Chapter 20: Maternal Physiologic Changes The uterus involutes rapidly after birth and returns to the true

e pelvis within 2 weeks. The rapid decrease in estrogen and progesterone levels after expulsion of the placenta is responsible for triggering many of the anatomic and physiologic changes in the puerperium. Assessment of lochia and fundal height is essential to monitor the progress of normal involution and to identify potential problems. The return of ovulation and menses is determined in part by whether the woman breastfeeds her infant. Few alterations in vital signs are seen after birth under normal circumstances. Hypercoagulability, vessel damage, and immobility predispose the woman to thromboembolism. Marked diuresis, decreased bladder sensitivity, and overdistention of the bladder can lead to problems with urinary elimination. Pregnancy-induced hypervolemia, combined with several postpartum physiologic changes, allows the woman to tolerate considerable blood loss at birth. Chapter 21: Nursing Care During the Fourth Trimester Postpartum care is modeled on the concept of health. Cultural beliefs and practices affect the patients response to the puerperium. The nursing care plan includes assessments to detect deviations from normal, comfort measures to relieve discomfort or pain, and safety measures to prevent injury or infection. Teaching and counseling measures are designed to promote the womans feelings of competence in self-management and baby care. Common nursing interventions in the postpartum period include evaluating and treating the boggy uterus and the full urinary bladder; providing for nonpharmacologic and pharmacologic relief of pain and discomfort associated with the episiotomy, lacerations, afterbirth pains, or breastfeeding; and instituting measures to promote or suppress lactation. Meeting the psychosocial needs of new mothers involves taking into consideration the composition and functioning of the entire family. Early postpartum discharge will continue as a result of consumer demand, medical necessity, discharge criteria for low risk childbirth, and cost-containment measures. Early discharge classes, telephone follow-up, home visits, warm lines, and support groups are effective means of facilitating physiologic and psychologic adjustments in the postpartum period. Chapter 22: Transition to Parenthood The birth of a child necessitates changes in the existing interactional structure of a family. Attachment is the process by which the parent and infant come to love and accept each other. Attachment is strengthened through the use of sensual responses or interactions by both partners in the parent-infant interaction. In adjusting to the parental role, the mother moves from a dependent state (taking in) to an interdependent state (letting go). Mothers may exhibit signs of postpartum blues (baby blues) or PPD. Fathers experience emotions and adjustments during the transition to parenthood that are similar to and also distinctly different from those of mothers. Modulation of rhythm, modification of behavioral repertoires, and mutual responsivity facilitate infant-parent adjustment.

 Many factors (e.g., age, culture, socioeconomic level, and expectations of what the child will be like) influence adaptation to parenthood. Parents face a number of tasks related to sibling adjustment that require creative parental interventions. Grandparents can have a positive influence on the postpartum family. Chapter 23: Postpartum Complications PPH is the most common and most serious type of excessive obstetric blood loss. Hemorrhagic (hypovolemic) shock is an emergency situation in which the perfusion of body organs may become severely compromised and death may ensue. The potential hazards of therapeutic interventions may further compromise the woman with hemorrhagic disorders. Postpartum infection is a major cause of maternal morbidity and mortality throughout the world. Postpartum UTIs are common because of trauma experienced during labor. Breast infection affects about 1% of women soon after childbirth. Structural disorders of the uterus and vagina related to pelvic relaxation are often the delayed but direct result of childbearing. An understanding of grief responses and the bereavement process is fundamental in the implementation of the nursing process. Therapeutic communication and counseling techniques can help families identify their feelings and feel comfortable in expressing their grief. Follow-up after discharge is an essential component in providing care to families who have experienced a loss. Nurses need to be aware of their own feelings of grief and loss to provide a nonjudgmental environment of care and support for bereaved families. Chapter 24: Physiologic Adaptations of the Newborn By full term the newborns various anatomic and physiologic systems have reached a level of development and functioning that permits a physical existence apart from the mother. The appearance of jaundice during the first day of life or persistence of jaundice beyond 7 to 10 days may indicate a pathologic process that requires further investigation. Heat loss in the healthy term newborn may exceed the capacity to produce heat; this can lead to metabolic and respiratory complications that threaten the newborns well-being. Assessment of the newborn requires data from the prenatal, intrapartum, and postpartum periods. The newborn assessment should proceed systematically so that each system is thoroughly evaluated. Some reflex behaviors are important for the newborns survival. Individual personalities and behavioral characteristics of infants play a major role in the ultimate relationship between infants and their parents. Each full-term newborn has a predisposed capacity to handle the multitude of stimuli in the external world. Chapter 25: Nursing Care of the Newborn Assessment of the newborn requires data from the prenatal, intrapartum, and postnatal periods. Knowledge of biologic and behavioral characteristics is essential for guiding assessment and interpreting data.

 Providing a protective environment is a key responsibility of the nurse and includes such measures as careful identification procedures, protection from abduction, support of physiologic functions, and measures to prevent infection. Maintenance of adequate ventilation includes ensuring an open airway and body temperature within the normal range. Parent education is a major responsibility of the nurse and includes involvement of parents in all phases of the nursing process. The newborn has social as well as physical needs. Circumcision is an elective surgical procedure. Parents appreciate anticipatory guidance in the care of the newborn. Chapter 26: Newborn Nutrition and Feeding Human milk is species specific and is the recommended form of nutrition for infants. It provides immunologic protection against many infections and diseases. Breast milk changes in composition with each stage of lactation, during each feeding, and as the infant grows. During the prenatal period, parents should be informed of the benefits of breastfeeding for infants, mothers, families, and society. Infants should be breastfed as soon as possible after birth and at least 8 to 12 times per day thereafter. There are objective, measurable indicators that the infant is breastfeeding effectively. Breast milk production is based on a supply-meets-demand principle; the more the infant nurses, the greater the milk supply. Commercial infant formulas provide satisfactory nutrition for most infants. Infants should be held for feedings. Parents should be instructed about the types of commercial infant formulas, proper preparation for feeding, and correct feeding technique. Unmodified (whole) cows milk is not appropriate for feeding the infant during the first year of life. Chapter 46: Respiratory Dysfunction Acute infection of the respiratory tract is the most common cause of illness in infancy and childhood. The incidence and severity of respiratory tract infections are influenced by the infectious agents involved, the childs age, and the childs natural defenses. Common respiratory tract infections of childhood include nasopharyngitis, pharyngitis (including tonsillitis), influenza, infectious mononucleosis, and OM. Croup syndromes involve acute inflammation and variable degrees of obstruction of the epiglottis, larynx, or trachea. The primary goals in the care of children with croup are observation for signs of respiratory distress and relief of laryngeal inflammation. Common infections of the lower airways are bacterial tracheitis, bronchitis, and RSVbronchiolitis. Pneumonias are classified according to site (lobar, bronchial, or interstitial) or by etiologic agent (viral, bacterial, mycoplasmal), or are associated with aspiration of foreign material. In TB, susceptibility to the bacillus can be influenced by heredity, age, stress, poor nutrition, and intercurrent infection. Second-hand smoke exposure is a major environmental pollutant contributing to respiratory illness in children. Asthma is the leading cause of chronic illness in children. General therapeutic management of asthma includes assessment of asthma severity, allergen control, drug therapy, symptom management, and sometimes hyposensitization.

 Support for the family of the child with asthma includes education about the disease and its therapy and facilitation of self-management. CF is the most common inherited disease in children. The diagnosis of CF is based on newborn screening finding of elevated IRT, DNA analysis showing a CFTR mutation, and a positive sweat chloride test (increased sweat electrolyte content). Choking and respiratory failure are respiratory emergencies that require immediate intervention. Abdominal thrusts are used in children in whom FB obstruction is witnessed or strongly suspected. A combination of back blows and chest thrusts is used for infants with FB obstruction. In a conscious choking child, attempts to relieve the obstruction are used only if the child is unable to make any sounds, the cough becomes ineffective, or the child has increasing respiratory difficulty with stridor. Chapter 47: Gastrointestinal Dysfunction Common nutritional disorders of infancy and early childhood may result from vitamin and mineral deficiency or excess, some types of vegetarian diets, protein-energy malnutrition, and food intolerance. Food consumption varies among vegetarians; therefore a detailed dietary intake is essential for planning adequate intakes, particularly in children and pregnant and lactating women. Protein-energy malnutrition may occur as a complication of underlying disease, lack of parental education about infant nutrition, inappropriate management of food allergy, or incorrect preparation of formula. Food intolerance encompasses food allergies and food sensitivities, which can have a number of systemic and local clinical manifestations. CMA and lactose intolerance may occur in some children. Infants are subject to fluid depletion because of their greater surface area relative to body mass, high rate of metabolism, and immature kidney function. Dehydration can be classified as isotonic, hypotonic, and hypertonic. Vomiting and diarrhea account for significant fluid depletion, especially in infants and small children. The amount, frequency, and characteristics of stool and vomitus are important nursing observations. Diarrhea can be caused by an inflammatory process of infectious origin, a toxic reaction to ingestion of poisonous substances, dietary indiscretions, or infections outside the alimentary tract. The primary treatment of diarrhea is the use of an oral rehydrating solution. Structural disorders of the GI tract include CL, CP, EA with TEF, anorectal malformations, and BA. CL/P, the most common facial malformation, may involve nutritional, dental, and speech problems. Hernias related to the GI tract can be minor (umbilical) or life-threatening (diaphragmatic, gastroschisis, omphalocele). HD requires surgical removal of aganglionic segments of bowel. Postoperative care of the child with abdominal surgery involves assessing the abdomen and providing hydration and nutrition, intravenous fluids, proper positioning, wound care, and psychologic support. Nursing care of GER is aimed at identifying children with suggestive symptoms, helping parents with home care feeding and positioning, and caring for the child undergoing surgical intervention.

 Although the cause of appendicitis is poorly understood, it is typically a result of obstruction of the lumen, usually by a fecalith. Common signs and symptoms are right lower quadrant abdominal pain, tenderness, and fever. Meckels diverticulum is a congenital malformation of the GI tract characterized by bloody stools. IBD refers to UC and CD. Peptic ulcers are poorly understood, but contributing factors include interference with the normal protective mechanisms of the mucosal lining and the presence of Helicobacter

pylori.
Viral hepatitis is caused by six types of virus: HAV, HBV, HCV, HDV, HEV, and HGV. HAV is spread by the fecal-oral route, whereas HBV and HCV are transmitted primarily by the parenteral route. The most effective measure in prevention and control of hepatitis in any setting is handwashing. BA is a serious disorder, often causing progressive liver failure, which is an indication for liver transplantation. General signs of obstruction include colicky abdominal pain, nausea and vomiting, abdominal distention, and decreased stool output. HPS is recognized by characteristic projectile vomiting, malnutrition, dehydration, and a palpable mass in the epigastrium and is relieved by pyloromyotomy. Intussusception is one of the most common causes of intestinal obstruction during infancy and is characterized by abdominal pain and blood in stools. Treatment is either nonsurgical hydrostatic reduction or surgical reduction. Malabsorption syndromes are disorders associated with some degree of impaired digestion or absorption. They include digestive, absorptive, and anatomic defects. Celiac disease is characterized by intolerance to gluten. It is thought to be either an inborn error of metabolism or an immunologic response. SBS is characterized by a loss of intestine resulting in a diminished ability to absorb a regular diet normally. Specialized enteral and parenteral nutrition is a major element of care for these children. Intestinal parasitic diseases constitute the most common infections in the world; giardiasis and enterobiasis are the most widespread parasitic infections among children in the United States. Although the incidence of poisoning has decreased in the past 30 years as a result of more stringent packaging regulations, childhood poisoning remains a serious health concern. The major principles of treatment for poisoning include assessment and the ABCs of resuscitation (airway, breathing and cardiovascular supportive measures), minimization of poison absorption, prevention of complications, family support, and prevention of recurrence. Communication with the area Poison Control Center is essential in the treatment of any poisoning. Acetaminophen poisoning is the most common accidental drug poisoning among children and occurs primarily from acute overdose. The most important factor contributing to lead poisoning is its availability in the childs environment. Lead-based paint is the most toxic source of lead. Because of increasing awareness of the detrimental effects of low levels of lead on the developing nervous system, acceptable BLLs have been decreasing and now are at less than 10 mcg/dl. Chapter 48: Cardiovascular Dysfunction CHD is the most common form of cardiac disease in children.

 Major categories to investigate in the cardiac history are poor weight gain, poor feeding habits, and fatigue during feeding; frequent respiratory tract infections and difficulties; and evidence of exercise intolerance. The most common tests used in assessing cardiac function are radiography, ECG, echocardiography, and cardiac catheterization. Cardiac catheterization procedures can be divided into three groups: (1) diagnostic procedures, including angiography, that measure pressures and saturations to establish cardiac diagnosis; (2) interventional procedures, in which catheters or balloon devices are used to correct cardiac defects; and (3) electrophysiology studies, in which catheters with electrodes are used to evaluate dysrhythmias. Diagnostic cardiac catheterization provides important information about oxygen saturation of blood within the chambers and great vessels, pressure changes, changes in cardiac output or stroke volume, and anatomic abnormalities. Several prenatal factors may predispose children to CHD: maternal rubella during pregnancy, maternal alcoholism, maternal age older than 40 years, and maternal type 1 diabetes. Congenital heart defects can be divided into four main groups, as determined by hemodynamic patterns: (1) defects that result in increased pulmonary blood flow, (2) obstructive defects, (3) defects that result in decreased pulmonary blood flow, and (4) mixed defects. Clinical consequences of congenital heart defects include CHF and hypoxemia. A child can have both hypoxemia and CHF, although usually they occur independently. Clinical manifestations of CHF are impaired myocardial function (tachycardia, cardiomegaly), pulmonary congestion (dyspnea, tachypnea, orthopnea, cyanosis), and systemic congestion (hepatosplenomegaly, edema, distended veins). Nursing measures in the care of a child with CHF are to assist in improving cardiac function, decrease cardiac demands, reduce respiratory distress, maintain nutritional status, promote fluid loss, and provide family support. Clinical manifestations of hypoxemia are cyanosis, polycythemia, clubbing, and delayed growth and development. The child is at increased risk for hypercyanotic spells, CVAs, brain abscess, and bacterial endocarditis. Caring for the child with CHD and the family requires helping them to adjust to the disorder and cope with the effects of the defect and fostering growth-promoting family relationships. Preoperative care of the child with a congenital heart defect involves introducing the child and family to the hospital and preparing them for preoperative and postoperative procedures. Providing postoperative care includes observing vital signs and arterial and venous pressures, maintaining respiratory status, allowing maximum rest, providing comfort, monitoring fluids, planning for progressive activities, giving emotional support, observing for complications of surgery, and planning for discharge and home care. Acquired cardiovascular disorders include bacterial endocarditis, RF, hyperlipidemia (hypercholesterolemia), and cardiac dysrhythmias. Prevention of bacterial endocarditis in certain children with CHD involves administration of prophylactic antibiotics when specific procedures are performed. Acute RF is a systemic inflammatory disease that can damage the cardiac valves and is associated with previous GABHS infection. Its incidence has increased in some areas of the United States. Cholesterol screening in children is controversial; currently, children with known risk factors for hyperlipidemia are screened and treated as needed. The influence of childhood cholesterol levels on later development of coronary artery disease is under investigation.

 Common dysrhythmias in children include slow (bradycardias, heart block) and fast (sinus tachycardia, SVT) rhythms. Heart transplantation has been extended to infants and children with cardiomyopathy and complex congenital heart defects involving ventricular dysfunction, such as hypoplastic left heart syndrome. Education of the child with hypertension and the family focuses on drug therapy, diet control, and appropriate exercise. KD is an extensive inflammation of small vessels and capillaries that may progress to involve the coronary arteries, causing aneurysm formation. The administration of -globulin is an important aspect of treatment. Emergency treatment for shock includes ensuring ventilation; administering vasopressors, fluids, blood, and antibiotics as needed; and providing supportive measures such as correct positioning, warmth, and psychologic reassurance to the child and family. Persons at risk for anaphylaxis may be identified by a history of previous allergic reaction, history of atopy, history of severe reactions in family, and positive skin test to the allergen. Chapter 49: Hematologic and Immunologic Dysfunction Anemia is defined as reduction of RBCs or Hgb concentration to levels below normal for age; disorders are classified either by etiology and physiology or by morphology. The nurses role in treatment of anemia is to assist in establishing a diagnosis, prepare the child for laboratory tests, administer prescribed medications, decrease tissue oxygen needs, implement safety precautions, and observe for complications. The main nursing goal in prevention of nutritional anemia is parent education regarding correct feeding practices. SCA is a hereditary hemoglobinopathy caused by normal adult Hgb (HbA) being partly or completely replaced by sickle Hgb (HbS). Nursing care of the child with SCA focuses on teaching the family how to prevent and recognize sickle cell problems; managing pain during crises; and helping the child and parents adjust to a lifelong chronic disease. Nursing care of the child with -thalassemia includes observing for complications of multiple blood transfusions, assisting the child in coping with the effects of illness, and fostering parent-child adjustment to long-term illness. Causes of acquired AA include irradiation, drugs, industrial and household chemicals, infections, and infiltration and replacement of myeloid elements; however, most cases are idiopathic. Clotting depends on three processes: vascular spasm, platelet aggregation, and coagulation and clot formation. Nursing care of the child with hemophilia involves preventing bleeding by decreasing the risk of injury, recognizing and managing bleeding with factor replacement, preventing the crippling effects of joint degeneration, and preparing and supporting the child and family for home care. Goals in the care of the child with leukemia are to prepare the family for diagnostic and therapeutic procedures, prevent complications of myelosuppression, manage problems of irradiation and drug toxicity, and provide continued emotional support. The lymphomas include Hodgkins lymphoma and NHL and are disorders involving the lymphoid system. Immunodeficiency disorders render the affected individual unable to fight infectious organisms. HIV infection is primarily acquired in infants during pregnancy or birth from an infected mother and in adolescents from engaging in high risk behaviors. Blood transfusions supply needed blood components.

 HSCT replaces the diseased or malfunctioning bone marrow with viable blood stem cells. Apheresis is the selective removal of a blood component. It can be used to supply cellular elements needed for therapy (i.e., platelets or stem cells) or to remove diseased components.