Name: Maternal-Child Nursing McKinney 4th Edition Test Bank
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ISBN-10 ‏ : ‎ 1437727751
ISBN-13 ‏ : ‎ 978-1437727753
Author: Emily Slone McKinney MSN RN C (Author), Susan Rowen James PhD RN (Author), Sharon Smith Murray MSN RN C (Author), Kristine Nelson RN MN (Author), Jean Ashwill MSN RN (Author)

Ideal for accelerated maternity and pediatrics courses, Maternal-Child Nursing, 4^th Edition is filled with user-friendly features to help you quickly master essential concepts and skills. It offers completely updated content that’s easy to read and understand. Plus, active learning tools give you the chance to practice applying your knowledge and make learning fun!

Table of Content:

Front Matter
Contributors
Reviewers
Preface
Concepts
Features
Objectives
Nursing Process
Critical Thinking Exercises
Evidence-Based Practice
Critical Alerts
Want to Know
Health Promotion
Clinical Reference Pages
Pathophysiology
Procedures
Drug Guides
Key Concepts
Ancillaries
For Students
For Instructors
Acknowledgments
Interactive Review – Maternal-Child Nursing Care
Introduction to Maternal-Child Health Nursing
Interactive Review – Introduction to Maternal-Child Nursing
Chapter 1 Foundations of Maternity, Women’s Health, and Child Health Nursing
Learning Objectives
Historical Perspectives
Maternity Nursing
“Granny” Midwives
Emergence of Medical Management
Government Involvement in Maternal-Infant Care
TABLE 1-1 FEDERAL PROJECTS FOR MATERNAL-CHILD CARE
Impact of Consumer Demands on Health Care
Development of Family-Centered Maternity Care
Current Settings for Childbirth
Traditional Hospital Setting
Labor, Delivery, and Recovery Rooms
FIG 1-1 A typical labor, delivery, and recovery room. Home-like furnishings (A) can be adapted quickly to reveal needed technical equipment (B).
Labor, Delivery, Recovery, and Postpartum Rooms
Birth Centers
Home Births
Nursing of Children
Historical Perspectives
Societal Changes
Hygiene and Hospitalization
Development of Family-Centered Child Care
Current Trends in Child Health Care
Cost Containment
Diagnosis-Related Groups
Managed care ExemplarManaged care organizations ExemplarManaged Care
Capitated Care
Effects of Cost Containment
Case management ExemplarNurse case management ExemplarCase Management
Evidence-Based Nursing Care
Outcomes Management
Nurse Sensitive Indicators
Variances
Clinical Pathways
Home care models ExemplarHome Care
Community Care
Access to Care
Public Health Insurance Programs
FIG 1-2 Uninsured Children by Poverty Status, Household Income, Age, Race and Hispanic Origin, and Nativity, 2009. Federal surveys now give respondents the option of reporting more than one race. This figure shows data using the race-alone concept. For example, Asian refers to people who reported Asian and no other race.
Preventative health activities ExemplarPreventive Health
Health Care Assistance Programs
Statistics on Maternal, Infant, and Child Health
Maternal and Infant Mortality
Maternal Mortality
FIG 1-3 Infant mortality rates, 1950-2007
Infant Mortality
Racial Disparity for Mortality
TABLE 1-2 INFANT MORTALITY DATA FOR SELECTED COUNTRIES (BASED ON 2007 DATA)
International Infant Mortality
TABLE 1-3 LEADING CAUSES OF DEATH AMONG CHILDREN AGES 1 TO 14 YEARS: DEATH RATES PER 100,000
Adolescent Births
Childhood Mortality
Morbidity
Ethics ExemplarEthical Perspectives on Maternity, Women’s Health, and Child Nursing
Ethics and Bioethics
Ethical Dilemmas
Ethical Principles
BOX 1-1 ETHICAL PRINCIPLES
Solving Ethical Dilemmas
Ethical Concerns in Reproduction
Elective Pregnancy Termination
Belief that Induced Abortion is a Private Choice
BOX 1-2 SUPREME COURT DECISIONS ON ABORTION SINCE ROE V. WADE
Belief that Elective Pregnancy Termination is Taking a Life
Implications for Nurses
Fetal Injury
Ethical Concerns in Child Health Nursing
Cessation of Treatment
Terminating Life Support
Social Issues
Poverty
Homelessness
FIG 1-4 The cycle of poverty.
Prenatal Care in the United States
Government Programs for Health Care: Medicaid
Distribution of health care ExemplarAllocation of Health Care Resources
Care versus Cure
Health Care Rationing
Violence
Legal Issues
Safeguards for Health Care
Scope of practice education requirements ExemplarNurse Practice Acts
Standards of Care
Agency Policies
Accountability
Malpractice
NURSING QUALITY ALERT: Elements of Negligence
Prevention of Malpractice Claims
Informed consent ExemplarInformed Consent
NURSING QUALITY ALERT: Requirements of Informed Consent
Competence
Full Disclosure
Understanding of Information
Voluntary Consent
Refusal of Care
Adoption
Documentation
Discharge teaching ExemplarDocumenting Discharge Teaching
Disclosure of medical errors ExemplarDocumenting Incidents
The Nurse as an Advocate
Maintaining Expertise
Current Trends and Their Legal and Ethical Implications
Use of Unlicensed Assistive Personnel
Concerns about Early Discharge
Dealing with Early Discharge
KEY CONCEPTS
References and Readings
Chapter 2 The Nurse’s Role in Maternity, Women’s Health, and Pediatric Nursing
Learning Objectives
The Role of the Professional Nurse
BOX 2-1 ANA CODE OF ETHICS FOR NURSES
Care Provider
FIG 2-1 In the prenatal clinic, the nurse teaches a woman one-on-one.
Teacher
Factors Influencing Learning
Principles of Teaching and Learning
Collaborator
Researcher
Advocate
Manager of Care
Advanced Preparation for Maternity and Pediatric Nurses
Certified Nurse-Midwives
Nurse Practitioners
Clinical Nurse Specialists
Clinical Nurse Leaders
Implications of Changing Roles for Nurses
Therapeutic Communication
Guidelines for Therapeutic Communication
Therapeutic Communication Techniques
Critical Thinking
The Purpose of Critical Thinking
Steps in Critical Thinking
A Recognizing Assumptions
B Examining Biases
C Analyzing the Need for Closure
D Data management Exemplar Managing Data
Collecting Data
Validating Data
Organizing and Analyzing Data
E Evaluating Other Factors
The Nursing Process in Maternity and Pediatric Care
BOX 2-2 COMMUNICATION TECHNIQUES
TABLE 2-1 BEHAVIORS THAT BLOCK COMMUNICATION
Assessment
Screening Assessment
Focused Assessment
Nursing Diagnosis
BOX 2-3 DEVELOPING INDIVIDUALIZED NURSING CARE THROUGH THE NURSING PROCESS
Assessment
Analysis
Planning
Implementing Nursing Interventions
Evaluation
Planning
Setting Priorities
Establishing Goals and Expected Outcomes
Implementation
Evaluation
Complementary and Alternative Medicine
Research studies ExemplarNursing Research and Evidence-Based Practice
KEY CONCEPTS
References and Readings
Chapter 3 The Childbearing and Child-Rearing Family
Learning Objectives
Family-Centered Care
Family Structure
FIG 3-1 Traditional, two-parent families typically have the resources to prepare for childbirth and the needs of infants.
Types of Families
Traditional Families
Nontraditional Families
Single-Parent Families
Blended Families
Adoptive Families
Multigenerational Families
FIG 3-2 A nurse caring for a child needs to know the child’s family structure and the identity of the child’s primary caregiver. This background becomes the context in which the nurse provides care. If family support is a concern, the nurse can provide information about local community resources. For example, in some communities, after-school programs and “warm lines” can help children with schoolwork and alleviate loneliness and fear.
Same-Sex Parent Families
Communal Families
Characteristics of Healthy Families
Factors that Interfere with Family Functioning
High-Risk Families
Marital Conflict and Divorce
Adolescent Parenting
Violence
Substance Abuse
Child with Special Needs
Healthy Versus Dysfunctional Families
Coping with Stress
Coping Strategies
BOX 3-1 COPING STRATEGIES OF FAMILIES
Internal Coping Strategies
Relationship Strategies
Cognitive Strategies
Communication Strategies
External Coping Strategies
Community Strategy: Maintaining Active Linkages with the Community
Social Support Strategies
Spiritual Strategies
Cultural Influences on Maternity and Pediatric Nursing
FIG 3-3 Visible and hidden layers of culture are like the visible and submerged parts of an iceberg. Many cultural differences are hidden below the surface.
Implications of Cultural Diversity for Nurses
Western Cultural Beliefs
TABLE 3-1 RELIGIOUS BELIEFS AFFECTING HEALTH CARE
Cultural Influences on the Care of People from Specific Groups
Asians and Pacific Islanders
Hispanics
African-Americans
American Indians and Alaska Natives
Middle Easterners
Cross-Cultural Health Beliefs
Traditional Methods of Preventing Illness
Traditional Practices to Maintain Health
Traditional Practices to Restore Health
Cultural Assessment
Parenting
Parenting Styles
Parent-Child Relationship Factors
Parental Characteristics
Characteristics of the Child
Temperament and Parental Expectations
BOX 3-2 CHARACTERISTICS OF TEMPERAMENT IN CHILDREN
Discipline
BOX 3-3 EFFECTIVE DISCIPLINE FOR POSITIVE SOCIALIZATION AND SELF-ESTEEM
Dealing with Misbehavior
Redirection
Reasoning
Time-Out
Consequences
Behavior Modification
SAFETY ALERT: Avoiding the Use of Corporal Punishment as Discipline
Corporal Punishment
Nursing Process and the Family
Family Assessment
Nursing Diagnosis and Planning
Intervention and Evaluation
CRITICAL THINKING EXERCISE 3-1
KEY CONCEPTS
References and Readings
Chapter 4 Communicating with Children and Families
Learning Objectives
Components of Effective Communication
Touch
FIG 4-1 Communication with children is enhanced by direct eye contact and by body language that conveys attentiveness and openness.
Physical Proximity and Environment
FIG 4-2 For effective communication, the nurse needs to be at the child’s eye level.
Listening
Attentiveness
Clarification through Reflection
Empathy
Impartiality
Visual Communication
NURSING QUALITY ALERT: Tips to Enhance Listening and Communication Skills
Tone of Voice
TABLE 4-1 OPEN AND CLOSED BODY POSTURES
Body Language
Timing
Family-Centered Communication
NURSING QUALITY ALERT: Communicating with Families
Establishing Rapport
Availability and Openness to Questions
FIG 4-3 The child’s continuing health care, both preventive and during illness, is enhanced by participation of the family.
Family Education and Empowerment
Effective Management of Conflict
BOX 4-1 STRATEGIES FOR MANAGING CONFLICT
TABLE 4-2 CHOOSING WORDS CAREFULLY
Feedback from Children and Families
Spirituality
Transcultural Communication: Bridging the Gap
BOX 4-2 WARNING SIGNS OF OVERINVOLVEMENT
BOX 4-3 WARNING SIGNS OF UNDERINVOLVEMENT
Therapeutic Relationships: Developing and Maintaining Trust
NURSING QUALITY ALERT: Maintaining a Therapeutic Relationship
Nursing Care
Communicating with Children and Families
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcome
Expected Outcomes
Expected Outcomes
Expected Outcomes
CRITICAL THINKING EXERCISE 4-1
Interventions
TABLE 4-3 DEVELOPMENTAL MILESTONES AND THEIR RELATIONSHIP TO COMMUNICATION APPROACHES
Play
BOX 4-4 STORYTELLING STRATEGIES
Storytelling
Explaining Procedures and Treatments
Strategies for Enhancing Self-Esteem
TABLE 4-4 CONSIDERATIONS IN CHOOSING LANGUAGE
TABLE 4-5 SELF-ESTEEM IN CHILDREN: COMMUNICATION PRACTICES
Evaluation
Communicating with Children with Special Needs
The Child with a Visual Impairment
NURSING QUALITY ALERT: Communicating with Children with Special Needs
The Child with a Hearing Impairment
The Child Who Speaks Another Language
The Child with Other Communication Challenges
The Child with a Profound Neurologic Impairment
KEY CONCEPTS
References and Readings
Chapter 5 Health Promotion for the Developing Child
Learning Objectives
Overview of Growth and Development
Definition of Terms
TABLE 5-1 STAGES OF GROWTH AND DEVELOPMENT The Following Stages and Age-Groupings Refer to Stages of Childhood Growth and Development
Stages of Growth and Development
Parameters of Growth
Principles of Growth and Development
Patterns of Growth and Development
FIG 5-1 Changes in body proportions with growth.
BOX 5-1 PATTERNS OF GROWTH AND DEVELOPMENT
BOX 5-2 DIRECTIONAL PATTERNS OF GROWTH AND DEVELOPMENT
Cephalocaudal Pattern (Head to Toe)
Examples
Proximodistal Pattern (from the Center Outward)
Examples
Critical Periods
Factors Influencing Growth and Development
Genetics
Environment
Culture
FIG 5-2 Pediatric environmental history (0 to 18 years of age).
Nutrition
Health Status
Family
Parental Attitudes
Child-Rearing Philosophies
Theories of Growth and Development
Piaget’s Theory of Cognitive Development
Nursing Implications of Piaget’s Theory
Freud’s Theory of Psychosexual Development
TABLE 5-2 THEORIES OF GROWTH AND DEVELOPMENT
Nursing Implications of Freud’s Theory
Erikson’s Psychosocial Theory
Nursing Implications of Erikson’s Theory
Kohlberg’s Theory of Moral Development
Nursing Implications of Kohlberg’s Theory
Theories of Language Development
Assessment of Growth
Assessment of Development
Denver Developmental Screening Test II (DDST-II)
Nurse’s Role in Promoting Optimal Growth and Development
Developmental Assessment
Interviewing ExemplarInterview
Play
Classifications of Play
Social Aspects of Play
Solitary Play
Parallel Play
Associative Play
Cooperative Play
Onlooker Play
Types of Play
Dramatic Play
Familiarization Play
FIG 5-3 Types of play.
Functions of Play
Physical Development and Play
Cognitive Development
Emotional Development
Social Development
Moral Development
Health Promotion
Vaccination ExemplarImmunizations
Active and Passive Immunity
SAFETY ALERT: Preventing Vaccine Reactions
Obstacles to Immunizations
Informed Consent
BOX 5-3 BARRIERS TO IMMUNIZATION
Immunization Schedule
Children with an Uncertain History of Immunization
Administration of Vaccines
Precautions and Contraindications
BOX 5-4 NURSING RESPONSIBILITY IN ADMINISTERING VACCINES
SAFETY ALERT: Special Considerations Related to Immunizations
BOX 5-5 COMMON MISCONCEPTIONS ABOUT ADMINISTRATION AND SAFETY OF VACCINES
Immunocompromised Children
Education
Nutrition and Activity
Carbohydrates
Fats
Proteins
Water
Vitamins and Minerals
Dietary Guidelines
BOX 5-6 KEY DIETARY RECOMMENDATIONS SPECIFIC TO CHILDREN AND ADOLESCENTS
Energy, Calories, and Servings
Physical Activity
FIG 5-4 MyPlate.
Cultural and Religious Influences on Diet
Assessment of Nutritional Status
Anthropometric Data
Clinical Evaluation
Dietary History
Twenty-Four-Hour Recall
Food Frequency Questionnaire
Food Diary
Safety
Injury prevention ExemplarInjury Prevention
Anticipatory Guidance
BOX 5-7 WHAT NURSES CAN DO TO PREVENT CHILDHOOD INJURIES
SAFETY ALERT: Relationship Between Safety and Childhood Development
Teaching Strategies
KEY CONCEPTS
References and Readings
Chapter 6 Health Promotion for the Infant
Learning Objectives
Growth and Development of the Infant
TABLE 6-1 SUMMARY OF GROWTH AND DEVELOPMENT: THE INFANT
HEALTH PROMOTION: Healthy People 2020 Objectives for Infants
Physical Growth and Maturation of Body Systems
Neurologic System
Respiratory System
Cardiovascular System
Safety Alert: Risks Caused by the Infant’s Immature Body Systems
Immune System
Gastrointestinal System
Renal System
Motor Development
PATIENT-CENTERED TEACHING: How to “Baby-Proof” the Home
Cognitive Development
NURSING QUALITY ALERT: Possible Signs of Developmental Delays
Sensory Development
Vision
Hearing
BOX 6-1 LANGUAGE DEVELOPMENT AND DEVELOPMENTAL MILESTONES IN INFANCY
1 to 3 Months
3 to 4 Months
4 to 6 Months
6 to 8 Months
8 to 9 Months
9 to 12 Months
Language Development
FIG 6-1 This 6-month-old infant responds delightedly to her mother with a true social smile. Such interactive responses between parent and child promote communication and emotional development.
Psychosocial Development
Parent-Infant Attachment
Stranger Anxiety
Health Promotion for the Infant and Family
CRITICAL THINKING EXERCISE 6-1
Immunization
BOX 6-2 CONTINUING ASSESSMENT QUESTIONS
Feeding and Nutrition
NURSING QUALITY ALERT: Essential Information for Infant Nutrition
Factors Influencing Choice of Feeding Method
Breastfeeding
Formula Feeding
Types of Formula
Cow’s Milk
EVIDENCE-BASED PRACTICE
Formula Feeding Techniques
Weaning
Juices
Water
Solid Foods
BOX 6-3 READINESS FOR INTRODUCTION OF SOLIDS
Finger Foods
Health Promotion: 2-Week-Old to 1-Month-Old Infant
Focused Assessment
Developmental Milestones
Health Maintenance
Physical Measurements
Immunizations
Health Screening
Anticipatory Guidance
Nutrition
Elimination
Dental
Sleep
Hygiene
Safety
Snacks
Food Allergies
HEALTH PROMOTION: The 2-Month-Old Infant
Focused Assessment
Developmental Milestones
Critical Milestones∗
Health Maintenance
Physical Measurements
Immunizations
Health Screening
Anticipatory Guidance
Nutrition
Elimination
Dental
Sleep
Hygiene
Safety
Play
Dental Care
Teething
Assessment of Dental Risk
Cleaning Teeth
Fluoride Supplementation
Bottle-Mouth Caries
HEALTH PROMOTION: The 4-Month-Old Infant
Focused Assessment
Developmental Milestones
Critical Milestones∗
Health Maintenance
Physical Measurements
Immunizations
Health Screening
Anticipatory Guidance
Nutrition
Elimination
Dental
Sleep
Hygiene
Safety
Play
Sleep and Rest
Safety
Motor Vehicle Safety
FIG 6-2 The infant rides facing the rear of the vehicle, ideally in the middle of the back seat. The infant seat is secured to the vehicle with the seatbelt, and straps on the car seat adjust to accommodate the growing baby.
FIG 6-3 After the child reaches 2 years of age and has attained the manufacturer’s height and weight recommendations for a rear-facing car seat, the child uses a forward-facing upright car safety seat. The safety straps should be adjusted to provide a snug fit, and the seat should be placed in the back seat of the car, ideally in the middle.
Providing a Safe Home Environment
Burn Prevention
Safe Baby Furnishings
PATIENT-CENTERED TEACHING: Crib Safety
Fall prevention ExemplarPreventing Falls
FIG 6-4 Safety education for parents of infants should emphasize the need for constant supervision and the use of restraining devices to prevent falls.
HEALTH PROMOTION: The 6-Month-Old Infant
Focused Assessment
Developmental Milestones
Critical Milestones∗
Health Maintenance
Physical Measurements
Immunizations
Health Screening
Anticipatory Guidance
Nutrition
Elimination
Dental
Sleep
Hygiene
Safety
Play
Preventing Asphyxiation
BOX 6-4 LEAD EXPOSURE RISK ASSESSMENT
Preventing Lead Exposure
Concerns during Infancy
Patterns of Crying
HEALTH PROMOTION: The 9-Month-Old Infant
Focused Assessment
Developmental Milestones
Critical Milestones∗
Health Maintenance
Physical Measurements
Immunizations
Health Screening
Anticipatory Guidance
Nutrition
Elimination
Dental
Sleep
Hygiene
Safety
Play
The Infant with Colic
Etiology
Management
Nursing Considerations
HEALTH PROMOTION: The 12-Month-Old Infant
Focused Assessment
Developmental Milestones
Critical Milestones∗
Health Maintenance
Physical Measurements
Immunizations
Health Screening
Anticipatory Guidance
Nutrition
Elimination
Dental
Sleep
Hygiene
Safety
Play
KEY CONCEPTS
References and Readings
Chapter 7 Health Promotion During Early Childhood
Learning Objectives
Growth and Development During Early Childhood
FIG 7-1 Growth and development of the toddler.
Physical Growth and Development
The Toddler
The Preschooler
FIG 7-2 Growth and development of the preschooler.
HEALTH PROMOTION: Healthy People 2020 Objectives for Toddlers and Preschoolers
Motor Development
The Toddler
The Preschooler
Cognitive and Sensory Development
The Toddler
The Preschooler
HEALTH PROMOTION: The 15- to 18-Month-Old Child
Focused Assessment
Developmental Milestones
Critical Milestones∗
Health Maintenance
Physical Measurements
Immunizations
Health Screening
Anticipatory Guidance
Nutrition
Elimination
Dental
Sleep
Hygiene
Safety
Play
TABLE 7-1 Characteristics of Preoperational Thinking
HEALTH PROMOTION: The 2-Year-Old Child
Focused Assessment
Developmental Milestones
Critical Milestones∗
Health Maintenance
Physical Measurements
Immunizations
Health Screening
Anticipatory Guidance
Nutrition
Elimination
Dental
Sleep
Hygiene
Safety
Self-Esteem and Competence
Play
Language Development
The Toddler
The Preschooler
Psychosocial Development
The Toddler
Negativism
Ritualism and the Importance of Routine
Separation Anxiety
Play
Psychosexual Development
FIG 7-3 Types of play.
BOX 7-1 Age-Related Activities and Toys for Toddlers and Preschoolers
General Activities
Toddler
Preschooler
Toys and Specific Types of Play
Toddler
Preschooler
NURSING QUALITY ALERT: Important Tasks of the Toddler Period
The Preschooler
Play
Psychosexual Development
Spiritual and Moral Development
Health Promotion for the Toddler or Preschooler and Family
Nutrition
BOX 7-2 Nutritious Snacks
Nutritional Requirements
Solid Foods
FIG 7-4 By age 1 year, most children are eating the same foods as the rest of the family. Toddlers should be offered three meals and two healthy snacks each day. Most 2-year-olds can drink from a cup and use a spoon well if given the opportunity to practice.
Age-Related Nutritional Challenges
Food Jags
Physiologic Anorexia
BOX 7-3 Increasing Nutritional Intake
Obesity Risk
Dental Care
Sleep and Rest
FIG 7-5 Care of the deciduous teeth promotes healthy development of the permanent teeth. Some toddlers and preschoolers enjoy brushing their own teeth, but because toddlers and preschoolers lack the manual dexterity to remove plaque adequately, parents must assume this responsibility.
CRITICAL THINKING EXERCISE 7-1
Discipline
Toddler Safety
Car Safety
PARENTS WANT TO KNOW: Guidelines for Disciplining a Toddler
PATIENT-CENTERED TEACHING: Childhood Poison Prevention
SAFETY ALERT: Car Safety
Airplane Safety
Fire and Burn Safety
Preventing Falls
Water Safety
Preventing Poisoning
Preschooler Safety
Car Safety
FIG 7-6 A high-back booster seat designed to properly hold a car lap and shoulder belt is strongly recommended for children who have outgrown a child safety seat. Booster seats raise the young child high enough to allow the car seatbelts to be correctly positioned over the child’s chest and pelvis.
Fire and Burn Safety
Firearm Safety
Personal Safety
Sexual Abuse
Selected Issues Related to the Toddler
Toilet Training
HEALTH PROMOTION: The 3-Year-Old Child
Focused Assessment
Developmental Milestones
Critical Milestones∗
Health Maintenance
Physical Measurements
Immunizations
Health Screening
Anticipatory Guidance
Nutrition
Elimination
Dental
Sleep
Hygiene
Safety
Self-Esteem and Competence
Play
BOX 7-4 Signs of Readiness for Toilet Training
Physical Readiness
Psychological Readiness
FIG 7-7 No set rules exist for toilet training. The nurse can help parents understand that both physical readiness and psychological readiness are necessary for success.
Temper Tantrums
Sibling Rivalry
PARENTS WANT TO KNOW: Strategies to Decrease Sibling Rivalry
Selected Issues Related to the Preschooler
Stuttering
PARENTS WANT TO KNOW: How to Help the Child Who Stutters
Preschool and Daycare Programs
HEALTH PROMOTION: The 4- and 5-Year-Old Child
Focused Assessment
Developmental Milestones
Critical Milestones∗
Health Maintenance
Physical Measurements
Immunizations
Health Screening
Anticipatory Guidance
Nutrition
Elimination
Dental
Sleep
Safety
Self-Esteem and Competence
Play
Preparing the Child for School
BOX 7-5 Checklist for School Readiness
KEY CONCEPTS
References and Readings
Chapter 8 Health Promotion for the School-Age Child
Learning Objectives
Growth and Development of the School-Age Child
Physical Growth and Development
HEALTH PROMOTION: Healthy People 2020 Objectives for School-Age Children
Body Systems
Dentition
Sexual Development
FIG 8-1 Growth and development of the school-age child.
NURSING QUALITY ALERT: Components of Sex Education
BOX 8-1 AGE-RELATED ACTIVITIES AND TOYS FOR THE SCHOOL-AGE CHILD
General Activities
Toys and Specific Types of Play
Motor Development
Development of Gross Motor Skills
Importance of Active Play
PATIENT-CENTERED TEACHING: Assessing an Organized Recreational Sports Program
Preventing Fatigue and Dehydration
Development of Fine Motor Skills
Cognitive Development
Intuitive Thought Stage
Concrete Operations Stage
Reversibility
Conservation
Classification and Logic
Humor
Sensory Development
Vision
Hearing
Language Development
Psychosocial Development
Development of a Sense of Industry
Fostering Self-Esteem
PATIENT-CENTERED TEACHING: How to Promote Self-Esteem in School-Age Children
Spiritual and Moral Development
Piaget
Kohlberg
Family Influence
Spirituality and Religion
Health Promotion for the School-Age Child and Family
Nutrition During Middle Childhood
Nutritional Requirements
Age-Related Nutritional Challenges
Dental Care
Malocclusion
Preventing Dental Injuries
Dental Health Education
Sleep and Rest
HEALTH PROMOTION: The 6- to 8-Year-Old Child
Focused Assessment
Developmental Milestones
Health Maintenance
Physical Measurements
Immunizations
Health Screening
Anticipatory Guidance
Nutrition
Elimination
Dental
Sleep
Safety
Play
Self-Esteem and Competence
CRITICAL THINKING EXERCISE 8-1
Discipline
Safety
Car Safety
Fire and Burn Safety
SAFETY ALERT: Fire Safety Rules
Bicycle, In-line Skating, Scooter, and Skateboard Safety
PATIENT-CENTERED TEACHING: Bicycle, In-line Skating, Scooter, and Skateboard Safety
Rules of the Road
Pedestrian Safety
Water Safety
HEALTH PROMOTION: The 9- to 11-Year-Old Child
Focused Assessment
Developmental Milestones
Health Maintenance
Physical Measurements
Immunizations
Health Screening
Anticipatory Guidance
Nutrition
Elimination
Dental
Sleep
Hygiene
Safety
Play
Self-Esteem and Competence
Selected Issues Related to the School-Age Child
Adjustment to School
Peer Influence
Influence of Teachers
Parents’ Role
School Refusal
Helping a Child Overcome School Refusal
Self-Care Children
Obesity ExemplarObesity
Assessing the Scope of the Problem
Prevention
Diet ExemplarInterventions and Anticipatory Guidance
PARENTS WANT TO KNOW: How to Prevent and Manage Obesity
EVIDENCE-BASED PRACTICE
Stress
Sources of Stress in Children
BOX 8-2 MANIFESTATIONS OF STRESS IN CHILDREN
School Pressures
Physical Threats
Competitive Sports
Tight Schedules and Adaptation Overload
Family Pressures
Media Influence
Interventions and Anticipatory Guidance
FIG 8-2 Health promotion for the school-age child and family.
NURSING QUALITY ALERT: Sources of Stress for School-Age Children
Bullying ExemplarPeer Victimization
KEY CONCEPTS
References and Readings
Chapter 9 Health Promotion for the Adolescent
Learning Objectives
Adolescent Growth and Development
HEALTH PROMOTION: Selected Healthy People 2020 Objectives for Adolescents
Physical Growth and Development
Psychosexual Development, Hormonal Changes, and Sexual Maturation
NURSING QUALITY ALERT: Understanding Tanner Staging
Female Sexual Maturation
TABLE 9-1 SEXUAL MATURITY RATING (SMR): TANNER STAGES OF ADOLESCENT SEXUAL DEVELOPMENT
Male Sexual Maturation
Motor Development
SAFETY ALERT: The Adolescent Who Is Involved in Athletics
BOX 9-1 NURSING GOALS FOR PREPARTICIPATION SPORTS PHYSICAL EXAMINATION
Cognitive Development
Sensory Development
Language Development
PARENTS WANT TO KNOW: Communicating with Adolescents
Psychosocial Development
FIG 9-1 Adolescent growth and development.
BOX 9-2 AGE-RELATED ACTIVITIES AND GAMES FOR ADOLESCENTS
General Activities
Games and Special Types of Play
NURSING QUALITY ALERT: The Adolescent and Erikson
Early Adolescence
Middle Adolescence
BOX 9-3 SIGNS OF GANG INVOLVEMENT
NURSING QUALITY ALERT: Elements of Adolescent Care
Vocational Exploration
Late Adolescence (18 to 21 Years)
Moral and Spiritual Development
Health Promotion for the Adolescent and Family
CRITICAL THINKING EXERCISE 9-1
Nutrition during Adolescence
BOX 9-4 FACTORS INFLUENCING THE ADOLESCENT’S DIET
Age-Related Nutritional Challenges
Nutritional Guidance for the Adolescent
Hygiene
Dental Care
PATIENT-CENTERED TEACHING: Caring for a Child with an Avulsed Tooth
Sleep and Rest
HEALTH PROMOTION: The Adolescent
Focused Assessment
Developmental Milestones
Health Maintenance
Physical Measurements
Immunizations
Health Screening
Anticipatory Guidance
Nutrition
Elimination
Dental
Sleep and Activity
Safety
Emotional Health
Exercise and Activity
Safety
Car Safety
Water Safety
Suicide
Violence Toward Others
BOX 9-5 FACTORS CONTRIBUTING TO ADOLESCENT VIOLENCE
Selected Issues Related to the Adolescent
Body Piercing
Tattoos
ADOLESCENTS WANT TO KNOW: Tattooing
Tanning
Sexual Activity
Adolescent Sexuality
NURSING QUALITY ALERT: Factors to Consider in Selecting Adolescent Contraception
Contraception
KEY CONCEPTS
References and Readings
Chapter 10 Hereditary and Environmental Influences on Development
Learning Objectives
Hereditary Influences
Structure of Genes and Chromosomes
DNA
FIG 10-1 Diagrammatic representation of the deoxyribonucleic acid (DNA) helix, which is the building block of genes and chromosomes.
Genes
Chromosomes
FIG 10-2 When viewed before karyotyping, chromosomes appear jumbled. This photo is a spectral karyotype (SKY) from a normal female.
Transmission of Traits by Single Genes
Alleles
Dominance
FIG 10-3 Karyotypes of chromosomes that were stained, creating bands to distinguish each chromosome and identify missing or duplicated chromosome material. A, Normal male karyotype: 46,XY. B, Normal female karyotype 46,XX.
Chromosome Location
Patterns of Single-Gene Inheritance
CRITICAL TO REMEMBER: Single-Gene Abnormalities
Autosomal Dominant Traits
BOX 10-1 SINGLE-GENE TRAITS
Genogram (Pedigree) Symbols
Autosomal Recessive
Characteristics
Transmission of Trait from Parent to Child
Examples
Genogram
Autosomal Dominant
Characteristics
Transmission of Trait from Parent to Child
Examples
Genogram
X-Linked Recessive
Characteristics
Transmission of Trait from Parent to Child
Examples
Genogram
Autosomal Recessive Traits
X-Linked Traits
X-Linked Recessive Disorders
Chromosome Abnormalities
FIG 10-4 Karyotype of a male with trisomy 21 (Down syndrome: 47, XY, +21).
CRITICAL TO REMEMBER: Chromosome Abnormalities
Numerical
Structural
Numerical Abnormalities
Trisomy
FIG 10-5 Karyotype of a female with monosomy X (Turner syndrome 45,X).
Monosomy
Polyploidy
Structural Abnormalities
FIG 10-6 Illustration of a translocation of chromosome material between chromosomes 4 and 20.
Multifactorial Disorders
CRITICAL TO REMEMBER: Multifactorial Birth Defects
Characteristics of Multifactorial Disorders
Risk for Occurrence
Environmental Influences
Teratogens
BOX 10-2 SELECTED ENVIRONMENTAL SUBSTANCES KNOWN OR THOUGHT TO HARM THE FETUS∗
Avoiding Fetal Exposure
Infections
Drugs and Other Substances
Ionizing Radiation
Maternal Hyperthermia
Manipulating the Fetal Environment
Mechanical Disruptions to Fetal Development
Genetic testing ExemplarGenetic Counseling
Availability
Focus on the Family
BOX 10-3 DIAGNOSTIC METHODS THAT MAY BE USED IN GENETIC COUNSELING
Preconception Screening
Prenatal Diagnosis for Fetal Abnormalities
Postnatal Diagnosis for an Infant with a Birth Defect
Process of Genetic Counseling
Supplemental Services
Nursing Care of Families Concerned About Birth Defects
Nurses as Part of a Genetic Counseling Team
PARENTS WANT TO KNOW: About Birth Defects
Nurses in General Practice
Women’s Health Nurses
Antepartum Nurses
Identifying Families for Referral
Helping the Woman Decide About Genetic Counseling
Teaching About Lifestyle
BOX 10-4 REASONS FOR REFERRAL TO A GENETIC COUNSELOR OR OTHER HEALTH CARE SPECIALIST
BOX 10-5 PROBLEMS ENCOUNTERED IN GENETIC COUNSELING AND PRENATAL DIAGNOSIS
Providing Emotional Support
Helping the Woman and Family Deal with Abnormal Results
Intrapartum and Neonatal Nurses
Pediatric Nurses
KEY CONCEPTS
References and Readings
Maternity Nursing Care
Interactive Review – Maternity Nursing Care
Chapter 11 Reproductive Anatomy and Physiology
Learning Objectives
Sexual Development
Prenatal Development
Childhood
Sexual Maturation
Initiation of Sexual Maturation
Female Puberty Changes
Breast Changes
Body Contours
Body Hair
Skeletal Growth
Reproductive Organs
Menarche
Male Puberty Changes
Growth of the Testes and Penis
TABLE 11-1 Major Hormones in Reproduction
TABLE 11-2 Comparison Of Secondary Sex Characteristics In Females And Males
Nocturnal Emissions
Body Hair
Body Composition
Skeletal Growth
Voice Changes
Decline in Fertility
FIG 11-1 External female reproductive structures.
Female Reproductive Anatomy
External Female Reproductive Organs
Mons Pubis
Labia Majora and Labia Minora
FIG 11-2 Internal female reproductive structures, anterior view.
Clitoris
Vestibule
Perineum
Internal Female Reproductive Organs
Vagina
Uterus
Divisions of the Uterus
Corpus
FIG 11-3 Internal female reproductive structures, midsagittal view.
Isthmus
Cervix
Layers of the Uterus
Perimetrium
Myometrium
FIG 11-4 Layers of the myometrium, showing the three types of smooth muscle fiber.
Endometrium
FIG 11-5 Structures of the bony pelvis, shown in lateral, A, and anterior, B, views.
Fallopian Tubes
Ovaries
Support Structures
Pelvis
Muscles
FIG 11-6 Muscles of the female pelvic floor.
Ligaments
Lateral Support
Anterior Support
Posterior Support
Blood Supply
Nerve Supply
Female Reproductive Cycle
FIG 11-7 The female reproductive cycle, showing the changes in hormone secretion from the anterior pituitary and interrelated changes in the ovary and uterine endometrium.
Ovarian Cycle
Follicular Phase
Ovulatory Phase
Luteal Phase
Endometrial Cycle
Proliferative Phase
Secretory Phase
Menstrual Phase
Changes in Cervical Mucus
The Female Breast
Structure
FIG 11-8 Structures of the female breast.
Function
Male Reproductive Anatomy and Physiology
External Male Reproductive Organs
Penis
Scrotum
FIG 11-9 Structures of the male reproductive system, midsagittal view.
Internal Male Reproductive Organs
Testes
FIG 11-10 Internal structures of the testis. Production of sperm begins within the tiny coiled seminiferous tubules. Immature sperm pass from the seminiferous tubules to the epididymis and then to the vas deferens. During their passage through these structures, the sperm mature and acquire the ability to propel themselves.
Accessory Ducts and Glands
KEY CONCEPTS
References and Readings
Pageburst Integrated Resource
Animation
Chapter 12 Conception and Prenatal Development
Learning Objectives
Gametogenesis
Oogenesis
FIG 12-1 Gametogenesis. A, Formation of the mature ovum. B, Formation of mature sperm.
TABLE 12-1 COMPARISON OF FEMALE AND MALE GAMETOGENESIS
Spermatogenesis
Conception
Preparation for Conception in the Female
Release of the Ovum
Ovum Transport
Preparation for Conception in the Male
FIG 12-2 Mature sperm.
Ejaculation
Transport of Sperm in the Female Reproductive Tract
Preparation of Sperm for Fertilization
Fertilization
Entry of One Spermatozoon into the Ovum
Fusion of the Nuclei of Sperm and Ovum
FIG 12-3 Process of fertilization. A, A sperm enters the ovum. B, The 23 chromosomes from the sperm mingle with the 23 chromosomes from the ovum, restoring the diploid number to 46. C, The fertilized ovum, now called a zygote, is ready for the first mitotic cell division.
Pre-Embryonic Period
Initiation of Cell Division
Entry of the Zygote into the Uterus
Implantation in the Decidua
Maintaining the Decidua
Location of Implantation
Mechanism of Implantation
FIG 12-4 Prenatal development from fertilization through implantation of the blastocyst. Implantation gradually occurs from the 6th through the 10th days. Implantation is complete by the 10th day.
Embryonic Period
Differentiation of Cells
Second Week
Third Week
Fourth Week
FIG 12-5 Embryonic development from the 3rd week through the 8th week after fertilization. CRL, Crown-rump length.
TABLE 12-2 TIMETABLE OF PRENATAL DEVELOPMENT BASED ON FERTILIZATION AGE∗
TABLE 12-3 DERIVATIVES OF THE THREE GERM LAYERS: DEVELOPING STRUCTURES
Fifth Week
Sixth Week
Seventh Week
Eighth Week
Fetal Period
Weeks 9 Through 12
Weeks 13 Through 16
Weeks 17 Through 20
Weeks 21 Through 24
Weeks 25 Through 28
Weeks 29 Through 32
FIG 12-6 Fetal development from 9 weeks of fertilization age through 38 weeks of fertilization age. Gestational age, measured from the first day of the last menstrual period, is about 2 weeks longer than the fertilization age.
Weeks 33 Through 38
Auxiliary Structures
Placenta
Maternal Component
Development
Circulation in the Maternal Side
Fetal Component
Development
Circulation in the Fetal Side
Metabolic Functions
Transfer Functions
Gas Exchange
FIG 12-7 A, Placental structure, showing relationship of placenta, fetal membranes, and uterus. Arrows indicate the direction of blood flow between the fetus and placenta through the umbilical arteries and vein. Blood from the woman bathes the fetal chorionic villi within the intervillous spaces to allow exchange of oxygen, nutrients, and waste products without gross mixing of maternal and fetal blood. B, Structure of a chorionic villus, showing its fetal capillary network.
FIG 12-8 Placental variations. Normal placenta, with insertion of umbilical cord near center and branching of fetal umbilical vessels over the surface Placenta with cord inserted near margin of placenta Placenta with a small accessory lobe Velamentous insertion of umbilical cord. Cord vessels branch far out on membranes. When membranes rupture, fetal umbilical vessels may be torn, and the fetus can hemorrhage.
TABLE 12-4 MECHANISMS OF PLACENTAL TRANSFER
Nutrient Transfer
Waste Removal
Antibody Transfer
Transfer of Maternal Hormones
Endocrine Functions
Fetal Membranes and Amniotic Fluid
Fetal Circulation
Umbilical Cord
Fetal Circulatory Circuit
FIG 12-9 A, Fetal circulation. Three shunts—the ductus venosus, the ductus arteriosus, and the foramen ovale—allow most blood from the placenta to bypass the fetal lungs and liver. B, Circulation after birth. Note that the fetal shunts have closed. The umbilical vessels, the ductus venosus, and the ductus arteriosus have been converted to ligaments.
Changes in Blood Circulation After Birth
FIG 12-10 A, Monozygotic twinning. The single inner cell mass divides into two inner cell masses during the blastocyst stage. These twins have a single placenta and chorion, but each twin develops in its own amnion. B, Dizygotic twinning. Two ova are released during ovulation, and each is fertilized by a separate spermatozoon. The ova may implant near each other in the uterus, or they may be far apart.
Multifetal Pregnancy
Monozygotic Twinning
Dizygotic Twinning
KEY CONCEPTS
References and Readings
Pageburst Integrated Resource
Animation
Chapter 13 Adaptations to Pregnancy
Learning Objectives
Physiologic Responses to Pregnancy
Changes in Body Systems
Reproductive System
Uterus
Growth
FIG 13-1 Uterine growth pattern during pregnancy.
Pattern of Uterine Growth
Contractility
Uterine Blood Flow
FIG 13-2 Cervical changes that occur during pregnancy. Note the thick mucous plug filling the cervical canal.
Cervix
Vagina and Vulva
FIG 13-3 Breast changes that occur during pregnancy. The breasts increase in size and become more vascular, the areolae become darker, and the nipples become more erect.
Ovaries
Breasts
Cardiovascular System
Heart
Heart Size and Position
Heart Sounds
Blood Volume
Total Volume
Plasma Volume
Red Blood Cell Mass
Cardiac Output
Systemic Vascular Resistance
Blood Pressure
Effect of Position on Blood Pressure
Supine Hypotension
FIG 13-4 Supine hypotensive syndrome. When the pregnant woman is supine, the weight of the uterus partially occludes the vena cava and the descending aorta. A side-lying position corrects supine hypotension.
Blood Flow
Blood Components
Respiratory System
Oxygen Consumption
Hormonal Factors
Progesterone
Estrogen
TABLE 13-1 LABORATORY VALUES IN NONPREGNANT AND PREGNANT WOMEN
Physical Changes
Gastrointestinal System
Mouth
Esophagus
Stomach
Large and Small Intestine
Liver and Gallbladder
Urinary System
Bladder
Kidneys and Ureters
Changes in Size and Shape
Functional Changes
Integumentary System
Skin
Hyperpigmentation
Cutaneous Vascular Changes
Connective Tissue
FIG 13-5 Linea nigra, a dark line of pigmentation from the fundus to the symphysis pubis, appears during pregnancy.
Hair
Musculoskeletal System
Calcium Storage
Postural Changes
Abdominal Wall
Endocrine System
Pituitary Gland
Thyroid Gland
Parathyroid Glands
Pancreas
Adrenal Glands
Changes Caused by Placental Hormones
Human Chorionic Gonadotropin
Estrogen
Progesterone
Human Chorionic Somatomammotropin (hCS)
Relaxin
Changes in Metabolism
Weight Gain
Water Metabolism
Dependent Edema
Carpal Tunnel Syndrome
Carbohydrate Metabolism
Sensory Organs
Eye
Ear
Immune System
Confirmation of Pregnancy
Presumptive Indications of Pregnancy
Amenorrhea
Nausea and Vomiting
Fatigue
Urinary Frequency
FIG 13-6 Maternal changes based on the date of the last menstrual period.
TABLE 13-2 INDICATIONS OF PREGNANCY AND OTHER POSSIBLE CAUSES
Breast and Skin Changes
Vaginal and Cervical Color Changes
FIG 13-7 Hegar’s sign—compressibility of the lower uterus—reflects softening of the isthmus of the cervix.
Fetal Movement
Probable Indications of Pregnancy
Abdominal Enlargement
Cervical Softening
Changes in the Uterus
Uterine Consistency
FIG 13-8 When the cervix is tapped, the fetus floats upward in the amniotic fluid. A rebound is felt by the examiner when the fetus falls back.
Ballottement
Braxton Hicks Contractions
Palpation of the Fetal Outline
Uterine Souffle
Pregnancy Tests
Agglutination Inhibition Test
Radioreceptor Assay
Radioimmunoassay
Inaccurate Pregnancy Test Results
Positive Indications of Pregnancy
Auscultation of Fetal Heart Sounds
Fetal Movements Felt by Examiner
Visualization of the Fetus
Antepartum Assessment and Care
Preconception and Interconception Care
Initial Visit
History
Obstetric History
BOX 13-1 CALCULATION OF GRAVIDA AND PARA
Menstrual History and Estimated Date of Delivery
CRITICAL THINKING EXERCISE 13-1
Gynecologic and Contraceptive History
Medical and Surgical History
Family Health History
Partner’s Health History
Psychosocial History
Physical Examination
Vital Signs
Blood Pressure
Pulse
Respiratory Effort
Temperature
Cardiovascular System
Venous Congestion
Edema
Musculoskeletal System
Posture and Gait
Height and Weight
Abdomen
Neurologic System
Integumentary System
Endocrine System
Gastrointestinal System
Mouth
Intestine
Urinary System
Protein
Glucose
Ketones
Bacteria
Reproductive System
Breasts
External Reproductive Organs
TABLE 13-3 COMMON LABORATORY TESTS
Internal Reproductive Organs
Pelvic Measurements
Laboratory Data
Risk Assessment
Subsequent Assessments
TABLE 13-4 SUMMARY OF HIGH-RISK FACTORS IN PREGNANCY
Vital Signs
Weight
Urinalysis
Fundal Height
FIG 13-9 Measuring the uterus involves measuring from the upper border of the symphysis pubis to the top of the fundus.
Leopold’s Maneuvers
Fetal Heart Rate
Fetal Activity
Signs of Labor
Ultrasound Screen
Glucose Screen
Isoimmunization
Pelvic Examinations
Multifetal Pregnancy
Diagnosis
Maternal Adaptation to Multifetal Pregnancy
Antepartum Care in Multifetal Pregnancy
Common Discomforts of Pregnancy
PATIENT-CENTERED TEACHING: How to Overcome the Common Discomforts of Pregnancy
Nausea and Vomiting
Heartburn
Backache
Round Ligament Pain
Urinary Frequency
Varicosities
Constipation
Hemorrhoids
Leg Cramps
Nausea and Vomiting
Heartburn
Backache
Round Ligament Pain
Urinary Frequency
FIG 13-10 Posture during pregnancy may cause or alleviate backache. A, Incorrect posture. The neck is jutting forward, the shoulders are slumping, and the back is sharply curved, creating back pain and discomfort. B, Correct posture. The neck and shoulders are straight, the back is flattened, and the pelvis is tucked under and slightly upward.
Varicosities
Constipation
Hemorrhoids
FIG 13-11 Techniques for lifting. Squatting places less strain on the back. A, Incorrect technique. Stooping or bending places a great deal of strain on muscles of the lower back. B, Correct technique. Squatting and moving the object close permits the stronger muscles of the legs to do the lifting.
Leg Cramps
Nursing Care
Family Responses to Physical Changes of Pregnancy
Assessment
Nursing Diagnosis and Planning
FIG 13-12 Exercises to prevent backache.
Expected Outcomes
Interventions
Teaching Health Behaviors
Bathing
NURSING CARE PLAN: Early Pregnancy Concerns
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Nursing Diagnosis to Consider
Hot Tubs and Saunas
Douching
Breast Care
Clothing
Exercise
FIG 13-13 During the third trimester, pillows supporting the abdomen and back provide a comfortable position for rest.
Sleep and Rest
Nutrition
Employment
Maternal Safety
Exposure to Teratogens
Travel
Immunizations
Teaching Necessary Lifestyle Changes
Prescription and Over-the-Counter Drugs
Complementary and Alternative Therapies
Tobacco
Alcohol
Illegal Drugs
Signs of Possible Complications
Evaluation
SAFETY ALERT: Signs of Possible Complications During Pregnancy
Psychological Responses to Pregnancy
Maternal Responses
First Trimester
Uncertainty
Ambivalence
The Self as Primary Focus
Second Trimester
Physical Evidence of Pregnancy
FIG 13-14 Fetal movement (quickening) confirms that a separate life is developing.
The Fetus as Primary Focus
Narcissism and Introversion
Body Image
NURSING CARE PLAN: Body Image During Pregnancy
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Nursing Diagnoses to Consider
Changes in Sexuality
Third Trimester
Vulnerability
Increasing Dependence
FIG 13-15 During the third trimester, the mother feels increasingly vulnerable. She cradles her fetus to signify her protectiveness.
Preparation for Birth
TABLE 13-5 PROGRESSIVE CHANGES IN MATERNAL RESPONSES TO PREGNANCY
Maternal Role Transition
Transitions Experienced throughout Pregnancy
Steps in Maternal Role Taking
Mimicry
Role Play
Fantasy
The Search for a Role Fit
Grief Work
Maternal Tasks of Pregnancy
Seeking Safe Passage
Securing Acceptance
Learning to Give of Herself
Committing Herself to the Unknown Child
Paternal Adaptation
Variations in Paternal Adaptation
Developmental Processes
Grappling with the Reality of Pregnancy and the Child
Struggling for Recognition as a Parent
FIG 13-16 Reality boosters such as hearing the sounds of the fetal heart make the fetus more real for the father.
Creating the Role of Involved Father
Parenting Information
Couvade
Adaptation of Grandparents
Age
Number and Spacing of Other Grandchildren
Perceptions of the Role of Grandparents
Adaptation of Siblings
Toddlers
Older Children
Adolescents
Factors that Influence Psychosocial Adaptations
Age
Multiparity
CRITICAL THINKING EXERCISE 13-2
FIG 13-17 A pregnant woman spends time with her child to provide affection and a sense of security.
Social Support
Absence of a Partner
TABLE 13-6 IMPACT OF SOCIOECONOMIC FACTORS ON FAMILY’S RESPONSE TO PREGNANCY
Socioeconomic Status
Abnormal Situations
Barriers to Prenatal Care
EVIDENCE-BASED PRACTICE
Cultural Influences on Childbearing
Differences within Cultures
Cultural Differences that May Cause Conflict
Health Care Practices Beliefs ExemplarHealth Beliefs
Health Maintenance During Pregnancy
Belief in Fate
Preventing Illness
Restoring Health
Modesty
Female Genital Cutting
Therapeutic communication ExemplarPatient Provider Communication ExemplarCommunication Techniques
Language
Communication Style
NURSING CARE PLAN: Language Barrier During Pregnancy
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Nursing Diagnoses to Consider
Developmental Family roles ExemplarDecision Making
Eye Contact
Touch
Time Orientation
Culturally Competent Nursing Care
Cultural Assessment
TABLE 13-7 PSYCHOSOCIAL ASSESSMENT
Cultural Negotiation
Nursing Care
Psychosocial Concerns
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Providing Information
Adapting Nursing Care to Pregnancy Progress
Discussing Resources
Helping the Family Prepare for the Birth
Modeling Communication Techniques
Identifying Cultural Factors that Could Cause Conflict
Evaluation
Childbirth education ExemplarPerinatal Education
Providers of Education
Class Participants
Choices for Childbearing
Setting and Health Care Provider
FIG 13-18 An expectant mother may ask a sister or close female friend to be her labor partner and to attend classes with her.
BOX 13-2 BIRTH PLAN CONSIDERATIONS
Support Person
Education
Types of Classes Available
Preconception Classes
Early Pregnancy Classes
Exercise Classes
Childbirth Preparation Classes
FIG 13-19 The nurse teaches the support person how to check for relaxation.
Cesarean Birth Preparation Classes
Breastfeeding Classes
Parenting Classes
Classes For Fathers
Postpartum Classes
KEY CONCEPTS
References and Readings
Chapter 14 Nutrition for Childbearing
Learning Objectives
Weight Gain During Pregnancy
Recommendations for Total Weight Gain
TABLE 14-1 RECOMMENDED WEIGHT GAIN DURING PREGNANCY
Pattern of Weight Gain
FIG 14-1 Distribution of weight gain in pregnancy for women of normal prepregnancy weight. The numbers represent a general distribution because variation among women is great. Weight increases with the greatest fluctuation are those attributed to extravascular fluids (edema) and maternal reserves of fat.
Maternal and Fetal Distribution
Factors that Influence Weight Gain
Nutritional Requirements During Pregnancy
Dietary Reference Intakes
Energy
Carbohydrates
Fats
TABLE 14-2 DIETARY REFERENCE INTAKES: RECOMMENDED ENERGY AND PROTEIN INTAKES
Calories
Protein
Vitamins
Folic Acid
Minerals
Iron
TABLE 14-3 DIETARY REFERENCE INTAKES: RECOMMENDATIONS FOR VITAMINS AND MINERALS
TABLE 14-4 FOODS HIGH IN IRON
BOX 14-1 CALCIUM SOURCES APPROXIMATELY EQUIVALENT TO 1 CUP OF MILK
Calcium
BOX 14-2 FOODS HIGH IN SODIUM
Sodium
Nutritional Supplementation
Purpose
Disadvantages and Dangers of Nutritional Supplementation
PATIENT-CENTERED TEACHING: Vitamins and Minerals
Water
Food Plan
Whole Grains
Vegetables and Fruits
TABLE 14-5 FOOD PLAN FOR PREGNANCY AND LACTATION
Dairy Group
Protein Group
Other Elements
Food Precautions
SAFETY ALERT: Food Safety During Pregnancy and Lactation
Factors that Influence Nutrition
Age
Nutritional Knowledge
Exercise
Diet Nutrition ExemplarCulture
Southeast Asian Dietary Practices
Effect of Culture on Diet During Childbearing
Increasing Nutrients with Traditional Foods
Hispanic Dietary Practices
Nutritional Risk Factors
Socioeconomic Status
Poverty
Food Supplement Programs
Adolescence
Nutrient Needs
Common Problems
NURSING CARE PLAN: Nutrition for the Pregnant Adolescent
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Nursing Diagnoses to Consider
Teaching the Adolescent
Vegetarianism
Meeting the Nutritional Requirements of the Pregnant Vegetarian
Energy
Protein
Calcium
Iron
Zinc
Vitamin B12
Vitamin A
Lactose Intolerance
Nausea and Vomiting of Pregnancy
Anemia
Abnormal Prepregnancy Weight
Eating Disorders
Food Cravings and Aversions
Pica
CRITICAL THINKING EXERCISE 14-1
Multiparity and Multifetal Pregnancy
Substance Use and Abuse
Smoking
Caffeine
Alcohol
Drugs
Other Risk Factors
Nutrition After Birth
Nutrition for the Lactating Mother
Energy
Protein
Fats
Vitamins and Minerals
Specific Nutritional Concerns
Dieting
Adolescence
Vegan Diet
Avoidance of Dairy Products
Inadequate Diet
Alcohol
Caffeine
Fluids
Foods to Avoid
Nutrition for the Nonlactating Mother
Weight Loss
Nursing Care
Nutrition for Childbearing
Assessment
Interview
Appetite
Eating Habits
Food Preferences
Identify Potential Problems
Diet History
Twenty-Four-Hour Diet History
Food Intake Records
Food-Frequency Questionnaires
Physical Assessment
FIG 14-2 Weight gain for pregnancy. The range for weight gain in women of normal prepregnancy weight is 11.5 to 16 kg (25 to 35 lb).
Weight at Initial Visit
CRITICAL THINKING EXERCISE 14-2
Weight at Subsequent Visits
Signs of Nutrient Deficiency
Laboratory Tests
Reassessing Nutritional Status at Each Visit
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Explaining Nutrient Needs
Providing Reinforcement
FIG 14-3 Women often make changes in their diets for the good of their unborn children that they would not consider for themselves alone.
Evaluating Weight Gain
Encouraging Supplement Intake
Making Referrals
Evaluation
KEY CONCEPTS
References And Readings
Chapter 15 Prenatal Diagnostic Tests
Learning Objectives
Indications for Prenatal Diagnostic Tests
Ultrasound
Emotional Responses
FIG 15-1 Two-dimensional sonogram showing the fetal body profile and details of the fetal arm, hand, and fingers.
BOX 15-1 INDICATIONS FOR FETAL DIAGNOSTIC PROCEDURES
Medical Conditions
Demographic Factors
Obstetric Factors
Concurrent Maternal Factors
FIG 15-2 Three-dimensional ultrasound image of a fetus in the third trimester, showing the detail of facial features.
First Trimester
Procedure
Purposes
Second and Third Trimesters
Procedure
Purposes
FIG 15-3 The sonographer provides information as she moves the transducer over the mother’s abdomen to obtain an image.
Advantages
Disadvantages
Doppler Ultrasound Blood Flow Assessment
Purpose
Color Doppler
FIG 15-4 Color Doppler imaging of the umbilical vein and two arteries. Blood flow toward the transducer is typically shown as red whereas the flow away from the transducer is shown as blue.
Alpha-Fetoprotein Screening
Purpose
BOX 15-2 CONDITIONS ASSOCIATED WITH ABNORMAL MATERNAL SERUM ALPHA-FETOPROTEIN LEVELS
Elevated Levels of Alpha-Fetoprotein (AFP)
Low Levels of AFP
Procedure
Advantages
Limitations
Multiple-Marker Screening
Chorionic Villus Sampling
Purpose
Indications
Procedure
FIG 15-5 Transcervical chorionic villus sampling. Tissue is aspirated to identify some genetic defects in the fetus. Transabdominal aspiration is an alternative method.
Advantages
Limitations
Amniocentesis
FIG 15-6 In amniocentesis, a needle is inserted through the mother’s abdomen to aspirate fluid from the amniotic sac. The fluid can then be tested to detect chromosomal abnormalities in fetal cells or other problems and to determine fetal lung maturity.
Purposes
Second-Trimester Amniocentesis
Third-Trimester Amniocentesis
BOX 15-3 COMMON INDICATIONS FOR SECOND-TRIMESTER AMNIOCENTESIS
Tests to Determine Fetal Lung Maturity
Test for Fetal Hemolytic Disease
Procedure
Advantages
Disadvantages
Risks
FIG 15-7 In percutaneous umbilical blood sampling, a needle is inserted through the mother’s abdomen and into an umbilical vessel (vein or artery) to withdraw a sample of fetal blood.
Percutaneous Umbilical Blood Sampling
Procedure
Risks
Antepartum Fetal Surveillance
Nonstress Test
Purpose
Procedure
Interpretation
FIG 15-8 A nonstress test is a noninvasive test that measures the ability of the fetal heart to accelerate, often in response to fetal movements. Here the nurse reassures the parents by pointing to fetal heart rate accelerations detected by the external fetal monitor.
Advantages
Disadvantages
FIG 15-9 A, Several accelerations have a duration of at least 15 seconds, reaching a peak of 25 to 30 beats per minute in this example of a reactive nonstress test. Comparable accelerations without fetal movement are also reassuring. B, In this recording of a nonreactive nonstress test, accelerations are absent after fetal movement.
Vibroacoustic (Acoustic) Stimulation
Purpose and Procedure
Fetal Responses
Risks
Contraction Stress Test
Purpose
Procedure
Interpretation
Advantages
Disadvantages
Biophysical Profile
Purpose
FIG 15-10 Interpretation of contraction stress test (CST). UPI, Uteroplacental insufficiency.
FIG 15-11 Effects of gradual hypoxemia and worsening fetal acidosis.
Procedure and Interpretation
TABLE 15-1 SCORING THE BIOPHYSICAL PROFILE FOR A TERM FETUS
Modified Biophysical Profile
Advantages
Disadvantages
Maternal Assessment of Fetal Movement
Advantages
Disadvantages
Nursing Care
The Patient Who Has Diagnostic Testing
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Providing Information
Providing Support
Helping Patients Set Realistic Goals
Supporting the Woman’s Decision
Evaluation
KEY CONCEPTS
References and Readings
Chapter 16 Giving Birth
Learning Objectives
Issues for New Nurses
Pain Associated with Birth
Inexperience or Negative Experiences
Unpredictability
Intimacy
Physiologic Effects of the Birth Process
Maternal Response
Reproductive System
Characteristics of Contractions
Coordinated Contractions
Involuntary Contractions
Intermittent Contractions
Contraction Cycle
Uterine Body
FIG 16-1 Contraction cycle.
Cervical Changes
FIG 16-2 Opposing characteristics of uterine contraction in the upper and lower segments of the uterus.
Effacement
Dilation
Cardiovascular System
Respiratory System
Gastrointestinal System
FIG 16-3 Cervical dilation and effacement. During labor, the multigravida’s cervix remains thicker than that of the primigravida.
Urinary System
Hematopoietic System
Fetal Response
Placental Circulation
Cardiovascular System
Pulmonary System
Components of the Birth Process
Powers
Uterine Contractions
Maternal Pushing Efforts
Passage
Passenger
Fetal Head
Bones, Sutures, and Fontanels
Fetal Head Diameters
Variations in the Passenger
Fetal Lie
Attitude
Presentation
FIG 16-4 Pelvic divisions and measurements. INLET The boundaries of the inlet are the symphysis pubis anteriorly, the sacral promontory posteriorly, and the linea terminalis on the sides. The inlet is slightly wider in its transverse diameter (13.5 cm) than in its anteroposterior (diagonal conjugate) diameter (11.5 cm or greater). The diagonal conjugate is slightly larger than both the obstetric and true conjugates. The obstetric conjugate is the narrowest of the three conjugate diameters but cannot be measured directly. The obstetric conjugate is estimated by first measuring the diagonal conjugate and then subtracting 1.5 to 2 cm. If the inlet is small, the fetal head may not be able to enter it. Because it is almost entirely surrounded by bone, except for cartilage at the sacroiliac joint and symphysis pubis, the inlet cannot enlarge much to accommodate the fetus. The bony measurements are essentially fixed.
MIDPELVIS The midpelvis, or pelvic cavity, is the narrowest part of the pelvis through which the fetus must pass during birth. Midpelvic diameters are measured at the level of the ischial spines. The anteroposterior diameter averages 12 cm. The transverse diameter (bispinous or interspinous) averages 10.5 cm. Prominent ischial spines that project into the midpelvis can reduce the bispinous diameter.
OUTLET Three important diameters of the pelvic outlet are (1) the anteroposterior, (2) the transverse (bi-ischial or intertuberous), and (3) the posterior sagittal. The angle of the pubic arch also is an important pelvic outlet measure. The anteroposterior diameter ranges from 9.5 to 11.5 cm, varying with the curve between the sacrococcygeal joint and the tip of the coccyx. The anteroposterior diameter can increase if the coccyx is easily movable. The transverse diameter is the bi-ischial, or intertuberous, diameter. This is the distance between the ischial tuberosities (“sit bones”). It averages 11 cm. The posterior sagittal diameter is normally at least 7.5 cm. It is a measure of the posterior pelvis. The posterior sagittal diameter measures the distance from the sacrococcygeal joint to the middle of the transverse (bi-ischial) diameter.
The angle of the pubic arch is important because it must be wide enough for the fetus to pass under it. The angle of the pubic arch should be at least 90 degrees. A narrow pubic arch displaces the fetus posteriorly toward the coccyx as it tries to pass under the arch.
FIG 16-5 A, Bones, sutures, fontanels of the fetal head. Note that the anterior fontanel has a diamond shape, whereas the posterior fontanel is triangular. B, Lateral view of the fetal head. Anteroposterior diameters vary with the amount of flexion or extension.
FIG 16-6 Lie. A, In a longitudinal lie, the long axis of the fetus is parallel to the long axis of the woman. B, In a transverse lie, the long axis of the fetus is at right angles to the long axis of the mother. The woman’s abdomen has a wide, short appearance.
Cephalic Presentation
FIG 16-7 Attitude. A, The fetus is in the normal attitude of flexion, with the head, arms, and legs flexed tightly against the trunk. B, The fetus is in an abnormal attitude of extension. The head is extended, and the right arm is extended. A face presentation is illustrated.
Vertex
FIG 16-8 Four types of cephalic presentation. The vertex presentation is normal. Note positional changes of the anterior and posterior fontanels in relation to the maternal pelvis.
Military
Brow
Face
Breech Presentation
Frank breech
Full (or complete) breech
Footling breech
Shoulder
Position
Right (R) or Left (L)
Occiput (O), Mentum (M), or Sacrum (S)
Anterior (A), Posterior (P), or Transverse (T)
FIG 16-9 Three variations of a breech presentation. Frank breech is the most common variation. Footling breeches may be single or double.
FIG 16-10 Four quadrants of the maternal pelvis, used to describe fetal position.
Psyche
Interrelationships of the Components of Birth
Individual and Cultural Values
FIG 16-11 Fetal presentations and positions.
Birth as an Experience
Normal Labor
Theories of Onset
Premonitory Signs
True Labor and False Labor
Mechanisms of Labor
PATIENT-CENTERED TEACHING: How to Know Whether Labor Is “Real”
Stages and Phases of Labor
First Stage of Labor
Latent Phase
Active Phase
FIG 16-12 Mechanisms (cardinal movements) of labor.
TABLE 16-1 CHARACTERISTICS OF NORMAL LABOR
FIG 16-13 A labor curve, often called a Friedman curve, may be used to identify whether a woman’s cervical dilation is progressing at the expected rate. Typical labor curves for a multiparous and a nulliparous woman are illustrated for comparison of patterns.
Second Stage of Labor
Third Stage of Labor
Fourth Stage of Labor
EVIDENCE-BASED PRACTICE
FIG 16-14 A, Fetal side of the placenta. B, Maternal side of the placenta. C, Separating membranes. D, Umbilical cord vessels—two arteries and one vein.
Duration of Labor
Nursing Care During Labor and Birth
Admission to the Birth Center
Nursing Responsibilities during Admission
Establishing a Therapeutic Relationship
Making the Family Feel Welcome
PATIENT-CENTERED TEACHING: When to Go to the Hospital or Birth Center
Contractions
Ruptured Membranes
Bleeding
Decreased Fetal Movement
Other Concerns
CRITICAL THINKING EXERCISE 16-1
Determining Family Expectations about Birth
Conveying Confidence
Assigning a Primary Nurse
Using Touch for Comfort
Respecting Cultural Values
Assessments at the Time of Admission
Focused Assessment
Fetal Assessment
Maternal Vital Signs
Impending Birth
Database Assessment
Basic Information
TABLE 16-2 INTRAPARTUM ASSESSMENT GUIDE Women who have had prenatal care have much of this information available on their prenatal record. The nurse need only verify it or update it as needed.
PROCEDURE: Leopold’s Maneuvers
Purposes
First Maneuver
Second Maneuver
Third Maneuver
Fourth Maneuver
Fetal Assessments
Labor Status
Physical Examination
Admission Procedures
Notifying the Physician or Midwife
Consent Forms
CRITICAL THINKING EXERCISE 16-2
Laboratory Tests
Intravenous Access
Assessments After Admission
Fetal Assessments
FHR
Amniotic Fluid
Maternal Assessments
Vital Signs
Contractions
Progress of Labor
Intake and Output
Response to Labor
PROCEDURE: Palpating Contractions
Purpose
The Support Person’s Response
Nursing Care
The Woman with False or Early Labor
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Providing Reassurance
Teaching
Evaluation
Nursing Care
The Woman in True Labor
SAFETY ALERT: Conditions Associated with Fetal Compromise
Fetal Oxygenation
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Interventions
Promoting Placental Function
Observing for Conditions Associated with Fetal Compromise
Evaluation
Discomfort
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Providing Comfort Measures
Lighting
Temperature
Cleanliness
Mouth Care
Bladder
Positioning
Water
Teaching
First Stage of Labor
Second Stage of Labor
Laboring Down
Positions
Method and Breathing Pattern
Labor Support
Providing Encouragement
FIG 16-15 Maternal positions for labor.
Giving of Self
Offering Pharmacologic Measures
Caring for the Birth Partner
Evaluation
Preventing Injury
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Interventions
Transfer to a Delivery Room
Positioning for Birth
Observing the Perineum
BOX 16-1 ASSISTING WITH AN EMERGENCY BIRTH
Nursing Priorities for an Emergency Birth in Any Setting
Preparing for an Emergency Birth in the Birth Facility
During the Birth
After the Birth
Evaluation
Nursing Care During the Late Intrapartum Period
Responsibilities During Birth
Responsibilities After Birth
Care of the Infant
Maintaining Cardiopulmonary Function
Supporting Thermoregulation
FIG 16-16 Sequence of delivery.
Identifying the Infant
FIG 16-17 Vaginal birth.
Care of the Mother
Observing for Hemorrhage
Vital Signs
Fundus
NURSING CARE PLAN: Normal Labor and Birth
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
TABLE 16-3 APGAR SCORE∗
FIG 16-18 When the birthing room nurse turns over care of the newborn to the nursery nurse, both check the identification bands and record for the same information.
Bladder
Lochia
Relieving Discomfort
Ice Packs
Analgesics
TABLE 16-4 MATERNAL PROBLEMS DURING THE FOURTH STAGE OF LABOR
Warmth
Promoting Early Family Attachment
KEY CONCEPTS
References and Readings
Pageburst Integrated Resource
Animation
Chapter 17 Intrapartum Fetal Surveillance
Learning Objectives
Fetal Oxygenation
Uteroplacental Exchange
Fetal Circulation
Fetal Heart Rate Regulation
Autonomic Nervous System
Baroreceptors
Chemoreceptors
Adrenal Glands
Central Nervous System
Pathologic Influences on Fetal Oxygenation
Maternal Cardiopulmonary Alterations
BOX 17-1 POTENTIAL MATERNAL, FETAL, OR NEONATAL RISK FACTORS
Antepartum Period
Maternal History
Problems Identified during Pregnancy
Intrapartum Period
Maternal Problems
Fetal or Placental Problems
Uterine Activity
Placental Disruptions
Interruptions in Umbilical Flow
Fetal Alterations
Risk Factors for Fetal Compromise
Auscultation and Palpation
Advantages
Limitations
Evaluating Auscultated Fetal Heart Rate Data
FIG 17-1 Low intervention methods for evaluating fetal heart rate during labor. A, Fetoscope with head attachment to enhance conduction of faint fetal heart sounds. B, Doppler ultrasound transducer to sense the fetal heart rate electronically.
Electronic Fetal Monitoring
PROCEDURE: Auscultating the Fetal Heart Rate
Purpose
Advantages
Limitations
Electronic Fetal Monitoring Equipment
Bedside Monitor Unit
FIG 17-2 Paper strip for recording electronic fetal monitoring data. Each dark vertical line represents 1 minute, and each lighter vertical line represents 10 seconds. Computerized displays that depict the fetal heart rate and uterine activity patterns have a similar appearance.
Paper Strip
Remote Surveillance
Devices for External Fetal Monitoring
FIG 17-3 The nurse applies the uterine activity transducer to the woman’s upper abdomen, in the fundal area. The Doppler transducer for sensing the fetal heart rate is usually placed on her lower abdomen when the fetus is in the cephalic presentation.
PROCEDURE: External Fetal Monitor
Purposes
FIG 17-4 Fetal scalp electrode and intrauterine pressure catheter (IUPC). A, Parts of the fetal scalp electrode before it is applied. B, Fetal scalp electrode and IUPC in place and connected to the bedside monitor unit.
Fetal Heart Rate Monitoring with an Ultrasound Transducer
Uterine Activity Monitoring with a Tocotransducer
Devices for Internal Fetal Monitoring
Fetal Heart Rate Monitoring with a Scalp Electrode
FIG 17-5 Intrauterine pressure catheter (IUPC) with transducer in its tip. This model has a lumen for amnioinfusion and is shown with its introducer over the catheter. The amnioinfusion port is on the side of the catheter connection and has a blue cap covering it when not in use.
Uterine Activity Monitoring with an Intrauterine Pressure Catheter
Evaluating Electronic Fetal Monitoring Strips
Baseline Fetal Heart Rate
Baseline FHR Variability
FIG 17-6 Electronic fetal monitor strip showing a reassuring pattern of fetal heart rate and uterine activity. The baseline fetal heart rate averages 135 beats per minute (bpm), with a moderate variability of 10 bpm. An acceleration to 150 bpm is present. The contraction frequency is approximately every 2 to 3 minutes, duration is about 50 to 60 seconds, intensity is 75 to 90 mm Hg, and uterine resting tone is approximately 10 mm Hg. Fetal scalp electrode and intrauterine pressure catheter (IUPC) are being used.
Periodic Patterns in FHR
Accelerations
Decelerations
Early Decelerations
FIG 17-7 Contrasts in fetal heart rate variability. A fetal scalp electrode is being used. A, Minimal variability (less than 5 beats per minute [bpm]). Note the smooth, flat line in the upper graph for the fetal heart rate. B, Moderate variability (average 20 bpm variability). Note the zigzag appearance of the fetal heart rate line compared with the flat appearance in A.
FIG 17-8 Accelerations in the fetal heart rate.
FIG 17-9 Early decelerations. The slowing of the fetal heart rate is gradual, and the nadir of the deceleration occurs at the peak of the contraction. It returns to the baseline by the end of the contraction. Cause: fetal head compression.
FIG 17-10 Late decelerations. Note that the decelerations look similar to early decelerations but are offset to the right. They begin at about the peak of the contraction, and the nadir occurs well after the peak of the contraction, often during the interval. Cause: uteroplacental insufficiency.
Late Decelerations
FIG 17-11 Variable decelerations. The decelerations are sharp in onset and offset. Note slight rate accelerations (shoulders) after each variable deceleration. These variable decelerations are periodic in that they occur during contractions. Cause: umbilical cord compression.
SAFETY ALERT: Differences Between Early and Late Decelerations
Both Early and Late Decelerations
Early Decelerations
Late Decelerations
Variable Decelerations
Uterine Activity
Significance of FHR Patterns
Reassuring Patterns
Indeterminate Patterns
Nonreassuring Patterns
SAFETY ALERT: Nursing Responses to Nonreassuring Fetal Heart Rate Patterns
FIG 17-12 Fetal scalp stimulation identifies fetal response to gentle massage. An acceleration in the fetal heart rate of 15 beats per minute for 15 seconds suggests that the fetus is in normal oxygen and acid-base balance. Accelerations often occur with vaginal examination unrelated to nonreassuring fetal heart rate patterns.
TABLE 17-1 REASSURING (NORMAL) AND NONREASSURING (ABNORMAL) FETAL SURVEILLANCE ASSESSMENTS
Clarification of Data
Fetal Scalp Stimulation
VAS
Fetal Scalp Blood Sampling
Fetal Oxygen Saturation Monitor
Cord Blood Gases and pH
Interventions for Nonreassuring Patterns
FIG 17-13 Obtaining a blood sample to determine umbilical cord blood gas values and pH. Samples are drawn from the umbilical artery and vein. Arterial samples most closely reflect fetal oxygen and acid-base status. The samples in capped syringes may be kept for up to 60 minutes at room temperature.
Identifying the Cause of a Nonreassuring Pattern
Increasing Placental Perfusion
Increasing Maternal Blood Oxygen Saturation
Reducing Cord Compression
FIG 17-14 The nurse teaches the woman and her partner about electronic fetal monitoring to reduce anxiety and promote the woman’s comfort during labor. Electronic fetal monitoring is only one method used to evaluate fetal well-being during labor.
Nursing Care
The Woman Having Intrapartum Fetal Monitoring
Learning Needs
Assessment
NURSING CARE PLAN: Intrapartum Fetal Compromise
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Focused Assessment
Potential Complication
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis and Planning
Expected Outcome
Interventions
Explaining FHR Auscultation with Uterine Palpation
Explaining the Electronic Fetal Monitor
Addressing Parents’ Safety Concerns
Coping with Misleading Data
PARENTS WANT TO KNOW: About Electronic Fetal Monitoring
Can I move around with the monitor?
What if I need to go to the bathroom?
Will the monitor shock me? I don’t know if I want to be hooked to an electrical outlet, especially since my water has broken
Why is the baby’s heart beating so fast?
Why do those numbers for the baby’s heart rate change all the time?
What do those numbers for contractions on the machine (external monitor) mean? They change all the time
My contractions don’t look very strong, but they sure seem strong to me! (External uterine activity monitor is being used.)
Will the internal monitor hurt my baby?
Including the Labor Partner
CRITICAL THINKING EXERCISE 17-1
CRITICAL THINKING EXERCISE 17-2
Enhancing Comfort
Evaluation
Fetal Oxygenation
Assessment
BOX 17-2 GUIDELINES FOR ASSESSMENT AND DOCUMENTATION OF FETAL HEART RATE AUSCULTATION FOR WOMEN AT LOW RISK
Active First-Stage Labor
Second-Stage Labor
Other Times to Document Fetal Heart Rate
Nursing Diagnosis and Planning
Interventions
Taking Corrective Actions
Reassuring Parents
Reporting Nonreassuring Patterns
Documentation ExemplarDocumenting Assessments and Care
Evaluation
BOX 17-3 DOCUMENTING ELECTRONIC FETAL MONITORING
Documentation When Monitoring Is Initiated
Monitor Strip
Labor Record (If Paper-Only Documentation)
Continuing Documentation
Monitor Strip
Labor Record
KEY CONCEPTS
References and Readings
Chapter 18 Pain Management for Childbirth
Learning Objectives
Unique Nature of Pain During Birth
Adverse Effects of Excessive Pain
Physiologic Effects
Psychological Effects
Variables in Childbirth Pain
Physical Factors
Sources of Pain
Tissue Ischemia
Cervical Dilation
Pressure and Pulling on Pelvic Structures
Distention of the Vagina and Perineum
Factors Influencing the Perception or Tolerance of Pain
FIG 18-1 Pathways of pain transmission during labor. Pain stimuli from cervical dilation enter the spinal cord at these segments. Pain stimuli from vaginal and perineal distention travel through the pudendal nerve and enter the spinal cord at these segments
Intensity of Labor
Cervical Readiness
Fetal Position
Characteristics of the Pelvis
Fatigue
Intervention of Caregivers
Psychosocial Factors
Culture
Anxiety and Fear
Previous Experiences with Pain
Preparation for Childbirth
Support System
Standards for Pain Management
Nonpharmacologic Pain Management
Advantages
Limitations
Preparation for Pain Management
FIG 18-2 General comfort measures such as the nurse’s reassuring presence or a cool, damp cloth applied to the face supplement other methods of nonpharmacologic and pharmacologic pain control.
Application of Nonpharmacologic Techniques
Relaxation techniques ExemplarRelaxation
Environmental Comfort
General Comfort
Reducing Anxiety and Fear
Implementing Specific Relaxation Techniques
Cutaneous Stimulation
Self-Massage
Massage by Others
FIG 18-3 The coach applies sacral pressure to counter the back pain that is common during labor.
Thermal Stimulation
Acupressure
Hydrotherapy
BOX 18-1 USE OF WATER THERAPY DURING LABOR
Benefits
Disadvantages
Contraindications and Precautions
Mental Stimulation
Imagery ExemplarImagery
FIG 18-4 A woman and her partner who are prepared for labor have learned a variety of skills to master pain as labor progresses. The coach uses hand signals to tell the woman how to change her pattern of paced breathing.
Focal Point
Breathing Techniques
First-Stage Breathing
Cleansing Breath
FIG 18-5 Slow-paced breathing. Although a specific rate may or may not be taught, slow-paced breathing should be no slower than half the woman’s usual respiratory rate to ensure adequate oxygenation. This pace is generally about six to nine breaths per minute.
FIG 18-6 Modified-paced breathing. The pattern for modified-paced breathing should be comfortable to the woman and no faster than twice her normal respiratory rate to prevent hyperventilation or interference with relaxation.
Slow-Paced Breathing
Modified-Paced Breathing
Pattern-Paced Breathing
FIG 18-7 Combining breathing techniques during a contraction. Slow- and modified-paced breathing can be combined by using the slower breathing at the beginning and end of the contraction and the more rapid breathing over the peak of the contraction.
FIG 18-8 Pattern-paced breathing. Pattern-paced breathing adds a slight emphasis or “blow” on the exhalation in a pattern. The diagram shows the emphasis after every third inhalation.
Controlling the Urge to Push
Common Problems
Second-Stage Breathing
Pharmacologic Pain Management
Special Considerations When Medicating a Pregnant Woman
Effects on the Fetus
Maternal Physiologic Alterations
Cardiovascular Changes
Respiratory Changes
Gastrointestinal Changes
Nervous System Changes
Effects on the Course of Labor
Effects of Complications
Interactions with Other Substances
Regional Pain Management Techniques
Epidural Block
FIG 18-9 A, Cross section of spinal cord, meninges, and protective vertebra. The dura and arachnoid lie close together. The pia mater is the innermost of the meninges and covers the brain and spinal cord. The subarachnoid space is between the arachnoid and pia mater. B, Sagittal section of spinal cord, meninges, and vertebrae. The epidural and subarachnoid spaces are illustrated. Note that the spinal cord ends at the L2 vertebra.
Technique
Dural Puncture
Contraindications and Precautions
FIG 18-10 Technique for epidural block.
Adverse Effects of Epidural Block
Maternal Hypotension
Bladder Distention
Prolonged Second Stage
Migration of the Epidural Catheter
Fever
TABLE 18-1 DRUGS COMMONLY USED FOR INTRAPARTUM PAIN MANAGEMENT
Adverse Effects of Epidural Opioids
Nausea and Vomiting
Pruritus
Delayed Respiratory Depression
Nursing Care
Intrathecal (Subarachnoid) Opioid Analgesics
Technique
Adverse Effects of Intrathecal Opioids
Nursing Care
Subarachnoid (Spinal) Block
Technique
Contraindications and Precautions
Adverse Effects of an SAB
Systemic Drugs for Labor
Opioid Analgesics
FIG 18-11 Technique for subarachnoid block.
FIG 18-12 Levels of anesthesia for epidural and subarachnoid blocks. A level of T10 through S5 is adequate for vaginal birth. A higher level, to T4-T6, is needed for cesarean birth.
Opioid Antagonists
Adjunctive Drugs
FIG 18-13 Blood patch for relief of spinal headache. Ten to 15 mL of the woman’s blood is injected into the epidural space to seal a dural puncture.
Sedatives
Vaginal Birth Anesthesia
Local Infiltration Anesthesia
Pudendal Block
FIG 18-14 Local infiltration anesthesia numbs the perineum just before birth for an episiotomy or after birth for suturing of a laceration. The birth attendant protects the fetal head by placing a finger inside the vagina while injecting the perineum in a fanlike pattern or as needed.
General Anesthesia
Technique
FIG 18-15 Pudendal block provides anesthesia for an episiotomy and the use of low forceps. A needle guide (“trumpet”) protects the maternal and fetal tissues from the long needle needed to reach the pudendal nerve. Only about 1.25 cm (½ in) of the long needle protrudes from the guide.
Adverse Effects of General Anesthesia
Maternal Aspiration of Gastric Contents
Respiratory Depression
Uterine Relaxation
Methods to Minimize Adverse Effects
FIG 18-16 Sellick maneuver to prevent vomitus from entering the woman’s trachea while she is being intubated for general anesthesia. An assistant applies pressure to the cricoid cartilage to obstruct the esophagus. Once the woman is successfully intubated with a cuffed endotracheal tube, gastric secretions cannot enter the trachea.
Nursing Care
Pain Management
Pain
Assessment
NURSING CARE PLAN: Intrapartum Pain Management
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Nursing Diagnoses and Collaborative Problems to Consider:
Labor Status
CRITICAL THINKING EXERCISE 18-1
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Promoting Relaxation
Reducing Outside Sources of Discomfort
Reducing Anxiety and Fear
Helping the Woman Use Nonpharmacologic Techniques
Massage
Mental Stimulation
Breathing
Incorporating Pharmacologic Methods
PARENTS WANT TO KNOW: How Will This Medicine Affect Our Baby?
Evaluation
Respiratory Compromise
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Interventions
Identifying Risk Factors
Reducing Risk for Aspiration or Lung Injury
Perioperative Care
TABLE 18-2 PHARMACOLOGIC METHODS OF INTRAPARTUM PAIN MANAGEMENT
Postoperative Care
Evaluation
KEY CONCEPTS
References and Readings
Chapter 19 Nursing Care During Obstetric Procedures
Learning Objectives
Amniotomy
Indications
Risks
Prolapse of the Umbilical Cord
Infection
Abruptio Placentae
Technique
FIG 19-1 A, Disposable plastic membrane perforator (Amnihook). B, Hook end of plastic membrane perforator. C, Correct method of opening the package. D, Technique for artificial rupture of membranes.
Nursing Considerations
Obtaining Baseline Information
Assisting with Amniotomy
Providing Care after Amniotomy
Identifying Complications
CRITICAL THINKING EXERCISE 19-1
Promoting Comfort
Induction and Augmentation of Labor
Indications
Determining Whether Induction Is Indicated
Contraindications
TABLE 19-1 BISHOP SCORING SYSTEM TO EVALUATE THE CERVIX
Risks
Technique
Cervical Ripening
Medical Methods
TABLE 19-2 PROSTAGLANDIN PREPARATIONS FOR CERVICAL RIPENING AT TERM
Mechanical Methods
Oxytocin Administration
FIG 19-2 Intravenous (IV) pump setup for infusion from two IV lines. Fluid in the primary line (nonadditive, or maintenance line) contains no medication but is regulated by the infusion pump to maintain the correct rate. Oxytocin solution is regulated in the secondary line in the same pump, giving the nurse options to change or discontinue the oxytocin infusion rate while maintaining the primary line infusion at the same rate. A single IV line at the lower part of the pump connects to the woman’s infusion site.
Nursing Considerations
DRUG GUIDE: Oxytocin (Pitocin)
CRITICAL THINKING EXERCISE 19-2
Observing the Fetal Response
Observing the Mother’s Response
SAFETY ALERT: Signs of Tachysystole
Nursing Actions for Tachysystole
Version
Indications
External Cephalic Version
Internal Version
Contraindications
Risks
Technique
External Version
FIG 19-3 External version. Intravenous (IV) access is established in case of emergency or for some tocolytic drugs. If terbutaline is the tocolytic drug, it is given by subcutaneous injection.
Internal Version
Nursing Considerations
Providing Information
Promoting Maternal and Fetal Health
Reducing Anxiety
Operative Vaginal Birth
Indications
Contraindications
FIG 19-4 Obstetric forceps and their application.
Risks
Technique
FIG 19-5 Birth assisted with a vacuum extractor. The chignon is scalp edema that often forms under the suction cup when the vacuum extractor is used.
Nursing Considerations
FIG 19-6 A, Vacuum extractor with a low-profile cup that can be used for occiput posterior fetal positions. Note the green band that denotes adequate suction and the red band that warns of excess suction. B, Application of the low-profile cup to the fetal head in an occiput posterior position.
Episiotomy
Technique
Nursing Considerations
FIG 19-7 Types of episiotomies.
Cesarean Birth
VBAC
BOX 19-1 VAGINAL BIRTH AFTER CESAREAN BIRTH
Indications
Contraindications
Risks
Technique
Preparation
FIG 19-8 Skin (abdominal wall) incisions for cesarean birth.
Surgical incision ExemplarIncisions
FIG 19-9 Uterine incisions for cesarean birth. The abdominal and uterine incisions do not always match. VBAC, Vaginal birth after cesarean.
Nursing Considerations
Providing Emotional Support
BOX 19-2 NURSING CARE FOR A WOMAN HAVING A CESAREAN BIRTH
Before the Cesarean Birth
During the Recovery Period
NURSING CARE PLAN: Cesarean Birth
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Nursing Diagnoses to Consider
Teaching
Promoting Safety
Providing Postoperative Care
KEY CONCEPTS
References and Readings
Chapter 20 Postpartum Adaptations
Learning Objectives
Reproductive System
Involution of the Uterus
Descent of the Uterine Fundus
Afterpains
Etiology
Nursing Considerations
FIG 20-1 Involution of the uterus. Height of the uterine fundus decreases by approximately 1 cm/day. The fundus is no longer palpable by 14 days.
Lochia
Changes in Color
Amount
FIG 20-2 Guidelines for assessing the volume of lochia based on the amount of stain on a perineal pad in 1 hour.
TABLE 20-1 CHARACTERISTICS OF LOCHIA
Cervix
Vagina
BOX 20-1 LACERATIONS OF THE BIRTH CANAL
Perineum
Periurethral Area
Vaginal Wall
Cervix
Perineum
Discomfort
Nursing Considerations
Cardiovascular System
Cardiac Output
Plasma Volume
Blood Values
Coagulation
Gastrointestinal System
Urinary System
FIG 20-3 A full bladder displaces and prevents contraction of the uterus.
Musculoskeletal System
Muscles and Joints
Abdominal Wall
Integumentary System
FIG 20-4 Diastasis recti occurs when the longitudinal muscles of the abdomen separate during pregnancy.
FIG 20-5 Abdominal exercises for diastasis recti. A, The woman inhales and supports the abdominal wall firmly with her hands. B, Exhaling, the woman raises her head as she pulls the abdominal muscles together.
Neurologic System
Endocrine System
Resumption of Ovulation and Menstruation
Lactation
Weight Loss
Postpartum Assessments
Clinical Pathways
Initial Assessments
Chart Review
Need for Rho(D) Immune Globulin
Need for Vaccines
Rubella Vaccine
Pertussis Vaccine
DRUG GUIDE: Rubella Vaccine
Risk Factors for Hemorrhage and Infection
SAFETY ALERT: Postpartum Risk Factors
Hemorrhage
Infection
Focused Assessments after Vaginal Birth
Vital Signs
Blood Pressure
Orthostatic Hypotension
TABLE 20-2 OBSERVATIONS OF THE UTERINE FUNDUS AND NURSING ACTIONS
Pulse
Respirations
Temperature
Pain
Fundus
Lochia
PROCEDURE: Assessing the Uterine Fundus
Purpose
Perineum
Bladder Elimination
SAFETY ALERT: Signs of a Distended Bladder
PROCEDURE: Assessing the Perineum
Purpose
Breasts
Lower Extremities
Homans Sign
Edema and Deep Tendon Reflexes
Care in the Immediate Postpartum Period
Providing Comfort Measures
Ice Packs
Sitz Baths
Perineal Care
Topical Medications
Sitting Measures
Analgesics
Promoting Bladder Elimination
CRITICAL THINKING EXERCISE 20-1
Providing Fluids and Food
Preventing Thrombophlebitis
Nursing Care After Cesarean Birth
Assessment
Pain Relief
Respirations
Abdomen
Intake and Output
Interventions
The First 24 Hours
Providing Pain Relief
Overcoming the Effects of Immobility
Providing Comfort
After 24 Hours
Resuming Normal Activities
Assisting the Mother with Infant Care
Preventing Abdominal Distention
Nursing Care
Teaching After Birth
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Preparing for Teaching
Determining Teaching Topics
NURSING CARE PLAN: Postpartum Hypotension, Fatigue, and Pain
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Nursing Diagnoses to Consider
Teaching the Process of Involution
Teaching Self-Care
Handwashing
Breast Care for Lactating Mothers
Measures to Suppress Lactation
Care of the Cesarean Incision
Perineal Care
Kegel Exercises
Promoting Rest and Sleep
Rest at the Birth Facility
Rest at Home
Providing Nutrition Counseling
Food Supply
Diet
Promoting Regular Bowel Elimination
Promoting Good Body Mechanics
Exercise
Preventing Back Strain
Counseling about Sexual Activity
FIG 20-6 Postpartum exercises.
Instructing About Follow-up Appointments
Teaching about Signs and Symptoms that Should Be Reported
Ensuring that All Elements Have Been Taught
Documenting Teaching
Evaluation
The Process of Becoming Acquainted
FIG 20-7 The infant is quiet and alert during the initial sensitive period. The newborn gazes at the mother and responds to her voice and touch. The mother touches only with her fingertips at first.
Bonding
Attachment
FIG 20-8 The mother begins to stroke her infant as she progresses in becoming acquainted.
NURSING QUALITY ALERT: Reciprocal Attachment Behaviors
Maternal Touch
FIG 20-9 Mothers progress from exploratory touching to enfolding the infant. Their pleasure is enhanced by skin-to-skin contact.
FIG 20-10 The binding-in, or claiming, process includes the mother’s identification of her baby’s specific features, relating them to other family members. This mother states, “His long toes are exactly like mine.”
Verbal Behaviors
The Process of Maternal Role Adaptation
Puerperal Phases
Taking-In Phase
Taking-Hold Phase
Letting-Go Phase
CRITICAL THINKING EXERCISE 20-2
Maternal Role Attainment
Heading Toward a New Normal
Appreciating the Body
Settling In
Becoming a New Family
Redefining Roles
Role Conflict
NURSING CARE PLAN: Adaptation of the Working Mother
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Nursing Diagnoses to Consider
Major Maternal Concerns
Body Image
Smoking
Postpartum Blues
FIG 20-11 Fathers’ behaviors at initial contact with their infants often correspond to maternal behaviors. The intense fascination that fathers exhibit is called engrossment. Note the eye-to-eye contact between father and infant.
Expanding family ExemplarThe Process of Family Adaptation
Fathers
FIG 20-12 A, Although they may hesitate to touch the infant, children often want to be close. B, This boy’s relief and joy are obvious as he reclaims a favorite spot.
Siblings
Grandparents
FIG 20-13 Grandparents may develop strong bonds with grandchildren.
Factors Affecting Family Adaptation
Discomfort and Fatigue
Knowledge of Infant Needs
Previous Experience
Expectations about the Newborn
Maternal Age
Maternal Temperament
Temperament of the Infant
Availability of a Strong Support System
Other Factors
Cesarean Birth
Preterm or Ill Infant
Birth of Multiple Infants
NURSING QUALITY ALERT: Factors That Affect Adaptation
Cultural Influences on Adaptation
Communication
Dietary Practices
Health Beliefs
Nursing Care
Maternal Adaptation
Assessment
TABLE 20-3 ASSESSING MATERNAL ADAPTATION
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Assisting the Mother through Recovery Phases
“Mother” the Mother
Monitor and Protect
Listen to the Birth Experience
Foster Independence
Promote Bonding and Attachment
FIG 20-14 By teaching about the newborn and family, the nurse helps parents develop confidence in their ability to provide care for the infant.
Involve Parents in Infant Care
Evaluation
Nursing Care
Family Adaptation
Assessment
Fathers
Siblings
Support System
Nonverbal Behavior
Nursing Diagnosis and Planning
Expected Outcomes
TABLE 20-4 ASSESSING FAMILY ADAPTATION
Interventions
Teaching the Family about the Newborn
Infant Needs
Infant Signals
Helping the Family Adapt
Providing Anticipatory Guidance about Stress Reduction
Helping the Father Co-parent
Providing Ways to Reduce Sibling Rivalry
Identifying Resources
Evaluation
Postpartum Home and Community Care
Criteria for Discharge
EVIDENCE-BASED PRACTICE
Community-Based Care
KEY CONCEPTS
References and Readings
Chapter 21 The Normal Newborn: Adaptation and Assessment
Learning Objectives
Initiation of Respirations
Development of the Lungs
FIG 21-1 Internal causes of the initiation of respirations are the chemical changes that take place at birth. External causes of respirations include thermal, sensory, and mechanical factors.
Causes of Respirations
Chemical Factors
Mechanical Factors
Thermal Factors
Sensory Factors
Continuation of Respirations
Cardiovascular Adaptation: Transition from Fetal to Neonatal Circulation
Ductus Venosus
Foramen Ovale
Pulmonary Blood Vessels
Ductus Arteriosus
Changes at Birth
CRITICAL THINKING EXERCISE 21-1
Neurologic Adaptation: Thermoregulation
Newborn Characteristics Leading to Heat Loss
Methods of Heat Loss
FIG 21-2 Methods of heat loss.
Nonshivering Thermogenesis
FIG 21-3 Sites of brown fat in the neonate.
Effects of Cold Stress
Neutral Thermal Environment
FIG 21-4 Effects of cold stress.
BOX 21-1 HAZARDS OF COLD STRESS
Hyperthermia
Hematologic Adaptation
Factors Affecting the Blood
Blood Values
Erythrocytes and Hemoglobin
TABLE 21-1 LABORATORY VALUES IN THE NEWBORN
Hematocrit
Leukocytes
Risk of Clotting Deficiency
Gastrointestinal System
Stomach
Intestines
Digestive Enzymes
Stools
Hepatic System
Blood Glucose Maintenance
Conjugation of Bilirubin
Source and Effect of Bilirubin
Normal Conjugation
FIG 21-5 Sources of bilirubin and how it is removed from the body.
Risk Factors for Elevated Bilirubin
Hyperbilirubinemia
Physiologic Jaundice
Nonphysiologic (Pathologic) Jaundice
Jaundice Associated with Breastfeeding
Breastfeeding or Early Onset Jaundice
True Breast Milk Jaundice
Blood Coagulation
Iron Storage
Drug Metabolism
Urinary System
Kidney Development
Kidney Function
Fluid Balance
Water Distribution
BOX 21-2 INTAKE AND OUTPUT IN THE NEWBORN
First 3 to 5 Days of Life
After the First 3 to 5 Days
Insensible Water Loss
Urine Dilution and Concentration
Acid-Base and Electrolyte Balance
Immune System
IgG
IgM
IgA
Psychosocial Adaptation
Periods of Reactivity
First Period of Reactivity
Period of Sleep or Decreased Activity
Second Period of Reactivity
Behavioral States
Deep or Quiet Sleep State
Light or Active Sleep State
Drowsy State
Quiet Alert State
Active Alert State
Crying State
Early Assessments
SAFETY ALERT: Protection from Bloodborne Infections
TABLE 21-2 SUMMARY OF NEWBORN ASSESSMENT
History
Assessment of Cardiorespiratory Status
Airway
Respiratory Rate
Breath Sounds
Infant respiratory distress syndrome ExemplarSigns of Respiratory Distress
Tachypnea
PROCEDURE: Assessing Vital Signs in the Newborn
Purpose
Temperature
Respirations
Apical Pulse
Retractions
Flaring of the Nares
Cyanosis
FIG 21-6 Acrocyanosis.
Grunting
Seesaw or Paradoxical Respirations
Asymmetry
Choanal Atresia
Color
Pallor
Ruddy Color
Heart Sounds
Position
Rhythm and Murmurs
Brachial and Femoral Pulses
Blood Pressure
Capillary Refill
Assessment of Thermoregulation
FIG 21-7 The infant is held securely to prevent injury and obtain an accurate reading when taking the temperature.
BOX 21-3 NORMAL VITAL SIGNS IN THE NEWBORN
Assessing for Anomalies
Head
Molding
Fontanels
FIG 21-8 Palpation of the anterior fontanel. Note elevation of the head.
Caput Succedaneum
FIG 21-9 Caput succedaneum is an edematous area on the head from pressure against the cervix. It may cross suture lines.
Cephalhematoma
Face
Neck and Clavicles
FIG 21-10 A cephalhematoma is characterized by bleeding between the bone and its covering, the periosteum. It may occur on one or both sides and does not cross suture lines.
Cord
Extremities
Hands and Feet
Hips
Vertebral Column
Measurements
Weight
FIG 21-11 Assessment of the hips. Place the fingers over the infant’s greater trochanter and thumbs over the femur. Flex the knees and hips. A, Barlow test: adduct the hips, and apply gentle pressure down and back with the thumbs. In hip dysplasia, the examiner can feel the femoral head move out of the acetabulum. B, Ortolani test: abduct the thighs, and apply gentle pressure forward over the greater trochanter. A “clunking” sensation indicates a dislocated femoral head moving into the acetabulum. A hip click is normal from ligament movement.
FIG 21-12 Note the symmetry of gluteal and thigh creases.
FIG 21-13 A tape is placed alongside the infant to measure the length. A mark can be made on the bed at the head and foot and the distance between the marks measured.
Length
Head and Chest Circumference
CRITICAL THINKING EXERCISE 21-2
Assessment of Body Systems
Neurologic System
Reflexes
Sensory Assessment
Ears
Eyes
Sense of Smell and Taste
Other Neurologic Signs
FIG 21-14 Reflexes.
FIG 21-15 An imaginary line is drawn from the outer canthus of the eye to the ear. The line should intersect with the area where the upper ear joins the head.
TABLE 21-3 SUMMARY OF NEONATAL REFLEXES
BOX 21-4 RISK FACTORS FOR HYPOGLYCEMIA
Assessment of Hepatic Function
Blood Glucose
SAFETY ALERT: Signs of Hypoglycemia
PROCEDURE: Obtaining Blood Samples from the Newborn by Heel Puncture
Purpose
EVIDENCE-BASED PRACTICE
Bilirubin
BOX 21-5 RISK FACTORS FOR HYPERBILIRUBINEMIA
Gastrointestinal System
Mouth
Suck
Initial Feeding
Abdomen
Stools
Genitourinary System
Kidney Palpation
Urine
Genitalia
Female
Male
Integumentary System
Skin
FIG 21-16 The testes are palpated from front to back with the thumb and forefinger. Placing a finger over the inguinal canal holds the testes in place for palpation.
Color
Harlequin Color Change
Mottling
Vernix Caseosa
Lanugo
Milia
FIG 21-17 Lanugo is abundant on this slightly preterm infant.
FIG 21-18 Milia.
FIG 21-19 Erythema toxicum.
Erythema Toxicum
Birthmarks
FIG 21-20 Mongolian spots.
FIG 21-21 Nevus simplex (stork bite, salmon patch).
FIG 21-22 Nevus flammeus (port-wine stain).
Marks from Delivery
Other Skin Assessments
Documentation
Breasts
Hair and Nails
Assessment of Gestational Age
Assessment Tools
Neuromuscular Characteristics
Posture
Square Window
Arm Recoil
Popliteal Angle
FIG 21-23 New Ballard Score.
Scarf Sign
FIG 21-24 Posture in newborns. A, The healthy, full-term infant remains in a strongly flexed position. B, The preterm infant’s extremities are extended.
FIG 21-25 The square window sign is performed on an arm without an identification bracelet. The nurse flexes the wrist and measures the angle. A, Infant near full term. B, Preterm infant.
Heel to Ear
Physical Characteristics
Skin
Lanugo
FIG 21-26 Arm recoil. A, Arms flexed. B, Arms extended. C, Recoil for the full-term infant.
FIG 21-27 The popliteal angle is measured by flexing the thigh against the abdomen and extending the lower leg to the point of resistance. A, Full-term infant. B, Preterm infant.
FIG 21-28 Scarf sign. The nurse determines how far the arm will move across the chest and observes the position of the elbow when resistance is felt. A, Full-term infant. B, Preterm infant. (Note the many visible veins in the preterm infant and the absence of visible veins in the full-term infant.)
FIG 21-29 Heel to ear. The nurse grasps the foot and brings it up toward the ear. The score is recorded when resistance is felt. A, Full-term infant. B, Preterm infant.
FIG 21-30 Plantar creases begin to develop at the base of the toes and extend to the heel. A, The postterm infant has deep creases. B, The preterm infant has few creases on the entire foot.
Plantar Surface
Breasts
Eyes and Ears
FIG 21-31 The nurse places a finger on either side of the breast bud and measures the size. In the full-term infant, the areola is raised and the nipple is easily distinguished from surrounding skin. (Note the peeling skin.)
Genitals
FIG 21-32 Ear maturation. A, The nurse folds the ears and notes how quickly they return to position. B, Ears in the full-term infant are well formed and have instant recoil. C, In the preterm infant, ears show less incurving of the pinna and recoil slowly or not at all.
FIG 21-33 Female genitals. As the female fetus matures, the labia majora cover the labia minora and clitoris completely; in the preterm infant, these structures are not covered. A, Near-term infant. B, Preterm infant.
Scoring
Gestational Age and Infant Size
FIG 21-34 Male genitals. A, The full-term infant has a pendulous scrotum with deep rugae. B, In the preterm infant, the testes may not be descended and rugae are few.
Assessment of Behavior
Periods of Reactivity
Behavioral Changes
Orientation
Habituation
Self-Consoling Activities
Parents’ Response
KEY CONCEPTS
References and Readings
Chapter 22 The Normal Newborn: Nursing Care
Learning Objectives
Early Care
Administering Vitamin K
Providing Eye Treatment
DRUG GUIDE: Vitamin K1 (phytonadione)
FIG 22-1 Administration of ophthalmic ointment. The nurse gently cleans the eyes of blood or vernix wiping from inner to outer canthus. Then, placing a finger and thumb near the edge of each lid, the nurse gently presses against the periorbital ridges to open the eyes, avoiding pressure on the eye itself. A ribbon of ointment is squeezed into each conjunctival sac.
DRUG GUIDE: Erythromycin Ophthalmic Ointment
Nursing Care
Cardiorespiratory Status
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Interventions
Positioning and Suctioning
PROCEDURE: Using a Bulb Syringe
Purpose
Providing Continuing Care
Evaluation
Nursing Care
Thermoregulation
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Interventions
Preventing Heat Loss
Preparing the Environment Before Birth
Providing Immediate Care
FIG 22-2 Radiant warmers allow easy access to the infant without increasing heat loss caused by exposure. The nurse should be careful not to come between the infant and the overhead source of heat when giving care.
Providing Ongoing Prevention
Restoring Thermoregulation
Performing Expanded Assessments
Evaluation
Nursing Care
Hepatic Function
NURSING CARE PLAN: The Normal Newborn
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Nursing Diagnoses to Consider
Blood Glucose
Assessment
Nursing Diagnosis and Planning
Interventions
Maintaining Safe Glucose Levels
Repeating Glucose Tests
Providing Other Care
Evaluation
CRITICAL THINKING EXERCISE 22-1
Bilirubin
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Evaluation
Ongoing Assessments and Care
Providing Skin Care
Bathing
Cleansing the Diaper Area
Providing Cord Care
Assisting with Feedings
FIG 22-3 The cord clamp is removed when the end of the cord is dry and crisp. The clamp is cut (A) and separated (B).
Positioning the Infant
Protecting the Infant
Identifying the Infant
Preventing Infant Abduction
FIG 22-4 The nurse unwraps the infant to compare the infant’s identification band with the mother’s band. The mother may be asked to read the identification number on her band as the nurse checks the infant’s band or the nurse may look at both bands together.
BOX 22-1 PRECAUTIONS TO PREVENT INFANT ABDUCTIONS
FIG 22-5 The nurse uses a code to open the door to maternity units.
Preventing Infection
Circumcision
Reasons for Choosing Circumcision
Reasons for Rejecting Circumcision
Pain Relief
Methods
Nursing Considerations
Assisting in Decision Making
FIG 22-6 Circumcision using the Gomco (Yellen) clamp. The physician pulls the prepuce over a cone-shaped device that rests against the glans. A clamp is placed around the cone and prepuce and is tightened to provide enough pressure to crush the blood vessels. This procedure prevents bleeding when the prepuce is removed after 3 to 5 minutes.
FIG 22-7 Circumcision using the PlastiBell. The physician places the PlastiBell, a plastic ring, over the glans, draws the prepuce over it, and ties a suture around the prepuce and PlastiBell. This procedure prevents bleeding when the excess prepuce is removed. The handle is removed, leaving only the ring in place over the glans. The PlastiBell usually falls off in 7 to 14 days.
PATIENT-CENTERED TEACHING: How to Care for an Uncircumcised Penis
Providing Care during Circumcision
Evaluating Pain
Providing Postprocedure Care
FIG 22-8 The infant is placed on the circumcision board just before the procedure is begun.
FIG 22-9 An infant with a newly circumcised penis.
PATIENT-CENTERED TEACHING: How to Care for a Circumcision Site
PATIENT-CENTERED TEACHING: Techniques for Infant Care
Handling the Infant
Head Support
Positioning
Wrapping
Normal Body Processes
Breathing
Using a Bulb Syringe
Temperature
Using a Thermometer
Urine Output
Stool Output
Diarrhea
Skin Care
Cord
Diaper Area
Bathing
Sponge Baths
Tub Bath
Behavior
Sleep Phases
Awake Phases
Socialization
Teaching Parents
SAFETY ALERT: Signs of Complications after Circumcision
Nursing Care
Parents’ Knowledge of Newborn Care
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Determining Who Teaches
Setting Priorities
Using Various Teaching Methods
Modeling Behavior
Teaching Intermittently
Including the Father
Documenting Teaching
Incorporating Cultural Considerations
Providing for Follow-up Care
Evaluation
Immunization
Newborn Screening
Hearing Screening
Other Screening Tests
Discharge and Newborn Follow-Up Care
Discharge
Follow-up Care
Home Visits
Content of the Home Visit
Identification of Jaundice
Feeding Concerns
General Considerations in Home Visits
Outpatient Visits
Telephone Counseling
Follow-up Calls
Warm Lines
Telephone Techniques
Guidelines and Documentation
KEY CONCEPTS
References and Readings
Chapter 23 Newborn Feeding
Learning Objectives
Nutritional Needs of the Newborn
Calories
Nutrients
Water
BOX 23-1 DAILY CALORIE AND FLUID NEEDS OF THE NEWBORN
Breast Milk and Formula Composition
Breast Milk
Changes in Composition
Lactogenesis I
Lactogenesis II
Lactogenesis III
Nutrients
Protein
Carbohydrate
Fat
Vitamins
Minerals
Enzymes
Infection-Preventing Components
Effect of Maternal Diet
Formulas
Cow’s Milk
Formulas for Infants with Special Needs
Considerations in Choosing a Feeding Method
Breastfeeding
BOX 23-2 BENEFITS OF BREASTFEEDING
For the Infant
For the Mother
Formula Feeding
Combination Feeding
Factors Influencing Choice
Support from Others
Culture
Employment
Staff Knowledge
Other Factors
Normal Breastfeeding
Breast Changes during Pregnancy
Milk Production
Hormonal Changes at Birth
Prolactin
Oxytocin
Continued Milk Production
Preparation of Breasts for Breastfeeding
FIG 23-1 Effect of prolactin and oxytocin on milk production. When the infant begins to suckle at the breast, nerve impulses travel to the hypothalamus and cause the anterior pituitary to secrete prolactin to increase milk production. Suckling causes the posterior pituitary to secrete oxytocin, producing the let-down reflex, which releases milk from the breast. Oxytocin also causes the uterus to contract, which aids in involution.
FIG 23-2 Normal everted nipple and other types of nipples that may cause the infant difficulty in latching on. Nipples shown after stimulation.
Nursing Care
Breastfeeding
Assessment
Maternal Assessment
Breasts and Nipples
BOX 23-3 HUNGER CUES IN INFANTS
Knowledge
Assessment of Infant Feeding Behaviors
LATCH Scoring Tool
Nursing Diagnosis and Planning
Expected Outcomes
FIG 23-3 For the cradle hold, the mother positions the infant’s head at or near the antecubital space and level with her nipple, with her arm supporting the infant’s body. Her other hand is free to hold the breast. Once the infant is positioned, pillows or blankets can be used to support the mother’s arm, which may tire from holding the baby.
Interventions
Assisting with the First Feeding
Teaching Feeding Techniques
Position of the Mother and Infant
FIG 23-4 For the football or clutch hold, the mother supports the infant’s head in her hand, with the infant’s body resting on pillows alongside her hip. This method allows the mother to see the position of the infant’s mouth on the breast, helps her control the infant’s head, and is especially helpful for mothers with heavy breasts. This hold also avoids pressure against an abdominal incision.
FIG 23-5 The cross-cradle or modified cradle hold is helpful for infants who are preterm or have a fractured clavicle. The mother holds the infant’s head in the hand opposite the side on which the infant will feed and supports the infant’s body across her lap with her arm. The other hand holds the breast. The mother can guide the infant’s head to the breast and see the mouth on the breast during the feeding.
FIG 23-6 The side-lying position avoids pressure on episiotomy or abdominal incisions and allows the mother to rest while feeding. She lies on her side, with her lower arm supporting her head or placed around the infant. Pillows behind her back and between her legs provide comfort. Her upper hand and arm are used to position the infant on the side at nipple level and hold the breast. When the infant’s mouth opens to nurse, the mother draws the infant to her to insert the nipple into the mouth.
Position of the Mother’s Hands
Latch-On Techniques
Eliciting Latch-On
FIG 23-7 C position of hand on breast. The hand is positioned so the thumb is on top of the breast while the fingers support the breast from below. Note the flaring of the infant’s lips.
FIG 23-8 Position of infant’s mouth while suckling. When the nipple and areola are properly positioned in the infant’s mouth, the gums compress the areola instead of the nipple. The tongue is between the lower gum and the breast. The infant’s lips are flared outward.
Position of the Mouth
Suckling Pattern
Removal from the Breast
Frequency of Feedings
Length of Feedings
Preventing Problems
Teaching
Minimizing Interruptions
EVIDENCE-BASED PRACTICE
Formula Gift Packs
Formula Supplements
Insufficient Milk Supply
Increasing Confidence
Providing Resources
Evaluation
MOTHERS WANT TO KNOW: Is My Baby Getting Enough Milk?
Common Breastfeeding Concerns
Infant Problems
SAFETY ALERT: Infant Signs of Breastfeeding Problems
Sleepy Infant
Nipple Confusion
Latch-on Problems
Infant Complications
Jaundice
Prematurity
NURSING CARE PLAN: Breastfeeding an Infant with a Complication
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Late Preterm Infants
Illness and Congenital Defects
Maternal Concerns
SAFETY ALERT: Maternal Signs of Breastfeeding Problems
Common Breast Problems
Engorgement
Nipple Pain
Flat and Inverted Nipples
Plugged Ducts
Illness in the Mother
FIG 23-9 Note the cracked area on this nipple.
FIG 23-10 Rolling helps flat nipples become erect in preparation for latch-on.
PATIENT-CENTERED TEACHING: Solutions to Common Breastfeeding Problems
Problem: Sleepy Infant
Prevention
Solutions
Problem: Nipple Confusion
Prevention
Solution
Problem: Latch-on Difficulty
Prevention
Solution
Problem: Engorgement
Prevention
Solutions
Problem: Nipple Pain
Prevention
Solutions
Problem: Flat or Inverted Nipples
Prevention
Solutions
Drug Transfer to Breast Milk
FIG 23-11 To massage the breasts the mother places her hands against the chest wall with her fingers encircling the breasts. She gently slides her hands forward until the fingers overlap. The position of the hands is rotated to cover all breast tissue. Massaging with the fingertips in a circular motion over all areas of the breast also is helpful.
Conditions in which Breastfeeding Should Be Avoided
Previous Breast Surgery
Employment
Milk Expression and Storage
FIG 23-12 To express milk from the breast, the mother places her hand just behind the areola, with the thumb on top and the fingers supporting the breast. The tissue is pressed back against the chest wall; then the fingers and thumb are brought together and toward the nipple to cause the milk to flow. The action is repeated to simulate the infant’s suckling. Moving the hands around the areola allows compression of all areas and complete removal of milk from the breast. Compression should be gentle to avoid trauma.
FIG 23-13 The nurse helps the mother use an electric breast pump.
Hand Expression
Use of a Breast Pump
Milk Storage
Breastfeeding after Multiple Births
Weaning
Home Care
Other Concerns
Formula Feeding
Nursing Care
Formula Feeding
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Teaching about Formula
Types of Formula
Ready-to-Use
Concentrated Liquid
Powdered Formula
Equipment
Preparation
SAFETY ALERT: Formula Dilution
Explaining Feeding Techniques
Positioning
Burping
FIG 23-14 This mother holds her infant close during bottle feeding. The bottle is positioned so the nipple is filled with milk at all times. The father offers encouragement.
Frequency and Amount
Cautions
Infant Variations
Evaluation
Key Concepts
References and Readings
Chapter 24 The Childbearing Family with Special Needs
Learning Objectives
Adolescent Pregnancy
Incidence of Teenage Pregnancy
Factors Associated with Teenage Pregnancy
BOX 24-1 FACTORS THAT CONTRIBUTE TO TEENAGE PREGNANCY
Sex Education
FIG 24-1 Pregnant adolescent. Of teenage girls who become pregnant, approximately 1 in 5 have had a previous birth.
Preconception Counseling
Options When Pregnancy Occurs
Socioeconomic Implications of Teenage Pregnancy
Implications for Maternal Health
Implications for Fetal-Neonatal Health
The Teenage Expectant Father
Impact of Teenage Pregnancy on Parenting
Nursing Care
The Pregnant Teenager
Assessment
Physical Assessment
Cognitive Development
Knowledge of Infant Needs
Family Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Eliminating Barriers to Health Care
NURSING CARE PLAN: An Adolescent’s Responses to Pregnancy and Birth
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Nursing Diagnoses to Consider
Applying Teaching or Learning Principles
Nutrition counseling ExemplarCounseling
Nutrition
Self-Care
Stress Reduction
Attachment to the Fetus
Breastfeeding
Promoting Family Support
Providing Support during Labor
Providing Referrals
Evaluation
Delayed Pregnancy
Maternal and Fetal Implications of Delayed Pregnancy
Advantages of Delayed Childbirth
Disadvantages of Delayed Childbirth
FIG 24-2 Older primigravidas bring maturity and problem-solving skills to the maternal role, but they are at somewhat increased risk for physiologic problems related to pregnancy and birth.
Nursing Considerations
Preconception Care
Reinforcing and Clarifying Information
Facilitating Expression of Emotions
Providing Parenting Information
Substance Abuse
Incidence
Maternal and Fetal Effects
Tobacco
TABLE 24-1 MATERNAL AND FETAL OR NEONATAL EFFECTS OF COMMONLY ABUSED SUBSTANCES
Alcohol
Marijuana
Cocaine
Actions
Maternal and Fetal Effects
Neonatal Effects
Amphetamines and Methamphetamines
Maternal and Fetal Effects
Neonatal Effects
Antidepressants
Maternal and Fetal Effects
Neonatal Effects
Opioids
Fetal Effects
Neonatal Effects
Diagnosis and Management of Substance Abuse
Nursing Care
Maternal Substance Abuse
Antepartum Period
Assessment
CRITICAL TO REMEMBER: Behaviors Associated with Substance Abuse
Medical and Obstetric History
History of Substance Abuse
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Examining Attitudes
Preventing Substance Abuse
Communicating with the Woman
Helping the Woman Identify Strengths
Providing Ongoing Care
Evaluation
Intrapartum Period
Assessment
Cocaine
CRITICAL TO REMEMBER: Signs and Symptoms of Recent Cocaine Use
Heroin
Nursing Diagnosis and Planning
Expected Outcome
Interventions
Preventing Injury
Admitting Procedure
Setting Limits
Initiating Seizure Precautions
Maintaining Effective Communication
Providing Pain Control
Preventing Heroin Withdrawal
Evaluation
Postpartum Period
Birth of an Infant with Congenital Anomalies
Factors Influencing Emotional Responses of Parents
Timing and Manner of Being Told
Prior Knowledge of the Defect
FIG 24-3 Touching and cuddling between parents and the infant with a congenital anomaly foster attachment and help resolve the grieving process. This infant has anomalies of the hand and arm.
Type of Defect
Irreparable Defect
Grief and Mourning
Nursing Considerations
Assisting with the Grieving Process
Promoting Bonding and Attachment
Providing Accurate Information
Facilitating Communication
Participating in Infant Care
Planning for Discharge
Providing Referrals
Perinatal Loss
Early Pregnancy Loss
Concurrent Death and Survival in Multifetal Pregnancy
Previous Pregnancy Loss
Nursing Care
Pregnancy Loss
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Interventions
Allowing Expression of Feelings
Acknowledging the Infant
Presenting the Infant to the Parents
Preparing a Memory Box or Packet
Respecting Cultural Practices
Assisting with Other Needs
Providing Referrals
Evaluation
Adoption
Intimate Partner Violence
FIG 24-4 The woman who is abused by her partner lives with an ever-present risk of violence. Because they may not seek help, all women should be asked about abuse whenever they receive health care.
EVIDENCE-BASED PRACTICE
Effects of Intimate Partner Violence during Pregnancy
Factors that Promote Violence
Characteristics of the Abuser
TABLE 24-2 MYTHS AND REALITIES OF VIOLENCE AGAINST WOMEN
Cycle of Violence
Nurses’ Role in Prevention of Abuse
Nursing Care
The Battered Woman
Assessment
FIG 24-5 Types of behaviors evident in each step of the cycle of violence.
CRITICAL THINKING EXERCISE 24-1
CRITICAL TO REMEMBER: Cues Indicating Violence Against Women
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Listening
Developing a Personal Safety Plan
Affirming She Is Not to Blame
Providing Education
Providing Referrals
Evaluation
Key Concepts
References and Readings
Chapter 25 Pregnancy-Related Complications
Learning Objectives
Hemorrhagic Conditions of Early Pregnancy
Abortion
Spontaneous Abortion
FIG 25-1 Three types of spontaneous abortion.
Threatened Abortion
Manifestations
Therapeutic Management
Inevitable Abortion
Manifestations
Therapeutic Management
Incomplete Abortion
Manifestations
Therapeutic Management
Complete Abortion
Manifestations
Therapeutic Management
Missed Abortion
Manifestations
Therapeutic Management
Disseminated Intravascular Coagulation (Consumptive Coagulopathy)
Recurrent Spontaneous Abortion
Manifestations
Therapeutic Management
Nursing Considerations
CRITICAL THINKING EXERCISE 25-1
Ectopic Pregnancy
Incidence and Etiology
FIG 25-2 Sites of tubal ectopic pregnancy. Numbers indicate the order of prevalence. (1) Ampular, (2) Fimbrial, (3) Isthmic, (4) Interstitial.
BOX 25-1 RISK FACTORS FOR ECTOPIC PREGNANCY
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
Gestational Trophoblastic Disease (Hydatidiform Mole)
FIG 25-3 Hydatidiform mole.
Incidence and Etiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
Nursing Care
The Woman with a Hemorrhagic Condition of Early Pregnancy
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Providing Information about Tests and Procedures
Teaching Measures to Prevent Infection
Providing Dietary Information
Teaching Signs of Infection to Report
Emphasizing the Importance of Follow-up Care
Evaluation
Hemorrhagic Conditions of Late Pregnancy
Placenta Previa
Incidence and Etiology
FIG 25-4 The three classifications of placenta previa.
Manifestations
Therapeutic Management
Nursing Considerations
Home Care
Inpatient Care
Abruptio Placentae
Incidence and Etiology
Manifestations
Therapeutic Management
FIG 25-5 Types of abruptio placentae.
SAFETY ALERT: Signs and Symptoms Suggesting Concealed Hemorrhage in Abruptio Placentae
CRITICAL THINKING EXERCISE 25-2
Nursing Considerations
Nursing Care
The Woman with a Hemorrhagic Condition of Late Pregnancy
Assessment
NURSING CARE PLAN: Antepartum Bleeding
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Nursing Diagnoses to Consider
Nursing Diagnosis and Planning
Interventions
Monitoring for Signs of Hypovolemic Shock
SAFETY ALERT: Signs and Symptoms of Impending Hypovolemic Shock Caused by Blood Loss
Monitoring the Fetus
Promoting Tissue Oxygenation
Collaborating with the Physician for Fluid Replacement
Providing Emotional Support
Care Related to Surgery
Evaluation
Hyperemesis Gravidarum
Etiology
Therapeutic Management
Nursing Considerations
Reducing Nausea and Vomiting
Maintaining Nutrition and Fluid Balance
Providing Emotional Support
Preeclampsia ExemplarHypertension During Pregnancy
TABLE 25-1 CLASSIFICATIONS OF HYPERTENSION IN PREGNANCY
Preeclampsia
Risk Factors
BOX 25-2 RISK FACTORS FOR PREGNANCY-RELATED HYPERTENSION
Pathophysiology
Preventive Measures
Manifestations
Classic Signs
Additional Signs
FIG 25-6 Generalized edema is a possible sign identified with preeclampsia, although it may occur in both normal pregnancy or in a pregnancy complicated by another disorder. A, Facial edema may be subtle. B, Pitting edema of the lower leg.
TABLE 25-2 ASSESSMENT OF EDEMA
Symptoms
Therapeutic Management
Home Care for Mild Preeclampsia
Activity Restrictions
Fetal Activity
Blood Pressure
TABLE 25-3 MILD VS SEVERE PREECLAMPSIA
Weight
Urinalysis
Diet
Fetal Assessment
Inpatient Management for Severe Preeclampsia
Antepartum Management
Bed rest
Anticonvulsant Medications
DRUG GUIDE: Magnesium Sulfate
Antihypertensive Medications
Intrapartum Management
Postpartum Management
PROCEDURE: Assessing Deep Tendon Reflexes
Purpose
Deep Tendon Reflex Rating Scale
TABLE 25-4 NURSING ASSESSMENTS FOR PREECLAMPSIA AND MAGNESIUM TOXICITY
Therapeutic Management of Eclampsia
Nursing Care
The Woman with Preeclampsia
Assessment
Assessments for Magnesium Toxicity
Psychosocial Assessment
NURSING CARE PLAN: Preeclampsia
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Potential Complications to Consider
Nursing Diagnosis and Planning
Interventions
Interventions for Seizures
Initiating Preventive Measures
Monitoring for Signs of Impending Seizures
Preventing Seizure-Related Injury
Protecting the Woman and Fetus during a Seizure
Providing Information and Support for the Family
Interventions for Magnesium Toxicity
Monitoring for Signs of Magnesium Toxicity
Responding to Signs of Magnesium Toxicity
Evaluation
HELLP Syndrome
Chronic Hypertension
Incompatibility Between Maternal and Fetal Blood
Rh Incompatibility
Pathophysiology
Fetal and Neonatal Implications
FIG 25-7 The process of maternal sensitization to the Rh factor.
PARENTS WANT TO KNOW: About Rh Incompatibility
Prenatal Assessment and Management
DRUG GUIDE: Rho(D) Immune Globulin (RhoGAM, HypRho-D, Gamulin Rh)
Postpartum Management
ABO Incompatibility
Key Concepts
References and Readings
Chapter 26 Concurrent Disorders During Pregnancy
Learning Objectives
Diabetes Mellitus
Pathophysiology
Etiology
Effect of Pregnancy on Fuel Metabolism
Early Pregnancy
Late Pregnancy
Classification
BOX 26-1 CLASSIFICATION OF DIABETES MELLITUS
Incidence
Pathology
Preexisting Diabetes Mellitus
Maternal Effects
Fetal Effects
Congenital Malformation
Variations in Fetal Size
NURSING CARE PLAN: Pregnancy and Diabetes Mellitus
Focused Nursing Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Nursing Diagnoses to Consider
Neonatal Effects
Hypoglycemia
Hypocalcemia
Hyperbilirubinemia
Respiratory Distress Syndrome
Maternal Assessment
History
Physical Examination
Laboratory Tests
Fetal Surveillance
Therapeutic Management
Preconception Care
Diet
Self-Monitoring of Blood Glucose (SMBG)
Insulin Therapy
First Trimester
Second and Third Trimesters
During Labor
Postpartum
Timing of Delivery
Diabetes, gestational ExemplarGestational Diabetes Mellitus
Risk Factors
Identifying Gestational Diabetes Mellitus
Glucose Challenge Test
Oral Glucose Tolerance Test
Maternal, Fetal, and Neonatal Effects
TABLE 26-1 MAJOR EFFECTS OF DIABETES MELLITUS ON PREGNANCY
Therapeutic Management
Diet
Exercise
Glucose Level Monitoring
Fetal Surveillance
Nursing Considerations
Increasing Effective Communication
Providing Opportunities for Control
Providing Normal Pregnancy Care
Nursing Care
The Pregnant Woman with Diabetes Mellitus
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Teaching Self-Care Skills
Self-Monitoring of Blood Glucose
Insulin Administration
Continuous Subcutaneous Insulin Infusion
Teaching Dietary Management
Recognizing and Correcting Hypoglycemia and Hyperglycemia
Hypoglycemia ExemplarHypoglycemia
SAFETY ALERT: Signs and Symptoms of Maternal Hypoglycemia
Hyperglycemia
SAFETY ALERT: Signs and Symptoms of Maternal Hyperglycemia
Explaining Procedures, Tests, and Plan of Care
Evaluation
Heart failure ExemplarCardiac Disease
SAFETY ALERT: Signs and Symptoms of Congestive Heart Failure
Incidence and Classification
EVIDENCE-BASED PRACTICE
U.S. Preventive Services Task Force (USPSTF) CHD Screening Recommendations
Implications for Nursing Practice
Rheumatic Heart Disease
Congenital Heart Disease
Left-to-Right Shunt
Atrial Septal Defect
Ventricular septal defect ExemplarVentricular Septal Defect
Patent Ductus Arteriosus
Right-to-Left Shunt
Tetralogy of Fallot
Eisenmenger Syndrome
Mitral Valve Prolapse
Peripartum and Postpartum Cardiomyopathy
Diagnostic Evaluation of Cardiac Disease
Therapeutic Management
Class I and Class II Heart Disease
BOX 26-2 NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION OF HEART DISEASE
Class III and Class IV Heart Disease
Drug Therapy
Anticoagulants
Antidysrhythmics
Antiinfectives
Drugs for Heart Failure
Intrapartum Management
Postpartum Management
Nursing Considerations
Anemias
Iron deficiency (anemia) ExemplarIron Deficiency Anemia
Maternal Effects
Fetal and Neonatal Effects
Therapeutic Management
Folic Acid Deficiency (Megaloblastic) Anemia
Maternal Effects
Fetal and Neonatal Effects
Therapeutic Management
Sickle Cell Disease
Maternal Effects
Fetal and Neonatal Effects
Therapeutic Management
Thalassemias
Maternal Effects
Fetal and Neonatal Effects
Therapeutic Management
Immune Complex Diseases
Systemic Lupus Erythematosus
Antiphospholipid Syndrome
Hashimoto’s Thyroiditis
Seizure Disorders: Epilepsy
Infections During Pregnancy
TABLE 26-2 INFECTIONS THAT IMPACT PREGNANCY: SEXUALLY TRANSMITTED DISEASES, VAGINAL AND URINARY TRACT INFECTIONS
Viral Infections
Cytomegalovirus
Fetal and Neonatal Effects
Therapeutic Management
Rubella
Fetal and Neonatal Effects
Therapeutic Management
Varicella-Zoster Virus
Fetal and Neonatal Effects
Therapeutic Management
Herpesvirus Serotypes 1 and 2
Fetal and Neonatal Effects
Therapeutic Management
Parvovirus B19
Fetal and Neonatal Effects
Therapeutic Management
Hepatitis B
Fetal and Neonatal Effects
Therapeutic Management
Human Immunodeficiency Virus (HIV)
Pathophysiology
Fetal and Neonatal Effects
Prevention
Therapeutic Management
Nursing Considerations
BOX 26-3 RECOMMENDATIONS FOR PREVENTION OF PERINATAL HUMAN IMMUNODEFICIENCY VIRUS INFECTION OF THE INFANT
Nonviral Infections
Toxoplasmosis
Fetal and Neonatal Effects
Therapeutic Management
Group B Streptococcus Infection
Fetal and Neonatal Effects
Therapeutic Management
Tuberculosis
Fetal and Neonatal Effects
Therapeutic Management
TABLE 26-3 MEDICAL CONDITIONS AND THEIR EFFECT ON PREGNANCY
KEY CONCEPTS
References and Readings
Chapter 27 The Woman with an Intrapartum Complication
Learning Objectives
Dysfunctional Labor
Problems of the Powers
Ineffective Contractions
TABLE 27-1 PATTERNS OF LABOR DYSFUNCTION
Hypotonic Labor Dysfunction
Hypertonic Labor Dysfunction
Ineffective Maternal Pushing
Problems with the Passenger
Fetal Size
Macrosomia
Shoulder Dystocia
FIG 27-1 Methods used to relieve shoulder dystocia. A, McRoberts maneuver. The woman flexes her thighs sharply against her abdomen, which straightens the pelvic curve. A supported squat has a similar effect and adds gravity to her pushing efforts. B, Suprapubic pressure by an assistant pushes the fetal anterior shoulder downward to displace it from above the mother’s symphysis pubis. Fundal pressure should not be used because it will push the anterior shoulder more firmly against the mother’s symphysis.
Abnormal Fetal Presentation or Position
Rotation Abnormalities
CRITICAL THINKING EXERCISE 27-1
FIG 27-2 A hands-and-knees position helps the fetus rotate from a left occiput posterior (LOP) position to an occiput anterior position.
FIG 27-3 The “lunge” to one side promotes rotation of the fetal occiput from a posterior position to an anterior one.
Deflexion Abnormalities
Breech Presentation
Multifetal Pregnancy
FIG 27-4 Twins can present in any combination of presentations and positions.
Fetal Anomalies
Problems of the Passage
Pelvis
Maternal Soft Tissue Obstructions
Problems of the Psyche
Abnormal Labor Duration
Prolonged Labor
FIG 27-5 Pelvic shapes.
Precipitate Labor
Nursing Care
The Woman in Dysfunctional Labor
Intrauterine Infection
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Reducing the Risk for Infection
Identifying Infection
Evaluation
SAFETY ALERT: Signs Associated with Intrapartum Infection
Maternal Exhaustion
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Conserving Maternal Energy
Promoting Coping Skills
Evaluation
Premature Rupture of the Membranes
Etiology
Complications
Therapeutic Management
Determining True Membrane Rupture
Gestation Near Term
Preterm Gestation
Maternal Antibiotics
Nursing Considerations
Preterm Labor
SAFETY ALERT: Late Preterm is Not Term
EVIDENCE-BASED PRACTICE
Associated Factors
Manifestations
Preventing Preterm Birth
Community Education
TABLE 27-2 MATERNAL RISK FACTORS FOR PRETERM LABOR
During Pregnancy
Improving Access to Care
Identifying Risk Factors
Progesterone Supplementation
Promoting Adequate Nutrition
Educating Women and Their Partners about Preterm Labor
Empowering Women and Their Partners
Therapeutic Management
Predicting Preterm Birth
Cervical Length
Fetal Fibronectin
Infections
Identifying Preterm Labor
Stopping Preterm Labor
Initial Measures
Identifying and Treating Infections
Identifying Other Causes for Preterm Contractions
Limiting Activity
Hydrating the Woman
Tocolytics
Magnesium Sulfate
Calcium Antagonists
Prostaglandin Synthesis Inhibitors
TABLE 27-3 DRUGS USED IN PRETERM LABOR
Beta-Adrenergic Drugs
Accelerating Fetal Lung Maturity
DRUG GUIDE: Betamethasone, Dexamethasone
Nursing Care
The Woman in Preterm Labor
Psychosocial Concerns
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Interventions
Providing Information
Promoting Expression of Concerns
Teaching What May Occur during a Preterm Birth
Evaluation
Management of Home Care
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Caring for Children
NURSING CARE PLAN: Preterm Labor
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Additional Nursing Diagnoses to Consider
Maintaining the Household
Evaluation
Boredom
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Interventions
Identifying Appropriate Activities
Changing the Physical Surroundings
Evaluation
Prolonged Pregnancy
Complications
Therapeutic Management
Nursing Considerations
Intrapartum Emergencies
Placental Abnormalities
Prolapsed Umbilical Cord
Etiology
FIG 27-6 Variations of prolapsed umbilical cord.
Manifestations
Therapeutic Management
SAFETY ALERT: Factors that Increase a Woman’s Risk for a Prolapsed Umbilical Cord
FIG 27-7 Measures to relieve pressure on a prolapsed umbilical cord until delivery can take place.
Nursing Considerations
Uterine Rupture
FIG 27-8 Uterine rupture in the lower uterine segment.
Etiology
Manifestations
Therapeutic Management
Nursing Considerations
Uterine Inversion
Etiology
Manifestations
Therapeutic Management
Nursing Considerations
Anaphylactoid Syndrome
Trauma
Therapeutic Management
Nursing Considerations
KEY CONCEPTS
References and Readings
Pageburst Integrated Resource
Animation
Chapter 28 The Woman with a Postpartum Complication
Learning Objectives
Postpartum Hemorrhage
Early Postpartum Hemorrhage
FIG 28-1 A, When the uterus remains contracted, the placental site is smaller, so bleeding is minimal. B, If uterine muscles fail to contract around the endometrial arteries at the placental site, hemorrhage occurs.
Uterine Atony
Predisposing Factors
Manifestations
BOX 28-1 COMMON PREDISPOSING FACTORS FOR POSTPARTUM HEMORRHAGE
FIG 28-2 Technique for fundal massage.
Therapeutic Management
DRUG GUIDE: Methylergonovine (Methergine)
DRUG GUIDE: Carboprost Tromethamine (Hemabate, Prostin/15M)
Trauma
FIG 28-3 Bimanual compression. One hand is inserted in the vagina, and the other compresses the uterus through the abdominal wall.
Predisposing Factors
Lacerations
Hematomas
Therapeutic Management
Late Postpartum Hemorrhage
Predisposing Factors
Therapeutic Management
Hypovolemic Shock
Pathophysiology
Manifestations
Therapeutic Management
Nursing Considerations
Immediate Care
SAFETY ALERT: Signs of Postpartum Hemorrhage
Nursing Care
The Woman with Excessive Bleeding
Assessment
Uterine Atony
Trauma
TABLE 28-1 NURSING ASSESSMENTS FOR POSTPARTUM HEMORRHAGE
Nursing Diagnosis and Planning
Interventions
Preventing Hemorrhage
Collaborating with the Health Care Provider
Providing Support for the Family
Posthemorrhage Care
Home Care
CRITICAL THINKING EXERCISE 28-1
Evaluation
Subinvolution of the Uterus
Therapeutic Management
Nursing Considerations
Venous thrombosis ExemplarThromboembolic Disorders
Incidence and Etiology
Venous Stasis
BOX 28-2 FACTORS THAT INCREASE THE RISK OF THROMBOSIS
Hypercoagulation
Blood Vessel Injury
Additional Predisposing Factors
Superficial Venous Thrombosis
Manifestations
Therapeutic Management
Deep Venous Thrombosis
Diagnostic Evaluation
Therapeutic Management
Preventing Thrombus Formation
Initial Treatment
Subsequent Treatment
Nursing Care
The Mother with Deep Venous Thrombosis
Assessment
WOMEN WANT TO KNOW: How Do I Prevent Thrombosis (Blood Clots)?
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Monitoring for Signs of Bleeding
Explaining Continued Therapy
Helping the Family Adapt to Home Care
Evaluation
Pulmonary embolism ExemplarPulmonary Embolism
Pathophysiology
Manifestations
Therapeutic Management
Nursing Considerations
Monitoring for Signs
Facilitating Oxygenation
Seeking Assistance
Puerperal Infection
Definition
Pathophysiology
Etiology
TABLE 28-2 RISK FACTORS FOR PUERPERAL INFECTION
Specific Infections
Endometritis
Etiology
Manifestations
Therapeutic Management
Complications
Nursing Considerations
Wound Infection
Manifestations
Therapeutic Management
Nursing Considerations
Urinary Tract Infections
Etiology
Manifestations
Therapeutic Management
Nursing Considerations
Mastitis
Etiology
Manifestations
FIG 28-4 Mastitis typically occurs in the breast of a woman who breastfeeds after 2 to 3 weeks following birth.
Therapeutic Management
Nursing Considerations
Septic Pelvic Thrombophlebitis
Manifestations
Therapeutic Management
Nursing Care
The Woman with an Infection
Assessment
SAFETY ALERT: Signs and Symptoms of Postpartum Infection
Nursing Diagnosis and Planning
Expected Outcome
NURSING CARE PLAN: Risk for Postpartum Infection
Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Nursing Diagnoses to Consider
Postpartum psychosis ExemplarAffective Disorders
Postpartum Mood Disorders
Postpartum Depression
Incidence
Etiology
Manifestations
Impact on the Family
Therapeutic Management
Postpartum Psychosis
Bipolar II Disorder
Postpartum Anxiety Disorders
Nursing Care
Postpartum Affective Disorders
Assessment
SAFETY ALERT: Signs and Symptoms of Postpartum Depression
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Providing Anticipatory Guidance
EVIDENCE-BASED PRACTICE
Demonstrating Caring
Helping the Mother Verbalize Feelings
Enhancing Sensitivity to Infant Cues
Helping Family Members
Discussing Options and Resources
Evaluation
CRITICAL THINKING EXERCISE 28-2
KEY CONCEPTS
References And Readings
Chapter 29 The High-Risk Newborn: Problems Related to Gestational Age and Development
Learning Objectives
Care of High-Risk Newborns
Late Preterm Infants
Incidence and Etiology
Characteristics of Late Preterm Infants
FIG 29-1 The infant in a neonatal intensive care unit (NICU) is cared for by nurses with highly specialized skills.
Therapeutic Management
Nursing Considerations
Assessment and Care of Common Problems
Thermoregulation
Feedings
Discharge
Preterm Infants
Incidence and Etiology
Scope of the Problem
Causes
Prevention
Characteristics of Preterm Infants
Appearance
Behavior
Assessment and Care of Common Problems
Problems with Respiration
Assessment
Nursing Interventions
Working with Respiratory Equipment
FIG 29-2 The oxygen hood is one way of delivering oxygen to an infant who can breathe unassisted.
Positioning the Infant
Suctioning Secretions
Maintaining Hydration
Problems with Thermoregulation
Assessment
FIG 29-3 This preterm infant has mildly mottled skin and slight abdominal distention and retractions.
SAFETY ALERT: Signs of Inadequate Thermoregulation
Nursing Interventions
Maintaining a Neutral Thermal Environment
Weaning to an Open Crib
Problems with Fluid and Electrolyte Balance
Assessment
Urinary Output
Weight
Signs of Dehydration or Overhydration
SAFETY ALERT: Signs of Fluid Imbalance in the Newborn
Dehydration
Overhydration
Nursing Interventions
Problems with the Skin
Assessment
Nursing Interventions
Problems with Infection
Assessment
Nursing Interventions
Problems with Pain
Assessment
NURSING QUALITY ALERT: Common Signs of Pain in Infants
Nursing Interventions
EVIDENCE-BASED PRACTICE
Nursing Care
The Preterm Infant
Environmentally Caused Stress
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
SAFETY ALERT: Signs of Overstimulation in Preterm Infants
Oxygenation Changes
Behavior Changes
Interventions
Scheduling Care
Reducing Stimuli
Promoting Rest
Promoting Motor Development
Individualizing Care
Communicating Infants’ Needs
Evaluation
Nutrition
Assessment
Feeding Tolerance
Readiness for Nipple Feeding
NURSING QUALITY ALERT: Advancing to Nipple Feeding
Signs of Readiness for Nipple Feedings
Signs of Nonreadiness for Nipple Feedings
Adverse Signs during Nipple Feedings
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Administering Parenteral Nutrition
Administering Enteral Feedings
Administering Gavage Feedings
Administering Oral Feedings
Preparing for Feedings
FIG 29-4 The nurse feeds a preterm infant.
Giving Bottle Feedings
CRITICAL THINKING EXERCISE 29-1
Facilitating Breastfeeding
NURSING CARE PLAN: The Preterm Infant
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnoses to Consider
Making Ongoing Assessments
Evaluation
Parenting
Assessment
NURSING QUALITY ALERT: Signs that Bonding May Be Delayed
Nursing Diagnosis and Planning
Expected Outcomes
FIG 29-5 An infant in the NICU is surrounded by highly technologic equipment. This can be very frightening to parents at first. Preparing parents before they visit is an important nursing responsibility.
Interventions
Making Advance Preparations
Assisting Parents at Birth
Supporting Parents during Early Visits
BOX 29-1 INTRODUCING PARENTS TO THE NEONATAL INTENSIVE CARE UNIT SETTING
Before Parents Visit the Neonatal Intensive Care Unit (NICU)
When Parents Visit the NICU
Providing Information
Instituting Kangaroo Care (KC)
FIG 29-6 This mother holds her 27-week-gestation infant under her clothes against her skin as she gives kangaroo care.
Facilitating Interaction
FIG 29-7 To promote family bonding with the infant, parents are involved as much as possible in the care of their infant. This father bottle feeds his infant in a radiant warmer.
Increasing Parental Decision Making
FIG 29-8 The parents look on while the grandmother holds the infant in the NICU.
Alleviating Concerns
Helping with Ongoing Problems
Preparing for Discharge
Evaluation
Common Complications of Preterm Infants
Respiratory Distress Syndrome (RDS)
Pathophysiology
Manifestations
Therapeutic Management
Nursing Considerations
Bronchopulmonary Dysplasia (Chronic Lung Disease)
Intraventricular Hemorrhage
Pathophysiology
Manifestations
Therapeutic Management
Nursing Considerations
Retinopathy of Prematurity
Pathophysiology
Therapeutic Management
Nursing Considerations
Necrotizing Enterocolitis (NEC)
Pathophysiology
Manifestations
Therapeutic Management
Nursing Considerations
Postterm Infants
Scope of the Problem
FIG 29-9 The postmature infant has dry, cracked, peeling skin and no vernix.
Assessment
Therapeutic Management
Nursing Considerations
Small-for-Gestational-Age Infants
Etiology
Scope of the Problem
Characteristics of Small-for-Gestational-Age (SGA) Infants
Therapeutic Management
Nursing Considerations
Large-for-Gestational-Age Infants
Etiology
Scope of the Problem
Therapeutic Management
Nursing Considerations
KEY CONCEPTS
References and Readings
Chapter 30 The High-Risk Newborn: Acquired and Congenital Conditions
Learning Objectives
Respiratory Complications
Asphyxia
Manifestations
Infants at Risk
DRUG GUIDE: Naloxone Hydrochloride (Narcan)
Neonatal Resuscitation
Transient Tachypnea of the Newborn
Etiology
Manifestations
Therapeutic Management
PROCEDURE: Performing Resuscitation in Newborns
Purpose
Nursing Considerations
Meconium Aspiration Syndrome
Etiology
Manifestations
Therapeutic Management
Nursing Considerations
Persistent Pulmonary Hypertension of the Newborn
Etiology
Manifestations
Therapeutic Management
Nursing Considerations
Hyperbilirubinemia
Etiology
Therapeutic Management
Phototherapy
Exchange Transfusions
Procedure
Complications
Role of the Nurse
Nursing Care
The Infant with Hyperbilirubinemia
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Maintaining a Neutral Thermal Environment
NURSING CARE PLAN: The Infant with Jaundice
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Nursing Diagnoses to Consider
Providing Optimal Nutrition
Protecting the Eyes
Enhancing Response to Therapy
FIG 30-1 The infant receiving phototherapy is wearing eye patches to protect the eyes.
Detecting Complications
Teaching Parents
Evaluation
CRITICAL THINKING EXERCISE 30-1
Infection
Transmission of Infection
Sepsis ExemplarSepsis Neonatorum
Etiology
TABLE 30-1 COMMON INFECTIONS IN THE NEWBORN
Therapeutic Management
Diagnostic Testing
Treatment
Nursing Considerations
Assessment
Risk Factors
Signs of Infection
Nursing Interventions
Preventing Infection
SAFETY ALERT: Signs of Sepsis in the Newborn
General Signs
Respiratory Signs
Cardiovascular Signs
Gastrointestinal Signs
Central Nervous System Signs
Signs that May Indicate Advanced Infection
Providing Antibiotics
Providing Other Supportive Care
Supporting Parents
Infant of a Diabetic Mother
Scope of the Problem
FIG 30-2 Macrosomia is common in infants of diabetic mothers.
Characteristics of Infants of Diabetic Mothers (IDMs)
Therapeutic Management
Nursing Considerations
Assessment
Nursing Interventions
Polycythemia
Causes
Manifestations
Therapeutic Management
Nursing Considerations
Hypocalcemia
Etiology
Manifestations
Therapeutic Management
Nursing Considerations
Prenatal Drug Exposure
EVIDENCE-BASED PRACTICE
Identification of Drug-Exposed Infants
SAFETY ALERT: Signs of Intrauterine Drug Exposure
Behavioral Signs
Signs Relating to Feeding
Respiratory Signs
Other Signs
Therapeutic Management
Nursing Considerations
Feeding
Assessment
Nursing Interventions
Rest
Assessment
Nursing Interventions
Bonding
Assessment
NURSING CARE PLAN: The Drug-Exposed Infant
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Nursing Diagnoses to Consider
Nursing Interventions
Phenylketonuria
Etiology
Manifestations
Therapeutic Management
Nursing Considerations
KEY CONCEPTS
References and Readings
Chapter 31 Management of Fertility and Infertility
Learning Objectives
Contraception
Role of the Nurse
Considerations when Choosing a Contraceptive Method
FIG 31-1 Success of contraception is more likely when both the woman and her partner are involved in discussions. The nurse demonstrates filling a foam applicator.
TABLE 31-1 ADVANTAGES AND DISADVANTAGES OF MOST COMMON CONTRACEPTIVE METHODS
Safety
Protection from Sexually Transmitted Diseases
Effectiveness
Acceptability
TABLE 31-2 PREGNANCY RATES OF COMMON TYPES OF CONTRACEPTION: UNITED STATES
Convenience
Education Needed
Benefits
Side Effects
Effect on Spontaneity
Availability
Expense
Preference
Religious and Personal Beliefs
Culture
Other Considerations
Informed Consent
Adolescents
Adolescent Knowledge
Misinformation
Risk-Taking Behavior
Counseling Adolescents
FIG 31-2 Although many adolescents choose oral contraceptives, the nurse emphasizes the need to use condoms for protection against sexually transmitted diseases. Demonstrating with actual contraceptives increases understanding.
CRITICAL THINKING EXERCISE 31-1
Perimenopausal Women
Contraception ExemplarMethods of Contraception
Sterilization
Tubal Sterilization
Vasectomy
Intrauterine Devices (IUDs)
FIG 31-3 The Copper T 380A (ParaGard) intrauterine device (IUD) and the levonorgestrel intrauterine system (LNG-IUS or Mirena). Currently, IUDs are considered a very safe method for preventing pregnancy.
Action
Side Effects
Teaching
Hormonal Contraceptives
Hormone Implant
Hormone Injections
Oral Contraceptives
Progestin Only
Combination
Benefits, Risks, and Cautions
SAFETY ALERT: Cautions in Using Oral Contraceptives
BOX 31-1 POTENTIAL BENEFITS, DISADVANTAGES, AND RISKS OF ORAL CONTRACEPTIVES
Side Effects
Teaching
Blood Hormone Levels
Missed Doses
Postpartum and Lactation
Other Medications
Follow-up
Emergency Contraception
TABLE 31-3 ACHES∗Warning Signs of Oral Contraceptive Complications
Transdermal Contraceptive Patch
FIG 31-4 The vaginal contraceptive ring (NuvaRing) is 5 cm (2 in) across and 4 mm thick.
Contraceptive Vaginal Ring
Barrier Methods
Chemical Barriers
Mechanical Barriers
Male Condom
Female Condom
FIG 31-5 The female condom. A woman can protect herself from sexually transmitted diseases without relying on use of the male condom.
COUPLES WANT TO KNOW: What Is the Proper Way to Use Condoms?
Sponge
Diaphragm
WOMEN WANT TO KNOW: How to Use a Diaphragm
Cervical Cap
Lea’s Shield
Natural Family Planning Methods
Calendar or Rhythm Method
Standard Days Method
Cervical Mucus and Two-Day Method
TABLE 31-4 NATURAL FAMILY PLANNING METHODS
COUPLES WANT TO KNOW: How to Assess Cervical Mucus and Basal Body Temperature
Cervical Mucus Assessment
Basal Body Temperature (BBT)
Symptothermal Method
Abstinence
Least Reliable Methods of Contraception
Breastfeeding
Coitus Interruptus
Nursing Care
Choosing a Contraceptive Method
Assessment
Introducing the Subject
Determining the Woman’s Understanding
Assessing the Woman’s Satisfaction
Assessing Appropriate Choices
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Increasing Understanding of the Chosen Method
Teaching about Other Methods
Protecting Against Sexually Transmitted Diseases
Including the Woman’s Partner
Ongoing Teaching
Evaluation
Infertility ExemplarRole of the Nurse in Infertility Care
Extent of Infertility
Factors Contributing to Infertility
Factors in the Man
Abnormalities of the Sperm
Erectile dysfunction ExemplarAbnormal Erections
Abnormal Ejaculation
Abnormalities of Seminal Fluid
Factors in the Woman
Disorders of Ovulation
Abnormalities of the Fallopian Tubes
Abnormalities of the Cervix
Repeated Pregnancy Loss
Abnormalities of the Fetal Chromosomes
Abnormalities of the Cervix or Uterus
FIG 31-6 Types of uterine malformations that may cause infertility or repeated pregnancy loss.
Endocrine Abnormalities
Immunologic Factors
Environmental Agents
Infections
Evaluation of Infertility
Preconception Counseling
History and Physical Examination
INFERTILE COUPLES WANT TO KNOW: What Is Infertility Treatment Like?
General
Men
Women
History
Physical Examination
Diagnostic Tests
Therapies to Facilitate Pregnancy
TABLE 31-5 SELECTED DIAGNOSTIC TESTS IN INFERTILITY
TABLE 31-6 SELECTED MEDICATIONS FOR INFERTILITY THERAPY
Medications
Surgical Procedures
Therapeutic Insemination
Egg Donation
Surrogate Parenting
Assisted Reproductive Techniques
In Vitro Fertilization (IVF)
FIG 31-7 In vitro fertilization (IVF). Multiple oocytes are obtained by using a transvaginal or laparoscopic approach. The retrieved oocytes are mixed with prepared sperm, incubated approximately 18 hours, and then evaluated for cell division. Embryos are then transferred to the uterus immediately or after 48 to 96 more hours to allow 5 days of further cell division before implantation.
Gamete Intrafallopian Transfer (GIFT)
Zygote Intrafallopian Transfer (ZIFT)
Comparison of In Vitro Fertilization, Gamete Intrafallopian Transfer, and Zygote Intrafallopian Transfer
Intracytoplasmic Sperm Injection (ICSI)
Responses to Infertility
Assumption of Fertility
Growing Awareness of a Problem
Seeking Help for Infertility
Identifying the Importance of Having a Baby
Sharing Intimate Information
Considering Financial Resources
Ethical Issues
Committing to Involvement in Care
Reactions During Evaluation and Treatment
Influences on Decision Making
Social, Cultural, and Religious Values
Difficulty of Treatment
Probability of Success
Financial Concerns
Psychological Reactions
Guilt
Isolation
Depression
Stress on the Relationship
Outcomes After Infertility Therapy
Pregnancy Loss After Infertility Therapy
Parenthood After Infertility Therapy
Choosing to Adopt
Menopause After Infertility
Nursing Care
The Infertile Couple
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Interventions
Assisting Communication
Increasing the Couple’s Sense of Control
Reducing Isolation
Promoting a Positive Self-Image
Evaluation
Key Concepts
References and Readings
Chapter 32 Women’s Health Care
Learning Objectives
Women’s Health Initiative
Healthy People 2020
Health Maintenance
Health History
Physical Assessment
Health promotion ExemplarPreventive Counseling
BOX 32-1 HEALTH HISTORY
Personal History
Menstrual History
Obstetric History
Sexual History
Family History
Psychosocial History
Screening Procedures
Breast Self-Examination
Clinical Breast Examination
WOMEN WANT TO KNOW: How to Perform Breast Self-Examination (BSE)
Inspection
Palpation
TABLE 32-1 SCREENING PROCEDURES
BOX 32-2 RISK FACTORS FOR BREAST CANCER
Mammography
Vulvar Self-Examination
Pelvic Examination
External Organs
Speculum Examination
Bimanual Examination
FIG 32-1 Bimanual palpation provides information about the uterus, fallopian tubes, and ovaries.
Pap Test
Purpose
Procedure
Classification of Cervical Cytology
Rectal Examination
Breast Disorders
Benign Disorders of the Breast
Fibrocystic Breast Changes
Fibroadenoma
Ductal Ectasia
Intraductal Papilloma
Diagnostic Evaluation
Nursing Considerations
Breast cancer mortality ExemplarBreast cancer ExemplarMalignant Tumors of the Breast
Incidence
Predisposing Factors
Pathophysiology
Manifestations
Staging
Therapeutic Management
Surgical Treatment
Adjuvant Therapy
Radiation Therapy
Chemotherapy
Hormonal Therapy
Immunotherapy
Breast Reconstruction
Timing
Methods
Psychosocial Consequences of Breast Cancer
Nursing Considerations
Cardiovascular Disease
EVIDENCE-BASED PRACTICE
Recognition of Coronary Artery Disease (CAD)
Risk Factors
BOX 32-3 RISK FACTORS FOR CORONARY ARTERY DISEASE IN WOMEN
Prevention
Hypertension
Smoking Cessation
Diet and Glucose Control
Increased Activity
Aspirin
Menstrual Cycle Disorders
Amenorrhea
Primary Amenorrhea
Etiology
Therapeutic Management
Secondary Amenorrhea
Nursing Considerations
Abnormal Uterine Bleeding
Etiology
Management
Nursing Considerations
Pain Associated with the Menstrual Cycle
Mittelschmerz
Primary Dysmenorrhea
Manifestations
Etiology
Therapeutic Management
Endometriosis
FIG 32-2 Common sites of endometriosis.
Etiology
Pathophysiology
Manifestations
Therapeutic Management
Nursing Considerations
BOX 32-4 SYMPTOMS OF PREMENSTRUAL SYNDROME (PMS)
Physical Symptoms
Behavioral Symptoms
Premenstrual Syndrome (PMS)
WOMEN WANT TO KNOW: How to Relieve Symptoms of Premenstrual Syndrome (PMS)
Diet
Exercise
Stress Management
Sleep and Rest
Etiology
Manifestations
Therapeutic Management
Nursing Considerations
FIG 32-3 The woman uses a calendar to record occurrence and severity of premenstrual symptoms.
Elective Termination of Pregnancy
WOMEN WANT TO KNOW: Guidelines for Self-Care After Elective Termination of Pregnancy
Methods of Induced Abortion
Nursing Considerations Related to Elective Pregnancy Termination
Menopause
Age at Menopause
Physiologic Changes
Psychological Responses
Therapy for Menopause
Nursing Considerations Related to Menopause
Osteoporosis
Predisposing Factors
Manifestations
FIG 32-4 With progression of osteoporosis, the vertebral column collapses, causing loss of height and back pain. Dowager’s hump is the term used for this curvature of the upper back.
Prevention and Therapeutic Management
Drug Therapy
Calcium and Vitamin D
Exercise
Nursing Considerations
Nursing Diagnoses
Pelvic Floor Dysfunction
Vaginal Wall Prolapse
Cystocele
Enterocele
FIG 32-5 Three types of vaginal wall prolapse. A, Note bulging of bladder into the vagina. B, Note loop of bowel between rectum and uterus. C, Note bulging of rectum into vagina. More than one type of vaginal wall prolapse may exist in the same woman.
Rectocele
FIG 32-6 Three degrees of uterine prolapse.
Uterine Prolapse
Manifestations
Therapeutic Management
Nursing Considerations
Pelvic Exercises
Stress incontinence ExemplarUrinary Incontinence
Disorders of the Reproductive Tract
Benign Disorders
Cervical Polyps
Uterine Leiomyomas
Ovarian Cysts
SAFETY ALERT: Signs and Symptoms that Should Always Be Investigated
BOX 32-5 RISK FACTORS FOR CANCER OF THE REPRODUCTIVE ORGANS
Uterus
Cervix
Ovaries
Malignant Disorders
Manifestations
Diagnostic Evaluation
Therapeutic Management
Cervical Cancer
Endometrial Cancer
Ovarian Cancer
Infectious Disorders of the Reproductive Tract
Candidiasis
Sexually Transmitted Diseases (STDs)
Incidence
Types of Sexually Transmitted Diseases (STDs)
Trichomoniasis
Bacterial Vaginosis
Chlamydial Infection
WOMEN WANT TO KNOW: About Sexually Transmitted Diseases
Gonorrhea
Syphilis
Herpes Genitalis
Human Papillomavirus (HPV)
Acquired Immunodeficiency Syndrome
Nursing Considerations
Pelvic Inflammatory Disease (PID)
Etiology and Pathophysiology
Manifestations
Therapeutic Management
Nursing Considerations
Toxic Shock Syndrome
Nursing Considerations
Key Concepts
References and Readings
Pageburst Integrated Resource
Animation
Pediatric Nursing Care
Interactive Review – Pediatric Nursing Care
Chapter 33 Physical Assessment of Children
Learning Objectives
General Approaches to Physical Assessment
Infants from Birth to 6 Months
Infants from 6 to 12 Months
NURSING QUALITY ALERT: Adapting the Physical Examination to the Child
Toddlers
Preschoolers
FIG 33-1 During the assessment, the nurse allows the child to remain on her mother’s lap, enlisting the child’s trust and increasing the likelihood of a successful physical examination.
School-Age Children
Adolescents
Techniques for Physical Examination
Inspection
Palpation
NURSING QUALITY ALERT: Using the Hands for Palpation
Percussion
Auscultation
Smell
Sequence of Physical Examination
General Appearance
BOX 33-1 SOUNDS IDENTIFIED DURING PERCUSSION
History Taking
BOX 33-2 POTENTIAL INDICATORS OF CHILD ABUSE
CRITICAL THINKING EXERCISE 33-1
Recording Data
BOX 33-3 THE COMPLETE HISTORY
Vital Signs
BOX 33-4 PROBLEM-ORIENTED HISTORY
Temperature
TABLE 33-1 NORMAL VITAL SIGNS BY AGE
Pulse
Respirations
Blood Pressure
Pain Assessment
Anthropometric Measurement
Height
NURSING QUALITY ALERT: Importance of Anthropometric Measurements
Weight
Head Circumference
FIG 33-2 Measuring head circumference. The head circumference is measured from birth through age 36 months. The nurse uses a nonstretching tape and measures in a “hat band” position, just above the eyebrows and around the occipital prominence in the back. Chest circumference is also routinely measured in the newborn; it is usually smaller than the newborn’s head circumference.
Chest Circumference
Midarm Circumference
Triceps Skinfold
Use of Growth Charts
Skin, Hair, and Nails
Skin
Inspection
BOX 33-5 SKIN COLOR TERMINOLOGY
NURSING QUALITY ALERT: Skin Inspection in Dark-Skinned Children
Palpation
Hair
Nails
Lymph Nodes
FIG 33-3 Location of superficial lymph nodes.
Head, Neck, and Face
Head
BOX 33-6 CHARACTERISTICS OF ENLARGED LYMPH NODES AND MASSES
BOX 33-7 HEAD SHAPE TERMINOLOGY
FIG 33-4 Fontanels are inspected and palpated for size, tenseness, and pulsation.
Neck
Face
FIG 33-5 The child’s ears are inspected for alignment. Low-set ears could indicate an intellectual disability or renal anomalies.
Nose, Mouth, and Throat
Nose
Mouth and Throat
FIG 33-6 The frontal, ethmoid, and maxillary sinuses.
FIG 33-7 Sequence of eruption of primary and secondary teeth.
Eyes
Visual Acuity
BOX 33-8 TYPES OF EYE CHARTS
Color Vision
Peripheral Vision
Binocular Vision and Strabismus
Corneal Light Reflex Test
Field-of-Vision Test
FIG 33-8 Visual fields (cranial nerve II) are tested in each eye separately. One eye is covered as the child stares straight ahead. An object is slowly moved from the side of the head into the field of vision. The child says “now” upon first seeing the object.
Tests for Eye Muscle Function
External Eye
FIG 33-9 External structures of the eye.
FIG 33-10 The cover/uncover test detects small degrees of deviated eye alignment. With one eye covered, the child gazes straight ahead with the uncovered eye. The cover is then removed, and the eye should continue to stare straight ahead. Movement in either eye suggests muscle weakness. Extraocular muscle function is controlled by cranial nerves III, IV, and VI.
Ophthalmoscopic Examination
Ears
Hearing Acuity
Infant Assessment
Preschool and School-Age Assessment by Audiometry
FIG 33-11 Landmarks of the external ear.
Preschool, School-Age, and Adolescent Assessment: The Whisper Test
Conduction Tests (Tuning Fork Hearing Tests)
External Ear
Otoscopic Examination
Thorax and Lungs
Inspection
Palpation
FIG 33-12 Inspection of the tympanic membrane with the otoscope. The auditory canal is inspected before the otoscope is inserted to see the child’s tympanic membrane.
To straighten the ear canal of a child older than 3 years, the nurse pulls the child’s pinna up and back.
For children younger than 3 years, the pinna is pulled down and back.
Auscultation
FIG 33-13 Anatomic landmarks of the thorax in infants and children.
Adventitious Breath Sounds
FIG 33-14 Common alterations in chest configuration.
Heart
Inspection
FIG 33-15 To identify areas of fremitus, tenderness, symmetry, and depth and equality of expansion, the nurse palpates the child’s posterior and anterior chest. When palpating any area, warm hands increase the child’s comfort.
Palpation
FIG 33-16 Auscultation is most easily done when the child is quiet, so this part of the examination is best performed first if the child is quiet or asleep. To allay fears, the child can play with the stethoscope first and can be distracted with a toy while the nurse is listening. Warming the stethoscope bell increases comfort. Infants and toddlers can be held sitting upright in the parent’s lap while the nurse listens to breath sounds.
If the child is upset, the examiner may have to listen to breath sounds between cries. Keeping this child in the comfort of her mother’s arms lessens distress.
Auscultation
FIG 33-17 Sequence for listening to breath sounds.
TABLE 33-2 ORIGIN AND CHARACTERISTICS OF ADVENTITIOUS BREATH SOUNDS
Normal Rate and Rhythm
Extra Heart Sounds, Including Murmurs
Peripheral Vascular System
NURSING QUALITY ALERT: Normal Findings in Children
FIG 33-18 Location of the heart within the thorax in the infant and the older child, showing landmarks and areas of auscultation.
Breast
Abdomen
FIG 33-19 Abdominal quadrants and structures.
FIG 33-20 Abdominal contours. The contour of the abdomen provides an indication of the child’s overall nutritional state.
Inspection
Auscultation
Percussion
Palpation
Male Genitalia
FIG 33-21 When a boy’s scrotum is examined, the cremasteric reflex may cause the testes to withdraw into the inguinal canal. To prevent this reflex, the examiner can have the boy sit in a tailor position. The examiner uses one hand to block the inguinal canal and the other to palpate.
Female Genitalia
FIG 33-22 Postpubertal female genitalia.
Musculoskeletal System
Infants
Toddlers, Preschoolers, and School-Age Children
Adolescents
Range of Motion
Muscle Strength and Mass
Joints
Gait
BOX 33-9 SCREENING PROCEDURE FOR SCOLIOSIS
Adam’s position demonstrates the rib hump of structural scoliosis. Lateral curvature of thoracic and lumbar segments of the spine, usually with some rotation of involved vertebral bodies. Functional scoliosis is flexible; it is apparent with standing and disappears with forward bending. It may be compensatory for other abnormalities such as leg-length discrepancy.
Structural scoliosis is fixed; the curvature is evident both when the individual stands and when the individual bends forward. Note the rib hump with forward flexion. When the child is standing, unequal shoulder elevation, unequal scapulae, obvious curvature, unequal elbow level, and unequal hip level is seen.
Neurologic System
TABLE 33-3 GROSS MOTOR DEVELOPMENT IN THE INFANT: PROGRESSION TO WALKING
Cerebral Function
TABLE 33-4 ASSESSING CRANIAL NERVES∗
BOX 33-10 SPECIFIC CEREBRAL FUNCTION TESTS
Cranial Nerves
Cerebellar Function
Motor System
Sensory System
Reflex Status
Neurologic “Soft” Signs
BOX 33-11 CEREBELLAR FUNCTION: TESTS OF BALANCE AND COORDINATION
Conclusion and Documentation
TABLE 33-5 EVALUATING COMMON REFLEXES
BOX 33-12 TESTS FOR EVALUATING SENSORY FUNCTION
Primary Forms of Sensation
Cortical and Discriminatory Forms of Sensation
BOX 33-13 EXAMPLES OF NEUROLOGIC “SOFT” SIGNS
Key Concepts
References and Readings
Pageburst Integrated Resource
Animation
Chapter 34 Emergency Care of the Child
Learning Objectives
CLINICAL REFERENCE
General Guidelines for Emergency Nursing Care
Encouraging parents to remain with their child in the emergency setting can bolster the family’s coping.
PEDIATRIC EMERGENCY EQUIPMENT
PEDIATRIC EMERGENCY MEDICATIONS
BOX 34-1 WORKING WITH CHILDREN IN EMERGENCIES: DEVELOPMENTAL GUIDELINES
Infants
Toddlers
Preschoolers
School-Age Children
Adolescents
Growth and Development Issues in Emergency Care
The Infant
The Toddler
The Preschooler
The School-Age Child
The Adolescent
The Family of a Child in Emergency Care
Emergency Assessment of Infants and Children
Primary Assessment
Airway Assessment
NURSING QUALITY ALERT: Initial Observations for Triage
TABLE 34-1 PRIMARY ASSESSMENT IN PEDIATRIC EMERGENCIES
Breathing Assessment
Cardiovascular Assessment
Disability: Neurologic Assessment
Hypothermia ExemplarExposure
Secondary Assessment
Vital Signs
TABLE 34-2 SECONDARY ASSESSMENT IN PEDIATRIC EMERGENCIES
History and Head-to-Toe Assessment
Diagnostic Tests
Weight
Parent-Child Relationship
EVIDENCE-BASED PRACTICE
Cardiopulmonary Resuscitation of the Child
Airway and Breathing
Initial Assessment and Intervention
Obstructed Airway Management
SAFETY ALERT: Airway Obstruction in Children
Circulation
TABLE 34-3 HEALTH CARE PROFESSIONAL BASIC LIFE SUPPORT ELEMENTS FOR INFANTS AND CHILDREN
Shock ExemplarThe Child in Shock
Etiology
Hypovolemic Shock
Distributive Shock
Cardiogenic Shock
PATHOPHYSIOLOGY: Shock
Hypovolemic Shock
Distributive Shock
Cardiogenic Shock
BOX 34-2 MANIFESTATIONS OF SHOCK IN CHILDREN
Hypovolemic Shock
Distributive (Septic) Shock: Early
Septic Shock: Late
Cardiogenic Shock
Manifestations
SAFETY ALERT: Hypotension in Children with Shock
TABLE 34-4 ASSESSING A CHILD’S GENERAL APPEARANCE: “LOOKS GOOD” VERSUS “LOOKS BAD”
Diagnostic Evaluation
Therapeutic Management
Hypovolemic Shock
Distributive Shock
Cardiogenic Shock
Nursing Care
The Child in Shock
Assessment
Hypovolemic Shock
Distributive Shock
Cardiogenic Shock
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcomes
Interventions
Maintaining Tissue Perfusion
Ensuring Oxygenation
Preventing Infection
Enhancing Coping
Evaluation
Pediatric Trauma
Mechanism of Injury
Blunt Trauma
Motor Vehicle Trauma
Pedestrian Injury
Penetrating Trauma
Multiple Trauma
Primary Survey
FIG 34-1 Waddell’s triad of injuries.
Airway Assessment and Management
Breathing Assessment and Management
FIG 34-2 The child with multiple trauma injuries must remain on an immobilization board (long backboard) with a cervical immobilization device in place until the child has been evaluated for spinal injuries.
Circulation Assessment and Management
NURSING QUALITY ALERT: Artificial Airways
Disability
Secondary Survey
Obtaining a History of the Injury
Trauma Scoring
Assessing for Child Abuse
BOX 34-3 HISTORY OF INJURY QUESTIONS
For a Victim of a Motor Vehicle Collision
For a Victim of a Fall
For a Victim of a Penetrating Injury
BOX 34-4 Trauma Scoring Systems
Trauma Score (TS)
Revised Trauma Score (RTS)
Pediatric Trauma Score (PTS)
Nursing Considerations
The Child and Family
The Child during Recovery
Ingestions and Poisonings
CRITICAL THINKING EXERCISE 34-1
Incidence
Manifestations
Diagnostic Evaluation
Therapeutic Management
TABLE 34-5 COMMON POISONOUS SUBSTANCES
Removal of Dermal and Ocular Toxins
Diluting the Ingested Toxin
Activated Charcoal
Antidotes
Nursing Care
The Child Who Has Ingested a Toxic Substance
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcomes
Expected Outcome
Interventions
NURSING QUALITY ALERT: Assessment of Poison Ingestion
Evaluation
Environmental Emergencies
Animal, Human, Snake, and Spider Bites
Etiology
Animal and Human Bites
Snake and Spider Bites
Incidence
Manifestations
Animal and Human Bites
Snake Bites
Spider Bites
Therapeutic Management
Animal Bites
Snake Bites
Spider Bites
Nursing Considerations
Submersion Injuries (Near Drowning)
Etiology
Incidence
Manifestations
PATHOPHYSIOLOGY: Submersion Injury
Therapeutic Management
Prehospital Emergency Management
Hospital Management
Nursing Care
The Child with a Submersion Injury
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcomes
Expected Outcome
Expected Outcomes
Interventions
Providing Respiratory Support
Restoring Appropriate Circulatory Status
Identifying and Preventing Neurologic Consequences
Restoring Fluid Balance
Controlling Infection
Maintaining Nutritional Status
Providing Emotional Care for the Family
Evaluation
NURSING QUALITY ALERT: Needs Expressed by Families of Critically Ill Children
Heat-Related Illnesses
Incidence
Manifestations and Therapeutic Management
Nursing Considerations
TABLE 34-6 Heatstroke Exemplar HEAT-RELATED ILLNESS
CRITICAL THINKING EXERCISE 34-2
Dental Emergencies
Incidence and Etiology
Therapeutic Management
Nursing Considerations
KEY CONCEPTS
References and Readings
Pageburst Integrated Resource
Animation
Chapter 35 The Ill Child in the Hospital and Other Care Settings
Learning Objectives
Settings of Care
The Hospital
24-Hour Observation
Emergency Hospitalization
Outpatient and Day Facilities
Rehabilitative Care
The Medical-Surgical Unit
The Intensive Care Unit
School based services exemplarSchool-Based Clinics
FIG 35-1 Parents are encouraged to stay with their child whenever possible. This mother is holding her child in the postanesthesia recovery room, a setting that in the past was off limits to parents.
Community Clinics
FIG 35-2 Nurses today help take health care on the road to provide services to those who otherwise might not obtain them. This mobile van is stationed at a public school, where it offers health screenings and prevention services to children.
Home Care
Stressors Associated with Illness and Hospitalization
NURSING QUALITY ALERT: Children’s Responses to Illness
The Infant and Toddler
Separation Anxiety
BOX 35-1 STAGES OF SEPARATION
Fear of Injury and Pain
Loss of Control
FIG 35-3 Separation is one of the stressors of hospitalization that affects both child and parent. A toddler exhibits separation anxiety by reacting with protest to leaving her parent’s arms.
Rooming-in reduces the stress of hospitalization and provides opportunities for parent teaching.
The Preschooler
Separation Anxiety
Fear of Injury and Pain
NURSING QUALITY ALERT: Maintaining a Safe Place
Loss of Control
Guilt and Shame
The School-Age Child
Separation
Fear of Injury and Pain
FIG 35-4 Activities for the hospitalized child are important for growth and development, stress relief, socialization, and a sense of control. This model railroad “trainscape” in a pediatric hospital provides children and adults with a welcome respite from real-life stresses.
Hospitalized teens need to interact with their peers, as they do when they are well. A lounge area that is separate from the playroom used by younger children fulfills this need.
Loss of Control
The Adolescent
Separation
Fear of Injury and Pain
Loss of Control
Fear of the Unknown
Regression
Factors Affecting a Child’s Response to Illness and Hospitalization
Age and Cognitive Development
Parental Response
EVIDENCE-BASED PRACTICE
BOX 35-2 DEVELOPMENTAL APPROACHES TO THE HOSPITALIZED CHILD
Neonate
Infant
Toddler
Preschooler
School-Age Child
Adolescent
Preparing the Child and Family
Coping Skills of the Child and Family
Psychological Benefits of Hospitalization
Play for the Ill Child
FIG 35-5 To provide diversion and allow interaction with other children, the play therapist wheels the child, while still in bed with traction in place, to the playroom.
Playrooms
Therapeutic Play
FIG 35-6 Therapeutic play can be used to teach children about medical procedures or help them work through their feelings about what has happened to them in the health care setting. Child life specialists are often members of the team in children’s hospitals to provide expert guidance for therapeutic play. Art materials allow children to express their thoughts and feelings about illness and hospitalization.
Giving a doll an injection can help a child work through anxiety and anger about injections she may be receiving.
Emotional Outlet Play
Teaching through Play
Enhancing Cooperation through Play
Unstructured Play
Evaluation of Play
Admitting the Child to a Hospital Setting
Taking the History
FIG 35-7 To reduce the stress of unfamiliar surroundings and people, the nurse assesses the child who remains in the security of her mother’s arms.
Physical Examination
Initial Inspection
Baseline Data
NURSING CARE PLAN: The Child and Family in a Hospital Setting
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
The Ill Child’s Family
Parents
FIG 35-8 The family of a hospitalized child may not speak the prevailing language. Interpreters are available (on-site or on-call) at many hospitals to help parents and children communicate with health care team members. This arrangement provides a familiar link to the parents’ and child’s culture and language.
PARENTS WANT TO KNOW: Information for Discharge
CRITICAL THINKING EXERCISE 35-1
Siblings
BOX 35-3 CARING FOR THE SIBLINGS OF AN ILL OR HOSPITALIZED CHILD
Factors that Add to the Stress of Siblings
Nursing Care Guidelines for Meeting the Needs of Siblings
Siblings of ill children may experience jealousy, insecurity, resentment, confusion, and anxiety. The nurse can help them cope by assessing and implementing care to meet their needs.
KEY CONCEPTS
References and Readings
Chapter 36 The Child with a Chronic Condition or Terminal Illness
Learning Objectives
Chronic Illness Defined
The Family of the Child with Special Health Care Needs
Family Dynamics and Impact on the Family
BOX 36-1 COMMON CHRONIC CONDITIONS OF CHILDHOOD
Coping and the Grieving Process
The Child with Special Health Care Needs
Coping and Growth and Development Concerns
BOX 36-2 THE ILLNESS EXPERIENCE: THE CHILD AND ADOLESCENT
Infant
Toddler
Preschooler
School-Age Child
Adolescent
Coping and Parental Responses to Developmental Issues
NURSING QUALITY ALERT: Goals for Chronic Care
Goals for the Child
Goals for the Family
The Child With a Chronic Illness
FIG 36-1 The nurse or a child life specialist can use therapeutic play, medical play, and therapeutic art to enhance self-expression, education, and growth and development.
Ongoing Care
Education
Communication
Caring for Parents
Grief Education and Support
Cultural and Religious Beliefs
Referrals
Schooling
The Nurse as Liaison
Caring for Siblings
FIG 36-2 Chronic illness is stressful for the siblings of an ill child. Siblings’ emotional needs may be overlooked. Siblings should be given the opportunity to express negative feelings, such as anger and jealousy, through therapeutic art and play, as well as through physical outlets, such as striking a punching bag, as this little girl is doing.
NURSING QUALITY ALERT: Nursing Care for Children with Chronic Conditions and Their Families
NURSING CARE PLAN: The Child with a Chronic Condition in the Community Setting
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Because more children with chronic conditions are living longer, more attend public school. However, these children are likely to be frequently hospitalized, so hospitals often provide an area where teachers can help them with their studies.
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
CRITICAL THINKING EXERCISE 36-1
Death dying ExemplarThe Terminally Ill or Dying Child
Coping and the Child’s Concept of Death
Infants and Toddlers
TABLE 36-1 THE CHILD’S CONCEPT OF DEATH
Preschoolers
School-Age Children
Adolescents
Coping and Responses to Death and Dying
The Child’s Response
The Parents’ Response
The Siblings’ Response
Caring for the Dying Child
Nursing Professionalism and Boundaries
FIG 36-3 The family of the child with a terminal condition needs compassion and support from the nurse. Nursing care includes physical care and support of the family’s care giving efforts, and assistance with the grieving process.
Communication with patient or family ExemplarCommunication
Family Dynamics, Beliefs, and Practices
BOX 36-3 RESOURCES ON DEATH AND DYING FOR FAMILIES AND HEALTH PROFESSIONALS
Internet Resources
Book Selections for Children
Book Selections for Adults—Parents and Nurses
Book Selections for Nurses
Pain Control
Hospice Care
The Dying Process and the Time of Death
Privacy for the Child and Family
Changes in Family Routines
Family Concerns about Oral Intake
Fluids and Oral Care
Responsiveness and Communication
Indicators of Imminent Death
NURSING QUALITY ALERT: Nursing Care for the Dying Child and the Child’s Family
NURSING CARE PLAN: The Terminally Ill or Dying Child
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
The Family after Death
The Nurse’s Response to the Dying Child
KEY CONCEPTS
References and Readings
Chapter 37 Principles and Procedures for Nursing Care of Children
LEARNING OBJECTIVES
Preparing Children for Procedures
Explaining Procedures
SAFETY ALERT: Standard Precautions
BOX 37-1 TIPS FOR PREPARING AND SUPPORTING CHILDREN UNDERGOING PROCEDURES
Before the Procedure
During the Procedure
After the Procedure
FIG 37-1 Because a child should feel that the hospital room is a safe place, a treatment room is used for invasive or painful procedures. The parent is present, not to restrain the child, but to provide emotional support.
Consent for Procedures
NURSING QUALITY ALERT: Preparation for Procedures
Holding and Transporting Infants and Children
Safety Issues in the Hospital Setting
FIG 37-2 Methods of transporting infants and children. The nurse carries the infant securely, anticipating sudden movement. A, Cradle carry. B, Football hold. C, Over-the-shoulder carry, which can be used until the infant is 6 to 7 months old. D, Transport can be fun for young children, especially when it is on wheels.
SAFETY ALERT: Using Restraints
Infection Control
Hand Hygiene
Standard Precautions
Implementing Precautions
Family Teaching
Bathing Infants and Children
Special Considerations
FIG 37-3 Using hand to support infant’s neck and head. When giving an infant a tub bath, the nurse supports the infant’s body at all times.
Documentation
Parent Teaching
Oral Hygiene
Feeding
Special Considerations
Documentation
Parent Teaching
Vital Signs
Measuring Temperature
FIG 37-4 Four methods of temperature measurement.
NURSING QUALITY ALERT: Measuring Temperature
Measuring Pulse
Evaluating Respirations
Measuring Blood Pressure
FIG 37-5 Locating the apical pulse. Apical pulse is lateral to the left midclavicular line (MCL) and fourth intercostal space (ICS) in children younger than 7 years and to the left MCL and fifth ICS in children older than 7 years.
FIG 37-6 Blood pressures can be measured in the upper arm, lower arm, thigh, calf, or ankle. An appropriate-size cuff must be used to obtain accurate results.
TABLE 37-1 RECOMMENDED DIMENSIONS FOR BLOOD PRESSURE CUFF BLADDERS
Documenting Vital Sign Measurement
Preparing the Child and Family
Parent Teaching
NURSING QUALITY ALERT: Measuring Vital Signs
Special Considerations: Cardiorespiratory Monitors
Fever-Reducing Measures
Description of Fever
Medications and Environmental Management
DRUG GUIDE: Acetaminophen (Tylenol, Tempra, Panadol)
Specimen Collection
Urine Specimens
Voided Specimens
Urinary Catheterization
PROCEDURE: Urine Specimen Collection from the Incontinent Child
Purpose
Home Adaptations
PROCEDURE: Urinary Catheterization
Purpose
Home Adaptations
BOX 37-2 GUIDELINES FOR URINARY CATHETER SELECTION BY AGE
Stool Specimens
PROCEDURE: Venipuncture
Purpose
Blood Specimens
Jugular and Femoral Venipuncture
FIG 37-7 Two additional sites for obtaining blood specimens from infants and young children are the large superficial external jugular veins and the femoral veins.
Capillary Blood Sampling
PROCEDURE: Capillary Blood Sampling
Purpose
Sputum Specimens
Throat and Nasopharyngeal Specimens
PROCEDURE: Nasal Washing
Purpose
PROCEDURE: Throat or Nasopharyngeal Culture
Purpose
SAFETY ALERT: Throat Cultures
Cerebrospinal Fluid Specimens
Bone Marrow Aspiration
Gastrointestinal Tubes and Enteral Feedings
Tube Route and Placement
Tube Selection
Safety Issues Related to Tube Placement
PROCEDURE: Feeding Tube Insertions
Purpose
Home Adaptations
Contraindications to Tube Placement
Enteral Feedings
NURSING QUALITY ALERT: Enteral Feedings
PROCEDURE: Administering Enteral Feedings (via the Orogastric, Nasogastric, or Nasointestinal Route)
Purpose
Intermittent Feedings (Bolus)
Continuous Feedings
Home Adaptations
Gastrostomy Tubes and Buttons
CRITICAL THINKING EXERCISE 37-1
Enemas
Enema Administration
Solutions and Volumes
Ostomies
TABLE 37-2 RECOMMENDED VOLUME AND DEPTH FOR ENEMA TIP INSERTION, BY AGE
Oxygen Therapy
Oxygen Administration
FIG 37-8 When administering oxygen to children, special consideration is given to the size and type of equipment selected, and the needs of the child and family for education and support. A, Nasal cannula. B, Simple facemask.
Documentation
Parent Teaching
FIG 37-9 A, The pulse oximeter is a reliable, noninvasive method that allows periodic or continuous measurement of blood oxygen saturation. The sensor is applied to a child’s finger (B) or an infant’s toe (C).
Assessing Oxygenation
PROCEDURE: Pulse Oximetry
Purpose
NURSING QUALITY ALERT: Assisting with Arterial Blood Gas Sampling
Tracheostomy Care
Suctioning
Stoma Care
PROCEDURE: Suctioning a Tracheostomy Tube
Purpose
Home Adaptations
PROCEDURE: Care of a Tracheostomy
Purpose
Home Adaptations
Surgical Procedures
Preparation for Surgery
Preoperative Medication and Anesthesia Induction
BOX 37-3 GUIDELINES FOR PREOPERATIVE FASTING
Postanesthesia Care
Postoperative Care
KEY CONCEPTS
References and Readings
Pageburst Integrated Resource
Animation
Chapter 38 Medication Administration and Safety for Infants and Children
LEARNING OBJECTIVES
Pharmacokinetics in Children
Absorption
Oral Route
FIG 38-1 Physiologic differences between children and adults affect drug absorption, metabolism, distribution, and excretion. These differences are most significant for infants.
Gastric Acidity
Gastric Emptying
Gastrointestinal Motility
Enzyme Activity
Other Routes
Distribution
Differences in Body Fluids
Differences in Fat Percentages
Differences in Proteins
Blood-Brain Barrier
Metabolism
Excretion
Concentration
Psychological and Developmental Factors
PARENTS WANT TO KNOW: Medication Administration and Parent Roles
Infants
Toddlers and Preschoolers
School-Age Children
Adolescents
Calculating Dosages
FIG 38-2 Nomogram for calculating body surface area (BSA), which is used for determining medication dosages for infants and children.
Medication Administration Procedures
Medication Reconciliation
Administering Oral Medications
CRITICAL THINKING EXERCISE 38-1
Preparation
FIG 38-3 Administering an oral medication to an infant using an oral syringe.
CRITICAL THINKING EXERCISE 38-2
Administration
FIG 38-4 Two methods of holding a child for an intramuscular (IM) injection at the vastus lateralis site.
Alternative Routes for Oral Medications
Administering Injections
Intramuscular Injections
TABLE 38-1 PREFERRED INTRAMUSCULAR INJECTION SITES IN CHILDREN
SAFETY ALERT: Guidelines for Maximum Safe Volumes for Intramuscular Injections∗
CRITICAL THINKING EXERCISE 38-3
Subcutaneous Injections
Intradermal Injections
Rectal Administration
FIG 38-5 Two of the preferred subcutaneous injection sites for infants and toddlers.
FIG 38-6 Intradermal injection site and technique.
Vaginal Administration
Ophthalmic Administration
Otic Administration
Nasal Administration
Topical Administration
PROCEDURE: Administering Otic Drops
Purpose
PROCEDURE: Administering an Ophthalmic Preparation
Purpose
Inhalation Therapy
FIG 38-7 Administration of nebulized medication to an infant.
Intravenous Therapy
Intravenous Catheter Insertion
FIG 38-8 Venous access sites in children.
PROCEDURE: Using a Metered-Dose Inhaler (MDI)
Purpose
NURSING QUALITY ALERT: Using EMLA Anesthetic Cream
FIG 38-9 Intravenous (IV) sites in children are secured and well-protected to allow for activities and prevent dislodging the IV catheter. A foot vein is an acceptable IV site for an infant who is not walking or crawling. A padded arm board gently limits movement of the hand, and a plastic shield allows visibility yet keeps the IV site intact.
Intravenous Catheter Monitoring
Intravenous Infusion Monitoring
FIG 38-10 Alaris® System intravenous (IV) infusion pump.
Infusion Rates and Methods
Administering Intravenous Medications
Intravenous Bolus Administration
BOX 38-1 DAILY MAINTENANCE FLUID REQUIREMENTS AND RATES Formula for Calculating Daily Fluid Requirements∗
Example 1:
Example 2:
Example 3:
Intravenous Intermittent Infusion Administration
CRITICAL THINKING EXERCISE 38-4
Venous Access Devices
Intermittent Infusion Ports
Central Venous Access Devices
Administration of Blood Products
Child and Family Education
PARENTS WANT TO KNOW: Medication Administration at Home
KEY CONCEPTS
References and Readings
Pageburst Integrated Resource
Animation
Chapter 39 Pain Management for Children
LEARNING OBJECTIVES
Definitions and Theories of Pain
Gate Control Theory
Acute and Chronic Pain
Research on Pain in Children
TABLE 39-1 PAIN AND PAIN MANAGEMENT IN CHILDREN: MYTHS AND REALITIES
Obstacles to Pain Management in Children
BOX 39-1 PAIN MANAGEMENT RESOURCES ON THE INTERNET
Assessment of Pain in Children
BOX 39-2 INDICATORS OF PAIN ACCORDING TO DEVELOPMENTAL LEVELS
Neonate and Infant
Toddler
Preschooler
School-Age Child
Adolescent
Assessment According to Developmental Level
Neonates and Infants
Toddlers
FIG 39-1 Infant total body response to pain with arms thrashing, tremors, and vigorous crying.
CRITICAL THINKING EXERCISE 39-1
Preschoolers
School-Age Children
FIG 39-2 Toddlers and preschoolers may express pain by guarding or touching the painful area. The toddler pulling on his ear is a characteristic expression of ear pain from otitis media.
FIG 39-3 School-age children may become very quiet and withdrawn when ill or in pain. The child with asthma is not attentive or active; his mother knew that something was wrong because of his withdrawn behavior.
Adolescents
TABLE 39-2 PAIN ASSESSMENT TOOLS
NURSING QUALITY ALERT: Assessing Pain in Children
Assessment Tools
Non-Pharmacologic and Pharmacologic Pain Interventions
FIG 39-4 A, The Hispanic version of the Oucher pain scale. B, The African-American version.
FIG 39-5 FACES Pain Rating Scale. Explain to the child that each face is for a person who feels happy because he or she has no pain (hurt) or sad because he or she has some or a lot of pain. Ask the child to choose the face that best describes his or her own pain.
FIG 39-6 Adolescent and Pediatric Pain Tool (APPT). Use with 8- to 17-year-olds.
BOX 39-3 PAIN EXPERIENCE HISTORY
Child Form∗
Parent Form
Non-Pharmacologic Interventions
PATIENT-CENTERED TEACHING: Pain Management for Children at Home
FIG 39-7 The boy listens to music, which serves as a distraction to refocus attention and reduce pain.
TABLE 39-3 NON-PHARMACOLOGIC PAIN RELIEF TECHNIQUES
Pharmacologic Interventions
Administration of Analgesics
NURSING QUALITY ALERT: Disadvantages of Intramuscular (IM) Analgesics
Patient-Controlled Analgesia
FIG 39-8 Patient-controlled analgesia (PCA) allows the child greater control over her own pain management.
BOX 39-4 ASPECTS OF PATIENT-CONTROLLED ANALGESIA (PCA) ORDERS
Topical Anesthetic Agents
Acetaminophen and Antiinflammatory Drugs
DRUG GUIDE: Ibuprofen
DRUG GUIDE: Acetaminophen
DRUG GUIDE: Ketorolac
Opioids
DRUG GUIDE: Codeine
DRUG GUIDE: Hydrocodone
DRUG GUIDE: Oxycodone
DRUG GUIDE: Morphine
DRUG GUIDE: Hydromorphone
DRUG GUIDE: Fentanyl
Procedural Sedation
NURSING QUALITY ALERT: Pain Management for Children
DRUG GUIDE: Methadone
Epidural Analgesia
KEY CONCEPTS
References and Readings
Chapter 40 The Child with a Fluid and Electrolyte Alteration
LEARNING OBJECTIVES
Clinical Reference
Review of Fluid and Electrolyte Imbalances in Children
PEDIATRIC DIFFERENCES RELATED TO FLUID AND ELECTROLYTE BALANCE
Infants
Infants and Young Children
Infants and Children
Alterations in Acid-Base Balance in Children
NURSING QUALITY ALERT: Treatment Goals in Acid-Base Imbalance
OVERVIEW OF FLUID AND ELECTROLYTE DISORDERS
ASSESSMENT OF FLUID DISTURBANCES
COMMON LABORATORY AND DIAGNOSTIC TESTS FOR FLUID AND ELECTROLYTE IMBALANCE∗
SELECTED LABORATORY VALUES FOR ACID-BASE DISTURBANCES
• ACID-BASE DISTURBANCES: PRINCIPAL CAUSES, CLINICAL MANIFESTATIONS, AND TREATMENT
Dehydration ExemplarDehydration
Etiology and Incidence
Manifestations
TABLE 40-1 TYPES OF DEHYDRATION: ETIOLOGY, CLINICAL MANIFESTATIONS, AND LABORATORY VALUES
SAFETY ALERT: Signs of Impending Shock in the Dehydrated Child
TABLE 40-2 ASSESSMENT OF THE SEVERITY OF DEHYDRATION
PATHOPHYSIOLOGY: Dehydration
Diagnostic Evaluation
Therapeutic Management
Minimal Dehydration
TABLE 40-3 ORAL REPLACEMENT AND REHYDRATION THERAPY IN CHILDREN WITH VOMITING OR DIARRHEA
Mild to Moderate Dehydration
Severe Dehydration
BOX 40-1 MAINTENANCE FLUID REQUIREMENTS AND MINIMUM URINE OUTPUT
Daily Fluid Requirements by Body Weight
Minimum Urine Output by Age-Group
SAFETY ALERT: Guidelines When Administering Potassium
Adjunctive Management
Nursing Care
The Child with Dehydration
Assessment
FIG 40-1 Testing skin turgor. Turgor refers to the elasticity of the skin, which is affected by the extent of hydration. The nurse tests turgor by gently grasping the skin. When the skin is released, it should instantly spring back into place; if it does not, tissue turgor is considered poor.
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Interventions
PATIENT-CENTERED TEACHING: Dehydration
Signs and Symptoms of Dehydration
Evaluation
Diarrhea ExemplarDiarrhea
EVIDENCE-BASED PRACTICE
CRITICAL THINKING EXERCISE 40-1
Etiology and Incidence
PATHOPHYSIOLOGY: Diarrhea
Manifestations
Diagnostic Evaluation
Therapeutic Management
TABLE 40-4 CAUSES AND MANIFESTATIONS OF DIARRHEA IN INFANTS AND CHILDREN
Prognosis
Nursing Care
The Child with Diarrhea
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcome
Interventions
PATIENT-CENTERED TEACHING: Caring for a Child with Diarrhea
Diet
Mild Diarrhea (Mushy Stools) in Children of Any Age
Moderate Diarrhea (Watery or Frequent Stools) in Children Younger than 1 Year
Moderate Diarrhea (Watery or Frequent Stools) in Children Older than 1 Year
Preventing the Spread of Infection
Skin Care
When to Call the Physician
Oral Rehydration Therapy
Evaluation
CRITICAL THINKING EXERCISE 40-2
Vomiting ExemplarVomiting
Etiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
PATHOPHYSIOLOGY: Vomiting
Nursing Care
The Vomiting Child
Assessment
NURSING QUALITY ALERT: Caring for the Child Who Is Vomiting
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcomes
Interventions
Evaluation
KEY CONCEPTS
References and Readings
Chapter 41 The Child with an Infectious Disease
Learning Objectives
Clinical Reference
Review of Disease Transmission
Chain of Infection
Transmission of Pathogens
Epidemiologic Investigations
Infection and Host Defenses
Immunity
Viral Exanthems
Nursing Considerations for the Child with a Viral Exanthem Infection
Rubeola (Measles)
Manifestations
FIG 41-1 Sample notification letter from school nurse informing parents and caregivers about an exposure to an infectious disease.
NURSING CARE PLAN: The Child with an Infection in the Community Setting
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
PATIENT-CENTERED TEACHING: How to Care for the Child with a Viral Exanthem
Complications
FIG 41-2 Rubeola (measles) lesions and rash distribution.
Therapeutic Management
Rubella (German Measles, 3-Day Measles)
Manifestations
Complications
FIG 41-3 Rubella (German measles) lesions and rash distribution.
FIG 41-4 Erythema infectiosum lesions and rash distribution.
Therapeutic Management
SAFETY ALERT: Congenital Rubella
Erythema Infectiosum (Fifth Disease, Parvovirus B19)
Manifestations
Complications
FIG 41-5 Roseola infantum lesions and rash distribution.
Therapeutic Management
Roseola Infantum (Exanthem Subitum)
Manifestations
Complications
Therapeutic Management
Enterovirus (Nonpolio) Infections (Coxsackieviruses, Group A and Group B), Echoviruses, and Enteroviruses
Manifestations
Complications
Therapeutic Management
FIG 41-6 Coxsackievirus mouth lesions.
Nursing Considerations
Varicella-Zoster Infections (Chickenpox, Shingles)
FIG 41-7 Chickenpox and shingles lesions and rash distribution.
Manifestations
Varicella
Herpes Zoster (Shingles)
Complications
Therapeutic Management
Nursing Considerations
SAFETY ALERT: Varicella and the Immunocompromised Child
Other Viral Infections
Mumps
Manifestations
Complications
Therapeutic Management
Nursing Considerations
Cytomegalovirus (CMV)
Therapeutic Management
Nursing Considerations
Epstein-Barr Virus (Infectious Mononucleosis)
Manifestations
Complications
Therapeutic Management
Nursing Considerations
PATIENT-CENTERED TEACHING: How to Care for the Child with Infectious Mononucleosis
Rabies
Manifestations
Therapeutic Management
Nursing Considerations
Bacterial Infections
Pertussis (Whooping Cough)
Manifestations
Complications
Therapeutic Management
BOX 41-1 STAGES OF MANIFESTATION OF PERTUSSIS
Catarrhal
Paroxysmal
Convalescent
Nursing Considerations
Scarlet Fever
Manifestations
Complications
Therapeutic Management
Nursing Considerations
Methicillin-Resistant Staphylococcus aureus (MRSA)
FIG 41-8 Scarlet fever rash distribution and appearance. Note the characteristic skin peeling.
PATIENT-CENTERED TEACHING: How to Care for the Child with Scarlet Fever
Manifestations
Therapeutic Management
Nursing Considerations
Clostridium difficile
Manifestations
Therapeutic Management
Nursing Considerations
Serious Bacterial Illness in Infants
Rare Viral and Bacterial Infections
Fungal Infections
Rickettsial Infections
Rocky Mountain Spotted Fever
Manifestations
Therapeutic Management
TABLE 41-1 RARE VIRAL AND BACTERIAL INFECTIONS
Nursing Considerations
Borrelia Infections
Relapsing Fever
FIG 41-9 Lesions of variola are at the same stage of development on all body parts.
BOX 41-2 PREVENTIVE MEASURES TO AVOID INSECT AND TICK BITES
Manifestations
FIG 41-10 Dog (wood) ticks and deer (black-legged) ticks compared with a pencil. Dog ticks: A, engorged female; B, female; C, male. Deer ticks: D, larvae; E, nymphs; F, males; G, females; H, engorged female.
Therapeutic Management
Nursing Considerations
Lyme Disease
FIG 41-11 Characteristic lesion of Lyme disease.
Manifestations
Therapeutic Management
Nursing Considerations
Helminths
Therapeutic Management
Nursing Considerations
TABLE 41-2 COMMON HELMINTHS
PATIENT-CENTERED TEACHING: How to Prevent Parasitic Infections
Sexually transmitted infections ExemplarSexually Transmitted Diseases
Chlamydial Infection
PATIENT-CENTERED TEACHING: Sexually Transmitted Diseases
Manifestations
Therapeutic Management
Gonorrhea
Manifestations
Therapeutic Management
Herpes Simplex Virus
Manifestations
Therapeutic Management
CRITICAL THINKING EXERCISE 41-1
Human Papillomavirus
Manifestations
Therapeutic Management
Bacterial Vaginosis
Manifestations
Syphilis
Manifestations
Therapeutic Management
Trichomoniasis
Manifestations
Therapeutic Management
Nursing Considerations
EVIDENCE-BASED PRACTICE
KEY CONCEPTS
References and Readings
Chapter 42 The Child with an Immunologic Alteration
Learning Objectives
CLINICAL REFERENCE
Review of the Immune System
Nonspecific Immune Functions
Specific Immune Functions
The Humoral Response
CELLS INVOLVED IN THE IMMUNE RESPONSE
PEDIATRIC DIFFERENCES IN THE IMMUNE SYSTEM
The Organs of the Immune System Mature during Infancy and Childhood
Immaturity of the Immunologic System Places the Infant and Young Child at Greater Risk for Infection
Disorders of the Immune System Manifest Differently in Children than in Adults
The Cell-Mediated Response
Development of Immunity
Active Acquired Immunity
Passive Acquired Immunity
IMMUNOGLOBULIN FUNCTION AND PEDIATRIC IMPLICATIONS
Common Laboratory and Diagnostic Tests of Immune Function
Immunodeficiencies
Allergy
COMMON LABORATORY AND DIAGNOSTIC TESTS OF IMMUNE FUNCTION
LABORATORY AND CLINICAL SCREENING TESTS FOR ALLERGY
Human Immunodeficiency Virus Infection
Etiology
CRITICAL THINKING EXERCISE 42-1
Incidence
PATHOPHYSIOLOGY: HIV Infection
Manifestations
BOX 42-1 CLINICAL FINDINGS ASSOCIATED WITH IMMUNODEFICIENCY
Frequently Present, Highly Indicative Signs
Frequently Present, Somewhat Suggestive Signs
Diagnostic Evaluation
Diagnosing HIV-Exposed Infants
Ongoing Diagnostic Monitoring
Therapeutic Management
HIV-Exposed Infants
HIV-Infected Infants and Children
Treatment Considerations
Treatment Initiation
Additional Issues Related to the Child with HIV Infection
Multigenerational Problems
TABLE 42-1 CONSIDERATIONS FOR INITIATING ANTIRETROVIRAL MEDICATIONS IN INFANTS AND CHILDREN WITH HIV
Disclosure
NURSING CARE PLAN: The Child with HIV Infection in the Community
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
TABLE 42-2 RECOMMENDATIONS FOR ROUTINE IMMUNIZATION OF HUMAN IMMUNODEFICIENCY VIRUS-INFECTED CHILDREN IN THE UNITED STATES
HIV and School Settings
PATIENT-CENTERED TEACHING: How to Care for the Child with an HIV Infection
Transmission
Prevention
Testing
Illness (AIDS)
Medications
Home Care
NURSING CARE PLAN: The Adolescent with HIV Infection
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Corticosteroid Therapy
Incidence
Pathophysiology
DRUG GUIDE: Prednisolone (Pediapred, Prelone)
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child Receiving Corticosteroids
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcomes
Expected Outcome
Interventions
SAFETY ALERT: The Child Taking Oral Corticosteroids
Evaluation
Immune Complex and Autoimmune Disorders
Immune Complex Disorders
Autoimmune Disorders
Systemic Lupus Erythematosus
Etiology
Incidence
Manifestations
PATHOPHYSIOLOGY: Systemic Lupus Erythematosus
Diagnostic Evaluation
FIG 42-1 The butterfly rash of systemic lupus erythematosus.
Therapeutic Management
Nursing Care
The Child with Systemic Lupus Erythematosus
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Interventions
TABLE 42-3 CLASSIFICATION OF ALLERGIC REACTIONS
Evaluation
Allergic Reactions
TABLE 42-4 COMMON ALLERGIC CONDITIONS IN CHILDREN
Anaphylaxis
Etiology
Incidence
PATHOPHYSIOLOGY: Anaphylaxis
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Anaphylaxis
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Interventions
PATIENT-CENTERED TEACHING: Communicating with the School about Peanut Allergies
Evaluation
PATIENT-CENTERED TEACHING: How to Prevent Insect Stings
KEY CONCEPTS
References and Readings
Chapter 43 The Child with a Gastrointestinal Alteration
Learning Objectives
CLINICAL REFERENCE
Review of the Gastrointestinal System
Upper Gastrointestinal System
Lower Gastrointestinal System
Prenatal Development
COMMON LABORATORY AND DIAGNOSTIC TESTS FOR GI DISORDERS
MAJOR DIGESTIVE ENZYMES
PEDIATRIC DIFFERENCES IN THE GASTROINTESTINAL SYSTEM
Disorders of Prenatal Development
Cleft Lip and Palate
Incidence
PATHOPHYSIOLOGY: Cleft Lip and Palate
Child born with a cleft lip and palate, before (A) and after (B) repair. Repair of facial clefts usually requires multiple surgeries at different stages in the child’s growth. Early repair of a cleft lip facilitates parent-infant bonding and improves feeding. Children generally experience good outcomes with today’s surgical, orthodontic, and speech therapy techniques.
Manifestations and Diagnostic Evaluation
Therapeutic Management
FIG 43-1 Before and after repair of a cleft lip or palate, special feeding techniques are essential for adequate nutrition. A feeder with compressible plastic sides allows gentle squeezing of the sides of the bottle to help eject the breast milk or formula. A slightly longer nipple allows the milk to be swallowed with less chance of milk entering the nasopharynx and without stimulating the gag reflex.
Esophageal Atresia with Tracheoesophageal Fistula
Etiology and Incidence
Manifestations
Diagnostic Evaluation
NURSING CARE PLAN: The Child with a Cleft Lip or Palate
Focused Assessment
Nursing Diagnoses
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnoses
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Plannning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
PATIENT-CENTERED TEACHING: Home Care of the Child with Cleft Lip or Palate
FIG 43-2 Most common type of esophageal atresia (EA) and tracheoesophageal fistula (TEF).
Therapeutic Management
PATHOPHYSIOLOGY: Esophageal Atresia and Tracheoesophageal Fistula
Nursing Care
The Infant with Tracheoesophageal Fistula
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcome
Expected Outcomes
Expected Outcome
Expected Outcome
Expected Outcome
SAFETY ALERT: Assessing and Managing the Child with Esophageal Atresia and Tracheoesophageal Fistula
Interventions
Minimizing Aspiration Risk
Postoperative Care
Gastrostomy Tube Use
Home Care
FIG 43-3 The skin-level gastrostomy button is good for children who require long-term gastrostomy feeding. It is relatively flat, reduces skin breakdown, increases comfort, and is fully immersible in water.
Evaluation
Upper Gastrointestinal Hernias
Other Developmental Disorders
Motility Disorders
Gastroesophageal Reflux Disease
Etiology
Incidence
TABLE 43-1 UPPER GI HERNIAS
Manifestations and Diagnostic Evaluation
Therapeutic Management
TABLE 43-2 DEVELOPMENTAL GI DEFECTS
BOX 43-1 TYPES OF GASTROESOPHAGEAL REFLUX
Physiologic (Gastroesophageal Reflux [GER])
Pathologic (Gastroesophageal Reflux Disease [GERD])
PATIENT-CENTERED TEACHING: Home Care of the Child with a Gastrostomy Tube
Diet
Positioning
Medications
Treatment of Acute Bleeding
PATHOPHYSIOLOGY: Gastroesophageal Reflux
Surgery
Nursing Care
The Infant with Gastroesophageal Reflux Disease
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcomes
Interventions
Minimizing Reflux
Family Education and Support
Evaluation
Constipation ExemplarConstipation and Encopresis
PATHOPHYSIOLOGY: Constipation and Encopresis
Etiology and Incidence
Manifestations
Constipation
Encopresis
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Constipation or Encopresis
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcomes
Expected Outcome
Interventions
Overcoming Withholding
Dietary Changes
Changing the Retention Habit
Emotional Support
Home Care
Evaluation
Recurrent Abdominal Pain/Irritable Bowel Syndrome
Etiology and Incidence
Manifestations and Diagnostic Evaluation
Therapeutic Management and Nursing Considerations
PATHOPHYSIOLOGY: Irritable Bowel Syndrome
Inflammatory and Infectious Disorders
Ulcers
PATHOPHYSIOLOGY: Ulcers
Etiology
Incidence
Manifestations and Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
Providing Information
Home Care
Infectious Gastroenteritis
Etiology
PARENTS WANT TO KNOW: Care of the Child with an Ulcer
Incidence
TABLE 43-3 CHARACTERISTICS OF INFECTIOUS GASTROENTERITIS
Manifestations
PATHOPHYSIOLOGY: Infectious Gastroenteritis
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Infectious Gastroenteritis
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcome
Expected Outcome
Expected Outcomes
Expected Outcomes
Expected Outcome
Interventions
Maintaining Fluid Balance
Decreasing Risk
Home Care
PATIENT-CENTERED TEACHING: Care of the Child with Infectious Gastroenteritis
Evaluation
Appendicitis
Etiology and Incidence
Manifestations and Diagnostic Evaluation
PATHOPHYSIOLOGY: Appendicitis
FIG 43-4 McBurney point is midway between the right anterior superior iliac crest and the umbilicus. It is usually the location of greatest pain in the child with appendicitis.
Therapeutic Management
Nursing Care
The Child with Appendicitis
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcome
Expected Outcomes
NURSING QUALITY ALERT: Assessing Appendicitis in the Young Child
Interventions
Uncomplicated Appendicitis
Ruptured Appendix
Home Care
Evaluation
Ulcerative colitis ExemplarInflammatory Bowel Disease
Etiology
Incidence, Manifestations, and Diagnostic Evaluation
Therapeutic Management
TABLE 43-4 CROHN DISEASE AND ULCERATIVE COLITIS
Nursing Care
The Child with Inflammatory Bowel Disease
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcomes
Expected Outcomes
Expected Outcomes
Interventions
Medications
Nutritional Management
Family Education and Support
PATHOPHYSIOLOGY: Inflammatory Bowel Disease
Home Care
Evaluation
Obstructive Disorders
Hypertrophic Pyloric Stenosis
Etiology and Incidence
Manifestations
PATHOPHYSIOLOGY: Hypertrophic Pyloric Stenosis
Diagnostic Evaluation
Therapeutic Management
NURSING QUALITY ALERT: Gathering Information from a Parent About Infant Vomiting
Nursing Care
The Child with Hypertrophic Pyloric Stenosis
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcomes
Interventions
Preoperative Care
Postoperative Care
Home Care
Evaluation
CRITICAL THINKING EXERCISE 43-1
Intussusception
Etiology and Incidence
Manifestations and Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Intussusception
Assessment
PATHOPHYSIOLOGY: Intussusception
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcome
Interventions
Initial Care
Post Reduction Care
Family Education and Support
Evaluation
Volvulus
Hirschsprung Disease
Etiology and Incidence
Manifestations and Diagnostic Evaluation
PATHOPHYSIOLOGY: Hirschsprung Disease
Therapeutic Management
Nursing Care
The Child with Hirschsprung Disease
Assessment
Nursing Diagnoses and Planning
Expected Outcome
Expected Outcomes
Expected Outcomes
Expected Outcome
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcomes
Interventions
Preparing the Child for Surgery
Preventing Infection and Maintaining Skin Integrity
Maintaining Nutritional and Hydration Status
Reducing Pain
Providing Education and Relieving Anxiety
Evaluation
Malabsorption syndromes ExemplarMalabsorption Disorders
Lactose Intolerance
Etiology and Incidence
Manifestations and Diagnostic Evaluation
Therapeutic Management
PATHOPHYSIOLOGY: Lactose Intolerance
Nursing Care
The Child with Lactose Intolerance
Assessment
PARENTS WANT TO KNOW: Care of the Child with Lactose Intolerance
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcome
Expected Outcomes
Interventions
Evaluation
Celiac Disease
Etiology and Incidence
Manifestations
Diagnostic Evaluation
PATHOPHYSIOLOGY: Celiac Disease
Therapeutic Management
Nursing Care
The Child with Celiac Disease
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcomes
Expected Outcome
Interventions
PATIENT-CENTERED TEACHING: Care of the Child with Celiac Disease
Evaluation
Short Bowel Syndrome
Etiology and Incidence
Pathophysiology
Manifestations
Therapeutic Management
Nursing Considerations
Hepatic Disorders
Viral Hepatitis
Etiology
Incidence
TABLE 43-5 DIFFERENTIATION OF VIRAL HEPATITIS
Manifestations
PATHOPHYSIOLOGY: Viral Hepatitis
Diagnostic Evaluation
Therapeutic Management
Hepatitis A
Hepatitis B
Nursing Care
The Child with Viral Hepatitis
Assessment
TABLE 43-6 HEPATITIS PROPHYLAXIS
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcomes
Interventions
Child and Parent Teaching
Home Care
Evaluation
Biliary Atresia
Etiology and Incidence
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
Nutritional Support
Skin Care
Developmental Stimulation
Continued Assessment
Family Education and Support
PATHOPHYSIOLOGY: Biliary Atresia
Home Care
Cirrhosis
PATHOPHYSIOLOGY: Cirrhosis
Etiology
Incidence
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
Nutritional Support
Skin Care
Prevention of Complications
Developmental and Parental Support
Home Care
KEY CONCEPTS
References and Readings
Pageburst Integrated Resource
Animation
Chapter 44 The Child with a Genitourinary Alteration
Learning Objectives
CLINICAL REFERENCE
Review of the Genitourinary System
Structure
PEDIATRIC DIFFERENCES IN THE GENITOURINARY SYSTEM
Function
COMMON LABORATORY AND DIAGNOSTIC TESTS FOR GENITOURINARY DISORDERS
Enuresis
Etiology
Incidence
PATHOPHYSIOLOGY: Enuresis
Manifestations
Nocturnal Enuresis
Diurnal Enuresis
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Enuresis
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcomes
Expected Outcome
Interventions
Evaluation
CRITICAL THINKING EXERCISE 44-1
Urinary tract infection ExemplarUrinary Tract Infections
Etiology
Incidence
PATHOPHYSIOLOGY: Urinary Tract Infections
BOX 44-1 MANIFESTATIONS OF URINARY TRACT INFECTION IN INFANTS AND CHILDREN
Infants
Children
Children with Pyelonephritis
Manifestations
PATHOPHYSIOLOGY: Hydronephrosis
PATHOPHYSIOLOGY: Vesicoureteral Reflux
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with a Urinary Tract Infection
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcomes
Interventions
NURSING QUALITY ALERT: Evaluation after a Documented Urinary Tract Infection
PATIENT-CENTERED TEACHING: How to Manage and Prevent Urinary Tract Infections
Evaluation
Cryptorchidism
Incidence
PATHOPHYSIOLOGY: Cryptorchidism
Manifestations
Diagnostic Evaluation
Therapeutic Management
NURSING QUALITY ALERT: Assessing for Cryptorchidism
Nursing Care
The Child with Cryptorchidism
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcomes
Interventions
Evaluation
Hypospadias and Epispadias
Etiology and Incidence
FIG 44-1 Epispadias and hypospadias are congenital anomalies in which the urethral opening is above or below its normal location on the glans of the penis. Stenosis of the opening could occur, leading to possible urinary tract infections (UTIs) or hydronephrosis. Hypospadias might interfere with fertility if it is left uncorrected.
PATHOPHYSIOLOGY: Hypospadias
Manifestations and Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Hypospadias
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcome
Expected Outcomes
Expected Outcome
Interventions
Evaluation
Miscellaneous Disorders and Anomalies of the Genitourinary Tract
Acute Poststreptococcal Glomerulonephritis
Etiology and Incidence
Manifestations
TABLE 44-1 MISCELLANEOUS DISORDERS AND ANOMALIES OF THE GENITOURINARY TRACT
Diagnostic Evaluation
Therapeutic Management
PATHOPHYSIOLOGY: Acute Poststreptococcal Glomerulonephritis
Nursing Care
The Child with Acute Poststreptococcal Glomerulonephritis
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcomes
Interventions
Preventing the Consequences of Fluid Excess
Providing Adequate Rest
Maintaining Skin Integrity
Maintaining Nutritional Status
Relieving Anxiety
Evaluation
Nephrotic Syndrome
NURSING QUALITY ALERT: Differences between Children with Glomerulonephritis and Children with Nephrotic Syndrome
Etiology
Incidence
Manifestations
Diagnostic Evaluation
Therapeutic Management
PATHOPHYSIOLOGY: Nephrotic Syndrome
Remission Induction
NURSING CARE PLAN: The Child with Nephrotic Syndrome
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnoses
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Additional Therapy
FIG 44-2 This child has nephrotic syndrome. He previously received steroid therapy and is now receiving CellCept immunosuppressant therapy to control the process. During the acute phase of the nephrotic syndrome, the child may have massive edema because blood proteins are lost in the urine. Skin pallor is also common.
Acute Renal Failure
Etiology and Incidence
PATHOPHYSIOLOGY: Acute Renal Failure
Manifestations
Diagnostic Evaluation
History
Fluid Volume Status
Laboratory Data
PATHOPHYSIOLOGY: Hemolytic Uremic Syndrome
Physical Examination
Imaging Studies
Therapeutic Management
Fluid Imbalances
Electrolyte Imbalances
Potassium
Sodium
Acid-Base Imbalances
Nutrition
NURSING QUALITY ALERT: Indications for Dialysis in Acute Renal Failure
Dialysis
Nursing Considerations
BOX 44-2 DIALYSIS
Hemodialysis
Teenager receiving hemodialysis.
Peritoneal Dialysis
Peritoneal dialysis. Implanted line allows instillation of the dialyzing fluid into this child’s peritoneal cavity.
Infection of the peritoneal cavity is the chief hazard of peritoneal dialysis. When the lines are open to begin or end the dialyzing cycle, both adult and child wear masks.
Peritoneal dialysis catheter exit site.
Chronic Renal Failure and End-Stage Renal Disease
Etiology
Incidence
Pathophysiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
Chronic Renal Failure
End-Stage Renal Disease
Kidney Transplantation
Nursing Care
The Child with Chronic Renal Failure and End-Stage Renal Disease
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcome
Expected Outcome
Expected Outcomes
Expected Outcome
Interventions
Evaluation
KEY CONCEPTS
References and Readings
Pageburst Integrated Resource
Animation
Chapter 45 The Child with a Respiratory Alteration
Learning Objectives
CLINICAL REFERENCE
Review of the Respiratory System
The Upper Airway
The Lower Airway
Prenatal Respiratory Development
Postnatal Respiratory Changes
Gas Exchange and Transport
Diagnostic Tests
Blood Gas Analysis
COMMON LABORATORY AND DIAGNOSTIC TESTS FOR RESPIRATORY DISORDERS
Pulmonary Function Tests
Pulse Oximetry
Transcutaneous Monitoring
End-Tidal Carbon Dioxide Monitoring
PEDIATRIC DIFFERENCES IN THE RESPIRATORY SYSTEM
Respiratory Illness in Children
Allergic Rhinitis
Etiology and Incidence
PATHOPHYSIOLOGY: Allergic Rhinitis
Manifestations
FIG 45-1 Children with allergic rhinitis often have dark circles under their eyes, called allergic shiners, and may be seen rubbing their noses upward with the palm—the “allergic salute.”
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
PATIENT-CENTERED TEACHING: How to Implement Environmental Modifications
Pollen and Dust
Mold
Dander
Sinusitis
Etiology and Incidence
Manifestations
PATHOPHYSIOLOGY: Sinusitis
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
Otitis media ExemplarOtitis Media
Etiology
Incidence
Manifestations
PATHOPHYSIOLOGY: Otitis Media
Diagnostic Evaluation
Therapeutic Management
FIG 45-2 Appearance of tympanic membrane in otitis media compared with normal tympanic membrane. A, Normal right tympanic membrane and middle ear. B, Acute otitis media: bulging right tympanic membrane. C, Otitis media with effusion: air-fluid level and bubbles visible through right retracted, translucent tympanic membrane. D, Otitis media with effusion: severely retracted, opaque right tympanic membrane.
Nursing Care
The Child with Otitis Media
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Interventions
Evaluation
EVIDENCE-BASED PRACTICE
Pharyngitis and Tonsillitis
Etiology
Incidence
Manifestations
TABLE 45-1 COMPARISON OF VIRAL AND BACTERIAL PHARYNGITIS
PATHOPHYSIOLOGY: Pharyngitis
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
Nursing Care
The Child Undergoing a Tonsillectomy
Assessment: Preoperative Period
Nursing Diagnosis and Planning: Preoperative Period
Expected Outcome
Expected Outcome
Interventions: Preoperative Period
Evaluation: Preoperative Period
Assessment: Postoperative Period
SAFETY ALERT: Caring for the Child Who Has Had a Tonsillectomy
Nursing Diagnosis and Planning: Postoperative Period
Expected Outcome
PATIENT-CENTERED TEACHING: Caring for a Child after a Tonsillectomy
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Interventions: Postoperative
Evaluation: Postoperative
CRITICAL THINKING EXERCISE 45-1
Laryngomalacia (Congenital Laryngeal Stridor)
Manifestations
Therapeutic Management
Nursing Considerations
Croup
Etiology and Incidence
Manifestations
TABLE 45-2 COMPARISON OF TYPES OF CROUP
PATHOPHYSIOLOGY: Croup
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Croup
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Interventions
Facilitating Airway Clearance
Maintaining Fluid Balance
Decreasing Fear
Providing Teaching
Evaluation
Epiglottitis (Supraglottitis)
Etiology and Incidence
Manifestations
Diagnostic Evaluation
SAFETY ALERT: Cardinal Signs and Symptoms of Epiglottitis
PATHOPHYSIOLOGY: Epiglottitis
Therapeutic Management
Nursing Considerations
Bronchitis
Etiology and Incidence
PATHOPHYSIOLOGY: Bronchitis
Manifestations and Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
Bronchiolitis
Etiology and Incidence
PATHOPHYSIOLOGY: Bronchiolitis
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Bronchiolitis
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcomes
Interventions
Facilitating Gas Exchange
Preventing Transmission
Maintaining Fluid Balance
Reducing Fever
Decreasing Anxiety
Evaluation
Pneumonia ExemplarPneumonia
Nursing Care
The Child with Pneumonia
Assessment
TABLE 45-3 COMPARISON OF TYPES OF PNEUMONIA
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Interventions
PATIENT-CENTERED TEACHING: Home Management of the Child with Pneumonia
Evaluation
BOX 45-1 COMMON ITEMS OF ASPIRATION
Foreign Body Aspiration
Etiology and Incidence
Pathophysiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
Pulmonary Noninfectious Irritation
Acute Respiratory Distress Syndrome
Pathophysiology
Passive Smoking
Pathophysiology
Smoke Inhalation
Pathophysiology
TABLE 45-4 PULMONARY NONINFECTIOUS IRRITANTS
Apnea
Manifestations
Diagnostic Evaluation
TABLE 45-5 APNEA OF PREMATURITY COMPARED WITH INFANT APNEA
Nursing Care
The Infant with Apnea
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Interventions
FIG 45-3 Teaching the family about using an apnea monitor and how to respond to alarms is an important element in caring for the child with infant apnea. The nurse must assess the parents’ ability to tolerate the stressors of living with a child who is prone to apnea and support them as they deal with these stressors.
Evaluation
Sudden Infant Death Syndrome
Etiology and Incidence
BOX 45-2 HOME APNEA MONITORING
PATHOPHYSIOLOGY: Sudden Infant Death Syndrome
Manifestations
Diagnostic Evaluation
Nursing Care
The Family of the Infant Who Has Died of SIDS
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Interventions
Evaluation
Asthma ExemplarAsthma
Etiology
Incidence
PATHOPHYSIOLOGY: Asthma
Immediate Reaction (Early-Phase Response)
Delayed Reaction (Late-Phase Response)
Manifestations
Diagnostic Evaluation
Therapeutic Management
Acute Asthma Episode
Long-Term Management
Environmental Control
Irritants and Allergens
Exercise
Infection
Emotions
Monitoring Symptoms
SAFETY ALERT: Emergency Asthma Management
BOX 45-3 MONITORING BREATHING CAPACITY WITH A PEAK FLOW METER
Procedure
Medications
Rescue Medications
Routine Medications
FIG 45-4 Asthma action plan.
BOX 45-4 CLASSIFICATION OF ASTHMA SEVERITY
Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent
Medication Delivery
Bronchopulmonary Dysplasia
Etiology
Incidence
PARENTS WANT TO KNOW: Tips on Using a Nebulizer
The powered nebulizer delivers a bronchodilator to the child who is having an acute asthma episode. This boy has a viral respiratory infection, which is a common trigger of acute asthma episodes in the pediatric population.
NURSING CARE PLAN: The Child Hospitalized with Asthma
Focused Assessment
Nursing Diagnoses
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
PATHOPHYSIOLOGY: Bronchopulmonary Dysplasia
Manifestations
Diagnostic Evaluation
Therapeutic Management
Oxygen Therapy
Medications
Nutrition
Prognosis
Nursing Considerations
Cystic Fibrosis
FIG 45-5 Example of a letter that can be used to notify the local public service company that a technology-dependent child is living in the service area.
PATIENT-CENTERED TEACHING: Safe Use of Oxygen at Home
Etiology
Incidence
FIG 45-6 Digital clubbing may be an indication of hypoxia, which often occurs in cystic fibrosis and other respiratory disorders.
Manifestations
Respiratory System
Digestive System
PATHOPHYSIOLOGY: Cystic Fibrosis
Respiratory System
Digestive System
Integumentary System
Reproductive System
Exocrine Glands
Reproductive System
Diagnostic Evaluation
Therapeutic Management
Respiratory Problems
Digestive Problems
Nursing Care
The Child with Cystic Fibrosis
Assessment
Respiratory Assessment
Digestive Assessment
Reproductive Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Interventions
Facilitating Airway Clearance and Gas Exchange
Preventing Infection
Providing Optimal Nutrition for Growth
Promoting Increased Exercise Tolerance
Meeting the Child’s and Family’s Emotional Needs
Home Care
Evaluation
Tuberculosis
Etiology
Incidence
PATHOPHYSIOLOGY: Tuberculosis
BOX 45-5 RISK FACTORS FOR THE DEVELOPMENT OF TUBERCULOSIS
Manifestations
Diagnostic Evaluation
Therapeutic Management and Nursing Considerations
Tuberculosis Infection
BOX 45-6 DEFINITION OF A POSITIVE MANTOUX SKIN TEST
Area of Induration ≥5 mm Considered Positive in:
Area of Induration ≥10 mm Considered Positive in:
Induration ≥15 mm Considered Positive in:
Tuberculosis Disease
Prevention and Screening
KEY CONCEPTS
References and Readings
Pageburst Integrated Resource
Animation
Chapter 46 The Child with a Cardiovascular Alteration
Learning Objectives
CLINICAL REFERENCE
Review of the Heart and Circulation
Normal Cardiac Anatomy and Physiology
Fetal Circulation
A, Normal heart cycle, represented as an electrocardiographic configuration. B, Cardiac electrical conduction system.
Normal pressures (in millimeters of mercury) and saturations (percents).
Transitional and Neonatal Circulation
DIFFERENCES IN THE HEART AND CIRCULATION OF NEONATES AND INFANTS
COMMON DIAGNOSTIC TESTS FOR CARDIAC DISORDERS
Congenital Heart Disease
Classification of CHD
TABLE 46-1 CLASSIFICATION OF CONGENITAL HEART DISEASE
Shunting: Saturation Considerations
Blood Flow Considerations
Physiologic Consequences of CHD in Children
Heart Failure
Etiology
Manifestations
PATHOPHYSIOLOGY: Heart Failure
Diagnostic Evaluation
Therapeutic Management
NURSING CARE PLAN: The Child with Heart Failure
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
EVIDENCE-BASED PRACTICE
PATIENT-CENTERED TEACHING: Giving Your Child Digoxin Elixir
NURSING QUALITY ALERT: Feeding the Infant or Child with Heart Failure
Pulmonary Hypertension
CRITICAL THINKING EXERCISE 46-1
Cyanosis
Hypercyanotic Episode
Nursing Care
The Child with Cyanosis
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcome
Interventions
Evaluation
Assessment of the Child with a Cardiovascular Alteration
TABLE 46-2 CARDIAC ASSESSMENT FOR THE CHILD WITH CHD∗
NURSING QUALITY ALERT: Assessing Murmurs
Cardiovascular Diagnosis
Cardiac Catheterization
Complications
Nursing Care
Congenital Cardiac Defects
The Child Undergoing Cardiac Surgery
Preoperative Preparation
Postoperative Management
TABLE 46-3 CONGENITAL CARDIAC DEFECTS
FIG 46-1 A, A preoperative visit to the intensive care unit and other units should be directed at an age-appropriate level for the child and the family before the child undergoes cardiac surgery. The experience prepares the family for the sights and sounds of the unit. B, Going home.
Monitoring Cardiac Output
Supporting Respiratory Function
Maintaining Fluid and Electrolyte Balance
Promoting Comfort
Promoting Healing and Recovery
Acquired Heart Disease
Infective Endocarditis
Etiology
PATIENT-CENTERED TEACHING: Care after Heart Surgery
Activity
Diet
Incision
School
When to Call the Physician
Checkup
Incidence
PATHOPHYSIOLOGY: Infective Endocarditis
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with IE
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcomes
Interventions
Evaluation
Cardiac Dysrhythmias ExemplarDysrhythmias
Etiology
Incidence
PATHOPHYSIOLOGY: Dysrhythmias
Tachydysrhythmias
Supraventricular tachycardia.
Bradydysrhythmias
Heart block—two or three P waves for every QRS. Cardiac output is based on the rate of the QRS complexes—ventricular contraction.
Manifestations
Diagnostic Evaluation
Therapeutic Management
Fast Pulse Rate
Supraventricular Tachycardia
Ventricular Tachycardia
Slow Pulse Rate
Bradydysrhythmias
Absent Rhythms
Nursing Care
The Child with a Dysrhythmia
Assessment
SAFETY ALERT: Dysrhythmias
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcomes
Interventions
Evaluation
Rheumatic Fever
Etiology
PATHOPHYSIOLOGY: Rheumatic Fever
Incidence
Manifestations
FIG 46-2 Clinical manifestations of rheumatic fever.
Diagnostic Evaluation
BOX 46-1 DIAGNOSIS OF ACUTE RHEUMATIC FEVER BY THE JONES CRITERIA—1992 UPDATE
Major Manifestations
Minor Manifestations
Therapeutic Management
Nursing Care
The Child with RF
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcomes
Expected Outcomes
Interventions
NURSING QUALITY ALERT: Streptococcal Prophylaxis for the Child with Rheumatic Fever
Evaluation
Kawasaki Disease
Etiology
Incidence
PATHOPHYSIOLOGY: Kawasaki Disease
Manifestations
Diagnostic Evaluation
FIG 46-3 Erythematous rash of Kawasaki disease.
Therapeutic Management
Nursing Care
The Child with Kawasaki Disease
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcome
Interventions
Evaluation
Hypertension ExemplarHypertension
Etiology
Incidence
PATHOPHYSIOLOGY: Hypertension
Manifestations
Diagnostic Evaluation
Therapeutic Management
Primary Hypertension
Weight Reduction
Physical Conditioning
Dietary Modification
Relaxation Techniques
Pharmacologic Treatment
Secondary Hypertension
SAFETY ALERT: Infusing Intravenous Antihypertensive Medications
Nursing Care
The Child with Hypertension
Assessment
Blood Pressure Screening
Physical Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Interventions
Evaluation
Cardiomyopathies
High Cholesterol Levels in Children and Adolescents
Assessment of Children at Risk
Therapeutic Management
Nursing Considerations
KEY CONCEPTS
References and Readings
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Animation
Chapter 47 The Child with a Hematologic Alteration
Learning Objectives
CLINICAL REFERENCE
Review of the Hematologic System
TYPES AND FUNCTIONS OF WHITE BLOOD CELLS
PEDIATRIC HEMATOLOGIC SYSTEM
Iron Deficiency Anemia
Etiology and Incidence
Manifestations
Diagnostic Evaluation
PATHOPHYSIOLOGY: Iron Deficiency Anemia
PARENTS WANT TO KNOW: Home Care of the Child with Iron Deficiency Anemia
Dietary Changes
Administration of Iron
Follow-up Care
Therapeutic Management
NURSING CARE PLAN: The Child with Iron Deficiency Anemia in the Community Setting
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
NURSING QUALITY ALERT: Obtaining a Dietary Intake History
Sickle Cell Disease
CRITICAL THINKING EXERCISE 47-1
PATHOPHYSIOLOGY: Sickle Cell Disease
Etiology
Incidence
Manifestations
Diagnostic Evaluation
Therapeutic Management
TABLE 47-1 CLINICAL MANIFESTATIONS AND THERAPEUTIC MANAGEMENT OF SICKLE CELL DISEASE COMPLICATIONS
PATIENT-CENTERED TEACHING: Home Care of the Child with Sickle Cell Disease
NURSING CARE PLAN: The Child with Sickle Cell Disease
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
EVIDENCE-BASED PRACTICE
Thalassemia
Etiology and Incidence
Manifestations
BOX 47-1 CHARACTERISTIC FEATURES OF A CHILD WITH BETA-THALASSEMIA
PATHOPHYSIOLOGY: Beta-Thalassemia
Diagnostic Evaluation
Therapeutic Management
PATIENT-CENTERED TEACHING: Home Chelation Therapy
Subcutaneous Route by Infusion Pump
Intravenous Route: Totally Implantable or Tunneled Access Device
Nursing Care
The Child with Beta-Thalassemia
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcomes
Expected Outcomes
Interventions
Evaluation
Hemophilia ExemplarHemophilia
Etiology and Incidence
Manifestations
PATHOPHYSIOLOGY: Hemophilia
FIG 47-1 Hemarthrosis and joint destruction are characteristic of hemophilia.
NURSING CARE PLAN: The Child with Hemophilia
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Diagnostic Evaluation
Therapeutic Management
SAFETY ALERT: Acetylsalicylic Acid: Contraindication
NURSING QUALITY ALERT: Interviewing a Child with Hemophilia
Von Willebrand Disease
Etiology
Pathophysiology
PATIENT-CENTERED TEACHING: Home Care of the Child with Hemophilia
Control of deficient blood clotting in hemophilia requires injection of the missing clotting factors. This young man is injecting his factor into an implanted central venous access port. Sterile technique is essential.
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Von Willebrand Disease
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Interventions
Evaluation
Immune Thrombocytopenic Purpura
Etiology and Incidence
Pathophysiology
Manifestations
Diagnostic Evaluation
FIG 47-2 Multiple petechiae are characteristic of immune thrombocytopenic purpura. This disorder results in the destruction of circulating platelets and decreased bone marrow production of new platelets.
Therapeutic Management
Nursing Care
The Child with Immune Thrombocytopenic Purpura
Assessment
PATIENT-CENTERED TEACHING: Home Care of the Child with Immune Thrombocytopenic Purpura∗
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcomes
Interventions
SAFETY ALERT: Actions to Avoid in Children with Low Platelet Counts
Evaluation
Disseminated intravascular coagulation ExemplarDisseminated Intravascular Coagulation
Etiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
PATHOPHYSIOLOGY: Disseminated Intravascular Coagulation
BOX 47-2 CONFIRMATORY LABORATORY FINDINGS IN DISSEMINATED INTRAVASCULAR COAGULATION
Aplastic Anemia
Etiology and Incidence
Manifestations
Diagnostic Evaluation
PATHOPHYSIOLOGY: Aplastic Anemia
Therapeutic Management
Nursing Care
The Child with Aplastic Anemia
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcome
Expected Outcomes
Interventions
Evaluation
KEY CONCEPTS
References and Readings
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Animation
Chapter 48 The Child with Cancer
Learning Objectives
Clinical Reference
Review of Cancer
CARDINAL SIGNS AND SYMPTOMS OF CANCER IN CHILDREN
Overt Signs
Signs and Symptoms That May Be Covert
DIAGNOSTIC TESTS AND PROCEDURES FOR CANCER
The Child With Cancer
Incidence
Childhood Cancer and Its Treatment
FIG 48-1 Incidence of Cancers in Children. Rate per million children younger than age 20 years, 2003-2007.
Therapeutic Management
Chemotherapy
BOX 48-1 COMMON SIDE EFFECTS OF CHEMOTHERAPY AND RADIATION THERAPY
Chemotherapy Side Effects
Suppression of the bone marrow because of chemotherapy or radiation therapy reduces the blood counts. Low platelet levels lead to spontaneous bruising, as shown. Nosebleeds and bleeding of the gums are other consequences. The nurse must make a special effort to observe for bruising in dark-skinned children because it will be more difficult to see.
Radiation Side Effects
Acute (During and Shortly after Irradiation)
Mucositis (inflammation of the mucous membranes) and mouth ulcers are common side effects of chemotherapeutic drugs. Any mucous membrane can be affected.
Subacute (1 to 6 Months after Irradiation)
Late Effects (More Than 6 Months after Irradiation)
Hair loss is a distressing side effect of cancer treatment. School-age children and adolescents are most likely to feel this distress. Activities such as crafts or playgroups help children feel more normal and provide interaction with others in an accepting environment.
Surgery
BOX 48-2 NURSING RESPONSIBILITIES AND PRECAUTIONS FOR CHEMOTHERAPY
Radiation Therapy
EVIDENCE-BASED PRACTICE
Hematopoietic Stem Cell Transplantation
Steroid Therapy
Biologic Agents
Complementary and Alternative Medical (CAM) Therapies
CRITICAL THINKING EXERCISE 48-1
Leukemia ExemplarLeukemia
Etiology
Incidence
Manifestations
Diagnostic Evaluation
Therapeutic Management
FIG 48-2 Varicella (chickenpox) can be deadly in the immunocompromised child. Thrombocytopenia (low platelet count) associated with chemotherapy can cause the varicella lesions to be hemorrhagic, like those shown here. Secondary infections of the lesions are also common because of low white blood cell (WBC) counts.
PARENTS WANT TO KNOW: Caring for the Child with Cancer
PATHOPHYSIOLOGY: Leukemia
NURSING CARE PLAN: The Child with Leukemia
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Malignant brain tumor ExemplarBrain Tumors
Etiology
Incidence
Manifestations
Diagnostic Evaluation
Therapeutic Management
FIG 48-3 Lobes of the brain.
PATHOPHYSIOLOGY: Brain Tumors
NURSING QUALITY ALERT: Signs of Brain Tumor in Children
Nursing Care
The Child with a Brain Tumor
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcome
Interventions
BOX 48-3 POTENTIAL FUNCTIONAL DEFICITS RELATED TO A BRAIN TUMOR
Evaluation
Malignant Lymphomas
Non-Hodgkin Lymphoma
Etiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
NURSING QUALITY ALERT: Tumor Lysis Syndrome
Nursing Care
The Child with Non-Hodgkin Lymphoma
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcomes
Interventions
Evaluation
Hodgkin lymphoma ExemplarHodgkin Disease
Etiology
SAFETY ALERT: Prevention of Urinary Tract Infection in the Immunocompromised Child
Manifestations
Diagnostic Evaluation
PATHOPHYSIOLOGY: Hodgkin Disease
Therapeutic Management
Nursing Considerations
Neuroblastoma
Etiology
Incidence
Pathophysiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Neuroblastoma
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcomes
Interventions
Evaluation
Osteosarcoma
Etiology
Incidence
Pathophysiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Osteosarcoma
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcomes
Interventions
Evaluation
Ewing Sarcoma
Etiology
Incidence
Pathophysiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
Rhabdomyosarcoma
Etiology
Incidence
Pathophysiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
Wilms Tumor
Etiology
Incidence
Pathophysiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
NURSING QUALITY ALERT: Assessing the Child with a Wilms Tumor
Nursing Care
The Child with Wilms Tumor
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcome
Expected Outcomes
Expected Outcome
Interventions
Evaluation
Retinoblastoma
Etiology
Incidence
Pathophysiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Retinoblastoma
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcome
Expected Outcomes
Interventions
Evaluation
Rare Tumors of Childhood
KEY CONCEPTS
References and Readings
Chapter 49 The Child with an Alteration in Tissue Integrity
Learning Objectives
Clinical Reference
Review of the Integumentary System
PEDIATRIC DIFFERENCES IN THE SKIN
Variations in the Skin of Newborn Infants
Common Birthmarks
Etiology
Incidence
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
PARENTS WANT TO KNOW: Care of Newborn and Infant Skin
Skin Inflammation
Seborrheic Dermatitis
FIG 49-1 “Cradle cap,” the most frequent form of seborrheic dermatitis in infants. The condition often begins in the first 2 to 3 weeks of life and usually disappears by age 12 months.
Contact Dermatitis
Etiology
FIG 49-2 Seborrheic diaper dermatitis.
PATHOPHYSIOLOGY: Contact Dermatitis
Incidence
Manifestations
FIG 49-3 Contact diaper dermatitis.
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Contact Dermatitis
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcome
Expected Outcomes
Interventions
Evaluation
Atopic Dermatitis
Etiology
Incidence
Manifestations
FIG 49-4 Atopic dermatitis, an allergic skin condition, usually begins in infancy and clears by age 2 to 3 years. However, it can continue into childhood. A, Lesions on cheeks often spread to the forehead, scalp, and extensor surfaces of arms and legs. B, Flexor surfaces of wrists, ankles, knees, and elbows may be affected in the childhood form of the disease.
PATHOPHYSIOLOGY: Atopic Dermatitis
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Atopic Dermatitis
Assessment
Nursing Diagnosis and Planning
DRUG GUIDE: Topical Corticosteroids
Expected Outcome
Expected Outcomes
Expected Outcome
Expected Outcomes
Expected Outcome
Expected Outcomes
Interventions
Evaluation
Skin Infections
Impetigo
Etiology
PATHOPHYSIOLOGY: Impetigo
Incidence
Manifestations
FIG 49-5 Impetigo lesions are usually located around the mouth and nose but may be located on the extremities.
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Impetigo
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcomes
Interventions
Evaluation
SAFETY ALERT: Caring for a Child with Impetigo
Cellulitis ExemplarCellulitis
Etiology and Incidence
Pathophysiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Cellulitis
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Interventions
Evaluation
Candidiasis
FIG 49-6 White, curdlike plaques of thrush (oral candidiasis, oral moniliasis), a common fungal infection in infants.
Etiology
Incidence
Manifestations
Diagnostic Evaluation
Therapeutic Management
FIG 49-7 Diaper candidiasis.
Nursing Care
The Child with Candidiasis
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcomes
Expected Outcomes
Interventions
FIG 49-8 Tinea (ringworm) is an infection caused by dermatophytes, a group of fungi. Tinea is classified according to the part of the body affected. Five common types of tinea are shown here. Tinea capitis (scalp); Tinea corporis (trunk, face, extremities); Tinea cruris (groin, buttocks, scrotum); Tinea pedis (feet); Tinea unguium (nails, nail beds).
Evaluation
Tinea Infection
Etiology
PATHOPHYSIOLOGY: Tinea Infection
Incidence
Manifestations
Diagnostic Evaluation
Therapeutic Management
Tinea Capitis
Tinea Corporis
Tinea Cruris
Tinea Pedis
Nursing Care
The Child with a Tinea Infection
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcome
Interventions
Evaluation
Herpes Simplex Virus Infection
PATIENT-CENTERED TEACHING: Home Care for a Child or Adolescent with a Tinea Infection
Etiology
Incidence
PATHOPHYSIOLOGY: Herpes Simplex Type 1 Infection
Manifestations
Herpes Labialis (“Cold Sore,” “Fever Blister”)
FIG 49-9 Herpes simplex infection in an infant.
Herpetic Gingivostomatitis
Herpetic Ocular Infection
Herpetic Whitlow
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with a Herpes Simplex Infection
Assessment
Nursing Diagnoses and Planning
Expected Outcomes
Expected Outcome
Expected Outcome
Expected Outcomes
Interventions
Evaluation
Skin Infestations
Lice Infestation
Etiology
Incidence
PATHOPHYSIOLOGY: Pediculosis
Manifestations
Pediculosis Capitis (Head Lice)
FIG 49-10 Head lice (pediculosis capitis). Note the nits attached to the hair shafts.
Pediculosis Corporis (Body Lice)
Pediculosis Pubis (Pubic Lice, Crab Lice)
Diagnostic Evaluation
Therapeutic Management
Killing Active Lice and Nits
Addressing the Environment
Nursing Care
The Child with Pediculosis
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcome
Expected Outcomes
Expected Outcomes
Interventions
Evaluation
CRITICAL THINKING EXERCISE 49-1
EVIDENCE-BASED PRACTICE
Mite Infestation (Scabies)
Etiology
Incidence
Pathophysiology
Manifestations
Diagnostic Evaluation
FIG 49-11 Scabies lesions on an infant.
Therapeutic Management
Nursing Considerations
Acne Vulgaris
Etiology
Incidence
PATHOPHYSIOLOGY: Acne Vulgaris
Manifestations and Diagnostic Evaluation
Therapeutic Management
FIG 49-12 An adolescent with acne vulgaris.
Nursing Care
The Adolescent with Acne Vulgaris
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcomes
Expected Outcome
Interventions
Evaluation
Miscellaneous Skin Disorders
TABLE 49-1 SKIN DISORDERS
Insect Bites or Stings
Burns ExemplarBurn Injuries
TABLE 49-2 SKIN LESIONS CAUSED BY INSECTS AND ARACHNIDS
Etiology
TABLE 49-3 AGE-RELATED RISKS FOR BURN INJURY
BOX 49-1 PEDIATRIC DIFFERENCES IN THE EFFECTS OF BURN INJURY
Incidence
FIG 49-13 These burns were sustained when the child’s pajamas caught fire while he was playing with matches.
FIG 49-14 These burns were sustained when the child sucked on an electrical socket.
Pathophysiology
PATIENT-CENTERED TEACHING: Measures to Prevent and Initially Manage a Burn
Prevention
Initial Emergency Burn Management
BOX 49-2 BURN CENTER REFERRAL CRITERIA
Depth of Burn Injury
Extent of Burn Injury
Severity of Burn Injury
FIG 49-15 Calculating total body surface area (TBSA) burned in children. The standard “rule of nines” and standard body surface charts must be adapted because of the difference in body proportions between adults and children.
TABLE 49-4 DEPTH OF BURN INJURY
Manifestations
Therapeutic Management
Superficial Burn Injuries
TABLE 49-5 CLASSIFICATION OF SEVERITY OF BURN INJURY IN CHILDREN
Superficial Partial-Thickness Burn Injuries
Wound Cleaning
Débridement
Application of Antimicrobial Agents and Dressings
FIG 49-16 Burn dressings can be changed in the hydrotherapy room. The room is kept warm because children who have been burned have poor body temperature control. The child life therapist reads a book to the child to distract her from the discomfort associated with the procedure.
TABLE 49-6 TOPICAL ANTIMICROBIAL AGENTS COMMONLY USED FOR BURNS
PATIENT-CENTERED TEACHING: Home Care for a Child with Burns
Parents will need to know the following to adequately care for the child:
Teach the parents the following:
NURSING CARE PLAN: The Child with a Minor Partial-Thickness Burn
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Conditions Associated with Major Burn Injuries
Conditions Associated with Electrical Injury
Cardiac Arrest or Dysrhythmia
Tissue Damage
Myoglobinuria
Metabolic Acidosis
TABLE 49-7 BODY SYSTEM ALTERATIONS AFTER MODERATE TO SEVERE BURNS
Other Complications
Key Concepts
References and Readings
Pageburst Integrated Resource
Animation
Chapter 50 The Child with a Musculoskeletal Alteration
Learning Objectives
Clinical Reference
Review of the Musculoskeletal System
Skeletal System
Child with hand differences.
Articular System
Muscular System
Cartilage
PEDIATRIC DIFFERENCES IN THE MUSCULOSKELETAL SYSTEM
Growth and Development
Diagnostic and Laboratory Tests
COMMON DIAGNOSTIC PROCEDURES FOR MUSCULOSKELETAL DISORDERS IN CHILDREN
Casts, Traction, and Other Immobilizing Devices
Splints
Casts
Traction
FIG 50-1 Child in a synthetic cast.
BOX 50-1 TYPES OF SKIN TRACTION
Buck
Bryant
Skin Traction
BOX 50-2 TYPES OF SKELETAL TRACTION
Halo
90/90 Femoral
Skeletal Traction
External Fixation Devices
FIG 50-2 Skeletal traction is used to reduce and immobilize fractures and allows greater pull than would be possible with skin traction. Osteomyelitis may be a serious complication because skeletal traction is invasive.
SAFETY ALERT: The Child in a Cast or Traction
Nursing Considerations
Neurovascular Status
FIG 50-3 Ilizarov external fixator.
Special Considerations for the Child in Halo Traction
TABLE 50-1 NEUROLOGIC ASSESSMENT FOR PATIENTS REQUIRING HALO TRACTION
Assessing and Managing Compartment Syndrome
Immobility
Special Considerations for the Child in Traction
Home Care
TABLE 50-2 CONSEQUENCES OF IMMOBILITY
Fracture ExemplarFractures
Etiology
FIG 50-4 Upper extremity fractures in children often occur when the child attempts to break a fall with an outstretched arm.
PARENTS WANT TO KNOW: Home Care for the Child in a Cast
Check the Edges of the Cast as Follows:
To Assist with Drying the Cast, Do the Following:
Swelling Generally Peaks within 24 to 48 Hours. To Prevent Problems, Do the Following:
Protect the Cast as Follows:
Contact the Physician If Any of the Following Occurs:
When Preparing to Remove the Cast, Do the Following:
Incidence
Manifestations
Therapeutic Management
Reduction Methods
Retention
PATHOPHYSIOLOGY: Fractures and Physeal Growth Plate Injuries
Nursing Considerations
Initial Trauma Assessment
Assessing and Managing Complications
TABLE 50-3 SPORT-SPECIFIC INJURY RISK
Soft Tissue Injuries: Sprains, Strains, and Contusions
Etiology
Incidence
Manifestations and Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
NURSING QUALITY ALERT: The Child with a Soft Tissue Injury
Osteomyelitis
Etiology
Incidence
PATHOPHYSIOLOGY: Osteomyelitis
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Osteomyelitis
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcomes
Expected Outcomes
Interventions
Administering IV Antibiotics
Providing Wound Care
Maintaining Nutritional Status
Teaching Home Management
Promoting Optimal Development
Evaluation
Scoliosis
TABLE 50-4 CLASSIFICATIONS OF SCOLIOSIS
Adolescent Idiopathic Scoliosis
Prevalence and Etiology
Manifestations
Diagnostic Evaluation
School Screening
FIG 50-5 Most spinal abnormalities in children are abnormal curvatures. In scoliosis, the spine curves laterally and the vertebrae rotate, pulling the ribs along. Kyphosis is a front-to-back rounding, usually of the thoracic spine; it is often accompanied by scoliosis. Lordosis is an exaggerated concave curvature of the spine, usually in the lumbar area.
Physical Examination
Radiographs
FIG 50-6 Plain radiographs of scoliosis before (A, B) and after spinal fusion (C, D).
Treatment
Nonsurgical Interventions
Surgical Intervention
FIG 50-7 Adolescent with scoliosis brace.
Surgical Complications
Postoperative Management
Follow-Up Care
Kyphosis
Scheuermann’s Kyphosis
NURSING CARE PLAN: The Adolescent Undergoing a Spinal Fusion
Focused Assessment
Preoperative Assessment
Postoperative Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Other Causes of Hyperkyphosis
Limb Differences
Etiology and Incidence
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
Developmental Dysplasia of the Hip
Etiology and Incidence
TABLE 50-5 LIMB DIFFERENCES
Manifestations
FIG 50-8 Genu varum (bowlegs). In the child with genu varum, or bowlegs, a persistent space is present between the knees when the ankles are together. Genu varum is a normal finding for 1 year after the child begins walking.
FIG 50-9 Genu valgum (knock knees). In the child with genu valgum, or knock knees, a space is present between the ankles when the knees are together. To remember the terminology, liken the r’s and g’s: genu var um—knees apar t; genu valg um—knees tog ether.
Diagnostic Evaluation
Therapeutic Management
PATHOPHYSIOLOGY: Developmental Dysplasia of the Hip
Nursing Care
The Child with Developmental Dysplasia of the Hip
Assessment
FIG 50-10 An infant in a Pavlik harness to treat developmental dysplasia of the hip.
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcome
Expected Outcomes
Expected Outcome
Expected Outcomes
Interventions
Teaching about the Pavlik Harness
Teaching about Spica Cast Care
FIG 50-11 Regular assessment of circulation, sensation, and movement in the lower extremities is essential when a child has a hip spica cast.
Alleviating Anxiety
Preventing Injury
FIG 50-12 Use a car seat that can accommodate the wide leg spread caused by the spica cast or a car vest restraint for older children.
Evaluation
Legg-Calvé-Perthes Disease
Etiology and Incidence
PATHOPHYSIOLOGY: Legg-Calvé-Perthes Disease
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Legg-Calvé-Perthes Disease
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcomes
Interventions
Facilitating Appropriate Activity
Teaching Home Management
Evaluation
Slipped Capital Femoral Epiphysis
Etiology and Incidence
Pathophysiology
Manifestations and Diagnostic Evaluation
Therapeutic Management and Nursing Considerations
CRITICAL THINKING EXERCISE 50-1
Clubfoot
Etiology and Incidence
FIG 50-13 An infant with left clubfoot. Note the positional difference between the two feet.
Manifestations and Diagnostic Evaluation
Therapeutic Management
Ponseti Casting Method
Clubfoot Recurrence
Nursing Considerations
Education and Anticipatory Guidance
Reduction of Discomfort and Pain
Patient Advocacy
Muscular Dystrophies
Etiology
Incidence
Pathophysiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
TABLE 50-6 MUSCULAR DYSTROPHIES OF CHILDHOOD
Nursing Considerations
TABLE 50-7 MAJOR TYPES OF JUVENILE IDIOPATHIC ARTHRITIS
Rheumatoid arthritis ExemplarJuvenile Idiopathic Arthritis
Etiology
Incidence
PATHOPHYSIOLOGY: Juvenile Idiopathic Arthritis
Manifestations
Diagnostic Evaluation
Therapeutic Management
Drug Therapy
DRUG GUIDE: Naproxen, Naproxen Sodium
Physical and Occupational Therapy
Surgical Treatment
Nursing Care
The Child with JIA
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcome
Interventions
Managing Pain
Promoting Mobility
Managing Potential Infections
Facilitating Emotional and Social Development
Family Education
Evaluation
Syndromes and Conditions with Associated Orthopedic Anomalies
TABLE 50-8 SYNDROMES AND CONDITIONS WITH ASSOCIATED ORTHOPEDIC ANOMALIES
Key Concepts
References and Readings
Pageburst Integrated Resource
Animation
Chapter 51 The Child with an Endocrine or Metabolic Alteration
Learning Objectives
Clinical Reference
Review of the Endocrine System
PEDIATRIC DIFFERENCES IN THE ENDOCRINE SYSTEM
Diagnostic Tests and Procedures
COMMON LABORATORY AND DIAGNOSTIC TESTS OF ENDOCRINE FUNCTION
Phenylketonuria
Etiology
Incidence
Manifestations
Diagnostic Evaluation
PATHOPHYSIOLOGY: Phenylketonuria
Therapeutic Management
Nursing Considerations
Inborn Errors of Metabolism
Congenital Adrenal Hyperplasia
Etiology
Manifestations
TABLE 51-1 INBORN ERRORS OF METABOLISM
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
SAFETY ALERT: Congenital Adrenal Hyperplasia
Congenital Hypothyroidism
Etiology
PATHOPHYSIOLOGY: Congenital Hypothyroidism
Incidence
Manifestations
Diagnostic Evaluation
FIG 51-1 A, This untreated 6-month-old infant with congenital hypothyroidism fed poorly and was constipated. She was lethargic and had no social smile or head control. Note her puffy face, large tongue, dull expression, and excessive hair growth (hirsutism) on the forehead. B, The same infant 4 months after treatment. Note the decreased facial puffiness, decreased forehead hirsutism, and an alert appearance.
Therapeutic Management
Nursing Care
The Infant with Congenital Hypothyroidism
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcomes
Expected Outcome
Interventions
NURSING QUALITY ALERT: The Child with Congenital Hypothyroidism
Evaluation
Acquired Hypothyroidism
Etiology
Pathophysiology
Manifestations
Diagnostic Evaluation
BOX 51-1 INDICATORS OF HYPOTHYROIDISM OR HYPERTHYROIDISM
Therapeutic Management
Nursing Care
The Child with Acquired Hypothyroidism
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcomes
Expected Outcome
Interventions
Evaluation
Hyperthyroidism (Graves Disease)
Incidence
Pathophysiology
Manifestations
NURSING QUALITY ALERT: Autoimmune Thyroid Disorders
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Hyperthyroidism
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcome
Expected Outcome
Expected Outcome
Interventions
Evaluation
Diabetes Insipidus
Etiology
Incidence
Manifestations
Diagnostic Evaluation
BOX 51-2 INDICATORS OF DIABETES INSIPIDUS OR SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE (SIADH)
Therapeutic Management
NURSING QUALITY ALERT: Diabetes Insipidus
Nursing Considerations
PATHOPHYSIOLOGY: Diabetes Insipidus
Syndrome of Inappropriate Antidiuretic Hormone
Etiology
Manifestations
PATHOPHYSIOLOGY: Syndrome of Inappropriate Antidiuretic Hormone
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
NURSING QUALITY ALERT: Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
BOX 51-3 SIGNS OF HYPONATREMIA
Precocious Puberty
Etiology
Incidence
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Precocious Puberty
Assessment
PATHOPHYSIOLOGY: Precocious Puberty
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcomes
Expected Outcome
NURSING QUALITY ALERT: Precocious Puberty
Interventions
Evaluation
Growth Hormone Deficiency
Etiology
Incidence
Manifestations
PATHOPHYSIOLOGY: Growth Hormone Deficiency
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Growth Hormone Deficiency
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcome
Expected Outcome
Expected Outcomes
NURSING QUALITY ALERT: Criteria for Suspecting Growth Hormone Deficiency
Interventions
Evaluation
CRITICAL THINKING EXERCISE 51-1
Diabetes, Type 1 ExemplarDiabetes Mellitus
Type 1 Diabetes Mellitus
Etiology
Incidence
Manifestations
Diagnostic Evaluation
TABLE 51-2 ACTIONS OF INSULIN
TABLE 51-3 COMPARISON OF HYPOGLYCEMIA, HYPERGLYCEMIA, AND KETOACIDOSIS
Therapeutic Management
Insulin Therapy
PATHOPHYSIOLOGY: Type 1 Diabetes Mellitus
TABLE 51-4 INSULIN ACTION BY TYPE
Schedule
FIG 51-2 Peak action of insulin injections is timed to correspond with the child’s usual meal and snack times to minimize the chance of hypoglycemia. L/A, Lispro/Aspart (rapid-acting insulin).
Administration
FIG 51-3 Subcutaneous insulin injection sites most commonly used. Rate of absorption varies by site.
Nutrition Therapy
Physical Activity
NURSING QUALITY ALERT: Managing the Child with Type 1 Diabetes Mellitus
Insulin
Nutrition
Exercise
Blood Glucose Monitoring
Blood Glucose Monitoring
Developmental Issues
Infant and Toddler
Preschooler
School-Age Child
Adolescent
TABLE 51-5 EXAMPLES OF DIABETES MANAGEMENT TASKS DELEGATED TO CHILD (WITH SUPERVISION)
NURSING CARE PLAN: The Child with Type 1 Diabetes Mellitus in the Community Setting
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Delegating Diabetes Management Responsibilities
Diabetic ketoacidosis ExemplarDiabetic Ketoacidosis
Etiology
Manifestations
PATIENT-CENTERED TEACHING: Home Management of Type 1 Diabetes Mellitus
Outcomes
General Information
Medication Therapy
The school-age child is usually able to perform daily self-monitoring of blood glucose with parental help. However, the child should not be expected to adjust the insulin dose based on the reading. By early adolescence, the child can be in charge of recording blood glucose values in the diary.
Home Glucose Monitoring
Hypoglycemia
When other parts of the treatment regimen have become familiar, the injection technique can be taught. Initially, self-injecting insulin may be frightening for the school-age child, so the parent may insert the needle and have the child then push the plunger. The child can then progress to performing self-injection.
Hyperglycemia
Nutrition/Exercise
Complications
Psychological Adjustment and Family Involvement
Community Resources
BOX 51-4 SICK-DAY MANAGEMENT FOR THE CHILD WITH TYPE 1 DIABETES MELLITUS
Diagnostic Evaluation
Therapeutic Management
Long-Term Health Care Needs for the Child with Type 1 Diabetes Mellitus
NURSING CARE PLAN: The Child in Diabetic Ketoacidosis (DKA)
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Diabetes, Type 2 ExemplarType 2 Diabetes Mellitus
Etiology
Incidence
Manifestations
Diagnostic Evaluation
Therapeutic Management
Medication Therapy
Nutrition Therapy
Physical Activity
Blood Glucose Monitoring
Prevention
KEY CONCEPTS
References and Readings
Pageburst Integrated Resource
Animation
Chapter 52 The Child with a Neurologic Alteration
Learning Objectives
Clinical Reference
Review of the Central Nervous System
Embryologic Development
The Myelin Sheath
PEDIATRIC DIFFERENCES IN THE CENTRAL NERVOUS SYSTEM
The Neural System
The Axial Skeleton
The Meninges
The Brain
The Cranial Nerves
The Spinal Cord
CSF ANALYSIS IN CHILDREN: NORMAL FINDINGS
CEREBROSPINAL FLUID ANALYSIS: FINDINGS IN PATHOLOGIC CONDITIONS
Cerebrospinal Fluid
Cerebral Blood Flow and Intracranial Regulation
COMMON DIAGNOSTIC TESTS AND PROCEDURES FOR NEUROLOGIC DISORDERS
LUMBAR PUNCTURE: EDUCATING THE FAMILY
For the lumbar puncture: Place one hand farther down, under the child’s neck. Your forearm moves behind the child’s head to support the neck. Place the other arm farther under the child’s upper thighs and curl the child’s body by bringing the knees up to the head. Note that this nurse’s weight is supported on the edge of the examination table, and the nurse leans slightly over the child, controlling the arms and legs. Because direct visibility of the child’s respiratory status is limited in this position, a cardiorespiratory monitor must be used for the child.
NURSING CARE PLAN: The Child with a Neurologic System Disorder
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Increased Intracranial Pressure
Etiology
Manifestations
BOX 52-1 DEVELOPMENTAL MANIFESTATIONS OF INCREASED INTRACRANIAL PRESSURE
TABLE 52-1 GLASGOW COMA SCALE MODIFIED FOR CHILDREN
Level of Consciousness
Behavior
NURSING QUALITY ALERT: Delirium ExemplarStandard Terms for Level of Consciousness
Pupil Evaluation
Motor Function
Vital Signs
FIG 52-1 Flexion and extension posturing.
PATHOPHYSIOLOGY: Increased Intracranial Pressure
Diagnostic Evaluation and Therapeutic Management
EVIDENCE-BASED PRACTICE
BOX 52-2 INSTRUMENTS FOR MONITORING INCREASED INTRACRANIAL PRESSURE
Spina Bifida
Etiology and Incidence
Manifestations
FIG 52-2 Three forms of spina bifida.
PATHOPHYSIOLOGY: Spina Bifida
FIG 52-3 This infant has a repaired myelomeningocele. Note the left clubfoot. This deformity often accompanies the defect because normal intrauterine movement does not occur in the fetus with spina bifida, interfering with the development of the extremities. The legs are flaccid, and normal neonatal flexion is absent. The infant also dribbles stool and urine constantly. Hydrocephalus commonly accompanies these neural tube defects.
Diagnostic Evaluation
Therapeutic Management
Hydrocephalus
Etiology
Incidence
Manifestations and Diagnostic Evaluation
TABLE 52-2 EARLY AND LATE MANIFESTATIONS OF HYDROCEPHALUS
PATHOPHYSIOLOGY: Hydrocephalus
Therapeutic Management
Cerebral palsy ExemplarCerebral Palsy
Etiology and Incidence
FIG 52-4 A ventriculoperitoneal shunt may be implanted in the child with hydrocephalus to prevent excess accumulation of cerebrospinal fluid (CSF) in the ventricles. The tubing diverts the CSF from the ventricles into the peritoneal cavity, where it is reabsorbed. Nursing care includes monitoring for infection, obstruction, and pain, administering antibiotics and pain medications as ordered, and teaching the family how to change dressings and how to recognize shunt blockages or other problems.
BOX 52-3 FACTORS ASSOCIATED WITH CEREBRAL PALSY
Prenatal
Perinatal
Postnatal
Manifestations
Diagnostic Evaluation and Therapeutic Management
PATHOPHYSIOLOGY: Cerebral Palsy
NURSING CARE PLAN: The Child with Cerebral Palsy in the Community Setting
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Head Injury
Types of Head Injuries
FIG 52-5 Epidural and subdural hematomas are the two most common cranial hematomas, occurring in 6% to 7% of all children with head injuries. With epidural hematoma, a rapid decline in neurologic function may occur 4 to 8 hours after a brief period of lucidity. If untreated, the increased intracranial pressure (ICP) can cause death in a short time. A subdural hematoma is often caused when the head strikes an immovable object. A subdural hematoma (along with retinal hemorrhage) in an infant or child may occur as a result of child abuse involving aggressive shaking, blunt impact, or both (abusive head trauma).
Skull Fractures
Contusion
Concussion
Intracranial Hemorrhage
Incidence
BOX 52-4 CLASSIFICATION OF SEVERITY OF HEAD INJURIES BASED ON GLASGOW COMA SCALE (GCS)∗
Manifestations
Diagnostic Evaluation
Therapeutic Management
PATHOPHYSIOLOGY: Head Injury
PARENTS WANT TO KNOW: Guidelines for the Child with a Head Injury∗
Postconcussion Syndrome
Second Impact Syndrome
Nursing Considerations
Spinal cord injury ExemplarSpinal Cord Injury
Etiology
PATHOPHYSIOLOGY: Spinal Cord Injury
Incidence
Manifestations
Diagnostic Evaluation
Therapeutic Management
FIG 52-6 Children who have injuries or birth defects that involve the upper spine may be placed in halo traction to stabilize the spine and prevent added nerve damage. Spinal cord injury is a catastrophic event for the child and family; intense nursing support and education as well as referral to support groups, will be needed.
Nursing Care
The Child with a Spinal Cord Injury
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcomes
Expected Outcome
Expected Outcome
Interventions
Evaluation
Seizure ExemplarSeizure Disorders
Etiology
Incidence
Pathophysiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
BOX 52-5 INTERNATIONAL CLASSIFICATION OF SEIZURES
Generalized Seizures
Tonic, Clonic, and Tonic-Clonic Seizures
Atonic Seizures
Myoclonic Seizures
Absence Seizures
Focal Seizures
Unknown
TABLE 52-3 COMMON SEIZURE MEDICATIONS
NURSING CARE PLAN: The Child with a Seizure Disorder in the Community Setting
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
PATIENT-CENTERED TEACHING: Guidelines for the Child or Adolescent Taking Seizure Medication
Status Epilepticus
Etiology
Incidence
Pathophysiology
NURSING QUALITY ALERT: Observations and Nursing Care during a Seizure
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Status Epilepticus
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Interventions and Evaluation
SAFETY ALERT: Drug Therapy for Generalized Tonic-Clonic Status Epilepticus
Bacterial meningitis ExemplarViral meningitis ExemplarMeningitis
Etiology
FIG 52-7 As part of the assessment for meningitis, the nurse can attempt to elicit Kernig sign and Brudzinski sign. Both are early indicators of meningitis in children and adolescents. Kernig sign The child can easily extend the leg when in the supine position. However, when the thigh is flexed toward the abdomen, pain prevents complete extension of the leg. Brudzinski sign In the supine position, the child bends her head toward her chest (in the younger child, the nurse can bend the child’s head). This action usually produces involuntary hip and knee flexion in the child with meninigitis.
Incidence
Manifestations
Diagnostic Evaluation
Therapeutic Management
PATHOPHYSIOLOGY: Meningitis
Nursing Care
The Child with Meningitis
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Interventions
NURSING QUALITY ALERT: Guidelines for the Child with Meningitis
CRITICAL THINKING EXERCISE 52-1
Evaluation
Guillain-Barré Syndrome
Incidence
Pathophysiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with Guillain-Barré Syndrome
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcomes
Expected Outcome
Interventions
Evaluation
Neurologic Conditions Requiring Critical Care
Headaches
Etiology
Incidence
Manifestations
Migraine
Tension-Type Headaches
Diagnostic Evaluation
TABLE 52-4 NEUROLOGIC CONDITIONS REQUIRING CRITICAL CARE
Nursing Care
The Child with Headaches
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcome
Interventions
Evaluation
KEY CONCEPTS
References and Readings
Pageburst Integrated Resource
Animation
Chapter 53 Psychosocial Problems in Children and Families
Learning Objectives
Clinical Reference
Overview of Psychosocial Disorders of Childhood
PSYCHOSOCIAL DISORDERS TYPICALLY MANIFESTED IN CHILDHOOD
Precipitating Factors
Diagnostic Evaluation
MENTAL STATUS EXAMINATION OF CHILDREN
EVIDENCE-BASED PRACTICE
Emotional Disorders
Anxiety Disorders
Social Anxiety Disorder
Separation Anxiety
Panic attack ExemplarPanic Disorder
Posttraumatic distress disorder ExemplarPosttraumatic Stress Disorder
Obsessive compulsive disorder ExemplarObsessive-Compulsive Disorder
Mood Disorders
Depressive disorders ExemplarDepression ExemplarMajor Depressive Disorder and Dysthymic Disorder
Adjustment Disorder
Bipoar ExemplarBipolar disorder ExemplarBipolar Disorder
Etiology and Physiology of Emotional Disorders
Biologic Factors
Environmental Factors
Traumatic brain injury ExemplarTraumatic Brain Injury
Manifestations
Therapeutic Management of Children with Emotional Disorders
Nursing Care
The Child with an Emotional Disorder
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Interventions
Evaluation
Self-harm ExemplarSuicide ExemplarSuicide
NURSING QUALITY ALERT: Resources for People with Thoughts of Suicide
Manifestations and Risk Factors
Therapeutic Management
Prevention
When Prevention and Intervention Fail
Nursing Care
The Child or Adolescent at Risk for Suicide
Assessment
BOX 53-1 QUESTIONS TO ASSESS SUICIDE POTENTIAL
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Interventions
Evaluation
Behavioral Disorders
Etiology
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with ADHD
Assessment
Nursing Diagnosis and Planning
Expected Outcomes
Expected Outcome
Expected Outcome
Expected Outcome
Interventions
Evaluation
Anorexia nervosa ExemplarBulimia ExemplarEating Disorders: Anorexia Nervosa and Bulimia Nervosa
Etiology
Manifestations
Anorexia Nervosa
FIG 53-1 In anorexia nervosa, the adolescent refuses to maintain adequate body weight, partly because of a distorted body image: She perceives herself as overweight when in fact she is below minimum weight.
Bulimia Nervosa
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child or Adolescent with an Eating Disorder
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Interventions
Evaluation
Substance Abuse
TABLE 53-1 Opioid ExemplarAlcohol intoxication ExemplarTobacco products Exemplar COMMONLY ABUSED DRUGS AND THEIR EFFECTS
Etiology
BOX 53-2 PHASES OF SUBSTANCE ABUSE
Phase 1: Experimentation
Phase 2: Early Drug Use
Phase 3: True Drug Addiction
Phase 4: Severe Drug Addiction
Manifestations
NURSING QUALITY ALERT: Relapse Among Substance Abusers
Therapeutic Management
Nursing Care
The Child or Adolescent with a Substance Abuse Problem
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Interventions
Evaluation
Child abuse ExemplarChildhood Physical and Emotional Abuse and Child Neglect
Etiology
Incidence
BOX 53-3 CHARACTERISTICS OF THE ABUSIVE FAMILY
Manifestations
Indicators of Physical Abuse
Indicators of Neglect
FIG 53-2 Physical signs of child abuse. The nurse should be alert for the typical behavioral indicators of abuse.
Nonaccidental distribution of bruises: All four surfaces of the torso are involved, but there are no bruises on arms and legs.
Pattern of injury: Linear scars of various ages indicate repeated abuse with a switch or a whip. The loop pattern on the boy’s anterior torso is consistent with a looped electrical cord used as a whip.
Scald burn of shoulder and neck: The typical distribution of a scald burn in a toddler. This type of injury occurs when a toddler pulls a cup of coffee or pan of water off a stove.
Nonaccidental immersion scald: Involvement of virtually the entire posterior surface of the legs indicates that the legs were held under scalding water; even an infant this young would flex the knees to avoid the hot water.
Indicators of Emotional Abuse
Indicators of Sexual Abuse
Other Specific Abusive Situations
Abusive Head Trauma
Munchausen Syndrome by Proxy
CRITICAL THINKING EXERCISE 53-1
NURSING CARE PLAN: The Abused Child
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
FIG 53-3 Disclosure of abuse may be slow because the child often has difficulty trusting any adult. Physical examination and interview of children who may be victims of sexual abuse require particular sensitivity because physical inspection of the child’s genitalia to detect signs of injury or sexually transmitted disease may frighten the child, who associates handling of the genitalia with pain or shame. Anatomically correct dolls are often used in the assessment of abuse within a family. These dolls help children express what they cannot express in words; young children in particular have a limited vocabulary to use when describing the events that have occurred. Note the communication techniques designed to reassure the child and give the child some power. The little girl is not immediately positioned for a genital examination. The physician first sits to talk with the child at her eye level and makes eye contact with her. Drawings may help to identify the abused child and assist in therapy. Art can also help the child express what cannot be expressed in words.
KEY CONCEPTS
References and Readings
Chapter 54 The Child with a Developmental Disability
Learning Objectives
CLINICAL REFERENCE
Genetics and Genomics
COMMON DIAGNOSTIC TESTS FOR INTELLECTUAL AND DEVELOPMENTAL DISORDERS
Intellectual and Developmental Disorders
Developmental Disability and the Americans with Disabilities Act: The Impact of Public Policy
Terminology
Mental Age, Functional Age, Adaptive Functioning
Intellectual Impairment and Intellectual Disability
Intellectual Impairment versus Mental Retardation
Autism Spectrum Disorders versus Pervasive Developmental Disorders
Etiology of Intellectual Disabilities and Pervasive Developmental Disorders
BOX 54-1 CAUSES OF INTELLECTUAL DISABILITY
Genetic
Alterations Occurring during Pregnancy
Neonatal Alterations
Acquired Childhood Conditions or Diseases
Environmental Problems
EVIDENCE-BASED PRACTICE
Incidence of Intellectual and Developmental Disorders
BOX 54-2 PROBLEMS RELATED TO INTELLECTUAL DISABILITY
Mild
Severe
Manifestations
FIG 54-1 Children with intellectual impairments may have other dysfunctions as well. The family of a child with an intellectual impairment often feels continual grief because the child does not meet their expectations. This child has additional dysfunctions that require respiratory and nutritional support.
Diagnostic Evaluation
BOX 54-3 EXPECTED SKILLS ACCORDING TO INTELLIGENCE QUOTIENT (IQ) SCORES
Normal Intelligence (IQ 85 to 115)
Borderline Intellectual Disability (IQ 71 to 84)
Mild Intellectual Disability (IQ 50-55 to ~70)
Moderate Intellectual Disability (IQ 35-40 to 50-55)
Severe Intellectual Disability (IQ 20-25 to 35-40)
Profound Intellectual Disability (IQ <20 to 25)
TABLE 54-1 SAFETY CONCERNS FOR DEVELOPMENTALLY DELAYED OR IMPAIRED CHILDREN
Management
General Strategies
Safety Challenges
SAFETY ALERT: The Child with a Developmental Disorder
Disorders Resulting in Intellectual or Developmental Disability
NURSING CARE PLAN: The Child with a Developmental Disorder or Disability in the Community Setting
Focused Assessment: The Child
Focused Assessment: The Family
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
FIG 54-2 Special Olympics International is the largest recreational program in the world for people with intellectual impairment. With more than 1 million athletes in 125 countries, Special Olympics offers opportunities for social interaction with peers and assists children who are intellectually disabled in reaching their maximum potential.
Down syndrome ExemplarDown Syndrome
FIG 54-3 Children with delayed motor or cognitive function, whether temporary or pervasive, benefit from early and vigorous therapy to help them reach their maximum development.
BOX 54-4 MEDICAL CONDITIONS ASSOCIATED WITH DOWN SYNDROME
Conditions Frequently Identified during the Neonatal Period
Conditions Frequently Identified during Childhood
Etiology
Incidence
PATHOPHYSIOLOGY: Down Syndrome
Manifestations
Diagnostic Evaluation
Therapeutic Management
Nursing Care
The Child with DS
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcomes
Interventions
Evaluation
Fragile X Syndrome
Etiology
Incidence
PATHOPHYSIOLOGY: Fragile X Syndrome
Manifestations
Intellectual Functioning
Physical Characteristics
Social and Emotional Relatedness
Speech and Language Capability and Sensory Impairment
Co-Morbid Disorders
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
Rett Syndrome
Fetal Alcohol Spectrum Disorder
Etiology and Incidence
PATHOPHYSIOLOGY: Fetal Alcohol Syndrome
Manifestations
Diagnostic Evaluation
FIG 54-4 Toddler with fetal alcohol syndrome. Subtle indicators are flat mid-face, indistinct philtrum, and low-set ears.
Nursing Care
The Infant with FAS
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcome
Expected Outcome
Expected Outcome
Interventions
Evaluation
Nonorganic Failure to Thrive
Etiology
Incidence
Manifestations and Risk Factors
Diagnostic Evaluation
Therapeutic Management
Nursing Considerations
Autism ExemplarAutism Spectrum Disorders
Asperger Syndrome
Autism
TABLE 54-2 Schizophrenia Exemplar DIFFERENTIAL DIAGNOSIS OF AUTISM, INTELLECTUAL DISABILITY, AND SCHIZOPHRENIA
Etiology
Incidence
Manifestations
Social
Language
Restricted Behavioral Repertoire
Diagnostic Evaluation
Therapeutic Management
CRITICAL THINKING EXERCISE 54-1
Nursing Care
The Child with Autism
Assessment
Nursing Diagnosis and Planning
Expected Outcome
Expected Outcomes
Expected Outcomes
Interventions
NURSING QUALITY ALERT: Maintaining Routine for the Child with Autism
Evaluation
KEY CONCEPTS
References and Readings
Chapter 55 The Child with a Sensory Alteration
Learning Objectives
CLINICAL REFERENCE
Review of the Eye
Structure and Function
Neonatal Development
Review of the Ear
Structure and Function
Neonatal Development
Speech Development
PEDIATRIC DIFFERENCES IN SENSORY FUNCTION
Vision
Hearing
Speech and Language
Vision screening ExemplarDisorders of the Eye
NURSING QUALITY ALERT: Vision Screening
Nursing Considerations for the Child with Color Deficiency
BOX 55-1 SIGNS AND SYMPTOMS OF POTENTIAL VISION PROBLEMS
Nursing Considerations for the Child with a Blocked Lacrimal Duct
Nursing Considerations for the Child with a Refractive Error
TABLE 55-1 TYPES OF REFRACTIVE DISORDERS
Nursing Considerations for the Child with Amblyopia
Nursing Considerations for the Child with Strabismus
PATIENT-CENTERED TEACHING: Information about Eye Patching
BOX 55-2 TYPES OF STRABISMUS
Child with early onset esotropia. The deviation may not be apparent until age 3 or 4 months.
Child with left exotropia. Most exodeviations in childhood are intermittent.
Glaucoma ExemplarNursing Considerations for the Child with Glaucoma
Cataracts ExemplarNursing Considerations for the Child with a Cataract
Eye Surgery
NURSING CARE PLAN: The Child Having Eye Surgery
Focused Assessment
Nursing Diagnosis
Planning
Expected Outcomes
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Nursing Diagnosis
Planning
Expected Outcome
Interventions and Rationales
Evaluation
Eye Infections
Nursing Considerations for the Child with Conjunctivitis
Nursing Considerations for the Child with Orbital Cellulitis
Nursing Considerations for the Child with a Corneal Ulcer
Eye Trauma
Nursing Considerations for the Child with a Corneal Abrasion
Nursing Considerations for the Child with Hemorrhage
Nursing Considerations for the Child with Hyphema
PARENTS WANT TO KNOW: How to Prevent Eye Injuries While Participating in Sports
Nursing Considerations for the Child with a Chemical Splash Injury
Conductive hearing loss ExemplarHearing Loss in Children
Etiology
SAFETY ALERT: Working with a Child Who Has a Visual Impairment
Incidence
BOX 55-3 TYPES AND ETIOLOGY OF HEARING LOSS
BOX 55-4 RISK FACTORS INDICATING THE NEED FOR HEARING SCREENING
Neonates (Birth to 28 Days)
Infants (29 Days to 2 Years) Developing Certain Conditions Associated with Hearing Loss
Diagnostic Evaluation
PATHOPHYSIOLOGY: Hearing Loss
BOX 55-5 HEARING TESTS USED FOR INFANTS
Auditory Brainstem Response
Evoked Otoacoustic Emissions
Therapeutic Management
Nursing Considerations for the Child with Hearing Loss
PATIENT-CENTERED TEACHING: How to Encourage Language Development
Talk
Look
Control Distance
Loudness
Be a Good Speech Model
Play and Talk
Read
Do Not Wait
CRITICAL THINKING EXERCISE 55-1
Language Disorders
FIGURE 55-1 Expressive speech disorders include disorders of voice, articulation, and fluency. A speech therapist works with the child to help the child speak more clearly and be better understood. Early intervention is important to correct speech disorders. The nurse should therefore assess speech patterns during each health screening. Referrals should be made for any problems noted.
KEY CONCEPTS
References and Readings
Features
Critical to Remember
Drug Guide
Nursing Care Plan
Nursing Quality Alert
Patient-Centered Teaching
Procedure
Safety Alert
Want to Know
Temperature Equivalents and Pediatric Weight Conversion
Temperature Equivalents: Celsius and Fahrenheit
Pediatric Weight Conversion: Pounds to Kilograms
Glossary

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