State Revision (1) PDF

Legal + Ethical Responsibilities Ethics - customs/habit Morality - customs/habit Values - freely chosen enduring beliefs and attitudes Relevant Legislations NZNO Guideline - Code of Ethics ➞ To guide nurses’ practice, and communicate the nursing profession’s ethical values ➞ The nationwide use of the Code will signal to other health professionals, managers and to the public that nurses are aware of their moral responsibilities ➞ For nurses to explore ethical beliefs, and as a guide to explore individual situations arising in nursing practice. Māori Values ☆ Rangatiratanga / self-determination ☆ Manaakitanga / hospitality, kindness, respect ☆ Tika / truth, justice, rights ☆ Whanaungatanga / relationships ☆ Wairuatanga / spirituality ☆ Kotahitanga / unity ☆ Kaitiakitanga / guardianship Western Values ☆ Autonomy / self-determination ☆ Beneﬁcence / doing good ☆ Non-maleﬁcence / doing no harm ☆ Justice / fairness ☆ Conﬁdentiality / privacy ☆ Veracity / honesty ☆ Fidelity / faithfulness ☆ Guardianship of the environment and its resources / protecting the environment/resources ☆ Being professional / being accountable for own nursing practice Code of Health and Disability Consumers Rights ➞ Establishes the rights of consumers, and the obligations and duties of providers to comply with the Code ➞ 10 rights 1. Consumers have rights and providers have duties: (1) Every consumer has the rights in this Code. (2) Every provider is subject to the duties in this Code. (3) Every provider must take action to— (a) Inform consumers of their rights; and (b) Enable consumers to exercise their rights. 2. Rights of consumers and duties of providers: Right 1 - Right to be treated with respect Right 2 - Right to freedom from discrimination, coercion, harassment, and exploitation Right 3 - Right to dignity and independence Right 4 - Right to services of an appropriate standard Right 5 - Right to eﬀective communication Right 6 - Right to be fully informed Right 7 - Right to make an informed choice and give informed consent Right 8 - Right to support Right 9 - Rights in respect of teaching or research Right 10 - Right to complain Health Practitioners Competence Assurance Act ➞ To protect the health and safety of members of the public by providing mechanisms to ensure that health practitioners are competent and ﬁt to practise their professions https://www.legislation.govt.nz/act/public/2003/0048/latest/DLM203320.html Mental Health Act (Compulsory Assessment + Treatment Act) 1992 ➞ Provides a legal framework for those who require compulsory psychiatric assessment + treatment for those experiencing mental illness ➞ Redeﬁnes the circumstances and the conditions under which persons may be subject to compulsory psychiatric assessment and treatment ➞ Reﬁnes the rights of such individuals and to provide better protection for those rights Reforms and consolidates the law relating to the assessment and treatment of persons suﬀering from mental disorder A person shall not be considered mentally disordered simply by reason of their: political, religious or cultural belief, sexual preferences, criminal or delinquent behaviour, substance abuse or intellectual disability 𝟏 Limb 1: Abnormal State of mind - mental disorder, in relation to any person, means an abnormal state of mind (whether of a continuous or an intermittent nature), characterised by delusions, or by disorders of mood or perception or volition or cognition, of such a degree that it disrupts usual functioning 𝟐 Limb 2: Danger to Self of Others - (a) Poses a serious danger to the health or safety of that person or of others; or (b) Seriously diminishes the capacity of that person to take care of himself or herself Compulsory treatment order ☆ Section 28 - must receive treatment up to 6 months - judge determines mental state ☆ Consent for patient under compulsory order given by psychiatrist/responsible clinician ☆ Family CANNOT see patient notes without patient consent ☆ Have to disclose to employer ☆ Authorised psychiatrist can commence discharge preparation ☆ Commence recovery pathway on day of admission, recognise progress through ongoing assessment and communication ☆ Section 7A - mandatory for practitioners to consult with family of patient (so patients under MHA will have their information shared with family unless doing so would compromise their care) Patient rights under the MHA ♬ Right to information ♬ Respect for cultural identity ♬ Right to an interpreter ♬ Right to treatment ♬ Right to be informed about treatment ♬ Right to refuse video recording ♬ Right to independent psychiatric advice ♬ Right to legal advice ♬ Right to company ♬ Right to have visitors and make phone calls ♬ Right to send/receive mail DAMHS (Directors of area mental health services) - high qualiﬁed and experienced health professionals who hold a senior role in mental health care. They report to the director of mental health DAMHS will normally act as the main point of contact between the Director and a mental health service. A DAMHS has the authority to approve and direct statutory oﬃcers (responsible clinicians and duly authorised oﬃcers) to ensure that the Act can be eﬀectively administered in a particular area. The DAMHS is also the person in charge of maintaining records and reporting to the Director of Mental Health and Director-General of Health. DAO (Duly authorised oﬃcers) - are frontline mental health professionals granted speciﬁc statutory powers to provide general advice and assistance to members of the public, and to deal with people who may be mentally disordered. (a) designate and authorise suﬃcient health professionals to perform at all times the functions and exercise the powers conferred on duly authorised oﬃcers by this Act within the area of that director; and (b) maintain an appropriate directory listing of a telephone number to ring when information or assistance is required under this Act. DI (District inspector) - Ensure the rights of the person are being met (beneﬁcence, nonmaleﬁcence, autonomy) Misuse of Drugs Act 1975 ➞ Classiﬁes drugs into 3 classes, based on risk of harm Class A - Very high risk of harm and illegal ☆ Cocaine ☆ Heroin ☆ LSD ☆ Mescaline ☆ Methamphetamine ☆ Phencyclidine (PCP) ☆ Psilocin and psilocybin Class B - Very high risk of harm and on prescription ☆ Amphetamine ☆ Cannabis (hashish, cannabis oil, or other preparation) ☆ Ephedrine ☆ GHB ☆ Hydromorphone ☆ MDMA (ecstasy) ☆ Methadone ☆ Methylphenidate ☆ Morphine ☆ Opium ☆ Oxycodone ☆ Pethidine ☆ Pseudoephedrine Class C - Moderate risk of harm ☆ Barbiturates (phenobarbital, barbital, etc.) ☆ Benzodiazepines (diazepam, alprazolam, lorazepam, nitrazepam, etc.) ☆ Benzylpiperazine (BZP) ☆ Cannabis (plant, leaf, fruit or seeds) ☆ Codeine ☆ Zopiclone ☆ Zolpidem Intellectual Disability Act (Compulsory Care and Rehabilitation) 2003 ➞ Establishes a scheme which authorises the provision of compulsory care + rehabilitation to individuals with an intellectual disability who have been charged with a prisonable oﬀence Purposes ☆ Provide courts with appropriate compulsory care/rehab options for people with an intellectual disability ☆ To recognise + safeguard special rights of individuals subject to the act ☆ Provide appropriate use of diﬀerent levels of care who, while no longer subject to criminal justice system, remain subject to the act Whaio Te Ao Marama / Māori Disability Action Plan 2012 ➞ Establish priority areas of action to enable disabled Māori to achieve their aspirations + reduce barriers that may impede them from gaining better outcomes Aims ☆ Improve outcomes ☆ Better support ☆ Good partnership ☆ Monitoring + reporting on the implementation of the Act Faivo Ora / National Paciﬁca Disability Plan 2014 ➞ Enable disabled Pasiﬁka to live in their homes + take part in the community Disability Support Services (DSS) ➞ Aim to have positive partnership with disabled people, their carers, + help them take part in the community NZ disability strategy ☆ Education ☆ Employment + economic security ☆ Health + wellbeing ✮ Barrier free + inclusive ✮ Health passport ☆ Rights protection + justice ✮ Safeguarding adults from abuse ☆ Accessibility ☆ Attitudes ☆ Choice + control ☆ Leadership Vulnerable Children's Act 2014 ➞ Ensure that children’s agencies work together to improve the well-being of vulnerable children ➞ Aimed at improving the protection of children at risk of abuse or neglect, including stronger vetting of adults who work with children Oranga Tamariki (Children, Young People + Families Act) 1998 ➞ Look after young children involved in child + family abuse Privacy Act 2020 ➞ Under the Act, it is an oﬀence to fail to inform the Privacy Commissioner when there has been a notiﬁable privacy breach ➞ Liability for breach notiﬁcations sits with the business or organisation, and not the individual employees The Health Information Privacy Code applies to the health information about identiﬁable individuals and applies to: ☆ all agencies providing personal or public health or disability services such as primary health organisations, district health boards, rest homes, supported accommodation, doctors, nurses, dentists, pharmacists and optometrists; and ☆ some agencies that do not provide health services to individuals but which are part of the health sector such as ACC, the Ministry of Health, the Health Research Council, health insurers and professional disciplinary bodies. Crimes Act ➞ 195A of the crimes amendment act states failure to protect a child or vulnerable adult is liable for the oﬀence of failing to take reasonable steps to protect them Suppression of Tohunga Act 1908 ➞ Outlawed traditional Māori health practices Nursing Leadership + Management Process of inﬂuencing the behaviour of others, regardless of the reason in an eﬀort to achieve goals in a given situation Management skills ☆ Developing peer relationships ☆ Negotiating ☆ Motivating ☆ Conﬂict resolution, networking, dissemination of information ☆ Ability to make decisions in conditions of extreme ambiguity ☆ Allocation of resources Leadership Implications ☆ Good time management - reduces stress ☆ Be able to identify stress within staﬀ ☆ Making organisational changes to reduce staﬀ, streamlining ☆ Role model positive behaviour ☆ Inspire hope + vision ☆ Knowledge of support systems Concepts 𝟏 Manaakitanga - leading with a moral purpose, learning health + social outcomes, team outcomes 𝟐 Pono - having self-belief, self-esteem, self-care, emphasises resilience, wellbeing + healthy lifestyle 𝟑 Ako - Being a learner, keeping up to date, own + others professional development 𝟒 Awhinatanga - guiding + supporting, empathy for individuals, groups + views of others 5 rights of delegation - RN retains accountability 𝟏 Right activity - in professional judgement of RN, the activity is appropriate for a speciﬁc health consumer 𝟐 Right circumstance - appropriate health setting, available resources, + other relevant factors 𝟑 Right person - right activity delegated to the right person to assist the right health consumer 𝟒 Right communication - clear + concise description of the activity (include objectives, limits, expectations, who to report back to) 𝟓 Right direction - appropriate monitoring, evaluation, intervention, feedback Professional practice Staﬀ member unethical/illegal in private life OR at work - report to charge nurse, can lead to suspension of registration Staﬀ member shows aggressive attitude towards patient - speak with nurse privately, calm down, remind of professional responsibility, let have space to calm down Maintain respect towards a patient ☆ Respect their values + beliefs ☆ Provide dignity ☆ Practise their rights Gaining trust with an anxious patient ☆ Get to know them ☆ Actively listen to their concerns ☆ Anticipate their needs Make non-judgemental decisions appropriate to the situation Considerations before delegating patients to ENs ☆ Enrolled nurse is able to decide priorities in nursing care, but only under guidance of RNs ☆ EN is asked for input into planning patient care but is not responsible for overall patient outcomes Count in CD cupboard is incorrect - report to charge nurse + pharmacy Colleague has sexual aﬀair with mental health patient - report to senior staﬀ Visitor/friend asks for info about patient/to see patient notes - do not allow as patient conﬁdentiality Ensure patient safety on discharge Police on ward + want to see patient - only if patient allows them to Police ring - do not disclose patient information Responsibilities when administering meds - 8 rights NCNZ ➞ Role to protect the public by setting standards for nursing in New Zealand. ➞ They are the regulatory authority responsible for the registration of nurses. ➞ It’s primary function is to protect the health and safety of members of the public by ensuring that nurses are competent and ﬁt to practise Tikanga Māori Large numbers of family in 4 bed room - negotiate about who + when to visit, only 2 people allowed to stay in hospital, explain reason Family claim it is spiritual illness - respect their beliefs + wishes Family want healer for child with asthma - support, however ensure safety of child Māori health model - Te Whare Tapu Wha (physical, emotional, spiritual, family) Cultural safety - extends beyond ethnic groups to include age or generation; gender; sexual orientation; occupation and socioeconomic status; ethnic origin or migrant experience; religious or spiritual belief; and disability Te Tiriti O Waitangi ☆ Tino rangatiratanga - self-determination, independence ☆ Equity - everyone can attain their full potential for health + wellbeing ☆ Active protection - achieve equitable health outcomes for Māori ☆ Options - health + disability services are provided in a culturally appropriate way ☆ Partnership - working together to share a common goal Power imbalance - when health professionals dominate decision making or otherwise assert power in a way that disadvantages patients or is not in their best interest for achieving partnership objectives Responsibility of nurses as Crown agents - to protect the health + safety of members of the public PATIENT/WHĀNAU DECIDE IF CARE IS CULTURALLY SAFE Māori Worldview ➞ Diﬀerent from Western - Western ethical principles may not be directly relevant to Māori + vice versa ➞ Māori knowledge systems link to the land + they have their own ways of acquiring + testing knowledge ➞ Tikanga reﬂects traditional values, beliefs + practices of Māori which enhance the relationships fundamental to the sustainability of life, and are embedded as kawa (primary values) Te Tiriti O Waitangi ➞ Treaty signed 6 Feb 1840 by representatives of the British Crown + Rangatira ➞ Founding document of NZ Events leading up to the signing ☆ Declaration of Independence ☆ Land wars ☆ Sickness + disease ☆ 150,000 Māori to 30-50,000 ☆ Acquisition of land ☆ Colonisation ☆ Lawlessness ☆ Fear of French ☆ Declining health of Māori ☆ Social change Article One: in Māori it gave Queen Victoria governance over the land, while in English it gave her sovereignty over the land, which is a stronger term. Article Two: the Māori version guaranteed chiefs ‘te tino rangatiratanga’ – chieftainship over their lands, villages and treasured things. It also gave the Crown a right to deal with Māori in buying land. The English version gave chiefs ‘exclusive and undisturbed possession’ of lands, forests, ﬁsheries and other property. It also gave the Crown an exclusive right to deal with Māori over buying land. Article Three: both versions gave Māori the queen’s protection and the rights of British subjects. TINO RANGATIRATANGA / self-determination ☾ The guarantee of tino rangatiratanga, which provides for Māori self-determination and mana motuhake in the design, delivery, and monitoring of health and disability services. ORITETANGA / equity ☾ The principle of equity, which requires the Crown to commit to achieving equitable health outcomes for Māori. KAWANATANGA / governance ☾ Abiding to the law. WAIRUATANGA / spirituality ☾ Right to practise Tohunga + Rongoa as well as maintain religious + cultural practices/values. Te Reo Māori ⊹ Whakapono / faith + trust, honesty, integrity, trustworthy + truthful, ethical leadership, seeking guidance + support when you need it ⊹ Tumanakotanga / aspirations of self + others, motivated, sense of mission, visionary, proactive, strategic ⊹ Mohiotanga / expanding on own knowledge, utilisation of evidence-based research, value + contribute to knowledge of others ⊹ Manaakitanga / hospitality, leading with moral purpose, learning health + social outcomes, team outcomes ⊹ Pono / reality + truth, having self-belief, self-esteem, + self-care, emphasises resilience, wellbeing/healthy lifestyle ⊹ Ako / to learn + teach, being a learner, keeping up to date, own + others professional development ⊹ Awhinatanga / guiding + supporting, empathy for individuals/groups and views of others ⊹ Wairuatanga / spirituality ⊹ Hinengaro / the mind ⊹ Taha tinana / physical wellbeing ⊹ Whanaungatanga / extended family ⊹ Mauri / life force in people + objects ⊹ Mana ake / unique identity of individuals + family ⊹ Hā a koro ma, a kui ma / breath of life from forbearers ⊹ Whatumanawa / the open + healthy expression of emotion Nursing Tools ABCDE 𝐀 AIRWAY ─────────── ✮ Remove obstructions (suction?) ✮ Immobilise cervical spine ✮ Head lift/chin tilt/intubate (LMA) ✮ Swallowing ability ✮ Vomit/blood/teeth/trauma 𝐁 BREATHING ───────── ✮ RR, SpO2, rate, rhythm, depth, AMU, WOB, wheeze/crackles, equal breath sounds, oxygen use ✮ Pneumothorax, ruptured diaphragm ✮ Chest X-ray 𝐂 CIRCULATION ──────── ✮ HR, BP, peripheral circulation ✮ Tissue perfusion, bleeding, shock (hypovolemic, cardiogenic, obstructive) ✮ Cool/moist extremities ✮ Bleeding, ﬂuids, pressure, distention, PPH ✮ IV access 𝐃 DISABILITY ───────── ✮ Pupils, BGL, BCS, assess + protect brain, seizure, meningitis, intoxication, MI ✮ LOC, movement, warmth, colour, sensation in all 4 limbs, abnormal repetitive movement 𝐄 EXPOSURE ───────── ✮ Identify injuries + protect, hypothermia, critical skin conditions (fascitis) ✮ Rashes, bites, hives ✮ Remove restrictive clothing SAMPLE 𝐒 Signs + symptoms 𝐀 Allergies 𝐌 Medication 𝐏 Past medical history 𝐋 Last meal 𝐄 Events leading to current illness ISBARR 𝐈 Identiﬁcation ✮ Name, age, sex, ward, team 𝐒 Situation ✮ Symptom, problem 𝐁 Background ✮ History, relevant medical problems 𝐀 Action ✮ Diagnosis, what has been done so far 𝐑 Response/rationale ✮ What you did and what you want done, review + plan Motivational interviewing ➞ Having courageous conversations to enable behaviour change and a client centric improved health outcome Purpose ☆ Increases desire for change ☆ Strengthening motivation to change ☆ Whānau-centred ☆ Brief intervention 1-4 sessions ☆ Establishing therapeutic relationships is essential for engagement and connecting Creating a safe physical, emotional and spiritual space that allows a transition from tapu to noa, and also a space in which kororo can take place The 4 processes ☆ Engaging ☆ Focusing ☆ Evoking ☆ Planning 3 Harms Privacy + conﬁdentiality must never be broken unless ☆ They are harming themselves ☆ They are harming others ☆ Someone is harming them The Gillick Competency ➞ Used when practitioners are trying to decide whether a child under 16 is mature enough to make decisions ➞ Helps to balance the need to listen to their wishes with the responsibility to keep them safe Fraser Guidelines ➞ Apply speciﬁcally to contraceptive advice and sexual health Proceed to give contraceptive advice and treatment to a girl under 16 provided the practitioner is satisﬁed ☆ That they will understand advice ☆ That they can not persuade her to inform her parents or to allow them to inform the parents she is seeking contraceptive advice ☆ That she will continue having sexual intercourse with or without contraceptive treatment ☆ Unless she receives contraceptive advice or treatment her physical and mental health will suﬀer ☆ That her best interests require contraceptive advice, and or treatment without parental consent Standard Precautions ♩ Hand hygiene ♩ PPE use ♩ Safe sharps disposal ♩ Aseptic non-touch technique ♩ Reprocessing of reusable medical equipment + instruments ♩ Resp. hygiene ♩ Routine environmental cleaning ♩ Waste management ♩ Appropriate linen handling Falls Risk Prevention ☆ Belongings within reach ☆ Bell within reach ☆ Breaks on ☆ Bed low ☆ Bed rails Documentation PIE - problem, implementation, evaluation SOAPIE - subjective data, objective data, assessment, planning, implementation, evaluation Date / name / designation ☆ Obs/vitals ☆ Meds ☆ Pain ☆ Wound ☆ Input/output ☆ Mobility ☆ General (social, personal cares, planning, subjective data) Nursing Theories Erik Erikson Psychosocial development (1958) ➞ A person's personality is developed over 8 stages ➞ In each stage the person faces a crisis + its outcome has a positive/negative impact on personality development CONFLICT AGE OUTCOME Trust vs mistrust 0 - 18 m Hope Autonomy vs shame + doubt 18 m - 3 Will Initiative vs guilt 3-5 Purpose Industry vs inferiority 5 - 12 Competency Identity vs role confusion 12 - 18 Fidelity Intimacy vs isolation 18 - 40 Love Generativity vs stagnation 40 - 65 Care Ego integrity vs despair 65 + Wisdom Abraham Maslow Hierarchy of Needs (1943) ➞ People are motivated to fulﬁl basic needs before moving on to other, more advanced needs ➞ People have an inborn desire to reach the top of the hierarchy PHYSIOLOGICAL Basic human needs like food, water, procreation, sleep, warmth SAFETY Control over life like health, ﬁnances, job stability SOCIAL NEEDS Friendships, relationships, religion ESTEEM Participation in activities, respect from others, academic success SELF-ACTUALISATION Achieved full potential + concerned about self-growth rather than opinions from others Sigmund Freud Psychosexual Development (1905) ➞ Personality is developed through a series of childhood stages in which pleasure-seeking energies become focused on certain erogenous areas ➞ A person’s libido determines their behaviour, if their issues are not resolved at the appropriate stage, ﬁxations can develop + they can become stuck at that stage ORAL (0-1) Rooting + sucking reﬂex If failed, person can have problems with smoking, drinking, eating, or nail biting ANAL (1-3) Bowel + bladder control If failed, can result in an anal-rentive or anal-expulsive personality PHALLIC (3-6) Genitalia Oedipus + electra complex LATENT (6-puberty) No libido Fixation can cause immaturity + inability to mature sexual interests as an adult GENITAL (puberty onwards) Maturing sexual interests Oedipus + electra complex ☆ Young boys want to replace the father in the household to possess the mother ☆ Young girls can experience this too but because of ‘penis envy’ ☆ The child identiﬁes with the same sex parent to possess the opposite sex parent. ☆ Freud believes that ‘penis’ envy is never resolved and girls become ﬁxated on this stage Ego - rational thoughts Superego - morals, social rules ID - basic needs + wants (unconscious) B. F. Skinner Operant conditioning (1938) ➞ An individual makes an association between a particular behaviour + consequence, thus believing behaviour comes from rewards + punishments NEUTRAL OPERANT Responses from environment that neither increase nor decrease the probability of a behaviour being repeated REINFORCERS Responses from the environment that increase the probability of a behaviour being repeated, they can be positive or negative PUNISHERS Responses from the environment that decrease the likelihood of a behaviour being repeated, punishment weakens behaviour Jean Piaget Cognitive development theory ➞ Suggests children move through 4 stages of mental development ➞ Focuses not only on understanding how children acquire knowledge but also on understanding the nature of intelligence SENSORIMOTOR STAGE 0-2 Infant knows the world through their movements + sensations PREOPERATIONAL STAGE 2-7 Children begin to think symbolically + learn to use words + pictures to represent objects Concrete thinking CONCRETE OPERATIONAL STAGE 7 - 11 Children begin thinking logically about concrete events FORMAL OPERATIONAL STAGE 12 + Abstract thought emerges Ivan Pavlov Classical conditioning (1902) ➞ Learning to associate an unconditioned stimulus that already brings about a particular response with a new (conditioned) stimulus, so that the new stimulus brings about the same response ➞ Dog + bell + salvation John Watson Behaviourism (1920) ➞ The idea behaviour can be controlled + predicted ➞ Based on the idea that behaviour is aﬀected by the environment Albert Bandura Social Cognitive Theory (1977) ➞ Based on behaviour + consequences Agrees with classical conditioning but adds ☆ Mediating processes occur between stimuli + responses ☆ Behaviour is learned through the process of observational learning (shown through the bobo doll where children imitate behaviour they see in adults) ☆ If behaviour is rewarding, the child continues that behaviour Vicarious reinforcement - see behaviour in another person with reward so more likely to partake in that behaviour 4 stages ☆ Attention ☆ Retention ☆ Reproduction ☆ Motivation Cognitive Behavioural Therapy (CBT) ➞ Form of talking therapy used in mental health, based on the idea that thinking, feeling + acting are related (cognition, emotion + behaviour) ➞ Works by identifying + replacing negative thoughts + changing the rewards for behaviours psychotherapeutic method used to alter distorted attitudes and problem behaviour by identifying and replacing negative thoughts and changing the rewards for behaviours ➞ Attempts to make sense of overwhelming problems by breaking them down into smaller parts. Empowerment Theory Recognition of an individual's autonomy and self-determination. Enables the individual through knowledge and conﬁdence to be able to make informed choices. Valued and accepted. Models of Care Te Wheke / The Octopus ➞ The dimensions are interwoven + this represents the close relationship of the tentacles Head ☆ Te whānau / the family Eyes ☆ Waiora / total wellbeing for the individual + family Tentacles ☆ Wairuatanga / spirituality ☆ Hinengaro / mind ☆ Taha tinana / physical wellbeing ☆ Whanaungatanga / extended family ☆ Mauri / life force in people/objects ☆ Mana ake / unique identity of individuals/family ☆ Hā akoro ma, a kui ma / breath of life from forbearers ☆ Whatumanawa / open + healthy expression of emotion Te Whare Tapa Wha ➞ Strong foundations + four equal sides, the symbol of the wharenui illustrates the four dimensions of Māori well-being ➞ Should one of the four dimensions be missing or in some way damaged, a person, or a collective may become ‘unbalanced’ and subsequently unwell Taha tiana / physical health ☆ Good physical health is required for optimal development ☆ For Māori, the physical dimension is just one aspect of health and cannot be separated from other aspects Taha wairua / spiritual health ☆ Health is related to unseen + unspoken energies ☆ The spiritual essence of a person is their life force, determines us as individuals + as a collective Taha whānau / family health ☆ Provide us with the strength to be who we are ☆ Link to ancestors, ties with past/present/future Taha hinengaro / mental health ☆ Thoughts, feelings + emotions are integral components of the body + soul ☆ About how we see ourselves in this universe + our interactions with that Ottawa Charter ➞ WHO developed an approach to improve health outcomes ➞ Framework for constructing health promotion programmes that address the determinants of health 5 action areas ☆ Building healthy public policy ☆ Creating supportive environments ☆ Strengthening community action ☆ Developing personal skills ☆ Re-orientating health services Te Pae Mahutonga (Southern Cross Star Constellation) ➞ Brings together elements of modern health promotion as they apply to Māori health Elements ☆ Mana ora ☆ Waiora ☆ Toiora ☆ Te oranga ☆ Nga Manukura ☆ Te Mana whakahaere Te Tiriti o Waitangi Goals in Health Promotion Practice ➞ Goal 1 - achieve Māori participation in all aspects of health promotion ➞ Goal 2 - achieve the advancement of Māori health aspirations Historical Inﬂuences on Māori ☆ Colonisation - impact of colonial government on Māori society ☆ Assimilation / integration - Māori became invisible ☆ Urbanisation - loss of land, moving to cities for work ☆ Alienation - isolation from whānau, hapu + iwi Transtheoretical Model ➞ Integrative model where behaviours can be modiﬁed or added, based on decision making Consists of 𝟏 Pre-contemplation 𝟐 Contemplation 𝟑 Determination 𝟒 Action 𝟓 Relapse 𝟔 Maintenance Primary Health Care ➞ Healthcare focusing on early diagnosis, eﬀective treatment, disease management ➞ Actions that protect the environment, prevent illness + injury, + promote health + wellbeing of communities ➞ Empower populations to live healthy lives ➞ Māori have lower life expectancy + higher risk CVD, cancer, diabetes, + resp diseases Role of public health nurse ♡ Focus on community health ♡ Educate + promote health + wellbeing and work towards preventing disease Points of contact Local ☆ Nurses, GP, Plunket Regional ☆ DHB services, public health services, PHO’s, tamariki ora National ☆ Government national strategies, Health Targets, PHC programmes, e.g. Screening, funding/access to services, management of common chronic illnesses and conditions, National Health Targets Global ☆ A few examples of PHC initiatives, e.g. World Health Organisation, Peer reviewed journal on Public Health Global perspective Quality improvement 6 dimensions Safety Eﬀectiveness Equity Eﬃciency Timeliness Patient centredness These dimensions rest on foundations of partnership, participation, protection principles of Tiriti o Waitangi Cervical Screening Purpose ☆ Looks for abnormal changes in cells on the surface of the cervix (the neck of the uterus or womb). ☆ Some cells with abnormal changes can develop into cancer if they are not treated. ☆ Treatment of abnormal cells is very eﬀective at preventing cancer as it allows for early detection, follow up testing, and treatment. Immunisations ➞ Immunisation provides one of the most cost eﬀective means of preventing infection in infants ➞ They not only help protect those receiving the vaccinations from developing serious diseases but also help protect entire communities by preventing and reducing the spread of infectious agents ➞ Immunisation is additionally important because antibiotics cannot destroy viruses; therefore, immunisation oﬀers the only means of control IM administration sites ☆ Deltoid ☆ Ventrogluteal ☆ Dorsogluteal ☆ Vastus lateralis ☆ Rectus femoris First assess ☆ Is child well today ☆ Assess need for vaccine ☆ Previous history of reactions (anaphylaxis) Breastfeeding + vaccinations - breast fed babies get additional antibodies from mothers milk, however this immunity does not last long, babies need immunisations to provide ongoing protection MMR vaccine - 12 months + 15 months Settle child after vaccine ♡ Lots of cuddles, ﬂuids, breastfeeding ♡ Reduce temp by undressing them to single layer ♡ Meds for temp/pain ♡ Ice pack wrapped in dry cloth + placed on injection site ♡ Distraction PASSIVE IMMUNITY ACTIVE IMMUNITY ♡ Transfer of active humoral immunity ♡ Happens when immune system is triggered (synthesised B cells) of ready made to produce antibodies to ﬁght a disease antibodies ♡ Natural infection - through infection ♡ Can occur naturally through breastfeeding ♡ Vaccination - weakened pathogen Whooping Cough (pertussis) ⟶ A bacterial infection that can lead to pneumonia ⟶ Whooping sounding cough, spread by droplets ⟶ Infants under 12 months are at highest risk of pertussis ⟶ Notiﬁable disease Immunisation - 6 weeks, 3 months, 5 months, 4 years, 11 years, 45 years ☆ Also given to pregnant women during 3rd trimester as at this stage it is eﬀective in passing high levels of antibody protection to newborn Diphtheria ➞ Bacterial infection that aﬀects the nerves, causing heart damage Measles ➞ A highly contagious virus ➞ Causes rash, fever, possibly permanent damage - life-threatening Symptoms ☆ High fever ☆ Enlarged lymph nodes ☆ Conjunctivitis ☆ Red rash (begins on head + spreads to extremities) Mumps ➞ Virus that aﬀects the body (parotid) glands around the neck + face, can cause meningitis ➞ Salivary glands - spreads through saliva Symptoms ☆ Swollen + painful salivary glands ☆ Fever ☆ Headache ☆ Fatigue ☆ Appetite loss Rubella ➞ Rash caused by rubella virus Symptoms ☆ Fever ☆ Sore throat ☆ Enlarged lymph nodes ☆ Generalised rash Side eﬀects ♡ Low birth weight ♡ Small head ♡ Brain inﬂammation ♡ Cataracts ♡ Damage to retina ♡ Hearing loss ♡ Heart defects ♡ Skin rash Immunisation prevents congenital rubella syndrome caused by rubi virus Infants born with rubella - severe birth defects ⟶ Rubella can aﬀect any part of babies developing body, may include cataracts, deafness, heart abnormalities, intellectual diﬃculties + behavioural problems, in some cases miscarriage Pregnant women should NOT receive MMR (measles, mumps, rubella) vaccine as it is a live vaccine ⟶ ONLY pertussis (tetanus, diphtheria, whooping cough) + inﬂuenza Chickenpox ➞ Papules + blisters, can become dormant + develop into shingles, varicella virus ➞ Contagious from 1 day before rash to 5-6 days after rash develops ➞ Given IM ➞ One dose is funded for children at 15 months - up to 2 doses funded for certain groups Attenuated vaccine - virus has been weakened before being included in vaccine Polio ➞ Virus that causes stiﬀ muscles + can lead to paralysis Tetanus ➞ Bacteria that produce toxins that cause stiﬀ muscles + breathing diﬃculties Inﬂuenza ➞ Free for 65+ and pregnant women ➞ Stops common strains of ﬂu HPV ➞ Causes cervical cancer Pneumococcal virus ➞ Can cause meningitis Hepatitis ➞ Virus that causes liver inﬂammation + serious damage, commonly ﬂu-like symptoms, jaundice, loss of appetite, tiredness, cirrhosis, liver failure, fat intolerance, sweating, pain, death HEP A Oral-faecal route, symptomatic >2 weeks, usual fully recover + develop immunity, vaccine available HEP B Blood/semen route, most recover, symptoms show after 6m, vaccine available HEP C Blood route, co infection with HIV, years to develop, requires lifestyle changes HEP D Blood route, requires hep B HEP E Oral-faecal route, drinking contaminated water, acute liver failure HEP F Oral-faecal route, poor sanitation, requires hep C Hepatitis A Spread ♡ Via faecal-oral route by consumption of contaminated/uncooked food ♡ Raw shellﬁsh, water, milk Prevention ♡ Hand hygiene ♡ Vaccination ♡ Cook food properly ♡ Boiling water Hepatitis B ➞ Virus that causes inﬂammation of liver ➞ Contagious + life-threatening Spread ♡ Through contact with blood or bodily ﬂuids (saliva, semen) of infected person ♡ Tattooing with unsterile equipment ♡ Needle stick injury ♡ From mother to child in birth Prevention ♡ Vaccine ♡ Avoid contact with body ﬂuids ♡ Avoid used syringe ♡ Safe sex Healthy lifestyle Food pyramid ☆ He iti a kai / eat little amount sweet + fried food ☆ He ata kai / eat some dairy, grains, nuts, + meat ☆ He kaha kai / eat mostly vegetables + fruits ☆ Unsaturated, low salt, low sugar, less processed Green prescription - written advice to eat well + exercise Healthy weight ☆ BMI septic shock Shock ➞ May result from trauma, heatstroke, blood loss, allergic reaction, severe infection, poisoning, severe burns, etc ➞ Insuﬃcient ﬂuid replacement = hypovolemic shock ➞ Dehydration + electrolyte imbalances ➞ Occurs when low blood volume causes a drop in BP and a drop in the amount of oxygen in body, preventing body's ability to carry out various metabolic activities as oxygen is not perfused into tissues adequately Cardiogenic - impaired heart function Hypovolemic - ﬂuid loss (up to 40%) Septicaemia - sepsis Symptoms ☆ Hypotension ☆ Weak/thready pulse ☆ Tachycardia ☆ Cool/pale/moist skin ☆ Reduced urine output (normal = 0.5mL/kg/hr) Compensatory, late, + severe shock ☆ Compensatory - the body is still able to compensate for absolute or relative ﬂuid loss, symptoms = agitation, tachycardia/pnea, change in pallor/cyanosis, nausea, thready pulse, narrowing pulse pressure, cool extremities, normal BP ☆ Late/decompensated - unable to maintain adequate perfusion to the brain/vital organs, occurs when blood volume decreases by more than 30%, characterised by persistent hypotension and inadequate vasoconstriction, symptoms = hypotension, Oliguria, Metabolic acidosis, Cold clammy skin, Tachycardia, Tachypnea and laboured/irregular breathing, Decreased body temperature, Decreased mental status, Weak/diminished peripheral pulses ☆ Severe shock - death is iminent, irreversible cellular + organ damage, blood loss >40%, symptoms = heart rate and breathing remain high before crashing, Blood pressure drops extremely low, Unconsciousness, Cold skin, Absent peripheral pulses Priorities - administer oxygen and IV ﬂuids Dehydration ♡ First signs - low BP, feeling thirsty, dry mouth, peeing little (44 - 1:50 ☆ Recurrence - 1-2% Investigations ☆ Karyotype ☆ Cardiac assessment ☆ FBC ☆ Thyroid function test Traits ☆ Low muscle tone ☆ Small stature ☆ Upward slant of eyes ☆ Single, deep crease across palm ☆ Wide short hands ☆ Small ears + mouth ☆ Flat nose ☆ Protruding tongue ☆ Enlarged colon Fragile X Syndrome ➞ X chromosome disorder twice as common in males ➞ Autistic behavioural tendencies + caudate nucleus (part of basal ganglia) abnormality Common health problems ☆ Connective tissue laxity ☆ Strabismus ☆ Scoliosis Prader-Willi Syndrome ➞ Paternal deletion of the 15q11-q13 chromosome region ➞ Occurs in 1-10,000/30,000 people Common health problems ☆ Hyperphagia ☆ Hypogonadism ☆ OCD ☆ Prone to obesity ☆ Risk of T2D Traits ☆ Hypotonia ☆ Feeding diﬃculties (unstable appetite, chronic overeating) ☆ Poor growth ☆ Delayed or incomplete development (delayed puberty, infertility) ☆ Mild-moderate intellectual impairment ☆ Behavioural problems ☆ Sleep abnormalities Angelman Syndrome ➞ Maternal deletion of the 15q11-q13 chromosome region Common health problems ☆ Epilepsy ☆ Sleep disturbances ☆ Dysphagia Velocardio-facial Syndrome ➞ 22q11.2 deletion syndrome aﬀecting 1 in 5000 births ➞ Cleft palate, cardiac malformation, autistic behavioural tendencies Common health problems ☆ Dysphagia ☆ Heart problems ☆ Mental health problems ☆ Renal abnormalities ☆ Scoliosis ☆ Low muscle tone Rett Syndrome ➞ Mainly in females, 1 in 9000 female births ➞ Autistic behavioural tendencies, “hand wringing” movements Common health problems ☆ Ataxia ASD ➞ 1 in 100 people have ASD, males aﬀected 4x more than females ➞ No known single cause Common health problems ☆ Sensory problems ☆ Seizures Foetal Alcohol Syndrome ➞ Between 0-10.7 per 10000 births in US ➞ More common in socially deprived areas ➞ Babies exposed to alcohol before birth (stop nervous system developing properly, prevent baby getting necessary nourishment) Common health problems ☆ Renal + cardiac defects ☆ Vision + hearing problems Traits ☆ Low birth weight ☆ Distinctive facial features (small face, low nasal bridge, short nose, ﬂat cupids bow, underdeveloped jaw) ☆ Heart defects ☆ Behavioural problems ☆ Intellectual disability Cerebral Palsy ➞ Results from an insult to the developing brain of the foetus or infant causing CNS damage + motor impairment Common health problems ➞ Dysphagia ➞ Epilepsy ➞ Hearing + vision impairment ➞ Prone to being underweight ➞ Hypo or hyper-tonic muscles ➞ Scoliosis Cushing’s Syndrome ➞ Cushing syndrome, also called hypercortisolism, is a set of symptoms resulting from exposure to high levels of the stress hormone cortisol ➞ Cortisol, a hormone in the body that is typically produced in response to stress, helps regulate blood pressure and blood sugar, reduce inﬂammation, and metabolise food. ➞ Cortisol production and release is stimulated by a series of hormone interactions. First, the hypothalamus secretes corticotropin-releasing hormone, known as CRH. CRH stimulates the anterior pituitary gland to produce adrenocorticotropic hormone (ACTH). Ultimately, ACTH signals cortisol production of the adrenal glands, which are small glands located on top of each kidney. STI / STD DISEASE MANIFESTATIONS DISEASE Urethritis, cervicitis, salpingitis Gonorrhoea Nongonococcal urethritis Pelvic inﬂammatory disease Ulcerative lesions with systemic Syphilis involvement Lymphogranuloma venereum Herpes simplex virus Ulcerative lesions only Chancroid Granuloma inguinale Non ulcerative lesions Molluscum contagiosum Genital warts Vulvovaginitis Trichomoniasis Candidiasis Gardnerella vaginalis vaginitis Systemic infections Cytomegalovirus Hepatitis AIDS Enteric infections Giardiasis Campylobacter enteritis Shigellosis Amoebic dysentery HIV / AIDS ➞ HIV is spread through unprotected sex and contact with infected blood that attacks the immune system. Mothers can pass HIV on to their babies during pregnancy, childbirth and while breastfeeding ➞ HIV is not curable and it can develop into AIDS ➞ When a person has HIV and one or more severe infections or cancers occur, they are said to have AIDS (AIDS deﬁning illness) ➞ HIV infection progresses through stages. In the early stages, a person may experience ﬂu-like symptoms (fever, fatigue, swollen lymph nodes) shortly after infection. However, some people with HIV may not experience noticeable symptoms for years. Zidovudine (AZT) - used to slow replication of the virus AIDS deﬁning Illnesses ☆ Candidiasis of the oesophagus, bronchi, trachea, or lungs (but NOT the mouth (thrush)) ☆ Cervical cancer, invasive ☆ Coccidioidomycosis, disseminated or extrapulmonary ☆ Cryptococcosis, extrapulmonary ☆ Cryptosporidiosis, chronic intestinal (greater than one month's duration) ☆ Cytomegalovirus disease or CMV (other than liver, spleen, or nodes) ☆ Cytomegalovirus retinitis (with loss of vision) ☆ Encephalopathy, HIV related ☆ Herpes simplex: chronic ulcer(s) (more than 1 month in duration); or bronchitis, pneumonitis, or esophagitis ☆ Histoplasmosis, disseminated or extrapulmonary ☆ Isosporiasis, chronic intestinal (more than 1 month in duration) Kaposi sarcoma ☆ Lymphoma, Burkitt's (or equivalent term) ☆ Lymphoma, immunoblastic (or equivalent term) ☆ Lymphoma, primary, of brain ☆ Mycobacterium avium complex or M kansasii, disseminated or extrapulmonary ☆ Mycobacterium tuberculosis, any site (pulmonary or extrapulmonary) ☆ Mycobacterium, other species or unidentiﬁed species, disseminated or extrapulmonary ☆ Pneumocystis pneumonia (PCP) ☆ Pneumonia, recurrent ☆ Progressive multifocal leukoencephalopathy ☆ Salmonella septicaemia, recurrent ☆ Toxoplasmosis of brain ☆ Wasting syndrome due to HIV Herpes (HSV) ➞ ⅕ NZers infected ➞ Transmitted through skin to skin contact, vaginal, oral, or anal sex with an infected person, or through childbirth ➞ Resides in latent state in spinal dorsal root nerves that supply sensation to skin; during recurrence, it follows the nerves that supply sensation to the skin/mucous membranes, where it multiples causing clinical lesion ➞ Incubation period - 2-12 days, infectious period - 7-12 days Types ☆ HSV-1 causes cold sores around the mouth ☆ HSV-2 causes an infection around the genital or anal area Complications ☆ Throat infection ☆ Eye infection ☆ Irregular menses ☆ Eczema ☆ Bladder infection Antiviral drugs for herpes ☆ Acyclovir – 200 mg 5 times daily for ﬁve days ☆ Valacyclovir – 1 g 3 times daily for seven days ☆ Famciclovir – as a single dose of 3 x 500 mg Human Papillomavirus (HPV) ➞ Infection caused by a virus. ➞ There are many types of HPV - some can lead to genital warts and cancers. It spreads through, most commonly, vaginal and anal sex when there is close skin-to-skin contact. ➞ In most cases it goes away on its own within two years, usually with no symptoms. However, when it doesn’t go away it can cause health problems, like genital warts or cancer (those with weak immune systems e.g. those with HIV are more likely to develop cancer). Genital warts ☆ Small bump or group of bumps in the genital area ☆ Can be small/large, raised/ﬂat, or shaped like a cauliﬂower Reduce risk ☆ Vaccine ☆ Get screened for cervical cancer ☆ Long term mutually monogamous partner ☆ Using condoms - however if a sore caused by syphilis is in a place the condom does not cover, it can still be transmitted Syphilis ➞ Syphilis is a systemic infection of the vascular system consisting of ﬁve distinct stages: incubation, primary and secondary stages, latency, and late syphilis ➞ Spread through direct contact with a syphilis sore during vaginal, anal or oral sex ➞ Caused by bacteria Treponema pallidum, an anaerobic spirochete ➞ In pregnancy, syphilis can infect the foetus leading to low birth weight, miscarriage or stillborn. Primary – painless moist ulcer at the site of infection called chancres that can occur weeks after exposure. Secondary - skin rash, swollen lymph nodes, fever, hair loss, headaches, muscle aches, Tertiary – large sores, cardiovascular syphilis, neurosyphilis, ocular syphilis Latent – No signs or symptoms ➞ During all stages of syphilis, invasion of tissue by T. pallidum results in pathologic changes in the vascular system. The inﬂammatory response in endothelial tissue causes the inﬁltration of lymphocytes and plasma cells, with subsequent endothelial swelling. The terminal arterioles and small arteries may become obliterated and no longer functional. Finally, long-term inﬂammation of vascular tissue results in the formation of hardened, ﬁbrous thickening in the blood vessels and eventually tissue necrosis Treatment ☆ Penicillin and Probenecid ☆ Probenecid - increases the levels of antibiotic in the blood, which helps the antibiotic work better Reduce risk ☆ Long term mutually monogamous partner ☆ Using condoms - however if a sore caused by syphilis is in a place the condom does not cover, it can still be transmitted Gonorrhoea ➞ Gonorrhoea is an inﬂammation of epithelial tissue by the gram-negative organism Neisseria gonorrhoeae ➞ Gonorrhoea is spread by having vaginal, anal, or oral sex with someone who has gonorrhoea. ➞ A pregnant woman with gonorrhoea can give the infection to her baby during childbirth. ➞ IF NOT TREATED IT CAN CAUSE STERILITY Symptoms - usually no symptoms ☆ Vaginal or Penile discharge ☆ Burning/painful urination ☆ Dysuria ☆ Swelling and redness ☆ Persistent sore throat ☆ Scrotal swelling ☆ In women, there may be no symptoms until complications arise. 3-6-day incubation period Once gonococcal infection has spread to other areas, localised infection occurs and may cause the formation of cysts and abscesses. Purulent exudate containing the organism causes damage to tissue, and ﬁbrous tissue replaces inﬂamed tissue. This hardened, ﬁbrous tissue may result in scarring and narrowing of the urethra, epididymis, or oviducts. In women, partial or complete closure of the oviducts results in sterility. Infection of the oviducts may also result in pelvic inﬂammatory disease if exudate is released into the peritoneal cavity Treatment ☆ ABs - becoming harder to treat d/t resistance Reduce risk ☆ Long term mutually monogamous partner ☆ Using condoms Chlamydia ➞ Many who have chlamydia don't develop symptoms, but they can still infect others through sexual contact ➞ It is spread through vaginal, anal, or oral sex with someone who has chlamydia ➞ IF NOT TREATED IT CAN CAUSE INFERTILITY ➞ The Chlamydia bacteria invades and infects the host cells, which they depend on to provide them with nutrients for survival ➞ If the human cells infected by the bacteria are starved of these nutrients, the bacteria die oﬀ too Symptoms - usually none ☆ Genital pain ☆ Discharge from the vagina or penis ☆ Burning sensation while urinating ☆ Scrotal Swelling ☆ Bleeding ☆ Frequent urination ☆ Abdominal, rectal or testicular pain ☆ Painful intercourse ☆ Arthritis (men) ☆ Conjunctivitis (newborns) ☆ Pneumonia (newborns) ☆ PID Treatment ☆ Tetracycline (antibiotic) Reduce risk ☆ Long term mutually monogamous partner ☆ Using condoms Skin Infections (that have not been mentioned yet) Impetigo ➞ Contagious bacterial disease occurring in two forms: bullous and non-bullous ➞ The toxins from the bacteria produce a weeping lesion with a honey-coloured crust. ➞ Group A Streptococcus, Staphylococcus aureus Staphylococcal scalded-skin syndrome (Ritter disease) ➞ Severe staphylococcal skin infection that produces an exfoliative toxin with painful blisters and bullae formation over large areas of the skin ➞ Requires emergency care and systemic antibiotic treatment Ringworm ➞ Tinea capitis (scalp ringworm) and tinea corporis (ringworm) are fungal infections of the scalp and body caused by dermatophytes Thrush ➞ A fungal infection of the mouth caused by Candida albicans Smallpox ➞ Smallpox (variola) was a highly contagious, deadly viral disease that has been eradicated worldwide by vaccination in 1980 ➞ There's no treatment or cure for smallpox Symptoms ☆ Flu-like symptoms ☆ Rash that appears ﬁrst on the face, hands and forearms and then later ☆ appears on the torso Hand, foot + mouth disease ➞ A contagious viral disease commonly caused by coxsackievirus and enterovirus Symptoms ☆ Fever ☆ Vesicular ulcerous lesions in the mouth ☆ Vesicular rashes on the hands, feet, and buttocks Insect bites + Parasites Scabies ➞ A pruritic lesion caused by the itch mite, which burrows into the skin and forms papules and vesicles ➞ The mite is very contagious and is transmitted by direct contact Pediculosis (lice) ➞ Caused by blood-sucking parasites that secrete toxic saliva and damage the skin to produce pruritic dermatitis ➞ Lice are spread by direct contact and are recognized by the ova or nits that attach to the shafts of body hairs Fleas ➞ Flea bites produce a pruritic wheal with a central puncture site and occur as clusters in areas of tight-ﬁtting clothing Bed bugs ➞ Blood-sucking parasites that live in cracks of ﬂoors, furniture, or bedding and feed at night ➞ They produce pruritic wheals and nodules Maternal Health Fertile (ovulation) window of menstrual cycle is biggest chance of pregnancy - day of ovulation (12-16 days after menstrual period begins) and the 5 preceding days Increase chance of healthy baby ☆ Folic acid ☆ Iron ☆ Healthy eating - protein rich diet, avoid ﬁsh + seafoods (mercury), avoid undercooked eggs + unpasteurized dairy Constipation ☆ Drink more water ☆ High ﬁbre diet ☆ Do gentle exercises Immunisation during pregnancy ☆ Pertussis vaccine ☆ Flu vaccine Smoking - can cause low birth weight, SIDS Alcohol - foetal alcohol syndrome Developmental delay is the result of parental health + behaviours Source of progesterone - corpus luteum Pregnant woman ﬁnds lump in breast - can be d/t hormonal changes causing a build up of breast milk Morning sickness ☆ Snacks ☆ Rest for few mins before getting up + get up slowly ☆ Avoid lying down right after eating ☆ Plenty of ﬂuids (ginger tea) ☆ High carb/low fat diet Signs of pregnancy ☆ Tender breast ☆ Dark areola ☆ Breast enlargement ☆ Nausea/vomiting ☆ Frequent urination Heartburn ☆ Caused by increased progesterone + growing baby pressing against stomach First foetal movements in primipara - 18-20 weeks (quickening) Menstrual bleeding returns - not breastfeeding = 6-8 weeks, breastfeeding = vary Woman is spotting at 28 weeks - bleeding often happens as lower part of uterus thins during third trimester which causes the area of placenta over cervix to bleed, risk of bleeding is higher if a lot of the placenta covers the cervix Aspirin - not recommended during pregnancy as can cause clot, however if mother has preeclampsia low dose is okay (60-100mg) Varicose veins ☆ Exercise regularly ☆ Elevate legs ☆ Avoid standing for a long period ☆ TEDs Mongolian spots ☆ Appear on skin at or shortly after birth ☆ Spots appear when melanocytes remain in deeper skin layer during embryonic development Baby’s weight loss after birth - babies are born with some extra ﬂuid so it is normal for them to lose weight when they lose the ﬂuid in the ﬁrst few days (7-10% of birth weight) but this should be regained within 2 weeks after birth How to “bring milk in” - frequent breastfeeding, massage breast + lean in to make it easy for baby to latch breast Baby’s respiratory response - change in temp + pressure while moving through birth canal stimulates baby’s resp response Baby blues - normal hormonal response, mother may be tearful, however if it continues for 2 weeks then possible postpartum depression Woman bleeding late in pregnancy - normal for small amount of blood mixed with mucus (show), which occurs when the plug of mucus sealing the cervix comes away Foetal growth Terms ☆ Embryo - from implantation to 5-8 weeks ☆ Zygote - union of sperm + egg ☆ Foetus - from 5-8 weeks to birth ☆ Ovum - female egg ☆ Age of viability - earliest age foetus can survive (24 weeks or >400g) Ways to assess foetal health ☆ Heart rate ☆ Fundal height ☆ Foetal movement Fertilisation + Early Stages Union of sperm nuclei + the secondary oocyte to form zygote Oocyte is ejected from ovary, picked up by the fallopian tube, cilia in fallopian tube push oocyte down tube; meanwhile the sperm comes up through the vagina through the uterine cavity + through fallopian tube using ﬂagella + meets the oocyte Sperm live 24-48 hrs once ejaculated, oocyte lives 6-24 hrs after ovulation Blastocyst attaches to endometrium 6 days after fertilisation, in the fundus Trophoblast cells form outer layer of blastocyst + provide nutrients to embryo (regulates blood ﬂow), eventually develops into part of placenta, yolk sac provides nourishment to blastocyst before placenta forms Development of the embryo (3 cups of coﬀee/day - associated with increased rate of miscarriage Artiﬁcial sweetener - eliminated slowly from baby’s bloodstream Teratogens Agents in foetal environment that either cause a birth defect or increase the likelihood of a birth defect occurring Critical period 1 - 1-3 weeks (fertilisation/implantation) Zygote may become damaged/destroyed Can impair successful implantation + promote miscarriage Critical period 2 - 3-9 weeks (main embryonic period) Can cause organ development abnormalities Critical period 3 - 9-58 weeks (fetal period) Less susceptible to congenital malformations however functional defects + growth delay may occur Rubella If transmitted to foetus in early pregnancy can cause hearing impairment, cognitive + motor changes, blindness, cardiac defects, restricted growth Post 16 weeks defects are rare Alcohol Increases risk of miscarriage, premature birth, low birthweight, + can cause foetal alcohol syndrome Foetal alcohol syndrome = problems with learning/behaviour, bones/joints/muscles/organs, managing emotions + social skills, hyperactivity, CNS impairment Smoking Restricts uterine blood vessels = decreased uterine blood ﬂow + O2 supply to fetus = impaired neurodevelopment + hypoxia Increased risk of miscarriage + early labour Common Discomforts of Pregnancy MORNING SICKNESS Caused by high levels of hormones, decreased BP, altered Week 4-12 metabolism of carbohydrates + BGL, large chemical + physical Sometimes continues changes triggered by pregnancy, which irritate the medulla throughout (hyperemesis oblongata vomiting centre gravidarum) Relief - small frequent meals of plain food high in carbs + low in fat, plenty of ﬂuids, ginger BLEEDING GUMS Blood vessels dilate d/t elevated progesterone levels, making Throughout pregnancy gums more vulnerable to bacteria + bleeding Relief - good oral hygiene, ﬂossing, mouthwash, dental visit URINARY FREQUENCY Caused by increased levels of progesterone + HCG + pressure on Most common in 1st trimester, bladder from uterus, this causes ﬂuid levels to increase which then again in 3rd trimester means kidneys ﬂush extra ﬂuid Relief - strengthening pelvic muscles (Kegels exercises), drink enough ﬂuids, ensure complete emptying of bladder NASAL STUFFINESS/EPISTAXIS Progesterone causes increased blood volume which exacerbates Throughout pregnancy, most vascular congestion + bleeding, HGH causes inﬂammation of common in 1st trimester mucous membranes lining nose, causing stuﬃness Relief - drink ﬂuids, saline drops/spray HEARTBURN Increased progesterone causes sphincter to relax + not close, so Starts after 8 weeks + may last stomach contents moves into oesophagus, may also be caused all of pregnancy (also common by pressure of growing foetus on stomach around 27 weeks) Relief - eat several small meals, eat slowly, drink between meals, avoid fatty foods, upright posture after eating CONSTIPATION Increase in progesterone causes GI motility to decrease + slows Starts 8-12 weeks, may get down passage of food through intestine (more time to absorb worse throughout pregnancy nutrients) Relief - ﬂuids, physical activity, ﬁbre, natural laxatives (kiwi + prunes) HAEMORRHOIDS Increased blood ﬂow to pelvic area + pressure from enlarged 2nd + 3rd trimesters uterus can cause rectal veins to swell Relief - bath, ice, avoid straining, ﬁbre, ﬂuids, stool softeners FAINTNESS/DIZZINESS Progesterone causes blood vessels to relax + widen, slowing Most common weeks 0-13, return of blood, uterus can also press on vena cava often lasts whole pregnancy Relief - ﬂuids, exercise, standing slowly, don’t get overheated, eat regular meals OEDEMA IN LOWER LEGS Increase in hormones aldosterone + cortisol cause body to retain Starts middle of 2nd trimester + ﬂuid + Na during pregnancy stays until delivery Relief - compression socks, elevate legs above heart level, sleep on left side, exercise SOB Uterus is expanding + pushing up into abdomen, reducing lung Can begin 1st trimester + gets capacity + progesterone alters smooth muscle tone of airways, worse over time causing faster RR Relief - good posture, breathing techniques, resting VARICOSE VEINS (superﬁcial Progesterone relaxes blood vessel walls + decreased valve phlebitis) function, increase in blood volume, uterus puts pressure on vena Common during 2nd + cava causing blood to pool in lower extremities 3rd trimesters Relief - move often, exercise, limit Na in diet, raise feet, wear compression socks Virchow's triad during pregnancy Increased levels of clotting factors = increased risk of clot forming Growing uterus presses on pelvic veins leading to decreased blood ﬂow + increased blood volume in lower extremities Causes venous stasis LOWER BACKACHE Increased release of relaxin which causes ligaments in pelvis to Between 5th + 7th months of become looser, aﬀecting stability of spine + separation of abdo pregnancy muscles, also muscle strain d/t weight of baby Relief - good posture, wear supportive shoes, don't lift heavy objects, exercise Human placental lactogen (hPL) - hormone with both growing promoting and lactogenic properties. It is produced from the 6th week of pregnancy and increases until full term. The placenta also produces several plasma proteins. Amniotic ﬂuid is constantly being renewed as the foetus swallows the ﬂuid and it is passed through the foetal kidneys adding to the amniotic ﬂuid. Hyperglycemia can cause excessive amniotic ﬂuid + oligohydramnios causes a reduction of amniotic ﬂuid Amniotic ﬂuid ☆ Shields the foetus against a blow of pressure to mother’s abdomen ☆ Protects against changes in temperature ☆ Allows movement therefore developing muscular development The umbilical cord (funiculus umbilicalis) transports oxygen and nutrients to the placental. It has one vein and two arteries. The vein carries blood from the placenta to the foetus and arteries from the foetus to the placenta. It has no nerve ﬁbres so it doesn't hurt to cut it after delivery. It is surrounded by Wharton’s jelly which is formed by the amnion and chorion. Foetal haemoglobin is more concentrated and has more oxygen Healthy Pregnancy ☆ Folic Acid (folate) to prevent birth defects. It helps form the neural tube and prevent spina biﬁda ☆ Smoke free to prevent birth defects - smoking can cause preterm birth, low birth weight and SIDs ☆ Drinking alcohol can result in foetal alcohol syndrome and preterm birth, low birth weight Blood pressure complications ➞ BP initially decreases in the ﬁrst trimester due to increased hormones. The hormones cause the blood vessels to dilate therefore dropping the mother's blood pressure + heart rate increases to compensate ➞ It then gradually increases again through the rest of pregnancy ➞ PIH is caused by ineﬀective dilation of the vascular network to accommodate the expanding blood volume of pregnancy Preeclampsia ➞ Occurs in 10% of pregnancies, usually 2nd + 3rd trimester More common in women who ☆ Are having their ﬁrst baby ☆ Are having their ﬁrst baby to a new partner ☆ Have a previous history of high BP ☆ Have diabetes ☆ Are having a multiple birth ☆ Have a family history of preeclampsia Symptoms ☆ High BP ☆ Proteinuria ☆ Headaches ☆ Visual disturbances ☆ Excessive swelling ☆ Pain in upper abdo ☆ Nausea ☆ Eclampsia - seizures Treatment ☆ Regular monitoring of baby + BP ☆ Antihypertensives ☆ Rest Vasoconstriction ⇝ Hypertension (>140) ⇝ Decreased blood supply to organs + baby ⇝ Swelling, headaches, organ failure ⇝ Decreased supply of nutrients + O2 to baby ⇝ Birth defects, poor foetal growth HELLP 𝐇 Haemolysis (RBC death) 𝐄 Elevated 𝐥 Liver enzymes 𝐋 Low 𝐩 Platelet count (poor clotting) RBCs are damaged or destroyed, blood clotting is impaired, and the liver can bleed internally, causing chest or abdominal pain. HELLP syndrome is a medical emergency. Women can die from HELLP syndrome or have lifelong health problems as a result. Gestational diabetes ➞ Increase in BP and BGL Physiological changes of pregnancy ☆ 20% increased consumption of oxygen ☆ Increased RR ☆ 40% increased CO (the maximum CO is found at about 20–28 weeks’ gestation) ☆ Peripheral vasodilation (swollen feet) ☆ Increased HR (maternal heart beat 10-20 bpm) ☆ BP initially decreases in ﬁrst and second trimester then increases to normal (when not pregnant) in third ☆ Increased need to urinate ☆ FSH/LH fall to extremely low levels due to the high levels of oestrogen and progesterone ☆ Prolactin levels increase ☆ Pituitary growth hormone (GH) levels fall but overall serum levels increase due to placental production ☆ Oxytocin levels increase to a peak at term ☆ T4 and T3 increase over the ﬁrst half of pregnancy but there is a normal to slightly decreased amount of free hormone due to increased TBG-binding. Normal ranges are slightly reduced in the second and third trimester. ☆ Women are relatively iodine-deﬁcient in pregnancy, if iodine levels are maintained in pregnancy, the thyroid gland should stay the same size and any increase be investigated. ☆ Although foetal need for calcium is high, maternal serum calcium levels are maintained in pregnancy by increased intestinal absorption ☆ There is also increased excretion in the urine, as a result of which pregnant women are at increased risk of renal stones. ☆ Cholecalciferol (vitamin D3) is converted to its active metabolite, 1,25-dihydroxycolecalciferol, by placental 1α-hydroxylase. Serum levels rise and are responsible for the increased intestinal absorption of calcium. ☆ Cortisol levels increase in pregnancy, which favours lipogenesis and fat storage. ☆ Insulin response also increases so blood sugar should remain normal or low ☆ Nausea and vomiting are common in early pregnancy. ☆ Appetite is usually increased, sometimes with speciﬁc cravings. ☆ Progesterone causes relaxation of the lower oesophageal sphincter and increased reﬂux, making many women prone to heartburn. Pressure on the stomach from the enlarging uterus further contributes to this in later pregnancy. ☆ Gastrointestinal motility is reduced and transit time is consequently longer. This allows increased nutrient absorption. Constipation is common. ☆ The gallbladder may dilate and empty less completely. Pregnancy also predisposes to the precipitation of cholesterol gallstones. ☆ Gums become spongy, friable and prone to bleeding. Good dental care is important. ☆ Mild glycosuria and/or proteinuria may occur because the increase in GFR may exceed the ability of the renal tubules to reabsorb glucose and protein. ☆ Increased water retention causes a reduction of plasma osmolality. ☆ The smooth muscle of the renal pelvis and ureter become relaxed and dilated, kidneys increase in length and ureters become longer, more curved and with an increase in residual urine volume. ☆ Bladder smooth muscle also relaxes, increasing capacity and risk of urinary tract infection. ☆ The enlarging uterus may put pressure on the ureters. ☆ A normal pregnancy creates a demand for about 1000 mg of additional iron. ☆ The basal metabolic rate increases slowly over the course of pregnancy, by 15-20%. ☆ It is thought that energy requirement does not increase signiﬁcantly during the ﬁrst or second trimesters, increasing by around 200 kcal per day in the third ☆ Active energy expenditure tends to fall over pregnancy. ☆ Recommended normal weight gain in pregnancy is 11.4 to 15.9 kg for a woman of normal body mass index (BMI). Around 5 kg is the foetus, placenta, membranes and amniotic ﬂuid and the rest is maternal stores of fat and protein and increased intra- and extravascular volume. Weight is no longer monitored in pregnancy as it does not aﬀect outcome and is aﬀected by a number of factors. ☆ Hyperpigmentation of the umbilicus, nipples, abdominal midline (linea nigra) and face (melasma (chloasma) are common due to the hormonal changes of pregnancy. ☆ Hyperdynamic circulation and high levels of oestrogen may cause spider naevi and palmar erythema. ☆ Striae gravidarum ('stretch marks') are common ☆ Increased ligamentous laxity caused by increased levels of relaxin contribute to back pain and pubic symphysis dysfunction. ☆ Shift in posture with exaggerated lumbar lordosis leading to the typical gait of late pregnancy Terms ☆ Amenorrhea - absence of menstrual periods ☆ Primigravida - ﬁrst pregnancy ☆ Multipara - has had a pregnancy ☆ Lightening - when the foetus rotates to become ready for labour ☆ Hegar's Sign - softening of the uterus, sign of pregnancy ☆ Ballottement - a sharp upward pushing against the uterine wall with a ﬁnger inserted into the vagina for diagnosing pregnancy by feeling the return impact of the displaced foetus ☆ Braxton hicks - when the uterus contracts and relaxes but not labour ☆ Operculum - mucus plug to seal the cervical canal ☆ Montgomery's tubercles are sebaceous (oil) glands that appear as small bumps around the dark area of the nipple ☆ Striae gravidarum - stretch marks ☆ Linea nigra - vertical brown line along the abdomen due to hormonal changes ☆ Melasma / chloasma - brown patches that appear on the face Drug interactions Category A - Medicines which have been taken by a large number of pregnant women and women of childbearing age, without any proven increase in the frequency of malformations or other direct or indirect harmful eﬀects on the foetus having been observed. Category B1- Medicines which have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful eﬀects on the human foetus having been observed. Studies in animals have not shown evidence of an increased occurrence of foetal damage. Category B2 - Medicines which have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful eﬀects on the human foetus having been observed. Studies in animals are inadequate or may be lacking, but available data show no evidence of an increased occurrence of foetal damage. Category B3 - Medicines which have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful eﬀects on the human foetus having been observed. Studies in animals have shown evidence of an increased occurrence of foetal damage, the signiﬁcance of which is considered uncertain in humans. Category C - Medicines which, owing to their pharmacological eﬀects (risk based on the mechanism of action of the medicine), have caused or may be suspected of causing harmful eﬀects on the human foetus or neonate without causing malformations. These eﬀects may be reversible. Category D - Medicines which have caused, are suspected to have caused, or may be expected to cause, an increased incidence of human foetal malformation or irreversible damage. These medicines may also have adverse pharmacological eﬀects. Category X - Medicines which have such a high risk of causing permanent damage to the foetus that they should not be used in pregnancy or when there is possibility of pregnancy. Labour / Birth Labour = time + processes that occur during parturition from the beginning of cervical dilation to the delivery of the placenta Duration Primigravida - 15 hrs Multigravida - 8 hrs Labour ➞ 3 stages - early, active, transitional Early Labour ➞ Several hours to several weeks ➞ Cervix dilated to 3cm and eﬀaces (thins out) ➞ Mild-moderate contractions 30-45 seconds long and 20 min apart - it gets closer and longer Labour signs ☆ Backache ☆ Menstrual like cramps ☆ Lower abdominal pressure ☆ Indigestion ☆ Diarrhoea ☆ Warmth in the abdomen ☆ Blood tinged mucus discharge ☆ Water break ☆ Lightening - foetus descends towards pelvic inlet (2-3 weeks prior to labour) ☆ Braxton hicks - give fundus workout, stretch bottom muscles, assist dilation (can occur throughout pregnancy) Things to do at home ☆ Time - Once contractions become fairly regular, write down the time between each contraction, as well as how long each contraction lasts. ☆ Aromatherapy - some essential oils are better than other ☆ Distraction - watch television or a DVD, play a board game, do crosswords. ☆ Relaxation and visualisation - breathe in gently, sigh out slowly, think positive thoughts. ☆ Stay mobile - go for short walks. ☆ Massage - neck and shoulder to release tension. ☆ A warm bath or shower. ☆ Small frequent meals, such as fruit, nuts, carbohydrates (plus small amounts of sugary foods) ☆ Sleep - try to rest and sleep in between contractions. ☆ Heat - a hot water bottle or wheat pack can be helpful on your back and stomach. ☆ Support people - have positive supportive people around you Rupture of membranes - occurs during labour or 24 hrs before starting labour, if this happens prematurely = risk of mother having intra amniotic infection, postpartum infection, endometriosis, death, risk of baby having resp distress, sepsis, haemorrhage, premature birth Active Labour ➞ Painful contractions ➞ 40-60 seconds long (peak pain halfway), 3-4 minutes apart ➞ Increased back pain, fatigue, leg discomfort ➞ Cervix dilate 3-7cm Monitoring ☆ Take blood pressure ☆ Monitor time and strength of contractions ☆ Evaluate quantity and quality of discharge ☆ Monitor foetus ☆ IV for epidural if wanted (test eﬀectiveness with ice) Transitional Labour ➞ End of 1st stage of labour, precedes pushing phase ➞ Most intense and painful but shortest ➞ Cervix dilate 7-10 cm ➞ 60-90 sec contractions, 2-3 min apart - contractions ‘step-up’ in intensity ➞ Strong pressure in lower back, rectal pressure, cervix rupture, nausea, vomiting, crampy legs, drowsiness, tightening in throat and chest, fatigue and exhaustion Delivery ➞ The second stage of labour begins when the cervix is fully dilated (open) and the baby's head moves down out of the uterus and into the vagina (or birth canal) ➞ The birth of your baby may take 30 minutes to an hour or longer. This second stage could be further extended if you have an epidural ➞ A small number of women will require assistance with their births, either by forceps or ventouse (vacuum extraction) Delivering placenta ☆ Physiological third stage - means waiting for your placenta to deliver spontaneously with your eﬀort. This may take up to an hour following the birth ☆ Active management - involves injecting an ecbolic (contracting drug) into your leg as your baby's shoulders are born. The ecbolic speeds up placental separation and your uterus (womb) contracts down to reduce blood loss and ensure your womb remains contracted Following Delivery Mother Assess fundus of uterus for ﬁrmness, height + centrality Assess lochia Clean + assess perineum + vulva for oedema, gaze or tear Assist with initiation of breastfeeding Postpartum vitals Shower Family time Assessment of placenta + membranes (for fullness) Baby Bonding with parents + cuddling Breast feeding Dry baby, keep warm, take temp Observe baby passing meconium/urine Observe umbilical clamp is secure Note any abnormalities Post-Partum Haemorrhage ➞ PPH occurs in 1 in 500 pregnancies ➞ It can occur 1 day after till 12 weeks after ➞ In a normal delivery a woman can lose 500ml of blood, and more in a Caesarean Section After your baby is delivered, the uterus normally contracts to push out the placenta. The contractions then help put pressure on bleeding vessels where the placenta was attached in your uterus. If the contractions are not strong enough, the vessels bleed more. It can also happen if small pieces of the placenta stay attached. Symptoms ☆ Heavy bleeding from the vagina ☆ Drop in blood pressure or signs of shock ☆ Nausea ☆ Pale Skin ☆ Swelling and pain around the vagina or perineum Risk Factors ☆ Previous PPH ☆ Long labour ☆ Twins, Triplets, Quadruplets ☆ Large baby (over 9 pounds) ☆ Excess amniotic ﬂuid ☆ Many past pregnancies (more than 5) ☆ Stretched uterus Conditions that cause PPH ☆ Uterine Atony (when the muscles don’t contract after birth, usually when the stretches to give birth to twins, or a baby over 9 pounds, have many children, a long labour or lots of amniotic ﬂuid.) ☆ Uterine Inversion (where the uterus turns inside out after giving birth) ☆ Uterine Rupture (where the uterus tears after labour, usually after a c section then a natural birth) ☆ Placental Abruption (where the placenta separates from the uterus either partially or completely) ☆ Placenta accreta/increta/percreta (when them placenta grows deeply in the uterus and cannot separate) ☆ Placenta Previa (where the placenta lies very low in the uterus and covers the cervix) ☆ Retained placenta (where the placenta is retained for over 60 minutes after giving birth, some may remain even if the placenta has passed) ☆ C-Sections ☆ General Anaesthesia ☆ Medications used in preterm labour ☆ Lacerations or tearing in the cervix or vagina (large baby or quick labour or use of episiotomy which is a cut made in the vagina to make it easier for the baby to pass through the vagina) ☆ Augmented labour /Medications used to induce labour ☆ Pre-Existing blood conditions ☆ Obesity ☆ Pre-Eclampsia / hypertension in pregnancy Diagnostic Tests ☆ Blood tests – Bleeding can cause low haematocrit, and blood clotting factors can be identiﬁed ☆ EBL – estimated blood loss through suction or pads used ☆ Pelvic Exam – to identify any tears, cuts or pieces of the placenta ☆ Physical Exam – BP, pulse, RR etc Treatment ☆ Fluids/blood transfusion to replace lost ﬂuid ☆ Surgery to repair the tears or remove pieces of the placenta ☆ Hysterectomy ☆ Massage the uterus to stimulate contractions and help pass blood clots ☆ O2 therapy – low blood volume = low haemoglobin and low o2 ☆ Embolization Antenatal Care Nursing assessment ☆ Determine Gestational age ☆ Previous Conceptions ☆ Previous successful births ☆ Signiﬁcant others involved in life/pregnancy ☆ How is the woman feeling, any questions? ☆ Health history - contact with teratogens ☆ Health literacy Health promotion + education ☆ Skin to skin contact is good ☆ Breastfeeding ☆ Physical changes ☆ Vitamin k ☆ Newborns screening ☆ Bonding ☆ Sleep ☆ Postnatal depression ☆ Immunisation Infant Solids - introduce at 6 months (pureed initially) + keep milk (formula/breastfeeding) in child’s diet 2 years Major developmental milestone at 9/12 months - sit/stand without assistance, walk without help, pick up objects, bubbling sounds Jaundice in newborn - immature liver does not break down bilirubin properly First 24 hours ☆ APGAR score 7-9 ☆ Babinski reﬂex ☆ Moro reﬂex ☆ Sucking reﬂex ☆ Gag reﬂex Initiation of ﬁrst breath - temp changes while moving through birth canal, lack of amniotic ﬂuid, exposure to air (nose breathing normal up to 6 months) Nasogastric feeding for infant ☆ Assess correct position of tube - aspirate ☆ Litmus test Prevent SIDS ☆ Always put baby to sleep on back ☆ Make sure baby’s head + face uncovered during sleep ☆ Do not expose baby to smoke ☆ Give baby own safe sleeping environment APGAR ➞ Each scores on a scale of 0-2, 2 being best ➞ A baby who scores 7 or above is considered healthy ➞ Given twice, 1 min old + 5 min old ➞ Weighed at birth + after 2 weeks to ensure birth weight is regained Lochia Breastfeeding ➞ Breast milk protects the baby against a range of infections and allergies ➞ Milk let-down - encourage breastfeeding, prolactin assists in formation ➞ Engorged breasts - occurs when breasts overly full with milk + ﬂuids, they feel ﬁrm + uncomfortable, usually 3-4 days after giving birth, to relieve hand express milk ➞ Colostrum - changes to breast milk 2-3 days after delivery ➞ After pains - normal hormonal changes, if severe could be mastitis ➞ Breastfeeding ideal for ﬁrst 6 months to provide passive immunity Normal for 2 hours for baby to cry constantly Colostrum → Breast Milk ☆ The milk starts as COLOSTRUM which is nutrient dense ☆ By two weeks the milk becomes whiter and thinner in appearance and increases in volume to meet the needs of the growing baby. ☆ Continued milk production is dependent on frequent stimulation and emptying of the breasts. Beneﬁts for mother ☆ Rest ☆ Saves time and money compared with formula ☆ Formula is an option to provide nutrients to baby when breastfeeding is not an option ☆ Releases necessary hormones to prevent PPH ☆ Burns calories – helps lose weight Beneﬁts for baby ☆ Provides all essential nutrients for ﬁrst 6 months of life ☆ Builds immunity ☆ Therapeutic for baby (physical and emotional) ☆ Better digested compared with formula ☆ Prevention of SIDS ☆ Less health complications throughout life Exclusive breastfeeding ☆ Baby has only had breast milk (expressed or from the breast) and prescribed medicines for their ﬁrst 6 months of life ☆ From then they begin on solid food while breastfeeding until they are 12 months old Frequency ☆ New-borns every 2-3 hours ☆ 2 months every 3-4 hours ☆ 6 months every 4-5 hours Signs that Baby is hungry ☆ Crying ☆ Licking their lips or sticking out their tongue ☆ Rooting reﬂex ☆ Putting their hand in their mouth ☆ Opening their mouth ☆ Fussiness ☆ Sucking on things Signs that Baby is having enough ☆ Not lose more than 7% of their birth weight in the ﬁrst few days after delivery ☆ Seem content for about 1-3 hours between feedings ☆ Have at least 6 diapers a day wet with very pale or clear pee by the time they are 7-10 days old Signs of dehydration in infants ☆ Dry skin, tongue, lips ☆ Rapid breathing ☆ Fewer wet diapers ☆ Tearless crying ☆ Sunken eyes + cheeks ☆ Sunken fontanelles ☆ Irritability Signs of oral thrush in infants ☆ White, velvety sores in mouth + on tongue ☆ Redness in mouth ☆ Diaper rash ☆ Mood changes - very fussy Let-down eﬀect - during breastfeeds or expression, oxytocin is released which pushes the milk through the ducts into the nipple opening. It takes 60 seconds and the women feel a tingling sensation or fullness of the breast Weight ☆ It is normal for babies to lose weight for the ﬁrst 3 days after birth. A loss of 7-10% in the ﬁrst week is normal. ☆ This should be regained by 2 weeks. ☆ Birth weight is doubled by 4 months and tripled by 13 months in boys and 15 months in girls. FROM 0 - 6 MONTHS, A BABY GROWS 1.5 - 2.5 CENTIMETRES A MONTH AND 140 - 200 GRAMS A WEEK. Postnatal depression Mother not sleeping + tearful - normal in ﬁrst 2 weeks, inform midwife, support group, counselling, medication (SSRIs can be used by breastfeeding mothers) Anatomy of newborn Fontanelles ☆ There are 2 fontanelles (the space between the bones of an infant's skull where the sutures intersect) that are covered by tough membranes that protect the underlying soft tissues and brain. ☆ Anterior fontanelle (also called soft spot). This is the junction where the 2 frontal and 2 parietal bones meet. The anterior fontanelle remains soft until about 18 months to 2 years of age. Doctors can assess if there is increased intracranial pressure by feeling the anterior fontanelle. ☆ Posterior fontanelle. This is the junction of the 2 parietal bones and the occipital bone. The posterior fontanelle usually closes ﬁrst, before the anterior fontanelle, during the ﬁrst several months of an infant's life. Infant Reﬂexes Tonic neck reﬂex (fencing reﬂex) When the infant’s head is turned to a particular side, the leg and arm on that side will extend, while the leg and arm on the opposite side will ﬂex. For example, if the infant’s head is gently turned to the right side the right leg and right arm will slightly extend, while the left leg and left arm will slightly ﬂex. Disappears by 4 months Grasp reﬂexes Palmar grasp reﬂexes (hand): when placing a ﬁnger or stroking the inside of the infant’s palm the hand will close around it…hence grasp it. Disappears 4-6 months. Plantar grasp reﬂex: when a ﬁnger is placed under the toes, the toes will curl. Disappears 9m – 12 months Moro reﬂex (startle reﬂex) This reﬂex occurs when the infant hears a sudden loud noise or experiences unexpected movement. Response the infant will throw out the arms (hence extend them) with the palms up and then move the arms back to the body. When placed in the supine position (with the head supported) and the head is allowed to fall lower than the body this reﬂex will occur. Disappears - 6 months Rooting reﬂex When the infant’s cheek or side of mouth is stroked, the head will turn towards it and the infant will open its mouth in an attempt to suck. This helps the baby ﬁnd its food source when feeding. Disappears - 4 months Sucking reﬂex When something touches the roof of the infant’s mouth the infant will automatically suck. Again, this helps with feeding by allowing the infant to pull food from the breast Disappears - 4 months and then becomes voluntary Babinski reﬂex When the bottom of the foot is stroked from the heel upward along the outward part of the foot, the big toe dorsiﬂexes (bends back) and the other toes fan or spread out. Disappears – 12 months Crawling reﬂex When the infant is placed on the stomach and pressure (such as a hand) is applied to the sole of the foot, the infant will attempt to push against the hand and move the arms and legs in a crawling like motion. Disappears around a few weeks after birth to a couple of months. Step reﬂex When holding the infant upright with legs and feet touching a surface, the infant will move the legs like taking steps or walking. Disappears - 3-4 months Birth defects Cleft lip/palate Congenital anomalies due to failure of soft tissue or bone to fuse. Risk Factors Medications take while pregnant Diabetes Obese during pregnancy Family history Treatment Cleft lip repair 3-6 months Cleft palate repair 2-24 months Before repair possible assess ability to suck/swallow/breathe, monitor ﬂuid intake and daily weights, hold infant upright and direct milk to the side/back of mouth, provide feeds in small amounts, suction and bub syringe at bedside, Complications Otitis media Speech impairments Coarctation of the Aorta (CoA) The areas of the aorta that are found before the narrowing will experience a HIGH blood pressure and areas found after the narrowing will experience a low blood pressure. This narrowing tends to occur after the left subclavian artery. There are two types of CoA Preductal: narrowing between the subclavian artery and before the ductus arteriosus Post ductal: narrowing occurs after the ductus arteriosus most common in adults. Signs and symptoms Nose bleeds Headaches Stroke Strong pulses in upper body Absent pulses in lower extremities Notching of the ribs due to collateral circulation (body creates extra circulation to bypass the narrowing, which will be seen on the ribs and cause them to have notched out appearance on a chest xray) Diagnostic Tests During a prenatal visit with a foetal ultrasound After birth with an echocardiogram Treatment Monitor for signs and symptoms Report blood pressures Medications prior to surgery that help the heart's function is digoxin and diuretics Surgery includes removing the area that is narrow and reconnecting the ends usually done by 2 years old May need a balloon angioplasty later on to reopen the artery if narrowing occurs again Complications Heart failure (due

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