Pathophysiology: (Narrative) A prolonged latent phase may result from oversedation or from entering labor early with a thickened

or uneffaced cervix. It may be misdiagnosed in the face of frequent prodromal contractions. Protraction of active labor is more easily diagnosed and is dependent upon the 3 Ps. The first P, the passenger, may produce abnormal labor because of the infant's size (eg, macrosomia) or from malpresentation. The second P, the pelvis, can cause abnormal labor because its contours may be too small or narrow to allow passage of the infant. Both the passenger and pelvis cause abnormal labor by a mechanical obstruction, referred to as mechanical dystocia. With the third P, the power component, the frequency of uterine contraction may be adequate, but the intensity may be inadequate. Disruption of communication between adjacent segments of the uterus may also exist, resulting from surgical scarring, fibroids, or other conduction disruption. Whatever the cause, the contraction pattern fails to result in cervical effacement and dilation. This is called functional dystocia. Uterine contractile force can be quantified by the use of an intra-uterine pressure catheter. Use of this device allows for direct measurement and calculation of uterine contractility per each contraction and is reported in Montevideo units (MVUs). For uterine contractile force to be considered adequate, the force produced must exceed 200 MVUs during a 10-minute contraction period. Arrest disorders cannot be properly diagnosed until the patient is in the active phase and had no cervical change for 2 or more hours with the contraction pattern exceeding 200 MVUs. Uterine contractions must be considered adequate to correctly diagnose arrest of dilation.

PREPARATION OF PATIENT: POSITION: The Patient is supine. Arms are extended on the padded arm boards. Pad all bony prominences and areas vulnerable to skin and neurovascular trauma or pressure. Very carefully insert foley catheter and connect it into a continuous drainage.

SKIN PREPARATION: Abdominal preparation. There includes breast line to upper third of thighs, from table line to table line, with patient in supine position.

DRAPING: Folded towels and a laparotomy sheet . Additional drape sheet to cover a second back table for care of the infant.

PREPARATION OF PATIENT:

POSITION: AN extension is secured to the table with a headrest device . The skull is fixed in position by still pins.. Alternatively, the head may be positioned on a padded donut. The arms are extended on padded arm boards.

SKIN PREPARATION: Hair is shaved. Care is taken to avoid getting prep solution on the eyes. Small cotton pledgets are placed in the ears. If a bone grafting is anticipated, the bone graft area is anticipated, the graft area is prepped and drape at the same time.

DRAPPING: Folded towels are placed around the operative site and secured by towel clips. A large drape sheet is placed below the head.

AGUILAR, MAY ANN A. NQD-2 Deep Brain Stimulation May Help Hard-To-Control High Blood Pressure ScienceDaily (Jan. 24, 2011) Researchers were surprised to discover what may be a potential new treatment for difficult-tocontrol high blood pressure, according to a case report published in the January 25, 2011, print issue of Neurology, the medical journal of the American Academy of Neurology. The report involved one man who received a deep brain stimulator to treat his pain from central pain syndrome that developed after a stroke. Deep brain stimulation uses a surgical implant similar to a cardiac pacemaker to send electrical pulses to the brain. The 55-year-old man was diagnosed with high blood pressure at the time of the stroke, and his blood pressure remained high even though he was taking four drugs to control it. While the electrical stimulation did not permanently alleviate his pain, researchers were surprised to see that stimulation decreased his blood pressure enough that he could stop taking all of the blood pressure drugs. "This is an exciting finding as high blood pressure affects millions of people and can lead to heart attack and stroke, but for about one in 10 people, high blood pressure can't be controlled with medication or they cannot tolerate the medication," said Nikunj K. Patel, BSc MBBS, MD, FRCS, of Frenchay Hospital in Bristol, UK, who wrote the case study. Patel noted that the decrease in blood pressure was a response to the deep brain stimulation, and not a result of changes to his other conditions. The man's blood pressure gradually decreased after the deep brain stimulator was implanted in the periaqueductalperiventricular grey region of the brain, which is involved in regulating pain. His blood pressure was controlled for the nearly three years of follow-up; at one point he went back on an anti-hypertension drug for a slight increase in blood pressure, but that drug was withdrawn when the blood pressure went down again. At one point researchers tested turning off the stimulator. This led to an increase of an average of 18/5 mmHg in blood pressure. When the stimulator was turned back on, blood pressure dropped by an average of 32/12 mmHg. Repeating the tests produced the same results. "More research is needed to confirm these results in larger numbers of people, but this suggests that stimulation can produce a large, sustained lowering of blood pressure," Patel said. "With so many people not responding to blood pressure medications, we are in need of alternative strategies such as this one."

Leadership Theories behavioral, situational, and transformation 1. Autocratic Leadership o Centralized decision making with the leader, making decisions, and using power to command and control others. o Associated with high performing groups, but close supervision was necessary and feelings of hostility were often present. 2. Democratic leadership o Participatory, with authority delegated to others o To be influential, the democratic leader uses expert power and the power base afforded by having close, personal relationships,. o These leaders engendered positive feelings in their groups and performance was strong whether or not the leader was present. 3. Laissez faire leadership o Passive and permissive and the leader defers decision making = low productivity and feeling of frustration Situational Theories y Addresses follower characteristics in relations to effective leader behavior y High task behavior is called a telling leadership style o telling leadership style high task behavior and low relationship behavior o selling leadership style high task, high relationship o participating leadership style low task and low relationship o delegating leadership style low task and relationship o NOTE: The leader not only changes leadership style according to followers needs but also develops followers over time to increase their level of maturity. Transformational Theories y Process in which leaders and followers raise one another to higher levels of motivation and morality. y It empowers others to engage in pursuing a collective purpose by working together to achieve visions of a preferred future. y Its influence by both the leader and the follower to a higher level of conduct and achievement the transforms them both Transitional leader y The manager that is concerned with the day to day operations y These leaders motivate others by behaving in accordance with values , provide a vision that reflects mutual values, and empowers others to contribute. y Transformational leadership has been a popular approach in nursing Generational Issues 1. Boomers o 1946 1964 o Demonstrate loyalty to an employer o Work hard with strong emphasis on money and acquire thing o More personalized training methods 2. Busters o 1965 1981 o Regularly change organizations to advance their development o More individual approach to work o Value work family balance lifestyle more highly o More computer skilled and comfortable with high tech tools o Note: Different styles reveal differences in how learning occurs and the methods best suites us. Supervising the Work of Others a. Supervision 1. Actively monitoring or overseeing acitivies of others 2. Nurses must be ware of the agencys goal, particularly as they relate to pt care. 3. Must monitor the extent to which these goal are met 4. Focus us upon the main goal of the job o Includes pt care and pt safely o Remember treat staff fairly Characteristics of Effective Supervisions 1. Ensure working conditions are suitable to meet patient needs o What does the staff nurse do if they are not? 2. Ensure resources are available to meet pt needs 3. Orientating/teaching/and guiding co workers, based upon individual backgrounds and needs 4. Stimulating desire for self improvement in others, as well as encouraging the use of unique talents and skills. 5. Acting as a role model with desired attitudes, skills, interests, and work habits. Evaluating Patient Care Performed by Others y Using nursing standards as quality care guidelines o Ex agency standards, ANA standards y Using specific criteria to measure pt care outcomes o Ex care maps, evidence based practice Accepting Responsibility for Subordinates

y y y y y y

a. Methods include: Clarify work expectations Assuming responsibility for ones own assignment Overseeing by walking around must is focused upon what you want to evaluate. Makin notes is effective Asking staff to tell you how they are progressing with their assignments Observing for patterns of behavior in subordinates, dependable? Provide quality care? Follow directions? Get stressed easily? Performing chart audits for the purpose of monitoring adherence to standard of care. Many agencies require the RNs be involved in this process.