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.

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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 Duramorph Betamethasone Marcaine Nifedipine Versed Labetalol Penicillin Xylocaine with epinephrine Calcium gluconate Ampicillin Epinephrine Reglan Methergine Nubain (IV) Prostin Mineral Oil Cervidil Ephedrine Ancef Fentanyl (IV) Indocin Morphine (IV) Phenergan (IM) Aqua Gold (antacid) Hemabate Clindamycin Sodium citrate (Bicitra) Cytotec Hydralazine Magnesium Sulfate Narcan Pitocin Terbutaline Zofran Xylocaine 1% plain cefotetan disodium (Cefotan)

Postpartum: Benadryl Tucks Demerol Hydrocortisone Cream Dermoplast Spray flu vaacine DSS Lansinoh

Lydocaine Ointment Senokot Percocet MMR

Methergine MOM Pertussis Tylenol

Ibuprofen Mylicon Prenatal Vitamins Tylenol/codeine

Metamusil Norco 5/325 and 10/325 Rhogam Toradol

Newborn Ampicillin Exosurf Caffeine Aquamephyton Hep B Vaccine Sodium Bicarbonate Cefotaxime Gentamycin Epinephrine Erythromycin Eye Ointment Survanta

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: Head: 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: 36.537.2 (97.7-98.9). Weight: may drop 10% in 1st week 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 Chest Abdomen Clavicles (feel), retractions, breast engorgement & discharge (nl: witch's milk). Circumference: 30-33 cm. (2 cm<head) 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 Extremities Spine: Straight, pilonidal dimple (?incomplete closure of spinal tract) Anus: Patent 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 Face Cry Breathing Patterns Arms 0 Relaxed muscles No Cry Quiet Grimace Whimper Mild moaning Change in breathing irregular, faster than usual, gagging, breath holding Vigorous Cry Note: silent cry if baby intubated (mouth, facial movement) 1 2

Relaxed

Relaxed (Not rigid) flexed Flexed/Extension tense, rapid is nl extension and flexion

Legs State of Arousal

Relaxed (Not rigid) flexed Flexed/Extension tense, rapid is nl extension and flexion 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 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 shift Pain assessment q shift, before, after meds Breath sounds Breasts Fundus Lochia Perineum (on side) Homan's sign Neuro: oriented Pain assessment Women: Cesarean Sections: Vital signs q 4 hours Pain assessment q 4 hours, before, after meds IV site or saline lock Lungs Breasts Bowel sounds and flatus Fundus Incision Pain assessment Safety: bed/siderails/Fall Risk Lochia Perineum (if had been in labor) Homan's sign Ambulation Elimination (urinating, BMs) Assessment of Maternal/Infant Bonding Assessment of Parenting Support Assessment of Support Systems Nutritional assessment Assessment of Breast Feeding

Ambulation Elimination (urinating, BMs) Nutritional assessment Assessment of Maternal/Infant Bonding Assessment of Parenting Support Assessment of Support Systems Assessment of Breast Feeding Safety: bed down/siderails/Fall Risk

Duramorph protocol: 02 sat, R at least q. 1 hour x 24 hours (check orders) Normal Newborn: Vital signs q. shift (not BP) Normocephalic (fontanels, caput, hematoma) Heart (murmurs) Chest symmetrical, breath sounds Bowel sounds Activity level Eyes Abd: inc. bowel sounds, cord Nl movement and strength I&O sheet for parent

Neuro: Cry, tone, Moro

Assessment of Breast/bottle feeding Newborn screening, Algo, birth certificate, Genitals pictures done Weight and transcutaneous bilirubin (done ID/security bands on on nights) Color (plethora, jaundice, cyanosis) Assessment of attachment behaviors Elimination (urinating, stools) Bulb syringe in crib, check for supplies Circumcision Pain assessment LATCH Score: Component 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) 0 (poor) 1 2 (fair) (well)