthe effectiveness of
contractions and makes labor more
painful
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Figure 53.2 Measuring the station of the fetal head while it is descending. In
this view, the station is -2/-3.
Station of the Fetal Head
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Figure 53.5 A. Fetal attitude. The relationship of body parts of this fetus is
normal. The head is flexed forward, with the chin almost resting on the chest.
The arms and legs are flexed.
Normal Fetal Attitude
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Figure 53.5 (continued) B. Frank breech presentation.
Breech Fetal Position
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Stages of Labor
First Stage of Labor
Latent Phase
Active Phase
Transition Phase
Second Stage of Labor
Third Stage of Labor
Fourth Stage of Labor
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Figure 53.9 Contraction patterns in first, second, and third stages of
labor. Primigravidas may be 100% effaced before labor begins.
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Figure 53.11 Effacement and dilatation of the cervix in the primigravida. A. Beginning of
labor. There is no cervical effacement or dilatation. The fetal head is cushioned by
amniotic fluid.
Effacement and Dilation
Beginning of Labor
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Beginning Cervical Effacement
and Dilatation
Figure 53.11 (continued) Effacement and dilatation of the cervix in the primigravida.
B. Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid
collects below the fetal head.
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Mid-Cervical Effacement and
Early Dilatation
Figure 53.11 (continued) Effacement and dilatation of the cervix in the primigravida.
C. Cervix about one-half effaced and slightly dilated. The increasing amount of amniotic
fluid exerts hydrostatic pressure..
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Complete Effacement and
Dilatation
Figure 53.11 (continued) Effacement and dilatation of the cervix in the primigravida.
D. Complete effacement and dilatation.
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Figure 53.13 The two most common types of episiotomy are
midline and mediolateral.
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Mechanism of Labor
Engagement
Descent
Flexion
Internal rotation
Extension
Restitution/External rotation
Expulsion (lateral flexion)
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Assessments
Ask about
contractions
Ask if membranes
ruptured V.S.
Labs, urine dipstick
for glucose and
protein FHR
Monitor contractions
Vaginal exams
Nitrazine test
Signs of PIH
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animation labor and birth
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Non Pharmacologic Comfort
Measures
Emotional Support
Informational Support
Physical Comfort Behaviors
First Stage
Second Stage
Advocacy Support
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Drugs Used in Labor
Management
Narcotic/Analgesics
Sedatives
Anesthetics
Local
Pudendal
Spinal/Epidural
Pudendal Block
. Pudendal block by transvaginal approach
Figure 53 17 (continued) A Schematic diagram showing pain path and sites of
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Figure 53.17 (continued) A. Schematic diagram showing pain path and sites of
interruption. A. Paracervical block (sensory pathways and site of interruption in
relation to fetus). B. Pudendal block by transvaginal approach. C. The lumbar
epidural block. The epidural space is located between the dura and the vertebra.
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Medical Interventions
for Labor Complications
Induction
Prostaglandins
Artificial Rupture of Membranes (AROM)
Pitocin (Oxytocin)
Forceps/Vacuum
Dilation and Curettage
Cesarean Section Emergent
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Artificial Rupture of Membranes
(AROM)
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Preterm Labor
20-37 weeks contractions with cervical
changes
Tocolytic for preterm see page 1474 in
Ramont table 53-6
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Induction of Labor
Prostaglandins (PGE 1) Softens cervix
Artificial rupture of membranes (ARM)
Pitocin (oxytocin)
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Precipitous Birth
Last < 3hours
Increased risk of ruptured uterus,
cervical and vaginal lacerations,
hemorrhage, fetal distress, and fetalcerebral trauma
Ramont page 1477 box 53-3
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Figure 53.21 Cord prolapse through the introitus. The prolapse of an
umbilical cord creates an emergency situation requiring birth by cesarean
section.
Cord Prolapse
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Cesarean Delivery
When labor does not progress normally
(dystocia), the nurse must be prepared
to assist with a cesarean birth.
Surgical birth is performed for a varietyof reasons, including:
Placenta previa, abruptio placentae, CPD,
fetal distress, breech presentation,
pregnancy-induced hypertension, multiple
pregnancy, and previous cesarean birth.
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POST PARTUM PERIOD
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Postpartum Period
Past placenta delivery to 6 weeks after
delivery
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Learning Outcomes
1. Describe the physical changes that
occur after a woman has delivered a
baby and placenta.
2. Identify psychological changes in thepostpartum woman.
3. Describe important aspects of support
for the postpartum woman.
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Learning Outcomes
4. Explain nursing interventions to use
when providing nursing care for a
postpartum woman.
5. Discuss methods of providing painrelief for the postpartum woman.
6. Identify crucial areas of client teaching
for the postpartum woman.
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Learning Outcomes
7. Describe important factors in self-care for
women after discharge.
8. Discuss client teaching about postpartum
emergencies.
9. Identify adaptations in postpartum care for
women after cesarean section.
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Learning Outcomes
10. Discuss important nursing
considerations regarding the new
family.
11. Discuss nursing care and teachingrelated to breastfeeding.
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Physiologic/Anatomic Changes of the
Postpartum Client
Breasts
Breast feeding vs. Non breast feeding
Cardiovascular system
Normal blood loss effect
Abdomen
Gastrointestinal System
Urinary System
Natural diuresis
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Physiologic/Anatomic Changes of the
Postpartum Client
Uterus Involution
Lochia
Types/Amount Cervix
Vagina
Perineum Intact
Lacerated/Episiotomy
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Involution
Figure 54.1 Involutionof the uterus. A. Immediately after delivery of the placenta, the
top of the fundus is in the midline and about halfway between the symphysis pubis and
the umbilicus. B. About 6 to 12 hours after birth, the fundus is at the level of the
umbilicus. The height of the fundus then decreases about one fingerbreadth (about 1 cm)
each day.
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Medications for the Post Partum Client
Analgesics
Narcotics
Salicylates
Anti inflammatory agents
Prostaglandins
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Postpartum Nursing Responsibilities
Breasts
Uterus
Bowel
Bladder
Lochia
Episiotomy/Incision
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Psychological Changes
Takinginstage: 1-2 days pastdelivery; recalls birth experience, relies
on others for care
Takingholdstage: 3rdday, control of
herself and infant
Lettinggostage: letting go of the
perfect pregnancy, perfect transition and
perfect baby. Desire to social interactionAttachment: Bond to infant
Negative feelings: negative, baby blues,
post-partum depression 55
Care of the Postpartum
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Care of the Postpartum
Woman
Vital signs should be assessed every 15
minutes in the first hour after birth.
When vital signs are stable, the time
interval can be lengthened.
Pain with dorsiflexion (Homans sign) is
an indication of an inflamed vessel in the
leg.
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Fundal Massage
Fundal massage is done to prevent or
correct uterine atony and remove clots
from the uterus in order to evaluate
uterine bleeding and preventhemorrhage.
A fundus requiring massage will be soft
and can be felt above the umbilicus.
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Fundal Massage
Figure 54.15 Nurse positioning hands to remove clots from uterus. Note that
lower hand supports the uterus.
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Hemorrhage
Life-threatening hemorrhaging can occur
in the postpartum woman hours or even
days after delivery.
A low blood pressure may indicatehemorrhage.
Tachycardia associated with
hypotension may indicate hemorrhage.
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Care After Cesarean
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Care After Cesarean
Delivery It is very important that adequate pain
relief be provided following a cesarean
section.
If the woman is receiving medication viaa PCA pump, she should be instructed
to push the button when she needs the
medication, and to notify the nurse if
pain relief is not adequate.
Care After Cesarean
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Care After Cesarean
DeliveryAn indwelling urinary catheter may be in
place. Measure intake and output,
checking for signs of blood.
Instruct the woman to keep the incisionclean until healing is complete.
Once the dressing is removed, the
woman may shower without any specialprecautions.
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Care After Cesarean Delivery
Instruct her to allow the incision to dry
completely after washing and to apply a
small dressing if desired.
If Steri-Strips have been applied to theincision, they will not be harmed by the
shower and will come off in about 1 week.
Teach the woman who has had a cesareansection that it is important not to overdo
activity for 4 to 6 weeks.
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Listening Skills
Listening is one of the most important
skills a postpartum nurse needs to learn.
It can make the difference between a
positive and a negative postpartumexperience.
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Client Teaching
Mother and baby care and education
should begin as soon as the mother and
baby are stable.
A womans choice regarding care ofherself and her infant must be
recognized as a very important element
in her care.
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Client Teaching
Instruct the client about expected
progression of lochiafrom red to dark
brown, to pale yellow or white.
Instruct the client to report anydeviations from this pattern.
Instruct the client regarding ways to
prevent perineal infection, such asfrequent pad changes, avoiding
tampons, and using a peri bottle after
voiding.
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Client Teaching
Instruct the client about expected
progression of lochiafrom red to dark
brown, to pale yellow or white.
Instruct the client to report anydeviations from this pattern.
Instruct the client regarding ways to
prevent perineal infection, such asfrequent pad changes, avoiding
tampons, and using a peri bottle after
voiding.
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Client Teaching
The teenage mother may require a
different approach to teaching. Hands-
on education with client return
demonstration is often most effective. The postpartum woman should be
instructed not to have intercourse until
she has seen her obstetrician or midwife
for a follow-up visit and has been told
that she may resume intercourse.
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Client Teaching
Instruct all postpartum women, whether
lactating or not, that absence of a
menstrual period does not mean they
are infertile. Encourage the woman to simplify
routines for this period of time and not to
make any major changes.
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Client Teaching
Instruct the woman in the signs of
postpartum emergencies in her infant
and herself and tell her to call the
pediatrician or obstetrician if any occur.
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THE NEONATE
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Learning Outcomes
1. Identify physiologic adaptations of theneonate.
2. Describe the use and method of
obtaining an Apgar score.3. List aspects of delivery room care and
nursing interventions for the neonate.
4. Explain nursery care of the neonate.
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Learning Outcomes
5. List differences that identify thegestational age of the neonate.
6. Describe the physical characteristics of
the neonate.7. Explain proper hygiene methods in
caring for a newborn.
8. Compare and contrast two methods ofproviding neonatal nutrition.
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Learning Outcomes
9. Identify common procedures in care of the
newborn.
10. Provide discharge teaching to parents of a
newborn.
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Neonatal Period
The neonateis the infant from deliverythrough the first month of life.
Initial care revolves around meeting the
basic biologic needs and helping thenewborn adjust to life outside the womb.
Most infants are born without
complications, and require routine care.
Foundations of Neonate
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Foundations of Neonate
CareAn understanding of the physiologic
adaptation to life outside the uterus
guides the nurses actions when setting
priorities in the care of the newborn. They involve:
Airway.
Breathing. Circulation.
Thermoregulation.
Figure 51.4 Fetal circulation. Blood leaves the placenta and enters the fetus through the umbilical vein. After circulating
through the fetus, the blood returns to the placenta through the umbilical arteries. The ductus venosus, the foramen
ovale and the ductus arteriosus allow the blood to bypass the fetal liver and lungs
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ovale, and the ductus arteriosus allow the blood to bypass the fetal liver and lungs.
I iti l N b A t
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Initial Newborn Assessment
Apgar Scoring A ppearance (Color)
P ulse (Heart rate)
G rimace (Reflex)
A ctivity (Muscle tone)
R espiratory Effort
APGAR
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APGAR score
Newborn Assessment
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Characteristics of the
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Characteristics of the
Newborn Skin
Acrocyanosis
Ecchymosis
Petechiae Lanuago
See Ramont page 1540 figure 56-11
Mongolian spots Milia
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Characteristics of the Newborn
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Characteristics of the Newborn
Head
Molding Caput succedaneum edema of scalp crossing
suture lines
Cephalhematoma accumulation of blood
between the periosterum and skull bones, doesnot cross suture lines.
See Ramont page 1542 figure 56-12
Strabismus lack of eye coordination see page1542 figure 56-13
Epsteins earls= small cyst on the palate
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R fl
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Reflexes
Rooting reflex ; Sucking reflex
Palmar grasp reflex:
Plantar reflex: last 8 months, foot touched
and toes curl under Babinski reflex: big toe dorsiflexs and other
toes flare
Stepping reflex
Tonic neck reflex Moro or startle reflex
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H i C
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Hygiene Care
Bathing: once temperature stable, nobath tub until cord falls off
Change diaper every 2 hours or more
frequently if needed Perineal care with each diaper change
Eye care eye ointment to prevent
ophthalmia neonatorum Umbilical cord care: with each diaper
change
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Newborn Assessment -
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Figure 56.21 Neonatal measurements are taken immediately after birth. For
height, it is often helpful to have two staff members work together to ensure the
accuracy of the measurement from crown to heel.
Taking Measurements
Newborn Assessment -
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Taking Measurements Head circumference
is a measurement of
a childs head
around its largestarea.
measures the
distance from above
the eyebrows and
pinas and around the
occiput.
C t f N b A t
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Components of Newborn Assessment
Body size andshape
Skin Characteristics
Reflexes
Nutritional needs
Temperature
Elimination
Rest/Activity
Bonding
N rser Care
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Nursery Care
Safety in the newborn nursery involvesprotecting the newborn from injury and
abduction.
Routine care of the neonate involvessponge baths, feeding, cord care,
circumcision care, and diapering in a
warm, calm environment.
The neonate should only be transported
in a bassinet, not held in the arms.
Umbilical Cord Alarm
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Figure 56.5 B. Umbilical alarm attached to newborn infant.
Umbilical Cord Alarm
Common Neonate
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Medications 1.0% tetracycline or 0.5% erythromycin
ophthalmic ointment (to prevent eye
inflammation and infection)
Vit. K. AquaMEPHYTON IM (to preventhemorrhagic disorders)
Hepatitis B immunization may be
administered in the newborn nurserywith parental consent.
Promotion of Optimum Health for the
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p
Newborn
Nutrition Breast
Formula
Sleep/Rest/Exercise Safety/Bonding
Family Structure/Support
Impact on Family Healthy vs. Abnormality
Breastfeeding
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Breastfeeding
When
Why
How
How
often
How
much
Neonate Nutrition
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Neonate Nutrition
A full-term infant needs 50 to 55 kcal/lb(110 to 120 kcal/kg) that equals 20 oz
(600 mL) of breast milk or formula per
day.At birth, the newborns stomach will hold
20 mL, or slightly less than an ounce.
Neonatal Nutrition
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Neonatal Nutrition
The infant will need to be fed every 2 to4 hours to meet nutritional needs.
The American Academy of Pediatrics
recommends breast milk for the firstyear of life.
It is important for parents to receive
information regarding the benefits ofboth breastfeeding and bottle-feeding.
Sleep
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Sleep
The neonate generally sleeps forapproximately 20 to 22 hours a day.
The newborn likes the security and
warmth offered by swaddling. The infant should be placed on his or
her back for sleeping.
All objects including stuffed animals,pillows and blankets should be removed
from the crib to prevent suffocation.
Neonatal Screening Tests
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Neonatal Screening Tests
Accomplished through heel sticks forblood draw to test for:
Hypoglycemia
Phenylketonuria Bilirubin
Heel Stick
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Figure 56.19 A. Potential puncture sites for heel sticks. Avoid shaded areas to
prevent injury to arteries and nerves in the foot.
Heel Stick
Newborn Jaundice
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Newborn Jaundice
Physiologic Occurs after the first 24 hours
Increased RBC during development
Improve O2 transport
Immature liver development
Inability to handle the breakdown process
Bilirubin held in the blood stream
Newborn Jaundice
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Newborn Jaundice
Pathologic Occurs priorto the first 24 hrs
ABO/Rh incompatibility
Treatment
Exchange transfusion
Phototherapy
F/U bilirubin
Phototherapy
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Phototherapy
Phototherapy
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Phototherapy
How does it work?
Bilirubin in the baby's body is changed
into another form that can be more
easily excreted in the stool and urine.
When do they have to use photo therapy?
When serum bilirubin is greater than 8mg/dl at 24 hours of life
Discharge Teaching
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Discharge Teaching
Any time care is provided in thepresence of the mother, and/or
significant others, teaching should be
provided regarding the care that isgiven, the reasons for the care, and
whether the parents should do the same
care at home.
The LPN/LVN assists the RN by
teaching parents about routine newborn
care.
Discharge Teaching
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Discharge Teaching Topics that require client teaching prior to discharge
include the following:
Nutrition
Elimination
Diapering
Hygiene
Placing infant on back to sleep
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Discharge Teaching
Topics that require client teaching prior todischarge include the following:
Perineal care
Circumcision care Umbilical cord care
Safety
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Newborn Assessment
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