Maternity Labor and Delivery

http://www.sonoma.edu/users/k/koshar/n303/n303clinical.html

http://www.sonoma.edu/users/k/koshar/n303/n_345_skills_checklist.html

http://www.sonoma.edu/users/k/koshar/n303/BSN_Skills.html

Skills you are likely to use in N303

 

Nursing Process: Assessing, diagnosing, planning, implementing, evaluating and documenting individualized care

Communication skills:· Oral and written communication with other health care providers· Patient history: complete and concise· Therapeutic communication· Patient and family teaching· Charting techniques· Patient confidentiality· Patient referrals to other health services

Psychomotor Skills:

· Universal precautions: handwashing, infection control and sterile technique· Physical Assessment: vital signs, pain, intake and output, inspection, palpation, auscultation and percussion techniques· Hygiene care: oral, hair, perineal, and genital· Comfort measures: Assessment of pain and effectiveness of treatment · Moving and ambulating patients: within the bed, bed to bed, bed to chair, sitting/lying to walking, cough and deep breathing and correct body mechanics· Medication administration: Understanding of the usage, dosage, route, side effects, drug/drug interactions, adverse reactions and contraindications. Oral, IM, subcutaneous and eye (newborn) administration.· Specimen collection: clean- catch and midstream urine, measuring blood glucose· Urinary catheters: straight catheter and inserting an indwelling catheter· Oxygen therapy and pulse oximetry· Incentive Spirometer: assisting patients· Suctioning: oral (newborn)· Wound care: Removing skin sutures and staples. Applying steri strips.

 

http://www.sonoma.edu/users/k/koshar/n303/n303_meds.html

N 303 Medications Not Uncommonly Used in Maternity

 

Labor and Delivery:

Ambien Ampicillin Ancef Cytotec

Duramorph Epinephrine Fentanyl (IV) Hydralazine

Betamethasone Reglan Indocin Magnesium Sulfate

Marcaine Methergine Morphine (IV) Narcan

Nifedipine Nubain (IV) Phenergan (IM) Pitocin

Versed Prostin Aqua Gold (antacid) Terbutaline

Labetalol Mineral Oil Hemabate Zofran

Penicillin Cervidil Clindamycin Xylocaine 1% plain

Xylocaine with epinephrine

EphedrineSodium citrate (Bicitra)

cefotetan disodium (Cefotan)

Calcium gluconate

 

 

 

 

 

 

 

 

Postpartum:

Benadryl Demerol Dermoplast Spray DSS

Tucks Hydrocortisone Cream flu vaacine Lansinoh

Lydocaine Ointment Methergine Ibuprofen Metamusil

Senokot MOM Mylicon Norco 5/325 and 10/325

Percocet Pertussis Prenatal Vitamins Rhogam

MMR Tylenol Tylenol/codeine Toradol

 

 

 

 

 

Newborn

Ampicillin Aquamephyton CefotaximeErythromycin Eye Ointment

Exosurf Hep B Vaccine Gentamycin Survanta

Caffeine Sodium Bicarbonate Epinephrine

 

 

 

Remember the 6 rights! Medication, Route, Time, Client, Dosage and Documentation

Note: For this course, you may use your drug book with these medications marked and highlighted for expedient access. You may also use electronic source such as Epocrates. You need to know the generic and brand names, the classification and use, the method of administration (i.e. po, IM), the doses and how often the medication is given (for prn also), side effects, and contraindications. Many of the medications are commonly prescribed so remember the context is related to patients in labor, postpartum and newborns. Although you do not need to memorize the medication, you must have looked them up ahead of time (which also means before the medication test!). You will be asked about all medications before you give them so you must have the information readily accessible. You are still responsible for knowing these medications even if you can't find them in your pharmacology resources. Where else might you find the information?

You need to know how to calculate IV drip rates and drug doses. You do not have to commit these calculations to memory. It seems prudent to bring a calculator and drug calculation

formulas with you to clinical. However, you should have a good understanding of how to calculate medications before you actually need to do this task in the clinical area. Anxiety makes it harder to complete these with accuracy, timeliness and confidence.

http://www.sonoma.edu/users/k/koshar/n303/n303_newborn_assessment.html

Newborn assessment

This can be a great way for teaching and assessing parent-newborn interaction. Remember to keep infant warm!

General Appearance:

Posture: flexed, symmetry (think birth trauma), no retractions, jittery

Color: pale pink to warm brown (darker skinned kids get darker), plethora (>RBC: HCT: 44-64%, Hgb: 14-24), circumoral cyanosis, acrocyanosis, jaundice (physiologic vs pathophysiologic),

Irregularities in color: eccymoses, petechiae (birth trauma), vernix, milia, lanugo, erythema toxicum, pigmented nevi (melanin), vascular nevi ((blood vessels), mongolian spots, harlequin sign, nevus flammeus: port wine staining (capillary angioma & stays same size), nevus flammeus: strawberry mark (gets bigger, then fades), stork bites, Cafe Au Lait spots (> 5 ? neurofibromatosis), mottling (cardiac?), rashes (infection?)

Skin: peeling, lanugo, diaper rash

Vital signs:Respirations (30-60, but can have transient tacypnea) do first, HR: 120-160 (listen through back for mummers), both R and HR are usually irregular, Auxiliary T: 36.5-37.2 (97.7-98.9). Weight: may drop 10% in 1st week

Head:Shape: round, molding, hematoma (doesn't cross sutures, may increase), caput succedaneum (fluid, does cross, usually decreases). Circumference: 33-35 cm

Fontanels: anterior, posterior, bulging, sunken, will pulse) Sutures: overriding

Eyes: Color, subconjuntival hemorrhages, strabismus, nystagmus (immature neuro)

Nose: Patent (check each nostril, look for flaring, sneeze ok)

Mouth: jittery (may with cry), palate (cleft: finger in mouth), thrush, Epstein pearls (inclusion cyst: nl), teeth

Ears: Position, symmetry

Neck: short, skin folds, head control

ChestClavicles (feel), retractions, breast engorgement & discharge (nl: witch's milk). Circumference: 30-33 cm. (2 cm<head)

Abdomen Skin: smooth, peeling, blood vessels visible (maybe a few), not loose

Umbilical cord: color, smell, cord clamp off or on, cord falls off 7-10 days, erythema, hernia, innies and outies, do cord care

Genitalia Female: Introitus patent, vaginal discharge (bloody or much nl).

Male: Urethral meatus (hypospadias, episapdius), Scrotum: testes descended (90% at term), hydrocele

GU: urination, # of wet diapers, can have orange crystals

Back & Buttocks

Spine: Straight, pilonidal dimple (?incomplete closure of spinal tract)

Anus: Patent

Extremities Count digits (polydactyly), webbing (syndactyly)

Pulses: femoral

Muscle tone: symmetrical movement, feet turn in (if can bring to midline: not club foot)

Reflexes Especially: Moro, sucking, grasp P. 546

Ballard Scale for Gestational Age Assessment: p. 567.

Gestational age assessment: by weight p. 568.

Bulb suction: Compress first, then in side of mouth

Heel stick: outside surface of sole.

Injections: vastus lateralis, stabilize leg

Pain scales:

CRIES: page 590. Goal: < 4.

Neonatal Infant Pain Scale (NIPS)

Categories 0 1 2

Face Relaxed muscles Grimace

Cry No Cry Quiet Whimper Mild moaningVigorous Cry Note: silent cry if baby intubated (mouth, facial movement)

Breathing Patterns

RelaxedChange in breathing irregular, faster than usual, gagging, breath holding

ArmsRelaxed (Not rigid) flexed is nl

Flexed/Extension tense, rapid extension and flexion

LegsRelaxed (Not rigid) flexed is nl

Flexed/Extension tense, rapid extension and flexion

State of Arousal

Sleeping/Awake quiet, peaceful or alert and settled

Fussy Alert, restless

Goal: 2 or less

 

CRIES Neonatal Postoperative Pain Scale P. 706. (Crying, Requires O2, Increased vital signs, Expression, Sleepless) Goal: < 4.

N 303 Daily Task List for Postpartum Patients: BRING THIS WITH YOU!

Go to huddle and then Listen to report Introduce self to nurse Introduce self to patient: do VS (first 1/2 hour!) on your maternal patients (not the

newborns). Include pulse oximetry too. Chart these right away. Meals: Assist with trays. Check diets (jot down in report) Medications: Check meds against MD orders. Know when meds are to be given and give

them within ½ hour that time. Five rights! Update the whiteboards in patient rooms Peruse chart for pertinent information. Check Medication reconciled (with meds they

take at home) Plan out care Physical assessments on patients. Chart by 11 am Appropriate teaching: self care, infant care, breastfeeding, discharge teaching Care planning Hourly rounding Document care and check (and sign) pink care plan. Nurse or instructor cosigns. Have

instructor check. Paperwork: Birth certificate, paternal papers, discharge orders, need any vaccines? End of shift: Check for: Filled water pitcher, patient rooms are straightened up, linens

clean, supplies restocked for moms and babies Sign off: with your resource nurse. eMAR: If you made a My List remove patient names

from list.

Good stuff to bring: Stethoscope, bandage scissors, pen light, black pen, red pen, small calculator.

Postpartum Assessments:

Women: Vaginal Births

Vital signs q shiftPain assessment q shift, before, after meds

Ambulation

Breath sounds Elimination (urinating, BMs)Breasts Nutritional assessmentFundus Assessment of Maternal/Infant BondingLochia Assessment of Parenting SupportPerineum (on side) Assessment of Support SystemsHoman's sign Assessment of Breast FeedingNeuro: oriented Safety: bed down/siderails/Fall RiskPain assessment

Women: Cesarean Sections:

Vital signs q 4 hours Lochia

Pain assessment q 4 hours, before, after meds

Perineum (if had been in labor)

IV site or saline lock Homan's sign

Lungs Ambulation

Breasts Elimination (urinating, BMs)

Bowel sounds and flatusAssessment of Maternal/Infant Bonding

Fundus Assessment of Parenting Support

Incision Assessment of Support Systems

Pain assessment Nutritional assessment

Safety: bed/siderails/Fall Risk Assessment of Breast Feeding

Duramorph protocol: 02 sat, R at least q. 1 hour x 24 hours (check orders)

Normal Newborn:

Vital signs q. shift (not BP) Activity levelNormocephalic (fontanels, caput, hematoma)

Eyes

Heart (murmurs) Abd: inc. bowel sounds, cordChest symmetrical, breath sounds Nl movement and strengthBowel sounds I&O sheet for parentNeuro: Cry, tone, Moro Assessment of Breast/bottle feeding

GenitalsNewborn screening, Algo, birth certificate, pictures done

ID/security bands onWeight and transcutaneous bilirubin (done on nights)

Color (plethora, jaundice, cyanosis) Assessment of attachment behaviors

Elimination (urinating, stools) Bulb syringe in crib, check for suppliesCircumcision Pain assessment

LATCH Score:

Component 0 (poor) 1 (fair) 2 (well)

L ( how well infant latches on: (amount of areola in mouth, bottom lip out, cheeks rounded)

A (audible swallowing)

T (nipple type: normal, flat, inverted)

C ( mother's comfort level)

H (Hold: how much help mom needs)

Total Score: (7-10 is good)