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NR 364 -Administering Prescribed Medications

NR 364 -Administering Prescribed Medications

NR 364 -Administering Prescribed Medications

Chapter 18

Administering prescribed medications

  • Vitamin K à IM
  • Eye prophylaxisà gonorrhea and chylamidia à erythromycin

APGAR scoring

  • A- appearance (color)
  • P- pulse rate
  • G- grimace
  • A- activity
  • R- respiratory
  • 8 or higher à no intervention needed
  • 4-7à moderate difficulty
  • 0-3à represent severe distress
Weight Low: <5.5 lb

Very low: <3.5lb

Extremely low: <2.5lb
Length Average is 20 in.; but can range 17-22
Head circumference 32-38 cm
Chest circumference 30-36 cm
Temp 97.7-99.5
Heart rate 110-160
Respirations 30-60
Blood pressure 50-75/30-45

Plantar creases– on soles of feet, more creases= increased maturity

Posture– greater the degree of flexion, greater the maturity

Square window– as the angle decreases, the newborn’s maturity increases

Arm recoil– higher the points, the greater the neuromuscular maturity

Popliteal angle– an angle less than 90 degrees indicates greater maturity

Scarf sign- an elbow that does not reach midline indicates greater maturity

Heel to ear– the lesser the flexibility, the greater the newborn’s maturity

 

Skin

  • Acrocyanosis is normal and intermittent
  • Vernix caseosa- thick white substance that protects skin of fetus
  • Stork bites- superficial vascular areas found on the nape of the neck; normal, fades within 1 year
  • Milia- epsteins pearls
  • Mongolian spots
  • Erythema toxicum- benign rash that occurs in up to 70% of newborns; lack of pattern
  • Harlequin sign- dilation of blood vessels on only one side of body
  • Nevus flammeus- port wine stain
  • Nevus vasculosis- strawberry mark or strawberry hemangioma

 

Reflexes

  • Sucking
  • Moro – 3-6 months
  • Stepping- 3-4 months
  • Tonic neck “fencing reflex”- 3-4 months
  • Rooting- 4-6 months
  • Babinski- disappears at 1 year of age
  • Grasps- palmar and plantar- 3-4 months
  • Protective reflexes- blinking, gagging/coughing, sneezing

 

Elimination

  • Meconium à transitional à yellow, seedy (if breastfed) OR foul smelling (formula fed)
  • Need up to 10 diapers a day à 70 a week

 

Hearing Screening

  • Two ways:
    • QAE: tones/clicks presented through earphone to newborn
    • ABR: soft, rapid tapping noise presented
  • A “pass” doesn’t always guarantee normal hearing

 

Common Issues

  • Transient tachypnea- accompanied by retractions, expiratory grunting, or cyanosis
    • Provide 02 and warmth
  • Physiologic Jaundice- common in newborns, yellow skin, mucous membranes and sclera
    • TX: phototherapy
  • Hypoglycemia- BGM < 35 or plasma concentration <40
    • Newborns at high risk; if prolonged à serious long term neuro problems

NR 364 -Administering Prescribed Medications

Appointments

  • 1st à 2 to 4 days after discharge
  • Then 2-4 weeks, 2 4 & 6 months, 9 months, 12 months, 15 & 18 months, 2 years of age
  • Immunizations!!!
    • First à Hep B received in the hospital soon after birth

 

Chapter 23

  • Average newborn: between 38-42 weeks and weighs 6-8 pounds
  • Appropriate for gestational age- AGA- 10th-90th percentile
    • SGA- <10th ; LGA- >90th

SGA

  • Not all fetuses who are SGA have IUGR; not all newborns who have IUGR are SGA
  • IUGR categorized as:
    • Symmetric- fetuses with equally poor growth rates of the brain, abdomen and long bones
    • Asymmetric- brain growth is pared compared to their abdomen and internal organs
  • Give a good maternal H&P to identify risk factors (smoking, HTN, chronic illnesses)
    • Check fetus for: abnormally large head compared to body
  • Common problems:
    • Perinatal asphyxia- difficulty adjusting to extrauterine life; frequently leading to acidosis and hypoxia
    • Hypothermia, hypoglycemia, polycythemia (mild hypoxia secondary to placental insufficiency), meconium aspiration

LGA (aka Macrosomia)

  • Poor motor skills, difficulty regulating behavioral states
  • Common problems: Birth trauma (bruising, edema), hypoglycemia (BG <40), polycythemia, hyperbilirubinemia (polycythemia & RBC breakdown, inability to feed)

Post Term Newborn

  • After 42 weeks there is an inability of placenta to provide adequate oxygen and nutrients to fetus
  • May be LGA, SGA, dysmature (weighs less than normal for EGA)
  • Common problems: perinatal asphyxia, hypoglycemia, polycythemia, hypothermia, meconium aspiration

Preterm Newborn

  • Cause unknown
  • Common complications: respiratory distress syndrome (RDS), anemia, infection or septicemia, delayed growth and development
  • Body systems are immature which affects transition to extrauterine life; increases risk for complications
    • Respiratory system: one of the last body systems to mature
      • Surfactant deficiency will lead to RDS, unstable chest wall, immature control center (leading to apnea), smaller respiratory passages (increased risk of obstruction)
      • Inability to initiate and establish respirations leads to hypoxemia and ultimately hypoxia
    • Cardiovascular system: if oxygen levels remain low secondary to perinatal asphyxia, fetal pattern of circulation may persist, blood flow to bypass the lungs
    • GI system: perinatal hypoxia causes shunting of blood to more important organs (heart/brain) which leads to damage to intestinal wall (risk for malnutrition and weight loss)
    • Renal system: immature; reduced ability to concentrate urine
    • Immune system: immature; increased risk of infection
    • Central nervous system: inadequate brown fat to generate heat; limited muscle mass activity
      • PREVENT COLD STRESS
    • Equipment for newborn resuscitation: 100% 02 supply, Narcan, suction, laryngoscope
    • Administering Oxygenation: use judiciously, too much can cause retinopathy of prematurity (ROP)
      • ROP- Potentially binding eye disorder that occurs when abnormal blood vessels grow and spread through the retina, leading to retinal detachment
    • Promote Stimulation- series of activities to encourage normal development
    • Pain management-
      • Premature Infant Pain Profile (PIPP)- assesses HR and o2 sat
      • CRIES- cry, requires oxygen, increased VS, expression & sleeplessness
      • Neonatal Infant Pain Scale (NIPS)- evaluates respiratory patterns
      • Meds for pain-
        • Morphine and fentanyl- IV, most commonly used opioids
        • Acetaminophen- mild pain
        • Benzodiazepines- sedatives during painful procedures
        • Local or topical anesthetics (EMLA cream) before procedures

NR 364 -Administering Prescribed Medications

ABCD’s of Newborn Resuscitation

  • Airway
    • Place infants head in “sniffing” position
    • Suction mouth, nose, trachea (if meconium-stained)
  • Breathing
    • Use positive pressure ventilation (PPV) and ventilate at 40-60 breaths/minute
    • Look for slight chest movement
  • Circulation
    • START if HR <60 after 30 seconds of effective PPV; 3 compressions: 1 breath every 2 seconds
      • Compress ½ of anterior-posterior diameter of the chest
    • Drug
      • Give epinephrine if HR is <60 after 30 seconds of compressions and ventilation
        • CAUTION: epi dosage is different for endotracheal and IV routes!
          • 1-0.3 ml/kg IV
          • 3-1 ml/kg endotracheal tube

 

Chapter 24

Acquired Conditions of Newborn

  1. Neonatal Asphyxia
    1. Insufficient oxygen delivery to meet demands; most common to occur in neonate; hypoxemia and hypercapnia (excess of carbon dioxide)
    2. Can lead to cerebral palsy, mental retardation, speech, hearing disabilities
  2. Transient tachypnea of the newborn (TTN)
    1. Mild respiratory distress; pulmonary liquid removed slowly or incompletely; occurs within hours of birth and resolves by 72 hours
  3. Respiratory Distress Syndrome (RDS)
    1. Breathing disorder resulting from lung immaturity and lack of alveolar surfactant
    2. Administer prenatal steroids; if untreated it will worsen
    3. Chest x-ray: hypoaeration, underexpansion and ground glass pattern
    4. Ventilation à CPAP, PEEP, antibiotics and fluids/vasopressors
  4. Meconium Aspiration Syndrome
    1. Inhalation of particulate meconium with amniotic fluid into lungs; secondary to hypoxic stress
    2. Chest x-rayà patchy fluffy infiltrates unevenly distributed; hyperaeration with atelectasis; ABG’sà metabolic acidosis; SUCTION!!
  5. Persistent Pulmonary Hypertension of the Newborn (PPHN)
    1. Cardiopulmonary disorder characterized by marked pulmonary HTN that causes right to left extrapulmonary shunting of blood and hypoxemia
    2. S/S- marked cyanosisà Echocardiogram confirms problemà USE OF ECMO (machine with bunch of wires/machines)
  6. Periventricular-Intraventricular Hemorrhage (PVH/IVH)
    1. Bleeding in the brain due to fragility of cerebral vessel; most common in first 72 hours after birth; grades 1-5 (least to most severe); especially in those born before 35 weeks
  7. Necrotizing Enterocolitis
    1. Serious GI disease occurring in newborns; most common and most seriously acquired GI disorder among hospitalized preterm neonates
    2. 3 pathologic mechanisms: bowel ischemia, bacterial flora and effect of feeding
  8. Infants of Diabetic mothers (pregestational or gestational)
    1. High levels of maternal glucose cross placenta and stimulate increased fetal insulin production leading to somatic fetal growth
    2. Newborn characteristics: rosy cheeks, short neck, buffalo hump, excessive subcu fat tissue
      1. Make sure to keep a neutral thermal environment
    3. Birth trauma
      1. Injuries to the newborn due to forces of labor and birth (difficult births requiring external/internal version or mid- or high forceps deliveries
      2. Fractures: breech births or shoulder dystocia-mid clavicular
      3. Brachial plexus injury- stretching, hemorrhage or tearing within a nerve associated with cervical cord injury
        1. Erb’s palsy- upper brachial plexus injury; Tx: immobilization of the upper arm
        2. Klumpke’s palsy- lower brachial plexus; less common
      4. Cranial nerve trauma- facial nerve palsy r/t forceps delivery
      5. Head trauma
        1. Cephalohematoma- localized effusion of blood beneath the periosteum of the skull; can grab it à very swollen
        2. Caput succedaneum- localized pitting edema with petechiae and ecchymosis on the scalp; “normal” swelling of head after birth
  • Subarachnoid hemorrhage- most common intracranial trauma
  1. Subdural hemorrhage (hematomas)- tears of the major veins overlying the cerebral hemispheres/cerebellum

NR 364 -Administering Prescribed Medications

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  1. Newborns of perinatal substance-abusing mothers
    1. Most common substancesà tobacco, alcohol, marijuana
    2. WITHDRAWAL- Wakefulness, Irritability, Temperature, Hyperactivity, Diarrhea, Respiratory distress, Apneic attacks, Weight loss, Alkalosis, Lacrimation
  2. Hyperbilirubinemia
    1. Results from level above 5mg/dL resulting from unconjugated bilirubin being deposited in the skin and mucous membranes à shown as jaundice
    2. Early-onset breastfeeding jaundice- r/t ineffective breastfeeding
    3. Late-onset breastfeeding jaundice- levels of 12-20; don’t stop unless >20; stop breastfeeding for 2 days
    4. Kernicterus- preventable neuro disorder caused by high bilirubin
    5. Immune hydrops- severe form of hemolytic disease that occurs when changes develop in the organs of the fetus secondary to severe anemia
  3. Newborn infections
    1. Sepsis- can result from bacterial, fungal or viral microorganisms or their toxins in blood/other tissues
      1. Congenital (intrauterine), Early-onset (perinatal period-during birth or shortly after), late onset (newborn period)
      2. Normal WBC for newborn is 10-30

 

Congenital Conditions

  1. Esophageal atresia (EA) and Tracheoesophageal fistula (TEF)
    1. EA- congenitally interrupted esophagus
    2. TEF- abnormal communication between trachea and esophagus
    3. “THREE C’S”- coughing, choking, cyanosis
  2. Omphalocele– umbilical ring defect with abdominal sac into external peritoneal sac
  3. Gastrochisis– herniation of abdominal contents through abdominal wall defect (no peritoneal sac)
  4. Imperforate anus– rectum ending in blind pouch or fistulas between rectum and perineum
  5. Bladder extrophy– midline closure defect leaving the bladder open and exposed outside of the abdomen

 

Chapter 5

  • Before graduating from high school, 25% of adolescents will contract an STI
  • Vaginitis– inflammation/infection of vagina- Caused by: candida, trichomonas, gardnerella
  • Vulvovaginal candidiasis– Most common cause of vaginal discharge; cottage cheese discharge
  • Trichomoniasis– Heavy yellow/green or gray/bubbly discharge
    • No alcohol with drug therapy (Flagyl)
  • Bacterial vaginosis– ‘Whiff test’ (stale fishy odor), clue cells
  • Chlamydia– most common bacterial STI in US
    • Combo regimen is gonorrhea is also present
  • Gonorrhea– 2nd most common infection in US; highly contagious and reportable to DOH
    • Meds: Ceftriaxone/Azithromycin/Doxycycline
  • Herpes- 1 (oral) & 2(genital)- Painful multiple vesicular lesions
    • Lifelong viral infection; antivirals to help
  • Syphilis= serious systemic disease; curable; may be vaginal, rectal, oral
    • 4 stages:
      • Primary- chancre that disappears within 1-6 weeks
      • Secondary- rash, sore throat, flu-like symptoms
      • Latent- no symptoms, no longer contagious;
      • Tertiary- tumors of skin, bones and liver; usually not reversible
    • Newborn-congenital syphilis- skin ulcers, rashes, weakened cry
    • Penicillin or doxycycline if allergic to penicillin
  • PID– pelvic inflammatory disease- result of ascending polymicrobial infection of upper female reproductive tract and nearby structures
    • Broad-spectrum oral antibiotics; if no improvement in 72 hours, admission to hospital
  • HPV– most common viral infection; cause of cervical cancer
  • HEP A/HEP B– associated with inflammation o the liver
    • A: spread via GI tract; flu-like symptoms, anorexia, RUQ pain
    • B: via saliva, blood, semen, menstrual blood & vaginal secretions; similar to HAV but with less fever and skin involvement
  • Scabies and Pubic lice– Eradicate infestation, Remove nits and Prevent spread/recurrence
  • HIV/AIDS– low CD4 (less than 200=AIDS)
    • Tests: oraquick à ELISAà western blot or assay to confirm
    • Therapy: HAART (highly active anti-retroviral therapy) combo of 3,4,5 drugs
    • To prevent transmission during pregnancy – three part regimen
      • Prenatally- antiretroviral 14 weeks and throughout pregnancy
      • During labor and delivery- AZT intravenously
      • Nursery- antiretroviral syrup within 12 hours of birth

NR 364 -Administering Prescribed Medications

Chapter 9- Emotional/Physical/Financial/Sexual Abuse

  • IPV- intimate partner violence– those dating/married
    • Goal: to enable victim to gain control of life; developing “game plan”
  • Three phases:
    • Tension Building- usually longest phase
    • Acute battering- explosion of violence
    • Honeymoon- calm and loving; “genuinely sorry”
  • Battered woman syndrome– rarely describes selves as abused
  • Violence against Pregnant Woman
    • Signs: poor attendance at prenatal visits, unrealistic fears, weight fluctuations, difficulty with pelvic exams & noncompliance with treatment
    • SAVE model: screen, ask, validate, evaluate
  • Sexual violence (aka “tragedy of youth”)– more than half of all rapes occur before age 18
    • Statutory rape- sex between an adult & a person under 18
    • Acquaintance rape- forced to have sex by a person he/she knows
  • Date rape drugs
    • Rohypnol (roofies, forget me nots)
    • Gamma hydroxybutyrate– liquid ecstacy or easy lay
    • Ketamine– special k, vitamin k, super acid- acts on CNS; can be fatal if mixed with other drugs
  • Rape recovery (4 phases)
    • Acute phase- disorganization; shock, fear, disbelief
    • Outward adjustment phase- denial; refuses to discuss
    • Reorganization- denial and suppression don’t work; attempts to make life adjustments by moving/changing jobs
    • Integration & recovery- survivor begins to feel safe and starts trusting
  • PTSD- 3 groups of symptoms
    • Intrusion- re-experiencing the trauma
    • Avoidance- avoiding trauma-related stimuli, social withdrawal
    • Hyperarousal- increased emotional arousal, exaggerated startle response
  • Female genital mutilation “cutting”
    • 4-10 years old; southern Africa; some places in middle east and asia (4 types)
  • Human trafficking– look for “sponsor” who doesn’t leave the room