Davis Advantage For Maternal-Child Nursing Care, 3e

F. A.
Davis Company
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Library of Congress Cataloging-in-Publication Data
Names: Scannell, Meredith J. author. | Ruggiero, Kristine, author. | Ward, Susan L.

Maternal-child nursing care.
Title: Davis advantage for maternal-child nursing care / Meredith Scannell, Kristine
Ruggiero.
Other titles: Advantage for maternal-child nursing care
Description: Third edition. | Philadelphia, PA : F. A. Davis Company, [2022] | Preceded by
Maternal-child nursing care / Susan L. Ward, Shelton M. Hisley, Amy Mitchell Kennedy.
2016. | Includes bibliographical references and index.
Identifiers: LCCN 2021023652 (print) | LCCN 2021023653 (ebook) | ISBN 9781719640985
(paperback) | ISBN 9781719640992 (ebook)
Subjects: MESH: Maternal-Child Nursing—methods | Holistic Nursing—methods |
Evidence-Based Nursing—methods | Cultural Diversity
Classification: LCC RG951 (print) | LCC RG951 (ebook) | NLM WY 157.3 | DDC 618.2/0231
—dc23
LC record available at https://lccn.loc.gov/2021023652
LC ebook record available at https://lccn.loc.gov/2021023653
Authorization to photocopy items for internal or personal use, or the internal or personal use
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organizations that have been granted a photocopy license by CCC, a separate system of
payment has been arranged. The fee code for users of the Transactional Reporting Service
is: 978-1-7196-4098-5/21 0 + $.25.
The successful development of this third edition of this book could not have been
possible without the support of so many. Thank you to everyone at F. A. Davis for
making this text the success it is. To our talented editors and reviewers, your
collective expertise provided ongoing guidance and direction. We appreciate the
feedback and guidance and overall support from everyone and a special thanks to
Amanda Minutola, Jacalyn Sharp, and Andrea Miller for really making this project a
success.
~Meredith and Kristine
To the wonderful, beautiful patients and families who have inspired the chapters in
these books, thank you. Having the distinct honor of working with so many
pediatric patients and families has been a true inspiration reflected in the pages in
this text. I can honestly say I love what I do; as a Nursing Professor (in an
accelerated BSN nursing program) and Pediatric Clinician I am always searching
for the best ways to teach important concepts of pediatric nursing in the most
concise, evidence-based, patient- and family-centered manner. This book is a
culmination of this. It is with my deepest appreciation and love to thank my family;
my parents, my children Jagger, Brody, Cruz, and my darling daughter Lola Mae.
Each of them has added to this book in the lessons I have been blessed with in
being their mom. And to my husband for his eternal love and unwavering support
and encouragement, and lastly to my late grandparents who continue to inspire me
with their love and life’s lessons.
~Kristine Ruggiero
Thank you for all the reviewers for providing expert advice and suggestions; your
comments were instrumental. To my friends and colleagues Vivian Tran, Hecmali
Dueno-Morales, Yinett Tejada, Marie Jonelle Duverne, and Eva Mauricio for
sharing pictures of themselves and family so that we have a more diverse
representation of families shown in the text. Thank you to my partner in life, Joe,
this would not be possible without your support, understanding, and love.
Thank you all.
~Meredith Scannell
Preface
Davis Advantage for Maternal-Child Nursing Care springs from our

passionate commitment to providing the best nursing care possible
to women and children and our desire to inspire others to make that
same commitment. In this all-inclusive source, we provide students
with current, comprehensive information about maternal-child
nursing in creative, dynamic ways and in a concise, easy-to-use
evidence-based format. Building on theoretical foundations in basic
nursing care, communication skills, and principles of health
promotion, the text challenges students to optimize outcomes for
their patients using critical thinking as they care for pregnant women
and children in the hospital and community environments. This
textbook also serves as an excellent resource for practicing nurses
who work with women, children, and families in a variety of settings.
Whether this course is taught as two separate entities, maternity
care and child health care, or combined into one course, the full
scope of nursing practice in this area is delivered in this text. We
believe that combining essential information about the two
specialties into a single textbook supports good educational practice
while being economically advantageous.
PHILOSOPHY
The primary intent of this textbook is to concisely and
comprehensively identify the myriad options for holistic, evidence-
based practice in maternal and child nursing care based on a
philosophy of physiological and developmental normalcy and
stressing safety and optimization of outcomes for mother and child.
In addition to comprehensive coverage of maternal and child nursing
care in traditional settings, we present essential elements for
providing cost-effective, high-quality, innovative nursing care in
community settings. Discussion of health-care delivery in community
settings is crucial in contemporary nursing education and reflects
today’s trend for women, families, and children to obtain health care
in the diverse settings in which they live, grow, play, work, or go to
school.
This book is built on a framework that views the delivery of nursing
care as a continuum spanning the traditional hospital inpatient
environment to the community setting. Students are presented with
information essential to providing appropriate, culturally informed
nursing care to women, families, and children. A variety of creative
learning aids are used to assist students in subject mastery and
prompt the delivery of care that appropriately addresses
contemporary needs while incorporating innovative approaches that
integrate provider–patient partnerships and alliances with coalitions
that serve women, families, and children across the lifespan.
Because the traditional hospital experience constitutes an
important component of nursing education, content on hospital-
based nursing care for women, families, and children examines
acute, traumatic, chronic, and terminal conditions. Likewise, content
that addresses community-based nursing care for women, families,
and children explores strategies and resources for the provision of
appropriate care in many different outpatient settings. With this text,
students learn that community-based care can take place in a variety
of ways at any time and in any place. It is our hope that the users of
this textbook will acquire the essential knowledge for professional
nursing practice in the specialties of maternal and child nursing and
that they will gain insights about providing nursing care in a myriad of
settings and with diverse populations.
Maternal and child health nursing is family-centered as well as
community-centered, as the maternal and child health nurse serves
as an advocate to protect the rights of all family members, including
the fetus. Additionally, the health of families depends on and
influences the health of communities. Both nursing theory and
evidence-based practice provide a foundation for nursing care.
THEMES AND KEY FEATURES
The overarching theme of this comprehensive maternal-child
resource focuses on how to provide contemporary nursing care to
women, families, and children in the traditional hospital setting as
well as in the community. In service to that goal are the broad
themes of holistic care, critical thinking, validating practice, and tools
for care. We use the following key features throughout the chapters
to creatively illustrate and emphasize information essential for the
delivery of safe, effective nursing care to diverse populations across
care settings, thus ensuring an educational experience rich with
critical thinking activities and clinical application opportunities.
Holistic Care
■ “Nursing Insight” boxes show students how experienced nurses

use their five senses to gain a deeper understanding about the
clinical situation or the patient’s condition.
■ “Collaboration in Caring” provides guidelines for working with other
health-care professionals to care for patients and families in
inpatient and in community-based environments.
■ “What to Say” helps students develop and enhance their
communication skills by providing verbatim examples or helpful
hints.
■ “Focus on Safety” helps students learn important protective
measures to keep mothers and children out of harm’s way.
Critical Thinking
■ “Learning Objectives” offer a guided approach to chapter content

and provide a gauge for assessing outcomes.
■ “Key Words” appear in boldface type accompanied by brief
definitions. Key words are also stored in the glossary for easy,
quick reference.
■ “Case Studies” facilitate students’ practice in the assimilation of
content from various chapters into actual patient situations. As
students work through the various case studies, they are
challenged to apply critical thinking and practice clinical decision
making.
■ “Clinical Judgment Alerts” help students recognize emergent or
critical situations and relate classroom or textbook information as
they deliver safe, effective nursing care in the hospital and
community-based environments.
■ “Concept Maps” visually summarize the relationships among the
most important concepts presented in every chapter. Students can
use the concept maps to review chapter content, enhance critical
thinking, and to more readily grasp the application of classroom
information in the clinical setting.
Validating Practice
■ “PICO(T) Questions” foster students’ understanding of evidence-

based practice.
■ “Optimizing Outcomes” enhance critical thinking skills for clinical
application and help establish the best possible outcomes and how
to obtain them.
■ “Concepts” assists students in focusing their learning on key
building blocks as they develop a deeper understanding of the
plethora of complex health information needed today by the
practicing nurse.
■ “Summary Points” bring together the information students should
be most careful to comprehend from the chapter.
Tools of Care
■ “Labs” boxes present crucial information about laboratory testing

and its relationship to the patient’s overall health status.
■ “Procedures” provide step-by-step instructions for performing
common procedures in maternal-child nursing and the rationales
for why things are done a particular way. Each procedure includes
an example of documentation to emphasize the critical nature of
proper, accurate documentation.
■ “Medication” presents crucial information about commonly
prescribed medications and helps students in their care of
mothers, children, and families.
■ “Assessment Tools” facilitate understanding of clinical evaluation
and help students make the connection between classroom or
textbook knowledge and the clinical setting.
■ “Diagnostic Tools” present crucial information about common
diagnostic measures and their relationship to various disease
entities.
■ “Patient Education” provides relevant information that families
need as they move through illness to recovery or acceptance of
chronic or terminal illness.
■ “Growth and Development” presents additional information about
how children grow and develop and is specifically related to
physiological or psychosocial information in each chapter.
THE TEACHING AND LEARNING PACKAGE

How students learn is evolving. In this digital age, we consume
information in new ways. The possibilities to interact and connect
with content in new, dynamic ways are enhancing students’
understanding and retention of complex concepts.
In order to meet the needs of today’s learners, how faculty teach is
also evolving. Classroom (traditional or online) time is valuable for
active learning. This approach makes students responsible for the
key concepts, allowing faculty to focus on clinical application.
Relying on the textbook alone to support an active classroom leaves
a gap. Davis Advantage is designed to fill that gap and help
students and faculty succeed in core courses. It is comprised of the
following:
■ A Strong Core Textbook that provides the foundation of
knowledge that today’s nursing students need to pass the NCLEX*
and enter practice prepared for success.
■ An Online Solution that provides resources for each step of the
learning cycle: learn, apply, assess.
■ Personalized Learning assignments are the core of the product
and are designed to prepare students for classroom (live or
online) discussion. They provide directed learning based on
needs. After completing text reading assignments, students take
a pre-assessment for each topic. Their results feed into their
Personalized Learning Plan. If students do not pass the pre-
assessment, they are required to complete further work within
the topic: watch an animated mini-lecture, work through an
activity, and take the post-assessment.
The personalized learning content is designed to connect
students with the foundational information about a given topic or
concept. It provides the gateway to helping make the content
accessible to all students and complements different learning
styles.
■ Clinical Judgment assignments are case-based and build off
key Personalized Learning topics. These cases help students
develop Clinical Judgment skills through exploratory learning.
Students will link their knowledge base (developed through the
text and personalized learning) to new data and patient
situations. Cases include dynamic charts that expand as the
case progresses and use complex question types that require
students to analyze data, synthesize conclusions, and make
judgments. Each case will end with comprehensive feedback,
which provides detailed rationales for the correct and incorrect
answers.
■ Quizzing assignments build off Personalized Learning Topics
(and are included for every topic) and help assess students’
understanding of the broader scope and increased depth of that
topic. The quizzes use NCLEX-style questions to assess
understanding and synthesis of content. Quiz results include
comprehensive feedback for correct and incorrect answers to
help students understand why their answer choices were right or
wrong.
■ Online Instructor Resources are aimed at creating a dynamic
learning experience that relies heavily on interactive participation
and is tailored to students’ needs. Results from the post-
assessments are available to faculty, in aggregate or by student,
and inform a Personalized Teaching Plan that faculty can use
to deliver a targeted classroom experience. Faculty will know
students’ strengths and weaknesses before they come to class
and can spend class time focusing on where students are
struggling. Suggested in-class activities are provided to help
create an interactive, hands-on learning environment that helps
students connect more deeply with the content. NCLEX-style
questions from the Instructor Test Bank and PowerPoint
slides that correspond to the textbook chapters are referenced in
the Personalized Teaching Plans.
Reviewers
Patricia Catlin, DNP, APRN, FNP

Associate Professor of Nursing Martin Methodist College Pulaski, TN
Georgina Colalillo, MS, RN, CNE

Professor of Nursing Queensborough Community College of the City
University of New York
Bayside, NY
Leslie Collins, DNP, MS, RN

Assistant Professor/Assistant Chair
Northwestern Oklahoma State University
Alva, OK
Mary Cousineau, MS, RN, PPCNP-BC, CNE

Adjunct Nursing Faculty, Curriculum Consultant
Hartnell College
Salinas, CA
Cheryl DeGraw, EdS, RN, MSN, CRNP

Department Chair, Nursing
Central Carolina Technical College
Sumter, SC
Angela M. Durry, MSN-Ed, RN

Clinical Assistant Professor
Towson University
Towson, MD
Leah E. Elliott. DNP, MSN-ED, RNC-OB, C-EFM, IBCLC
Professor of Nursing
Bakersfield College
Bakersfield, CA
Shaana Escobar, RN, DNP

Associate Professor of Nursing
Arkansas Tech University
Russellville, AR
Carolyn J. Godfrey, PhD in Nursing Education

Professor of Nursing/Full Time Faculty
St. Louis Community College at Forest Park
St. Louis, MO
Julie E. Grady, PhD, MSN, RN, CNL

Assistant Professor
Curry College, School of Nursing
Milton, MA
Tricia L. Harrison, MSN, RNC, CNE

Assistant Professor
University of Nevada, Reno
Reno, NV
Constance D. Hill-Williams, PhD, RN

Assistant Professor
San Jose State University
San Jose, CA
Sheila Kathleen Hurst, PhD, RN

Assistant Professor
North Idaho College
Coeur d’Alene, ID
Laura Karges, MS RN CPN

Associate Professor
Union College, Division of Nursing
Lincoln, NE
Francine Laterza, EdD, RN, PNP

Assistant Professor
Mercy College
Bronx, NY
Rebecca Luetke, PhD, MSN, RN, SANE-P

Colorado Mountain College
Glenwood Springs, CO
Barbara McClaskey, PhD, APRN-CNS BC, RNC

University Professor
Pittsburg State University
Pittsburg, KS
Deborah O’Hearn, DNP, RN

Assistant Faculty/Coordinator Skills Lab and Simulation
Florida Gateway College
Lake City, FL
Lori M. Overstreet, PhD, MSN, RN-BC

Florida State College at Jacksonville
Jacksonville, FL
Debra Pile, DNP, APRN, PCNS

Associate Professor
Wichita State University
Wichita, KS
Mimi Pomerleau, DNP, WHNP-BC, RNC-OB, CNE

Professional Development Manager
Brigham and Women’s Hospital
Boston, MA
Marisue Rayno, RN, EdD
Nursing Professor
Luzerne County Community College
Nanticoke, PA
Candice Rome, DNP, RN

Associate Professor, Chair of Digital Learning Programs
Gardner-Webb University
Boiling Springs, NC
Lisette Saleh, PhD, MSN, RNC-OB

Assistant Professor
Texas Christian University
Fort Worth, TX
Melissa Smiley, RN, MSN

Nursing Faculty
Wayne Community College
Goldsboro, NC
Christine Stephens, MSN RN

Assistant Professor of Nursing
St. Louis Community College
St. Louis, MO
Tama Stevens, MSN, RN

Nursing Instructor
Galen College of Nursing
Cincinnati, OH
Zelda Suzan, EdD, RN, CNE

Associate Professor (Retired)
Phillips School of Nursing at Mount Sinai Beth Israel
New York, NY
Laura J. Wallace, RN, CNM, PhD

Associate Professor
Brenau University
Gainesville, GA
Contents in Brief
UNIT 1
Foundations in the Nursing Care of Maternal, Family, and Child
Care
1 Core Concepts of Maternal and Pediatric Health Care Across the Continuum
UNIT 2
The Process of Human Reproduction
2 Reproduction
3 Conception and Development of the Embryo and Fetus
UNIT 3
The Prenatal Journey
4 Physiological and Psychosocial Changes During Pregnancy
5 Promoting a Healthy Pregnancy
6 Caring for the Woman Experiencing Complications During Pregnancy
UNIT 4
The Birth Experience
7 The Process of Labor and Birth
8 Caring for the Woman Experiencing Complications During Labor and Birth
UNIT 5
Care of the New Family
9 Physiological Transition of the Newborn
10 Caring for the Newborn at Risk
11 Caring for the Postpartal Woman and Her Family
12 Caring for the Woman Experiencing Complications During the Postpartal
Period
UNIT 6
Foundations in Nursing Care of Children
13 Caring for the Developing Child
14 Developmentally Appropriate Nursing Care Across Care Settings
15 Caring for the Child With a Respiratory Condition
16 Caring for the Child With a Gastrointestinal Condition
17 Caring for the Child With a Cardiovascular Condition
18 Caring for the Child With an Immunological or Infectious Condition
19 Caring for the Child With an Endocrinological or Metabolic Condition
20 Caring for the Child With a Neurological or Sensory Condition
21 Caring for the Child With a Musculoskeletal Condition
22 Caring for the Child With an Integumentary Condition
23 Caring for the Child With a Genitourinary Condition
24 Caring for the Child With a Hematological Condition
25 Caring for the Child With a Cognitive or Psychosocial Impairment
26 Caring for the Child With Cancer
27 Caring for the Child With a Chronic Condition, Disability, or End-of-Life Care
Online Only
UNIT 7
Women’s Health
28 Promoting the Safety of Women and Families
29 Promoting Premenstrual, Perimenopausal, and Menopausal Health
30 Promoting Breast Health
31 Promoting Reproductive Health: Various Gynecological Disorders
32 Promoting Reproductive Health: Sexually Transmitted Diseases
33 Promoting Reproductive Health: Common Reproductive Cancers
Appendix A Centigrade to Fahrenheit Temperature Conversions
Appendix B Expected Temperatures in Children
Glossary
Photo & Illustration Credits
Index
Detailed Table of Contents
UNIT 1
Foundations in the Nursing Care of Maternal, Family, and Child
Care
1 Core Concepts of Maternal and Pediatric Health Care Across the Continuum
Introduction
Nursing Roles
Standards of Practice
Nursing Process
ANA Clinical Practice Guidelines
Ethical Considerations
Family-Centered Care
Evidence-Based Practice
The Nursing Process and Evidence-Based Care
Building a Trusting Nursing-Patient Relationship
Client Rights
Rights to Privacy
An Ethical Framework for Professional Practice
Implications of the Health Insurance Portability and Accountability Act
(HIPAA)
Malpractice
Abortion Services
The Family Unit
Types of Families
Family Theories and Development Frameworks
Parenting Styles
Cultural Practices
Communication Patterns
Feeding Practices
Low-Income Populations
Trends in Maternal, Infant, and Child Epidemiology
Global Health
Maternal Morbidity and Mortality
Infant Morbidity and Mortality
Health Disparities
Complementary and Alternative Therapies
Trends in Health Care
Telemedicine
Medical Homes
Group Health Appointments
Healthy People 2030
UNIT 2
The Process of Human Reproduction
2 Reproduction
Introduction
Sexual Differentiation in the Embryo
Male Sex
Female Sex
Female Reproductive System
External Structures
Internal Structures
Breasts
The Interplay of Hormones and Reproduction
Hormones Released by the Hypothalamus
Hormones Released by the Pituitary Gland
Hormones of the Menstrual Cycle
Hormones Released by the Gonads
Sexual Maturation
Puberty
Female Secondary Sexual Characteristics
The Menstrual Cycle and Reproduction
Uterine (Endometrial) Cycle
Hypothalamic-Pituitary-Ovarian Cycle
Body Changes Related to the Menstrual Cycle and Ovulation
Natural Cessation of Menses
Menstrual Disorders
Male Reproductive System
External Structures
Internal Structures
Characteristics of Semen and Sperm
Male Hormonal Influences
Age-Related Development of the Male Reproductive System
Human Sexual Response
Contraceptive Care
Planning and Implementation of Care
Obtaining the Sexual History
Types of Contraception
Clinical Termination of Pregnancy
Surgical Termination of Pregnancy
Medication (Medical) Termination of Pregnancy
Complications
Nursing Care Related to Elective Pregnancy Termination
Infertility
Treatment Options for Infertility
Psychological Considerations of Infertility
3 Conception and Development of the Embryo and Fetus
Introduction
Basic Concepts of Genetics
Chromosomes, DNA, and Genes
Disease Inheritance
Multifactorial Inheritance
Unifactorial Inheritance
Cellular Division
The Process of Fertilization
The Process of Implantation and Placental Development
Development of the Embryo and Fetus
The Yolk Sac
Origin and Function of the Umbilical Cord
The Fetal Circulatory System
Fetal Membranes and Amniotic Fluid
Human Growth and Development
Preembryonic Period
Embryonic Period
The Fetal Period
Factors That May Adversely Affect Embryonic and Fetal Development
Chromosomes and Teratogens
The Nurse’s Role in Prenatal Evaluation
Heredity and Genetics
Maternal Age and Chromosomes
Multifetal Pregnancy
The Nurse’s Role in Minimizing Threats to the Developing Embryo and Fetus
UNIT 3
4 Physiological and Psychosocial Changes During Pregnancy
Introduction
Physiological Adaptations in Pregnancy
Reproductive System
General Body System Changes
Hormonal Influences
Musculoskeletal System
Immune System
Integumentary System
Neurological System
Signs of Pregnancy
Presumptive Signs of Pregnancy
Probable Signs of Pregnancy
Positive Signs of Pregnancy
Establishing the Estimated Date of Birth
Common Discomforts During Pregnancy
Nausea
Vomiting
Ptyalism
Dyspepsia
Dental Problems
Nasal Congestion
Hyperventilation and Shortness of Breath
Upper and Lower Backache
Leukorrhea
Urinary Frequency
Leg Cramps
Dependent Edema
Varicosities
Round Ligament Pain
Carpal Tunnel Syndrome
Supine Hypotensive Syndrome
Fatigue
Psychosocial Adaptations During Pregnancy
The Healthy Mind
Psychosocial Adaptations
Body Image Changes
Anxiety
Trauma History
Developmental and Family Changes
Factors That Interfere With Psychosocial Adaptations During Pregnancy
Nursing Assessment of Psychosocial Changes and Prenatal Health
Education
Screening and Diagnostic Tests During Pregnancy
5 Promoting a Healthy Pregnancy
Introduction
Choosing A Pregnancy Care Provider
Preconception Care
Prenatal Care
The First Prenatal Visit
Genetic Testing
The Prenatal Physical Examination
Subsequent Prenatal Examinations
Nutrition
Important Nutritional Elements
Prevention of Foodborne Illness
Weight Gain During Pregnancy
Factors Affecting Nutrition During Pregnancy
Exercise, Travel, Work, and Rest During Pregnancy
Exercise
Travel
Work
Rest
Medications
FDA Classification System for Medications Used During Pregnancy
Over-the-Counter Medications
Prescription Medications
Herbal and Homeopathic Preparations
Using a Pregnancy Map to Guide Prenatal Visits
Childbirth Education to Promote a Positive Childbearing Experience
Finding Information on Childbirth Education
Methods of Childbirth Preparation
Birth Plans
Breastfeeding
6 Caring for the Woman Experiencing Complications During Pregnancy
Introduction
Bleeding Complications in Pregnancy
Early Pregnancy Complications
Bleeding Disorders Later in Pregnancy
Preterm Labor
Morbidity and Mortality
Etiology and Risk Factors
Assessment of Cervical Length and Funneling
Management
Premature Rupture of the Membranes
Management
Patient Education
Hypertensive Disorders of Pregnancy
Classifications and Definitions
Pre-eclampsia
Eclampsia
HELLP Syndrome
Disseminated Intravascular Coagulopathy
Nursing Care
Multiple Gestation
Associated Complications
Determination of Chorionicity
Nursing Implications
Infections
Urinary Tract Infection
Group B Streptococcal Infection
TORCH Infections
Systemic Lupus Erythematosus
RHO(D) Isoimmunization
Pathophysiology
Management
ABO
Respiratory Complications
Asthma
Diabetes in Pregnancy
Definition and Classification of Diabetes Mellitus
Maternal and Perinatal Morbidity and Mortality
Management
The Thyroid Gland and Pregnancy
Hyperthyroidism
Hypothyroidism
Venous Thrombosis and Pulmonary Embolism
Psychiatric Complications During Pregnancy
Consulting With the Pregnant Psychiatric Patient
Depression
Bipolar Disorder
Schizophrenia
Anxiety Disorders
Eating Disorders
Assessment and Diagnostic Tools to Determine Fetal Well-Being
Doppler Ultrasound Blood Flow Studies (Velocimetry)
Fetal Biophysical Profile
Nonstress Test
Contraction Stress Test
Electronic Fetal Heart Rate Monitoring
Special Conditions and Circumstances That May Complicate Pregnancy
The Pregnant Woman Who Requires Bedrest
The Adolescent Pregnant Patient
The Advanced Age Pregnant Patient
The Pregnant Patient Who Has Suffered Trauma
Intimate Partner Violence During Pregnancy
UNIT 4
7 The Process of Labor and Birth
Introduction
The Onset of Labor
The Process of Labor and Birth
Powers
Passageway
Passenger
Passageway + Passenger
Psychosocial Influences
Signs and Symptoms of Impending Labor
Energy Spurt
Distinguishing True Labor From False Labor
Lightening
Braxton Hicks Contractions
Cervical Changes
Bloody Show
Rupture of the Membranes
Childbirth Settings and Labor Support
Routine Hospital and Birth Center Procedures
Establishing a Positive Relationship
Collecting Admission Data
Initial Admission Assessments
Assessment of the Fetus During Labor and Birth
Fetal Position
Assessment of the Fetal Heart Rate
Additional Methods of Fetal Assessment
Nursing Interventions
First Stage of Labor
Latent Phase
Active Phase
Transition Phase
Nursing Care During the First Stage of Labor
Caring for the Birth Partner
Second Stage of Labor
Promoting Effective Pushing
Achieving a Position of Comfort
Preparation for the Birth
Lacerations
Episiotomy
Birth
Third and Fourth Stages of Labor
Third Stage of Labor
8 Caring for the Woman Experiencing Complications During Labor and Birth
Introduction
Dystocia
Dysfunctional Labor Patterns
Precipitous Labor and Birth
Pelvic Structure Alterations
Trial of Labor
Amniotomy
Induction of Labor
Indications for Induction
Administration of Cervical Ripening Agents
Nonpharmacological Methods for Induction of Labor
Nursing Considerations
Assisted Operative/Vaginal Delivery
Forceps-Assisted Birth
Vacuum-Assisted Birth
Maternal Conditions That Complicated Childbirth
Hypertensive Disorders
Cardiac Disease
Diabetes Mellitus
Preterm Labor and Birth
Complications of Labor and Birth Associated With the Fetus
Fetal Malpresentation
Shoulder Dystocia
Cephalopelvic Disproportion
Multiple Gestation
Nonreassuring FHR Patterns
Nuchal Cord
Amniotic Fluid Complications
Oligohydramnios
Hydramnios
Meconium
Chorioamnionitis
Complications Associated With the Placenta
Placenta Previa
Placental Abruption
Disseminated Intravascular Coagulation
Rupture of the Uterus
Uterine Inversion
Umbilical Cord Prolapse
Variations Related to Umbilical Cord Insertion and the Placenta
Anaphylactoid Syndrome of Pregnancy
Cesarean Birth
Definition and Incidence
Indications
Surgical Procedures
Nursing Care
Vaginal Birth After Cesarean
Areas for Continued Research
Post-Term or Prolonged Pregnancy
Medical Management
Perinatal Loss
UNIT 5
9 Physiological Transition of the Newborn
Introduction
Adaptations of the Respiratory System
Intrapulmonary Fluid, Fetal Breathing Movements, and Surfactant
The First Breath
Factors That May Interfere With Respiration
Cardiopulmonary Transitions
Cardiovascular Adaptation
Changes After Placental Expulsion
Thermogenic Adaptation
The Neutral Thermal Environment
Physiological Adaptations for Heat Production
Mechanisms for Neonatal Heat Loss
Preventing Hyperthermia
Factors Related to Cold Stress
Hematopoietic Adaptation
Blood Volume
Blood Components
Hepatic Adaptation
Glycogen and Blood Glucose Maintenance
Hypoglycemia
Iron Storage
Hyperbilirubinemia
Gastrointestinal Adaptation
Stomach and Digestive Enzymes
Intestinal Peristalsis
Stools
Kidney Function
Immunological Adaptation
Psychosocial Adaptation
Early Stages of Activity
Newborn Behavioral States
Sleep States
Newborn Assessment
Immediate Newborn Assessment
Newborn Metabolic Screening Tests
Head-to-Toe Neonatal Physical Assessment
A Systems Approach to Assessment of the Newborn
Care of the Newborn
Temperature Assessment
Bathing the Newborn
Nail Care
Umbilical Cord Care
Diapering
Circumcision
Eye Care
Hepatitis B Vaccination
Fostering Attachment
Ensuring Optimal Nutrition
Discharge Planning for the Infant and Family
Car Seat Safety
10 Caring for the Newborn at Risk
Introduction
A & P Review: The Newborn at Risk
Circulatory System
Respiratory System
Neurological System
The Neonatal Intensive Care Unit
Classification of the Neonatal Intensive Care Unit
The High-Risk Newborn
Classification of High-Risk Newborns
Care of the High-Risk Newborn
Nutritional Care of the High-Risk Newborn
Skin Care
Developmental Care
Transporting the High-Risk Newborn
Small for Gestational Age (SGA) Newborns
Characteristics of an SGA Newborn
Conditions Affecting the SGA Newborn
Large for Gestational Age (LGA) Newborns
Conditions Affecting the LGA Newborn
Birth Injuries
Brachial Plexus Injuries (BPI)
The Preterm Newborn
Respiratory Distress Syndrome (RDS)
Apnea of Prematurity (AOP)
Bronchopulmonary Dysplasia (BPD)
Physiological and Pathological Jaundice
Anemia of Prematurity (AOP)
Necrotizing Enterocolitis (NEC)
Gastroesophageal Reflux Disease (GERD)
Retinopathy of Prematurity (ROP)
Acute Intracranial Hemorrhage (ICH)
Nutritional Care of the Preterm Newborn
The Post-Term Newborn
Signs and Symptoms
Conditions Affecting the Post-Term Newborn
Additional Considerations for the High-Risk Newborn
Newborn Screening
Congenital Hypothyroidism (CH)
Neurological Conditions
Cleft Lip and Cleft Palate
Congenital Diaphragmatic Hernia (CDH)
Abdominal Wall Defects
Infections in the Newborn
Developmental Delays
Discharge Planning
11 Caring for the Postpartal Woman and Her Family
Introduction
Ensuring Safety for the Mother and Infant
Protecting the Infant From Abduction
Early Maternal Assessment
Vital Signs
Medications
Concise Postpartum Assessment Guide to Facilitate Nursing Care
BUBBLE-HE Mnemonic
Assessment of Pain
Maternal Physiological Adaptations and Continued Assessment of the Patient
Hematological and Metabolic Systems
Neurological System
Renal System, Fluid, and Electrolytes
Respiratory System
Cardiovascular System
Immune System
Ovulation
Gastrointestinal System
Developing Cultural Sensitivity
Clinical Implications of Culturally Appropriate Care
Promoting Recovery and Self-Care in the Puerperium
Activity and Rest
Nourishment
Elimination
Perineal Care
Care of the Postpartal Surgical Patient
Permanent Sterilization (Tubal Ligation)
Care of the Patient After Cesarean Birth
Educating Parents to Make Informed Infant Nourishment Choices
The Physiology of Lactation
Strategies for Breastfeeding Success
Evaluation of Nourishment: Infant Weight Gain
Positions for Breastfeeding
Difficulty Feeding
Collecting and Storing Breast Milk
Infant Weaning
Assisting the Mother Who Chooses to Formula-Feed
Promoting Family and Infant Bonding
Facilitating the Transition to Parenthood
Assumption of the Maternal Role
Assumption of the Paternal Role
Factors That May Interrupt the Bonding Process
Adjustment of Siblings to the Newborn
Adjustment of Grandparents to the Newborn
Emotional and Physiological Adjustments During the Puerperium
Emotional Events
Physiological Responses to Emotional Events
Postpartal Discharge Planning and Teaching
Promoting Maternal Self-Care
Lochia
Hygiene
Abdominal Incision
Body Temperature
Urination
Bowel Function
Nutrition
Fatigue
Weight Loss
Exercise
Pain Management
Sexual Activity and Contraception
Planning for the Follow-Up Examination
Patients With Special Needs During the Puerperium
Care of the Adolescent
The Woman Placing Her Infant for Adoption
The Older Woman
Community Resources for the New Family
Support Groups
Home Visits
Telephone Follow-Up
Outpatient Clinics
12 Caring for the Woman Experiencing Complications During the Postpartal
Period
Introduction
Postpartum Hemorrhage
Incidence and Definition
Early vs. Late Postpartum Hemorrhage
Uterine Atony
Trauma
Tissue
Thrombin
Collaborative Management of PPH
Hematomas
Definition, Incidence, and Risk Factors
Signs and Symptoms
Collaborative Management
Thrombophlebitis and Thrombosis
Signs and Symptoms
Pulmonary Embolus
Puerperal (Postpartum) Infections
Endometritis (Metritis)
Wound Infections
Mastitis
MRSA
Postpartum Psychosocial Complications
Postpartum Blues
Postpartum Depression
Postpartum Psychosis
Childbirth-Induced Post-Traumatic Stress Disorder
Summarizing Postpartum Psychosocial Nursing Care
UNIT 6
Foundations in Nursing Care of Children
13 Caring for the Developing Child
Introduction
Influences on Growth and Development
Principles of Childhood Growth and Development
Growth and Development Theories
Psychosocial Development Theories
Attachment Theories
Social Learning Theories
Cognitive Theories
Intelligence Theories
Moral Development Theories
Family Development Theories
Child Temperament
Growth and Development Milestones
Newborn and Infant
Toddler (1–3 Years)
Early Childhood (Preschooler) (3–6 Years)
School-Age Child (6–12 Years)
Adolescence (12–19 Years)
14 Developmentally Appropriate Nursing Care Across Care Settings
Introduction
Reasons for Accessing Medical Care
Atraumatic Care of the Pediatric Patient
Gathering the Child’s Health History
Establishing a Relationship With the Patient and the Family
Asking Questions
Use of Culturally Appropriate Care
Comprehensive Health History
Health Assessment
Anthropometric Measurements
Vital Signs
Physical Assessment
The Child in Pain
Understanding Pain in Children From a Developmental Perspective
Pain Assessment and Management
The Child Who Has a Disability
Understanding the Child With a Disability
Across Care Settings
Hospital-Based Care
Decreasing the Stress of Hospitalization
Therapeutic Play
Guided Imagery
Role Modeling
Parents With a Hospitalized Child
Effects of a Hospitalized Child on Parents
Holistic Nursing Care for the Child
Bathing
Feeding
Rest
Safety Measures
Medication Administration
Infection Control Measures
Fever-Reducing Measures
Emotional and Spiritual Support
Preparing Children for Procedures
Explaining Procedures
Preparing an Infant for a Procedure
Preparing a Toddler for a Procedure
Preparing a Preschooler for a Procedure
Preparing a School-Age Child for a Procedure
Preparing an Adolescent for a Procedure
Informed Consent
Common Procedures
IV Lines
Peripheral IV Lines
Central Venous Access
Peripherally Inserted Central Catheter
Vascular Access Port
Measuring Intake and Output
X-ray Examinations
Specimen Collection
Enteral Tube Feedings
Ostomies
Restraining the Child
Community Settings
Primary Health Care Provider’s Office or Clinic
Medical Home
Other Community Settings
Care in the School Setting
15 Caring for the Child With a Respiratory Condition
Introduction
Anatomy and Physiology Review of the Respiratory System
Developmental Aspects of the Respiratory System
Congenital Respiratory Conditions and Structural Anomalies
Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF)
Acute Respiratory Distress Syndrome (ARDS)
Cystic Fibrosis
Upper Airway Disorders
Rhinosinusitis
Pharyngitis
Tonsilitis
Croup
Acute Epiglottitis
Lower Airway Disorders
Bronchitis
Bronchiolitis and Respiratory Syncytial Virus (RSV)
Pneumonia
Infectious Conditions
Pertussis
Pulmonary Tuberculosis
Influenza
Pulmonary Noninfectious Irritation
Foreign Body Aspiration
Respiratory Conditions Related to Allergens
Allergic Rhinitis
Asthma
SARS-CoV-2 (COVID-19)
16 Caring for the Child With a Gastrointestinal Condition
Introduction
Anatomy and Physiology Review of the GI System
Accessory Structures
Developmental Aspects of the Gastrointestinal System
Structural Gastrointestinal Disorders
Inguinal Hernia
Umbilical Hernia
Anorectal Malformations
Obstructive Gastrointestinal Disorders
Hypertrophic Pyloric Stenosis
Intussusception
Malrotation and Volvulus
Inflammatory Disorders
Peptic Ulcer Disease
Inflammatory Bowel Disease
Appendicitis
Meckel’s Diverticulum
Pancreatitis
Gallbladder Disease
Functional Gastrointestinal Conditions
Irritable Bowel Syndrome
Acute Diarrhea
Chronic Diarrhea
Vomiting
Constipation
Gastroesophageal Reflux and Gastroesophageal Reflux Disease
Hirschsprung’s Disease
Malabsorption Disorders
Lactose Intolerance
Celiac Disease
Short Bowel Syndrome
Hepatic Disorders
Biliary Atresia
Cirrhosis
Portal Hypertension
Nonalcoholic Fatty Liver Disease
Hepatitis
Abdominal Trauma: Injuries
17 Caring for the Child With a Cardiovascular Condition
Introduction
Review of the Heart and Normal Cardiac Function
Understanding the Heart Anatomy
Normal Flow
Physiology
Preload, Afterload, and Contractility
Prevention of Heart Disease in Children
Caring for the Child With a Cardiovascular Condition
Growth and Development
Congestive Heart Failure
Signs and Symptoms
Diagnosis
Collaborative Care
Education/Discharge Instructions
Congenital Heart Disease
Signs and Symptoms
Diagnosis
Collaborative Care
Segmental Classification of Congenital Heart Defects
Left-to-Right Shunt Lesions
Obstructive Lesions
Cyanotic Congenital Heart Defects
Conal-Truncal Defects
Complex Single Ventricle-Type Defects
Cardiac Diseases
Subacute Bacterial Endocarditis
Kawasaki Disease
Cardiomyopathy
Additional Cardiac Conditions
Cardiac Trauma
Hypercholesterolemia–Hyperlipidemia
Hypertension
Pulmonary Arterial Hypertension
Neurally Mediated Syncope
Long QT Syndrome
Rhythm Disturbances
Invasive Tests
Cardiac Catheterization
Angiography
Biopsy
Closure Devices
Opening Devices
Surgical Interventions
Pacemakers
Cardiac Transplantation
Nursing Care for the Child With a Cardiac Condition in the Hospital
Transferring the Stable Child to a Surgical or Medical Unit
Community-Based Nursing Care for the Child With a Cardiac Condition
Monitoring the Child at Home
Returning to School
Cardiopulmonary Resuscitation
18 Caring for the Child With an Immunological or Infectious Condition
Introduction
Anatomy and Physiology of the Immune System
The Body’s Defense
Congenital Immunodeficiency Disorders
Antibody Deficiency: B-Cell Disorders
Combined Deficiency T- and B-Cell Disorders
Phagocyte Defect Disorders
Complement Defect Disorders
Other Congenital Immunodeficiency Disorders
Human Immunodeficiency Virus (HIV [AIDS])
Signs and Symptoms
Diagnosis
Prevention
Collaborative Care
Autoimmune Disorders
Dermatomyositis
Hypermobility Syndrome
Allergic Reaction
Anaphylaxis
Infectious Diseases of Childhood
Infections
Viral Infections
Fifth Disease (Erythema Infectiosum)
Cytomegalovirus Infections
Herpes Simplex Virus
Herpes Zoster (Shingles)
Infectious Mononucleosis
Fungal Infections
Candida Albicans (Oral Thrush)
Fungal Infections
Bacterial Infections
Animal-Borne Infectious Diseases
Rabies
Cat Scratch Disease
West Nile Virus
Influenza Pandemics
Immunizations
Nursing Care
Resistant Organisms
Signs and Symptoms
Diagnosis
Prevention
Nursing Care
19 Caring for the Child With an Endocrinological or Metabolic Condition
Introduction
Anatomy and Physiology Review of the Endocrine System
Pathophysiological Conditions of the Endocrine System
Conditions of the Anterior Pituitary
Conditions of the Posterior Pituitary
Conditions of the Thyroid
Graves’ Disease
Conditions of the Parathyroid
Conditions of the Adrenals
Metabolic Conditions
Type 1 Diabetes Mellitus
Diabetic Ketoacidosis
20 Caring for the Child With a Neurological or Sensory Condition
Introduction
The Nervous System
Altered Level of Consciousness
Increased Intracranial Pressure
Signs and Symptoms
Diagnosis
Prevention
Collaborative Care
Seizure Disorders and Epilepsy
Signs and Symptoms
Diagnosis
Prevention
Collaborative Care
Inflammatory Neurological Conditions
Meningitis
Encephalitis
Reye’s Syndrome
Guillain-Barré Syndrome
Juvenile Myasthenia Gravis
Botulism
Developmental Neurological Conditions
Spina Bifida
Hydrocephalus
Cerebral Palsy
Neurological Injuries
Traumatic Brain Injury
Abusive Head Trauma
Spinal Cord Injury
Nontraumatic Neurological Conditions
Headaches
Sensory Conditions
Eye Disorders
Hearing Disorders
Language Disorders
Signs and Symptoms
Diagnosis
Prevention
Collaborative Care
21 Caring for the Child With a Musculoskeletal Condition
Introduction
Anatomy and Physiology Review of the Musculoskeletal System
Pediatric Differences in the Musculoskeletal System
Bones
Joints
Ligaments and Tendons
Muscles
Immobilizing Devices
Casts
Principles of Traction
Common Musculoskeletal Conditions in Children
Plagiocephaly
Craniosynostosis
Torticollis
Clubfoot
Metatarsus Adductus (Varus)
Developmental Dysplasia of the Hip (DDH)
Legg-Calve-Perthes Disease
Slipped Capital Femoral Epiphysis
Pectus Excavatum
Polydactyly/Syndactyly
Dislocated Radial Head
Soft Tissue Injuries
Sports Injuries
Osgood-Schlatter Disease
Fractures
Osteomyelitis
Juvenile Arthritis
Scoliosis
Kyphosis
Lordosis
Osteogenesis Imperfecta
22 Caring for the Child With an Integumentary Condition
Introduction
The Skin
Skin Lesions
Wounds and Wound Healing
Skin Infections
Overview of Common Skin Infections
Viral Infections
Hypersensitive Skin Reactions
Eczema and Dermatitis
Infestations
Pediculosis Capitis
Scabies
Bites and Stings
Insects
Lyme Disease
Rocky Mountain Spotted Fever
Cat Scratch Disease
Burns
Child Development and Burn Injuries
Burn Severity
Fluid Resuscitation
Prevention of Infection
Pain Management
Maintaining Circulation
Nursing Care for Minor Burns
Hypothermia
Signs and Symptoms
Diagnosis
Prevention
Nursing Care
Frostbite
Signs and Symptoms
Diagnosis
Prevention
Nursing Care
23 Caring for the Child With a Genitourinary Condition
Introduction
Anatomy and Physiology Review of the Kidneys
Fluid and Electrolyte Balance
Risk for Fluid and Electrolyte Imbalance
Types of Dehydration
Pathophysiology of Dehydration
Common Disorders of the Urinary System
Urinary Tract Infections
Vesicoureteral Reflux
Hematuria
Diagnosis
Glomerulonephritis
Hemolytic Uremic Syndrome
Nephrotic Syndrome
Structural Defects of the Urinary System
Exstrophy of the Bladder
Functional Disorders of the Urinary Tract
Dysfunctional Elimination Syndrome
Renal Trauma
Signs and Symptoms
Diagnosis
Prevention
Collaborative Care
Renal Failure
Acute Kidney Injury
Chronic Kidney Disease
Renal Replacement Therapy
Hemofiltration
Hemodialysis or Peritoneal Dialysis
Kidney Transplant
Prevention
Collaborative Care
Reproductive Disorders Affecting Girls
Vulvovaginitis
Labial Adhesions
Amenorrhea
Reproductive Disorders Affecting Boys
Varicocele
Cryptorchidism
Hypospadias and Epispadias
Testicular Torsion
Phimosis
24 Caring for the Child With a Hematological Condition
Introduction
Hematological System
Common Hematological Conditions
Anemia
Iron-Deficiency Anemia
Sickle Cell Disease
Thalassemia
Hemophilia
Von Willebrand’s Disease
Immune Thrombocytopenia
Aplastic Anemia
Neutropenia
Blood Transfusion Therapy
Blood Product Administration
Collaborative Care
Allergic Reaction
Bone Marrow Transplantation
Apheresis
Plasmapheresis
Erythrocytapheresis (Red Cell Exchange)
Leukapheresis (Stem Cell Collection or Leukodepletion)
25 Caring for the Child With a Cognitive or Psychosocial Impairment
Introduction
Culture, Diversity, and Health Disparities
Barriers to Child and Adolescent Mental Health
Mental Illness in Children
Anxiety
Post-traumatic Stress Disorder
Mood Disorders
Depression
Bipolar Disorder
Suicide
Schizophrenia
Common Pediatric Mental Health Disorders
Reactive Attachment Disorder
Attention-Deficit/Hyperactivity Disorder
Oppositional Defiant Disorder and Conduct Disorder
Maltreatment of Children
Signs and Symptoms
Diagnosis
Nursing Care
Substance Use and Abuse
Eating Disorders
Signs and Symptoms
Anorexia Nervosa
Sleep Disorders
Learning Disabilities, Cognitive Impairments and Developmental Disabilities
Learning Disabilities and Cognitive Impairment
Developmental Disabilities
26 Caring for the Child With Cancer
Introduction
Epidemiology
Physiology of Cancer
Pattern of Tumor Progression
Prevention of Common Childhood Cancer
Common Childhood Cancers
Leukemia
Solid Tumors
Bone Tumors
Lymphomas
Liver Cancer
Holistic Nursing Care of the Child With Cancer
Nutrition
Infection
Chemotherapy
Radiation
Surgery
Pain Control
Psychosocial Support
Nausea and Vomiting
Alopecia
Mucositis
Diarrhea and Constipation
Anemia
Thrombocytopenia
Neutropenia
Long-Term Effects of Cancer Treatments
Medical Emergencies
Hemorrhagic Cystitis
Tumor Lysis Syndrome
Septic Shock
Other Emergencies
The Psychological Impact of Pediatric Cancer
27 Caring for the Child With a Chronic Condition, Disability, or End-of-Life Care
Introduction
Prevalence of Chronic Conditions
Chronic Conditions and Technology
Effect of a Chronic Condition
The Child Living With a Chronic Condition
Nursing Care
Emotional Responses to a Chronic Condition
Nursing Care
Establishing a Therapeutic Relationship
Education for the Child With a Chronic Condition/Disability
Caring for the Child Receiving End-of-Life Care
Perceptions of Death
Before the Child Dies
Nursing Care
Palliative Care, Hospice Care, and End-of-Life Care
Grieving
Signs and Symptoms
Grief Theories
Coping Patterns
Saying Good-Bye
Nursing Care
The Sibling Says Good-Bye
Organ Tissue Donation
Online Only
UNIT 7
Women’s Health
28 Promoting the Safety of Women and Families
Introduction
Definition, Incidence, and Effect on Individuals and Society
Health Outcomes
Risk Factors
Types of Abuse
Physical Violence
Sexual Coercion
Psychological (Emotional) Violence
Isolation
Economic Abuse
Phases of Abuse
Tension-Building Phase
Acute Violence and Explosion Phase
The Honeymoon Phase
Victims’ Reactions to the Phases of Abuse
Special Populations
Pregnant Women
Older Populations
LGBTQI Communities
Immigrant Communities
Adolescents
Intimate Partner Violence Screening, Documenting, and Reporting
Screening for IPV
Trauma-Informed Care
Documenting IPV
Reporting IPV
Education and Counseling
Leaving an IPV Relationship
Treatment and Follow-Up
Sexual Violence
Assault History
Medical Treatment
Mental Health Care
Discharge Instructions
Mandatory Reporting
29 Promoting Premenstrual, Perimenopausal, and Menopausal Health
Introduction
Premenstrual Syndrome (PMS)
Phases of the Uterine (Endometrial) Cycle
Prevalence and Economic Effect
Symptoms of PMS
Premenstrual Dysphoric Disorder (PMDD)
Causes of Premenstrual Disorders
Diagnostic Criteria for PMS and PMDD
Patient Care and Management of PMS Symptoms
The Climacteric, Premenopause, Menopause, Perimenopause, and
Postmenopause
Symptoms of Menopause
Long-Term Effects
Promoting Comfort During the Menopausal Transition
Complementary and Alternative Medicine
30 Promoting Breast Health
Introduction
Anatomy of the Breast
Benign Breast Masses
Preventive Health
Clinical Breast Examinations
Breast Self-Awareness
Lifestyle Choices and Breast Health
Evaluating Breast Abnormalities
Biopsy
Testing for Estrogen and Progesterone Receptors
Evaluating Breast Symptoms
Nipple Discharge
Skin Changes
Breast Pain (Mastalgia)
Breast Cancer
Risk Factors
Demographics and Personal Health History
Lifestyle Factors
Gene Defects
Tumor Types
Indicators of Disease Prognosis
Breast Cancer Treatment
Cancer Recurrence
Nursing Care for Women Dealing With Breast Cancer
31 Promoting Reproductive Health: Various Gynecological Disorders
Introduction
Menstrual Disorders
Amenorrhea
Abnormal Genital Bleeding
Dysmenorrhea
Common Vaginal Infections
Bacterial Vaginosis
Candidiasis
Toxic Shock Syndrome
Endometriosis
Etiology, Pathogenesis, and Risk Factors
Signs and Symptoms
Diagnosis
Treatment Options
Implications for Nurses
Leiomyomas (Fibroids)
Signs, Symptoms, and Diagnosis
Treatment
Abnormal Uterine Bleeding
PALM: Structural Causes
COEIN: Nonstructural Causes
Treatment
Hysterectomy
Ovarian Tumors
Follicular Cysts
Corpus Luteum Cysts
Polycystic Ovary Syndrome
Diseases of the Vulva
Bartholin’s Gland Abscess
Parasites
Molluscum Contagiosum (Seed Wart)
Vulvar Condylomata
Vulvar Lichen Simplex Chronicus, Lichen Sclerosus, and Lichen Planus
The Nurse’s Role in Promoting Vulvar Health
32 Promoting Reproductive Health: Sexually Transmitted Diseases
Introduction
Chlamydia Trachomatis
Neisseria Gonorrhoeae
Pelvic Inflammatory Disease (PID)
Syphilis
Parasitic STDs
Trichomoniasis
Pediculosis Pubis
Scabies
Viral STDs
Human Papillomavirus (HPV)
Herpes Simplex Virus (HSV) 1 and
HIV/AIDS
Hepatitis
Hepatitis B Virus (HBV)
Hepatitis C Virus (HCV)
Hepatitis D Virus (HDV)
Chancroid
The Nurse’s Role in Fostering Reproductive Health Through STD Education
and Counseling
33 Promoting Reproductive Health: Common Reproductive Cancers
Introduction
The Cervix and the Cervical Transformation Zone
Cervical Cancer
Risk Factors
Symptoms
Screening and Early Detection
Management of Abnormal Cervical Cytology/Colposcopy Findings
Diagnostic Work-Up and Treatment of Cervical Cancer
Human Papillomavirus
HPV DNA Testing
Potential Manifestations of HPV Infection
The Nursing Role in Reducing Patient Risk of Cervical Cancer
HPV Vaccines
HPV Education and Counseling for Teens and Their Parents
Ovarian Cancer
Endometrial Cancer
Premalignant and Malignant Vulvar Lesions
Appendix A Centigrade to Fahrenheit Temperature Conversions
Appendix B Expected Temperatures in Children
Glossary
Photo & Illustration Credits
Index
UNIT 1
Foundations in the Nursing Care

of Maternal, Family, and Child
Care
CHAPTER 1
Core Concepts of Maternal and

Pediatric Health Care Across the
Continuum
KEY WORDS
Standards of practice
Nursing process
Nursing outcomes classification (NOC)
Nursing interventions classification (NIC)
Evidence-based practice
Beneficence
Nonmaleficence
Respect for autonomy
Justice
Family of origin
Family of choice
Nuclear family
Commune
Cohabitation
Forming
Storming
Norming
Performing
Adjourning
Epidemiology
Complementary and alternative health care/medicine (CAM)
Telehealth
INTRODUCTION
The scope and complexity of current health problems continue to
present formidable challenges for nurses, and roles and
responsibilities within the profession are often evolving. There is no
room for complacency in nursing’s future. Nurses must constantly
keep up with the exponential growth of information, evidence-based
knowledge, and technological advances. At the same time, our
profession is likely to deal with ethics questions that have never
been faced before. The growth and diversity of the population, both
in the United States and globally, will require more cultural sensitivity
than ever before. The continual threat of chronic diseases demands
creative, holistic approaches. Infectious disease threats will continue
to challenge health-care resources at the national and international
levels. Natural and man-made disasters will tax the nation’s systems
to their fullest extent.
Nurses must extend their caring work beyond individual patients
and families to communities, sociopolitical systems, and national and
global health arenas if they are to have a significant effect on health
promotion. Nurses are at the forefront of working with patients and
families through societal, economic, and cultural issues while
examining the health disparities that create barriers to physical and
mental health care.
NURSING ROLES
The Institute of Medicine (IOM), known as the National Academy of
Medicine (NAM) as of 2015, concludes that a higher level of nursing
education decreases negative patient outcomes. In its 2011 report
The Future of Nursing: Leading Change, Advancing Health, IOM
predicted that 80% of the nursing workforce would have a BSN by
2020.
This report recommends for nurses at all levels obtain advanced
education, especially encouraging nurses with a diploma or
associate’s degree to continue their education for a bachelor’s
degree. The dynamic health-care system and the increase in
complexity of care necessitate highly educated nurses.
The IOM also established specific recommendations to achieve
these goals:
■ Require nursing schools to offer seamless pathways to higher
education
■ Encourage health-care organizations to actively encourage and
provide incentives for diploma and ADN nurses to obtain a BSN
within 5 years of graduation
■ Engage private and public stakeholders to provide more
opportunities for funding and expansion of programs to increase
students
■ Increase state, federal, and local funding for second-degree
nursing students (Institute of Medicine, 2011)
As nursing students, you will be thrust into settings in which you
have to grapple with the health and safety of your patients in various
settings, especially in maternal/child settings. As future nurses, we
must ensure that these systems are working for our patients, not
against them. Take advantage of opportunities in your clinical
settings to bring about change with a positive approach to patient-
centered care. Although it is not always easy to find out the things
you need to know about your patients, being a good communicator is
key to becoming a good nurse.
Student nurses should develop critical thinking and leadership
skills they can apply not only at the bedside but across all health-
care settings and systems to provide patient-centered, evidence-
based health care while improving quality, access, and value.
Nurses who pursue leadership through advanced degrees can
take a range of possible pathways (Table 1-1).
STANDARDS OF PRACTICE
Standards of practice are guidelines that determine the scope and
practice of nurses. The state nurse practice act of each state is the
most important law that affects nursing practice. Each nurse practice
act protects the public by defining the scope of nursing. States
create a board of nursing charged with creating rules and regulations
for nurses. Other laws may also have aspects that regulate nursing
practice. For example, reporting laws oblige nurses who witness the
abuse of a child, elderly person, or disabled individuals to report the
incident to the appropriate agencies. Another example is the federal
Health Insurance Portability and Accountability Act (HIPAA) that
requires nurses and other individuals to adhere to certain rules and
regulations when sharing patients’ health-care information with
others.
Aspects of state nursing practice acts include:
■ Definitions
■ Authority, power, and composition of a nursing board
■ Educational program standards
■ Standards and scope of nursing practice
■ Types of nursing titles and nursing licenses
■ Protection of titles
■ Requirements for licensure and relicensure
■ Grounds for disciplinary action, other violations, and possible
remediations
NURSING PROCESS
The nursing process was developed as a framework of systematic
problem-solving and actions for nurses to use in identifying,
preventing, or treating the individual health needs of patients
(American Nurses Association, 2017). The nursing process was
problem-oriented, goal-directed, and involved critical thinking and
decision making (Fig. 1-1). It provides the foundation of the
profession and guides the nurse in helping the patient and family
choose appropriate interventions, providing care, and quantifying
and evaluating the chosen outcome goal. The five steps of the
nursing process include assessment, diagnosis, planning,
implementation, and evaluation (American Nurses Association,
2017).
The assessment is a continuous, systematic data collection that
includes vital signs, head-to-toe examination, health history, and
medical record chart review. The nurse then takes all this data and
formulates a nursing diagnosis. The North American Nursing
Diagnosis Association (NANDA) developed a list of standardized
nursing diagnoses used by the nurse. These individualized patient
care plans express the nurse’s assessment findings, diagnosis, and
plans of action to other caregivers. By using the NANDA
International Nursing Outcomes Classification (NOC) and
Nursing Interventions Classification (NIC), the nurse can make
clear associations between interventions and outcomes. Using these
standards also helps nursing students and novice professionals
develop the intellectually and technically complex competencies to
link assessment cues accurately with outcomes and interventions.
TABLE 1-1
Nursing Roles in Maternal, Child, and Family Health
TYPE OF EDUCATIONAL MATERNAL, CHILD, AND
NURSE PREPARATION FAMILY HEALTH CLINICAL
AREAS
Registered Someone who has graduated Registered nurses found
Nurse from an accredited nursing working in hospital settings
program and has successfully include labor and delivery,
passed the national licensure postpartum, outpatient clinics,
examination. Accredited gyn clinics, and home care.
programs may have one of the
following graduation degrees:
associates degree, bachelor’s
degree, or diploma.
Clinical Nurse Someone who has graduated Clinical nurse specialists will
Specialist from an accredited school with focus in a specific area of health
advanced training and care, which can include specific
education earning a master’s patient populations, such as
degree in nursing. maternity or pediatrics, or
specialize in a specific health-
care problem (i.e., breastfeeding
clinical nurse specialist) or
specialize in a specific setting
(i.e., postpartum).
Certified-Nurse Someone who has graduated Certified nurse midwives’ scope
Midwife from an accredited midwifery of practice includes patients
school and has passed the from adolescents, during
national certification test earning pregnancy, birth, postpartum,
a master’s degree or higher in and menopause, and includes
nursing or public health. care of infants from birth to 1
month of age. CNMs work in a
variety of settings including
hospital, birth centers, and
home care. CNMs may work
collaboratively with physicians
or autonomously depending on
state laws.
Family Nurse Someone who has graduated Certified FNP works in a variety
Practitioner from an accredited Family of clinical settings such as
Nurse Practitioner program and hospitals and outpatient clinics.
has passed the national FNP may work collaboratively
certification test earning a
master’s degree or higher in with physicians or autonomously
nursing. depending on state laws.
Pediatric Nurse Someone who has graduated Certified PNP works in a variety
Practitioner from an accredited Pediatric of clinical settings such as
Nurse Practitioner program and hospitals and outpatient clinics.
has passed the national PNP may work collaboratively
certification test earning a with physicians or autonomously
master’s degree or higher in depending on state laws.
nursing.
Women’s Someone who has graduated Certified WHNP works in a
Health Nurse from an accredited Women’s variety of clinical settings such
Practitioner Health Nurse Practitioner as hospitals and outpatient
program and has passed the clinics. WHNP may work
national certification test earning collaboratively with physicians
a master’s degree or higher in or autonomously depending on
nursing. state laws.
FIGURE 1-1 Traditional nursing process.
The planning phase involves establishing priorities to identify and

address the patient’s health needs and goals in cooperation with the
patient and family. Nurses should help patients develop both short-
term and long-term goals that are realistic and measurable. After
each patient evaluation, the nurse decides whether an intervention
should continue, be discontinued because it has succeeded, or be
discontinued and replaced with a potentially more effective
alternative.
Nursing interventions are more than the actions nurses take to
help patients and families toward their desired outcome. Nursing
interventions must be appropriate for both the selected nursing
outcomes and diagnoses. They require comprehensive, preliminary
assessment of patient and family strengths and health concerns;
communication with the patient and family about the acceptability of
the chosen interventions; and the ability to coordinate with the
patient, family, and other health-care providers to help the patient
fulfill the chosen health outcomes.
Before nurses choose nursing interventions, they must identify
clear, appropriate, feasible outcomes and determine whether the
patient and family agree with these targets. Just as nursing
interventions are more than the sum of outcome-directed actions,
outcomes are more than the ultimate end goal of the health state.
Outcomes are dynamic and demand frequent measurement of the
responsiveness of the chosen interventions. Outcomes should be
evaluated for continuing meaningfulness, both physiologically and
personally; for direction and purpose, whether health restoration,
maintenance, promotion, or threat prevention; and for consistency
with the culture and lived experience of the patient and family.
It is not always easy to learn the things you need to know about
your patients; many times, it is even harder to tell them about things
that are happening to them, especially the difficult things. As nurses,
we spend the majority of time with our patients, especially in
maternal and pediatric settings. Our patients and their families rely
on us to explain the plan of care or decipher what the doctor just told
them. Often, psychosocial issues are the least clear-cut but the most
relevant to the patients and families. Nurses lead the way in dealing
with the emotional and social aspects of caring for a patient.
ANA CLINICAL PRACTICE GUIDELINES

Ethical Considerations
Life and death decisions are a part of nursing, and ethics are
therefore fundamental to the integrity of the nursing profession.
Every day, nurses support each other to fulfill their ethical obligations
to patients and the public, but in an ever-changing world, there are
increased challenges (ANA, 2019). Ethics and human rights are
addressed in health care in various ways including at a hospital level
with an Ethics Board up to the state and national level through policy
development. Practicing nurses should understand the policies at
their hospital and how to address ethical concerns through the ethics
board. To this end, the American Nurses Association (ANA), for the
last 25 years, has made its mission to address issues in ethics and
human rights at the state, national, and international level (ANA.org,
2019). In addition, the ANA issues a yearly report addressing ethical
issues faced by nurses at all levels. This report attempts to address
the long-range objectives regarding ethics and human rights.
Nurses in maternal child nursing often utilize a family-centered care
(FCC) model. As a philosophy of care, FCC and the related term
patient-centered care (PCC) have been recognized by multiple
medical societies, health-care systems, state and federal legislative
bodies, the IOM, and Healthy People 2030 as integral to patient
health, satisfaction, and health-care quality (Dall’Oglio et al, 2018).
Evidence-Based Practice
Evidence-based practice is the process health-care professionals
use to find, critically appraise, and apply the best available health-
care evidence. This process allows nurses and other providers to
integrate personal expertise with a systematic research. It involves
finding and selecting resources, research, and policies that relate to
the area of interest. Sources of evidence can be journal literature,
books, conferences, dissertations, unpublished scientific papers,
government reports, policy statements, laws, regulations,
surveillance data, and expert opinion. An evidence-rating system can
help providers choose the best available literature about a given
topic:
■ Level I: Evidence from systematic review, randomized control trials
(RCTs), or evidence-based reviews
■ Level II: Evidence from one well-designed RCT
■ Level III: Evidence from well-designed studies without
randomization
■ Level IV: Evidence from other types of studies including case-
control and cohort studies
■ Level V: Evidence from systematic reviews of descriptive and
qualitative studies
■ Level VI: Evidence from one descriptive or qualitative study
■ Level VII: Evidence from the opinion of authorities and/or reports of
expert committees
The PICO(T) question is a systematic process health-care
providers can use to construct a clinical question to address
evidence-based practice. PICO(T) stands for population,
intervention/indicator, comparison/control, outcome, and time. The P
should be limited to a specific patient population or subgroup of the
population of interest. The intervention encompasses the planned
study activities. The comparison group provides a means to compare
the intervention group, whether a control group or a group receiving
a different intervention. Outcomes describe the effect of the
intervention in terms of specific health outcomes, vital signs, or
patient behaviors.
Evidence-based research requires the practitioner to possess a
strong foundation in research methodology and the pathological or
physiological process being investigated so he or she can critically
analyze the findings. The link between poverty as a risk factor and
the health outcomes of obesity, violence, asthma, lead poisoning,
substance abuse, teen pregnancy, and mental disorders has been
demonstrated through epidemiological, controlled quantitative and
qualitative studies and nursing research. Nurses and others
interested in improving the health of these vulnerable groups have
taken research findings and developed evidence-based practices
that promote, prevent, and protect health behaviors in vulnerable
populations.
Scientific literature helps nurses not only stay current in their
technical clinical abilities but also choose the most effective
interventions. Professional organizations such as Association of
Women’s Health, Obstetric and Neonatal Nurses (AWHONN),
Society of Pediatric Nurses (SPN), ANA, National Association of
Pediatric Nurse Associates and Practitioners (NAPNAP), American
College of Nurses Midwives, National Association of Neonatal
Nurses (NANN), and Emergency Nurses Association (ENA) are just
some of the organizations that have developed evidence-based
clinical practice guidelines for the safest, most consistent, and
effective provision of family-centered nursing care. Not only are
these evidence-based practice guidelines beneficial to the individual
nurse’s practice, they can also be used by the nurse to advocate for
change at the institutional level.
With an ever-increasing level of patient knowledge and health-
seeking sophistication, the demand for higher-level nursing
knowledge quickly becomes apparent. Nurses are responsible for
many important judgments and decisions every day and therefore
must understand how to evaluate and use research literature as part
of their clinical decision-making. An understanding of the “pyramid of
evidence” will lead the nurse to appreciate the strengths and
weaknesses of research studies and identify which levels of
research are more reliable (Fig. 1-2).
Evidence-based guidelines are available for a number of
interventions. The nurse must be diligent in seeking these out so that
excellence in practice can always be achieved, measured, and held
up for scrutiny. In addition, nurses should remember that evidence-
based practice is not “best practice” until it combines the
investigational guidelines and scientifically sound interventions with
clinical expertise and the patient’s values and preferences.
FIGURE 1-2 Pyramid of Evidence.
The Nursing Process and Evidence-Based Care

Evidence-based practice constantly questions the status quo and
focuses on the outcome rather than the process of treatment. It
helps to take the nursing process to the next level, from treating
illness to predicting and preventing health problems, complications,
and risks. A nurse using the traditional nursing process of assess,
diagnose, plan, implement, and evaluate most likely uses some form
of a body systems approach to data collection, focused primarily on
medical systems’ health problems. A nurse practicing from an
evidence-based focus assesses health risk factors; patient and
family strengths and self-worth; learning needs; family role and
relationship patterns; values, cultural beliefs, and spiritual health;
and patient perception of or response to the risk or problem, in
addition to the medical body systems assessment.
The evidence-based nurse makes a clinical judgment about
existing health problems and can also predict potential problems
based on knowledge of prior research. Evidence-based knowledge
includes awareness of signs, symptoms, and related health factors
as well as a grounded understanding of their etiology. The use of a
concept map, clinical pathway, or care map can aid the nurse in this
awareness of relationships and help him or her prioritize diagnoses
or directing care pathways.
Like the traditional nursing process, building the concept map
involves five steps that help nurses analyze the relationship of data
to the health problem and develop critical thinking skills.
First, the nurse should draw a skeleton diagram with the medical
diagnosis placed in the center and the nursing diagnoses, patient
responses, or general impressions of health threats surrounding the
medical diagnosis (Fig. 1-3). At this point in the map development,
potential problems are yet to be addressed. The initial focus is on
problems that are currently major issues in maintaining wellness.
FIGURE 1-3 Concept map construction begins with gathering and

analyzing assessment data.
For step 2, the nurse gathers and categorizes the assessment

data under one or more of the identified patient problem areas (Fig.
1-4). Then he or she describes the essential ongoing assessment
data that signifies improvement or deterioration in the health status
of the primary medical diagnosis (Fig. 1-5).
Step 3 of the map involves analyzing the relationships among the
data and prioritizing the patient responses that led to the nursing
diagnoses. The problem or diagnosis with the most supporting data
is usually the most important aspect of this step (Fig. 1-6).
Step 4 requires the nurse, along with the patient and family, to
develop the beneficial goals and outcomes they hope to attain. This
step corresponds to the planning phase of the nursing process. The
outcomes drive the selection of interventions to be initiated by the
nurse, patient, and family and other caregivers. They should
describe the assessment data that determine whether there has
been successful progress toward achieving goals. The outcomes
should address clinical health (the medical diagnosis, signs, and
symptoms), functional health (mind-spirit-emotions), quality of life (as
defined by the patient/caregiver), health risk reduction, health
protection, health promotion, therapeutic relationships, and personal
satisfaction.
Whether the nurse uses Maslow’s hierarchy of needs (Fig. 1-7) or
a professional theorist to determine the priority status of outcomes
and interventions, it is important to recognize that the context or
circumstances of health problem plays a key role in prioritization and
implementation. When the previous steps are completed, it becomes
much easier to choose interventions that can be achieved within the
time and environmental constraints of the health event and that build
on the strengths of the patient and family.
Step 5 of the map is the evaluation of the patient’s response to the
health event, interventions, and progress toward the outcome goals.
Evaluation is not a one-time nursing responsibility but an ongoing
process. The nurse is looking for a pattern of patient responses to
the health event that should guide ongoing reassessment, planning,
and provision of safe and effective care. Concept mapping helps the
nurse develop disciplined, critical thinking that promotes accuracy,
depth of data collection, early identification of risks, realistic goals,
and a broader understanding of patient health problems.
BUILDING A TRUSTING NURSING-PATIENT

RELATIONSHIP
Achieving a trusting relationship with each patient is an essential
aspect of the nurse’s role that enhances patient care, the patient
experience, and patient health outcomes. A key component to
establishing a trusting nursing-patient relationship is open
communication skills. Open communication allows patients to open
up to the nurse and disclose essential information that may be
important to their overall health. For example, patients who are in
human trafficking situations often do not openly disclose this to
health-care providers in fear of retaliation. Research shows that
nurses who employ therapeutic communication skills that are open
and caring can help patients who may be trapped in human
trafficking situations (Scannell & Conso, 2020). Nurses who take the
time to establish positive communication with patients will gain a
better understanding of their needs.
FIGURE 1-4 Categorizing the assessment data.

FIGURE 1-5 Identifying essential assessment data to evaluate the
health status.
FIGURE 1-6 Analyzing relationships and prioritizing patient

responses.
FIGURE 1-7 Maslow’s Hierarchy of Needs.
CLIENT RIGHTS
Rights to Privacy
The federal regulation known as The Emergency Medical Treatment
and Active Labor Act (EMTALA) was created to ensure that all
women receive emergency treatment or active labor care whenever
such treatment is sought. Under the EMTALA regulation, true labor is
considered an emergency medical condition. Nurses working in a
birthing unit must be familiar with the full range of responsibilities
included in the EMTALA regulations: (1) provide services to pregnant
women when an urgent pregnancy problem such as labor, rupture of
the membranes, decreased fetal movement, or recent trauma is
experienced and (2) fully document all relevant information to include
assessment findings, interventions implemented, and the patient’s
response to the care provided. Any pregnant woman who presents
to an obstetric triage must be treated as if she is experiencing “true
labor” until a qualified health-care provider determines that she is not
in labor (American College of Obstetricians and Gynecologists,
2020).
The ENA Position Statement on obstetrical emergencies advises
hospitals and emergency departments to develop policies and
procedures in compliance with EMTALA (Emergency Nurses
Association, 2017). Recommendations include disaster planning that
accounts for pregnant (antepartum), postpartum, and newborns;
plans for births that occur as emergencies outside of labor and
delivery units; and policies that prevent delay or denial of care for
obstetrical patients based on social or economic status or on nature
of health problem (Emergency Nurses Association, 2017).
An Ethical Framework for Professional Practice

Nurses study ethics and learn about the ANA Code of Ethics for
Nurses (ANA, 2001). This code has been established for more than
25 years and guides nurses in a code of ethics. Nurses learn that
they must display good moral character and act for the benefit of the
public. According to the Code, a nurse has the freedom to express
an informed personal opinion while upholding professional and moral
boundaries (ANA, 2018). Throughout their careers, nurses are
intimately drawn into daily encounters with other humans and as a
result often face difficult legal and ethical concerns involving the
Patient’s Bill of Rights, informed consent, confidentiality, pain relief,
and end-of-life care.
Four basic principles are commonly used to help solve ethical
dilemmas: beneficence, nonmaleficence, respect for autonomy, and
justice or fairness. Beneficence means acting for the patient’s
benefit. Nonmaleficence is known best by the saying credited to
Hippocrates: “First, do no harm” or “Primum non nocere” in Latin.
Respect for autonomy means that patients have a right to make
decisions about themselves and the right to have the information that
is needed to make certain decisions. Justice or fairness means that
all patients should be treated equally. The problem is that it is not
unusual for those principles to conflict. For example, beneficence
and respect for autonomy are clearly in conflict.
Many health-care settings have bioethics committees that confront
the more difficult ethical problems, and some individual health
systems such as the Veterans Health Administration have
established a mandate requiring ethical consultation committees.
Nurses are often asked to sit on interdisciplinary committees that
usually include clergy, attorneys, social workers, physicians, ethics
consultants, and advocacy organizations. Discrimination should not
occur based on social or economic status, religion, culture, or type of
illness.
Nurses also have an ethical duty to address aspects of
discrimination they witness or observe. The ANA recognizes that
discrimination can occur within the health-care setting and directly
contributes to health-care disparities (American Nurses Association,
2018). The ANA encourages nurses to reflect upon their own biases
and their own personal and professional values regarding civility,
mutual respect, and inclusiveness. This allows the nurse to gain a
better understanding of internal biases to help foster safe patient
care (American Nurses Association, 2018). Nurses can be
champions in improving discriminatory practice by advocating for
policies and practices at all levels that embrace inclusivity, civility
and mutual respect for all people, including patients, families, as well
as fellow colleagues (American Nurses Association, 2018).
Implications of the Health Insurance Portability and

Accountability Act (HIPAA)
HIPAA was passed in 1996. It has several components, including
procedural mandates (Title II) designed to protect the privacy of an
individual’s health information. The portability component (Title I)
ensures that a person moving from one health plan to another will be
able to continue his or her insurance coverage. Expanded federal
sanctions attached to health-care fraud are also included in the
HIPAA law. The American Recovery and Reinvestment Act of 2009,
which includes the Health Information Technology for Economic and
Clinical Health Act (HITECH), also has provisions to address health
information technology for economic and clinical health. It is aimed at
enhancing health care while promoting electronic health records
(EHRs) and electronic transactions.
When passed, HIPAA resulted in a flurry of modifications to entire
health-care systems. Many office settings were required to
reorganize their sign-in procedures. Others had to rebuild patient
interviewing spaces, install expensive computer safeguarding
mechanisms, supply units with paper shredders, and extend
continuous training to employees. With this law, patients clearly have
the right to protected health information (PHI). The consequences for
breaking a HIPAA law can include both civil and criminal charges.
Courts can impose substantial fines and even imprisonment if a
patient’s health information is knowingly disclosed.
Nurses frequently have ready access to confidential patient data;
extreme vigilance is required. Addresses, telephone numbers,
occupations, and e-mail addresses need to be protected, along with
the patient’s medical history, diagnosis, and condition. Nurses must
be particularly cautious with conversations that take place in public
places such as elevators and lunchrooms. Communication needs to
be limited to only those who need to know the specific information to
provide care for the patient.
Malpractice
Malpractice is a specific type of negligence applied to health-care
professionals, including nurses, who cause harm by failing to provide
a patient with the standard of care. A valid malpractice claim requires
the patient to prove four elements: duty, breach of duty, causation,
and damages. Duty indicates that the nurse and patient engaged in
a professional relationship in which the nurse had a duty to provide
nursing care. The care delivered should meet the standard of care
established by state practice acts, national treatment guidelines,
and/or institution policies and protocols. Breach of duty occurs when
the nurse has failed to provide health care that met these
established standards. Causation means that the breach of duty
caused the patient’s injury, which in turn directly resulted in financial
damages. Malpractice in obstetrics often results in higher financial
damages than malpractice in other specialty areas (Glaser et al,
2017).
Preventable errors may occur because of a breakdown in
communication between a health-care provider and patient or
between two health-care providers. These communications can
occur in verbal as well as digital communication, such as over e-
mail. In addition to communication errors, malpractice may include
errors of omission, in which the health-care provider failed to perform
a necessary action, and errors of commission, which means doing
the wrong thing or doing the right thing in the wrong way.
Nurses must safeguard against these areas to reduce their risk of
malpractice. Some key safeguards are knowing provisions of the
State Practice Act and regulatory laws of the specific State Board of
Nursing. Follow established national and organizational guidelines.
Know the specific policies and procedures of the health-care
institution where they are working. Employ specific documentation
techniques, such as using direct quotes to accurately document
patient needs, progress or change in conditions, therapies and
outcomes, and general observations and assessments. Other
documentation must include the completion of discharge planning
information and patient education and validation that the patient
understood the information.
Abortion Services
Health policy decisions always involve choices, and whenever there
are choices to be made, values and the potential for values conflicts
are involved. One of the most polarizing political debates in modern
times concerns the issue of abortion. Throughout the years since the
passage of Roe vs. Wade, “abortion has kept its grip on the
American imagination … dividing the body politic on issues of control
of women’s bodies, rights to privacy, fetal viability, and broader
concerns over the moral shape of our country …” (Ginsburg, 1998,
p. ix).
How and where a nation spends money has a major influence on
the overall health of the population.
THE FAMILY UNIT

The nurse can best promote FCC by:
■ Establishing therapeutic communication with the patient and family
■ Developing relationship-centered, patient-focused encounters
■ Discussing the concept map/(plan of care) with other caregivers
■ Designating discharge planning needs and personnel in the
concept map
■ Consulting with the case manager when evaluating the concept
map outcomes
■ Investigating evidence-based practice from all healthcare
disciplines (e.g., medicine, nursing, pharmacology, respiratory
therapy, primary school education, criminal justice, and social
sciences)
Types of Familiess
The family is widely defined by many different sources reflective of
the social, biological, and legal domains. Various definitions describe
members who compose the family, their interdependence, and
methods of interaction. A family consists of two or more members
who self-identify as a family and interact with and depend on one
another socially, emotionally, and financially. Most often, family
structure involves either the family of origin (the family that reared
the individual) or the family of choice (the family adopted through
marriage or cohabitation). A single person belongs to a family of
origin but may choose not to become a member of a family of
choice. A single individual cannot constitute a family. Instead, most
definitions of family include a prerequisite of at least one other
person who is self-defined as being a part of the family.
In contemporary society, the traditional nuclear family, which
consists of a male partner, female partner, and their children, actually
represents only a small number of families. There are many
variations of family and household structures. Other family members,
termed extended family, may also live in the same household, such
as grandparents living in the home and helping raise the children
(Fig. 1-8). The married-blended family, formed as a result of death or
divorce, consists of unrelated family members who join to form a
new household. It could also include a teenager who becomes a
parent and is living with their infant and parents. A single-parent
family includes an unmarried/divorced/separated individual with a
biological or adopted child. A grandparent family is one in which one
or both grandparents are raising the child because the biological
parents are not involved due to other circumstances (Fig. 1-9). A
commune is a group of men, women, and children. Cohabitation,
or domestic partnership, describes an unmarried man and woman
who share a household and may or may not have children together,
or from other previous relationships living together; a same-sex
family (lesbian, gay, bisexual, or transgender) consists of same-sex
partners who live together with or without children (Fig. 1-10), and a
no-parent family is one in which children live independently in foster
or kinship care, such as living with a grandparent or aunt (Shah,
Kennedy, Clark, Bauer, & Schwartz, 2016).
FIGURE 1-8 Extended family.
FIGURE 1-9 In some families, grandparents raise their grandchildren

when the parents cannot.
Family Theories and Development Frameworks
Development of a specialized body of knowledge provides the
foundation for a profession. Although nursing theories and models
are essential in defining nursing and nursing practice, theories from
other disciplines provide insights into other dimensions of health and
human behavior. For example, family theory, which draws from a
number of related disciplines, helps guide assessment and
intervention within a holistic framework that views the entire family as
client. The following discussion presents several theoretical models
representing a cross section of useful concepts to assist in nursing
assessment and facilitate a creative application to family
interactions.
Family Systems Theory

A systems approach to understanding the family centers on the
recognition that changes that occur in one member affect the entire
family. The family systems theory, which views persons as “open
systems,” has a central theme: “The sum of the parts is greater than
the whole.” According to this theory, the family shares a unique
identity that is far more complex than that of its collective members.
The family is dynamic, constantly adjusting to information that filters
in from the surrounding environment and from within the family.
When working with families, the nurse uses the family systems
theory to “view the family as a unit and focus on observing the
interaction among family members rather than studying family
members individually.”
Patterns of family communication reveal much about family
functioning. In addition to providing information about “who is saying
what and to whom,” they also convey information about the structure
and functions of family relationships in relation to the power base,
decision-making processes, affection, trust, and coalitions.
Dysfunctional communication inhibits healthy nurturing and
diminishes personal feelings of self-esteem and self-worth.
FIGURE 1-10 LGBTQ families often decide to raise children
together.
The nurse or family therapist assesses a repeating negative

pattern such as excessive drinking to determine whether it has been
replaced by assertive yet supportive and positive communication.
For example, a wife complains to the nurse that her husband drinks
more whenever they have an argument about their children. The
husband notes that his wife complains to him about the children
whenever he tries to relax by drinking. The nurse educates the family
that interventions regarding either the arguing or the drinking could
help to break the pattern of negative communication and refers them
to a support group or a counselor to learn new patterns.
Group Theory
Group theory can be applied to the family as a group. Norms (rules
of conduct), roles, goals, and power structure are inherent family
concepts along with the division of household chores, expectations
of completed homework, and curfew enforcement. According to
group theory, stages of groups (forming, storming, norming,
performing, and adjourning/terminating) explain expected behaviors
that occur in any given stage.
Forming describes the beginning phase of the group. In families,
the forming stage usually occurs through marriage or cohabitation.
Storming, the next stage, is the disordered time of confusion or
chaos when two or more distinct personalities discover their
differences. Norming describes how groups (or families) adjust to
individual members by applying rules and procedures that the
members agree to follow. Performing is the ideal stage in which the
group (i.e., the family) accomplishes their goals and produces
results. In the family, desirable results would include good
citizenship, education and health of its members, and active
contribution to society. Adjourning, or terminating, represents the
final stage in a group when it has accomplished its goals and
disbands to possibly form a different group. Families experience this
stage when members die, divorce, or leave the family to begin their
own families.
Because families represent long-term relationships anchored in
the performing stage of meeting goals and taking care of one
another, the stages tend to be more stable than with groups.
Forming occurs when a child is brought into the family by birth or by
adoption. Storming describes the emotional clashes that occur
during times of transition (e.g., an adolescent testing the rules) or
crisis (e.g., adjusting to a move or job change). Norming generally
occurs when parental rules are imposed. For example, family
norming may involve teaching the children to talk more softly inside
the house than when playing in the yard. Performing occurs as each
family member performs specific duties to accomplish the daily tasks
of life. Adjourning or termination may follow a death in the family or
the launching of a high school graduate into college. The healthy
family adjusts for the loss and resets roles and norms to fit the new
family structure.
Bowen Family Systems Theory

Bowen family systems theory is a human behavior theory that views
the family as an emotional unit and uses systems thinking to
describe the complex interactions within the family unit, according to
the Bowen Center for the Study of the Family. The theory is useful
when identifying family problems or challenges rooted in family
processes such as communication, connecting between members,
and teaching values. The nuclear family emotional system describes
the pattern of adaptive/maladaptive emotional expression that exists
as a theme in the family. According to this theory, one family could
be characterized as stoic or cold in their interactions with others,
whereas another is described as emotional and highly reactive to
situations and circumstances.
According to Bowen, differentiation of self is demonstrated when a
family member breaks away from the learned emotional system and
instead expresses emotions that differ from the learned family
pattern. For example, a father whose family of origin is
nondemonstrative of love and caring may openly hug and kiss his
spouse and children and verbally express his love for them. In an
emotional cutoff, a family member has separated from the original
family pattern in a dramatic and sometimes permanent way. This
may occur when a family member who was reared in a dysfunctional
family chooses not to perpetuate the learned pattern of alcoholism or
abuse.
Family systems theory also views birth order as a predictor of
certain behavior patterns that may be desirable or conflicting
depending on the birth order of the chosen mate. A firstborn child
with behaviors related to high responsibility and control may clash
with a spouse who is also a firstborn. The “baby of the family”
(youngest sibling) may seek out a spouse who was a firstborn to
serve as a caretaker.
With the family systems approach, most interactions take place in
the form of a duo or dyad. Triangulation occurs when the dyad
diverts attention away from its own conflict by focusing on a third
person such as the child, teacher of the problem child, or police
officer who comes into a domestic disturbance. Police, nurses, and
counselors have often taken the displaced anger of a couple they
are trying to help and instead unwittingly become the third part of a
triangle.
The multigenerational transmission process describes how one
learns or transmits family emotional systems across generations.
Watching grandparents express affection teaches patterns to
grandchildren who will model similar behaviors to their own children
(unless self-differentiation or an emotional cutoff changes the
pattern). Family projection process is how and what children are
taught. Societal regression describes patterns of the family
projection process that exist in cultures as part of a dominant theme.
Parenting Styles
Parenting is a significant aspect of the function of a family unit.
Psychologists generally recognize four parenting styles (Shah et al,
2016). Diana Baumrind, a developmental psychologist, first created
this framework in the 1960s through her research at the University of
California, Berkeley. She conducted a series of studies that looked at
people’s approach to parenting based on the demands they placed
on their children and their responsiveness to their kids’ needs, and
identified three primary parenting styles; a fourth parenting style was
added later (Box 1-1).
These four parenting styles—which still form the foundation for
much of today’s research into childhood development—represent a
broad spectrum of behavior that explains how most parents care for
their kids. Of course, every parent-child relationship is unique, and
every day is different, but understanding Baumrind’s parenting styles
helps the pediatric nurse to better identify the needs of the parent-
child dynamic and better support the patient and family needs to
improve outcomes of care.
CULTURAL PRACTICES
It is important for the nurse to be aware of and respect cultural
variations that may exist in family structure and communication
styles. Developing cultural sensitivity enables the nurse to appreciate
the views, practices, and beliefs of people from different nationalities,
ethnicities, religions, and cultural groups (Venes, 2021). Many
cultures emphasize the extended family to a much greater extent
than the traditional American nuclear family.
Communication Patterns
Patterns of communication vary among populations. Cultural
customs may guide selection of the family member who will be
designated as the primary historian in a health-care interview. When
planning interventions, it is important to consider the cultural role of
the family member who makes the primary decisions.
In all care settings, nurses should use the services of
professionals who can interpret word meanings correctly. Relying on
family members often results in literal translation of words and
omission of information—problems that create confusion and
misunderstanding. In settings where professional interpreters are not
available, the use of services such as an international thesaurus, or
handheld personal information devices, can be useful alternatives.
BOX 1-1
Types of Parenting Styles

Authoritarian Parenting Style: Authoritarian parenting is a strict style in which
parents set rigid rules and high expectations for their children but don’t allow
them to make decisions for themselves. When rules are broken, punishments
are swift and severe.
Authoritative Parenting Style: Authoritative parents provide their children with
boundaries and guidance but give their children more freedom to make
decisions and learn from their mistakes.
Permissive Parenting Style: Permissive parents give their kids very few limits
and have more of a peer relationship than a traditional parent-child dynamic.
They’re usually super-responsive to their kids’ needs (think helicopter parent)
and give in to their children’s wants.
Neglectful Parenting Style: A style added later by researchers Eleanor
Maccoby and John Martin, neglectful parents don’t interact much with their kids,
placing no limits on their behavior but also failing to meet their children’s needs.
(Kuppens & Ceulemans, 2019).
Feeding Practices
Culture plays an important role in infant feeding. For immigrants who
are new to the United States maintaining traditional meals, customs,
and food preparations can sustain cultural identity and provide
comfort in an unfamiliar place. Some cultural practices include
breastfeeding on demand and early introduction of solid foods,
whereas others may feel that exposure of the breast is indecent—a
view that may decrease the mother’s comfort with breastfeeding. It is
imperative for nurses to recognize biases that the Western view of
health and nutrition is the only appropriate method to feeding an
infant. Nurses need to evaluate the effect of the cultural practices
objectively and intervene only if the mother or baby is at risk for
harm.
What to Say
When Talking With an Adolescent About Losing Weight
Discussions about weight loss can be a sensitive issue for overweight patients.
During adolescence, body weight has a dramatic effect on the development of
self-image and self-esteem. When talking about weight loss with this age
group, remain sensitive to cultural differences related to food choices and
eating patterns. Regardless of whether the patient is ready to begin a weight
control program, he or she may still benefit from talking openly about healthy
eating and exercise. To open the conversation, the nurse can begin with a
simple question to determine whether the patient is willing to talk about the
issue:
“Cindy, can we talk about your weight? What are your thoughts about your
weight right now?”
To determine the degree of readiness to engage in weight control, additional
questions can be asked:
“What are your goals concerning your weight?”
“What kind of help would you like from me regarding your weight?”
Nurses should avoid the use of words that may make patients feel
uncomfortable, such as “obese,” “obesity,” “fat,” and “excess fat.”
Family assessment is integral to the delivery of competent,

appropriate, holistic care. For most nurses, developing a knowledge
base that is sensitive to the cultural variations of structure and
function in the American family presents a personal challenge.
Awareness of personal perceptions and values that may negatively
affect therapeutic interactions with families is a professional
responsibility. Nurses at every level of preparation and throughout
their professional careers must engage in an ongoing process of
developing and refining attitudes and behaviors that will promote
culturally competent care. The professional nurse grows in cultural
competence by seeking more knowledge through review of literature
and evidence-based practice, attendance at cultural seminars, and
exposure to other cultures in a variety of settings. National standards
have been implemented to help nurses provide culturally sensitive
nursing care (Box 1-2). The more we learn about other cultures, the
more we learn about ourselves as nurses and as human beings.
BOX 1-2
National Standards on Culturally and

Linguistically Appropriate Services
These standards are primarily intended for health-care organizations, but they
are useful for nurses who aim to provide culturally sensitive nursing care.
These standards recommend that all health-care organizations do the following
things:
• Ensure that staff provides care that is effective, understandable, and
respectful in ways compatible to health beliefs and preferred language.
• Employ staff that is representative of the demographic characteristics of the
area.
• Provide continuing education in culturally and linguistically appropriate service
delivery.
• Provide language assistance at no cost to the consumer at all points of
contact and during all hours of operation.
• Provide individuals with oral and written notices about their rights to receive
language assistance services in their preferred language.
• Ensure the competence of language assistance to persons with limited
English proficiency by providing interpreters and bilingual staff; family should
not be used to provide interpretive services (except on request of the
individual receiving care).
• Ensure that written patient materials and signage are in the language of
commonly encountered groups.
• Employ a strategic plan that outlines clear goals, policies, operational plans,
and management accountability to provide culturally and linguistically
appropriate services.
• Conduct initial and ongoing assessments of activities that integrate cultural
and linguistic measures into internal audits, performance improvement
programs, patient satisfaction assessments, and outcome-based evaluations.
• Ensure that data about race, ethnicity, and spoken and written language are
documented in the health record, integrated into the organization’s
information systems, and periodically updated.
• Maintain a current demographic, cultural, and epidemiological profile of the
community to use for planning and implementing services that meet the
cultural needs of the service area.
• Develop community partnerships using formal and informal mechanisms to
design and implement culturally appropriate activities.
• Ensure that conflict and grievance resolution processes are culturally and
linguistically sensitive and able to identify, prevent, and resolve cross-cultural
conflicts or complaints by care consumers.
• Make information about successful innovations for implementing culturally
and language appropriate standards available to the public.
Adapted from the Office of Minority Health. (2007). National Standards on
Culturally and Linguistically Appropriate Services (CLAS). Department of Health
and Human Services. Retrieved May 11, 2012 from
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15.
LOW-INCOME POPULATIONS
The link between poverty as a contributor and risk factor of poor
health outcomes has been well established. Low-income populations
have increased rates of mental illness, chronic disease, higher
morbidity and mortality rates, substance abuse, and domestic
violence (Healthy People, 2020). People living in poverty are
exposed to environmental conditions that contribute to illness and
disease. Low-income communities often have an abundance of fast-
food restaurants, liquor stores, and convenience stores, with limited
access to grocery stores that sell fresh fruits and vegetables. These
factors can create malnutrition and contribute to obesity and
substance use. Limited public transportation and lack of a car make
it difficult to access health care and make it to doctor’s appointments.
Increased exposure to environmental pollutants also has a negative
effect on health.
Low socioeconomic status and economic hardship impacts the
family’s ability to access and pay for health care and other services.
Families living in the bottom 25% of the income bracket have on
average $500 dollars a month after rent is paid (Hyde, 2018). This
money often has to be spent on other household necessities, such
as food, electricity, heat, transportation, and child care (Hyde, 2018).
Many families are faced with trying to decide how to spend these
limited funds. This becomes a genuine struggle when families cannot
afford medications and health-care costs. In some cases, families
may choose medications over other necessities such as food. Often,
families cannot keep up with the cost of living and may face the
possibility of becoming homeless.
Nurses must be aware of their patients’ social circumstances so
that they can assist with early referrals to social workers or other
community experts to secure resources appropriate to the family’s
needs. Available resources include state and government
supplemental programs, insurance sources, loans and grants, and
religious or community programs that aid families through
catastrophic losses such as fire or health crises. Additional strategies
to help patients should be advocated for, such as school lunch
programs and early Head Start Programs that can help minimize the
negative effects of living in poverty (Healthy People 2020). The
added stress experienced by low-income families can have a
significant negative affect on language development, cognitive
development, and function, and may lead to a dysfunctional parent-
child relationship (Justice et al, 2020).
TRENDS IN MATERNAL, INFANT, AND CHILD

EPIDEMIOLOGY
Maternal and newborn morbidity and mortality place huge burdens
on families, communities, and societies as a whole. Health as a
concept may be self-defined, but to examine population health, one
is limited to using health status indicators that can be directly
measured. The health of a nation is measured by collecting
statistical data and making inferences. Epidemiology is the
statistical analysis of the distribution and determinants of disease in
populations over time. Mortality (death) and morbidity (illness) rates
are examined for trends. Mortality rates provide information about
where nursing efforts should be focused, and morbidity rates identify
populations where the illness occurs most frequently. Nurses
working in areas of maternal, child, and infant health should be
aware of the maternal, infant, and pediatric morbidity and mortality.
Infant mortality is an important indicator as it is reflective of the
overall health of the population (World Population Review, 2020).
Having an awareness of morbidity and mortality rates allows for
nurses to examine practices that may be contributing to these health
problems that will help to develop interventions to help address the
problem (Box 1-3).
BOX 1-3
Common Mortality Statistics Terms

Birth Rate: the number of live births per 1,000 population in 1 year
Fetal mortality rate: the number of fetal deaths weighing 500 mg or per 1,000
live births
Infant mortality rate: the number of deaths of infants under age 1 year per
1,000 live births
Maternal mortality rate: the number of maternal deaths per 100,000 live births
that occur during a pregnancy or up to 42 days postpartum
Neonatal mortality: the number of infant deaths from time they were born until
28 days per 1,000 live births per year
Perinatal mortality rate: includes both fetal and neonatal deaths per 1,000 live
births per year
Source: Venes, 2021
Global Health
In today’s world in which everything is interconnected, global health
issues require complex interprofessional cooperation to create
solutions. It is important for the nurse to understand emerging issues
in global health including emerging infectious diseases such as
COVID-19, human trafficking, and maternal-newborn health
(Edmonson et al, 2017).
Maternal Morbidity and Mortality

There has been growing concern over the maternal morbidity and
mortality rates in the United States Maternal mortality is defined as a
pregnancy-related death of a woman during pregnancy or within 1
year of the end of pregnancy from a pregnancy complication
(Centers for Disease Control and Prevention, 2019). In the latest
data from the CDC, the maternal rate of death is found to be 16.9
deaths per 100,000 live births, and this rate has not shown any
significant decreases in the last few years (Centers for Disease
Control and Prevention, 2020a).
Rates of maternal mortality occur approximately 31% during
pregnancy, 36% at delivery or in the week after, and 33% occur 1
week to 1 year postpartum (Centers for Disease Control and
Prevention, 2019).
Leading causes of maternal mortality in the United States (Centers
for Disease Control and Prevention, 2020b) include:
■ Other cardiovascular conditions, 15.7%.
■ Other noncardiovascular medical conditions, 13.9%.
■ Infection or sepsis, 12.5%.
■ Cardiomyopathy, 11.0%.
■ Hemorrhage, 11.0%.
■ Thrombotic pulmonary or other embolism, 9.0%.
■ Cerebrovascular accidents, 7.7%.
■ Hypertensive disorders of pregnancy, 6.9%.
■ Amniotic fluid embolism, 5.6%.
■ Anesthesia complications, 0.3%.
Three in five maternal deaths could have been prevented (CDC,
2019). Given this staggering number, preventive efforts are a key to
addressing this health problem. Interventions to improve maternal
health should be comprehensive and cover a wide range of
strategies that involve health-care providers, health-care
organizations, patients and families, states and communities, as well
as policies and governmental actions that can be implemented to
help improve outcomes. See Table 1-2 on strategies and measures
to improve maternal health.
Infant Morbidity and Mortality

Infant mortality, a serious problem with lasting effects on the parents
and family, is defined as the death of an infant anytime within the first
year of life (Centers for Disease Control and Prevention, 2020c). The
United States currently ranks 52nd in the world infant mortality rate
with some low-income countries having lower infant mortality rates
(World Population Review, 2020). In 2018 the CDC reported 5.7
deaths per 1,000 live births (Table 1-3). However, there is a
staggering difference of infant mortality rates among states, with the
highest infant mortality rate in Mississippi at 8.3 deaths per 1,000 live
births and the lowest rate in New Hampshire at 3.8 deaths per 1,000
live births (Fig. 1-11). For many states and countries, infant mortality
rates are an indicator of the overall health of that community
(Centers for Disease Control and Prevention, 2020c).
The leading causes of infant mortality (Centers for Disease Control
and Prevention, 2020d) include:
1. Birth defects.
2. Preterm birth and low birth weight.
3. Maternal pregnancy complications.
4. Sudden infant death syndrome.
5. Injuries (e.g., suffocation or strangulation).
As nurses we need to ensure preventive measures are
implemented in the preconception phase to help lessen the risk of
having a newborn with a defect. Mothers should be encouraged to
have adequate nutrition including folic acid supplement of at least
400 mcg per day (Centers for Disease Control and Prevention,
2020a). Patients who are planning to conceive should ensure that
they are up to date with all their immunizations. Education also
needs to occur so that mothers are aware of environmental factors,
infections, medications, and substance use that can cause birth
defects. Mothers and partners should also be screened for genetic
conditions so that they are aware of their risks and seek counseling
about their choices. Prenatal care can address infant mortality by
providing early identification of infants with birth defects and ensuring
adequate treatment is available.
Accidents, or unintentional injuries, are the leading cause of death
in children ages 1 to 14, which suggests that more community
education and effort are needed to address child safety hazards (Fig.
1-12). Firearms cause many accidental or unintentional injuries
among this age group (Goyal et al, 2019). Research found states
with strict laws about firearms have lower rates of accidental or
unintended deaths by firearm (Goyal et al, 2019). Nurses can be
instrumental in advocating for stricter laws and assisting with
community efforts to adopt stricter policies around firearms. The
ENA has recognized this issue as emergency nurses who work in
areas pediatric emergency departments are often the first to care for
these patients after a firearm injury (Emergency Nurses Association,
2019). The ENA advocates for better laws, more research into
firearm prevention, assessing for patients in homes with firearms,
education regarding firearm injury prevention, and advocacy for
prevention programs (Emergency Nurses Association, 2019).
The ENA has also released a position statement on seat belts and
child safety (Emergency Nurses Association, 2018). The ENA
recommends that nurses working in emergency departments
advocate for national, standardized child passenger safety laws that
protect children as well as educate parents on the correct child
passenger safety standards and best practices including appropriate
age and size child safety seat using the manufacturer’s guidelines
(Emergency Nurses Association, 2018).
TABLE 1-2
Strategies and Measures to Improve Maternal Health
TARGET FOR STRATEGIES AND MEASURES TO IMPROVE
STRATEGY MATERNAL HEALTH
Health-care Providers • Help patients manage chronic conditions such as
hypertension and diabetes
• Communicate about warning signs
• Screen for domestic and interpersonal violence
• Use tools to flag warning signs early so women can
receive timely treatment
• Encourage preventive measures to improve health;
breastfeeding, proper nutrition, proper weight gain in
pregnancy, vaccinations, etc.
• Improve cultural competence among health-care
providers
Health-care • Standardize coordination of care and response to
Organizations obstetric emergencies, such as the postpartum
hemorrhage protocol bundle
• Train nonobstetric providers to consider recent
pregnancy history for patients seeking nonobstetric
health care
• Early referrals to obstetric providers for patients seeking
nonobstetrical health care
• Strengthen health systems and collect data to establish
high-priority areas that need to be addressed
Patients and Families • Know and communicate about symptoms of
complications, provide patient education with teach-
back methods to ensure knowledge retention
• Ensure patients report any pregnancy history any time
medical care is received in the year after delivery,
including miscarriages and ectopic pregnancies
States and • Assess and coordinate delivery hospitals for risk-
Communities appropriate care
• Support review of the causes behind every maternal
death
Policies and • Address inequalities in access to quality health care
Government • Implement universal health-care coverage
Sources: California Maternal Quality Care Collaborative, n.d.; Centers for Disease
Control and Prevention, 2020c; Scannell, 2018; World Health Organization, 2020.
TABLE 1-3
Pediatric Morbidity and Mortality
AGE OF CHILDREN CAUSE OF DEATH
Children aged 1–4 years • Accidents (unintentional injuries)
• Congenital malformations, deformations, and
chromosomal abnormalities
• Assault (Homicide)
Children aged 5–14 years • Accidents (unintentional injuries)
• Cancer
• Intentional self-harm (suicide)
Source: Centers for Disease and Control and Prevention, 2020.
FIGURE 1-11 Infant Mortality Rates by State, 2018.
Health Disparities
Health disparities can be viewed as the extra burden carried by
certain racial, ethnic, gender, and age groups for different health
problems. Racial disparities are a concerning problem in the United
States, with significant differences in maternal outcomes based on
one’s race. In the latest data from the CDC, rates of maternal
mortality from 2011–2016 have demonstrated significant racial
disparities:
■ 42.4 deaths per 100,000 live births for black non-Hispanic women.
■ 30.4 deaths per 100,000 live births for American Indian/Alaskan
Native non-Hispanic women.
■ 14.1 deaths per 100,000 live births for Asian/Pacific Islander non-
Hispanic women.
■ 13.0 deaths per 100,000 live births for white non-Hispanic women.
■ 11.3 deaths per 100,000 live births for Hispanic women (CDC,
2019).
FIGURE 1-12 Children using bike helmets.
Nurses need to be change agents in addressing racial disparities

to promote health equality. Historically, nurses have been recognized
as important advocates for patients and families. Nurses lead efforts
to change or adjust laws and legislation to assist and empower
families in areas such as child care, elder care, work leave for care
of newborns and sick family members, tax breaks for dependents
including elderly members, assistance with health-care costs, and
public education for health-care choices to improve quality health
care.
The Agency for Healthcare Quality and Research has identified six
domains of quality health care that nurses should advocate for in all
areas of health care:
■ Safe: Avoiding harm to patients from the care intended to help
them.
■ Effective: Providing services based on scientific knowledge to all
who could benefit and refraining from providing services to those
not likely to benefit (avoiding underuse and misuse, respectively).
■ Patient-centered: Providing care that is respectful of and
responsive to individual patient preferences, needs, and values
and ensuring that patient values guide all clinical decisions.
■ Timely: Reducing waits and sometimes harmful delays for both
those who receive and those who give care.
■ Efficient: Avoiding waste, including waste of equipment, supplies,
ideas, and energy.
■ Equitable: Providing care that does not vary in quality because of
personal characteristics such as gender, ethnicity, geographic
location, and socioeconomic status (Agency for Healthcare
Research and Quality, 2018).
The National Institutes of Health (NIH) has launched a
multidisciplinary network of scientists to explore new approaches to
understanding the origins of health disparities. With the use of
cutting-edge conceptual and computational models, the network’s
goal is to identify important areas where interventions or policy
changes could have the greatest effect in eliminating health
disparities. NIH will be the first network to apply systems science
approaches to the study of health inequities and has plans to
produce ongoing reports and publications on the collaborative work
of network members (National Institute of Health, n.d.).
Nurses are perfectly situated to partner with representatives of the
underserved populations who they wish to advocate for or serve.
Such partnerships allow nurses and other professionals to gain a
deeper understanding of the context of disparities and work
collaboratively with representatives of disparities populations. Taking
these actions empowers nurses to help promote social justice for
individuals traditionally marginalized by various health disparities.
COMPLEMENTARY AND ALTERNATIVE

THERAPIES
Complementary therapy is nontraditional medical treatment used
together with conventional medical treatment; an alternative therapy
is used to address health concerns in place of conventional medical
treatment. These low-tech, high-touch, noninvasive, nonintrusive,
nontraditional interventions support the family and child’s whole
mind, body, energy, environment, and spiritual healing. The nurse
approaches this healing methodology from a holistic philosophy of
caring, aimed toward a goal of patient-centered autonomy and a
patient-defined sense of well-being.
Most people in the United States now use some sort of
complementary and alternative health care/medicine (CAM)
therapy, but many are reluctant to disclose that information to
traditional medical personnel. They may have the perception that
nurses and physicians may not approve of the use of CAM. Because
of its prevalence, health-care providers should have a working
knowledge of CAM and try to integrate these methods with traditional
treatments. In this way, the patient obtains the benefit of each.
Integrating CAM with conventional health care is called “integrative
health care.” Ideally, the nurse can thread integrative health care
with the practice of conventional maternal child nursing for the
maximum benefit of the patient.
CAM modalities may be used to relieve various illness symptoms,
control pain, improve immune function, decrease anxiety and
depression, improve circulation, excrete toxins, and enhance
healing. Examples of CAM interventions include acupuncture, guided
imagery, aromatherapy, art therapy, prayer, chanting, meditation,
channeling, therapeutic touch, acupressure, tai chi, magnetic forces,
massage, music therapy, and hydrotherapy (Fig. 1-13).
The nurse must be aware that not all CAM interventions are
noninvasive, and some may have side effects and negative
consequences. It is important to remember that CAM may involve
the use of nutritional and herbal supplements, diet adjustments and
fasting, chiropractic and body manipulation, and drugs that have not
been fully tested for safety and efficacy.
FIGURE 1-13 Storytelling, joking, and humor are therapeutic

complementary and alternative medicine interventions.
The nurse can provide support to the patient or family that uses
CAM by:
■ Investigating what they think caused a health event and how they
have been able to avoid this type of illness in the past.
■ Encouraging them to seek approaches of healing that are
evidence-based, including both traditional and alternative
medicine.
■ Respecting the participation of a family chosen healer.
■ Acknowledging the patient’s/family’s religious and spiritual beliefs.
■ Reflecting on and understanding personal beliefs and recognizing
when they may conflict with those of the patient.
■ Avoiding judgment.
The family-centered nurse has a responsibility to advocate for the
patient and family who choose to use CAM; assess for and educate
about the implications, contraindications, and benefits of CAM to the
family and patient; and promote health practices that have been
proven safe and effective in restoring well-being, whether via
conventional treatments or CAM. The nurse must recognize that
health can be achieved through various means, both high-tech and
high-touch, and that individual well-being is most optimally
accomplished when care is directed by concerns expressed,
interventions chosen, and outcomes defined by the patient and
family. It is easy to understand why the nurse-patient relationship
and a focus on the patient as a whole being (mind, body, energy,
environment, and spirit) unlock the success of CAM healing.
Nurses must help patients understand the most up-to-date
information available. Evidence-based practice is built on the
premise that interventions need to be questioned, examined, and
confirmed or refuted in their ability to support healthy outcomes. The
nurse using evidence-based practice searches computer databases
and current literature for reports that evaluate the safety, quality, and
credibility of particular interventions. These searches produce
reports from rigorous research studies, textbook and journal
readings, stated expert opinions, and best practices resulting from
quality improvement activities. For more about evidence-based
practice, refer to the earlier part of this chapter.
TRENDS IN HEALTH CARE

Telemedicine
Telemedicine is the use of telecommunication technologies and
computers to provide medical and health-care information and
services to patients at another site. Telehealth is the removal of time
and distance barriers for the delivery of health-care services or
related activities (Venes, 2021). Telenursing is the use of
telemedicine technology to deliver nursing care and conduct nursing
practice (Venes, 2021).
In the area of maternal health care, a perinatal nursing service
may be prescribed for women at risk for preterm labor. The service
provides daily contact with a perinatal nurse and the use of an
electronic device for conducting home monitoring to detect uterine
contractions. Telecare is also used to monitor wound healing in
medical-surgical patients. An inexpensive digital camera attached to
a computer allows specialists to view the various stages of wound
healing, make clinical assessments, and provide patient
consultation.
The use of telemedicine has great potential for reducing the need
for hospital admissions and frequent office visits. Some nurses resist
home telecare, fearful that “high-touch” care is being replaced by
“high-tech” care. However, home telecare, when creatively and
appropriately used, can serve to administer personalized patient
care and communication, result in better outcomes, and increase
patient satisfaction. The increased application of technology ensures
that nurses’ caring presence in the virtual world will continue to
expand. Despite the movement into “high technology,” nurses must
remain cognizant of the need to provide “human-centered,” holistic
care. Holism is a philosophy of care built on a framework that values
the human relationship and focuses on meeting the physical,
emotional, spiritual, and social needs of the person.
To practice holistic nursing is to blend technology with healing
while providing care that encompasses the interrelated relationships
between the patient, the patient’s family and other support persons,
the provider(s), and the community.
Medical Homes
Some professional organizations have promoted the “medical home”
concept. Medical homes are reimbursed not only on a fee-for-service
basis, but they also receive a monthly fee for the oversight function.
With this model, one provider oversees and coordinates each
individual’s care, attending to preventive measures and screening,
as well as episodic and chronic illness. There are currently many
different medical home initiatives, including some designed to bring
clinical improvement to pregnant women and their newborn children
(Agrawal, 2017).
Group Health Appointments

The concept of the group health-care visit provides another example
of an innovative care delivery model. Developed in response to
patients’ and practitioners’ dissatisfaction with the traditional model
of health care, the group healthcare model seeks to maximize the
outpatient health-care experience through provision of care to
multiple patients simultaneously during one extended appointment.
With this care delivery design, patients and practitioners can spend
increased time together to cultivate trusting and productive
relationships while benefiting from the power of peer support. Group
care may be used with a variety of patient populations (adolescents),
to deliver specific maternal-child services (e.g., prenatal care and
well-baby visits) to address needs for persons with chronic
conditions (e.g., diabetes, polycystic ovary syndrome, and obesity)
or those with behavioral conditions (tobacco smoking) (Byerley &
Haas, 2017).
Healthy People 2030

The family is the starting point for societal changes needed to ensure
the health of families in the future. The national initiative Healthy
People 2030 outlines objectives and indicators that provide the basis
for interventions, education, and policy on improving health in this
decade. All of the indicators encompassed in this important national
health initiative have an effect on the family, such as physical activity,
overweight and obesity, tobacco use, substance abuse, responsible
sexual behavior, mental health, injury and violence, environmental
quality, immunization, and access to health care. Target areas
concerning social policy and access to health care for families are
underscored in the charge to reduce the proportion of families that
experience difficulties or delays in obtaining health care.
SUMMARY POINTS
■ Nurses are uniquely positioned to address barriers and disparities that impact
physical and mental health at the individual, community, and population
levels.
■ Standards of practice define the scope of the nurse role and responsibilities in
each state.
■ The Clinical Practice Guidelines of the ANA address ethical considerations,
FCC, evidence-based care, and the nursing process.
■ The trusting therapeutic relationship between the nurse and patient is the
foundation of quality care that promotes health.
■ The nurse must be aware of issues that affect client rights such as privacy
considerations, HIPAA, malpractice, and the provision of safe and legal
abortion.
■ FCC considers the importance of a person’s family in his or her health
outcomes.
■ Nurses should display cultural sensitivity when caring for patients and families
that come from a different ethnic, religious, racial, national, or cultural
backgrounds.
■ Awareness of public health trends and innovations in health-care delivery will
help the nurse provide high-quality, patient-centered, and family-centered
care.
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Happen Before, During, and Up to a Year After Delivery.
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deaths.html
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https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm
Centers for Disease Control and Prevention. (2020b). Folic Acid. Centers for
Disease Control and Prevention.
https://www.cdc.gov/ncbddd/folicacid/index.html
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Surveillance System. https://www.cdc.gov/reproductivehealth/maternal-
mortality/pregnancy-mortality-surveillance-system.htm
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https://www.cdc.gov/nchs/fastats/child-health.htm
Centers for Disease Control and Prevention. (2020a). Infant Mortality.
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm
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Position Statement. https://www.ena.org/practice-resources/resource-
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9
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country
To explore learning resources for this chapter, go to

Davis Advantage
UNIT 2
The Process of Human

Reproduction
CHAPTER 2
Reproduction
CONCEPTS
Female Reproduction
Male Reproduction
Pregnancy
Contraception
Fertility
Infertility
KEY WORDS
Uterine tubes
Gonadotropins
Human chorionic gonadotropin (hCG)
Puberty
Thelarche
Menarche
Tanner scale
Spinnbarkeit
Amenorrhea
Dysmenorrhea
Spermatogenesis
Fertility awareness methods (FAM)
Assisted reproductive technologies (ART)
LEARNING OBJECTIVES
At the completion of this chapter, the student will be able to:

■ Identify anatomy and explain physiological functions of the female and male
reproductive systems.
■ Analyze the actions and interactions of hormones from the hypothalamus,
pituitary, and gonads, as well as other hormones that affect the reproductive
system.
■ Discuss physiological events that accompany the menstrual cycle.
■ Develop an understanding of physiological changes that occur during
menopause.
■ Identify advantages and disadvantages of barrier and hormonal contraceptive
methods, intrauterine devices, and permanent sterilization.
■ Teach patients how to use various methods of contraception.
■ Differentiate among the various assisted reproductive technologies and
identify potential alternatives to childbearing for the infertile couple.
PICO(T) Questions
Evidence-based practice (EBP) intends to provide nursing care that
integrates the best available evidence. An initial step in EBP is writing a
PICO(T) question that effectively guides the research. PICO(T) is an
acronym that stands for population (P), intervention or issue (I),
comparison of interest (C), outcome (O), and time frame (T). Depending on
the question, all or some of the question components are used in the
research process. Use these PICO(T) questions to spark your thinking as
you read the chapter.
1. Do (P) women with (I) early onset of menarche have an (O) earlier onset of
menopause than (C) women with average age onset of menarche?
2. Do (P) postmenopausal women (I) who are treated with estrogen-only
hormone therapy (HT) and receive individual education about risks of breast
cancer (O) stay on the treatment for a shorter length of time (C) than those
who do not receive education?
INTRODUCTION
This chapter provides an overview of the anatomy and physiology of
the male and female reproductive systems. Growth and development
over the life span are explored with a primary focus on females along
with special issues related to male development. The menstrual
cycle and events that occur in the absence of fertilization as well as
those that take place soon after conception are explored. A
discussion of key hormones that affect the menstrual cycle enhances
understanding of the symphony of cyclic events during the
reproductive years.
SEXUAL DIFFERENTIATION IN THE EMBRYO

In humans, the course of sexual maturation is quite lengthy,
extending from embryonic development to full maturation in later
adolescence. Although the sex of an individual is determined at
conception, it takes about 8 weeks of development before the
reproductive system becomes differentiated as male or female.
Before 8 weeks’ gestation, the embryo displays no distinguishing
sexual characteristics. At 5 weeks after conception, the first
reproductive tissue arises from the mesoderm, the embryo’s middle
layer. The first structure formed is a gonad (sex gland), which is
composed of an internal portion called a medulla and an external
portion known as the cortex. During the next few weeks, the gonad
undergoes various developmental changes. Primitive reproductive
ducts form, a pair of mesonephric ducts and a pair of
paramesonephric ducts. The mesonephric ducts are dominant in
males, and the paramesonephric ducts are dominant in females.
Depending on the sex of the embryo, one ductal pair becomes
dominant in genital development, whereas the other genital pair
regresses. Differing male/female developmental changes in the
embryonic mesonephric/paramesonephric duct structure are the first
changes that occur.
Male Sex
In a male embryo, the cortex of the gonad regresses and the
medulla develops into a testis at around the seventh to eighth week
of gestation. The mesonephric ducts evolve into the efferent ductule,
vas deferens, epididymis, seminal vesicle, and ejaculatory duct.
Collectively, these structures become the male genital tract. This
process is stimulated by the production of testosterone in the testes.
The testes also secrete Müllerian regression factor, which
suppresses the paramesonephric ducts. The testes do not produce
spermatozoa (sperm) until puberty. Beginning in the 12th
developmental week, androgens begin to stimulate the growth of the
external genitalia.
Female Sex
In a female embryo, the medulla of the first primitive gonad
regresses, whereas the cortex develops into an ovary at
approximately 10 weeks. During fetal life, underdeveloped egg cells,
oogonia, develop to become oocytes (primitive eggs). At birth, 2 to 4
million oocytes are present in the ovary. The process of oocyte
development that results in maturation of human ova is called
oogenesis. External female genitalia develop in the absence of
androgens. At approximately 12 weeks, the clitoris is formed, and
the labia majora and minora develop from the surrounding
connective tissue. By 16 weeks, the paramesonephric ducts have
evolved into the fallopian tubes, uterus, and vagina.
FEMALE REPRODUCTIVE SYSTEM

External Structures
The external genital structures include the mons pubis, labia majora,
labia minora, clitoris, vestibule of the vagina, urethral (urinary)
meatus, Skene’s glands, Bartholin’s glands, vaginal introitus
(opening), hymen, and the perineum (Fig. 2-1).
The vulva (pudendum femininum) is the portion of the female
external genitalia posterior to the mons pubis. It consists of the labia
majora, labia minora, clitoris, vestibule of the vagina, vaginal
opening, and Bartholin’s glands (Venes, 2021).
Mons Pubis
The mons pubis, or mons veneris, is a layer of subcutaneous tissue
anterior to the genitalia covering the symphysis pubis. It is located in
the lowest portion of the abdomen and typically is covered with pubic
hair. The texture and amount of pubic hair varies from fine and
sparse to thick and coarse.
FIGURE 2-1 Female external genitalia.

Labia
The labia majora are the two folds of tissue that lie lateral to the
genitalia and protect the delicate tissues between them. The external
labia are covered with pubic hair, whereas the medial surfaces,
which are moist and pink, are hairless. The labia minora are two
folds of tissue that lie within the labia majora. Similar to but smaller
than the labia majora, these structures are moist, have no hair
follicles, and resemble mucous membrane. The labia minora contain
sebaceous glands that provide lubrication and protective
bacteriocidal secretions. The lower aspect of the labia minora forms
the fourchette, a tense fold of mucous membrane at the posterior
opening of the vagina.
Clitoris
The clitoris is located at the upper junction of the labia minora. The
prepuce, or clitoral hood, is a small fold of skin that partially covers
the glans (head) of the clitoris. Composed of erectile tissue, the
clitoris is the primary organ of sexual pleasure and orgasm in
women. The clitoris contains a rich blood and nerve supply and is
extremely sensitive. Sensory receptors located in the clitoris send
information to the sexual response area in the brain.
Vestibule
The vestibule is an oval-shaped space enclosed by the labia minora.
It contains openings to the urethra and vagina, the Skene’s glands,
and the Bartholin’s glands. This area is extremely sensitive to
chemical irritants. Nurses should be prepared to educate women
about the potential discomforts associated with the use of dyes and
perfumes found in soaps, detergents, and feminine hygiene products
and encourage discontinuation if symptoms develop.
Urethral (Urinary) Meatus

The urethral or urinary meatus (opening) is located in the midline of
the vestibule, approximately 0.4 to 1 inch (1 to 2.5 cm) below the
clitoris. The small opening is often shaped like an inverted “V.” The
vaginal orifice, or introitus, lies in the lower portion of the vestibule
posterior to the urethral meatus. The hymen, a connective tissue
membrane, encircles the vaginal introitus.
Skene’s Glands and Bartholin’s Glands

The Skene’s glands (paraurethral glands), located on each side of
the urethra, produce mucus that helps to lubricate the vagina. The
Skene’s glands are not readily visible. The Bartholin’s glands, also
known as the greater vestibular or vulvovaginal glands, are located
deep within the posterior portion of the vestibule near the posterior
vaginal introitus. These glands secrete a clear mucus that moistens
and lubricates the vagina during sexual arousal.
Hymen
Surrounding the opening of the vagina is a small portion of tissue
called the hymen. During puberty, the smooth, circular,
nonstretchable hymen becomes a stretchable tissue with irregular
edges. The hymen can tear due to vulvar injury, tampon insertion, or
with sexual activity and intercourse, which may cause bleeding,
discomfort, or pain. Contrary to some societal and cultural beliefs,
bleeding does not necessarily occur during first intercourse.
Perineum
The perineum, an anatomical landmark, is the skin-covered region
between the vagina and the anus. The perineal body consists of
fibromuscular tissue located between the lower part of the vagina
and the anus.
Internal Structures
The internal female reproductive structures consist of the ovaries,
fallopian tubes (oviducts, or uterine tubes), uterus, adjacent
structures (adnexa), and vagina (Fig. 2-2 and Fig. 2-3). The ureters,
bladder, and urethra are structures of the internal urinary system.
Ovaries
The ovaries are sometimes referred to as the essential female organ
because they produce ova (female gametes or eggs) required for
reproduction. This pair of oval structures each measures
approximately 1.5 inches (4 cm) long. The ovaries are located on
each side of the uterus below and behind the fallopian tubes. In
addition to ova production, they are responsible for secretion of
estrogen and progesterone, hormones that help regulate the
menstrual cycle. Oogenesis (the process of meiosis for egg cell
formation) results in the formation of mature eggs within the ovary.
Oogenesis occurs at regular (usually monthly) intervals.
Oogenesis begins in the ovaries and is regulated by follicle-
stimulating hormone (FSH), which initiates the growth of ovarian
follicles. Each follicle contains an oogonium, or egg-generating cell
(Fig. 2-4). FSH also stimulates the follicle cells to secrete estrogen,
which promotes maturation of the ovum. For each primary oocyte
that undergoes meiosis, only one functional egg cell is produced.
The remaining three cells, termed polar bodies, have no function and
deteriorate. A mature ovarian follicle, also called a graafian follicle,
contains the secondary oocyte. If the egg is fertilized, the second
meiotic division occurs, and the ovum nucleus becomes the female
pronucleus.
The ovarian surface is termed the germinal epithelium. Each ovary
has hundreds of thousands of follicles that contain immature female
sex cells. All these follicles develop in utero and are present at birth.
During a postpubertal woman’s monthly menstrual cycle, one follicle
develops and releases a mature ovum. (Please refer to the
menstrual cycle discussion later in this chapter for additional
information.) Throughout a woman’s reproductive years, only 300 to
400 follicles develop into mature ova and are released for potential
fertilization by a sperm.
The ovaries are supported in their position in the pelvis by three
important ligaments: the mesovarium, the ovarian ligament, and the
infundibular pelvic ligament or suspensory ligament. The ovarian
ligament positions the fimbriae (fingerlike projections) of the fallopian
tube in contact with the lower pole of the ovary to enhance pickup of
the ovum following ovulation.
FIGURE 2-2 Uterus and surrounding structures of the female
genitourinary system shown in a midsagittal section through the
pelvic cavity.
Figure 2-3 Internal structures of the adnexa.
FIGURE 2-4 Oogenesis is the processes of mitosis and meiosis. For
each primary oocyte that undergoes meiosis, only one functional
ovum is formed.
Fallopian Tubes
The two fallopian tubes are also called the uterine tubes or
oviducts. Measuring approximately 4 inches (10 cm) in length, the
lateral end of each encloses an ovary; the medial end opens into the
uterus. Anatomically, the fallopian tubes are composed of four
layers. Beginning with the external layer and progressing inward to
the internal layer, these include the peritoneal (serous), which is
covered by the peritoneum; the subserous (adventitial); the
muscular; and the mucous layers. The blood and nerve supplies are
housed in the subserous layer. The muscular layer has an inner
circular and an outer longitudinal layer of smooth muscle. It provides
peristalsis that assists in transporting the ovum toward the uterus for
potential implantation. The mucosal layer contains cilia, hairlike
projections that help direct the ovum toward the uterus.
The fallopian tubes are attached at the upper outer angles of the
uterus and then extend upward and outward (Fig. 2-5). The diameter
of each tube is approximately 6 mm. Anatomically, the tubes consist
of three divisions: infundibulum, ampulla, and isthmus. The
infundibulum is the funnel-shaped portion located at the distal end of
the fallopian tube. The ovum enters the fallopian tube through a
small opening (ostium) located at the bottom of the infundibulum.
Several fingerlike processes (fimbriae) surround each ostium and
extend toward the ovary. The longest fimbria, the fimbria ovarica, is
attached to the ovary. The ampulla, which is the second division of
the fallopian tube, is two-thirds the length of the tube and is most
often the site of ovum fertilization. The third division of the fallopian
tube, the isthmus, is nearest the uterus and is typically the site for
tubal ligation (permanent sterilization).
A patent fallopian tube can convey the ovum from the ovary to the
uterus and the spermatozoa from the uterus toward the ovary.
Fertilization usually occurs in the outer one-third of the fallopian tube,
which provides a safe, nourishing environment for the ovum and
sperm. If fertilization occurs, the fertilized ovum (termed a zygote
until the first cell division) is slowly and gently swept into the uterus
by fallopian peristalsis and cilia movement, where implantation takes
place. If fertilization does not occur, the ovum dies within 24 to 48
hours and disintegrates, either in the tube or in the uterus.
Internally, each tube connects laterally with its corresponding
ovary and medially with the uterus. This creates a continuous route
that passes from the vagina into the uterus and then out to the tubes
and ovaries. If the vagina is infected by a pathogen, the infection
could be transmitted to the ovaries. Although most vaginal infections
are readily curable, residual scarring from the inflammatory process
can narrow tubes, increasing the risk for tubal pregnancies or
infertility resulting from blockage.
Uterus
The uterus, centrally located in the pelvic cavity between the bladder
(anteriorly) and rectum (posteriorly), is approximately 3 inches long
by 2 inches wide (7.5 cm × 5 cm). It is a pear-shaped organ with the
narrower end positioned closest to the vagina. The uterine interior is
hollow and forms a path from the vagina to the fallopian tubes. The
uterus permits sperm to ascend toward the fallopian tubes and
provides a nourishing environment for the zygote until placental
function begins. In addition, this environment protects and nurtures
the growing embryo/fetus throughout the pregnancy. In the absence
of conception, the uterus sheds the outermost layers of the inside of
the endometrium during menstruation to prepare for another
menstrual cycle as the endometrium regenerates.
Figure 2-5 Fallopian tube and ovary.
The arteries of the uterus include the hypogastric arteries and the
ovarian artery, which branch off from the abdominal aorta. This rich
blood supply ensures ample oxygenation and nutrition to facilitate
the growing uterus and fetus during pregnancy. The uterine veins
drain into the internal iliac veins. The vasculature of the uterus is
twisted and tortuous, but as the gravid (pregnant) uterus expands,
these vessels straighten out, allowing a continued rich blood supply
throughout pregnancy.
The uterus receives its nerve supply via the afferent (sensory) and
efferent (motor) autonomic nervous systems. These two systems are
important in regulating both vasoconstriction and muscle
contractions. The uterus also has an innate intrinsic motility as well,
so a patient with a spinal cord injury above level T6 may still have
adequate uterine contractions to deliver a fetus vaginally.
Uterine pain nerve fibers reach the spinal cord at levels T11 and
T12. Because of this location and the presence of other pain
receptors there, pain from the ovaries, ureters, and uterus may be
similar and potentially reported by a woman who identifies pain in the
flank, inguinal, or vulvar areas. Several sensory nerve fibers that
contribute to dysmenorrhea (painful menstruation) are housed in the
uterosacral ligaments.
UTERINE ANATOMY
The uterus is divided into three sections: the corpus, the isthmus,
and the cervix. The corpus of the uterus is the upper two-thirds of the
uterine body and contains the cornua portion, where the fallopian
tubes enter, and the fundus or uppermost section superior to the
cornua.
The layers of the corpus of the uterus include the perimetrium, the
myometrium, and the endometrium. The perimetrium is the outer,
incomplete layer of the parietal peritoneum (the serous membrane
that lines the abdominal wall). The myometrium, or middle layer, is
composed of layers of smooth muscle that extend in three directions
—longitudinal, transverse, and oblique. The tridirectional formation of
the muscular layers facilitates effective uterine contractions during
labor and birth. The endometrium is the third and innermost uterine
layer. It is composed of three layers, two of which are shed with each
menses.
The isthmus is a slight constriction on the surface of the uterus
midway between the uterine body (the corpus, or upper two-thirds),
and the cervix, or neck. During pregnancy, the isthmus becomes
incorporated into the lower uterine segment and acts as a passive or
noncontractile part of the uterus during labor. The isthmus is the site
for the uterine incision when a low-transverse cesarean section is
performed.
The cervix is the lower, narrow tube-shaped end of the uterus,
extending from the inside of the uterus and opening into the vagina.
The cervix secretes mucus, which lubricates the vaginal canal, forms
a barrier to sperm penetration into the uterus during nonfertile
periods, facilitates sperm passage into the uterus during fertile
periods, provides an alkaline environment to facilitate the viability of
sperm that have been deposited in the acidic vagina, forms a solid
plug called an operculum to protect a pregnancy from outside
pathogens, and functions as a bacteriostatic agent. The composition
of cervical mucus changes during the menstrual cycle, and these
changes are important in the fertility assessment.
The vaginal portion of the cervix is composed of squamous
(epithelial) cells. This portion of the cervix is fleshy pink in color. The
canal portion of the cervix that leads into the uterine epithelium is
composed of columnar cells. This tissue is bright red in color. The
juncture of these two cell types is called the squamocolumnar
junction. After puberty, this junction is active with cellular growth
activity and cell turnover, and it is the site where dysplasia (abnormal
tissue development) may occur. During a Pap test, this area is
screened for abnormal cellular changes that can occur with
infections such as HPV, some of which lead to the development of
cervical cancer.
UTERINE SUPPORT STRUCTURES

Uterine position in the body varies with age, pregnancy, and
distention of related pelvic viscera. Typically, the uterus lies over the
urinary bladder. The cervix points down and backward and enters
the apex (the pointed extremity portion) of the vagina at a right
angle. Several ligaments hold the uterus in place, but also allow for
some movement.
The uterus is supported in the pelvis by the broad, round, cardinal,
pubocervical, and uterosacral ligaments and the pelvic muscles (Fig.
2-6). The broad and round ligaments support the upper portion of the
uterus, whereas the cardinal, pubocervical, and uterosacral
ligaments provide support for the middle portion. The lower portion of
the uterus is supported by the muscles of the pelvic floor.
The broad ligaments are supportive stretches of peritoneum that
extend from the lateral pelvic sidewalls to the uterus. Within these
structures are the fallopian tubes, arteries and veins, ligaments,
ureters, and other tissues.
Figure 2-6 Uterine ligaments.
FIGURE 2-7 Female bony pelvis.
Vagina
The vagina is a tubular organ approximately 4 inches (10 cm) in
length that internally extends between the uterus and perineal
opening. It is located between the rectum, urethra, and bladder. The
vagina is composed of smooth muscle lined with mucous membrane
arranged in rugae (small ridges), which allow distention during
childbirth and collapse following labor. The vagina provides
lubrication to facilitate intercourse, stimulates the penis during
intercourse, acts as a receptacle for semen, transports tissue and
blood from the body during menses, and functions as the lower
portion of the birth canal during childbirth.
The apex of the vagina, also termed the vaginal vault or fornix, is
the upper, recessed area around the cervix. Following intercourse,
sperm pool in the fornix, where they have close contact with the
cervix and its alkaline pH. The vaginal pH is typically acidic (4.5 to
5.5) during the reproductive years. The acid environment, though
harmful to sperm, helps to protect the genital tract from pathogens.
Pelvic Anatomy
BONY PELVIS
The pelvis forms a bony ring that transmits body weight to the
lower extremities. In women, the pelvis is structured to adapt to the
demands of childbearing, supporting and protecting the pelvic
contents and creating a relatively fixed axis for the birth passage
(Dashe et al, 2018).
The bony pelvis is composed of four bones: the sacrum, the
coccyx, and two innominate (hip) bones. The bilateral innominate
bones are formed by the fusion of the ilium, ischium, and pubis
bones (Fig. 2-7).
PELVIC FLOOR
The bony pelvis contains a pelvic floor of soft tissues that provides
support and stability for surrounding structures. Most of the perineal
support comes from the pelvic diaphragm (musculofascial layer
forming the lower boundary of the abdominopelvic cavity) and the
urogenital diaphragm (musculofascial sheath lying between the
ischiopubic rami surrounding the female vagina). The pelvic
diaphragm includes fascia and the levator ani and coccygeus
muscles (Dashe et al, 2018).
Above the pelvic diaphragm lies the pelvic cavity; below and
behind is the perineum. The urogenital diaphragm includes fascia,
deep transverse perineal muscles, and the urethral constrictor
(Dashe et al, 2018). The muscles of the pelvic floor include the
levator ani (consists of the iliococcygeal, pubococcygeal
[pubovaginal], and puborectal muscles) and the coccygeus. These
structures create a “sling” that provides support for internal pelvic
structures and the pelvic floor. The ischiocavernosus muscle extends
from the clitoris to the ischial tuberosities on each side of the lower
bony pelvis. Two transverse perineal muscles extend from fibrous
tissue of the perineum to the ischial tuberosities to stabilize the
perineum (Fig. 2-8).
TRUE/FALSE PELVIS
The pelvis consists of two sections known as the false pelvis and
the true pelvis, divided by the linea terminalis, or pelvic brim. The
false pelvis is superior to the linea terminalis. Its anterior boundary is
the abdominal wall, its posterior boundary is the lumbar vertebrae,
and the lateral boundary is the iliac fossa. The false pelvis helps to
support the gravid uterus and direct the presenting part of the fetus
toward the true pelvis.
Figure 2-8 The muscles of the female pelvic floor.
The true pelvis, located below the linea terminalis, is important for
childbearing. Its size and structure direct the fetus downward for
delivery, and its dimensions must be large enough to accommodate
the fetus for a vaginal birth. Its boundaries are partly bony and partly
ligamentous. Superiorly, the true pelvis is bounded by the sacral
promontory (anterior projecting portion of the base of the sacrum)
and the sacral alae (broad bilateral projections from the base of the
sacrum), the linea terminalis, and the upper margins of the pubic
bones. Inferiorly, the lowest portion of the true pelvis is the pelvic
outlet. The anterior landmarks of the true pelvis consist of the pubic
bones, the ascending superior rami of the ischial bones, and the
obturator foramen. The sacrum serves as the posterior landmark.
Bilaterally, the true pelvis is bordered by the ischial bones and the
sacrosciatic notches and ligaments. The true pelvis is divided into
three sections: the inlet, the midpelvis, and the outlet. Each of these
three components is important during the labor process.
PELVIC DIAMETERS AND PLANES
To assess whether a woman’s pelvis is adequate to deliver an
average-sized fetus, health-care providers may use a measurement
called pelvimetry. Pelvic measurements are approximate because it
cannot be measured directly and soft tissue covering the pelvis can
distort the actual size. Despite findings from clinical pelvimetry, most
women experience a trial of labor (allowing uterine contractions to
evaluate labor progress, e.g., cervical dilation and fetal descent) to
assess the feasibility of vaginal birth.
Three portions of the true pelvis are measured during pelvimetry:
the pelvic inlet, the midpelvis, and the pelvic outlet. The narrowest
portion of the pelvic inlet is the line between the sacral promontory
and the inner pelvic arch, including the symphysis pubis. It is termed
the obstetrical conjugate and should measure at least 4.5 inches
(11.5 cm). Once the fetus passes this landmark, the presenting part
is considered engaged in the pelvis. The midpelvis, which constitutes
the area between the ischial spines, is the narrowest lateral portion
of the female pelvis. This measurement needs to be at least 4.7
inches (12 cm) to allow for a vaginal birth.
During labor, the ischial spines serve as a landmark for assessing
the level of the fetal presenting part into the pelvis. At the pelvic
outlet, two measurements are assessed: the angle of the ascending
rami (pubic arch), which should be at least 90 to 100 degrees, and
the distance between the ischial tuberosities, which should be at
least 3.9 inches (10 cm). These are the minimal measurements
deemed necessary to allow the fetus to descend through the pelvis
for birth. During pregnancy, the joints of the pelvis soften and
become more flexible from the effects of the hormone relaxin. This
important physiological change creates additional space to
accommodate childbirth.
PELVIC TYPES
Each woman has one of four basic bony pelvic types. Each type is
characterized by a distinct shape that has important implications for
childbirth (Caldwell & Moloy, 1933) (Fig. 2-9):
■ Gynecoid: The gynecoid pelvic type is the typical, traditional
female pelvis that is best suited for childbirth. The
anterior/posterior and lateral measurements in the inlet, midpelvis,
and outlet of the true pelvis are largest in the gynecoid pelvis. The
inlet is round to oval-shaped laterally. In addition, the ischial spines
are less prominent, the shortened sacrum has a deep, wide curve,
and the subpubic arch is wide and round. All these characteristics
enhance the feasibility for a vaginal birth. The other pelvic
structures can pose problems for vaginal birth.
■ Android: The android pelvis resembles a typical male pelvis. The
inlet is triangular or heart-shaped and laterally narrow. The
subpubic arch is narrow; there are more bony prominences,
including the ischial spines, which are also prominent and narrow.
These characteristics can cause difficulty during fetal descent.
■ Anthropoid: The anthropoid pelvis resembles the pelvis of the
anthropoid ape. Similar to the gynecoid pelvis, the anthropoid
pelvis is oval-shaped at the inlet, but in the anterior-posterior rather
than lateral plane. The subpubic arch may be slightly narrowed.
Fetal descent through an anthropoid pelvis is more likely to be in a
posterior (facing the woman’s front) rather than anterior (facing the
woman’s back) presentation.
■ Platypelloid: The platypelloid pelvis is broad and flat and bears no
resemblance to a lower mammal form. The pelvic inlet is wide
laterally with a flattened anterior-posterior plane, and the sacrum
and ischial spines are prominent. The subpubic arch is generally
wide. Fetal descent through a platypelloid pelvis is usually in a
transverse presentation and often will not allow for a vaginal birth.
Figure 2-9 Comparison of the four Caldwell-Moloy pelvic types. The

average woman has a gynecoid pelvis; others may have a variation
or a mixture of types. Few women have pure android, anthropoid, or
platypelloid types.
FIGURE 2-10 Mammary gland shown in a midsagittal section.
Ureters, Bladder, and Urethra

The ureters, bladder, and urethra and its external opening (meatus)
are part of the urinary system, not the reproductive system. The
urethra is a mucous membrane-lined tube that passes from the
bladder out of the body to allow urination. Its position is posterior to
the symphysis pubis and anterior to the vagina. The urethra is
approximately 1.2 inches (3 cm) in length.
Breasts
The female breasts or mammary glands are considered accessory
organs of the reproductive system (Fig. 2-10). The two breasts lie
over the pectoral and anterior serratus muscles. Breast tissue
consists primarily of glandular, fibrous, and adipose tissue
suspended within the conically shaped breasts by Cooper’s
ligaments that extend from the deep fascia.
The glandular tissue contains 15 to 24 lobes separated by fibrous
and adipose tissue. Each lobe contains several lobules composed of
numerous alveoli clustered around tiny ducts layered with secretory
cuboidal epithelium called alveoli or acini. The epithelial lining of the
ducts secretes various components of milk. The ducts from several
lobules come together to form the lactiferous ducts, which are larger
ducts that open on the surface of the nipple.
The wide variation in breast size among women is related to the
differing amounts of adipose tissue that surrounds the mammary
glands. At puberty, development of an adolescent’s breasts is
controlled by the hormones estrogen and progesterone.
The primary function of the breasts is to provide nutrition to
offspring through the process known as lactation.
Preparation for milk production takes place during pregnancy as the
ovaries and placenta produce hormones (estrogen and
progesterone) to prepare the breasts structurally for lactation by
promoting growth of the ducts and secretory cells. After birth and
delivery of the placenta, estrogen abruptly decreases. This triggers
the anterior pituitary gland to increase the secretion of prolactin
(PRL). The posterior pituitary and hypothalamus play a role in the
production and secretion of oxytocin, a hormone that causes
contractions and the release of milk from the alveoli.
Parts of the Breast

NIPPLES
Centrally located on the breast, the nipples contain several pores
that secrete colostrum (breast fluid that precedes breast milk) and
breast milk during lactation. The nipples consist primarily of erectile
tissue to assist with infant latch-on during suckling.
AREOLA
The areola is a more deeply pigmented area that surrounds the
nipple. Its diameter ranges from 1 to 3.9 inches (2.5 to 10 cm).
MONTGOMERY TUBERCLES
The Montgomery tubercles are papillae located on the surface of
the nipple and the areola. They secrete a fatty substance that
lubricates and protects the nipple and areola during breastfeeding.
THE INTERPLAY OF HORMONES AND

REPRODUCTION
Knowledge of the functions of key hormones associated with
reproduction is essential to an understanding of the female
menstrual cycle. The following discussion centers on hormones that
play a major role in the process of human reproduction.
Hormones Released by the Hypothalamus

Hormones released by the hypothalamus stimulate the release of
other hormones, they are termed “releasing factors.” Factor
hormones act on the anterior pituitary and stimulate the release of
hormones from the pituitary. Releasing factors from the
hypothalamus include:
■ Gonadotropin-releasing hormone (GnRH): Stimulates the release
of the gonadotropins FSH and luteinizing hormone (LH) from the
anterior pituitary. These hormones are released when the
hypothalamus detects decrease in ovarian hormones (estrogen
and progesterone). In the premenopausal female, GnRH affects
the cyclic process of follicular growth, ovulation, and maintenance
of the corpus luteum. In the male, GnRH affects spermatogenesis,
the process of meiosis in the testes to produce sperm cells.
■ Corticotropin-releasing hormone (CRH): Regulates
adrenocorticotropic-stimulating hormone (ACTH) secretion by the
anterior pituitary to activate the sympathetic nervous system. CRH
is also released by the pregnant woman and her embryo soon
after implantation. CRH appears to provide a protective action by
minimizing a maternal immunological rejection that could result in
a miscarriage. Other effects of CRH relate to the woman’s
response to stress.
■ Growth hormone-releasing hormone (GH-RH): Stimulates the
production and release of growth hormone (GH) by the anterior
pituitary.
■ Growth hormone-inhibiting hormone (GH-IH), also known as
somatostatin: Inhibits the release of GH.
■ Thyrotropin-releasing hormone (TRH): Regulates thyroid
hormones (T3 and T4) by stimulating the anterior pituitary to
release thyroid-stimulating hormone (TSH). TRH also stimulates
the release of PRL.
■ Prolactin-inhibiting factor (PIF), also known as prolactostatin:
Inhibits the synthesis and release of PRL by the pituitary gland.
Dopamine, another hormone released by the hypothalamus, also
inhibits PRL (Fig. 2-11)
FIGURE 2-11 Hormonal feedback mechanisms that regulate the

female menstrual cycle.
Hormones Released by the Pituitary Gland

The anterior pituitary produces the following hormones:
■ TSH, also known as thyrotropin: Regulates the endocrine function
of the thyroid gland.
■ Adrenocorticotropic hormone (ACTH), also known as corticotropin:
Controls the development and functioning of the adrenal cortex,
including its secretion of glucocorticoids and androgens (Venes,
2021).
■ PRL: Stimulates the maturation of the mammary glands during
pregnancy; initiates milk production and provides some inhibition
to the stimulation of FSH and LH.
■ GH, also known as somatotropin: Stimulates growth and cell
reproduction (e.g., height growth during childhood) in humans. GH
is also responsible for increased muscle mass, calcium retention,
and bone mineralization, the growth of various organ systems,
protein synthesis, stimulation of the immune system, reduced
uptake of glucose in the liver, and lipolysis promotion.
■ Gonadotropins (gonad-stimulating hormones): FSH and LH
stimulate and inhibit the ovaries. These hormones help regulate
the menstrual cycle by producing positive and negative feedback
of estrogen and progesterone from the ovaries. The feedback
systems stimulate the hypothalamic secretion of releasing
hormones that act on the anterior pituitary gland.
The posterior pituitary releases oxytocin, which stimulates uterine
contractions and the release of milk from milk ducts in the breasts
during lactation. A synthetic form of oxytocin can be administered
during labor to enhance uterine contractions and after birth to
promote expulsion of the placenta and minimize uterine bleeding.
Collectively, the pituitary hormones are essential in the regulation
of gonadal, thyroid, and adrenal function; lactation; body growth; and
somatic development.
Hormones of the Menstrual Cycle

The menstrual cycle is hormonally mediated through events that take
place in the hypothalamus, anterior pituitary gland, and ovaries. The
hypothalamus stimulates the anterior pituitary gland to produce
gonadotropin. FSH, one of these hormones, stimulates the growth
and development of the graafian follicle, which secretes estrogen.
Estrogen stimulates proliferation of the endometrial lining of the
uterus. After ovulation, the anterior pituitary gland secretes LH,
which stimulates development of the corpus luteum. Progesterone
secreted by the corpus luteum prompts further development of the
lining of the uterus in preparation for the fertilized ovum. When
pregnancy does not occur, the corpus luteum degenerates and the
levels of estrogen and progesterone decline. These decreased
hormone levels cause the uterus to shed its lining during
menstruation and trigger positive feedback to the hypothalamus,
which stimulates the anterior pituitary gland to secrete FSH once
again. See Figure 2-11 for a schema depicting the hormonal
feedback mechanisms that regulate the menstrual cycle. The
interrelationships between the levels of hormone secretion,
development of ovarian follicles, and changes in the uterine
endometrium are presented in Figure 2-12.
Hormones Released by the Gonads

The gonadal hormones are estrogen, progesterone, and
testosterone. Estrogen and progesterone are primarily female
hormones; testosterone is primarily a male hormone. These
hormones are produced chiefly by the gonads (ovaries and testes)
and have a significant influence on sexual characteristics and the
menstrual cycle. Fluctuating levels of estrogen and progesterone
stimulate or suppress the hypothalamus or pituitary gland to release
or cease releasing their hormones in a complex orchestration of
events that regulate the menstrual cycle.
Estrogen
Estrogen, the primary female sex hormone, is present in high levels
in women of childbearing age and in much lower levels in men. In
females, estrogen is responsible for development of the secondary
sex characteristics (e.g., breast development, widening of the hips,
and deposition of fat in the buttocks and mons pubis). It also helps
regulate the menstrual cycle by stimulating proliferation of the
endometrial lining in preparation for pregnancy.
Progesterone
Progesterone also plays a role in regulation of the menstrual cycle
by decreasing uterine motility and contractility (caused by estrogen)
and preparing the uterus for implantation after fertilization. During
pregnancy, progesterone readies the breasts for lactation.
Testosterone
Testosterone, the primary male hormone, is produced by the testes
in men and the ovaries in women. Testosterone is responsible for the
development of the male genital tract and secondary sex
characteristics (body hair distribution, growth and strength of the
long bones, increase in muscle mass, and deepening of the voice
through enlargement of the vocal cords). In both genders,
testosterone enhances the libido, increases energy, boosts immune
function, and helps protect against osteoporosis.
Figure 2-12 The female reproductive cycle. Levels of the hormones
secreted from the anterior pituitary are shown relative to one another
and throughout the cycle. Changes in the ovarian follicle are
depicted. The relative thickness of the endometrium is also shown.
Human Chorionic Gonadotropin, Prostaglandins, Relaxin and

Inhibin
Human chorionic gonadotropin (hCG) is an important hormone
during early pregnancy. It is produced by the trophoblast (outermost
layer of the developing blastocyst) and maintains the ovarian corpus
luteum (remainder of ovarian follicle after ovulation) by keeping
levels of progesterone and estrogen elevated until the placenta has
sufficiently developed to assume that function. hCG may also play a
role in limiting the maternal immune response to the pregnancy.
Serum or urine hCG levels are measured to diagnose pregnancy.
Prostaglandins are unsaturated, oxygenated fatty acids classified
as hormones. Prostaglandins are found in many body tissues,
occurring in high concentrations in the female reproductive tract.
Prostaglandins modulate hormonal activity and affect ovulation,
fertility, and cervical mucus viscosity. Premenstrually, the release of
prostaglandins in the uterus causes vasoconstriction and muscle
contractions that lead to the tissue ischemia and pain associated
with dysmenorrhea (painful menses). During pregnancy,
prostaglandins are believed to help maintain a reduced placental
vascular resistance and play a part in the biochemical process that
initiates labor.
Relaxin is a hormone primarily produced by the corpus luteum
during pregnancy, although the uterine decidua and the placenta are
also believed to produce small amounts. Relaxin may be detected in
maternal serum by the time of the first missed menstrual period.
Although its role in pregnancy is not fully understood, relaxin aids in
the softening and lengthening of the uterine cervix and works on the
myometrial smooth muscle to promote uterine relaxation. Inhibin is
secreted by the ovaries, and the primary role is to inhibit the
secretion of FSH from the anterior pituitary gland. For more on the
roles of female reproductive hormones, see Table 2-1.
SEXUAL MATURATION
Puberty
Puberty is the biological time frame between childhood and
adulthood characterized by physical body changes that lead to
sexual maturity. During this period, adolescents experience a growth
spurt, develop secondary sexual characteristics, and achieve
reproductive maturity. The timing of puberty onset and its progress
vary among individuals and are influenced primarily by genetics.
However, other
factors such as geographical location, exposure to light, nutritional
status, and general health also influence the timing of puberty. We
know that puberty is initiated by events that lead to the production of
GnRH in the hypothalamus. GnRH stimulates the manufacture of
FSH and LH in the anterior pituitary. The increasing levels of FSH
and LH initiate a gonadal response that varies between males and
females.
In females, sexual maturation begins with thelarche, the
appearance of breast buds. Thelarche, which occurs at about 13
years of age, is the first signal that ovarian function has begun and is
followed by the growth of pubic hair. During thelarche, there is a
growth spurt and the development of other sex characteristics such
as pubic hair and menses (Venes, 2021).
Major hormonal events surrounding menarche involve the
secretion of FSH from the pituitary gland. FSH stimulates the ovaries
to begin follicular maturation and to produce estrogen. After
maturation of an ovum, LH stimulates release of the ovum from the
ovary (ovulation). Left behind is the corpus luteum (“yellow body”
that remains in the ovary following ovulation), a structure that
produces progesterone.
In males, LH stimulates the Leydig cells in the testicles to mature
the testes and begin testosterone production. FSH and LH stimulate
sperm production. Increasing levels of estrogen, progesterone,
testosterone, and other circulating androgens stimulate the
hypothalamus to release more GnRH, which perpetuates the cycle.
As puberty progresses, the gonads become increasingly sensitive to
hormone stimulation and begin to function. Testosterone secretion
causes testicular enlargement, which is the first sign of pubertal
change in males.
TABLE 2-1
Hormones of Female Reproduction
HORMONE SECRETED BY FUNCTIONS
FSH Anterior pituitary • Initiates development of ovarian
follicles
• Stimulates secretion of estrogen by
follicle cells
• Stimulates the follicle, ovum, or sac to
mature
LH Anterior pituitary • Causes the release of the ovum for
ovulation
• Converts the ruptured ovarian follicle
into the corpus luteum
• Stimulates secretion of progesterone
by the corpus luteum
Estrogen* Ovary (follicle) • Promotes maturation of ovarian
Placenta during follicles
pregnancy • Promotes growth of blood vessels in
the endometrium
• Initiates development of the secondary
sex characteristics:
• growth of the uterus and other
reproductive organs
• growth of the mammary ducts and fat
deposition in the breasts
• broadening of the pelvic bone
• subcutaneous fat deposition in hips
and thighs
Progesterone Ovary (corpus • Promotes successful implantation of
luteum) Placenta the embryo in the endometrium
during pregnancy • Promotes further growth of blood
vessels in the endometrium and
storage of nutrients
• Inhibits contractions of the myometrium
Inhibin Ovary (corpus • Inhibits secretion of FSH
luteum) • Softening and lengthening effect on the
uterine cervix
• Works on the myometrial smooth
muscle to promote uterine relaxation
Relaxin Ovary (corpus • Inhibits contractions of the myometrium
luteum) Placenta to facilitate implantation
during pregnancy • Promotes stretching of ligaments of the
pubic symphysis
Source: Adapted from Scanlon, V. C., & Sanders, T. (2018). Essentials of anatomy
and physiology, 8th ed. Philadelphia: FA Davis Company.
Development of secondary sexual characteristics begins around
age 11 to 13 years of age, and puberty is completed when a young
person reaches sexual maturity at approximately 18 to 20 years of
age. The time frame from the first stages of puberty to full sexual
maturation ranges from 1.5 to 9 years. In females, puberty is
generally initiated about 2 years earlier in the life span than in males.
Throughout the process of puberty, individuals experience a myriad
of physical, psychological, and emotional changes. Alterations in
body image and social interactions typically accompany these
changes.
Female Secondary Sexual Characteristics

At birth, oocytes are present in the ovary as primary follicles in a
state of suspended meiosis. With the onset of puberty, hormonal
stimulation prompts the ovaries to secrete small amounts of
estrogen. As the process of puberty progresses, estrogen levels rise
and menarche occurs. However, estrogen levels at this time are
usually insufficient to stimulate ovulation and the menstrual periods
are generally unpredictable and irregular. As the gonadotropin cycles
continue, the ovaries mature from sustained hormonal stimulation
and eventually become capable of follicular maturation with
increasing numbers of cycles. Over time, regular cyclic ovulation is
established, and each menstrual period becomes more predictable.
Examples of some of the pubertal changes that occur in the female
are presented in Table 2-2.
Other female secondary sexual characteristic changes include
growth and development of the vagina, uterus, and fallopian tubes;
darkening and growth of the areola and external genitals; and
widening of the hips. Appearance of the secondary sexual
characteristics precedes menarche. Estrogen is primarily responsible
for changes in the breasts, although progesterone, thyroxine,
cortisol, insulin, and PRL also affect glandular development.
Assessment Tools
Tanner Staging of Sexual Maturity
Many different factors can influence puberty, such as age, genetics,
environment, nutrition, and cultural practices. The nurse can determine a
patient’s stage of puberty with the Tanner scale, a measurement tool based on
the development of secondary sex characteristics (Tanner, 1962) (Fig. 2-13).
FIGURE 2-13 Maturation states in females. A, Preadolescent. No

pubic hair, just fine body hair similar to hair on abdomen. B, Sparse
growth of long, downy hair, straight or slightly curled mainly along
labia. C, Darker, coarser, curlier hair that spreads over pubic
symphysis. D, Hair is coarse and curly and covers more area. E,
Adult. Hair may spread over medial surfaces of thighs but not over
abdomen.
THE MENSTRUAL CYCLE AND REPRODUCTION

Menstruation is the periodic discharge of bloody fluid from the vagina
that women experience during reproductive years. Menstrual flow
begins at puberty and continues for approximately 3 to 4 decades.
The menstrual cycle refers to the changes that occur in the uterus,
cervix, and vagina at menstruation and during the interval between
each menstruation, termed the “intermenstrual period.” The average
time for a menstrual cycle is 28 to 32 days, although women
experience considerable variation among monthly cycles. Factors
such as stress, nutritional status, excessive exercise, fatigue, and
illness can alter an individual’s cycle intervals and length.
Menstruation and ovulation, key elements in the reproductive
cycle, are controlled by positive and negative feedback systems
associated with hormones released by the hypothalamus, pituitary,
and ovaries. In synchrony, the hormones coordinate the complex
biochemical events that result in the monthly menstrual cycle.
Regulation of the menstrual cycle involves an overlapping of the
uterine (endometrial), hypothalamic-pituitary, and ovarian cycles (see
Figs. 2-11 and 2-12).
TABLE 2-2
Female Body Changes Associated With Puberty
TYPE OF BODY DEFINITION AVERAGE AVERAGE
BODY CHANGE AGE AGE
CHANGE INITIATED COMPLETED
Growth spurt Adolescent Height increase 10 11.8
growth spurt 2.4–4.3 inches
(6–11 cm) in 1
year
Secondary Thelarche Breast budding 9.8 14.6
Adrenarche ↑ Adrenal 10.5
androgen
secretion
→ axillary and
pubic hair
Primary Menarche First menstrual 12.8
period
Uterine (Endometrial) Cycle

The uterine, or endometrial, cycle has four phases: menstrual,
proliferative, secretory, and ischemic.
Menstrual Phase
The menstrual phase is the time of vaginal bleeding, approximately
days 1 to 6 of the menstrual cycle. The onset of menses signals the
beginning of the follicular phase of the ovarian cycle. Menstruation is
triggered by declining levels of estrogen and progesterone produced
by the corpus luteum. The decrease in hormones results in poor
endometrial support and constriction of the endometrial blood
vessels. These changes lead to a decreased supply of oxygen and
nutrients to the endometrium. Disintegration and sloughing of the
endometrial tissue occurs. During menstruation, constriction of the
endometrial blood vessels limits the likelihood of hemorrhage.
Prostaglandins also play a role in menstruation. The uterus
releases prostaglandins that cause contractions of the smooth
muscle and decrease the risk of hemorrhage. Prostaglandin-induced
uterine contractions often produce dysmenorrhea (painful
menstruation) in the days surrounding the onset of menstrual flow.
Other systemic effects of prostaglandins include headache and
nausea. Over-the-counter medications that inhibit prostaglandin
synthesis such as nonsteroidal anti-inflammatory agents (NSAIDs)
can be used to control the discomfort associated with dysmenorrhea
and premenstrual syndrome (PMS).
Menstrual fluid is composed of endometrial tissue, blood, cervical
and vaginal secretions, bacteria, mucus, leukocytes, prostaglandins,
and other debris. The color of menstrual fluid is typically dark red but
varies throughout the days of menses. The amount of discharge is
typically 30 to 40 mL, and the duration of bleeding is 4 to 6 days ± 2
days.
Proliferative Phase
The proliferative phase is the end of menses through ovulation
(approximately days 7 to 14). At the beginning of the proliferative
phase, the endometrial lining is 1 to 2 mm thick. Circulating estrogen
levels are low. Gradually increasing levels of estrogen, enlarging
endometrial glands, and the growth of uterine smooth muscle
characterize the proliferative phase. Endometrial receptor sites for
progesterone are developed during this time. Systemic effects of the
increasing amount of estrogen include an increased secretion of
thyroxine-binding globulin (TBG) by the liver, an increase in the
breast mammary duct cells, thickening of the vaginal mucosa, and
changes in cervical mucus (i.e., increased amount and elasticity) to
facilitate sperm penetration at midcycle.
Secretory Phase
The secretory phase is the time of ovulation to the period just before
menses (approximately days 15 to 26). This phase of the
endometrial cycle is characterized by changes induced by increasing
amounts of progesterone. Progesterone creates a highly vascular
secretory endometrium suitable for implantation of a fertilized ovum.
Glycogen-producing glands secrete endometrial fluid in preparation
for a fertilized ovum. At this time, endometrial growth ceases, and
the numbers of estrogen and progesterone receptors decrease.
Other progesterone effects during the secretory phase include
increased glandular growth of the breasts, thinning of the vaginal
mucosa, and increased thickness and stickiness of the cervical
mucus.
Ischemic Phase
The ischemic phase is from the end of the secretory phase to the
onset of menstruation (approximately days 27 to 28). During the
ischemic phase, estrogen and progesterone levels are low, and the
uterine spiral arteries constrict. The endometrium becomes pale in
color as a result of a limited blood supply, and the blood vessels
ultimately rupture. Rupture of the endometrial blood vessels leads to
the onset of menses (this event marks day 1 of the next cycle) and
initiation of the menstrual phase of the cycle.
Hypothalamic-Pituitary-Ovarian Cycle
The menstrual cycle is controlled by complex interactions between
hormones secreted by the hypothalamus, anterior pituitary, and
ovaries. Hormones from the hypothalamic-pituitary-gonadal (ovarian)
axis interact with one another and influence the secretion of
hormones from other sites. The hypothalamus and anterior pituitary
communicate through the hypophyseal portal system (a system of
venous capillary blood vessels that supplies blood and endocrine
communication between the hypothalamus and pituitary). The major
interacting hormones include GnRH (hypothalamus), LH, and FSH
(pituitary), and estrogen and progesterone (ovaries).
Hypothalamic-Pituitary Component
The pituitary receives GnRH input from the hypothalamus. GnRH
stimulates the secretion of FSH and LH. FSH prompts the ovaries to
secrete estrogen and progesterone, and these hormones inhibit the
continued secretion of hypothalamic GnRH. FSH also induces the
proliferation of ovarian granulosa cells. LH stimulates the growth of
the ovarian follicles and prompts ovulation and luteinization
(formation of the corpus luteum) of the dominant follicle. The corpus
luteum produces high levels of progesterone along with small
amounts of estrogen.
Ovarian Component
The ovarian portion of the hypothalamic-pituitary-ovarian axis occurs
in two phases: the follicular phase and the luteal phase. The phases
are distinguished by events in the ovarian cycle, especially those
related to ovulation.
FOLLICULAR PHASE
Day 1 of the menstrual cycle begins with the onset of bleeding
(menstruation). This event marks the beginning of the follicular
phase, which lasts about 14 days but can vary from 7 to 22 days.
This variance often accounts for the irregularity in menstrual cycles
in some women (Dashe et al, 2018). The follicular phase is
characterized by dominance in estrogen, FSH, and LH.
FSH stimulates the ovary to prepare a mature ovum for release at
ovulation. LH stimulates the theca cells of the ovary to produce
androgens that convert to estrogen in the granulosa cells of the
ovary. Immediately before ovulation, the hypothalamus secretes
GnRH. This action prompts the anterior pituitary to release LH and
FSH. The surge of LH stimulates the release of the ovum, and
ovulation generally occurs within 10 to 16 hours after the LH surge.
Ovulation signifies the end of the follicular phase of the ovarian
follicular cycle. The ovum is capable of fertilization by a sperm cell
for approximately 12 to 24 hours after ovulation. The follicle that
contained the mature ovum remains in the ovary and becomes the
corpus luteum, a structure that plays a major role during the second
half, or luteal phase, of the ovarian cycle.
LUTEAL PHASE
The luteal phase of the ovarian cycle begins at ovulation and ends
with the onset of menses. When pregnancy is not achieved following
ovulation, the corpus luteum dominates the second half of the
menstrual cycle. In the absence of fertilization, the life span of the
corpus luteum is 14 days. The corpus luteum secretes estrogen and
progesterone, producing negative feedback that signals the anterior
pituitary gland to decrease production of FSH and LH. As the end of
the luteal phase nears (approximately 8 to 10 days), low levels of
FSH and LH cause regression of the corpus luteum. Degeneration of
the corpus luteum is associated with declining levels of estrogen and
progesterone. The resultant low progesterone levels stimulate the
hypothalamus to secrete GnRH, whereas the decreased levels of
estrogen and progesterone trigger endometrial sloughing. The
corpus albicans (“white body”) forms from the remnants of the
corpus luteum and eventually disappears.
Body Changes Related to the Menstrual Cycle and Ovulation

Before ovulation, several events indicate that the woman’s body is
preparing for fertilization of the released ovum. Increased estrogen
secretion by the ovaries produces changes in the cervical mucus
that help sperm successfully locating the ovum. Cervical mucus
dramatically increases in amount and quality. It becomes watery and
clear, creating a pathway for sperm to readily swim through the
cervix. The elasticity (spinnbarkeit) of the cervical mucus increases,
and the woman can assess this change by stretching the mucus
between her fingers (Fig. 2-14). Another method of assessment
involves stretching the cervical mucus between two glass slides. At
the time of ovulation, the cervical mucus can be stretched to 8 to 10
cm or longer. If the mucus is thin, watery, and stretchable, the
woman is ready to conceive. Some females will also experience
mittelschmerz, which is pain/discomfort in the lower abdomen on the
side in which the ovary is ovulating, which may be confused with
other medical conditions such as appendicitis and ectopic
pregnancy. Breast tenderness is often another bodily symptom that
many females will experience during ovulation.
FIGURE 2-14 Spinnbarkeit (elasticity).
Physiological changes also accompany ovulation. The basal body

temperature (BBT) increases 0.3°C to 0.6°C (or 0.6°F to 1.1° F)
approximately 24 to 48 hours after ovulation, and some women
experience mittelschmerz (abdominal pain that occurs at the time of
ovulation, typically described as a cramping sensation) and midcycle
spotting. It is still possible to become pregnant at this point in the
menstrual cycle, even when spotting is present.
Natural Cessation of Menses

Climacteric Phase
The climacteric is a phase characterized by the decline in ovarian
function and the associated loss of estrogen and progesterone
production.
Perimenopausal Phase
Perimenopause, the time preceding menopause, is the period
associated with declining fertility and can last several years. The
number of ovarian follicles responsive to gonadotropins is
decreased, and the responsive follicles do not develop as quickly as
before. Because of these normal changes, many cycles during
perimenopause are anovulatory (no ova are released from the
ovary). Anovulatory menstrual cycles are irregular and often variable
in the amount of blood flow. The peri/postmenopausal period is
characterized by greatly decreased amounts of endogenous
estrogen, which can cause many physical changes including:
■ Vasomotor instability (hot flashes and night sweats)
■ Atrophy of the urogenital sites (vaginal dryness and urinary
disturbances)
■ Amenorrhea (cessation of menses) or irregular menstrual cycles
■ Decrease in pubic and axillary hair
■ Skin changes (hyper/hypopigmentation, decreased sweat and
sebaceous gland activity, thinning of the epidermal and dermal
skin layers, and decrease in hair distribution)
■ Musculoskeletal changes (bone thinning and osteoporosis)
■ Psychological changes (anxiety, depression, irritability, libido
changes, and insomnia)
Menopause
Menopause simply refers to the last menstrual period.
Postmenopausal Phase
Postmenopause is the time after the permanent cessation of the
menstrual cycle and is diagnosed when there has been no menstrual
cycle in 1 year. It is characterized by estrogen production solely by
the adrenal glands. On average, postmenopause occurs around 40
to 58 years of age. Health risks increase during this time period and
although controversial, menopausal HT, prescribed on a highly
individual basis, may be appropriate for short-term use to minimize
moderate to severe vasomotor symptoms (e.g., hot flashes and night
sweats) and improve quality of life. HT can be provided as estrogen-
only or as estrogen and progestin. Estrogen-only HT reduces the
symptoms of menopause. Adverse effects of estrogen therapy
include increased risk of venous thromboembolism (VTE), especially
in women with a history of VTE or factor V Leiden (a
hypercoagulability disorder), and breast cancer (when taken longer
than 3 to 5 years). Due to these adverse effects, HT should always
be prescribed at the lowest dose and for the shortest time period to
achieve symptom control. Other non-HT treatments include the use
of antidepressants, gabapentin, and nonpharmacological modalities
such as yoga, meditation, and tai chi, which have been shown to
help reduce symptoms (Venes, 2021).
Menstrual Disorders
Various menstrual disorders may occur during adolescence. The
most common conditions are menstrual cramps, dysmenorrhea
(painful menstruation that interferes with daily activities), and PMS.
Amenorrhea
Amenorrhea is the absence of menses and has several possible
causative factors. Primary amenorrhea is defined as lack of
menarche by the age of 16. Secondary amenorrhea is the absence
of a menstrual cycle for more than 3 months in girls or women who
previously had regular menstrual cycles and are not pregnant
(Venes, 2021). Physiological causes for amenorrhea include
pregnancy, postpartum, lactation, menopause, and medications such
as contraceptives that cease the menstrual cycle. Pathological
causes for amenorrhea can be related to a vast array of factors such
as hormonal imbalances, behavior conditions such as anorexia or
excessive exercising, stress, and disease. Evaluation for
amenorrhea often begins with ruling out physiological amenorrhea.
Because amenorrhea is often a symptom of other diseases,
evaluation will include full assessment, including dietary assessment,
behavioral assessment, head-to-toe evaluation, and blood work with
hormone panel of GnRH, FSH and LH levels, CBC, thyroid
stimulating hormone, and PRL levels.
Dysmenorrhea
Painful cramping in the uterus during menstruation occurs from
myometrial contractions induced by prostaglandins during the
second phase of the menstrual cycle. Prostaglandins are chemical
mediators that cause pain as part of the inflammatory response;
during menstruation, cramps are frequently accompanied by back
pain and headache. Peaking levels of prostaglandins cause the
symptoms to begin a day or two before the beginning of menstrual
flow and continue until about the second or third day of menstrual
flow.
Dysmenorrhea is painful menstruation that affects a woman’s
ability to perform daily activities for at least 2 days each month. It
affects approximately 50% of menstruating women with 10%
experiencing debilitating pain. Primary dysmenorrhea occurs with
ovulatory menstrual cycles. Symptoms include lower abdominal pain
that may radiate to the lower back or legs, headache, nausea,
vomiting, diarrhea, irritability, fatigue, and depression. Secondary
dysmenorrhea is menstrual pain that often occurs after the age of 20
and is associated with a gynecological condition such as fibroids or
endometriosis (Venes, 2021).
Health-care teaching for females experiencing dysmenorrhea
should be holistic in nature and include relaxation and breathing
techniques, the use of heat to reduce uterine contractions and
increase blood flow to the uterine tissues, exercise or rest, and the
use of NSAIDs to inhibit the synthesis of prostaglandin. For some
women, dysmenorrhea is symptomatic of other conditions, including
pelvic inflammatory disease (PID) and endometriosis. Severe pain
and dysmenorrhea that disrupts a woman’s life should be evaluated
by a healthcare provider.
Premenstrual Syndrome
PMS is another commonly occurring disorder associated with
menstruation that affects adolescents. Symptoms range from
irritability and mood changes to fluid retention, heart palpitations, and
visual disturbances. Although the most common cause of PMS is the
normal fluctuation of estrogen and progesterone during the
menstrual cycle, other factors may be associated with PMS
symptoms as well. For example, some PMS symptoms may result
from an imbalance in the levels of estrogen and progesterone,
hyperprolactinemia (an excessive secretion of PRL, the hormone
responsible for stimulation of breast development), alterations in
carbohydrate metabolism and hypoglycemia, and an excessive
production of aldosterone resulting in sodium and water retention.
Recommendations for reducing the severity of the symptoms
associated with PMS include the incorporation of simple lifestyle
changes. Adolescents should be encouraged to have 60 minutes or
more of physical activity daily, eat a well-balanced diet, and get
adequate sleep and rest. Dietary changes include increasing the
daily intake of whole grains, vegetables, and fruits, while decreasing
the intake of salt, sugar, and caffeine
For more problematic symptoms, treatment may include the use of
diuretics to reduce fluid retention, the administration of NSAIDs to
inhibit synthesis of prostaglandins and provide pain relief, central
nervous depressants to promote relaxation, antidepressants, and
vitamin supplements. Other medical treatment may include
combined hormonal contraception containing low-dose estrogen,
which will help to reduce incidence of dysmenorrhea and
premenstrual symptoms.
MALE REPRODUCTIVE SYSTEM

External Structures
The external structures consist of the perineum, penis, and scrotum
(Fig. 2-15).
Perineum
The male perineum is a roughly diamond-shaped area that extends
from the symphysis pubis anteriorly to the coccyx posteriorly and
laterally to the ischial tuberosity.
Penis
The penis is composed of three cylindrical masses of erectile tissue
that surround the urethra. The function of the penis is to contain the
urethra and serve as the terminal duct for the urinary and
reproductive tracts by excreting urine and semen. During sexual
arousal, the penis becomes erect to allow penetration for sexual
intercourse.
The glans penis is the tip of the penis. It contains many nerve
endings and is very sensitive, which is important for sexual arousal.
The urethra is approximately 8 inches (20 cm) long and serves as a
passageway for both urine and ejaculated semen. It extends from
the urinary bladder to the urethral meatus at the tip of the penis.
Circumcision is a surgical procedure in which the prepuce (epithelial
layer covering the penis; foreskin) is separated from the glans penis
and excised.
Figure 2-15 The male reproductive system shown in a midsagittal

section through the pelvic cavity.
Scrotum
The scrotum is a two-compartment pouch covered by skin. It is
suspended from the perineum and contains two testes, the
epididymis, and the lower portion of the spermatic cord. The scrotum
functions to enclose and protect the two testes. A large component
of the protection occurs through temperature regulation of the testes
accomplished by the dartos and cremaster scrotal muscles. These
muscles control elevation of the scrotal sac to help maintain the
testes in a controlled temperature environment. When exposed to
cold, the scrotal muscles contract, causing the testes to be elevated
closer to the body to preserve warmth.
Internal Structures
The internal male reproductive structures include the testes,
epididymides, ducts (vas deferens and ejaculatory duct), urethra,
spermatic cords, and accessory glands (seminal vesicles, prostate,
bulbourethral glands, and urethral glands).
Testicles/Testes
The male testes produce sperm, which are necessary for
reproduction. The two testicles are composed of several lobules,
seminiferous tubules, and interstitial cells separated by septa. They
are encased in the tunica albuginea capsule. The seminiferous
tubules open into a plexus (rete testis) drained by efferent ductules
located on the top of the testicle that enters the head of the
epididymis. The seminiferous tubules contain spermatogonia, or
sperm-generating cells, that divide first by the process of mitosis to
produce primary spermatocytes (Fig. 2-16).
One testicle is housed in each compartment of the scrotum. The
function of the testicle is twofold and includes spermatogenesis and
the production and secretion of the male hormone testosterone by
the interstitial cells of Leydig.
Spermatogenesis, the formation of mature sperm within the
seminiferous tubules, is a process that occurs in the following four
stages (see Fig 2-16).
1. Spermatogonia, the primary germinal epithelial cells, grow and
develop into primary spermatocytes. Spermatogonia and primary
spermatocytes both contain 46 chromosomes; these consist of
44 autosomes and the two sex chromosomes, X and Y.
2. The primary spermatocytes divide to form secondary
spermatocytes. In this stage, no new chromosomes are formed;
the pairs only divide. Each secondary spermatocyte contains half
the number of autosomes—22. One secondary spermatocyte
contains an X chromosome, and the other contains a Y
chromosome, one of which will combine with the ova to
determine the sex of the fetus.
3. Each secondary spermatocyte then undergoes another division
to form spermatids.
4. In the final stage, the spermatids undergo a series of structural
changes that transform them into mature spermatozoa (sperm),
each containing a head, neck, body, and tail. The head houses
the nucleus; the tail contains a large amount of adenosine
triphosphate (ATP), which provides energy for sperm motility.
Epididymis
The two epididymides are tightly coiled tubes on the top of each
testis. The epididymides store maturing sperm cells and convey
sperm to the vas deferens. They also secrete seminal fluid and serve
as the site where sperm become motile.
Ducts
Each testicle has a secretory duct, the vasa deferentia, which
extends beyond the epididymis through the inguinal canal, into the
abdomen, and over and behind the bladder to excrete seminal fluid.
The vasa deferentia connects the epididymis with the ejaculatory
ducts, which then connect to the seminal vesicle ducts. The
ejaculatory ducts pass through the prostate gland and terminate in
the urethra.
Figure 2-16 Spermatogenesis. The processes of mitosis and
meiosis are shown. For each primary spermatocyte that undergoes
meiosis, four functional sperm cells are formed. The structure of a
mature sperm cell is also shown.
Urethra
The urethra is a mucus membrane-lined tube that passes from the
bladder to the exterior of the body. It joins with the two ejaculatory
ducts in the prostate gland. Its length is approximately 8 inches (20
cm). In males, the urethra functions in both the urinary and
reproductive systems.
Spermatic Cords
The two spermatic cords are fibrous cylinders located in the inguinal
canals. They enclose the seminal ducts, blood and lymphatic
vessels, and nerves.
Accessory Glands
The accessory glands include the seminal vesicles, prostate,
bulbourethral glands, and urethral (Littre’s) glands. The two seminal
vesicles are pouches located on the posterior surface of the bladder.
They secrete the viscous nutrient-rich component of seminal fluid.
This fluid, which accounts for 60% of semen volume, contains
alkaline prostaglandin to help neutralize semen pH.
The prostate, located inferior to the bladder, is a donut-shaped
structure that encircles the urethra. It secretes a thin, milky, alkaline
fluid rich in zinc, citric acid, acid phosphatase, and calcium. Prostatic
fluid helps protect sperm from the acidic environments of the vagina
and male urethra and accounts for 30% of the semen volume.
Each of the two bulbourethral glands is a small pea-shaped organ
that contains a 1-inch (2.5-cm) long duct leading into the urethra.
These glands are located below the prostate gland and secrete fluid
to lubricate the end of the penis. This fluid makes up 5% of the
semen volume.
Multiple urethral, or Littre’s, glands are located along the urethra,
especially in the penile section. They secrete mucus that is
incorporated into the semen.
Characteristics of Semen and Sperm

Seminal fluid consists of secretions from the testes, the
epididymides, the seminal vesicles, the prostate, the bulbourethral
glands, and the urethral glands. Seminal fluid, secreted during
ejaculation, is slightly alkaline with a pH of about 7.5. The typical
amount present in one ejaculate is 2 to 5 mL. Each milliliter of
ejaculate contains approximately 120 million sperm cells, about 40%
of which are motile. Each milliliter also contains about 5 million white
blood cells along with secretions from the testes, epididymides,
seminal vesicles, prostate, and bulbourethral glands. The following
pathway traces the events from the formation of sperm to the
ejaculation of semen:
1. The testes produce sperm that are transported to the epididymis.
2. Sperm and seminal fluid move to the vas deferens.
3. The seminal fluid moves to the ejaculatory duct before exiting the
body through the urethra.
Sperm can survive for up to 72 hours postejaculation in a woman’s
body with in optimal alkaline conditions. Sperm take an average of 5
minutes to travel from the cervix to the fallopian tubes under
favorable conditions.
Male Hormonal Influences

The testes produce androgens, the male sex hormones.
Testosterone is the dominant male hormone. At the time of puberty,
testosterone stimulates enlargement of the testes and accessory
organs and prompts development of male secondary sex
characteristics, which include changes in body hair (coarse hair on
face, chest, and pubic area and sometimes decreased hair on the
head), a deepening of the voice, thickened skin, increased upper
body musculature and narrow waist, and a thickening and
strengthening of bone (Shier, Butler, & Lewis, 2011). Testosterone
also prompts a linear growth spurt.
Age-Related Development of the Male Reproductive System

Similar to embryological development in the female, the male genital
organs develop in the abdomen of the fetus but remain immature
until birth nears. The testes develop near the kidneys and descend
into the scrotum through the inguinal canal after 35 weeks’ gestation.
Scrotal examination is an important component of the male
neonate’s physical assessment to ensure that the testes have
descended and do not remain in the inguinal canal. Cryptorchidism
is the condition in which the testes fail to descend; sterility results
unless the testes are surgically placed in the scrotum (Scanlon &
Sanders, 2018). It is important to locate both testes in a newborn
because testicular failure to descend may indicate gonadal
malgenesis, which can lead to testicular cancer and fertility issues in
young adulthood.
The reproductive functions of the testes begin at puberty. Once
critical hormone levels have been reached, the final stages of
reproductive system development occur. A gradual decline in
hormone production normally occurs during late adulthood. Although
the hormonal decline may be associated with a decrease in sexual
desire and fertility, most men maintain the ability to reproduce into
old age.
HUMAN SEXUAL RESPONSE

In the 1960s, the research work of Masters and Johnson (1966)
helped define sexuality as a natural component of a healthy human
personality. Before that time, human sexuality was often viewed as a
negative, nonexistent, or shameful characteristic that should be
shrouded in secrecy. The work of these researchers gave new
insights into the physical components of human pleasure during
sexual response and orgasm.
Masters and Johnson described four human sexual response
phases: excitement, plateau, orgasmic, and resolution. The
excitement phase is characterized by physiological responses to
internal and/or external cues. Women experience vaginal lubrication,
breast and pelvic engorgement, and increased heart rate, respiratory
rate, and blood pressure. Clitoral and labial tissues become swollen,
the nipples become erect, and the vagina becomes distended and
elongated. Men experience penile engorgement with an increase in
circumference and length (erection) along with scrotal thickening and
elevation.
During the plateau phase, women experience the most heightened
sense of sexual tension. The labia become more congested, the
vagina becomes more fully expanded, and the uterus rises out of the
pelvis in preparation for intercourse. Most women also experience
sexual flushing, tachycardia, and hyperventilation. In men, the
testicles enlarge and become elevated and the coronal
circumference of the penis increases. Both genders experience
generalized muscular tension.
The orgasmic phase is characterized by an intense desire for
sexual release caused by congestion of the blood vessels.
Tachycardia, elevation of blood pressure, and hyperventilation are
intensified. These sensations build until orgasm is reached. Muscular
contractions occur in the man’s accessory reproductive organs (vas
deferens, seminal vesicles, and ejaculatory duct). Bladder sphincter
muscles relax while the urethra and perirectal muscles contract,
followed by ejaculation as orgasm occurs.
An overall release of muscular tension takes place during the
resolution phase. Both genders experience a feeling of warmth and
relaxation, and women may experience a brief refractory period or
“rest time” before they are interested in sexual intercourse again.
Some women are capable of experiencing multiple orgasms in a
shorter span of time compared with men.
Masters and Johnson were instrumental in opening the topic of
human sexual response for discussion and study in the United
States. The media often send the message that sexuality involves
only a physical expression such as the act of intercourse. In
actuality, human sexuality is a multidimensional phenomenon that
touches and permeates many aspects of human behavior. Humans
display diverse gender identification and sexual orientation.
Definitions of common terms describing sexual orientation are
presented in Table 2-3.
Sexuality and its reproductive implications are woven into the
fabric of human behavior. Because it is such an emotion-laden
aspect of life, people have many concerns, problems, and questions
about sex roles, behaviors, inhibitions, education, morality, and
related components such as contraception. The reproductive
implications of sexual behavior must also be considered. Some
people desire pregnancy; others wish to avoid it. Health concerns
are yet another issue that must be addressed. It is essential that
nurses who practice in reproductive care settings develop an
awareness and understanding of personal feelings, values, and
attitudes about sexuality. These insights allow the nurse to provide
sensitive, individualized care to women who have their own set of
values and beliefs.
TABLE 2-3
Common Terms: Gender Identity and Sexual Orientation
Heterosexual Attracted to the opposite sex
Homosexual Attracted to the same sex
Lesbian Woman attracted to other women
Gay Man attracted to other men
Bisexual Sexual attraction to both men and women
Transgender Used when a person identifies with the opposite gender
of his or her biological sex
Intersex Person with both male and female primary and
secondary sex characteristics
Asexual Little or no sexual attraction to men or women
What to Say
Sexual Identity and Gender Orientation
Nurses should ask patients about sexual identity and gender orientation to
avoid making assumptions and to facilitate care targeted to the patient’s unique
concerns. Nurses and other health-care professionals need to address sexual
concern of all patients and ask questions in a nonjudgmental way. Avoid
discrimination and language that assumes heterosexuality. Questions to ask
regarding sexuality identity and gender orientation include:
• How would you like to be addressed?
• What name would you like to be called?
• What pronouns would you like me to use?
• Are you currently sexually active?
• Are your current sexual partners male, women, or both?
• In the past have your sexual partners been men, women, or both?
• Sexual orientation: Bisexual, gay, heterosexual, lesbian, queer, other, not sure
or don’t know?
• What safe sex methods do you use?
• Are you currently experiencing any sexual problems?
Source: (Dundin & Scannell, 2020; The Joint Commission, 2011)
CONTRACEPTIVE CARE
Seeking guidance and making decisions about contraception
(products that prevent pregnancy) are prompted by a number of
influences, primarily the desire to take control over one’s
reproductive life. Nurses can be instrumental in assisting women
who want to practice safe sex and providing effective contraception
when they do not desire to become pregnant. Women of all ages are
capable of responsible sexual behavior when given enough
education, motivation, and opportunity. One of the primary goals
during the contraceptive care visit is to determine and provide the
contraceptive method that best fits the woman or couple. Obtaining
the medical, social, and cultural history helps to safeguard the
patient’s health and guide discussion of the contraceptive choices
available to her. Patients often come for care with a specific birth
control method in mind. However, it is essential that the nurse
explore the woman’s knowledge and understanding of contraceptive
choices, her needs and motivations for using a method, preferences,
and level of commitment to use the method consistently. Open,
honest discussion where appropriate information can be provided in
a nonthreatening environment empowers the patient to make an
informed choice of a birth control method that is best suited to her
lifestyle.
Early assessment for current or past medical problems that may
interfere with pregnancy or which may be
contraindicated for a pregnancy is important. Some women may take
medications that can interfere with the efficacy of certain types of
contraception. For example, women with chronic health problems
such as diabetes, stroke, multiple sclerosis, cancer, or pain may take
medications associated with fetal anomalies (Table 2-4). If a patient
takes a contraceptive that has limited efficacy due to medication
interactions, she may experience an unexpected pregnancy that can
place the fetus as serious risk. Individualized counseling, guidance,
and reliable information help empower women to make informed,
realistic choices about reproductive planning.
Women also need to be counseled about the ideal age for
childbearing and the implications of delaying pregnancy too long.
Those who have not conceived by the mid to late 30s may remain
childless and subsequently feel regret. Outside pressures exerted by
cultural influences and family expectations often compound the
feelings of remorse. Providing all women with current information
about the natural aging process and its influence on fertility
empowers women of all ages to make informed decisions that best
suit their needs.
FOCUS ON SAFETY
Laws About Reproductive Health Care for Minors
Nurses who provide counseling or referrals to minors must be knowledgeable
about the legal rights and restrictions in place in their practice state. State and
federal laws may limit a minor’s ability to access reproductive health services
independent of his or her parents or guardian. In addition, not all states allow
minors to consent to contraceptive services and prenatal care; consent by a
minor to place a child for adoption or obtain abortion services also varies by
state.
Planning and Implementation of Care

Regardless of the patient’s age and contraceptive method selected,
the nurse must first seek the woman’s confirmation that she truly
wants contraception. Birth control is always an individual choice.
Feelings of helplessness and manipulation may result when the
woman believes that someone else has decided what is “best” for
her or coerces her into contraceptive use.
Obtaining the Sexual History

The sexual history elicits information concerning prior treatment for
sexually transmitted infections (STIs), pain with intercourse
(dyspareunia), postcoital spotting or bleeding, and frequency of
intercourse. Women who have intercourse more frequently and on a
regular basis are more likely to become pregnant. An important
component of holistic reproductive care centers on helping women to
understand their body’s natural functioning in relation to the
menstrual cycle, so that they can problem solve about the timing of
intercourse to achieve pregnancy if desired.
When the purpose of the reproductive health visit is obtaining
contraception, an immediate evaluation may take place at the
conclusion of the patient encounter in determining the best type of
contraception. This evaluation centers on mutually agreed on
outcomes that reflect the patient’s understanding of, and comfort
level with, the chosen method. The nurse should counsel patient on
all the following items of contraception:
TABLE 2-4
Drugs That Adversely Affect the Female Reproductive System
DRUG CLASS DRUG POSSIBLE ADVERSE
REACTIONS
Androgens Danazol Vaginitis, with itching, dryness,
Fluoxymesterone, burning, or bleeding;
methyltestosterone, amenorrhea
testosterone Amenorrhea and other
menstrual irregularities;
virilization, including clitoral
enlargement
Antidepressants Tricyclic Changed libido, menstrual
antidepressants irregularity
Selective serotonin Decreased libido, anorgasmia
reuptake inhibitors
Antihypertensives Clonidine, reserpine Decreased libido
Methyldopa Decreased libido, amenorrhea
Antipsychotics Chlorpromazine, Inhibition of ovulation
perphenazine, (chlorpromazine only),
prochlorperazine, menstrual
thioridazine, irregularities, amenorrhea,
trifluoperazine, change in libido
haloperidol
Beta blockers Atenolol, labetalol Decreased libido
hydrochloride, nadolol,
propranolol
hydrochloride,
metoprolol
Cardiac glycosides Digoxin Changes in cellular layer of
vaginal walls in postmenopausal
women
Corticosteroids Dexamethasone, Amenorrhea and menstrual
hydrocortisone, irregularities
prednisone
Cytotoxics Busulfan Amenorrhea with menopausal
Chlorambucil symptoms in premenopausal
Cyclophosphamide women, ovarian suppression,
Methotrexate ovarian fibrosis and atrophy
Tamoxifen Amenorrhea
Thiotepa Gonadal suppression (possibly
irreversible), amenorrhea,
ovarian fibrosis
Menstrual dysfunction, infertility
Vaginal discharge or bleeding,
menstrual irregularities, pruritus
vulvae (intense itching of the
female external genitalia)
Amenorrhea
Estrogens Conjugated estrogens, Altered menstrual flow,
esterified estrogens, dysmenorrhea, amenorrhea,
estradiol, estrone, cervical erosion or abnormal
ethinyl estradiol secretions, enlargement of
Dienestrol uterine fibromas, vaginal
candidiasis
Vaginal discharge, uterine
bleeding with excessive use
Progestins Medroxyprogesterone Breakthrough bleeding,
acetate, norethindrone, dysmenorrhea, amenorrhea,
norgestrel, cervical erosion, and abnormal
progesterone secretions
Thyroid hormones Levothyroxine sodium, Menstrual irregularities with
thyroid USP, and others excessive doses
Miscellaneous Lithium carbonate Decreased libido
L-tryptophan Decreased libido
Spironolactone Menstrual irregularities,
amenorrhea, possible polycystic
ovarian syndrome
Source: Dillon, P. M. (2016). Nursing health assessment: The foundation of clinical

practice, 3rd Ed. Philadelphia: F.A. Davis Company.
■ Effectiveness
■ Correct use
■ How it works
■ Common side effects
■ Risks and benefits
■ Warning signs
■ Return to fertility after discontinuation
■ Protection against STIs (World Health Organization, 2016)
Types of Contraception
Behavioral Methods
This type of contraception includes actions that women and men
take to prevent pregnancy without the use of medication or
equipment. These methods are often less reliable than other
methods and often fail because of incorrect use. Couples who are
committed to behavioral contraceptive methods should be aware of
the risk for pregnancy and think about how they would feel if a
pregnancy occurs. Health-care providers need to consider many
social factors if recommending these methods, as well as engage
patients in a complete discussion of risks and benefits.
NATURAL FAMILY PLANNING AND FERTILITY AWARENESS
Natural family planning (NFP) is a contraceptive method that
involves identifying the fertile time period and avoiding intercourse
during that time every cycle. Fertility awareness methods (FAMs)
identify the fertile time during the cycle and use abstinence or other
contraceptive methods during the fertile periods. These methods
require motivation and considerable counseling to be used
effectively. They may interfere with sexual spontaneity and require
several months of symptom/cycle charting before they may be used
effectively.
The patient and her partner need to be fully committed to use
these methods successfully, as success depends on the degree of
adherence to NFP. There are several variations: (1) the calendar, or
rhythm, method in which the fertile days are calculated; (2) the
standard days method in which color-coded strung beads are used
to track infertile days; (3) the cervical mucus method (also called the
“ovulation detection method” or the “Billings Ovulation Method”) in
which the changes in cervical mucus are used to track fertile periods;
(4) the BBT method in which body temperature changes are used to
detect the fertile period (Fig. 2-17; Box 2-1); and (5) the
symptothermal method that combines the BBT and cervical mucus
methods and involves recording various symptoms such as changes
in cervical mucus, mittelschmerz (abdominal pain at midcycle),
abdominal bloating, and the BBT to recognize signs of ovulation.
These methods are not best suited for adolescents or couples who
would be devastated by an unplanned pregnancy as there is a
higher failure rate resulting in an unplanned pregnancy compared
with other methods.
FIGURE 2-17 A basal body temperature chart.
BOX 2-1
Basal Body Temperature as an Indicator of

Ovulation
During the preovulatory phase, the basal temperature is usually below 98°F
(36.7°C). As ovulation approaches, estrogen production increases. At its peak,
estrogen may cause a slight drop, then a rise, in the basal temperature. Before
ovulation, a surge in LH stimulates the production of progesterone. The LH
surge causes a 0.5°F–1°F (0.3°C–0.6°C) rise in the basal temperature. These
changes in the basal temperature create the biphasic pattern consistent with
ovulation. Progesterone, a thermogenic, or heat-producing hormone, maintains
the temperature increase during the second half of the menstrual cycle.
Although the temperature elevation does not predict the exact day of ovulation,
it does provide evidence of ovulation about 1 day after it has occurred. Release
of the ovum probably occurs 24–36 hours before the first temperature
elevation.
Ovulation predictor kits detect the surge in LH that occurs 24 to 36

hours before ovulation. The kits vary in price and procedure, but
most are similar to home pregnancy tests and are performed on the
woman’s urine. Intercourse can then be timed to avoid or achieve
pregnancy.
COITUS INTERRUPTUS
Coitus interruptus, or the “withdrawal method,” involves the male
withdrawing his penis from the vagina before ejaculation. However,
ejaculation may occur before withdrawal is complete and
spermatozoa may be present in the pre-ejaculation fluid. This is one
of the least effective methods of contraception but can be used by
couples in a monogamous relationship who are not able to use other
methods of contraception. Men with unpredictable or premature
ejaculation have difficulty using this method successfully and should
be counseled on the risk of unplanned pregnancy. Coitus interruptus
does not eliminate the risk of STIs.
LACTATIONAL AMENORRHEA METHOD (LAM)

Breastfeeding can be a temporary form of contraception, although
it is used more effectively in underdeveloped countries where
mothers breastfeed their infants exclusively. Some lactating mothers
may ovulate but not menstruate. It is difficult to determine when
fertility is restored. This method is 98% effective when the following
conditions are met: 1. the mother exclusively breastfeeds, 2. has had
no menstrual period since giving birth, and 3. whose infant is
younger than 6 months of age. Lactation amenorrhea is considered
a temporary method and additional methods should be considered if
the patient doesn’t meet all 3 conditions (Centers for Disease Control
and Prevention, 2020).
ABSTINENCE
Abstinence is the only contraceptive method with a 100%
effectiveness rate. If a couple chooses to be abstinent (refrain from
vaginal intercourse), intimacy and sexuality may be expressed in
many other ways. Abstinence requires commitment and self-control,
but success with this method can lead to increased self-esteem and
enhanced communication about emotions and feelings.
Barrier Methods
Barrier methods block the sperm from reaching the ovum. They are
relatively inexpensive, and some types of barrier methods can be
used more than once. Although less effective than certain other
forms of contraception, barrier methods have gained in popularity as
many also offer protection against STIs. Many people dislike barrier
methods due to the inconvenience, because they often require
preplanning before intercourse.
Barrier methods have few side effects, although latex allergy may
lead to life-threatening anaphylaxis. Evidence shows consistent use
of latex condoms reduces the rate of HIV transmission, and both
condoms and diaphragms can reduce the risk of cervical STIs.
Barrier methods must be applied or inserted with clean hands. The
key to success with these contraceptives is consistent use with every
act of intercourse, and the nurse must ensure that women know how
to use their barrier method correctly and that they are satisfied with
their choice. Nurses should also inform patients about emergency
(postcoital) contraception (EC), offer to provide it to them in advance
of need, and ensure that they know how to obtain EC and also how
to use in cases where there was inadequate protection or a concern
with the integrity of the barrier method.
DIAPHRAGM
The diaphragm is a latex or silicone dome-shaped barrier device
with a spring rim that resembles half a tennis ball. The effectiveness
in preventing pregnancy for typical use is around 83%. Diaphragms
are available in several sizes and styles; the styles differ in the inner
construction of the circular rim. The diaphragm must be fitted by a
trained healthcare professional to ensure that the cervix will be
completely covered (Centers for Disease Control and Prevention,
2020).
Use of the diaphragm requires some planning. The diaphragm can
be inserted into the vagina up to 6 hours before intercourse, and it
must be filled with a spermicide applied inside and along the rim
before insertion (Fig. 2-18). The diaphragm must remain in place for
at least 6 hours after intercourse. If intercourse occurs again before
6 hours have elapsed, the diaphragm should be left undisturbed and
another applicator of spermicide should be inserted into the vagina.
The diaphragm should remain in place for 6 hours after the last act
of intercourse. To ensure continued protection, the diaphragm should
be replaced every 2 years, and may need to be refitted after weight
loss or weight gain, term birth, or second-trimester abortion.
FOCUS ON SAFETY
Inquire About Latex Allergy
Before advising any patients on contraceptives, especially when dispensing
latex diaphragms or latex male condoms, ask about a personal or partner
history of allergy to latex. Use of latex contraceptive devices is contraindicated
in patients with latex sensitivity, but latex-free devices are available.
CERVICAL CAP
The cervical cap is a thimble-shaped silicone device that fits firmly
around the base of the cervix close to the junction of the cervix and
vaginal fornices, similar to the diaphragm but smaller. It is somewhat
more difficult to use than the diaphragm because it must be placed
exactly over the cervix, where it is held in place by suction. The seal
provides a physical barrier to sperm and the spermicide placed on
the inside and on the outside of the cap provides a chemical barrier.
The cap may be worn for up to 48 hours. Women who choose the
cervical cap, available by prescription only, should practice insertion
and removal after the fitting and return in 1 week with the cap
inserted to check for proper placement.
FIGURE 2-18 Diaphragm insertion.
FOCUS ON SAFETY
Counseling Patients About the Diaphragm and Cervical Cap
Certain women are not suitable candidates for the diaphragm or cervical cap.
Patients who have a history of toxic shock syndrome, PID, cervicitis,
papillomavirus infection, a previous abnormal Pap test or cervical cancer, and
undiagnosed vaginal bleeding should choose another contraceptive method.
Also, women who have an abnormally short or long cervix may not be able to
use this barrier device.
Patient Education
Use of the Cervical Cap
Before insertion, approximately one-third of the cap is filled with spermicide; a
small amount of spermicide is also applied to the outside of the cap. Taking
care not to spill the inner spermicide, the woman inserts the cap into the vagina
and places it directly over the cervix. The woman is taught to use her finger to
trace around the rim of the cap to make certain the entire cervix is covered.
The cervical cap can be inserted up to 6 hours before intercourse and should
remain in place for 6 hours after the last intercourse. No additional spermicide
is necessary with repeated intercourse. The cap should never remain in place
longer than 48 hours and it should never be used during menses or when a
vaginal infection is present. To remove the cap, the woman is taught to rotate
the device and then push the tip of her finger against the dome to dimple it.
This action breaks the suction and allows room for the finger to fit between the
dome and the removal strap. The strap is then hooked with the finger and the
device is gently pulled down and out. The cap is then washed with mild
(nondeodorant, nonperfumed) soap and water. The cap should be dried
thoroughly and stored in a cool, dry place.
CONDOMS
Condoms are generally considered a male contraceptive device
although the female condom (vaginal sheath) is also available. Male
condoms may be made of latex rubber, polyurethane, or natural
membranes. Latex male condoms are widely recognized for their
role in preventing HIV infection and STIs. Natural skin condoms do
not offer protection against HIV and STIs because they contain small
pores that may permit the passage of viruses including HIV, hepatitis
B, and herpes simplex.
Male condoms are one of the oldest-known methods of
contraception. When used correctly, male condoms are placed over
the erect penis before any genital, oral, or anal contact. Condoms
are inexpensive, require no prescription, and are available in a
variety of sizes, shapes, and colors. To prevent pregnancy and the
spread of STIs, they must be used correctly at every act of
intercourse. With typical use, male condoms are about 87% effective
in preventing pregnancy (CDC, 2020).
Made of polyurethane, the female condom or vaginal sheath is
less widely used than the male condom. The female condom
resembles a sheath with a ring on each end: The closed end is
inserted into the vagina and anchored around the cervix; the open
end is placed at the vaginal introitus. The device is coated with a
silicone-based lubricant, and additional (spermicide-free) lubricant
for the outside is provided with the condom. Although no prescription
is needed, female condoms are often difficult to find, and they are
more expensive than male condoms. Female condoms contain no
latex; female condoms are safe for use in individuals with latex
allergies. When used correctly and consistently, female condoms are
about 79% effective in preventing pregnancy (CDC, 2020).
SPERMICIDES
Spermicides are available in the form of gels, creams, foams,
films, and suppositories. Readily available over the counter without
the need for a prescription, these formulas are inserted into the
vagina or used with diaphragms or cervical caps. Spermicides act as
chemical barriers that cause death of the spermatozoa before they
can enter the cervix. Although spermicides can be messy, the
lubrication afforded by the spermicide-based methods may improve
sexual satisfaction for both partners.
Women who are at risk for HIV should not use spermicides as
their only method of birth control (Hatcher et al, 2011). Because
spermicidal suppositories and films require 10 to 15 minutes to
become effective, women who cannot comply with this time
constraint may wish to use a spermicidal foam, cream, or gel
instead. Because of the low effectiveness rates associated with
spermicides, the woman who believes that pregnancy would be
personally disastrous may wish to choose another contraceptive
method. Spermicides should not be used in women with acute
cervicitis because of the potential for further cervical irritation. Rarely,
topical irritation may develop from contact with spermicides. When
this occurs, the product should be discontinued, and another
contraceptive method should be selected. The typical use
effectiveness of spermicides in preventing pregnancy is 79% (CDC,
2020).
Patient Education
Use of Spermicides
The woman should wash her hands before inserting any spermicide.
Spermicides are most effective when used with a diaphragm or cervical cap.
Most contraceptive films and suppositories require a period of 15 minutes to
elapse after insertion to become effective, and they should be inserted no
longer than 1 hour before intercourse. The spermicide should be inserted deep
into the vagina so that it contacts the cervix. Although douching is never
recommended, it should be avoided for 6 hours after intercourse to avoid
washing the spermicide away. Many spermicides contain nonoxynol-9 (N-9),
and patients should be counseled on the benefits and risks, as this chemical
may cause genital lesions and increase the transmission of STIs including HIV.
CONTRACEPTIVE SPONGE
The contraceptive sponge is a single-use vaginal spermicide. Soft,
round, and disposable, the polyurethane device has a concave
dimple on one side that is designed to fit over the cervix; the other
side contains a woven polyester loop to facilitate removal.
Effectiveness of the sponge ranges from 86% in women who have
not had a baby and 73% in women who have had a baby (CDC,
2020). The sponge is permeated with the spermicide nonoxynol-9.
The contraceptive sponge is contraindicated in women who are
allergic to the spermicide nonoxynol-9. The sponge should not be left
in place for more than 30 hours (which includes the 6-hour waiting
period after the last act of intercourse) because of the risk of toxic
shock syndrome. It should not be used during menstruation or
immediately after abortion or childbirth or if a woman has a history of
toxic shock syndrome.
FOCUS ON SAFETY
Teach About Toxic Shock Syndrome
Women who use the diaphragm, cervical cap, or contraceptive sponge should
be aware of the possible association between these devices and toxic shock
syndrome (TSS). Common signs of TSS include fever of sudden onset greater
than 101.1°F (38.4°C), rash, and hypotension with a systolic blood pressure
less than 90 mm Hg.
Hormonal Methods
Hormonal contraceptive methods include oral medications, the
transdermal patch, the vaginal ring, long-acting injectables, the
subdermal implant, and the progestin-releasing intrauterine device
(IUD). Estrogen and progestins decrease the pituitary’s release of
FSH and LH to prevent ovulation. Progestins also thicken cervical
mucus to prevent sperm penetration.
ORAL CONTRACEPTIVES
This method, known as “the pill,” or oral contraceptive pill (OCP),
has been available for more than 40 years and is 93% effective in
preventing a pregnancy (CDC, 2020). Hormonal contraceptives
contain a synthetic estrogen in the form of ethinyl estradiol,
mestranol, or estradiol valerate; ethinyl estradiol is the most common
estrogen used. Estrogens work by preventing the release of FSH
from the anterior pituitary. When FSH levels are kept low, the ovarian
follicle is unable to form, and ovulation is prevented.
Progestins provide effective contraception when used alone or in
combination with estrogen. When combined with an estrogen,
progestins inhibit the LH surge, which is required for ovulation. When
used alone, progestins are believed to inhibit ovulation
inconsistently. Progestin-only contraceptives are thought to function
primarily by creating a thickened cervical mucus (which produces a
hostile environment for sperm penetration) and causing endometrial
atrophy. These alterations inhibit egg implantation and decrease the
penetration of sperm and ovum transport.
In the United States, oral contraceptives are available in
monophasic, biphasic, triphasic, and 4-phasic preparations.
Monophasic formulas provide fixed doses of estrogen and progestin
throughout a 21-day cycle. Biphasic preparations provide a constant
amount of estrogen throughout the cycle, but there is an increased
amount of progestin during the last 11 days. Triphasic formulas,
designed to more closely mimic a natural cycle, provide varied levels
of estrogen and progestin throughout the cycle. Triphasic
preparations reduce the incidence of breakthrough bleeding
(bleeding that occurs outside menstruation) in many women. The 4-
phasic OCP, offers four progestin/estrogen dosing combinations
during each 28-day cycle and is the first contraceptive to contain the
“bioidentical” synthetic estrogen estradiol valerate (rather than
ethinyl estradiol).
Women who wish to use oral contraceptives should have their
baseline blood pressure taken and recorded. Depending on the
patient’s history or symptoms, a breast and pelvic examination may
be indicated; neither is needed before initiating OCPs in an
asymptomatic woman. A Pap test is not needed before starting
OCPs. STI testing, if indicated (based on symptoms, age, or
institutional policy), may be serum or urine-based. No other
screening tests are routinely needed unless the woman’s history or
blood pressure dictates a need for further assessment. Most health-
care providers schedule women for a return visit approximately 3
months after initiating the medication to confirm patient acceptance
and correct use of the method and to detect any complications.
Optimizing Outcomes
Medications That Decrease the Effectiveness of Oral Contraceptives

The nurse must take a thorough history on any patient who wishes to use oral
contraceptives for birth control. Certain medications such as rifampin (Rifadin,
Rimactane), isoniazid, barbiturates, and griseofulvin (Fulvicin-U/F, Gris-PEG,
Grifulvin V) can decrease the effectiveness of oral contraceptives, and higher
doses of estrogen must be used. Vomiting and diarrhea affect the absorption of
oral contraceptives, thus patients who experience these symptoms should use a
backup method such as condoms. Interactions with certain drugs such as
acetaminophen, anticoagulants, and some anticonvulsants (e.g., phenytoin
sodium, carbamazepine, primidone, and topiramate), may reduce efficacy of the
OCP.
Many noncontraceptive benefits are associated with OCPs (Box 2-

2). Healthy, nonobese perimenopausal women who do not smoke,
maintain a normal blood pressure, and have a normal well-woman
annual examination can safely use oral contraceptives. Oral
contraceptives can moderate the irregular bleeding that often occurs
during the perimenopausal period and provide contraception. When
used on an extended cycle basis, hot flashes and vaginal dryness
may also be alleviated. Careful consideration and assessment are
essential in women older than 35, as the onset of perimenopause
and menopause in women who use hormonal contraception may be
difficult to detect.
BOX 2-2
Noncontraceptive Benefits of Oral

Contraceptive Pills
Oral contraceptive pills are associated with a decreased incidence of:
• Fibrocystic breast changes
• Iron-deficiency anemia, caused by a reduced amount of menstrual flow
• Colorectal, endometrial, and ovarian cancer and the formation of ovarian
cysts
• Mittelschmerz and dysmenorrhea, because of the lack of ovulation
• Premenstrual dysphoric syndrome, as a result of increased progesterone
levels
• Acute PID and scarring of the fallopian tubes
• Ectopic pregnancy
• Endometriosis
• Uterine fibroids
• Osteopenia and osteoporosis
Contraindications
The nurse must be fully aware of several absolute and relative
contraindications to the use of combined OCPs. Most
contraindications to OCPs are related to the estrogen component,
including hypertension, migraine headaches, epilepsy, obstructive
jaundice in pregnancy, gallbladder disease, surgery with prolonged
immobilization, and sickle cell disease.
When counseling patients about OCPs, the nurse must be aware of
the following absolute contraindications:
■ Cigarette smoking (at least 15 cigarettes/day) and age greater
than 35 years
■ Uncontrolled hypertension
■ Undiagnosed abnormal vaginal bleeding
■ Diabetes of more than 20 years’ duration or with vascular
complications
■ History of blood clots, pulmonary embolism, or deep venous
thrombosis or congestive heart failure
■ Cerebrovascular disease or coronary artery disease
■ Severe migraine headaches
■ Estrogen-dependent neoplasia
■ Known or suspected breast cancer
■ Active liver disease
■ Known or suspected pregnancy
■ History of complications from organ transplants or presently
preparing for transplant surgery
■ Kidney or adrenal gland insufficiency/liver disease (drospirenone
[fourth generation progestin] use only)
Optimizing Outcomes
Teaching About Use of Oral Contraceptive Pills
The woman should identify a convenient and obvious place to keep her pills so
that she will remember to take one every day. Ovulation suppressants work only
when they are taken consistently and conscientiously. Several different
protocols (e.g., “quick start,” “first day start,” and “Sunday start”) are available
for the initiation of OCPs. If a patient begins menstruating more than 5 days
before the OCPs are started, a backup method of contraception should be used
for the first 7 days. OCPs should be taken at approximately the same time each
day. Many OCP formulations are available. Many are taken daily for 21 days;
withdrawal bleeding usually occurs within 1 to 4 days after the last pill is taken.
Some OCP packages contain seven inert or iron pills during the fourth week so
that the woman never stops taking a pill. Other OCPs contain folate to reduce
the risk of neural tube defects in a pregnancy conceived while taking the
product or shortly after discontinuing the product. Extended cycle oral
contraceptives are also available. The extended cycle OCPs offer users the
convenience of only four planned menses, each lasting about 2 to 3 days, per
year. In addition to the nurse’s verbal instructions, it is imperative that all women
receive written information to take home with them and are encouraged to call if
they have questions or experience any problems. OCPs offer no protection
against STIs or HIV.
Patient Education
Side Effects of Oral Contraceptives
Patient teaching must emphasize warning signs that must be immediately
reported to the health-care provider. The acronym “ACHES” can prompt the
health-care provider and patient to remember the warning signs:
• Abdominal pain (problem with liver or gallbladder)
• Chest pain or shortness of breath (blood clot in lungs or heart)
• Headaches: Sudden or persistent (hypertension or cardiovascular accident)
• Eye problems (hypertension or vascular accident)
• Severe leg pain (thromboembolism)
“ACHES” uses the first letter of each sign of cardiovascular, liver, gallbladder,
or thromboembolic complications that are side effects of estrogen use and can
be life-threatening. If patients experience any of these signs, they must stop
taking the pill and promptly contact the health-care provider. In addition to the
“ACHES” signs, patients who become severely depressed or jaundiced or who
develop a breast lump should notify their health-care provider.
A number of unpleasant and often troublesome side effects may accompany
OCP use, especially during the first 3 months. Nurses should teach patients
that they might experience scanty periods, bleeding between periods
(breakthrough bleeding), nausea, breast tenderness, headaches, and cyclic
weight gain from fluid retention. If patients understand that these side effects
may occur, they are more likely to seek health-care provider advice before
arbitrarily discontinuing use of the OCP. The symptoms often subside after a
few months of use, or they may be diminished with a change in routine or in the
brand of contraceptive.
LOW-DOSE PROGESTIN-ONLY CONTRACEPTIVE PILLS

Low-dose progestin-only contraceptive pills are often referred to
as the “minipill” because they contain no estrogen. Although
ovulation may occur, the progestins cause thickening of the cervical
mucus and endometrial atrophy, reducing the activity of the cilia in
the fallopian tubes. These changes inhibit implantation and decrease
the penetration of sperm and ovum transport. The minipill is used
primarily by women who have a contraindication to the estrogen
component of the combination OCP. It must be taken continuously at
the same time every day, and there are no days off between pill
packs. A backup contraceptive method (or abstinence) should be
used for the first 2 days after starting progestin-only contraceptive
pills. The minipill may be used during breastfeeding (after the first 6
weeks postpartum) because it does not interfere with milk
production. Certain drugs (e.g., rifampicin, certain anticonvulsants,
some antiretroviral drugs, and Saint John’s wort) may interact with
progestin-only OCPs; women taking these medications should be
advised to use a backup contraceptive method while taking them.
Irregular menses frequently occur with the progestin-only pills.
TRANSDERMAL CONTRACEPTIVE PATCH
The transdermal contraceptive patch is a hormonal method that
delivers low levels of estrogen and a progestin (norelgestromin) that
are readily absorbed into the skin. When used correctly the patch is
93% effective (CDC, 2020). The patch is applied to the abdomen,
buttock, upper outer arm, or upper torso once weekly for 3 weeks,
followed by one patch-free week. It should not be placed on the
breasts. During the patch-free week, withdrawal bleeding occurs.
The contraceptive patch costs slightly more than combined OCPs.
The side effects, contraindications, and warning signs for the patch
are the same as for the OCPs. However, the patch may cause a
topical reaction at the placement site, so patients should be
educated on signs of topical reaction, of redness, pruritus, and
discomfort.
VAGINAL CONTRACEPTIVE RING
The vaginal contraceptive ring contains estrogen and etonogestrel
(ENG), a progestin, and is 97% effective (CDC, 2020). It is a soft,
flexible ring that is inserted deep into the vagina by the fifth day of
the menstrual cycle and left in place for 3 weeks. It is removed
during the fourth week to allow withdrawal bleeding, and a new ring
is inserted at approximately the same time of day that the old ring
was removed. The vaginal contraceptive ring is associated with
increased vaginal discharge or wetness (not infection) compared
with other forms of hormonal contraception. Women who have
significant pelvic relaxation, vaginal stenosis or obstruction, or who
are uncomfortable touching their genitalia may not be suitable
candidates for the vaginal contraceptive ring.
Patient Education
Use of the Vaginal Contraceptive Ring
Patients are taught the following steps for insertion: wash and dry the hands;
remove the ring from the foil pouch; assume a position of comfort; and squeeze
the rim of the ring and place the leading edge into the vagina, sliding it into
place until it is comfortable. The exact position of the ring is not critical for its
function. To remove the ring, hook the index finger under the forward rim and
pull it out. If possible, allow the patient to insert the ring in the examining room.
The contraceptive ring should not be removed before, during, or after
intercourse. The patient should not douche. The ring may be used concurrently
with tampons. If the contraceptive ring comes out of the vagina for a time
period of less than 3 hours, it should be rinsed with lukewarm water and
reinserted. If the contraceptive ring is out of the vagina for over 3 hours, the
ring may be rinsed and reinserted, but a backup contraceptive method should
be used for 7 days. Before discarding a used contraceptive ring, the patient
should take care to protect the environment by placing the used ring in its
original foil pouch or in a closed plastic bag. It should never be flushed down
the toilet. Unopened vaginal rings must be protected from sunlight and high
temperatures.
INJECTABLE HORMONAL CONTRACEPTIVE METHODS

Depo-Provera (Dmpa-Im), Depo-Subq Provera 104 (Depot
Medroxyprogesterone).
Depo-Provera (medroxyprogesterone acetate) is a progestin-only
long-term contraceptive (CDC, 2020). It is injected either
intramuscularly (150 mg) or subcutaneously (104 mg) for effects that
last about 3 months. The first injection should be given within the first
5 to 7 days of menstruation to ensure the patient is not pregnant.
Medroxyprogesterone 150 mg is injected deeply into the deltoid or
gluteus maximus muscle and functions by suppressing ovulation and
altering the cervical environment. The administration site should not
be massaged after injection because this action may reduce the
effectiveness of DMPA.
Irregular bleeding is the most common side effect of Depo-
Provera. Most women who use this method experience spotting
during the first few months, usually until the second injection.
Amenorrhea often occurs after about 6 months of use. Other side
effects include weight gain, depression, headache, and breast
tenderness. Although severe allergic reactions occur rarely, some
clinics ask patients to remain nearby for 20 minutes after an
injection. Depo-Provera may produce temporary and usually
reversible decreased bone mineral density.
Subdermal Hormonal Implant Nexplanon
Nexplanon, a second generation of Implanon, is a subdermal
contraceptive that is highly effective (99.9%) for 3 years (CDC,
2020). The single-rod implant, which is inserted on the inner side of
the woman’s upper arm, contains ENG, a progestin. Nexplanon
functions to prevent pregnancy by suppressing ovulation, altering the
endometrial structure, and creating a thickened cervical mucus that
hinders sperm penetration. ENG is metabolized by the liver. Certain
antiepileptic agents, certain antiretroviral agents, and rifampicin may
interfere with absorption and contraceptive effectiveness. Nexplanon
contains barium to allow for localization on x-ray or CT scan. The
implant may be inserted at any time during the menstrual cycle as
long as pregnancy has been reasonably excluded; after childbirth,
the insertion of the implant is safe at any time in nonbreast-feeding
women. Bleeding irregularities frequently occur during the first
several months after insertion; amenorrhea becomes more common
with increasing duration of use. Other reported adverse symptoms
include breast pain, emotional lability, weight gain, headache,
nausea, abdominal pain, loss of libido, and vaginal dryness.
INTRAUTERINE DEVICES
The IUD is a small plastic device that is inserted into the uterus
and left in place for an extended period of time, providing continuous
highly effective (99%) contraception. The exact mechanism of action
is not fully understood, although it is believed that the IUD causes a
sterile inflammatory response that results in a spermicidal
intrauterine environment. Few sperm are able to reach the fallopian
tubes, and if fertilization does occur, the intrauterine environment is
unfavorable for implantation.
Three types of IUDs are currently available in the United States:
two levonorgestrel (LNg) intrauterine systems (LNg-IUS) (Mirena;
Skyla, recently approved by the FDA), which release a progestin;
and the Copper T 380A (TCu-380A) (ParaGard) (Fig. 2-19).
The LNg-IUS slowly and constantly releases a small amount of
LNg, a progestin, into the endometrial cavity. Mirena must be
replaced every 5 years; Skyla must be replaced every 3 years. The
Copper T 380A has fine copper wire wrapped around it, and this
device may remain in place for 10 years. All three types of IUDs are
shaped like the letter “T.” They are inserted in a collapsed position
and then expand into shape in the uterus once the inserter is
withdrawn. The IUD is contained wholly within the uterus and the
attached plastic threads, or “tail,” (which facilitates removal by the
health-care practitioner), extends through the cervix and into the
vagina. All types of IUDs are nonlatex devices impregnated with
barium sulfate for radiopacity. Mirena and ParaGard may be inserted
at any time during the menstrual cycle as long as pregnancy may be
reasonably excluded; they may also be inserted immediately after
childbirth or first trimester abortion. Skyla should be inserted during
the first 7 days of the menstrual cycle or immediately after a first
trimester abortion; postpartum insertion should be postponed for a
minimum of 6 weeks.
FIGURE 2-19 Intrauterine device (IUD) properly positioned in the

uterus.
Once in place, the IUD has several advantages over other

methods of contraception. There is no continued expense, no daily
attention is required, and the device does not interfere with sexual
enjoyment. IUDs decrease the incidence of endometrial cancer and
ectopic pregnancy. In addition, the Copper T 380A may be used for
emergency—and then long-term—contraception, and the LNg-IUS
reduces dysmenorrhea and menstrual blood loss from a variety of
causes (e.g., leiomyomas and adenomyosis). The IUD is appropriate
for women who are at risk for developing complications related to
OCPs or who desire to avoid the systemic effects of hormonal
preparations. When pregnancy is desired, the IUD is removed by the
health-care practitioner. Side effects may include irregular bleeding
and/or spotting for about 3 months following IUD insertion (both
types). Also, during the first few months, the LNg-IUS (Mirena and
Skyla) may be associated with lower abdominal pain, back pain, and
hormonal side effects similar to those caused by oral contraceptives
(e.g., breast tenderness, headache, mood changes, nausea, and
acne), as well as amenorrhea after the first year of use.
Dysmenorrhea and longer, heavier periods may occur in the first few
cycles of use with the TCu-380A (ParaGard). Women who harbor
STIs in their cervices have an increased risk of developing upper
genital tract infections, regardless of their IUD status.
Contraindications to IUDs include pregnancy, active pelvic
infection, endometritis, mucopurulent cervicitis, and pelvic
tuberculosis. Immediate postpartum insertion is contraindicated
among women in whom peripartum chorioamnionitis, endometritis,
or puerperal sepsis is diagnosed. The IUD should not be newly
inserted in women with cervical or endometrial cancer, and insertion
may be difficult in women with severe uterine distortion from
anatomical abnormalities (e.g., cervical stenosis, bicornuate uterus,
and leiomyomas [fibroids] that distort the uterine cavity).
Patient Education
Teaching About the IUD
The IUD should be considered a long-term form of contraception—it is
relatively expensive if used for only a short period of time. Sharp cramping may
occur at the time of insertion. If analgesia is needed, products that contain
naproxen or ibuprofen work best. Although rare, perforation of the uterus can
occur at the time of IUD placement. Minimal spotting may occur for a day or
two after insertion, and this is normal. Patients must refrain from placing
anything in the vagina for the first 24 hours after insertion.
Women who use the IUD may experience irregular bleeding, menorrhagia
(heavy menstrual flow), or dysmenorrhea (painful menstruation) for several
months following insertion. The progestin-releasing IUD can decrease
menstrual bleeding and dysmenorrhea; the copper-bearing IUD can increase
menstrual flow and cramping. Women who become pregnant using the IUD are
more likely to have an ectopic pregnancy or spontaneous abortion. All IUD
patients must understand warning signs (“PAINS”) that may indicate infection or
ectopic pregnancy.
Occasionally, the IUD may be expelled. The symptoms of IUD expulsion
include unusual vaginal discharge, cramping, spotting, and dyspareunia.
However, some IUD expulsions are asymptomatic. A vaginal “string check”
should be performed each month to ensure that the IUD remains in place. If the
strings are not felt or if they seem to be longer or shorter than they were
previously, the woman should return to her health-care provider for evaluation.
If pregnancy occurs with the IUD in place, the device is usually removed
vaginally to decrease the possibility of infection or spontaneous abortion. The
IUD offers no protection against STIs or HIV (CDC, 2020)
Nurses should also teach these “PAINS” warning signs to IUD users. Tell
patients to seek medical attention if they experience:
• Period late (pregnancy)
• Abdominal pain, pain with intercourse (infection)
• Infection exposure or vaginal discharge
• Not feeling well, fever, or chills (infection)
• Strings missing, shorter, or longer (IUD expelled)
Emergency Postcoital Contraception

Emergency contraception (EC) is available to women whose birth
control methods failed, who had unprotected intercourse, or who
have been the victims of sexual assault. Two forms of emergency
postcoital contraception are available: hormonal methods, which
include estrogen and progestin, progestin-only, and antiprogestin
emergency contraceptive pills (ECPs); and the insertion of a copper-
releasing IUD.
EMERGENCY CONTRACEPTIVE PILL
The one-pill formulation of the EC Plan B One-Step is now
available on drugstore shelves (i.e., without a prescription) to
anyone, regardless of age or gender. Plan B is also available from
generic manufacturers over-the-counter for women age 17 and older
in most states.
Often referred to as the ECP, three types of ECPs available in the
United States: combined ECPs that contain both estrogen and
progestin (two doses are taken 12 hours apart); one-dose progestin-
only ECPs (i.e., Plan B One-Step [one tablet] and the generic
formulation Next Choice [two tablets]), which contain LNg; and a
one-dose ECP that contains an antiprogestin (ulipristal acetate
[Ella]). Progestin-only ECPs have largely replaced the combined
ECPs because they are more effective and associated with fewer
side effects. ECPs may be initiated immediately after unprotected
intercourse or up to 120 hours after unprotected intercourse. Side
effects (e.g., bleeding, nausea and vomiting, abdominal pain, breast
tenderness, headache, dizziness, and fatigue) may occur but
generally resolve within 24 hours. Although certain ordinary OCPs
can be taken for EC, the dose varies with the brand and may require
taking a large number of tablets. Calculation of ECP effectiveness
involves many assumptions (e.g., accurate estimates of timing of
intercourse and cycle day) that are difficult to validate. Depending on
the EC medication used, the efficacy in reducing pregnancy ranges
between 1.2% to 2.1% risk of pregnancy after taking ECP (WHO,
2018).
IUD METHOD
The copper-releasing IUD can be inserted up to 5 days after
unprotected intercourse to prevent pregnancy. If emergency IUD
insertion is planned and cannot be carried out immediately, other
types of ECP treatment should be considered. The IUD is then
inserted the day ECP treatment is initiated, the day after ECP
treatment is completed, or within 7 days of beginning the next
menstrual period. If intrauterine contraception is initiated immediately
after ECP use, the patient should abstain from intercourse or use a
backup contraceptive method for the first 7 days.
Optimizing Outcomes
Teaching Patients About Postcoital Emergency Contraception

EC is sometimes confused with the medical abortion procedure. The high
hormone levels in the OCPs prevent or delay ovulation, thicken cervical mucus,
alter sperm transport to prevent fertilization, and interfere with normal
endometrial development. ECPs may at times inhibit implantation of a fertilized
egg in the endometrium. However, women should be informed that the best
available evidence is that the ability of LNg and ulipristal acetate ECPs to
prevent pregnancy can be fully accounted for by mechanisms that do not
involve interference with postfertilization events. Hence, ECPs do not cause
abortion or harm an established pregnancy. ECPs can delay ovulation, so
women should be advised to abstain from intercourse or use a backup method
of contraception for the remainder of their menstrual cycle.
Women should also be reminded that ECPs will not protect them from more
than one episode of unprotected intercourse. Patients who wish to begin OCPs
as their contraceptive method may initiate a new pill pack the day after ECP
treatment is completed and should abstain from intercourse or use a backup
method for the first 7 days. If the patient initiates a non-OCP hormonal
contraceptive method (e.g., implant, injectable, vaginal contraceptive ring, or
transdermal patch) immediately after ECP treatment, she should use a backup
method (e.g., condoms) for the remainder of her cycle and have a pregnancy
test 3 weeks later to rule out pregnancy that may have resulted from ECP
failure.
Permanent Contraceptive Methods

FEMALE STERILIZATION
Sterilization should be considered a permanent and irreversible
form of birth control. Although both the male and female procedures
are theoretically reversible, the permanency of the method should be
emphasized. An essential nursing role centers on counseling to
empower the couple to make an informed decision. The nurse must
also ensure that informed consent documentation has been obtained
and is attached to the patient’s chart.
Bilateral tubal ligation (BTL) or “tying the tubes” causes
interruption in the patency of the fallopian tubes. This permanent
birth control method is most easily performed during cesarean birth
or in the first 48 hours following a vaginal birth because at this time
the uterine fundus is located near the umbilicus and the fallopian
tubes are immediately below the abdominal wall. At other times, the
procedure is performed in an outpatient surgery clinic, usually under
general anesthesia.
Tubal ligation may be accomplished in various ways. In the
postpartum period, a minilaparotomy incision is made near the
umbilicus—or just above the symphysis pubis at other times. The
fallopian tubes are brought through the incision and a small segment
is removed (partial salpingectomy). The remaining ends are
cauterized or tied or both. Another method of tubal ligation is
accomplished with a laparoscope. The surgeon locates the fallopian
tubes and obstructs them with clips or rings or destroys a portion of
them with electrocoagulation (Fig. 2-20).
FIGURE 2-20 Types of tubal sterilization. A, Partial salpingectomy.
B, Filshie or Hulka-Clemens Clip. C, Silastic or Falope ring.
MALE STERILIZATION
Vasectomy is a surgical procedure performed under local
anesthesia that involves a small incision or puncture in the scrotum
and is greater than 99% effective in preventing pregnancy. The vas
deferens is ligated, chemically occluded, cauterized, clipped, or cut
to interrupt the passage of sperm into the seminal fluid (Fig. 2-21).
Following vasectomy, the semen no longer contains sperm. Sexual
function is unaffected. Vasectomy should be considered a
permanent method of contraception. Complications following
vasectomy include infection, hematoma, and excessive pain and
swelling.
CLINICAL TERMINATION OF PREGNANCY

A clinical termination of pregnancy, or abortion, is a procedure
performed to deliberately end a pregnancy before the fetus reaches
a viable age. The legal definition of viability (usually 20 to 24 weeks)
varies from state to state. Abortion has been legal in the United
States since the 1973 Supreme Court decision in Roe v. Wade. See
Chapter 1 for an exploration of the ethical issues regarding abortion.
An abortion performed at the patient’s request is an elective
abortion; when performed for reasons of maternal or fetal health or
disease, the term therapeutic abortion applies. Abortions performed
during the first trimester are technically easier and safer than
abortions performed during the second trimester. Methods for
performing early elective abortion include vacuum aspiration and
medical methods. Second-trimester abortion is associated with
increased complications and costs and involves cervical dilation and
removal of the fetus and placenta.
Surgical Termination of Pregnancy

Vacuum aspiration is the most common method for surgical abortion
for pregnancies up to 12 weeks’ gestation. Very early (5 to 7 weeks
after the last menstrual period [LMP]) procedures, called menstrual
extraction and endometrial aspiration, can be done with a small
flexible plastic cannula with no cervical dilation or anesthesia.
Laminaria, dried seaweed that swells as it absorbs moisture and
mechanically dilates the cervix, may be inserted 4 to 24 hours before
the pregnancy termination. Upon removal, the cervix has usually
dilated two to three times its original diameter and further
instrumental dilation is unnecessary.
Abortions performed between 8 and 12 weeks’ gestation require
mechanical cervical dilation after injection of a local anesthetic. A
plastic cannula is then inserted into the uterine cavity. The contents
are aspirated with negative pressure and the uterine cavity is often
scraped with a curet to ensure that the uterus is empty. Patients may
experience cramping for 20 to 30 minutes following the procedure.
Complications include uterine perforation, cervical lacerations,
hemorrhage, infection, and adverse reactions to the anesthetic
agent.
FIGURE 2-21 Vasectomy.
Abortion during the second trimester involves cervical dilation with

removal of the fetus and placenta. This procedure is termed “dilation
and evacuation” (D & E). Similar to vacuum curettage, greater
cervical dilation and use of a larger cannula are required because of
the increased volume in the products of conception. Before the
procedure, laminaria and/or misoprostol (a prostaglandin E1
analogue) is used to soften and dilate the cervix. D & E may be
associated with long-term adverse effects from cervical trauma.
Nursing care during surgical abortion includes continued patient
assessment and emotional support. The woman should be informed
about what to expect: abdominal cramping and sounds emitted by
the suction device. After the procedure, the patient rests in a
recovery area for 1 to 3 hours to ensure that no excessive cramping
or bleeding occurs. The aspirated uterine contents are inspected to
ascertain that all fetal parts and adequate placental tissue have been
aspirated.
Although checkup visits are usually scheduled between 2 weeks
and 6 weeks postabortion, serum levels of hCG may remain
elevated. This can occur even if the abortion successfully ended the
pregnancy. Women whose hCG levels are still present in the urine
(at the follow-up appointment) should be encouraged to return for
urine hCG levels every 2 weeks until the test is negative. Persistently
elevated hCG levels are associated with a delay in the return of
menses.
Patient Education
Complications of Abortion
Signs of short-term complications after clinical termination of pregnancy may
include:
• Fever of 100.4°F (40°C)
• Abdominal pain or tenderness in the abdomen
• Prolonged or heavy vaginal bleeding or passing large blood clots
• Foul smelling vaginal discharge
• No menstrual period within 6 weeks
Medication (Medical) Termination of Pregnancy

Medication (or medical) abortion is an alternative for the surgical
form of abortion, and for some women this method feels more
“natural” and more closely resembles a miscarriage. A medication
abortion can be performed during the first 7 to 9 weeks of pregnancy,
depending on the regimen used. The woman who considers
medication abortion should be carefully educated about what to
expect. Specific medications are used to induce uterine contractions
to end the pregnancy. These include mifepristone (Mifeprex,
originally called RU-486), an abortifacient; and methotrexate
(amethopterin, Folex, Rheumatrex, Trexall), an antimetabolite used
to treat certain types of cancer. Uterine cramping and bleeding begin
several days after medication administration, and most patients
experience a period of painless heavy bleeding along with the
expulsion of tissue (the products of conception). This experience
may trigger strong emotions. The nurse should advise the patient
that she would most likely benefit from the presence of a caring,
trusted close friend or relative who can help her through the
experience and lend emotional and physical support. Follow-up visits
usually include ultrasonography (to confirm that the uterus is empty)
and assessment of hCG levels. In some situations, the return office
visit may be replaced by telephone follow-up combined with a
sensitive urine pregnancy test at home 30 days after mifepristone is
given. A surgical abortion procedure may be necessary if medication
attempts are unsuccessful.
Collaboration in Caring
Medication Abortion Through Telemedicine
Telemedicine, the delivery of health-care services at a distance using
information and communication technology, has been used to provide early
access to medication abortion. Telemedicine can address some of the
challenges women have in accessing these services. Telemedicine typically
involves consultation with a physician or midlevel provider using video
teleconference. If the patient is eligible for medication abortion, the medical
provider will prescribe or directly send the patient medication. The patient may
require ultrasound pre and/or post abortion in an outpatient setting. A
systematic review conducted by Endler and colleagues (2019) found that
women who used telemedicine for abortion services had similar successful
outcomes as women who were seen in-person. In addition, women who chose
this model of abortion service reported high levels of satisfaction, and there
was no significant difference in the prevalence of adverse events among
telemedicine patients compared with face-to-face patients (Endler et al, 2019).
Medication termination of pregnancy is probably not the ideal

choice for adolescents. Some clinics offer this method of abortion
only to women 18 years of age or older because of legal concerns.
This method has proven useful in evacuating pregnancies that occur
in the fallopian tubes. Medication termination of a tubal pregnancy
has enabled many women to avoid surgery and preserve the
fallopian tubes for future conception.
Medication termination during the second trimester most often
includes an administration of prostaglandins via vaginal suppository,
gel, or intrauterine injection. Repeated doses are often needed, and
side effects including headache, nausea, vomiting, di zziness,
diarrhea, cramping, fever, and chills usually occur. Rarely used
methods include the intrauterine instillation of hypertonic solutions
such as saline or urea and uterotonic agents (e.g., misoprostol and
dinoprostone).
Complications
Legal abortion is actually safer than pregnancy, especially when
performed early. All patients should be told to expect cramping and
some bleeding after an abortion. Some of the rare complications
associated with abortion include infection; uterine atony; incomplete
abortion (i.e., retained products of conception), hemorrhage;
cervical, uterine, or abdominal organ trauma; embolism; Asherman
syndrome (condition characterized by the presence of endometrial
adhesions or scar tissue); and postabortal syndrome (occurs after
first-trimester vacuum aspiration abortion procedures, manifested by
severe abdominal cramping and pain from intrauterine blood clots).
Patients should be cautioned to call the office should any signs of
short-term complications (e.g., excessive bleeding, pain, and fever)
occur. Most complications develop within the first few days after the
abortion. In most clinical settings, patients are asked to return in 2
weeks for a follow-up examination.
Nursing Care Related to Elective Pregnancy Termination

Holistic nursing care for women who are considering abortion
includes guidance for pregnancy testing, ultrasonography to
accurately determine the weeks of gestation, and individualized
counseling about the available options. Any woman who is unsure of
her decision deserves emotional support and time to make the
choice that she feels is appropriate for her. Many women find this to
be a difficult and complicated decision. Once a woman chooses to
have an abortion, a medical history and physical examination with
appropriate screening tests (e.g., complete blood count [CBC], blood
typing and Rh, gonococcal smear, serological test for syphilis [STS],
urinalysis, and Pap test) are obtained. Informed consent documents
are signed and placed on the patient’s chart. The nurse counsels the
patient about potential complications such as excessive bleeding
and infection, reinforces information about follow-up visits, and offers
strategies for self-care. The nurse must ensure that the patient
understands how to contact a health-care provider if needed.
Women who are RhoD-negative should receive Rho(D) immune
globulin (RhoGAM) if they do not have a preexisting sensitivity to
Rh(D)-positive blood. Because fertility returns quickly after a
pregnancy termination, the nurse should also provide information
about contraception.
INFERTILITY
Fertility requires that the sperm and the ovum can meet; that the
sperm is viable, normal, and able to penetrate a viable, normal egg;
and that the lining of the uterus can support the implanted embryo.
Sterility is the term applied when there is an absolute factor that
prevents reproduction. Infertility is diagnosed if a woman age 34 or
younger has not conceived within 12 months (for women 35 and
older, within 6 months) of actively attempting pregnancy. Infertility
can be due to an issue with the female, male, or both (Centers for
Disease Control and Prevention, 2020). Decrease in female fertility
is often related to health conditions such endometriosis, ovulation
disorders, and tubal occlusions. Male fertility is related to overall
sperm number, size, shape, and motility. Decreased fertility is
associated with insufficient sperm counts affected by active contact
sports, smoking, and tight, constrictive clothing. Decreased fertility is
also associated with an autoimmune disorder that results in the
manufacture of antibodies to one’s own sperm. The presence of
varicose veins on the scrotum (varicocele) can cause testicular
warming and adversely affect the life span of the sperm. Decreased
sperm motility or “slow swimming” caused by ineffective flagella also
affects male fertility.
The nurse’s role in infertility care begins with education and
counseling during the initial assessment, which starts with a detailed
history of any past medical, surgical, gynecological, and obstetrical
histories. The nurse should also take a detailed assessment of
environmental factors in the home, work, or community that can
affect fertility and determine with the patient and/or couple whether
the timing of intercourse and length of coital exposure are adequate.
The nurse assesses the couple’s understanding about the most
fertile times to have intercourse during the menstrual cycle. Teaching
about the signs and timing of ovulation, the most effective times for
intercourse (every 48 hours around ovulation), and positions to
enhance sperm retention is an important nursing intervention during
the initial evaluation.
The initial infertility work-up should be conducted in a sensitive,
unhurried manner that conveys caring and promotes a trusting,
therapeutic relationship. An in-depth interview, preferably with both
partners, may reveal medical problems (e.g., chronic illness),
lifestyle patterns (e.g., tobacco use, substance abuse, and sexual
orientation), or other factors such as advanced age that can
adversely affect fertility. Depending on findings from the history and
physical examination, the evaluation will most likely include an
assessment of ovarian function, cervical mucus (amount and
receptivity to sperm), sperm adequacy, tubal patency, and the
general condition of the pelvic organs. Patients will often need
follow-up appointments and additional referrals depending on
assessment findings. The patient and partner need to be educated
on lifestyle behavior changes such as obtaining normal BMI;
exercising; and reducing alcohol, tobacco, and other recreational
drugs. Patients can also be instructed on stress-reducing modalities
such as meditation and yoga, which can also have a positive effect
on fertility.
The nurse should instruct patients about the need to monitor their
own fertility and ovulation. The first step is determining whether
regular ovulation is occurring. The patient will need instruction on
how to monitor for ovulation and record the BBT each morning. The
patient and couple can also monitor cervical mucus or obtain an
over-the-counter ovulation kit. Instructions for the couple on sexual
practices can include having intercourse every other day during the
fertility period in efforts to increase sperm levels and in different
positions to allow for anatomy factors that may contribute to difficulty
in conceiving. Females should avoid douching, which can alter the
vaginal pH affecting sperm mobility. Men should be counseled on the
need to avoid excessive heat to the testes and excessive bike riding,
which can alter the normal morphology of sperm.
Labs
Infertility Laboratory Work-up for Females
• Sexually transmitted infections
• Thyroid function test
• Glucose tolerance test
• Serum prolactin [PRL] levels
• Hormonal assays
• Follicular stimulating hormone [FSH]
• Estradiol
• Luteinizing hormone [LH]
• Progesterone
• Dehydroepiandrosterone sulfate [DHEA]
• Androstenedione
• Testosterone
• 17 alpha-hydroxy progesterone [17-OHP]
• Vitamin studies—Vitamin A
A wide range of diagnostics that can be performed to assist in the specific
cause of infertility (Table 2-5)
Evaluation of the man begins with a semen analysis to assess the

quality and quantity of sperm. The nurse explains the purpose of the
test and advises the man to collect the semen specimen by
masturbation following a 2- to 3-day abstinence. He is instructed to
note the time the specimen was obtained. This information allows
the laboratory to evaluate liquefaction of the semen. The specimen
should be transported near the body (to preserve warmth) and
should arrive at the laboratory within 1 hour after collection.
Additional testing may include serum samples for evaluation of
endocrine function (testosterone, estradiol, LH, and FSH), antisperm
antibody, ultrasonography, testicular biopsy, and sperm penetration
assay. Referral to a urologist may be indicated. A postcoital test
(PCT) may be ordered to assess the cervical mucus, sperm, and
degree of sperm penetration through the cervical mucus. The test is
performed on a sample of cervical mucus obtained several hours
after intercourse.
Treatment Options for Infertility

Medications
Depending on the cause of infertility, a number of pharmacological
methods are used to induce ovulation, supplement the woman’s
levels of FSH and LH, prepare the uterine endometrium for
implantation, and support the pregnancy following conception and
implantation (see Table 2-1).
Medications are commonly used to stimulate follicle development
in women who are anovulatory or who ovulate infrequently.
Clomiphene citrate (Clomid, Serophene) is frequently prescribed.
This antiestrogenic agent binds to hypothalamic estrogen receptors
to trigger the release of FSH and LH. Patients who will undergo
assisted reproductive techniques (ART), including in vitro fertilization
(IVF), gamete intrafallopian transfer, and tubal embryo transfer, may
also receive agents to induce superovulation, or the release of
several ova. After adequate follicular stimulation, hCG is
administered to prompt ovulation.
TABLE 2-5
Common Diagnostic Methods Used in the Evaluation of Female Infertility
TYPE/NAME OF TEST ROLE OF THE NURSE
Pelvic Examination
To identify and assess for any vaginal or Instruct the patient that procedure
uterine anomalies. includes a speculum examination and
should empty bladder before the
procedure for comfort.
Postcoital Test (PCT); Huhner Test
Assessment of the quality and quantity Instruct the patient to arrange to come in
of cervical mucus and sperm function at 6–12 hours after intercourse for
the time of ovulation. evaluation of the cervical mucus and
coital technique.
Ultrasound Examination
To evaluate structures of the pelvic and Reassure the patient that sonography
reproductive organs; identify maturing uses sound waves, not radiation, to
ovarian follicles and the timing of evaluate the pelvic structures. The
ovulation. examination may be conducted
transabdominally or transvaginally, and
specific instructions are given depending
on method.
Hysterosalpingogram
Radiological procedure which This is performed during the follicular
radiopaque dye is injected through the phase of the menstrual cycle to avoid
cervix. The dye enters the uterus and interrupting an early pregnancy. It may
fallopian tubes, and through x-ray exert a therapeutic effect as well:
examination, any abnormalities in the Instillation of the water-based dye may
uterine structure or tubal patency can be flush out debris or adhesions in the
identified. uterine cavity. The patient should be
given a NSAID (e.g., ibuprofen) 30
minutes to 1 hour before the procedure
as it can cause moderate to severe
cramping and shoulder pain “referred”
from the subdiaphragmatic collection of
gas may occur.
Tests of Endocrine and Hormone Function
To evaluate the hypothalamus, pituitary Inform the patient that testing is
gland, and ovaries. Various assays performed on serum samples, and
determine levels of PRL, FSH, LH, timing is an important consideration in
estrogen, and progesterone. Depending interpretation of the results. Explain that
on the history and physical findings, FSH and LH stimulate ovulation, and
additional testing may be indicated such estrogen and progesterone make the
as thyroid tests. endometrium receptive for implantation
of the fertilized ovum.
Endometrial Biopsy
Involves the removal of a sample of the Teach the patient about the purpose and
endometrium with a small pipette appropriate timing of the test: It should
attached to suction. Provides information be performed not earlier than 10–12
about the effects of progesterone days after ovulation (2–3 days before
(produced by the corpus luteum after menstruation is expected). Cramping,
ovulation) on the endometrium. pelvic discomfort, and vaginal spotting
may occur; a mild analgesic (e.g.,
ibuprofen) may be used to alleviate the
discomfort.
Hysteroscopy and Laparoscopy
Procedures that involve the use of an Explain the purpose of the test and other
endoscope to examine the interior of the procedures that may be done at the
uterus and the pelvic organs under same time. When general anesthesia is
general anesthesia. Hysteroscopy may to be used, the patient should take
be performed without general nothing by mouth for several hours
anesthesia in the office. Abnormalities before the planned procedure. Advise
such as polyps, myomata (fibroid her that because carbon dioxide gas will
tumors), and endometrial adhesions are be instilled in the abdomen to enhance
identified. organ visibility, she may experience
postoperative cramping and referred
shoulder pain, which can be relieved
with a mild analgesic.
Induction of ovulation increases the risk of multiple births because

many ova may be released and fertilized. Depending on the
medications used, daily ultrasound examinations and serum
estrogen levels may be obtained to monitor ovarian response.
Ovarian hyperstimulation is a serious complication that may result
from ovulation induction. It is characterized by marked ovarian
enlargement, ascites with or without pain, and pleural effusion.
Throughout therapy, repeated office visits and testing are necessary
and nursing interventions center on continued education and patient
support. Emotional instability, anxiety, and depression are common
reactions to the dramatic hormonal alterations and need for frequent
surveillance.
PROCEDURES ■ Assisted Reproductive
Technologies
Assisted reproductive technologies (ART) intend to achieve pregnancy by
placing ova and sperm together to promote fertilization. ART includes gamete
intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), frozen
embryo transfer (FET), and IVF-embryo transfer.
GIFT involves laparoscopy and ovulation induction. The patient must have at
least one patent fallopian tube. Three to five oocytes are harvested from the
ovary and immediately placed into a catheter along with washed, motile donor,
or partner sperm. The sperm and oocytes are injected into the fimbriated ends
of the fallopian tube(s) through a laparoscope. Fertilization takes place in the
fallopian tube, and the fertilized egg (zygote) then travels via the tube to the
uterus for implantation.
ZIFT is a procedure that evolved from the GIFT procedure. Following
ovulation induction, retrieved oocytes are fertilized outside the woman’s body,
and the subsequent zygotes are placed in the distal fallopian tube(s).
TET involves placement at the embryo stage. The patient must have at least
one patent fallopian tube. Exogenous progesterone is used to enhance
endometrial preparation.
IVF involves retrieval of the oocytes from the ovaries, usually via an intra-
abdominal approach or a transvaginal approach under ultrasound guidance.
The oocytes are then combined with partner or donor sperm in the laboratory.
After fertilization, the normally developing embryos are placed in the uterus
(Fig. 2-22). Success with IVF is dependent on many factors, such as the
woman’s age and the indication for the procedure. On average, women who
undergo three IVF cycles have a good chance of achieving pregnancy.
FIGURE 2-22 The process of in vitro fertilization. A, Ovulation. B,
Intra-abdominal retrieval of the ova. C, Ova fertilization and growth in
culture medium. D, Fertilized ova is placed in the uterus.
Surgical Options
Surgical interventions using endoscopic techniques may be useful in
correcting obstructions. Laparoscopic ablation (destruction) of
endometrial implants may help patients with endometriosis achieve
pregnancy, especially during the first few months immediately
following the procedure. Newer laser surgical techniques are
minimally invasive and useful in reducing adhesions that have
resulted from infection, prior surgical procedures, and endometriosis.
Microsurgical techniques may be successful in correcting
obstructions in the fallopian tubes or in the male tubal structures.
Transcervical tuboplasty (surgery for correction of fallopian tube
abnormalities) is a minimally invasive technique that involves
insertion of a catheter through the cervix into the uterus and the
fallopian tube. A balloon is inflated to clear any blockage.
THERAPEUTIC INSEMINATION
Therapeutic insemination (previously termed “artificial
insemination”) involves the placement of semen at the cervical os or
directly in the uterus (intrauterine insemination [IUI]) by mechanical
means. Partner sperm or donor sperm is used. Clomiphene citrate
and ultrasound monitoring for follicle development are frequently
used to ensure timing of the insemination with ovulation. Fertilization
most often occurs in the fallopian tube. The technique involves the
insertion of a small catheter into the vagina and through the cervix to
facilitate the deposition of sperm directly into the uterus. Before the
IUI, the sperm are “washed”: They are removed from the seminal
fluid and placed in a special solution that enhances motility and
improves the chances for fertilization.
Egg Donation
Use of a donor oocyte may be an option for women who do not
produce ova. The egg donor may be someone known to the
individual or an anonymous donor through an egg donor bank. The
donor will be screened for health conditions. Once a donor is
chosen, the ova is retrieved, and the process of IVF occurs. The
developing embryo is placed into the patient’s uterus.
Surrogate Parenting
Surrogate parenting occurs when a woman agrees to carry the
couple’s fetus. This may occur with IVF and the patient’s ovum and
the partner’s sperm, or with the surrogate’s ovum and the partner’s
sperm or donated sperm. Custody issues should be addressed
beforehand to avoid any complications of guardianship and parental
rights when the baby is born.
Psychological Considerations of Infertility

Infertility treatment is often stressful and anxiety provoking for the
patient, partner, and family members. Some patients experience
feelings of guilt about the inability to conceive and anger or
frustration when close friends and family members become
pregnant. Patients may also develop depression and isolate
themselves from family or friends who may ask probing questions or
have expectations of family planning for the couple. The requirement
to have intercourse during periods of fertility can put stress on both
partners. The cost of infertility work-up and treatments often adds
stress because health insurance policies may not cover infertility and
out-of-pocket expenses for infertility treatments can be exorbitant.
The expense may prohibit patients from pursuing optimal or
preferred treatments. Health-care providers need to be aware of the
psychological responses and assess patients at each visit to
promote well-being. Patients should be educated on the different life
stressors of infertility and be encouraged to express their feeling at
each visit.
SUMMARY POINTS
■ Gender maturation is a lengthy process that begins during embryonic

development and reaches full maturity during late adolescence.
■ External structures of the female reproductive system include the mons pubis,
labia, clitoris, vestibule, urethral meatus, Skene’s and Bartholin’s glands,
vaginal introitus, hymen, and perineum.
■ Internal structures of the female reproductive system include the ovaries,
fallopian tubes, uterus, and vagina.
■ Hormones secreted by the pituitary gland are essential in the regulation of
gonadal, thyroid, and adrenal function; lactation; body growth; and somatic
development.
■ Menstruation and ovulation are controlled by a complex interplay of positive
and negative feedback systems associated with hormones released by the
hypothalamus, pituitary, and ovaries.
■ The male reproductive system consists of the testes, where spermatogonia
and male sex hormones are formed; a series of continuous ducts that allow
spermatozoa to be transported outside the body; accessory glands that
produce secretions to foster sperm nutrition, survival, and transport; and the
penis, which functions as the reproductive organ of intercourse.
■ Sexuality is a multidimensional concept that covers a wide range of aspects
and degrees of sexuality.
■ A variety of contraceptives are available; contraceptive care should empower
the patient to choose the method best suited for her.
■ Infertility is the inability to conceive and carry a child when the couple wishes
to do so. Reproductive alternatives include IVF, GIFT, ZIFT, oocyte/embryo
donation, TDI, surrogate motherhood, and adoption.
REFERENCES
Blackburn, S. T. (2012). Maternal, fetal, and neonatal physiology: A clinical
perspective (4th ed.). St. Louis, MO: W.B. Saunders.
Caldwell, W., & Moloy, H. (1933). Anatomical variations in the female pelvis and
their effect in labor with a suggested classification. American Journal of
Obstetrics and Gynecology, 26, 479–505.
Centers for Disease Control and Prevention. 2020. “Reproductive Health.” 2020.
https://www.cdc.gov/reproductivehealth/index.html
Dashe, J. S., Bloom, S. L., Spong, C. Y., & Hoffman, B. L. (2018). Williams
obstetrics. New York: McGraw Hill.
Dundin, A., & Scannell, M. (2020). Vulnerable Populations. In Fast facts about
sexually transmitted infections (STIs): A nurse’s guide to expert patient care
(pp. 123–133). New York: Springer Publisher Company.
Endler, M., Lavelanet, A., Cleeve, A., Ganatra, B., Gomperts, R., & Gemzell-
Danielsson, K. (2019). Telemedicine for medical abortion: A systematic review.
BJOG: An International Journal of Obstetrics and Gynaecology, 126(9), 1094–
1102.
The Joint Commission. (2011). Advancing effective communication, cultural
competence, and patient-and family-centered care for the lesbian, gay,
bisexual, and transgender (LGBT) community: A field guide. Joint Commission.
Scanlon, V. C., & Sanders, T. (2018). Essentials of anatomy and physiology (8th
ed.). Philadelphia: F.A. Davis. Shier, D., Butler, J., & Lewis, R. (2011). Hole’s
essentials of human anatomy and physiology (11th ed.). New York, NY:
McGraw-Hill. Tanner, J. M. (1962). Growth at adolescence (2nd ed.). Oxford:
Blackwell Scientific.
Venes, D. (2021). Taber’s cyclopedic medical dictionary (24th ed.). Philadelphia:
F.A. Davis.
World Health Organization. (2016). Selected practice recommendations for
contraceptive use. Geneva. World Health Organization. (2018). Emergency
Contraception. Geneva, Switzerland: Retrieved from https://www.who.int/news-
room/fact-sheets/detail/emergency-contraception

Davis Advantage
CHAPTER 3
Conception and Development of the

Embryo and Fetus
CONCEPTS
Pregnancy
Development
Nursing
KEY WORDS
Genome
Gamete
Homologous
Autosomes
Homozygous
Heterozygous
Genotype
Phenotype
Mutation
Carrier
Meiosis
Mitosis
Morula
Blastocyst
Nidation
Chorionic villi
Amnion
Wharton’s jelly
Ductus venosus
Foramen ovale
Ductus arteriosus
Amniotic sac
Lanugo
Ectoderm
Endoderm
Mesoderm
Neural tube defect
Congenital anomalies
Dysplasia
Trisomy
LEARNING OBJECTIVES
After completing this chapter, the student will be able to:

■ Outline the process of fertilization, implantation, and placental development.
■ Discuss the structure and function of the placenta and umbilical cord.
■ Identify the time intervals and major events of the preembryonic, embryonic,
and fetal stages of development.
■ Discuss threats to embryo/fetal well-being and development and explain the
nurse’s role in minimizing threats to the developing fetus.
PICO(T) Questions
Use this PICO(T) question to spark your thinking as you read the chapter.
Does (I) preconception education related to teratogens and fetal health lead to
(O) a lower incidence of structural or developmental anomalies (P) in
newborns when provided to both men and women (C) compared with women
only?
INTRODUCTION
The beginnings of human life occur when an ovum unites with a
spermatozoon. Fertilization of an ovum by a spermatozoon creates a
zygote, which must successfully implant into the uterus for growth,
development, and continued survival. The understanding and
application of genetics in genomics is a fundamental aspect of
nursing and applies to all aspects in maternal child health nursing.
This chapter examines the key events that take place during
conception and fetal development. Threats to the embryo/fetus,
influences of heredity and genetics, and the basics of multifetal
pregnancy are also explored along with the nurse’s role in genetics
and genomics.
BASIC CONCEPTS OF GENETICS

Genetics is the study of single genes and their effects. Genomics is
the study of the functions and interactions of all genes in the
genome (a complete copy of the genetic material in an organism)
(National Human Genome Research Institute, 2020). Present-day
advances in genetic and genomic information have exerted an
increasing influence on health-care decisions and nursing practice.
Chromosomes, DNA, and Genes

Before our present understanding of DNA, scientists noticed that
traits were passed down from preceding generations. In the 19th
century, Gregor Mendel proposed that the “strength” of some
characteristics explains the variations in patterns of inheritance.
Later in the 19th century, scientists identified chromosomes
(threadlike packages of genes and other DNA) in the nucleus of the
cell and found that one-half of each pair was derived from the
maternal gamete (mature germ cell) and one-half from the paternal
gamete. The fundamental unit of heredity in humans is a linear
sequence of working subunits of deoxyribonucleic acid, commonly
known as DNA. DNA are the genes that carry the instructions that
allow cells to make proteins and transmit hereditary information from
one cell to another. Most DNA is located in chromosomes found in
the nucleus of cells. Genes occupy a specific location along each
chromosome, known as a locus. Genes come in pairs, with one copy
inherited from each parent. Many genes come in a number of variant
forms, known as alleles. Different alleles produce different
characteristics such as hair color or blood type. One form of the
allele (the dominant one) may be more greatly expressed than
another form (the recessive one).
All normal somatic (body) cells contain 46 chromosomes that are
arranged as 23 pairs of homologous or matched chromosomes.
One chromosome of each pair is inherited from each parent. Twenty-
two of the pairs are autosomes (nonsex chromosomes that are
common to both males and females), and there is one pair of the sex
chromosomes that determines gender (Fig. 3-1). The autosomes are
involved in the transmission of all genetic traits and conditions other
than those associated with the sex-linked chromosomes. The large X
chromosome is the female chromosome; the small male
chromosome is the Y chromosome. The presence of a Y
chromosome causes the embryo to develop as a male; in the
absence of a Y chromosome, the embryo develops as a female.
Thus, a normal female has a 46 XX chromosome constitution; a
normal male has a 46 XY chromosome constitution. The two distinct
sex chromosomes carry the genes that transmit sex-linked traits and
conditions. Because the chromosomes are paired, there are two
copies of each gene. If the gene pairs are identical, they are
homozygous; if they are different, they are heterozygous. In the
heterozygous state, if one allele is expressed over the other, this
allele is considered dominant. Recessive traits can be expressed
when the allele responsible for the trait is found on both
chromosomes.
The sex of the embryo is determined at fertilization and is
dependent on the sperm (X or Y) that fertilizes the ovum (Fig. 3-2).
The union of these highly specialized cells marks the beginning of
the development of each unique human being. Clinical practice is
based on a calculation of pregnancy weeks, beginning with the first
day of the last normal menstrual period (LNMP). However,
fertilization usually occurs approximately 2 weeks after the beginning
of the woman’s LNMP. Gestation is defined as the length of time
from conception to birth. The gestational period in humans ranges
from 259 to 287 days. In this chapter, the weeks of gestation are
calculated from the time of fertilization.
FIGURE 3-1 The sex chromosomes.
FIGURE 3-2 Inheritance of gender.
Understanding Abnormalities in Sex Chromosomes

Turner syndrome, the most common sex chromosome deviation in
females, is characterized by a chromosomal constitution of 45X; all
or part of one X chromosome is missing (monosomy X). Affected
females usually exhibit juvenile external genitalia, undeveloped
ovaries, short stature, and webbing of the neck. When present,
involvement of the cardiovascular system (e.g., bicuspid aortic valve
and coarctation of the aorta) poses the most serious risk to patients
(NIH, 2019). Intelligence may be impaired. In males, Klinefelter’s
syndrome, or trisomy XXY, is the most common sex chromosome
deviation. The presence of the extra X chromosome results in poorly
developed male secondary sexual characteristics, small testes, and
infertility. Intelligence may be impaired as well.
Differentiating Genotype From Phenotype

Although genotype refers to the genetic makeup of an individual
when referring to a specific gene pair, it is sometimes used to refer to
an individual’s entire genetic makeup or all of the genes that a
person can pass on to future generations. An individual’s genome is
the complete set of genes present (about 21,000). The term
phenotype refers to the observable expression of a person’s
genotype: physical features, a biochemical or molecular trait, or a
psychological trait. A trait or disorder is dominant if it is
phenotypically apparent when only one copy of an allele associated
with the trait is present. It is recessive if it is phenotypically apparent
only when two copies of the alleles associated with the trait are
present.
Consider, for example, the inheritance of eye color. Although eye
color is determined by many pairs of genes, with many possible
phenotypes, one pair is considered the principal pair, with brown
eyes dominant over blue eyes. A Punnett square (diagram drawn to
determine the possible combinations of alleles in the offspring of a
particular set of parents) may be used to illustrate inheritance of eye
color (Fig. 3-3). Both parents are heterozygous for eye color; their
genotype consists of a gene for brown eyes and a gene for blue
eyes, but their phenotype is brown eyes (Scanlon & Sanders, 2018).
FIGURE 3-3 Use of a Punnett square to demonstrate inheritance of
eye color.
DISEASE INHERITANCE
Heritable characteristics are those that can be passed on to
offspring. The manner of transmission to the next generation
depends on the number of genes involved in the expression of the
trait. A number of phenotypic characteristics can result when two or
more genes on different chromosomes act together (known as
multifactorial inheritance). A trait or disorder may also be controlled
by a single gene (unifactorial inheritance). A family pedigree, or map
of family relationships, is useful to assess the incidence of inherited
disorders.
Multifactorial Inheritance
Most congenital malformations result from multifactorial inheritance,
a combination of genetic and environmental factors. Examples
include malformations such as cleft lip, cleft palate, neural tube
defects (NTD), pyloric stenosis, and congenital heart disease that
may range from mild to severe, depending on the number of genes
for the particular defect and the amount of the environmental
influence.
Unifactorial Inheritance
Unifactorial mendelian or single-gene inheritance describes a pattern
of inheritance that results when a specific trait or disorder is
controlled by a single gene. There are many more single-gene
disorders than chromosomal abnormalities. Patterns of inheritance
for single-gene disorders include autosomal dominant, autosomal
recessive, and X-linked dominant and recessive modes of
inheritance.
Autosomal Dominant Inheritance

Autosomal dominant inheritance disorders are caused by a single
altered gene along one of the autosomes. In most situations, the
affected individual comes from a family of multiple generations that
have the disorder. The variant allele may also arise from a mutation
(a spontaneous, permanent change in the normal gene structure). In
this situation, the disorder occurs for the first time in the family. An
affected parent who is heterozygous for the trait (i.e., has a
corresponding healthy recessive gene for the trait) has a 50%
chance of passing the variant allele to each offspring.
Examples of autosomal dominant disorders include
neurofibromatosis (a progressive disorder of the nervous system that
causes the formation of nerve tumors throughout the body), Marfan’s
syndrome (a connective tissue disorder in which the child is taller
and thinner than normal and has associated heart defects), factor V
Leiden mutation (a disorder that significantly increases the
individual’s risk for deep venous thrombosis and pulmonary emboli),
achondroplasia (dwarfism), Huntington’s disease (a progressive
disease of the central nervous system [CNS] characterized by
involuntary writhing, ballistic, or dance-like movements), and
facioscapulohumeral muscular dystrophy (a form of osteogenesis
imperfecta, a disorder in which the bones are extremely brittle). A
typical pedigree of a family with neurofibromatosis, a dominantly
inherited autosomal disorder, is shown in Figure 3-4. Several human
genetic diseases, with their patterns of inheritance, are briefly
described in Table 3-1.
Autosomal Recessive Inheritance

Autosomal recessive inheritance disorders are expressed in an
individual when both members of an autosomal gene pair are
altered. Although each parent carries the recessive altered gene,
neither is affected by the disorder because each is heterozygous for
the trait and the altered gene is not expressed. When two individuals
carrying the same recessive altered gene reproduce, both may pass
the altered gene to their offspring. Each parent, or carrier, of the
autosomal recessive disorder has a 25% risk of passing the disorder
to each offspring, who will then have no normal gene to carry out the
necessary function. Because parents must pass the same altered
gene for expression of the disorder to occur in their children, an
increased incidence of the disorder occurs in consanguineous
matings (closely related parents). In addition, specific populations
may have a greater frequency of recessive disorders than other
populations. For example, sickle cell anemia occurs more frequently
in African American populations than in Caucasian populations. A
Punnett square illustrating the inheritance pattern of sickle cell
anemia is presented in Figure 3-5. Other examples of autosomal
recessive inheritance disorders include galactosemia,
phenylketonuria (PKU), maple syrup urine disease, Tay-Sachs
disease, and cystic fibrosis (CF).
FIGURE 3-4 Family pedigree for neurofibromatosis, an autosomal
dominant disorder.
X-Linked Dominant Inheritance

X-linked dominant inheritance disorders are the result of an
alteration in a gene located along an X chromosome (Fig. 3-6).
Because females have two X chromosomes, these disorders occur
twice as frequently in females as in males. When the gene is
dominant, it need be present on only one of the X chromosomes for
symptoms of the disorder to be expressed. X-linked dominant
disorders are passed from an affected male to all of his daughters
because the daughters receive the father’s altered X chromosome.
Conversely, none of the sons are affected because they receive only
the father’s Y chromosome.
TABLE 3-1
Human Genetic Diseases
DISEASE (PATTERN OF DESCRIPTION
INHERITANCE)
Sickle cell anemia (R) The most common genetic disease among
people of African ancestry. Sickle cell
hemoglobin forms rigid crystals that distort and
disrupt red blood cells; oxygen-carrying capacity
of the blood is diminished.
Canavan disease (R) Degenerative brain disorder that primarily affects
children of eastern and central European Jewish
(Ashkenazi) descent. Characterized by
developmental delay, hypotonia, large head,
seizures, blindness, and gastrointestinal reflux;
most affected children die within the first several
years of life.
Cystic fibrosis (R) Genetic disease of the exocrine glands of the
mucous, salivary, and sweat glands, which
causes production of thick mucus and clogs the
bronchial tree and pancreatic ducts. Most severe
effects are chronic respiratory infections and
pulmonary failure. Higher prevalence found
among persons of white/European descent.
Familial dysautonomia (Riley- Neurological disorder seen almost exclusively in
Day syndrome (R) individuals of eastern and central European
Jewish (Ashkenazi) descent. Characterized by
abnormal suck and feeding difficulties, episodic
vomiting, abnormal sweating, pain and
temperature sensitivity, labile blood pressure
levels, absent tearing, and scoliosis.
Tay-Sachs disease (R) Degeneration of neurons and the nervous
system results in death usually by the age of 4
years. Higher prevalence among persons of
Eastern and Central Jewish ancestry, and
French Canadian and Cajun descent.
Phenylketonuria (R) Lack of an enzyme to metabolize the amino acid
phenylalanine leads to severe mental and
physical retardation. These effects may be
prevented by the use of a diet (beginning at
birth) that limits phenylalanine.
Huntington’s disease (D) Uncontrollable muscle contractions begin
between the ages of 30 and 50 years, followed
by loss of memory and personality. There is no
treatment that can delay mental deterioration.
Hemophilia (X-linked) Lack of coagulation factor VIII impairs chemical
Duchenne’s muscular dystrophy clotting; may be controlled with coagulation
(X-linked) factor VIII from donated blood. Higher
prevalence among persons who are of African,
Mediterranean, Middle Eastern, Southeast
Asian, or West Indian descent.
Replacement of muscle by adipose or scar
tissue, with progressive loss of muscle function;
often fatal before age 20 years because of
involvement of cardiac muscle.
R = recessive; D = dominant.
Sources: American College of Obstetricians and Gynecologists, 2017; Scanlon &
Sanders, 2018; Sommers, 2019.
FIGURE 3-5 Inheritance of sickle cell anemia, an autosomal

recessive disorder.
FIGURE 3-6 Family pedigree for X-linked dominant inheritance.
A female with an X-linked dominant disorder has a 50% chance of

passing the altered genes to her offspring. Each child of a female
with the X-linked dominant disorder has a 1 in 2 chance of
expressing the disorder. Examples of X-linked dominant disorders
include hypophosphatemia (vitamin D-resistant rickets) and cervico-
oculo-acoustic syndrome.
X-Linked Recessive Inheritance

X-linked recessive inheritance disorders are more common than X-
linked dominant disorders and occur more frequently in males
because males have a single X chromosome that carries the altered
gene. Thus, when the male receives a “single dose” of the altered
gene, the disorder is expressed. For the disorder to be expressed in
the female, the altered gene must be present on both X
chromosomes.
A female who is a carrier of a gene that causes an X-linked
recessive disorder has a 50% risk of passing the abnormal gene to
her male offspring. Each son has a 1 in 2 chance of expressing the
disorder. The female carrier also has a 50% chance of passing the
altered gene to her female offspring, who will have a 1 in 2 chance of
becoming carriers of the altered gene. A son who is affected by an
X-linked disorder has a 100% chance of passing the variant X to his
daughters because the affected father has only one X to pass on.
Fathers cannot transmit the altered gene to their male offspring
because they transmit the Y instead of the X chromosome to their
sons. The Punnet square in Figure 3-7 illustrates the inheritance
pattern for red-green color blindness, an X-linked recessive
inheritance disorder. Other X-linked recessive inheritance disorders
include hemophilia A, Duchenne’s (pseudohypertrophic) muscular
dystrophy, and Christmas disease, a blood-factor deficiency
(Scanlon & Sanders, 2018).
CELLULAR DIVISION
Human cells can be categorized into either gametes (sperm and egg
cells) or somatic cells (any body cell that contains 46 chromosomes
in its nucleus). Gametes are haploid cells. They have only one
member of each chromosome pair and contain 23 chromosomes.
Somatic cells are diploid, which means that they contain
chromosome pairs (a total of 46 chromosomes). One member of
each pair comes from the mother, and one member comes from the
father. Cells reproduce through either meiosis or mitosis. Meiosis is
a process of cell division that leads to the development of sperm and
ova, each containing half the number (haploid) of chromosomes as
normal cells. Mitosis is the process of the formation of two identical
cells that are exactly the same as the original cell and have the
normal (diploid) number of chromosomes.
Meiosis occurs during gametogenesis, the process in which germ
cells, or gametes, are produced. During cell division, the genetic
complement of the cells is reduced by one-half. During meiosis, a
sex cell containing 46 chromosomes (the diploid number of
chromosomes) divides into two, and then four cells, each containing
23 chromosomes (a haploid number of chromosomes). The resulting
“daughter cells” are exactly alike, but they are all different from the
original cell. The process of meiosis includes two completely
different cell divisions. During the first cell division, the chromosomes
replicate each of the 46 chromosomes (diploid number of
chromosomes). The chromosomes then become closely intertwined,
and the sharing of genetic material occurs. New combinations are
produced, and this process accounts for the variations of traits in
individuals. Next, the chromosomes separate, and the cell divides
and forms two daughter cells, each containing 23 double-structured
chromosomes (the same amount of DNA as a normal somatic cell).
FIGURE 3-7 Inheritance of red-green color blindness.
In the second division, each chromosome divides, and each half

(or chromatid) moves to opposite sides of the cell. The cells divide
and form four cells containing 23 single chromosomes each, a
haploid number of chromosomes, or half the number of
chromosomes present in the somatic cell. Gametes must contain the
haploid number of chromosomes. When the female and male
gametes unite to form a fertilized ovum (zygote), the normal (diploid)
number of 46 chromosomes is reestablished. The entire process
results in the creation of four haploid gamete cells from one diploid
sex cell.
Mitosis is the phase in the cell cycle that permits duplication of two
genetically identical daughter cells, each containing the diploid
number of chromosomes. The process of mitosis allows each
daughter cell to inherit the exact human genome.
THE PROCESS OF FERTILIZATION

Fertilization is a complex series of events. Transportation of gametes
must occur to allow the oocyte and the sperm to meet. Most often,
this meeting takes place in the ampulla portion of the fallopian tube
(Fig. 3-8).
After completion of the first meiotic division, the secondary oocyte
is expelled from the ovary during ovulation. The oocyte then makes
its way to the infundibulum (funnel-shaped passage) at the end of
the fallopian tube and passes into the ampulla of the tube. At the
time of ejaculation, about 200 to 600 million sperm are deposited
around the external cervical os and in the fornix of the vagina. During
ovulation, the amount of cervical mucus becomes more favorable for
sperm to travel into the uterus and upward through the fallopian
tubes. The fallopian tubes are lined with cilia, hairlike projections
from the epithelial cells that serve a dual action: movement of the
ovum toward the uterus and movement of the sperm from the uterus
toward the ovary. Of the 200 to 600 million sperm deposited,
approximately 200 actually reach the fertilization site.
Sperm must undergo a process called capacitation, whereby a
glycoprotein coat and seminal proteins are removed from the surface
of the sperm’s acrosome (the caplike structure surrounding the head
of the sperm). The sperm become more active during this process of
capacitation, which takes about 7 hours and usually occurs in the
fallopian tube but may begin in the uterus. An acrosomal reaction
occurs when the capacitated sperm comes into contact with the zona
pellucida surrounding the secondary oocyte. During the acrosomal
reaction, enzymes from the sperm’s head are released. This helps to
create a pathway through the zona pellucida, allowing the sperm to
reach the egg and fertilization to occur.
Once a sperm penetrates through the zona pellucida, a reaction
takes place to prevent fertilization by other sperm. The oocyte then
undergoes its second meiotic division and forms a mature oocyte
and secondary polar body. The nucleus of the mature oocyte
becomes the female pronucleus. The sperm loses its tail within the
cytoplasm of the oocyte and then enlarges to become the male
pronucleus. Fusion of pronuclei of both the oocyte and sperm create
a single zygote containing the diploid number of chromosomes. The
zygote is genetically unique in that it contains half of its
chromosomes from the mother and half from the father.
FIGURE 3-8 Ovulation, fertilization, and early embryonic

development.
THE PROCESS OF IMPLANTATION AND

PLACENTAL DEVELOPMENT
After conception, the fertilized ovum, or zygote, remains in the
ampulla for 24 hours and then, propelled by ciliary action, travels
toward the uterus. During this time, cleavage (mitotic cell division of
the zygote) occurs. By 3 to 4 days after fertilization, there are
approximately 16 cells. The zygote is now called a morula and
enters the uterus. Once the morula enters the uterus, fluid passes
through the zona pellucida into the intercellular spaces of the inner
cell mass and forms a large fluid-filled cavity. The morula is now
called a blastocyst and contains an inner mass of cells called the
embryoblast. The embryo develops from the embryoblast and
contains an outer cell layer called the trophoblast. The chorion and
placenta develop from the trophoblast.
The cells of the inner cell mass are termed embryonic stem cells.
In these cells, all the DNA has the potential to develop into any of the
200 kinds of human cells that will be present at birth. As the cells
continue to divide and increase in number, some DNA will be
“switched off” in each cell, the genes will become inactive, and the
possibilities for specialization of each cell will decrease (Scanlon &
Sanders, 2018).
The uterus secretes a mixture of lipids, mucopolysaccharides, and
glycogen that nourishes the blastocyst. The zona pellucida
degenerates approximately 5 to 6 days after fertilization. This
process allows the blastocyst to adhere to the endometrial surface of
the uterus to obtain nutrients. Implantation begins as the trophoblast
cells invade the endometrium. By the 10th day after fertilization,
nidation (implantation of the fertilized ovum into the endometrium)
has occurred, and the blastocyst is buried beneath the endometrial
surface.
The placenta develops from the trophoblast cells at the site of
implantation. This important organ is essential for the transfer of
nutrients and oxygen to the fetus and the removal of waste products
from the fetus, and any alteration in its function can adversely affect
growth and development. As the trophoblast cells invade the
endometrium, spaces termed lacunae develop. The lacunae fill with
fluid from ruptured maternal capillaries and endometrial glands. This
fluid nourishes the embryoblast by the process of diffusion. The
lacunae later become the intervillous spaces of the placenta. At
about the same time, the trophoblast cells form primary chorionic
villi, small nonvascular processes that absorb nutritive materials for
growth. Blood vessels begin to develop in the chorionic villi around
the third week, and a primitive fetoplacental circulation is
established.
The trophoblast cells continue to invade the endometrium until 25
to 35 days after fertilization, when they reach the maternal spiral
arterioles. Spurts of maternal blood form hollows around the villi,
creating intervillous spaces containing reservoirs of blood that supply
the developing embryo and fetus with oxygen and nutrients. The
placenta has become well-established by 8 to 10 weeks after
conception. By 4 months, the placenta has reached maximal
thickness, although circumferential growth progresses as the fetus
continues to grow. The placenta is responsible for providing
oxygenation, nutrition, waste elimination, and hormones necessary
to maintain the pregnancy (Fig. 3-9).
The placenta is a metabolic organ with its own substrate needs.
Metabolic activities of the placenta include glycolysis,
gluconeogenesis, glycogenesis, oxidation, protein synthesis, amino
acid interconversion, triglyceride synthesis, and lengthening or
shortening of fatty acid chains. The placenta uptakes glucose,
synthesizes estrogens and progesterone from cholesterol, and uses
fatty acids for oxidation and membrane formation. Placental
transport of gases, nutrients, wastes, and other substances occurs in
a bidirectional movement from maternal to fetal circulation and from
fetal to maternal circulation. Transport across the placenta increases
with gestation because of the decreased distance between the fetal
and maternal blood, increased blood flow, and increased needs of
the developing fetus.
FIGURE 3-9 Placenta and umbilical cord.
Substances are transported across the placenta by several

mechanisms. These include simple (passive) diffusion, facilitated
diffusion, active diffusion, pinocytosis and endocytosis, bulk flow,
accidental capillary breaks, and independent movement. Pinocytosis
is the process by which cells absorb or ingest nutrients and fluid;
endocytosis is a method of ingestion of a foreign substance by a cell
wall (Venes, 2017).
■ Simple diffusion: Substances transported via this mechanism
include water, electrolytes, oxygen, carbon dioxide, urea, simple
amines, fatty acids, steroids, fat-soluble vitamins, narcotics,
antibiotics, barbiturates, and anesthetics.
■ Facilitated diffusion: Substances transported are glucose and
oxygen.
■ Active transport: Substances transported via this mechanism
include amino acids, water-soluble vitamins, calcium, iron, and
iodine.
■ Pinocytosis and endocytosis: Globulins, phospholipids,
lipoproteins, antibodies, and viruses use these mechanisms of
transport.
■ Bulk flow and solvent drag: Water and electrolytes use these
mechanisms of transport.
■ Accidental capillary breaks: These facilitate the transport of intact
blood cells.
■ Independent movement: Maternal leukocytes and microorganisms
such as Treponema pallidum use this mechanism of transport.
Placental endocrine activity plays a crucial role in maintaining the
pregnancy. The four main hormones produced by the placenta are
human chorionic gonadotropin (hCG), human placental lactogen
(hPL), progesterone, and estrogens. hCG maintains the corpus
luteum (a structure that secretes progesterone) during early
pregnancy until the placenta has sufficiently developed to produce
adequate amounts of progesterone. hPL regulates glucose
availability for the fetus and promotes fetal growth by altering
maternal protein, carbohydrate, and fat metabolism. Progesterone
helps to suppress maternal immunological responses to fetal
antigens, thereby preventing maternal rejection of the fetus.
Progesterone has a number of additional functions; it decreases
myometrial activity and irritability, constricts myometrial vessels,
decreases maternal sensitivity to carbon dioxide, inhibits prolactin
secretion, relaxes smooth muscle in the gastrointestinal and urinary
systems, increases basal body temperature, and increases maternal
sodium and chloride secretion.
Estrogen production increases significantly during pregnancy. This
essential hormone enhances myometrial activity, promotes
myometrial vasodilation, increases maternal respiratory center
sensitivity to carbon dioxide, softens fibers in the cervical collagen
tissue, increases the pituitary secretion of prolactin, increases serum
binding proteins and fibrinogen, decreases plasma proteins, and
increases sensitivity of the uterus to progesterone in late pregnancy.
The placenta also plays an important role in protecting the fetus
from pathogens. Although many bacteria are too large to pass
through the placenta, most viruses and some bacteria are able to
cross the placenta. Maternal antibodies (e.g., all subclasses of IgG)
transit the placenta primarily by pinocytosis; others cross by the
process of diffusion. Although the fetus has a unique genetic
makeup that is different from the mother’s, maternal rejection of the
fetus usually does not occur. The exact reason for this phenomenon
is not known.
DEVELOPMENT OF THE EMBRYO AND FETUS

The Yolk Sac
Early in the pregnancy, the embryo is a flattened disk that is situated
between the amnion (thick membrane that forms the amniotic sac
surrounding the embryo and fetus) and the yolk sac. The yolk sac is
a structure that develops in the embryo’s inner cell mass around day
8 or 9 after conception. It is essential for the transfer of nutrients to
the embryo during the second and third weeks of gestation when
development of the uteroplacental circulation is underway.
Hematopoiesis (formation and development of red blood cells)
occurs in the wall of the yolk sac beginning in the third week. This
function gradually declines after the eighth gestational week when
the fetal liver begins to take over this process. As the pregnancy
progresses, the yolk sac atrophies and is incorporated into the
umbilical cord. Key events that take place during early development
of the embryo are shown in Figure 3-10.
Origin and Function of the Umbilical Cord

During the time of placental development, the umbilical cord is also
being formed. The body stalk connects the embryo to the yolk sac
that contains blood vessels connecting to the chorionic villi. The
vessels contract to form two arteries and one vein as the body stalk
elongates and develops into the umbilical cord. Maternal blood flows
through the uterine arteries and into the intervillous spaces of the
placenta. The blood returns through the uterine veins and into the
maternal circulation. Fetal blood flows through the umbilical arteries
and into the villous capillaries of the placenta. The blood returns
through the umbilical vein and into the fetal circulation. Wharton’s
jelly is a specialized connective tissue that surrounds the two
arteries and one vein in the umbilical cord. This tissue, in addition to
the high volume and pressure in the blood vessels, is important
because it helps to protect the umbilical cord from compression.
Most umbilical cords have a central insertion site into the placenta
and at term are approximately 21 inches (55 cm) long with a
diameter that ranges from 0.38 to 0.77 inch (1 to 2 cm).
The Fetal Circulatory System

The embryo receives nutrition from maternal blood by diffusion
through the extraembryonic coelom (fluid-filled cavity surrounding
the amnion and yolk sac) and the yolk sac by the end of the second
week. Blood vessels begin to develop in the yolk sac during the
beginning of the third week, and embryonic blood vessels begin to
develop about 2 days later. A primordial heart tube joins with blood
vessels in the embryo, connecting the body stalk, chorion, and yolk
sac to form a primitive cardiovascular system. The heart begins to
beat, and blood begins to circulate by the end of the third week.
FIGURE 3-10 Key events during early development of the embryo.
During the third week, capillaries develop in the chorionic villi and
become connected to the embryonic heart through vessels in the
chorion and the connecting stalk. By the end of the third week,
embryonic blood begins to flow through capillaries in the chorionic
villi. Oxygen and nutrients from maternal blood diffuse through the
walls in the villi and enter the embryo’s blood. Carbon dioxide and
waste products diffuse from blood in the embryo’s capillaries through
the wall of the chorionic villi and into the maternal blood. The
umbilical cord is formed from the connecting stalk during the fourth
week.
Blood travels through the fetus in a unique way. The umbilical cord
contains three vessels: two arteries and one vein. Blood flows
through the vein from the placenta to the fetus. A small amount of
blood flows through the liver and then empties into the inferior vena
cava. Most of the blood bypasses the liver and then enters the
inferior vena cava by way of the ductus venosus, a vascular
channel that connects the umbilical vein to the inferior vena cava.
The blood then empties into the right atrium, passes through the
foramen ovale (an opening in the septum between the right and left
atria) into the left atrium, then moves into the left ventricle and on
into the aorta. From the aorta, blood travels to the head, upper
extremities, and lower extremities. Blood returning from the head
enters the superior vena cava, then the right atrium and the right
ventricle before entering the pulmonary artery. Most of the blood that
enters the pulmonary artery bypasses the lungs and enters the aorta
through the ductus arteriosus, a vascular channel between the
pulmonary artery and descending aorta. The remaining blood flows
to the pulmonary circulation to support lung development. The blood
then returns through the pulmonary vein to the left atrium, the left
ventricle, to the aorta, and returns to the placenta through the two
arteries. Most of the blood in the lower extremities enters the internal
iliac artery and the umbilical arteries to the placenta to be
reoxygenated and recirculated. Some of the blood in the lower
extremities passes back to the ascending vena cava and is mixed
with oxygenated blood from the placenta without being oxygenated.
The placenta is the site of oxygenation and waste elimination.
Blood travels through the umbilical vein from the placenta to the
fetus (Fig. 3-11). There are three shunts unique to fetal circulation:
1. Some blood circulates through the liver, but most bypasses the
liver through the ductus venosus and enters the inferior vena
cava.
2. Blood from the superior vena cava enters the right atrium,
passes through the foramen ovale, through the right ventricle,
and into the aorta supplying blood to the head and upper and
lower extremities.
3. Blood returning from the head enters the right atrium and then
flows through the right ventricle and into the pulmonary artery.
Most of this blood bypasses the lungs through the ductus
arteriosus. A small amount of blood flows through the pulmonary
circulation, back into the right atrium, right ventricle, and then into
the aorta.
Figure 3-11 Fetal circulation.
The arterial Po2 of the fetus is about one-fourth of the maternal

Po2 because of the structure and function of the placenta (i.e.,
oxygenation of fetal blood takes place at a low Po2) and because
arterial blood in the fetal circulation is formed by the mixing of
maternal oxygenated blood with fetal deoxygenated blood. Fetal
hemoglobin has a lower oxygen content than that of the adult. The
highest oxygen concentration (Po2 = 30 to 35 mm Hg) is found in the
blood returning from the placenta via the umbilical vein; the lowest
oxygen concentration occurs in blood shunted to the placenta where
reoxygenation takes place. The blood with the highest oxygen
content is delivered to the fetal heart, head, neck, and upper limbs,
while the blood with the lowest oxygen content is shunted toward the
placenta. The low Po2 level is important in maintaining fetal
circulation because it keeps the ductus arteriosus open and the
pulmonary vascular bed constricted. Fetal hemoglobin enables the
fetus to adapt to the lowered Po2. This unique type of hemoglobin
has a high affinity for oxygen at low tensions, which improves
saturation and facilitates oxygen transport to the fetal tissues. The
increased perfusion rate (compared with the adult) also helps to
compensate for the lower oxygen saturations and increased oxygen-
hemoglobin affinity.
Fetal Membranes and Amniotic Fluid

The embryonic membranes (chorion and amnion) are early
protective structures that begin to form at the time of implantation.
The thick chorion, or outer membrane, forms first. It develops from
the trophoblast and encloses the amnion, embryo, and yolk sac. The
chorion contains fingerlike projections (chorionic villi) that may be
used for genetic testing (chorionic villus sampling) during the first
trimester. The villi beneath the embryo grow and branch out into
depressions in the wall of the uterus, and from this structure, the
fetal portion of the placenta is formed.
The amnion arises from the ectoderm during early embryonic
development. This membrane is a thin, protective structure that
contains the amniotic fluid. The amniotic cavity, or space between
the amnion and the embryo, houses the embryo and yolk sac,
except in the area where the developing embryo attaches to the
trophoblast via the umbilical cord. With embryonic growth, the
amnion expands and comes into contact with the chorion. The two
fetal membranes are slightly adherent and form the amniotic fluid-
filled sac (the amniotic sac), also called the bag of waters. The fetal
membranes provide a barrier of protection from ascending infection.
Amniotic fluid is vital for fetal growth and development. It cushions
the fetus and protects against mechanical injury, helps the fetus to
maintain a normal body temperature, allows for symmetrical fetal
growth, prevents adherence of the amnion to the fetus, and aids in
fetal musculoskeletal development by providing freedom of
movement. It is essential for normal fetal lung development. The
amniotic fluid volume is dynamic, constantly changing as the fluid
moves back and forth across the placental membrane.
Amniotic fluid first appears at about 3 weeks. Approximately 30 mL
of amniotic fluid are present at 10 weeks’ gestation, and this amount
increases to approximately 800 mL at 24 weeks’ gestation. After that
time, the total fluid volume remains fairly stable until it begins to
decrease slightly as the pregnancy reaches term. At term, amniotic
fluid volume is estimated at 700 to 800 mL.
During late gestation, fetal urine and fetal lung secretions are the
primary contributors to the total amniotic fluid volume. Fetal
swallowing and absorption through the placenta are the primary
pathways for amniotic fluid clearance. The fetus swallows
approximately 600 mL every 4 hours, and up to 400 mL of amniotic
fluid flows from the fetal lungs every 24 hours. Amniotic fluid is
slightly alkaline and contains antibacterial and other protective
substances similar to those found in maternal breast milk (e.g.,
transferrin, beta-lysin, peroxidase, fatty acids, immunoglobulins [IgG
and IgA], and lysozyme). It also contains albumin, uric acid,
creatinine, lecithin, sphingomyelin, bilirubin, vernix, leukocytes,
epithelial cells, and lanugo (fine, downy hair).
HUMAN GROWTH AND DEVELOPMENT

Preembryonic Period
The preembryonic period refers to the first 2 weeks of human
development after conception. Rapid cellular multiplication, cell
differentiation, and establishment of the embryonic membranes and
primary germ layers occur during this time.
Embryonic Period
Critical development that occurs during the embryonic period
involves cleavage of the zygote, blastogenesis (early development
characterized by cleavage and formation of three germ layers that
later develop into tissues and organs), and the early development of
the nervous system, cardiovascular system, and all major internal
and external structures. The preembryonic period refers to the first 2
weeks beginning at fertilization, which for most is approximately 2
weeks after the LNMP. The embryonic period is the time period
beginning with the third week after fertilization and continuing until
the end of the eighth week. This critical period is known as
organogenesis and denotes the formation and differentiation of
organs and organ systems. This period of time is critical in the
development as exposure to any teratogen has a profound effect on
the correct development of the organs.
Week 1
Fertilization usually occurs in the outer third portion of the uterine
tube. The zygote then travels toward the uterus, while undergoing
cleavage (series of mitotic cell division) and forming blastomeres
(cells formed from the first mitotic division). Approximately 3 days
after fertilization, a morula (a ball of 12 or more blastomeres) enters
the uterus. A cavity forms within the morula, creating a blastocyst
that consists of a trophoblast that encloses both the embryoblast
(gives rise to the embryo and some extraembryonic tissues) and the
blastocystic cavity (fluid-filled space). The trophoblast begins to
invade the uterus, and the blastocyst is superficially implanted by the
end of the first week.
Week 2
The trophoblast undergoes rapid proliferation and differentiation as
the blastocyst continues the process of uterine implantation. The
yolk sac develops, the amniotic cavity appears, and the embryoblast
differentiates into the bilaminar embryonic disk. Implantation of the
blastocyst is completed by the end of the second week.
Week 3
The third week is characterized by the appearance of a primitive
streak (proliferation and migration of cells to the central posterior
region of the embryonic disk), the development of the notochord
(cellular rod along the dorsal surface that will later be surrounded by
vertebrae), and differentiation of the three germ layers: embryonic
ectoderm (outer layer; gives rise to skin, teeth, and glands of the
mouth and nervous system), endoderm (inner layer; gives rise to
epithelium of the respiratory, digestive, and genitourinary tracts), and
mesoderm (lies between the ectoderm and endoderm; gives rise to
the connective tissue) (Table 3-2).
Week 4
At the beginning of the fourth week, the flat trilaminar embryonic disk
folds into a C-shaped, cylindrical embryo. Development continues as
the three germ layers differentiate into various organs and tissues.
By 28 postovulatory days, four limb buds and a closed otic vesicle
that later develops into the labyrinth of the inner ear are present (Fig.
3-12).
During the third and fourth weeks, development of the nervous
system is well underway. A thickened portion of the ectoderm
develops into the neural plate. The top portion will differentiate into
the neural tube, which forms the CNS (brain and spinal cord), and
the neural crest, which will develop into the peripheral nervous
system. Later, the eye and inner ear develop as projections of the
original neural tube. During the early period of development, the
embryo’s nervous system is particularly vulnerable to environmental
insults.
Optimizing Outcomes
Preventing Neural Tube Defects
Defective closure of the neural tube during the fourth week of development
results in a condition known as a neural tube defect (NTD). This malformation
involves defects in the skull and spinal column and is primarily caused by failure
of the neural tube to close. Tissues overlying the spinal cord, including the
meninges, vertebral arches, muscles, and skin, may be affected as well. NTDs
include rachischisis (spina bifida), myelocele, myelomeningocele, and
meningocele. NTDs are the second most frequent structural fetal malformations
and occur in 1 to 2 per 1,000 live births. Folic acid supplementation has been
found to decrease the incidence of NTDs (Centers for Disease Control and
Prevention [CDC], 2018). Currently, the United States Public Health Service
recommends that all women of childbearing age who are capable of becoming
pregnant consume 0.4 to 0.8 milligrams of folic acid daily to reduce the
incidence of NTDs.
Week 8
By the end of the eighth week, there is a clear distinction between
the upper and lower limbs; the external genitals are well developed,
although not always well enough to distinguish the gender; and the
embryo has a human appearance (Fig. 3-13). The main organ
systems have also begun to develop by the end of 8 weeks. Except
for the cardiovascular system, however, there is minimal function of
most of the organ systems.
TABLE 3-2
Derivatives of the Three Germ Layers
ECTODERM MESODERM ENDODERM
Epidermis, epithelium of Smooth muscle coats, Epithelium of the pharynx,
mouth, oral glands, teeth, connective tissues, and thyroid, thymus,
and organs of special vessels associated with parathyroid, respiratory
sense tissues and organs passages, gastrointestinal
tract, liver, and pancreas
Central nervous system Blood
Peripheral nervous system Bone marrow
Hypophysis Muscular tissues
Adrenal medulla Skeletal tissues Adrenal
cortex
FIGURE 3-12 Embryo at 4 weeks’ gestation (28 postovulatory days).
All four limb buds are present.
The Fetal Period

The beginning of the ninth week marks the beginning of the fetal
period when the embryo has developed into a fetus with
recognizable features. The fetal period is characterized by rapid
body growth. The rate of head growth during this period of time
slows down compared with the rate of body growth. During the first
12 weeks of pregnancy, the weight of the fetus triples and the body
length doubles.
Weeks 9 to 12
The fetal head is half the length of the crown-rump length at the
beginning of the ninth week. The face is recognizably human at 10
weeks. Body growth increases, and as a result, the crown-rump
length more than doubles by the 12th week. Head growth does not
keep pace with body growth and slows considerably by the 12th
week but remains proportionately large compared with the rest of the
body. Ossification centers appear in the skeleton. The intestines
leave the umbilical cord and enter the abdomen. The external
genitalia differentiate and are distinguishable by week 12. At 9
weeks, the liver serves as the major site for red blood cell production
(erythropoiesis). However, by 12 weeks, the spleen begins to take
over this process. Urine production commences between 9 and 12
weeks.
Weeks 13 to 16
There is very rapid growth during this period. Although coordinated
movements of the limbs occur by the 14th week, they are too small
to be felt by the mother. Ossification of the skeleton takes place, and
the bones become clearly visible on ultrasound examination. The
external genitalia are recognizable by 12 to 14 weeks, the ovaries
are differentiated, and the primordial (primitive) ovarian follicles are
present by 16 weeks.
FIGURE 3-13 The embryo at 8 weeks (56 to 57 postovulatory days)
has a human appearance.
Weeks 17 to 20
Growth continues but slows during this period. Maternal awareness
of fetal movements (quickening) is frequently reported during this
time. The skin is now covered with a thick, cheeselike material called
vernix caseosa that protects the fetal skin from exposure to the
amniotic fluid. By 20 weeks, hair appears on the eyebrows and head.
Fine downy hair (lanugo) is usually present by 20 weeks and covers
all parts of the body except the palms, soles, or areas where other
types of hair are usually found. Subcutaneous deposits of brown fat,
used by the newborn for heat production, help to make the skin less
transparent in appearance. The fetal uterus is formed at 18 weeks in
females, and in males, the testes have begun to descend but are still
located in the abdominal wall. By 20 weeks, the fetus weighs about
300 grams and is approximately 7.3 inches (19 cm) long.
Weeks 21 to 25
The fetus gains significant weight during this time. The skin appears
pink or red because blood is now visible in the capillaries. Rapid eye
movements begin at 21 weeks. By 24 weeks, the fetus has
fingernails, and the lungs have begun to secrete surfactant, a
substance that decreases surface tension in the alveoli and is
necessary for survival following birth.
Weeks 26 to 29
A fetus may survive if born during this time because the lungs can
breathe air, and the CNS can regulate body temperature and direct
rhythmic breathing. The eyelids are open, the toenails are evident,
and subcutaneous fat is present under the skin. Erythropoiesis
occurs in the spleen but ends at 28 weeks when the bone marrow
takes over that function.
Weeks 30 to 34
At 30 weeks, the pupillary light reflex is present.
Weeks 35 to 40
At 35 weeks, the fetus has a strong hand grasp reflex and orientation
to light. At 38 to 40 weeks, the average fetus weighs 3,000 to 3,800
grams and is 17.3 to 19.2 inches (45 to 50 cm) long (Table 3-3).
FACTORS THAT MAY ADVERSELY AFFECT

EMBRYONIC AND FETAL DEVELOPMENT
Damage to the developing embryo/fetus may result from genetic
factors or from various environmental hazards, toxins, and/or
medication exposures. Damage to the developing embryo/fetus can
result in a birth defect, which is any structural anomaly. Teratogens
are any drugs, radiation, or infectious agents that can cause a birth
defect.
Chromosomes and Teratogens

Genetic defects are due to chromosomal disorders, whereas
nongenetic defects are caused by environmental hazards and toxins,
substance use, medications and vaccines, and viruses. Congenital
anomalies may occur singularly or in combination with other multiple
anomalies, and they may be of little or of great clinical significance.
Single, minor anomalies occur in approximately 14% of newborns.
The greater the number of anomalies present, the greater the risk of
a major anomaly. Statistically, 90% of infants with three or more
minor anomalies will also have one or more major anomaly.
Major developmental defects are more common in early embryos
that are usually spontaneously aborted. Teratogens or environmental
factors may adversely affect the process of implantation, resulting in
loss of the zygote, or can cause a birth defect. Teratogens may have
specific effects associated with congenital anomalies (e.g., alcohol:
fetal alcohol syndrome; rubella: cataracts; and tetracycline: stained
teeth), or they may produce dysmorphic (damage to the structure
and form) features. The extent of the teratogenic effect depends on
the developmental timing, duration, and route; dosage, duration, and
timing of exposure; and maternal genetic susceptibility. Greater
exposure during early gestation is associated with more severe
effects.
TABLE 3-3
Embryonic and Fetal Growth and Development
WEEKS WEIGHT LENGTH CHARACTERISTICS
(CROWN
TO RUMP)
2 weeks ? 2 mm Blastocyst implanted in uterus.
4 weeks 0.4 g 4 mm Embryo is curved, tail prominent. Upper limb
buds and otic pits present. Heart
prominence evident.
8 weeks 2g 3 cm Head rounded with human characteristics.
Unable to determine sex. Intestines still
present in umbilical cord. Ovaries and testes
distinguishable.
12 weeks 19 g 8 cm Resembles human being, with
disproportionately large head. Eyes fused.
Skin pink and delicate. Upper limbs almost
reached final length. Intestines in the
stomach. Sex distinguishable externally.
16 weeks 100 g 13.5 cm Scalp hair appears. External ears present.
Lower limbs well developed. Arm-to-leg ratio
proportionate. Fetus active.
20 weeks 300 g 18.5 cm Head and body hair (lanugo) present. Vernix
covers skin. Quickening felt by the woman.
24 weeks 600 g 23 cm Skin reddish and wrinkled. Some
subcutaneous fat present. Some respiratory-
like movements. Fingernails present. Lean
body.
28 weeks 1,100 g 27 cm Eyes open with eyelashes present. Much
hair present. Skin slightly wrinkled. More fat
now present.
32 weeks 1,800 g 31 cm Skin is smooth. Increase in weight gain more
than length. Toenails present. Testes
descending.
36 weeks 2,200 g 34 cm Skin pale, body plump. Body lanugo almost
gone. Able to flex arm and form grasp.
Umbilicus in center of body. Testes in
inguinal canal, scrotum small with few rugae.
Some sole creases present.
40 weeks 3,200 + g 40 cm Skin smooth and pink. Lanugo on upper
back and shoulders. Ear lobes formed and
firm. Chest prominent and breasts often
protrude slightly. Testes with well-defined
rugae. Labia majora well developed.
Creases cover soles of feet.
Teratogen Exposure During Organogenesis

The period of organogenesis lasts from approximately the second
until the eighth week of gestation, during which time the embryo
undergoes rapid growth and differentiation. During organogenesis,
the embryo is extremely vulnerable to teratogens such as
medications, alcohol, tobacco, caffeine, illegal drugs, radiation,
heavy metals, and maternal (TORCH) infections. Structural defects
are most likely to occur during this period because exposure to
teratogens either before or during a critical period of development of
an organ can cause a malformation.
After 11 weeks, the fetus becomes more resistant to damage from
teratogens because the organ systems have been established.
However, organ function can still be adversely affected. Insults that
occur later in fetal life or during early infancy may cause mental and
developmental disabilities, blindness, hearing loss, deafness,
stillbirth, or malignancy.
The most critical time for brain development is between 3 and 16
weeks of gestation. However, the brain continues to differentiate and
grow rapidly until at least the first 2 years of life. Diet and nutrition
are important during this time because amino acids, glucose, and
fatty acids are considered to be the primary dietary factors in brain
growth.
Medications and Other Substances

It is estimated that 9 out of 10 pregnant women will take medicine
during pregnancy. Many women unintentionally take medications
during the first trimester when they do not yet know they are
pregnant, yet the most harm to the fetus may result during this
period (CDC, 2020). Health-care professionals must be aware of the
possible adverse effects of medications that can cause birth defects
and consider the risk and benefits of all medications in pregnancy. To
identify drugs that are unsafe for maternal ingestion because of their
teratogenic potential, the U.S. Food and Drug Administration (FDA)
has established five categories of safety (Table 3-4).
A small number of medications and other substances are known
or are strongly suspected to be human teratogens. These include
fat-soluble vitamins, alcohol, tobacco, caffeine, cocaine, opiates,
anticonvulsants (e.g., valproic acid and divalproex sodium), warfarin
(Coumadin), cardiovascular agents (e.g., Lipitor, Mevacor, and
Pravachol), retinoids (e.g., Soriatane, Tegison, Accutane, and
Avage), certain hormones (e.g., Android, Androlone-D, and
Pitressin), antineoplastic agents (e.g., Targretin, Casodex, and
Emcyt), certain antiinfective agents (e.g., Penetrex, Novo-Quinine,
and Virazole), thalidomide, and methylmercury.
Patient Education
Methylmercury Risks
Methylmercury is a known neurotoxin that is especially harmful to the
developing fetus, infants, and children. Exposure to methylmercury can cause
permanent CNS damage leading to lower IQ as well as memory, attention,
language, behavioral, and cognitive problems. Methylmercury is found in most
seafoods, with the higher concentrations in the larger fish: swordfish, shark,
king mackerel, marlin, orange roughy, ahi tuna, and tilefish (FDA, 2019). Fish
consumption is the primary source of exposure to methylmercury, and FDA
recommends pregnant women avoid the larger fish and consume 8–12 ounces
of a variety of seafood from ones that are lower in mercury (FDA, 2019).
Nurses who work with women of childbearing age are perfectly positioned to
educate them about the risks of certain seafood and counsel patients on the
types of seafood with lower levels of mercury. In 2019 the FDA issued updated
recommendations to indicate recommended types of seafood for pregnant
women, available at https://www.fda.gov/food/consumers/advice-about-eating-
fish.
FAT-SOLUBLE VITAMINS
Both high and low doses of vitamin A (Retinol) can cause fetal
malformations that include anomalies of the CNS, microtia (deformity
of the outer ear), and clefts (a fissure or elongated opening that
originates in the embryo, such as a branchial or facial cleft). Vitamin
D deficiency may cause poor fetal growth, neonatal hypocalcemia,
rickets, poor tooth enamel.
TABLE 3-4
FDA Pregnancy Categories
CATEGORY DEFINITION
Category A Controlled studies in pregnant women have
demonstrated no associated fetal risk
Category B No associated fetal risk in animals, but no controlled
studies in pregnant women; or animal studies indicate a
risk, but controlled human studies fail to demonstrate a
risk
Category C Evidence of adverse effects in animal fetuses, but no
controlled studies in pregnant women; or no adequate
animal or human reproduction studies are available
Category D Evidence of adverse effects and fetal risk in humans;
benefits and risks must be considered before prescribing
Category X Evidence of fetal risk and congenital anomalies in
humans; risks outweigh the benefits; not prescribed
during pregnancy
NOTE: Although still in use, these categories were developed over 30 years ago.
Since 2015, the FDA has been transitioning to a more narrative description of
safety measures. Medications on the market after 2015 will no longer have a
category listing.
ALCOHOL
Ethyl alcohol is one of the most potent teratogens known. In the
latest national survey on alcohol consumption in pregnancy, 11.5%
of pregnant women reported that they were currently drinking and
3.9% of pregnant women reporting binge drinking within the past 30
days (Denny, Acero, Naimi, & Kim, 2019).
No safe threshold level for the use of alcohol during pregnancy
has ever been established. Current data suggest that children of
mothers who chronically ingested large amounts of alcohol or who
engaged in binge drinking (five or more drinks on one occasion)
during pregnancy especially are at greatest risk for permanent
damage or Fetal Alcohol Spectrum Disorder (FASD). FASD includes
a broad spectrum of birth defects including microcephaly, facial
dysmorphic features, and impaired cognitive, behavioral, and/or
neural functioning (Queensland Clinical Guidelines, 2016). (See
Chapter 5 for further discussion.)
TOBACCO
Smoking in pregnancy has several adverse effects on the
developing fetus. Nicotine causes vasoconstriction of the uterine
blood vessels, resulting in decreased blood flow and supply of
nutrients and oxygen to the fetus. This results in low-birth-weight
infants and preterm labor (Banderali et al., 2015). Cessation of
smoking during pregnancy is beneficial to the developing fetus, and
infants born to women who stop smoking during the first trimester
have birth weights similar to those of infants born to nonsmoking
women (Association of Women’s Health, Obstetric & Neonatal
Nursing [AWHONN], 2017). (See Chapter 5 for further discussion.)
CAFFEINE
Caffeine, the most popular drug in the United States, is present in
many beverages (e.g., sodas, coffee, tea, and hot cocoa) and other
substances including chocolate, cold remedies, energy drinks, and
analgesics. Caffeine stimulates CNS and cardiac function and
produces vasoconstriction and mild diuresis. The half-life of caffeine
is tripled during pregnancy. Although caffeine readily crosses the
placenta and stimulates the fetus, it is not known to be a teratogen.
However, high caffeine consumption (more than 300 mg of caffeine
per day) during pregnancy may increase the risk of miscarriage, and
the World Health Organization recommends restricting caffeine in
pregnancy (World Health Organization, 2019). (See Chapter 5 for
further discussion.)
COCAINE AND CRACK
Cocaine and crack (a form of freebase cocaine that can be
smoked) use during pregnancy causes vasoconstriction of the
uterine vessels and adversely affects blood flow to the fetus.
Cocaine use in pregnancy is associated with spontaneous abortion,
abruptio placentae, stillbirth, intrauterine growth restriction (IUGR),
fetal distress, meconium staining, and preterm birth. Problems
manifested in children born to women who use cocaine during
pregnancy include altered neurological and behavior patterns,
neonatal strokes and seizures, and congenital malformations (e.g.,
genitourinary anomalies, limb reduction deformities, intestinal
atresia, and heart defects) (OTIS, 2018). (See Chapter 5 for further
discussion.)
OPIATES
Use of opiates such as morphine and heroin by women who are
pregnant may cause spontaneous abortion, premature rupture of the
membranes, preterm labor, placental abruption, and preeclampsia
(Queensland Clinical Guidelines, 2016). Injection of opiates with
shared needles increases the risk of bloodborne transmission
diseases, including hepatitis and HIV, which can be transmitted
perinatally or during the delivery to the infant. Fetal exposure to
opiates can have serious consequences including IUGR, perinatal
asphyxia, prematurity, intellectual impairment, sudden infant death,
impaired bonding, gastric dysfunction, and neonatal infection
(Queensland Clinical Guidelines, 2016). Neonatal withdrawal
(abstinence) syndrome can occur as newborns are addicted to
opioids at birth and then experience withdrawal after birth, which is
characterized by hyperirritability, gastrointestinal dysfunction,
respiratory distress, and autonomic disturbances.
SEDATIVES
Barbiturates and tranquilizers produce maternal lethargy,
drowsiness, and CNS depression. In the neonate, these substances
are associated with withdrawal syndrome, seizures, and delayed
lung maturity.
AMPHETAMINES
Amphetamines are also known as “speed,” “crystal,” and “ice;” use
of these substances during pregnancy is associated with maternal
malnutrition, tachycardia, and withdrawal symptoms that include
lethargy and depression. The fetus is at an increased risk for IUGR,
prematurity, placental abruption, cardiac anomalies, cleft palate,
abnormal brain development, impaired CNS, impaired bonding, and
attention deficit and behavioral problems (Queensland Clinical
Guidelines, 2016). Following birth, affected neonates may exhibit
hypoglycemia, sweating, poor visual tracking, lethargy, and difficulty
feeding.
CANNABIS
Delta-9-tetrahydrocannabinol (THC), the active component in
cannabis (marijuana), passes through the placenta and may remain
in the fetus for up to 30 days. Rates of marijuana use have increased
in recent years as more states have legalized cannabis for medical
and recreational use. One large study of 1,206 pregnant women
rates found a cannabis use rate of 17.5% (Rodriguez et al., 2019).
The carbon monoxide levels produced with marijuana smoking are
five times higher than amounts produced with cigarette smoking.
Marijuana use in pregnancy may cause preterm birth, IUGR,
placental abruption, small for gestational age, and stillbirth
(Rodriguez et al., 2019). Long-term fetal outcomes can have an
adverse effect on neonatal neurobehavior (e.g., hyperirritability,
tremors, and photosensitivity) and can affect cognitive and language
development in infants up to 48 months of age. (See Chapter 5 for
RADIATION
High levels of radiation during pregnancy may cause damage to
chromosomes and embryonic cells. Radiation can adversely affect
fetal physical growth and cause intellectual and developmental
disabilities. Unborn babies are particularly at risk to damage from
radiation exposure during the first trimester. Consequences of
radiation exposure during this time include stunted growth,
deformities, abnormal brain function, or cancer that may develop
sometime
later in life (CDC, 2019).
LEAD
In the United States, the most common source of exposure to lead
occurs from lead-based paint in older homes, lead-contaminated
house dust, and soil and vinyl products. Lead passes through the
placenta and has been found to be associated with spontaneous
abortion, fetal anomalies, and preterm birth. The nervous system is
the most sensitive target of lead exposure. Fetuses and young
children are especially vulnerable to the neurological effects of lead
because their brains and nervous systems are still developing and
the blood–brain barrier is incomplete. Fetal anomalies associated
with lead exposure include hemangiomas, lymphangiomas,
hydrocele, minor skin abnormalities (e.g., skin tags and papillae),
and undescended testes.
Patient Education
Preventing Environmental Exposures
Many environmental exposures may pose significant health risks to
childbearing women and their families. Educating pregnant women is essential
so that they can avoid unnecessary exposures in the home, within the
community, and at their place of employment. Personal care products such as
moisturizers, lotions, and cleaning supplies may contain toxins that can be
teratogenic. Lead in paint found in older homes can cause developmental
delays. Environmental exposures due to pesticides, pollution, smoke, radon, or
radiation can affect fetal development. Work-related exposures, which vary
depending on the specific job, can be another source of exposure to
teratogenic chemicals.
PESTICIDES
Pesticides are commonly found in food, water, air, soil, and at
home, school, and in the workplace. Exposure to pesticides may
occur via inhalation, ingestion, and dermal or ocular contact.
Maternal/fetal/infant transfer may occur via amniotic fluid,
transplacental transport, or during lactation. Fetal exposure to
environmental contaminants after the period of cellular differentiation
or during times of increased cellular proliferation can result in
structural or functional defects, altered growth, and death. These
times of increased sensitivity to environmental contaminants can
cause vulnerability to significant birth defects.
TORCH Infections
TORCH infections are a group of agents that can infect the fetus or
newborn. These include Toxoplasmosis, “Other” transplacental
infections, Rubella virus, Cytomegalovirus (CMV), and the Herpes
simplex virus (HSV). The fetal risks associated with the various
TORCH infections are listed in Box 3-1.
TOXOPLASMOSIS
Toxoplasma gondii, a single-celled parasite, is responsible for
toxoplasmosis. This parasite is found throughout the world, and
although more than 40 million people in the United States may be
infected, most are unaware of the disease according to the CDC.
Most individuals who become infected with toxoplasmosis are
asymptomatic. When present, symptoms are described as “flu-like”
and include glandular pain and enlargement (lymphadenopathy) and
myalgia. Severe infection may cause damage to the brain, eyes, or
organs. Toxoplasmosis is usually acquired by eating raw or poorly
cooked meat contaminated with T gondii. This disease may also be
acquired through close contact with feces from an infected animal
(usually a cat) or from contact with soil that has been contaminated
with T gondii.
Once maternal infection occurs, the T gondii organism crosses the
placental membrane and infects the fetus, causing damage to the
eyes and brain. If the infection is acquired early in gestation, there is
an increased risk of fetal death.
FOCUS ON SAFETY
Toxoplasmosis Prevention
To minimize the risk of infection, pregnant women should avoid raw or poorly
cooked meats and contact with animals that may be infected with the
toxoplasmosis parasite. Pregnant women should be advised to avoid changing
the cat litter box and for someone else in the household to assume that task.
They should also wear gloves when gardening and perform hand hygiene
when done with gardening to avoid accidental contact with animal feces.
OTHER TRANSPLACENTAL INFECTIONS
Contemporary revisions identify the “other” transplacental
infections recognized as teratogens to include varicella-zoster virus
(chickenpox), HIV, hepatitis B virus (HBV), human parvovirus B19,
syphilis, and more recently Zika virus. The varicella-zoster virus
(VZV), a member of the herpes family, causes chickenpox and
shingles. Infection with VZV during the first 4 months of pregnancy is
associated with a number of congenital anomalies including muscle
atrophy, limb hypoplasia (underdevelopment), damage to the eyes
and brain, and intellectual and developmental disabilities.
HIV may be transplacentally transmitted to the fetus in utero.
Infection may also occur intrapartally (during labor and birth) from
exposure to maternal blood and body fluids and postpartally (after
birth) through breast milk. It was once thought HIV-positive women
should avoid pregnancy; however, with the advances in HIV
medications this is no longer the recommendation. Research has
found HIV transmission is significantly reduced with antiretroviral
medications started early in pregnancy or before pregnancy, keeping
the viral load low (Atkin et al., 2019). Women who are HIV-positive
should be counseled on the need for antiviral medications and
referred to health-care professionals who have expertise in this field.
Hepatitis B virus infection during pregnancy is associated with an
increased risk for stillbirth and preterm birth. Infants may be infected
transplacentally, serum to serum, or following exposure to
contaminated maternal blood, urine, feces, genital secretions, or
saliva. Infection occurs most commonly during birth or in the first few
days of life, and the rate of transmission is highest when the mother
has contracted the virus immediately before birth. Infected infants
may become chronic carriers at risk for significant liver disease.
Human parvovirus B19, also known as “fifth disease,” may cause
miscarriage or the development of nonimmune hydrops (fetal
hemolytic disorder) and IUGR. Transmission occurs transplacentally,
and the virus may be isolated from amniotic fluid, fetal blood, and
fetal tissue.
Treponema pallidum, the microorganism that causes syphilis,
readily crosses the placenta. Serious fetal infection and congenital
anomalies are almost always associated with primary maternal
infections that occur during pregnancy. However, T pallidum can be
destroyed with adequate treatment that will prevent placental
transmission and fetal infection. Secondary infections acquired
before pregnancy rarely result in fetal disease and anomalies. Left
untreated, only 20% of pregnant women with primary syphilis
infections will give birth to a normal term infant. Neonatal
manifestations of congenital syphilis infection include prematurity,
skin rash, snuffles, hydrops fetalis, failure to thrive,
hepatosplenomegaly, lymphadenopathy, and bone lesions
(osteochondritis, osteomyelitis, and periostitis). Late-onset
manifestations of congenital syphilis infection include keratitis
(inflammation of the cornea), deafness, and bowing of the shins
(Workowski & Bolan, 2015).
BOX 3-1
TORCH Infections
TORCH infections can cause serious harm to the embryo/fetus, especially
during the first 12 weeks when developmental anomalies may occur.
TOXOPLASMOSIS
Associated with consumption of infested undercooked meat and poor hand
washing after handling cat litter. Fetal infection occurs if the mother acquires
toxoplasmosis after conception and passes it to the fetus via the placenta. Most
infants are asymptomatic at birth but develop symptoms later.
MATERNAL EFFECTS
Flu-like symptoms in the acute phase.
FETAL/NEONATAL EFFECTS
Miscarriage likely in early pregnancy. In neonates, CNS lesions can result in
hydrocephaly, microcephaly, chronic retinitis, and seizures. Retinochoroiditis
may appear in adolescence or adulthood.
“OTHER” INFECTIONS
Includes varicella-zoster virus, HIV, hepatitis B virus, human parvovirus B19,
and syphilis.
• Varicella-zoster virus: transmitted via respiratory secretions; maternal effects
include flu-like illness, lymphadenopathy, diffuse vesicular rash with crust
formation. Fetal/neonatal effects include congenital varicella syndrome
associated with skin lesions, ocular defects, limb abnormalities, and CNS
abnormalities.
• HIV: transmitted transplacentally, intrapartally, and postpartally; maternal
effects include postpartum endometritis, fever, malaise, anorexia, weight loss,
opportunistic infections, and generalized lymphadenopathy. Fetal/neonatal
effects include preterm birth, IUGR, perinatal mortality, and opportunistic
infections.
• Hepatitis B virus: transmitted transplacentally, intrapartally; maternal effects
include fever, malaise, nausea, abdominal discomfort, may be associated with
liver failure. Fetal/neonatal effects include intrauterine death, preterm birth,
and chronic hepatitis infection.
• Human parvovirus B19: transmitted via respiratory droplets; maternal effects
include headache, mild fever, malaise, myalgia, joint pain, and red, pruritic
rash on the cheeks. Fetal/neonatal effects include anemia, nonimmune
hydrops, congenital anomalies, and death.
• Syphilis: transmitted transplacentally; maternal effects include primary
(chancre), secondary (fever, malaise, and red macular rash on palms or soles
of feet), and lymphadenopathy. Fetal/neonatal effects include stillbirth, IUGR,
prematurity, hydrops, and bone lesions.
• Zika: acquired through infected mosquitos or through sexual contact with
semen infected with the virus. In pregnancy, the virus is transmitted
transplacentally with more severe effects to the fetus in the first trimester.
Fetal effects include microcephaly, neurological, and behavioral
impairments.
RUBELLA (GERMAN MEASLES)
Spread by respiratory droplets; also transplacentally.
MATERNAL EFFECTS
Fever, rash, and mild lymphedema.
Miscarriage, IUGR, cataracts, congenital anomalies, hepatosplenomegaly,
hyperbilirubinemia, intellectual and developmental disabilities, and death. Other
symptoms may develop later. Infants born with congenital rubella are
contagious and should be isolated. Patients are instructed not to become
pregnant for 1 month after receiving the immunization; a signed consent form
must be obtained before administration of the vaccine.
CYTOMEGALOVIRUS (CMV)
Respiratory droplets, semen, cervical and vaginal secretions, breast milk,
placental tissue, urine, feces, and banked blood (nearly 50% of adults in United
States have antibodies for this virus).
MATERNAL EFFECTS
Asymptomatic illness, cervical discharge, and mononucleosis-like syndrome.
Fetal death or severe generalized disease with hemolytic anemia and jaundice,
hydrocephaly or microcephaly, pneumonitis, hepatosplenomegaly, intellectual
and developmental disabilities, cerebral palsy, and deafness. The
organs/tissues affected most often are blood, brain, and liver.
HERPES SIMPLEX VIRUS (HSV)
HSV II is sexually transmitted; infant is usually infected during exposure to
lesion in birth canal, most at risk during a primary infection in the mother (50%
neonatal mortality).
MATERNAL EFFECTS
Blisters, rash, fever, malaise, nausea, and headache.
Miscarriage, preterm birth, stillbirth, transplacental infection is rare but can
cause skin lesions, IUGR, intellectual and developmental disabilities,
microcephaly, seizures, and coma.
Pregnant women who acquire a Zika infection during pregnancy
can pass this to the growing fetus, perinatally causing congenital
Zika syndrome, with the most risk in the first trimester (Pomar et al.,
2019). The range of birth defects associated with congenital Zika
syndrome include microcephaly, fetal hydrops, IUGR, ocular
anomalies, epilepsy, extreme irritability, motor abnormalities, and
impairment (Pomar et al., 2019). Prevention methods remain critical
for pregnant women living or traveling to areas where there is a Zika
outbreak or epidemic, such as taking precautions in preventing
mosquito bites. In addition, Zika virus can be spread through sexual
contact from males who have recently been infected as Zika virus
can survive for a long period of time; avoid pregnancy for 6 months
in men and 2 months in women after the last possible exposure to
Zika (Pomar et al., 2019).
RUBELLA
The virus that causes rubella (also known as German measles)
can cause damage to the developing embryo/fetus. The earlier in the
pregnancy that the disease is contracted, the greater the risk to the
developing embryo. The risk to the fetus in causing severe birth
defects is greatest if the pregnant woman experiences a primary
rubella infection during the first 12 weeks of gestation. Birth defects
associated with congenital rubella syndrome include hearing loss,
eye defects causing vision loss or blindness, heart defects,
intellectual and developmental disabilities, low birth weight, skin
rashes, and in some cases liver damage or brain damage (CDC,
2019).
CYTOMEGALOVIRUS
Cytomegalovirus (CMV) is a member of the herpesvirus family and
is the most common viral infection in the fetus (Sommers, 2019).
CMV can be transmitted during pregnancy to the fetus during a
primary infection or reactivation of an old infection, which can occur
in a pregnant woman due to her immunocompromised state
(Sommers, 2019). During pregnancy, CMV can have an effect on the
growing fetus and is the most common congenital infection. In the
first trimester, CMV can cause spontaneous abortion (miscarriage).
CMV infection that occurs later in the pregnancy may result in fetal
IUGR, microphthalmia, chorioretinitis, blindness, hearing impairment,
microcephaly, hydrocephaly, cerebral calcification, intellectual and
developmental disabilities, deafness, cerebral palsy, and
hepatosplenomegaly. In the neonate, asymptomatic CMV infections
are often associated with audiological, neurological, and
neurobehavioral disturbances.
HERPES SIMPLEX VIRUS (HSV)
Spontaneous abortion is increased threefold if maternal infection
from HSV occurs in early pregnancy. Infection after the 20th
gestational week is associated with an increased rate of prematurity.
The transmission of the herpes virus occurs at the time of delivery
during passage through the birth canal but may also occur
transplacentally via ascending infection before labor or rupture of the
membranes. Congenital anomalies associated with the HSV include
extensive brain and neurological conditions such as chorioretinitis,
herpetic keratitis, microphthalmia, hydrocephalus, anencephaly,
porencephaly, cerebellar anomalies, microcephaly, and cerebral
hemorrhage (Fa et al., 2020). Other congenital anomalies include
dermatological scarring, cardiac condition, limb hypoplasia, and
hepatosplenomegaly (Fa et al., 2020).
THE NURSE’S ROLE IN PRENATAL EVALUATION

The clinical gestational period is divided into three trimesters that
each last for 3 months. By the end of the first trimester, all major
organs are developed. During the second trimester, the fetus
continues to grow in size, and most fetal anomalies can be detected
using high-resolution real-time ultrasound. By the beginning of the
third trimester, the fetus has a chance for survival, and most survive
if born at or after 35 weeks’ gestation.
At the initial prenatal visit, the nurse performs an assessment that
includes careful consideration of cultural, emotional, physical, and
physiological factors that may signal a need for genetics counseling
and comprehensive fetal evaluation.
Maintaining and Communicating a Caring and Accepting Attitude
The nurse must be knowledgeable of various cultural practices and beliefs that
may affect fetal development. Culture and experience influence every aspect of
individuals’ lives and how they care for themselves and their families. Nurses
should maintain an unbiased and accepting attitude when working with patients
with beliefs and practices that differ from their own. Understanding one’s
internal biases and beliefs is the first step ensuring an unbiased disposition
when providing patient care. Recognizing that cultural values and experiences
shape an individual’s likelihood to continue or discontinue familial beliefs and
practices helps the nurse develop a more accepting attitude and deliver
appropriate care in a culturally sensitive manner.
HEREDITY AND GENETICS

According to the CDC, birth defects are the leading cause of infant
death, affecting 1 in every 33 births in the United States (CDC,
2018). Birth defects, or congenital anomalies, are structural
abnormalities present at birth. Congenital anomalies may result from
four different pathological processes: malformation, disruption,
deformation, and dysplasia. Malformation is the alteration in
embryonic development caused by genetic transmission,
chromosomal anomalies, environmental factors, and
multifactorial/unknown causes. This defect results from an intrinsic
abnormal development that is present from the beginning of
development, such as one that arises from a chromosomal
abnormality.
A disruption is caused by an external force that alters previously
normal tissue and interferes with normal development. Maternal
exposure to teratogens, such as drugs, viruses, or environmental
hazards, may also cause a disruption. Disruptions are not inherited
although an individual may be predisposed to the development of a
disruption. Deformations are physical alterations in form, shape, or
position that are caused by extrinsic mechanical factors (e.g.,
clubfoot that results from intrauterine fetal restraint or fetal
compression defects that result from decreased amniotic fluid
[oligohydramnios]). Dysplasia (an abnormal development of tissue)
is caused by an abnormal organization of cells that results in
abnormal tissue formation.
Damage that may alter embryological development can occur to
the chromosomes of one or both parents before conception. During
the preembryonic period (up to 14 days after conception), where the
zygote is protected by the zona pellucida, exposure to teratogens
most likely causes either no harmful effects or produces severe
damage that results in loss of the pregnancy.
What to Say
Prenatal Identification of a Fetal Anomaly
Prenatal testing may identify a fetus with a congenital anomaly. When this
occurs, families are generally faced with a flood of emotions and difficult
decisions. The nurse plays an important role in providing support and
education regarding options available to these couples. A nonjudgmental and
caring attitude is vital at this difficult and vulnerable time.
Therapeutic communication is enhanced when the nurse uses statements
such as:
“It is normal to have fear, grief, or even be angry.”
“It is normal to have concerns about your ability to have a normal baby.”
“I am here to answer your questions and listen to your concerns. If I do not
know the answers I will either find and share them or arrange for a
colleague to meet with you.”
The nurse should avoid using statements such as:
“You can always have other children.”
“I know how you feel.”
“At least you do not know the baby yet.”
Genetic Counseling
With genetic counseling, a health-care professional with advanced training and
knowledge in the genetics advises patients about the need for genetic testing
and associated risks of specific genetic diseases (Stoll et al., 2018). Geneticists
and genetic counselors work in a variety of clinical and nonclinical settings.
Advancements in genetic testing and increased recommendations for genetic
testing from healthcare organizations has resulted in a shortage of available
geneticists and genetic counselors. Health-care providers need to work in
collaboration with genetic counseling assistants or telehealth referral services
to enable patients to receive genetic counseling in the face of limited options
(Stoll et. al., 2018).
MATERNAL AGE AND CHROMOSOMES

A trisomy occurs when a fetus develops with three particular
chromosomes instead of the normal number of two. Figure 3-14
illustrates the extra chromosome that occurs with Down syndrome.
The three most common trisomies found in live newborns are
trisomy 18 (Edwards’ syndrome), trisomy 21 or 22 (Down syndrome),
and trisomy 13 (Patau syndrome).
Trisomy 13 and trisomy 18 are rare; each occurs only about once
in every 5,000 live births. Trisomy 21 is the most common trisomy
and occurs in approximately every 650 live births (Scanlon &
Sanders, 2018). The prognosis for both trisomy 13 and 18 is very
poor; approximately 70% of infants with these chromosomal
disorders die within the first 3 months of life from complications
associated with respiratory and cardiac abnormalities. Neonatal
effects from these three most common trisomies include CNS
abnormalities, intellectual and developmental disabilities, and
hypotonia at birth. Although children with Down syndrome have
intellectual disabilities, these individuals display a wide range of
mental ability. Advanced maternal age (age 35 and above at the time
of birth) is associated with an increased risk of chromosomal
abnormalities (1% risk beginning at age 35 and increasing each
year, up to an 8% risk at age 46), with trisomy 21 accounting for half
of all of these.
FIGURE 3-14 Trisomy 21.
Deletion and translocation describe other chromosomal

abnormalities. A deletion is a loss of a portion of DNA from a
chromosome (Fig. 3-15). This alteration can be caused by an
unknown event, mutation, or exposure to radiation, or it may occur
during cell division. When a gene necessary for cell function is
absent, disease may result. A translocation occurs when all or a
segment of one chromosome breaks off and attaches to the same or
to a different chromosome (Fig. 3-16). Parents who have a
chromosomal translocation or who have had a child with structural
malformations are at increased risk for having another affected child.
See Table 3-5 to review the characteristics of chromosomal
syndromes.
FIGURE 3-15 Deletion.
Figure 3-16 Translocation.
Labs
Genetic Laboratory Testing
Carrier screening: Carrier screening is part of genetic testing to determine
whether one of the parents has a specific genetic trait that can be passed on
to the fetus. Carrier screening can include blood work, saliva samples, and
buccal samples.
Cell-free fetal DNA: A maternal blood sample is taken to assess for cell-free
fetal DNA, which is a screening test to help identify certain genetic conditions
such as trisomy 13, 18, and 21. Any positive test should be followed up with a
diagnostic test.
Alpha-fetoprotein: Part of the triple marker test for fetal genetic screening, a
maternal blood sample is used to evaluate plasma protein produced by the
fetal liver yolk sac and GI sac that crosses from the amniotic fluid into
maternal blood circulation. Low levels may indicate certain genetic conditions
such as Down syndrome or trisomy 18, and elevated levels can indicate
NTDs.
Deoxyribonucleic acid (DNA) testing: This is available as prenatal testing for
parents or postnatal testing for the infant in which a birth defect is suspected.
Chorionic villus sampling: Ultrasound-guided needle aspiration of tissue
located from the fetal aspect of the placenta is used for testing fetal genetic
makeup and blood type. Done early in pregnancy, around 8 to 13 weeks’
gestation, this is a high-risk procedure associated with spontaneous
miscarriage and limb reduction.
Percutaneous umbilical blood sampling (PUBS): A needle is inserted into
the fetal umbilical vessel under ultrasound to diagnose inherited blood
disorders and assess for treatment of isoimmunization. An ultrasound is used
to help guide the needle through the abdominal wall to the umbilical cord to
withdraw a fetal blood sample. This is a high-risk procedure associated with
fetal bleeding.
Preimplantation genetic diagnosis: Genetic testing of IVF embryos, testing
enables identification of specific inheritable genetic traits and conditions that
can cause disease.
Level II Ultrasound: Fetal ultrasound is used to evaluate structural changes
associated with genetic conditions.
Fetal nuchal translucency: Intravaginal ultrasound measures fluid collection
in the subcutaneous space between the skin and the cervical spine of the
fetus, enabling identification of fetal abnormalities associated with genetic
conditions such as trisomy 13, 18, and 21, and Turner syndrome.
Amniocentesis: Needle aspiration of amniotic fluid is used to determine
chromosome analysis. Performed around 15 to 20 weeks’ gestation,
approximately 20 to 30 cc of amniotic fluid is taken to analyze. There is a risk
of amniocentesis including spontaneous miscarriage, vaginal bleeding, and
leaking of amniotic fluid.
TABLE 3-5
Chromosomal Syndromes and Characteristics
CHROMOSOME CHARACTERISTICS LABORATORY
SYNDROME FINDINGS
Trisomy 21 (Down CNS: Mild-moderate intellectual Low level of alpha-
Syndrome) disability fetoprotein
Head: Sloping forehead, low set ears DNA or karyotyping
with small canals, protruding tongue reveals three
copies of the
Extremities: Broad hands and short
chromosome 21
fingers with single palmer crease
Cardiac: Valve disease
Trisomy 18 CNS: Intellectual disabilities DNA or karyotyping
(Edwards Head: microcephalic, small jaw and reveals three
Syndrome) mouth, low set ears Cardiac: Cardiac copies of the
anomalies chromosome 18
Extremities: clenched fists with

overlapping fingers, syndactyly (webbing
of the fingers)
Trisomy 13 (Patau CNS: Severe intellectual disability, spinal DNA or karyotyping
Syndrome) cord abnormalities reveals three
Head: very small or undeveloped eyes, copies of
cleft lip and/or palate chromosome 13
Extremities: extra fingers or toes, weak

muscle tone
Klinefelter Trunk: Gynecomastia DNA testing reveals
syndrome (Males) Reproductive: Underdeveloped an extra
reproductive organs, small firm testes, chromosome; (47,
infertile XXY) genotype
Extremities: Abnormally long legs

Skin: Minimal body/facial hair
Turner Syndrome Head: Webbed neck DNA testing reveals
(Females) Reproductive: Ovarian malfunction, one normal X
underdeveloped reproductive organs, chromosome and
infertile the other sex
chromosome is
Cardia: cortication of the aorta altered or missing
Trunk: Short Stature
Sources: National Institute of Health, 2019; Venes, 2021.
MULTIFETAL PREGNANCY
Monozygotic (identical) twins develop from one fertilized oocyte
(zygote) that divides into equal halves during an early cleavage
phase (series of mitotic cell divisions) of development (Fig. 3-17).
Monozygotic twins are genetically identical, always the same gender,
and very similar in physical appearance. The number of amnions
and chorions depends on the timing of division (cleavage) of the
zygote. If the division occurs during the two- to eight-cell stages,
there will be two amnions, two chorions, and two placentas. For most
monozygotic twins, the division occurs at the end of the first week
after fertilization and results from the division of the singular
embryoblast into two embryoblasts. When the division occurs during
this time, each fetus has its own amnion but resides within a single
chorion and receives oxygen and nutrients from the same placenta.
Depending on the timing of cleavage, the following multifetal
combinations occur:
■ Division that occurs during the first 72 hours after fertilization: two
embryos, two amnions, and two chorions develop with two distinct
placentas or a single fused placenta.
■ Division that occurs between the fourth and eighth day: two
embryos, each in a separate amnion sac covered by a single
chorion.
■ Division that occurs approximately 8 days after fertilization after
the chorion and amnion have differentiated: two embryos in a
common amniotic sac.
■ Division that occurs after the embryonic disk has formed: cleavage
is incomplete and conjoined twins result.
Conjoined twins occur when the embryonic disk does not divide
completely or when adjacent embryonic disks fuse. Conjoined
twinning occurs in approximately 1 in 50,000 to 100,000 births. Twins
may be connected to one another by the skin only or by cutaneous
and other tissues. In many cases, surgical separation is possible, but
depending on the anatomical region of attachment and the sharing of
vital organs, surgery may not be feasible.
Dizygotic (fraternal) twins develop from two zygotes and may be
the same or different genders. Dizygotic twins are no more
genetically similar than other siblings born to the same parents.
Amnions and chorions are separate, although the chorions and
placentas may be fused. The incidence of dizygotic twinning is
approximately 1 in 500 Asians, 1 in 125 Caucasians, and as high as
1 in 20 in some African populations. Triplets may result from the
division of a single zygote into three zygotes (one original fertilized
egg), from the division of one zygote (identical twins are formed) plus
another zygote (a total of two original fertilized eggs), or from three
different zygotes (a total of three original fertilized eggs).
THE NURSE’S ROLE IN MINIMIZING THREATS TO

THE DEVELOPING EMBRYO AND FETUS
Nurses provide holistic care to the family unit. The nurse must
assess for environmental lifestyle and family risks. Family history
evaluation is a screening tool for inherited risk, and this information
should be reviewed and updated on a regular basis.
FIGURE 3-17 Multiple gestations. A, Monozygotic twins with one
placenta, one chorion, and two amnions. B, Dizygotic twins with two
placentas, two chorions, and two amnions.
Assessment Tools
Risk Factor Assessment
Key components of an assessment include screening for environmental,
lifestyle, and family factors that may pose a risk for the woman or growing
fetus.
ENVIRONMENT
Do you use strong cleaning products at home or at work?
Do you live in a home constructed before 1978 or are otherwise potentially
exposed to lead paint? Do you use pesticides?
Do you have concerns about toxic hazards in your work or home?
LIFESTYLE
Do you drink any caffeinated beverages? How many in a day?
Do you smoke cigarettes? How many in a day? Do you drink alcohol? What
kind, and how much in a day?
Do you use substances such as cannabis, cocaine, crack, or heroin? Which
ones, and how often?
Are you currently, or have you ever been, enrolled in a substance abuse
program?
FAMILY
Conducting a family history is one of the best approaches to determine genetic
risks and is easily done through a basic three-generation pedigree evaluation.
The Surgeon General has an online family history assessment tool that can be
completed by patients as well as health-care professionals that is available on
the CDC website titled My Family Health Portrait, located at
https://phgkb.cdc.gov/FHH/html/index.html.
Diagnostic Tools
Preconception Carrier Screening for Genetic Diseases
Carrier screening for specific genetic conditions is frequently determined by an
individual’s ancestry. Certain autosomal recessive disease conditions are more
prevalent in various races and ethnicities. The American College of
Gynecologists and Obstetricians Committee Opinion on Genetics recommends
carrier screening to determine specific risks associated with genetic conditions,
especially in persons in higher-risk categories (American College of
Obstetricians and Gynecologists, 2017).
Karyotyping of the parents as well as their child with a genetic disorder may
be appropriate during the preconception period. A karyotype is a method of
genetic testing that compares tested chromosomes to normal chromosomes to
determine abnormalities (Van Leeuwen & Bladh, 2021) (Fig. 3-18). Cells,
obtained from a sample of peripheral venous blood or a scraping of the buccal
membrane tissue, are stained and photographed following a period of growth in
the laboratory.
FIGURE 3-18 Karyotype of human chromosomes of male and

female.
Through preventive strategies, preconception counseling can

significantly decrease the incidence of birth defects and problems
associated with preterm birth along with other disorders linked to
maternal illness and nutritional deficiencies. Counseling should
include discussion of possible fetal risks from exposure to
teratogens. Factors that could potentially harm the developing fetus
are identified, and the woman is advised of her risks. When possible,
strategies to reduce or prevent risk to the fetus are discussed with
the woman and her family. If exposure has occurred, every effort
should be made to identify the timing of the contact and the amount
of exposure. This information is essential because the calculation of
risk varies according to the teratogen and the timing and dose of the
exposure.
SUMMARY POINTS
■ A genotype is an individual’s gene composition; a phenotype refers to the

observable expression of a person’s genotype; a genome is a complete copy
of the genes present.
■ The developing embryo/fetus lives in a unique environment where all
essential elements needed for normal growth and development are provided.
■ The gestational period, which lasts an average of 40 weeks from the time of
fertilization, occurs in three stages: the preembryonic stage, the embryonic
stage, and the fetal stage.
■ Structural refinement and perfection of function of all systems occur during the
fetal stage.
■ Teratogens, substances that cause harm to the developing fetus, may be in
the form of chemicals, viruses, environmental agents, physical factors, and
drugs.
■ By educating pregnant women about fetal developmental events and
avoidance of potential hazards, nurses can help to ensure a healthy outcome
for the mother and her infant.
REFERENCES
American College of Obstetricians and Gynecologists. (2017). Carrier screening
for genetic conditions. committee opinion no. 691. Retrieved from
https://www.acog.org/Clinical-Guidance-and-Publications/Committee-
Opinions/Committee-on-Genetics/Carrier-Screening-for-Genetic-Conditions
Association of Women’s Health, Obstetric & Neonatal Nursing (AWHONN). (2017).
Position Statement. Tobacco use and women’s health. Journal of Obstetric,
Gynecologic and Neonatal Nursing, 46(5), 794–796.
Atkin, K., Scannell, M., & Nicholas, P. K. (2019). Use of dolutegravir for
antiretroviral therapy for women of childbearing age. Journal of Obstetric,
Gynecologic, and Neonatal Nursing: JOGNN/NAACOG, 48(6), 664–673.
Banderali, G., Martelli, A., Landi, M., Moretti, F., Betti, F., Radaelli, G.,… Verduci,
E. (2015). Short and long term health effects of parental tobacco smoking
during pregnancy and lactation: A descriptive review. Journal of Translational
Medicine, 13(1), 327. Centers for Disease Control and Prevention. (2018). Data
and statistics on birth defects. Retrieved from
https://www.cdc.gov/ncbddd/birthdefects/data.html
Centers for Disease Control and Prevention. (2019). Radiation and pregnancy: A
fact sheet for clinicians. Radiation and Pregnancy: A Fact Sheet for Clinicians,
Retrieved from
https://www.cdc.gov/nceh/radiation/emergencies/prenatalphysician.htm
Centers for Disease Control and Prevention. (2019). Rubella.
https://www.cdc.gov/rubella/pregnancy.html
Centers for Disease Control and Prevention. (2020). Treating for Two: Medicine
and Pregnancy. https://www.cdc.gov/pregnancy/meds/treatingfortwo/index.html
Denny, C. H., Acero, C. S., Naimi, T. S., & Kim, S. Y. (2019). Consumption of
alcohol beverages and binge drinking among pregnant women aged 18–44
Years—United States, 2015–2017. Morbidity and Mortality Weekly Report,
68(16), 365.
Fa, F., Laup, L., Mandelbrot, L., Sibiude, J., & Picone, O. (2020). Fetal and
neonatal abnormalities due to congenital herpes simplex virus infection: A
literature review. Prenatal Diagnosis, 40(4), 408–414.
Food and Drug Administration. (2019). Advice about eating fish. Retrieved from
https://www.fda.gov/food/consumers/advice-about-eating-fish
National Human Genome Research Institute. (2020). Genetic disorders, genomics,
and health care. Retrieved from https://www.genome.gov/human-genome-
project/Completion-FAQ
National Institute of Health (NIH) (2019). U.S. National Library of Medicine.
Genetics Home Reference. Retrieved October 13, 2019, from
https://ghr.nlm.nih.gov/
Organization of Teratology Information Specialists (OTIS). (2018). Cocaine.
Retrieved from https://mothertobaby.org/fact-sheets/cocaine-pregnancy/
Pomar, L., Musso, D., Malinger, G., Vouga, M., Panchaud, A., & Baud, D. (2019).
Zika virus during pregnancy: From maternal exposure to congenital zika virus
syndrome. Prenatal Diagnosis, 39(6), 420–430.
Queensland Clinical Guidelines. (2016). Queensland clinical guidelines on
perinatal substance use: Maternal. Retrieved from
https://www.health.qld.gov.au/data/assets/pdf_file/0023/140738/g-psumat.pdf
Rodriguez, C. E., Sheeder, J., Allshouse, A. A., Scott, S., Wymore, E., Hopfer, C.,.
Metz, T. D. (2019). Marijuana use in young mothers and adverse pregnancy
outcomes: A retrospective cohort study. BJOG: An International Journal of
Obstetrics & Gynaecology, 126(12), 1491–1497.
Scanlon, V. C., & Sanders, T. (2018). Essentials of anatomy and physiology (8th
ed.). Philadelphia: F.A. Davis.
Smith, B. R. (2013). The multidimensional human embryo, Carnegie Stages.
Retrieved from http://embryo.soad.umich.edu/carnStages/carnStages.html
Stoll, K., Kubendran, S., & Cohen, S. A. (2018). The past, present and future of
service delivery in genetic counseling: Keeping up in the era of precision
medicine. American Journal of Medical Genetics. Part C, Seminars in Medical
Genetics, 178(1), 24–37.
Surgeon General. (2019). Public Health Genomics and Precision Health
Knowledge Base (v6.0). Retrieved October 27, 2019, from
https://phgkb.cdc.gov/FHH/html/index.html.
Van Leeuwen, A. M., & Bladh, M. L. (Eds.). (2021). Davis’s comprehensive manual
of laboratory and diagnostic tests with nursing implications (9th ed.).
Philadelphia: FA Davis.
Venes, D. (Ed.). (2021). Taber’s cyclopedic medical dictionary (24th ed.).
Philadelphia: F.A. Davis.
Workowski, K. A., & Bolan, G. A. (2015). Sexually transmitted diseases treatment
guidelines, 2015. MMWR Recomm Rep, 64(RR-03), 1–137. doi:rr6403a1
World Health Organization. (2019). WHO recommendations on antenatal care for
a positive pregnancy experience. World Health Organization.

Davis Advantage
UNIT 3

CHAPTER 4
Physiological and Psychosocial

Changes During Pregnancy
CONCEPTS
Female reproduction
Pregnancy
Family
KEY WORDS
Fundus
Lightening
Braxton-Hicks contractions
Chadwick’s sign
Goodell’s sign
Operculum
Leukorrhea
Montgomery tubercles
Striae gravidarum
Supine hypotension syndrome
Vena caval syndrome
Gingivitis
Ptyalism gravidarum
Hyperemesis gravidarum
Pyrosis
Pruritus gravidarum
Prolactin
Let-down reflex
Diastasis recti
Linea nigra
Chloasma
Palmar erythema
Dyspepsia
LEARNING OBJECTIVES
■ Describe the physiological changes that occur during pregnancy and their
etiologies.
■ Identify nursing measures to relieve discomfort caused by the physiological
changes.
■ Describe the psychosocial changes that occur during pregnancy and the
factors that influence these changes.
■ Identify nursing interventions to help families adapt to the psychosocial
changes.
PICO(T) Questions
Use these PICO(T) questions to spark your thinking as you read the
chapter.
1. Are (P) women’s reported (I) levels of physical discomfort with pregnancy (O)
changed by whether the pregnancy was planned (C) or unplanned?
2. Is there a (O) change (I) in the level or rate of acceptance of pregnancy by
(P) men who are first-time fathers (C) compared with men who have
previously had children?
INTRODUCTION
From the time just before conception through the following 10 lunar
months, a woman’s body undergoes many complex alterations
during pregnancy. The accompanying physical, psychological, and
emotional changes focus on the growth, development, and
integration of the baby and the new family. The beginning of a new
life is a time of awe and amazement shaped by events that bring
about unique changes for the woman and her family.
This chapter explores the physiological and psychosocial changes
that occur during pregnancy and their effects on the woman, the
fetus, and the family.
PHYSIOLOGICAL ADAPTATIONS IN PREGNANCY

Reproductive System
The reproductive system undergoes one of the most significant
changes in size and function while the developing fetus grows.
Uterus
The uterus provides a home for the growing fetus. Blood flow to the
organ increases during pregnancy as progesterone acts on the
smooth muscle of the vasculature to provide adequate circulation for
endometrial growth and placental function. This ensures adequate
fetal nutrition and oxygenation as well as the removal of waste
products.
Under the influence of estrogen and progesterone, the myometrial
cells and muscle fibers undergo hyperplasia and hypertrophy,
processes that allow the uterus to enlarge and stretch as the fetus
grows. Throughout the pregnancy, the uterus will change in size,
shape, and position. At the beginning of pregnancy, the uterus is
shaped like a light bulb or inverted pear and can be felt above the
symphysis pubis. By the end of the first trimester, the uterus
develops into a soft, enlarged globular structure that rises out of the
pelvis and into the abdominal cavity. By 20 weeks gestation, the top
of the uterus or fundus reaches the umbilicus, and by term (38–40
weeks), the uterus reaches below the xiphoid. Lightening may
occur, which is when the fundal height decreases by 1–2 cm at the
end of the pregnancy when the fetus descends into the pelvis in
preparation for birth (Fig. 4-1). By term, the uterine muscles stretch
and thin to 0.6 inch (1.5 cm) or less, and the weight of the uterus
increases from 1.8 oz to 2.2 lb (70 g to 1,100 g).
Estrogen causes the uterine muscles to contract. Braxton-Hicks
contractions are irregular and painless. They may begin as early as
the 16th week of gestation and are often relieved with hydrating and
walking. As the pregnancy advances and fetal size increases,
contractions become increasingly more frequent and intense and
can be easily felt by the woman. Until late in the second trimester,
these contractions prepare the uterine muscles for the synchronized
activity necessary for effective labor.
Cervix
One of the earliest signs of pregnancy is the bluish-purple
discoloration that appears on the cervix, vagina, and vulva related to
increase in blood flow. This color change is known as Chadwick’s
sign and occurs around the sixth to eighth week of pregnancy (Fig.
4-2). High levels of circulating estrogen stimulate the cervical
glandular tissue, which increases in cell number and becomes
hyperactive. Increased blood flow and engorgement produce the
bluish discoloration.
Stimulation from the hormones estrogen and progesterone
produces cervical softening (Goodell’s sign). This physiological
change is related to several events, including a decrease in the
collagen fibers of the connective tissue, increased vascularity and
edema, and slight tissue hypertrophy and hyperplasia. Before
pregnancy, the cervix is firm and its texture resembles that of the tip
of the nose. After conception, the cervix softens and its texture is
closer to that of an ear lobe.
Patient Education
Feminine Hygiene During Pregnancy
The nurse should discuss the importance of hygiene with the patient. Gentle
external cleansing with plain soap and water is adequate. Douching, or internal
cleansing of the vagina, should be avoided. This practice can alter the vaginal
pH and allow pathogens to grow as well as disrupt the cervical mucus plug.
FIGURE 4-1 Pattern of uterine growth during pregnancy.
FIGURE 4-2 Chadwick’s sign.

PROCEDURE ■ Fundal Height
Measuring fundal height can help to determine the gestational age. Fundal
heights are measured in centimeters and correlate with the gestational age of
the fetus. Obtaining the fundal height includes a soft measuring tape in
centimeters and starting with the landmark of the top of the symphysis pubis
bone to the top of the fundus. The measured centimeters should correlate with
the weeks’ gestation +/– 2 weeks. Certain conditions can make this
assessment less reliable, such as maternal habitus, fetal position, twin
pregnancies, and poor growth and development. Any measurement greater or
less than 2 cm/week difference warrants further testing.
Vagina and Vulva

As pregnancy develops, vaginal mucosa thickens and the rugae
(vaginal folds) become more prominent. The rugae deepen from
hyperplasia and hypertrophy of the epithelial and elastic tissues,
which allows for adequate stretching of the vaginal vault during
childbirth. As the pregnancy progresses, the area becomes
edematous from poor venous return caused by the weight of the
gravid uterus. For some women, the increased pelvic congestion can
lead to heightened sexual interest and orgasmic experience.
Estrogen and progesterone cause a proliferation of the mucus-
producing cervical glands. Early in pregnancy, the endocervical
tissue takes on a honeycomb-like appearance. Cervical mucus fills
the endocervical canal and forms a mucus plug (operculum), which
helps to keep harmful agents out of the uterus. Leukorrhea,
increased whitish vaginal discharge, results from hyperplasia of the
vaginal mucosa and increased mucus production from the
endocervical glands. The pH of the vaginal fluids becomes more
acidic and decreases from 6.0 to 3.5. This change results from the
action of Lactobacillus acidophilus on the increased glycogen levels
in the vaginal epithelium. Increased glycogen levels also create a
vaginal environment more susceptible to the growth of Candida
albicans, which causes monilial vaginitis (yeast infection).
Ovaries
After ovulation, the luteinizing hormone (LH) secreted from the
pituitary gland stimulates the corpus luteum (functional cyst on the
ovary) to produce progesterone for 6 to 7 weeks. Once the placenta
has developed, it takes over progesterone production. At that time,
the corpus luteum ceases to function and is gradually absorbed by
the ovary. Ovulation ceases during pregnancy as the high circulating
levels of estrogen and progesterone inhibit the pituitary release of
follicle-stimulating hormone (FSH) and LH.
Breasts
Estrogen and progesterone produce changes in the mammary
glands. Breast enlargement, fullness, tingling, and increased
sensitivity occur during the early weeks of gestation and are often
the first sign of pregnancy. The superficial veins become more
prominent from the vascular relaxation effects of progesterone. Often
the venous congestion is more noticeable in primigravidas. The
Montgomery tubercles (sebaceous glands) on and around the
areola enlarge and provide lubrication for the nipple tissue. Striae
gravidarum (stretch marks) may develop as the breast tissue
stretches (Fig. 4-3).
During the second trimester, a clear, thin fluid called precolostrum
is found in the acini cells, the smallest parts of the milk glands.
Precolostrum becomes colostrum, a creamy whitish-yellow liquid that
may leak from the nipples as early as the 16th week of gestation.
This substance contains antibodies, essential proteins, and fat to
nourish the baby and prepare the intestines for digestion and
elimination. The body converts colostrum to mature milk during the
first few days after birth.
FIGURE 4-3 Pregnant abdomen with striae gravidarum.
General Body System Changes

HEART
As the fetus grows, the diaphragm is shifted upward. The heart
shifts upward and to the left, rotating on the axis with a more lateral
apex (Fig. 4-4). Heart rate increases by 10 to 15 beats per minute to
meet the demands of the growing fetus. The heart experiences
cardiac hypertrophy, a normal physiological increase in size resulting
from the increased blood volume and cardiac output. Exaggerated
first and third heart sounds and systolic murmurs are common during
pregnancy. The murmurs are usually asymptomatic and resolve
within the first 2 weeks postpartum after the plasma volume levels
return to normal.
FIGURE 4-4 Growth of the uterus displaces the maternal heart
upward and laterally to the left. Red line = nonpregnant, dotted blue
line = pregnant
CARDIAC OUTPUT
Cardiac output increases during pregnancy and peaks around the
20th to 24th week of gestation at about 30% to 50% above
prepregnancy levels, remaining increased for the duration of the
pregnancy. With the increased vascular volume and cardiac output,
vasodilation (related to progesterone-induced relaxation of the
vascular smooth muscle) reduces blood pressure in the second
trimester.
During the first trimester, blood pressure normally remains the
same as prepregnancy levels but then gradually decreases until
around 20 weeks of gestation. After 20 weeks, the vascular volume
expands and the blood pressure increases to reach prepregnancy
levels by term.
SUPINE HYPOTENSION SYNDROME

The pregnant woman may experience supine hypotension
syndrome, or vena caval syndrome (faintness related to
bradycardia) if she lies on her back. The pressure from the enlarged
uterus exerted on the vena cava decreases the amount of venous
return from the lower extremities and causes a marked decrease in
blood pressure, with accompanying dizziness, diaphoresis, and
pallor (Fig. 4-5).
Patient Education
Relieving Vena Caval Syndrome
Educate clients on the need to lie on their left side or in semi-Fowler’s position
to reduce pressure on the vena cava. If they need to lie supine, a wedge
should be placed under the hip to relieve direct pressure.
Hematological System
TOTAL VOLUME
An increase in maternal blood volume of 40% to 50% begins
during the first trimester and peaks at term, primarily caused by an
increase in plasma and erythrocyte volume. Additional erythrocytes,
needed because of the extra oxygen requirements of the maternal
and placental tissue, ensure an adequate supply of oxygen to the
fetus. The elevation in erythrocyte volume remains constant during
pregnancy.
FIGURE 4-5 Supine hypotension, or vena caval syndrome, may

occur if the pregnant woman lies on her back.
Most of the increased blood flow is directed to the uterus, and of

this amount, 80% is channeled to the placenta. Blood flow to the
maternal kidneys is increased by 30% to 50% to enhance the
excretion of maternal and fetal wastes. Dilation of the capillaries and
increased blood flow to the skin help eliminate the extra heat
generated by fetal metabolism. The extra blood volume decreases
during the first 2 weeks postpartum and a substantial amount of fluid
loss in the first 3 postpartal days occurs through maternal diuresis.
HEMATOCRIT
During pregnancy, hematocrit values may appear low because of
the increase in total plasma volume (on average, 50%). Because the
plasma volume is greater than the increase in erythrocytes (30%),
the hematocrit (a measurement of the red blood cell concentration in
the plasma) decreases by about 7%. This alteration is termed
“physiological anemia of pregnancy.” The hemodilution effect is most
apparent at 32 to 34 weeks. The mean acceptable hemoglobin level
in pregnancy is 11 to 12 g/dL of blood. Some women experience
symptoms of fatigue related to this phenomenon, although altered
sleep patterns may also contribute. The nurse should teach the
patient to hydrate adequately by drinking six to eight glasses of
water each day and ensure that her diet is high in protein and iron.
Although gastrointestinal absorption of iron is enhanced during
pregnancy, most women must add supplemental iron to meet the
needs of the expanded erythrocytes and those of the growing fetus.
Iron is also necessary for the formation of hemoglobin, the oxygen-
carrying component of the erythrocyte. The fetal need for iron is
greatest during the last 4 weeks of pregnancy, when the fetal iron
stores are amassed.
LEUKOCYTES, PROTEINS, PLATELETS, AND IMMUNOGLOBULINS

During pregnancy, the number of leukocytes increases and the
average white blood cell count ranges from 5,000 to 15,000/mm3.
During labor and postpartum, these levels may climb as high as
25,000/mm3. Although the exact reason for this increase is unclear,
leukocyte counts normally increase in response to stress and
vigorous exercise.
FIBRINOGEN
Although the platelet cell count does not change significantly,
fibrinogen volume may increase by as much as 50%. This leads to
an increase in the sedimentation rate. Blood factors VII, VIII, IX, and
X also increase, causing hypercoagulability. The hypercoagulable
state coupled with venous stasis (poor blood return from the lower
extremities) places the pregnant woman at an increased risk for
venous thrombosis, embolism, and when complications are present,
disseminated intravascular coagulation (DIC).
PLASMA
Plasma proteins also increase, although because of the
hemodilution effect during pregnancy, protein concentrations
decrease, especially the albumin level. Decreased plasma albumin
leads to a drop in osmotic pressure, which causes body fluids to
move into the second space. This change produces edema.
Respiratory System
During pregnancy, changes occur to meet the woman’s increased
oxygen requirements. The tidal volume (amount of air breathed in
each minute) increases by 30% to 40%. This change is related to the
elevated levels of estrogen and progesterone. Estrogen prompts
hypertrophy and hyperplasia of the lung tissue. Progesterone
decreases airway resistance by causing relaxation of the smooth
muscle of the bronchi, bronchioles, and alveoli. These alterations
produce an increase in oxygen consumption by approximately 15%
to 20%, along with an increase in vital capacity (the maximum
amount of air that can be moved in and out of the lungs with forced
respiration). The increase of progesterone causes a normal
physiological state of chronic hyperventilation and resting respiratory
rates will be slightly increased.
Labs
Common Laboratory Values in Pregnancy
Laboratory Values Usual Normal Female Normal Value in Pregnancy
Value
Serum Values
Hemoglobin 11.7–15.5 g/dL Decreased by 1.5–2 g/dL
Lowest point occurs at 30–34
weeks
Hematocrit 38%–44% Decreased by 4%–7%, lowest
point at 30–34 weeks
Leukocytes 4.5–11.0 × 103/mm3 Gradual increase of 3.5 ×
103/mm3
Platelets 150–400 × 103/mm3 Slight decrease
Amylase 30–110 U/L Increased by 50%–100%
Chemistries
Albumin 3.4–4.8 g/dL Early decrease by 1 g/dL
Calcium (total) 8.2–10.2 mg/dL Gradual decrease of 10%
Chloride 97–107 mEq/L No significant change
Creatinine 0.5–1.1 mg/dL Early decrease by 0.3 mg/dL
Fibrinogen 200–400 mg/dL Progressive increase of 1–2
g/L
Glucose (fasting) 65–99 mg/dL Gradual decrease of 10%
Potassium 3.5–5.0 mEq/L Gradual decrease of 0.2–0.3
mEq/L
Protein (total) 6.0–8.0 g/dL Early decrease of 1 g/dL, then
stable
Sodium 135–145 mEq/L Early decrease of 2–4 mEq/L,
then stable
Urea nitrogen 8–20 mg/dL Decrease in first trimester by
50%
Uric acid 2.3–6.6 mg/dL First trimester decrease of
33%, rise at term
Urine Chemistries
Creatinine 11–20 mg/kg per 24 hr No significant change
Protein 10–140 mg per 24 hr Up by 250–300 mg/day by the
20th week
Creatinine clearance 75–115 mL/min/1.73 Increased by 40%–50% by the
m2 16th week
Serum Hormones
Cortisol 8–21 g/dL Increased by 20 g/dL
Prolactin 3.3–26.7 ng/mL Gradual increase, 5.3–215.3
ng/mL, peaks at term
Thyroxine (T4) total 5.5–11.0 mcg/dL 5.5–16.0 mcg/dL
Triiodothyronine (T3) 70–204 ng/dL Early sustained increase of up
total to 50%
116–247 ng/dL (last 4 months
of gestation)
Adapted from Chapman, L., & Durham, R. (2013). Maternal-newborn nursing:

The critical components of nursing care. (2nd ed.). Philadelphia: F.A. Davis;
and Van Leeuwen, A. M., & Bladh, M. L. (2021). Davis’s comprehensive
handbook of laboratory and diagnostic tests with nursing implications (9th ed.).
As the uterus grows, anatomical changes place upward pressure

that elevates the diaphragm and increases the subcostal angle. The
chest circumference may increase by as much as 2.4 inches (6 cm).
Although the “up and down” capacity of diaphragmatic movement is
reduced because of increasing pressure from the growing fetus,
lateral movement of the chest and intercostal muscles accommodate
for this loss of movement. Many women verbalize an increased
awareness of the need to breathe and may perceive this sensation
as dyspnea (difficulty breathing) despite normal oxygenation. The
nurse should offer reassurance and educate the woman about
normal alterations and symptoms. Under normal circumstances,
resting with the head elevated while taking slow, deep breaths
causes an improvement in the symptoms. However, certain lung
diseases, including asthma and emphysema, may be aggravated by
the normal physiological changes as the oxygen demands of the
pregnancy increase. If symptoms persist or worsen, the woman
should contact her health-care provider.
Eyes and Nose

Blurred vision, the most common visual complaint in pregnant
women, is caused by corneal thickening associated with fluid
retention and decreased intraocular pressure. These changes begin
during the first trimester, persist throughout pregnancy, and regress
by 6 to 8 weeks postpartum. As part of anticipatory guidance, the
nurse teaches that, because the changes are only temporary, a
corrective lens prescription should not be changed until the
pregnancy has been completed.
An increase in mucus production results from the combined effects
of progesterone (increased blood flow to the mucus membranes of
the sinus and nasal passages) and estrogen (hypertrophy and
hyperplasia of the mucosa). Nasal stuffiness and congestion (rhinitis
of pregnancy) are common complaints. The nurse should educate
the patient about these normal changes and offer reassurance.
Increasing the oral fluid intake helps to keep the mucus thin and
easier to mobilize.
Edema (an effect of estrogen) of the nasal mucosa, along with
vascular congestion (an effect of progesterone), may cause epistaxis
(nosebleeds). The woman should be advised to use caution when
blowing her nose and to avoid probing the nasal cavities with a
cotton swab. The use of nasal sprays to relieve congestion should
be avoided because their rebound effect can cause congestion to
worsen. Normal saline nasal sprays may be used sparingly to
moisten the nasal passages.
ORAL
Both gingivitis (inflammation of the gums) and periodontitis
(inflammation of the gums and supporting structures) occur
frequently in pregnant women due to the increased blood supply to
the gums, estrogen-related tissue hypertrophy, and edema.
Periodontal disease in pregnancy is associated with adverse
outcomes such as low-birth-weight infants and pre-eclampsia
(Hartnett et al., 2016). Epulis gravidarum (red raised nodules on the
gum lines) can develop and cause bleeding and discomfort. (Fig. 4-
6). Oral health should be assessed early on in pregnancy, and
women should be reminded for the need for good oral hygiene and
routine dental cleanings during pregnancy.
Ptyalism gravidarum causes excessive saliva production during
pregnancy. This condition starts in the first trimester and can last
until several days after the delivery of the infant. It is often
accompanied with a bitter taste that can be unpleasant. The cause of
these symptoms is uncertain, although stimulation of the salivary
glands from eating starch or decreased unconscious swallowing
when nauseated may contribute. Nausea and vomiting of pregnancy
(NVP), also known as morning sickness, occurs because of rising
levels of human chorionic gonadotropin (hCG) and relaxation of the
stomach, esophagus, and gastroesophageal sphincters. NVP is the
primary reason women are admitted to the hospital in the first
trimester.
FIGURE 4-6 Gingival hypertrophy; epulis.
Hyperemesis gravidarum is excessive and persistent nausea

and vomiting in pregnancy. This serious condition can lead to
dehydration, electrolyte imbalances, and weight loss. Treatment may
include intravenous fluid replacements and antiemetics.
Pyrosis (heartburn) is a common condition that occurs in up to
80% of pregnant women by the end of the third trimester. The effect
of progesterone on smooth muscle causes relaxation of the
esophagus. The movement of food is slowed and the
gastroesophageal, or cardiac, sphincter (circular muscle located at
the top of the stomach) weakens. This alteration prevents efficient
closure when the stomach is emptying and allows the reflux of
stomach contents into the esophagus, producing heartburn from
irritation to the esophageal lining by gastric secretions and acids.
Recommendations include eating small meals, avoiding lying down
after meals for at least 1 hour, and avoiding spicy foods. Limited use
of antacids can alleviate some of these symptoms.
LIVER
Liver functions are only slightly altered during pregnancy. Stasis of
bile in the liver (intrahepatic cholestasis) occasionally occurs late in
pregnancy and can cause severe itching (pruritus gravidarum).
This condition disappears soon after delivery. Patients should be
advised that avoiding high-fat meals can reduce the presence or
frequency of these symptoms. The liver, which breaks down
maternal toxins, must deal with fetal waste products and toxins as
well. The additional workload can lead to altered liver function tests,
especially if accompanied by hepatic vessel vasoconstriction
associated with pre-eclampsia.
GALLBLADDER
The gallbladder, which stores bile, is also composed of smooth
muscle that relaxes during pregnancy. This alteration can lead to
stasis of the bile (cholestasia) or inflammation and infection
(cholecystitis). In addition, the progesterone-induced prolonged
emptying time combined with elevated blood cholesterol levels may
predispose the woman to gallstone formation (cholelithiasis). Pain in
the epigastric region after ingestion of a high-fat meal is the major
symptom of these conditions. The pain is self-limiting and usually
resolves within 2 hours. Cholelithiasis occurs more often in obese
individuals with fair skin and in women older than 40.
During the pregnancy, the gravid uterus pushes the appendix up
and posterior; the typical location of pain (McBurney’s point) is not a
reliable indicator for a ruptured appendix during pregnancy. Pregnant
women who are having abdominal pain with a fever need to be
assessed for the possibility of appendicitis.
HEMORRHOIDS
During pregnancy, food remains in the stomach longer for
enhanced digestion and moves more slowly through the small
intestine to allow for complete absorption of nutrients. Because the
large intestine is also sluggish from the effects of progesterone on
the smooth muscle, more water is reabsorbed from the bowel, and
bloating and constipation can occur. Straining at defecation may
cause or exacerbate hemorrhoids (vein varicosities in the lower
rectum and anus). Encourage patients to drink at least 8 to 10
glasses of water each day, add fiber to their diets to produce bulk,
and exercise to encourage peristalsis. They should be taught to
avoid straining with bowel movements. Warm or cool sitz baths may
be helpful for hemorrhoid discomfort.
Urinary System
Multiple changes in the urinary system help facilitate normal waste
elimination for the woman and the fetus. The increasing
progesterone in pregnancy relaxes the urethra, sphincter
musculature, and bladder. Peristalsis that normally facilitates the
movement of urine from the kidneys to the bladder is reduced,
causing stagnation of urine in the bladder.
The ureters, composed of smooth muscle, are also affected by
progesterone. Elongation and dilation, especially of the right ureter,
occurs. Peristalsis that normally facilitates the movement of urine
from the kidneys to the bladder is reduced. This change, coupled
with pressure on the ureters from the enlarging uterus, causes an
obstruction of urine flow. The stagnant urine becomes an excellent
medium for the growth of microorganisms.
These changes can cause bacteria to ascend into the bladder,
which can cause asymptomatic bacteriuria (ASB) or urinary tract
infections (UTIs). Patients should be encouraged to drink at least 8
to 10 glasses of water each day and empty their bladders at least
every 2 to 3 hours and immediately after intercourse. These
measures help to prevent stasis of urine and the bacterial
contamination that leads to infection. Due to this concern, women
will have frequent urinalysis throughout the pregnancy or urine dip
for assessment of a UTI.
Kidneys slightly enlarge due to the increase in vasculature. The
glomerular filtration rate (GFR) and renal plasma flow increase due
to renal vasodilation, which occurs under the influence of
progesterone. This affects the reabsorption and handling of waste. In
a nonpregnant (nondiabetic) state, glucose is reabsorbed by the
proximal and collecting tubule. During pregnancy, this process
becomes less effective, which results in excretion of glucose
(approximately 1–10 g/per day) and protein (up to 300 mg/day).
In the first trimester, pregnant women often experience urinary
urgency, frequency, and nocturia due to the pressure of the growing
fetus on the bladder. In the second trimester, these symptoms are
often relieved as the uterus grows and moves into the abdomen,
relieving pressure on the bladder. However, these symptoms often
return in the third trimester when the fetal presenting part descends
into the pelvis (Fig. 4-7).
Endocrine System
THYROID GLAND
The thyroid gland changes in size and activity during pregnancy,
and the size increase can be felt upon palpation. Enlargement is
caused by increased circulation from the progesterone-induced
effects on the vessel walls and by estrogen-induced hyperplasia of
the glandular tissue. In early pregnancy, elevated levels of thyroxine-
binding globulins cause an increase in the total thyroxine (T4) and
total 3,5,3-triiodothyronine (T3). The active hormones free T4 and
free T3 remain unchanged from normal nonpregnant levels. Levels of
total T4 continue to be elevated until several weeks postpartum.
Increased T4-binding capacity is noted by an increase in the serum
protein-bound iodine (PBI). These changes in thyroid regulation
cause a progressive increase in the basal metabolic rate (BMR) of
up to 25% by term. The BMR is the amount of oxygen consumed by
the body over a unit of time (mL/min). Maternal effects of the
increase in BMR include heat intolerance and an elevation in pulse
rate and cardiac output. Within a few weeks following birth, thyroid
function returns to normal levels.
FIGURE 4-7 Compression of the bladder results from the growing
uterus.
PARATHYROID GLANDS
The parathyroid glands, which regulate calcium and phosphate
metabolism, increase in size from estrogen-induced hyperplasia and
hypertrophy. Maternal concentrations of parathyroid hormone
increase as the fetus requires more calcium for skeletal growth
during the second and third trimesters. Calcium intake is extremely
important for the pregnant woman, whose daily intake should be at
least 1,200 to 1,500 mg.
PITUITARY GLAND AND PLACENTA
The anterior lobe of the pituitary gland, stimulated by the
hypothalamus, increases in size and in weight. Pregnancy is
possible because of the actions of FSH (stimulates growth of the
graafian follicle) and LH, which prompts final maturation of the
ovarian follicles and release of the mature ovum. During pregnancy,
ovarian follicle maturation may continue, but ovulation does not
occur.
Prolactin, also produced by the anterior pituitary gland, is
responsible for initial lactation. Although this hormone increases 10-
fold during pregnancy, the elevated levels of estrogen and
progesterone inhibit lactation by interfering with prolactin binding to
the breast tissue. Prolactin may also play a role in fluid and
electrolyte shifts across the fetal membranes.
Oxytocin and vasopressin are produced in the posterior lobe of the
pituitary. Oxytocin primarily causes uterine contractions, but high
levels of progesterone prevent contractions until close to term.
Oxytocin also stimulates milk ejection from the breasts, or the let-
down reflex. Vasopressin causes vasoconstriction. Vasoconstriction
leads to an increase in maternal blood pressure and exerts an
antidiuretic effect that promotes maternal fluid retention to maintain
circulating blood volume. The increased blood volume that occurs
during pregnancy, along with changes in plasma osmolarity (the
fluid-pulling capacity of the plasma to retain fluids), controls the
release of vasopressin.
Maternal metabolism is altered to support the pregnancy by
thyrotropin and adrenotropin. These hormones, produced by the
anterior pituitary gland, exert their effects on the thyroid and adrenal
glands. Thyrotropin causes an increased basal metabolism, and
adrenotropin alters adrenal gland function to increase fluid retention
by the kidneys.
Human placental lactogen (hPL), also known as human chorionic
somatomammotropin (hCS), is produced by the placental
syncytiotrophoblasts. It is an insulin antagonist and acts as a fetal
growth hormone. Human placental lactogen increases the number of
circulating fatty acids to meet maternal metabolic needs and
decreases maternal glucose utilization, which increases glucose
availability to the fetus.
ADRENAL GLANDS
The adrenal glands, located above the kidneys, change little
during pregnancy. The adrenal cortex produces cortisol, a hormone
that allows the body to respond to stressors. Cortisol is increased
during pregnancy because of decreased renal secretion (an
alteration prompted by high estrogen levels). Cortisol regulates
protein and carbohydrate metabolism and is believed to promote
fetal lung maturation and stimulate labor at term. Following birth, it
may take up to 6 weeks for maternal cortisol levels to return to
normal.
By the second trimester, the adrenal cortex secretes increased
levels of aldosterone, a mineral corticoid that causes the renal
reabsorption of sodium. This physiological alteration promotes the
reclaiming of water and helps to enhance circulatory volume. The
increase in aldosterone may be a protective response to the
increased renal and excretory gland sodium excretion that occurs as
a result of the effects of progesterone.
PANCREAS
The pancreas secretes insulin produced by the beta cells of the
islets of Langerhans. Pregnancy prompts an increase in the number
and size of the beta cells. These changes alter carbohydrate
metabolism during pregnancy.
PROSTAGLANDINS
Prostaglandins are lipids found in high concentrations in the
female reproductive tract and the uterine decidua during pregnancy.
Their exact function is unknown although they may maintain a
reduced placental vascular resistance. A decrease in prostaglandin
levels may contribute to hypertension and pre-eclampsia. At term, an
increased release of prostaglandins from the cervix as it softens and
dilates may contribute to the onset of labor.
HORMONAL INFLUENCES
Many hormones are responsible for the changes that take place
during and beyond pregnancy. Each serves a specific function in the
development process for the embryo, fetus, and neonate. The
pituitary gland secretes hormones that influence ovarian follicular
development, prompt ovulation, and stimulate the uterine lining to
prepare for pregnancy and maintain it until the placenta becomes
fully functional. Other pituitary hormones alter metabolism, stimulate
lactation, produce pigmentation changes in the skin, stimulate
uterine muscle contractions, prompt milk ejection from the breasts,
allow for vasoconstriction to maintain blood pressure, and regulate
water balance.
After conception, ovulation ceases. The corpus luteum produces
progesterone and, to a lesser degree, estrogen. Progesterone is the
hormone primarily responsible for maintaining the pregnancy. Once
implantation occurs, the trophoblast secretes hCG to prompt the
corpus luteum to continue progesterone production until this function
is taken over by the placenta. The ovarian hormones work in
synchrony to maintain the endometrium, provide nutrition for the
developing morula and blastocyst, aid in implantation, decrease the
contractility of the uterus to prevent spontaneous abortion, initiate
development of the ductal system in the breasts, and promptly
remodel maternal joint collagen.
The placenta provides hormones essential to the survival of the
pregnancy and fetus. Placental hormones:
■ Prevent the normal involution of the ovarian corpus luteum
■ Stimulate production of testosterone in the male fetus
■ Protect the pregnancy from the maternal immune response
■ Ensure that added glucose, protein, and minerals are available for
the fetus
■ Prompt proliferation of the uterus and breast glandular tissue
■ Promote relaxation of the woman’s smooth muscle
■ Create a loosening of the pelvis and other major joints
As the pregnancy progresses, the abdominal wall weakens, and the
rectus abdominis muscles separate (diastasis recti) to
accommodate the growing uterus. As the weight of the uterus shifts
upward and outward, a lumbar lordosis (anterior convexity of the
lumbar spine) develops and the center of gravity shifts forward (Fig.
4-8). Low back pain usually accompanies this physiological change
especially in the second and third trimester.
The sacroiliac joint becomes lax and the symphysis pubis widens,
causing instability. These changes, coupled with the change in the
maternal center of gravity and weight of the growing fetus, result in
an unsteady gait and a risk for falling. The patient’s gait takes on the
appearance of a “pregnancy waddle” as the bones of the pelvis shift
and move. Women should be encouraged to maintain good posture
and keep the abdominal muscles toned through exercise.
Pregnant women frequently complain of sharp, quick pain in the
lower abdominal quadrants or in the groin area. Most often, the pain
is related to stretching and hypertrophy of the round ligaments that
support the uterus (round ligament pain) and often occurs when
there is movement that causes an increase in stretching. Due to the
dextrorotation of the gravid uterus as it rises out of the pelvis, the
right maternal side is most commonly affected. Women can lean
toward the affected side to relieve the overstretching, which often
resolves round ligament pain.
Figure 4-8 Lumbar lordosis.
Calcium stores mobilize to provide for the fetal calcium needs

necessary for skeletal growth. The total maternal serum calcium
decreases, but the ionized calcium level remains unchanged from
the prepregnant state. The increase in circulating maternal
parathyroid hormone stimulates an increased absorption of calcium
from the intestines and decreases the renal loss of calcium to
maintain adequate calcium levels.
Calcitonin, a hormone important in the metabolism of calcium and
phosphorus, suppresses bone resorption by inhibiting the activity of
osteoclasts. Osteoclasts are a cell type that “digests” bone matrix,
causing a release of calcium and phosphorus into the blood.
Calcitonin is produced primarily in the thyroid gland, but it is also
synthesized in many other tissues, including the lungs and intestinal
tract. The activity of calcitonin, coupled with adequate nutrition,
protects the maternal skeleton from a loss of bone density despite an
increase in the turnover of bone mass. Calcium intake is of major
importance during pregnancy, and women should be encouraged to
increase their dietary calcium through the consumption of dairy
products, calcium-fortified orange juice, and dark green leafy
vegetables.
Calcium supplementation may be advised for patients who are
vegetarian or lactose-intolerant. Pregnant women often complain of
cramping in the lower extremities and calves, especially at night. The
cramps, sometimes called “charley horses,” can be extremely painful
and are caused by poor circulation to the extremities. They have also
been associated with imbalances in calcium and phosphorus.
Increasing or decreasing calcium intake may be helpful. For
immediate relief of the cramping, the woman should be instructed to
stand and lean forward to stretch the calf muscle or have someone
gently push her toes back toward her shin and hold this position for
several seconds. Daily walks can also help because ambulation
improves circulation to the muscles.
Immune System
The production of maternal immunoglobulins (IgA, IgG, IgM, IgD,
and IgE) is unchanged in pregnancy. Circulating levels of maternal
IgG are decreased during pregnancy because of the transfer across
the placenta to the growing fetus. IgM has a large molecular size and
is unable to cross the placenta. IgA, IgD, and IgE also remain in the
maternal circulation. During pregnancy, immune system function
experiences a normal physiological decrease. This allows for the
mother to carry the pregnancy and inhibits the body from rejecting
the fetus, which can be seen as a foreign body. As a result, the
symptoms of maternal autoimmune diseases such as lupus
erythematosus may improve during pregnancy. However, this also
increases the mother’s susceptibility to infections such as varicella
and influenza. It is critical to advise mothers on proper hand hygiene
and to avoid crowds and individuals with active infections; also
encourage expecting mothers to receive the influenza vaccine.
Estrogen, progesterone, and alpha-melanocyte-stimulating
hormones cause many changes in the appearance, structure, and
function of the integumentary system. The skin undergoes
pigmentation changes related to the influence of estrogen. Moles
(nevi), freckles, and recent scars may darken or multiply in number.
The nipples, areolae, axillae, vulvar area, and perineum also darken
in color.
The linea alba, a light line that extends from the umbilicus to the
mons pubis (and sometimes upward to the xiphoid process),
darkens, becoming the linea nigra. The linea is more noticeable in
the women who have naturally darker complexions. Melasma
gravidarum, also known as chloasma, forms the “mask of
pregnancy.” This dark, blotchy, brownish pigmentation change
occurs around the hairline, brow, nose, and cheeks. The heightened
pigmentation fades after pregnancy but can recur after exposure to
the sun and in subsequent pregnancies. The nurse should teach the
patient about the importance of avoiding excessive sun and UV
radiation exposure, which can exacerbate the symptoms. Educate
women to wear sunscreen every day.
Alterations in hair as well as nail growth and texture may occur.
The nails may become stronger and grow faster. The number of hair
follicles in the dormant phase may decrease, and this change
stimulates new hair growth. Once the infant is born, this process is
reversed, and the mother experiences an increase in hair shedding
for approximately 1 to 4 months. Although this change may be
disconcerting, the nurse can reassure the patient that virtually all hair
will be replaced within 6 to 12 months. During pregnancy, hair may
react differently to dyes and chemicals.
Increased adrenal steroid levels cause the connective tissue to
lose strength and become more fragile. This change can cause
striae gravidarum, or “stretch marks,” on the breasts, buttocks,
thighs, arms, and abdomen. Striae appear as reddish, pink-purple
lines in wavy, depressed streaks that fade to a silvery white color
after birth but do not usually disappear completely. Little evidence
exists on preventing striae gravidarum; however, some women may
use natural creams and oils such as cocoa butter, aloe vera, or
almond oil as treatments to help alleviate the marks.
Increased levels of estrogen during pregnancy may cause
angiomas and palmar erythema. Angiomas, also called “vascular
spiders,” are tiny, bluish, end-arterioles that occur on the neck,
thorax, face, and arms. They may appear as star-shaped or
branched structures that are slightly raised and do not blanch with
pressure. More common in Caucasian women, angiomas appear
most often during the second to fifth month of pregnancy and usually
disappear after birth. Palmar erythema is a condition characterized
by color changes over the palmar surfaces of the hands, usually a
diffuse reddish-pink mottling.
Neurological System
The central nervous system appears to be affected by the hormonal
changes of pregnancy, although the specific alterations other than
those involving the hypothalamic-pituitary axis are less well known.
Many women complain of a decreased attention span, poor
concentration, and memory lapses during and shortly after
pregnancy. Cunningham and colleagues (2014) identified a
pregnancy sleep pattern phenomenon characterized by reduced
sleep efficiency, fewer hours of night sleep, frequent awakenings,
and difficulty going to sleep. Nurses can advise patients that
afternoon napping may help alleviate the fatigue associated with the
sleep alterations.
SIGNS OF PREGNANCY
The many changes the body experiences during pregnancy are often
markers for many women in determining or suggesting they may be
pregnant. Signs of pregnancy are categorized into presumptive,
probable, and positive signs (Table 4-1).
Presumptive Signs of Pregnancy

The subjective signs of pregnancy are the symptoms that the patient
experiences and reports. Because these symptoms may be caused
by other conditions, they are the least indicative of pregnancy. In
combination with other pregnancy symptoms, the following
presumptive signs may serve as diagnostic clues:
■ Amenorrhea (the absence of menses) is one of the earliest
symptoms and is especially significant in a woman whose
menstrual cycle is ordinarily regular. Amenorrhea may also be
caused by chronic illness; infection; or endocrine, metabolic, or
psychological factors.
■ Nausea and vomiting (“morning sickness”) may occur at any time,
and women who experience this symptom tend to have a
decreased incidence of spontaneous abortion and perinatal
mortality. Nausea and vomiting may also be caused by infection or
gastrointestinal or emotional disorders.
■ Frequent urination (urinary frequency) is caused by pressure
exerted on the bladder by the enlarging uterus. Urinary frequency
may also be caused by infection, cystocele, pelvic tumors, or
urethral diverticula.
■ Breast tenderness results from hormonal changes during
pregnancy. This symptom may also be associated with
premenstrual syndrome, mastitis, and pseudocyesis (false
pregnancy).
■ Perception of fetal movement (quickening) occurs during the
second trimester. The sensation of fetal movement may also result
from flatus, peristalsis, and abdominal muscle contractions.
■ Skin changes include stretch marks (striae gravidarum) and
increased pigmentation. These changes may also result from
weight gain and oral contraceptive pills (OCPs).
■ Fatigue may also be associated with illness, stress, or lifestyle
changes.
Probable Signs of Pregnancy

The probable signs of pregnancy are objective indicators that are
observed by the examiner. These signs result from physical changes
in the reproductive system. However, because they may be caused
by other conditions, a positive diagnosis of pregnancy cannot be
based on these findings alone.
■ Abdominal enlargement may also be caused by uterine or
abdominal tumors.
■ Piskacek’s sign (uterine asymmetry with a soft prominence on the
implantation side) may also be associated with uterine tumors.
■ Hegar’s sign (softening of the lower uterine segment) may also be
caused by pelvic congestion.
■ Goodell’s sign (softening of the tip of the cervix) may also be
caused by infection, hormonal imbalance, or pelvic congestion.
■ Chadwick’s sign (violet-bluish color of the vaginal mucosa and
cervix) may also be caused by pelvic congestion, infection, or a
hormonal imbalance.
■ Braxton Hicks contractions (intermittent uterine contractions) may
also be associated with uterine leiomyomas (fibroids) or other
tumors.
■ Positive pregnancy test may occur from certain medications,
premature menopause, choriocarcinoma (malignant tumors that
produce hCG), or the presence of blood in the urine.
■ Ballottement (passive movement of the unengaged fetus) may be
because of uterine tumors or cervical polyps instead of the
presence of a fetus.
TABLE 4-1
Presumptive, Probable, and Positive Signs of Pregnancy
CATEGORY SIGNS AND SYMPTOMS POSSIBLE ALTERNATIVE
OF SIGNS CONDITIONS
Presumptive • Amenorrhea • Nutritional issues, STIs,
• Nausea and vomiting endocrine factors
• Urinary frequency • GI disorders, infections,
• Fatigue anorexia
• Breast tenderness and • UTI, tumors
changes, Montgomery’s • Premenstrual changes
glands
• Quickening
Probable • Goodell’s sign (softening of the • Increased vascular congestion
cervix) • Uterine tumors
• Chadwick’s sign (blue/purplish • Obesity
color change of cervix) • Medications (oral
• Hegar’s sign contraception)
• Ballottement • Choriocarcinoma, hyditaform
• Enlargement of uterus or mole
abdomen
• Pigmentation of skin
• Positive pregnancy test
• Braxton Hicks contractions
Positive • Ultrasound These signs positively confirm
• Fetal heart tones heard pregnancy.
• Fetal movement felt by doctor
or midwife
Positive Signs of Pregnancy

The positive indicators of pregnancy are attributable only to the
presence of a fetus:
■ Fetal heartbeat heard by Doppler
■ Visualization of the fetus by ultrasound
■ Fetal movements palpated by a qualified examiner (doctor or
certified nurse midwife)
Labs
Pregnancy Testing
If a pregnancy is suspected, the woman usually first undergoes hCG testing. A
detectable level of hCG must be present in the urine or blood for a pregnancy
test to be positive. hCG is produced by the syncytiotrophoblastic cells found in
the outer layer of the trophoblast, secreted into the maternal plasma, and then
excreted in the urine. hCG levels peak between days 60 and 70 of pregnancy
and then gradually decrease over approximately the next 40 days to reach a
plateau maintained throughout the pregnancy. hCG can be detected in
maternal blood as early as 1 day after implantation and in urine around day
26. The hCG molecule contains both an alpha subunit and a beta subunit.
Because of the large number of commercial pregnancy tests available,
women should be advised to use a home pregnancy test that is specific for the
beta subunit of hCG because this marker prevents cross reactions with other
hormones. The alpha subunit is very similar in molecular structure to LH.
Women with high LH levels (e.g., those experiencing perimenopause) who
use a pregnancy test designed to detect the complete hCG molecule risk
obtaining a false-positive result. If the over-the-counter pregnancy test used
relies on urinary hCG, the patient should be advised to follow the
manufacturer’s recommendations carefully to avoid an unreliable result. If a
home pregnancy test is negative and the signs and symptoms of pregnancy
persist, the test should be repeated in a week or the woman should see her
health-care provider.
A chemical pregnancy occurs when a home pregnancy test has confirmed
the presence of hCG, but a late and often heavy menstrual period follows. In
these instances, conception probably occurred but for some reason the
pregnancy was unable to develop into a viable embryo. Before the
development of sophisticated methods for detecting an early pregnancy, most
of these early and unfruitful fertilizations would have gone undiagnosed.
Establishing the Estimated Date of Birth

The antenatal period begins with the first day of the last normal
menstrual period (LMP) and ends when labor begins. This time
frame is approximately 280 days in length or 40 weeks or 10 lunar
months or 9 calendar months. Pregnancy is divided into three
trimesters. Each trimester is approximately 14 weeks or 3 months in
duration. Historically, the period from 3 weeks before until 2 weeks
after the estimated date of birth (EDB) was considered “term.”
However, neonatal outcomes (especially respiratory morbidity) vary
depending on the timing of birth within the 5-week gestational age
range. To address the lack of uniformity in defining “term,” a
workgroup of professionals convened in late 2012 to refine the
definition of term pregnancy. The Defining “Term” Pregnancy
Workgroup recommended that the label “term” be replaced with
adoption of the following terminology:
■ Early term—births between 37 weeks 0 days and 38 weeks 6 days
■ Full term—births between 39 weeks 0 days and 40 weeks 6 days
■ Late term—births between 41 weeks 0 days and 41 weeks 6 days
■ Postterm—births 42 weeks 0 days or after
The EDB or the estimated date of delivery (EDD) (formerly termed
the “estimated date of confinement,” or EDC) is based on the date of
the LMP with the assumption that the woman has a 28-day cycle.
An important aspect of history-taking involves collecting data to
confirm the accuracy of the duration of the pregnancy. First, the date
and a description of the LMP are obtained to help determine whether
the LMP was a “normal” period rather than bleeding associated with
implantation. The nurse should ask the patient if her last period was
normal for her in relation to the amount and duration of blood loss.
The length of the menstrual cycle and its predictability are also
important factors.
The EDB may be calculated using Naegele’s rule. To use
Naegele’s rule, add 7 days, then subtract 3 months from the date of
the patient’s LMP and add a year where necessary (Box 4-1).
Because Naegele’s rule is based on a 28-day menstrual cycle,
menstrual cycle irregularity and variations in cycle length most likely
invalidate the use of Naegele’s rule as the sole method for
estimating gestational age. A gestation wheel is a useful tool for
readily determining the gestational age during pregnancy (Fig. 4-9).
BOX 4-1
Naegele’s Rule
Naegele’s rule is used to calculate the Expected Date of Birth (EDB)—
Expected Date of Delivery (EDD) This calculation is based on the first day of
the woman’s last normal period. Seven days are added to the LMP, 3 months
subtracted, and where necessary a year added.
For example, if the woman’s LMP was June 8, 2014, add 7 days = June 15,
2014. Subtract 3 months = March 15, 2014. Add a year = March 15, 2015.
Therefore, EDB = March 15, 2015. (An alternative way is to add 7 days and
then add 9 months % year where needed.)
Remember to ask the woman about her last menstrual period (LMP). Did her
period start on the expected date? Was blood loss normal (the same as her
usual menstrual blood loss)? Was her period different in any way? What form of
contraception had she been using and when was this method discontinued?
(Hormonal contraception may delay the return to a normal ovulation pattern.)
These questions will help you to determine an accurate date for the woman’s
LMP. Remember: Some women experience bleeding at the time of
implantation, which normally occurs 7–9 days after fertilization. Care needs to
be taken not to mistakenly use the date of implantation bleeding as the LMP.
FIGURE 4-9 A gestation wheel is a handy tool for determining the

gestational age. The arrow labeled “first day of LMP” is placed on the
date of the LMP. The date at the arrow labeled “expected delivery
date” is then noted.
Correct calculation of the EDB is dependent on a reliable date of

the LMP. Hormonal birth control methods such as combined OCPs
and long-lasting progesterone injections can cause continued
suppression of ovulation. Therefore, a discrepancy may exist
between when the woman thought she ovulated and conceived and
when these events actually occurred. In this case, the LMP may not
be an accurate tool for estimating the due date.
Occasionally, pregnancy occurs in women who are taking oral
contraceptives, usually as the result of forgotten pills or poor
absorption from causes such as vomiting, diarrhea, or antibiotic use.
Thus, contraceptive pill use may have unwittingly been continued
during the early weeks of gestation.
Diagnostic Tools
Ultrasound
A pelvic ultrasound or transvaginal ultrasound is often performed in the first
trimester to diagnose a pregnancy, obtain an estimated due date, and to rule
out abnormalities with pregnancy. It uses the reflection of pulses of high-
frequency inaudible sound of approximately 20,000 to 10 billion (109)
cycles/sec to produce a picture (Venes, 2021).
COMMON DISCOMFORTS DURING PREGNANCY

The major hormonal and anatomical changes that take place in the
woman’s body cause common complaints of pregnancy. As the
pregnancy progresses, most patients report at least some of the
common discomforts, which are presented in Table 4-2. Anticipatory
guidance includes educating women about the normal physiological
changes that occur during pregnancy, symptoms that frequently
accompany the changes, and strategies for dealing with the
discomfort.
Nausea
Nausea is often one of the first symptoms of pregnancy experienced.
Although commonly known as “morning sickness,” nausea can occur
at any time of the day or night. Although the exact cause of nausea
is unknown, it most probably is related to the increased levels of the
pregnancy hormones. Nausea is primarily noted during the first
trimester of the pregnancy and usually resolves by 13 to 14 weeks,
although it may persist throughout the pregnancy. Nausea during the
early weeks of pregnancy is believed to be a reassuring indicator of
embryo/fetal development with adequate hormonal support.
Complaints of nausea should never be dismissed without further
assessment to rule out pregnancy-related complications such as
hyperemesis gravidarum, multiple gestation, gestational
trophoblastic disease, or maternal gastrointestinal or eating
disorders.
Nurses can suggest strategies to help offset the nausea, such as
the avoidance of “trigger foods” (foods that cause nausea from sight
or smell) and tight clothing that constricts the abdomen. The use of
relaxation techniques (e.g., slow, deep breathing and mental
imagery) can also help to decrease nausea. Other techniques that
are often helpful include consuming plain, dry crackers or sucking on
peppermint candy before arising; adhering to small, frequent meals;
consuming liquids and solids separately; avoiding cold, acidic, or
sweet beverages; and remaining in an upright position after eating.
Medication is usually not necessary for the nausea of early
pregnancy; nurses should be aware of complementary measures as
many women prefer natural nausea relief to over-the-counter or
prescription medications. Some well-known alternative therapies to
lessen nausea include vitamin B6 and ginger tablets or syrup. These
oral supplements can be purchased over the counter and should be
taken with meals. Acupressure bracelets, often used for the
prevention of motion sickness, can also be purchased without a
prescription and may be beneficial in reducing nausea during early
pregnancy. Aromatherapy with lemon or cardamon oil has been
shown as a complementary care measure that can help reduce
nausea (Ozgoli & Saei Ghare Naz, 2018).
TABLE 4-2
Common Discomforts During Each Trimester of Pregnancy
TRIMESTER COMMON DISCOMFORTS
First Nausea
Vomiting
Fatigue
Breast tenderness
Urinary frequency
Nocturia
Second Dyspepsia
Hemorrhoids
Gum hyperplasia and bleeding
Dependent edema
Leg varicosities
Hyperventilation and shortness of breath
Numbness and tingling of fingers
Supine hypotensive syndrome
Third Fatigue
Urinary frequency
Dyspepsia
Hemorrhoids
Gum hyperplasia and bleeding
Leg cramps
Dependent edema
Leg varicosities
Dyspareunia
Nocturia
Round ligament pain
Braxton hicks contractions
Supine hypotensive syndrome
All Trimesters Ptyalism
Nasal congestion
Back pain
Leukorrhea
Constipation
Insomnia
Vomiting
Vomiting in early pregnancy often accompanies the nausea,
although it is important to ascertain that the amount vomited is not
excessive. During the assessment, nurses should question patients
about vomiting frequency and amount and their ability to consume
and retain foods and liquids. It is important to assess for weight loss,
dehydration, urine ketones, blood alkalosis, and hypokalemia, which
are clinical findings that may be indicative of a more serious
complication, hyperemesis gravidarum, often requiring prescribed
medication and, in severe cases, intravenous fluids and
hospitalization.
Acupuncture for Nausea During Pregnancy
A treatment modality of traditional Chinese medicine, acupuncture involves
stimulation of specific points by the manual insertion and manipulation of fine
needles into the skin. During pregnancy, acupuncture stimulation at the PC6
point (Neiguan) located three finger-width breadths above the wrist crease may
be effective in relieving symptoms of nausea and vomiting.
Ptyalism
Ptyalism can be quite distressing for the pregnant woman, who must
frequently wipe her mouth or spit into a cup. Women with ptyalism
can also have nausea and vomiting and have difficulty with
maintaining adequate weight gain. Limited strategies have been
identified, but some strategies for relief include staying hydrated with
frequent drinks of water, chewing gum, or lozenges. Patients can
also be advised to eat small, frequent meals and avoid starchy foods
such as potatoes, bread, and pasta. Although little can be done to
reduce the amount of saliva, it is important to rule out dental
abnormalities, upper gastrointestinal problems, and pica, which has
been seen in patients with ptyalism (Nesbeth et al., 2016).
Dyspepsia
Dyspepsia, or heartburn, results from reflux of acidic gastric
contents into the lower esophagus. Dyspepsia is caused by the
progesterone-induced relaxation of the cardiac sphincter and
delayed gastric emptying. As the pregnancy advances, the enlarging
uterus pushes up on the stomach and compresses it, causing
reduced capacity.
Nurses can suggest a number of relief measures for dyspepsia.
Patients can be taught to consume small, frequent meals to avoid
overloading the stomach; maintain good posture; remain upright
after meals; avoid greasy/fatty, spicy, and very cold foods; and
consume beverages with meals. Changes in the diet and eating
patterns may be helpful in reducing heartburn, although it is unlikely
to disappear until after the baby is born. Patients should also be
aware of any types of triggers that can increase the chance of
heartburn such as tea, soda, or chocolate. Drinking cultured or sweet
milk and using over-the-counter antacids may also be helpful.
Patients who have persistent symptoms may need to consult with
their health-care providers about pharmacological treatments, which
may include antacids or an H2 receptor antagonist.
Dental Problems
Elevations in pregnancy hormones cause the gums to become
edematous and friable, which can lead to bleeding during brushing.
Open lesions and other dental problems, such as caries, can open a
direct pathway for pathogens to enter the bloodstream. Meticulous
dental care during pregnancy is important to prevent infections and
other dental complications. The dentist should be informed of the
pregnancy so that an abdominal shield can be used if x-ray films are
needed. If treatment is indicated, most local anesthetics can be used
safely during pregnancy.
Nasal Congestion
Nasal congestion, a common maternal complaint, is known as
rhinitis of pregnancy. Increased levels of estrogen and progesterone
cause swelling of the nasal mucus membranes and produce
symptoms of excess mucus and congestion. It is important to rule
out colds and allergies. The nurse can suggest relief measures such
as increasing fluids; taking a hot, steamy shower; using a vaporizer
or humidifier; and the occasional administration of nasal saline
drops. Decongestants should be avoided during the first trimester.
Hyperventilation and Shortness of Breath

Increased metabolic activity during pregnancy increases the amount
of carbon dioxide in the maternal respiratory system.
Hyperventilation decreases the amount of carbon dioxide and may
trigger a feeling of “air hunger.” Patients may also experience
shortness of breath related to uterine enlargement and the upward
pressure exerted on the diaphragm. Once pathological conditions
such as upper respiratory infection, asthma, cardiac problems, and
anemia have been ruled out, the nurse should explain the cause of
hyperventilation to the patient and suggest that she consciously
attempt to regulate her breathing. Other measures that may be
helpful include breathing into a paper bag to decrease the symptoms
of hyperventilation, maintaining good posture, and stretching the
arms above the head.
Upper and Lower Backache

Low backache is a common problem in pregnancy that occurs as the
fetus grows and there are physiological changes in the maternal
anatomy. Low back pain can be exacerbated by activities that
require prolonged standing, walking, bending, or lifting. Nurses
should educate all patients about strategies that may prevent or
relieve backache. Women can be taught to wear supportive, low-
heeled shoes; use proper body mechanics; perform back
strengthening and pelvic rock exercises; take frequent rest periods;
sleep on a firm, supportive mattress; and wear a well-fitting,
supportive bra. Body massage and warm tub baths may also be
helpful.
Patient Education
Lumbar Support for Back Pain
Sitting in a firm chair and the use of a small pillow or blanket rolled and placed
in the lumbar region (lumbar roll) for support can help decrease lower back
pain. Mothers should be instructed to avoid excessive weight gain, wear low or
flat shoes, and maintain proper body mechanics when lifting or bend to
minimize back pain.
Leukorrhea
High levels of estrogen stimulate vascularity and hypertrophy of the
cervical glands, causing an increase in vaginal discharge. The
discharge is usually yellow to white in color, thin, and more acidic
than normal. It is important to rule out vaginal and sexually
transmitted infections and rupture of membranes. The nurse can
counsel the patient to wear cotton underwear, avoid tight-fitting
clothing, and follow strict hygiene to prevent infection. If a panty liner
or sanitary pad is worn to absorb moisture, it should be changed
frequently to prevent dampness and odor.
Urinary Frequency
In early pregnancy, urinary frequency is caused by pressure exerted
by the enlarging uterus on the bladder. During the second trimester,
bladder pressure lessens once the uterus becomes an abdominal
organ. In the third trimester, a number of physiological events cause
urinary frequency. The fetal presenting part once again exerts
pressure on the bladder. Progesterone relaxes the muscles of the
urethra and may lead to incontinence, while an increase in the GFR
causes increased urine production. It is important to rule out UTI,
rupture of the membranes, kidney stones, gestational diabetes, and
stress urinary incontinence. The nurse can suggest relief measures,
including intake of adequate hydration, Kegel exercises, use of panty
liners, frequent voiding, and decreasing fluid intake 2 to 3 hours
before bedtime.
Leg Cramps
The actual cause of leg cramps is unknown, although decreased
levels of calcium and phosphorus have been implicated. As the
uterus enlarges, pressure is exerted on the major blood vessels,
causing impaired circulation to the lower extremities. It is important
to rule out thrombosed blood vessels, muscular strain, and other
injuries to the lower extremities. The patient should be advised to
engage in regular exercise and maintain good body mechanics,
elevate the legs above the heart several times throughout the day,
dorsiflex the foot, and consume a diet that includes adequate
amounts of calcium and phosphorus.
Dependent Edema
Edema in the lower extremities is caused by relaxation of the blood
vessels (an effect of increased progesterone) and the increased
pressure placed on the pelvic veins by the enlarging uterus. Tight,
restrictive clothing that inhibits venous return from the lower
extremities increases the edema. Once pathological conditions such
as gestational hypertension, renal disease, liver disease, cardiac
disease, vascular disorders, trauma, and infection have been ruled
out, the nurse can suggest relief measures. These include avoiding
constrictive clothing, elevating the legs periodically throughout the
day, and assuming a side-lying position when resting.
Varicosities
A positive family history coupled with the normal physiological
changes of pregnancy predispose the patient to the development of
varicose veins. Physiological changes of pregnancy include vascular
relaxation from the effects of progesterone and impaired venous
circulation from pressure exerted by the enlarged uterus.
Constrictive clothing also increases the risk for varicose veins.
Nursing care for patients with varicosities includes regular
assessment of lower extremity peripheral pulses and education.
Patients should be taught to avoid crossing their legs and the use of
constrictive clothing such as knee-high stockings. They should also
be encouraged to elevate their legs above the level of the heart at
least twice a day. For some women, a maternity girdle may provide
relief.
Round Ligament Pain

The round ligaments support the uterus as it enlarges during
pregnancy. These structures attach to the fundus on each side, pass
through the inguinal canal, and insert into the upper portion of the
labia majora. As the uterus enlarges, the round ligaments stretch
and produce a painful sensation in the lower quadrants. Once
pathological conditions such as preterm labor, rupture of an ovarian
cyst, ectopic pregnancy, appendicitis, gallbladder disease, and
peptic ulcer disease have been ruled out, the nurse can educate the
patient about the cause of the pain and make suggestions for relief
measures. Taking a warm bath, applying heat, supporting the uterus
with a pillow when resting, and using a pregnancy girdle may help to
diminish the discomfort.
Carpal Tunnel Syndrome

Edema from vascular permeability can lead to collection of fluid in
the wrist that puts pressure on the median nerve beneath the carpal
ligament. This alteration leads to carpal tunnel syndrome
(compression of the median nerve, where it travels down to the
transverse carpal ligament), a condition that usually develops during
the third trimester. It is manifested by pain and paresthesia (a
burning, tingling, or numb sensation) in the hand that radiates to the
elbow. The pain occurs in one (usually the dominant) or both hands
and is intensified with attempts to grasp objects. Elevation of the
hands at night may reduce the edema. Occasionally, a woman may
need to wear a “cock-up splint” to prevent the wrist from flexing, an
action that puts additional pressure on the median nerve. Carpal
tunnel syndrome usually subsides after the pregnancy and the
accompanying edema have ended, although some women may
require surgical treatment if symptoms persist.
Supine Hypotensive Syndrome

Supine hypotension is caused by pressure of the enlarging uterus on
the inferior vena cava while the woman is in a supine position. Vena
caval compression impedes venous blood flow, reduces the amount
of blood in the heart, and decreases cardiac output, causing
dizziness and syncope. Pathological causes of supine hypotension
include cardiac or respiratory disorders, anemia, hypoglycemia,
dehydration, anxiety, and stress. Once these conditions have been
ruled out, the nurse should educate the patient about the causes of
supine hypotension and advise the woman to rest on her side and
slowly move from a lying to a sitting to a standing position to
minimize changes in blood pressure.
Fatigue
Fatigue occurs primarily during the first and third trimesters of
pregnancy. In the first trimester, the fatigue is most likely related to
physiological and hormonal changes. Psychological concerns may
also lead to insomnia. During the third trimester, fatigue is usually
related to physical discomforts and an increasing inability to sleep.
Nurses can counsel patients to take naps during the day when
possible, establish a bedtime ritual that includes going to bed at
approximately the same time each night, increase daytime exercise,
and practice relaxation techniques. If these strategies are not
effective or the patient exhibits signs of psychosocial stress or
depression, she should be referred for additional evaluation.
PSYCHOSOCIAL ADAPTATIONS DURING

PREGNANCY
The Healthy Mind
Maternal attachment to the fetus is an important area to assess and
can be useful in identifying families at risk for maladaptive behaviors.
The nurse should assess for indicators such as unintended
pregnancy, intimate partner violence (IPV), difficulties in the partner
relationship, sexually transmitted infections, limited financial
resources, substance use, adolescence, poor social support
systems, low educational level, and the presence of mental
conditions that might interfere with the patient’s ability to bond with
and care for the infant. It is important to remember that, depending
on what is going on in her life at the time of the pregnancy, any
woman has the potential for maladaptive behaviors.
Readiness for Motherhood

Motherhood is not necessarily instinctive for the pregnant woman.
Each woman must work through the process of becoming a mother.
Some women may have carefully planned their pregnancy and
considered the process of motherhood. Women who had an
unplanned pregnancy may take much longer to become ready for
motherhood. Maternal age may also play a role; for example,
adolescents may need more time to prepare for motherhood than
older women do. Many of the woman’s decisions about motherhood
relate to her childhood. The pregnant woman must be able to picture
herself as a mother. To do so, she relies on her life experiences of
being nurtured as a child and enjoying the types of relationships that
she has developed over the years with other women. The
relationship with her own mother plays a significant role in how she
views motherhood. If the woman’s mother is available, her
acceptance of the pregnancy and respect for her daughter’s
autonomy play an integral role in assisting the woman to become a
successful mother. Absence of these components may impede the
pregnant woman’s ability to develop into the motherhood role.
A pregnant woman demonstrates a positive attitude toward her
pregnancy by educating herself about maternal changes during
pregnancy, fetal growth and development, and motherhood (Fig. 4-
10). Many helpful books, brochures, online resources, and
community programs on pregnancy and parenting are available for
mothers-to-be.
FIGURE 4-10 Learning about maternal changes, fetal growth and
development, and motherhood fosters a positive attitude toward the
pregnancy.
Psychosocial Adaptations
Pregnancy can bring about various psychosocial adaptations. Each
pregnancy is unique and how a woman adapts to and experiences
her pregnancy will be individual as well. For some women, it will be a
time of joy and happiness, whereas for other women the pregnancy
might cause feelings of nonacceptance, fear, and uncertainty,
resulting in a negative effect on mental health. Pregnancy is a time
of change, which brings stress that can challenge one’s ability to
cope with the changes that will take place over many months,
affecting not only the woman but also her partner and other family
members. The nurse must have a basic understanding of how the
woman’s progression through the developmental phases and
accompanying emotions affect her and her family’s acceptance of
the pregnancy and the unborn child. Nursing care for the woman and
her family through each pregnancy milestone should be tailored with
respect to personal and family values, cultural customs, and spiritual
beliefs and health maintenance behaviors. Topics for health
education related to the psychosocial adaptations to pregnancy are
Body Image Changes

The numerous body changes that occur with pregnancy cause one
of the most significant psychosocial adaptations. The first trimester
brings few obvious signs, and pregnancies often go unnoticed by the
mother and others. For some women, the body changes that occur
in the second trimester are welcomed, as they create visible signs of
the growing pregnancy (Talmon & Ginzburg, 2018). However, for
some women, the body changes are unexpected and changes in the
skin such as linea nigra or stretch marks are unpleasant and
unwanted. Some women may experience these changes negatively
and feel a loss of control over the body, leading them to become
anxious and concerned (Talmon & Ginzburg, 2018). Women should
be counseled on these skin changes early so that they can anticipate
these changes; they should also be educated on proper weight gain
and adequate nutrition. See Chapter 5 for more information on
weight gain and nutrition.
Anxiety
Pregnancy-related anxiety often occurs due to the woman’s fears
and concerns about the pregnancy and can be related to the body
changes, fear about childbirth, and fear about the growing or
newborn infant. Depending on the level of anxiety, a serious negative
effect on the pregnancy could lead to adverse maternal and fetal
outcomes. This can have a debilitating effect in which the woman
becomes preoccupied with worrying and thoughts about not causing
accidental harm to the infant (Thorsness, Watson, & LaRusso,
2018). Other signs and symptoms of pregnancy-related anxiety
include insomnia, hypervigilance, infant avoidance, or frequent and
excessive health-care use.
Women should be screened at least once during pregnancy for
anxiety. Treatment may include pharmacological therapies, but
recommendations for nonpharmacological therapies include
adequate sleep, healthy diet, exercise, mindful-based practices such
as meditation and yoga, and peer support (Thorsness, Watson, &
LaRusso, 2018).
Optimizing Outcomes
Promoting Stress Management During Pregnancy

Several complementary therapies can safely be used during pregnancy. Those
often recommended by nurse midwives and obstetricians include:
• Massage therapy: Increases blood flow to maternal and fetal tissues;
increases relaxation
• Chiropractic care: Treats lower back pain and headaches related to increased
hormone levels
• Acupuncture and acupressure: Treat many physical ailments during pregnancy
without the introduction of medications
• Relaxation exercises, meditation, and breathing techniques: Increase blood
flow to maternal and fetal tissues; increase relaxation
• Light therapy: Enhances mood and treats depression
• Reflexology: Stimulates nerve pathways to increase blood flow and energy
flow to corresponding areas of the body
• Aromatherapy: Increases relaxation
• Mindfulness-based yoga: Enhances physical well-being and diminishes
psychological stress
TABLE 4-3
Health Education Topics Related to the Psychosocial Adaptations to
Pregnancy
TOPICS TO FIRST SECOND THIRD
INCLUDE TRIMESTER TRIMESTER TRIMESTER
Developmental Mother: Acceptance Mother: Binding-in Mother: Separating
Tasks of Pregnancy of pregnancy into to the pregnancy, herself from the
her self-system ensuring safe pregnancy and the
Father: passage, and fetus, trying various
Announcement and differentiating the caregiving
realization of the fetus from herself strategies
pregnancy Father: Anticipation Father: Role
Couple: of adapting to the adaptation,
Realignment of role of fatherhood preparation for
relationships and Couple: labor and birth
roles Realignment of Couple:
roles and division of Preparation of the
tasks nursery
Psychosocial Ambivalence about Active dream and Dislikes being
Changes During pregnancy fantasy life pregnant but loves
Pregnancy Introversion Concerns with body the child
Passivity and image Anxious about
difficulty with Nesting behaviors childbirth, but sees
decision making Sexual behavior labor and birth as
Sexual and adjustment deliverance
emotional changes Expanding to a The couple
Changing self- variety of methods experiments with
image of expressing various mothering
Ethical dilemmas of affection and or fathering roles
prenatal testing intimacy Woman is
introspective
Adapted from Mattson, S., & Smith, J. E. (2010). Core curriculum for maternal-
newborn nursing (4th ed.). St. Louis, MO: W.B. Saunders.
Trauma History
A history of trauma can have a profound effect on the psychological
adaptation in pregnancy. Past trauma can often affect mental health,
resulting in maladaptive behaviors and post-traumatic stress
disorders (PTSD), which can affect the pregnancy, delivery, and
postpartum adjustment. PTSD, which includes symptoms such as
repetitive thoughts of reliving the trauma experience, avoidance of
people and places, negative mood and emotions, and hyperarousal,
has been significantly associated with adverse pregnancy and
newborn outcomes. Women with histories of trauma may experience
an increase in PTSD symptoms that risk their health and that of the
fetus.
FOCUS ON SAFETY
Mental Health and Trauma Screening
Screening all women for current and past mental health disorders is highly
recommended (Scannell, 2018). Nurses should undergo a comprehensive
history intake asking about IPV and other past traumas. Trauma-informed care
is a framework that places the patient at the center of their health-care
decisions, with past and present trauma as integral to the decision-making
process. Using this framework minimizes the risk of retraumatization and
maximizes the availability of culturally appropriate health-care choices that fit
the patient’s needs and goals. Many individuals experience many different
forms of trauma, all of which can result in life-long effects. As nurses we must
recognize we have no way of distinguishing survivors from nonsurvivors and
need to provide sensitive care to all patients so as not to traumatize them
further during the health-care experience. Key strategies in trauma-informed
care include recognizing the patient’s individual needs, honoring patient rights,
and learning about their unique perspectives. This approach allows the patient
to be the expert in what is important in their own recovery process.
Core principles of trauma-informed care include:
• Providing physical and emotional safety including confidentiality
• Maintaining transparency by explaining all policies, procedures, and tests
• Building trust with patients by listening and believing what they say
• Viewing patients as the central member of the care team and experts in their
own lives
• Providing patients with options to facilitate independent decision-making
• Sharing power with patients; giving them a strong voice.
• Recognizing the potential for retraumatization
• Understanding the effect of trauma and how the current pregnancy may be
affected
• Protecting the patient from any power differential
• Recognizing the patient’s fears and expectations
• Asking them about what is bothering them
What to Say
When Practicing Trauma-Informed Care
One of the hallmarks of trauma-informed care is patient communication that
places them at the center of choices about their pregnancy, remains sensitive
to traumas they may have experienced, and is free of blame or judgment. For
example, instead of asking “Why weren’t you using condoms if you didn’t want
to get pregnant?” you could ask “Can you share why you feel that your
pregnancy is unexpected?” in a trauma-informed framework. Using this
approach encourages dialogue between health-care professionals and
patients, which can build an open, trusting nurse relationship.
The nurse should ask about possible traumas resulting from:
• Previous traumatic birth of another child
• Previous loss of another pregnancy
• Abuse or neglect during childhood
• Sexual assault
• Domestic violence
• Community violence
• Political violence
• Cultural violence
• Historical violence
• Military trauma (both sexual and nonsexual)
• Discrimination
Developmental and Family Changes

According to Duvall and Miller (1984), the expecting woman and
family undergo stages of family development to prepare for their new
roles as child-care providers. The home must be reorganized to
accommodate the infant, family member duties and responsibilities
must often be realigned, and lifestyle changes are made to
accommodate the needs of the family. For the expectant woman and
her partner and other family members, emotional responses can
often be unpredictable and labile and require patience,
understanding, and good communication. The couple needs to
expand their knowledge about pregnancy, birth, and parenting to
enhance their understanding and prepare for these life-altering
events.
Rubin (1975) described specific tasks that a woman must
accomplish to integrate the maternal role into her personality. The
“tasks of pregnancy” generally occur concurrently during the
pregnancy and help the woman develop her self-concept as a
mother. To be successful in accomplishing these tasks, the pregnant
woman must incorporate the pregnancy into her total identity. That
is, she must “accept the reality of the pregnancy” and integrate it into
her self-concept, “accept the child,” “reorder” her relationships, learn
to “give of herself for the child,” and “seek safe passage through the
pregnancy, labor, and birth” (Mattson & Smith, 2010). A summary of
the maternal tasks of pregnancy is presented in Table 4-4.
Today, the family unit can encompass many different individuals
who will assume roles within the infant’s life. Due to circumstance,
extended family members such as grandparents may take on a more
primary role in raising the child. Adjustments for the family can be
seen in the person who may be assuming the role of primary
caregiver. Being open-minded to different family units is essential to
helping promote physiological changes for the women and members
of the family.
Acceptance of the Pregnancy

The mother-to-be needs to accept the pregnancy and incorporate it
into her own reality and self-concept. This process is known as
“binding in.” During the first trimester, the woman’s focus centers on
her physical discomforts (e.g., fatigue and nausea) and needs rather
than on the developing child. By the second trimester, she feels fetal
movement (quickening), has most likely seen the baby on ultrasound
and heard their heartbeat, and begins to conceptualize the child as
an individual within her. During the third trimester, as the due date
approaches, the mother-to-be wants the child and just as strongly
wants the pregnancy to be over. At this point, she is tired and needs
a considerable amount of emotional and physical support from her
family and friends.
TABLE 4-4
Maternal Tasks of Pregnancy
General Principles Pregnancy progressively becomes part of the woman’s
total identity.
She feels unique because she can’t share her sensory
experience with others.
Her focus turns inward, and she is overly sensitive.
She seeks the company of other women and pregnant
women.
Giving of self is an essential component of motherhood.
She needs to feel loved and valued, and she needs to
have the child accepted by her partner. Throughout
pregnancy, the partner’s major role is to nurture and
respond to the pregnant woman’s feelings of
vulnerability.
Absence of a female support system during pregnancy is
a singular index of a high-risk pregnancy.
Acceptance of First trimester: She accepts the idea of pregnancy but
Pregnancy; Self in not the child. She is uncertain and ambivalent, and her
Maternal Role; primary focus is on herself, not the fetus. Although she
“Binding-in” may begin to “bind in” to the idea that she is pregnant,
the baby is not yet real to her.
Second trimester: With sensation of fetal movement, or
“quickening,” she becomes aware of the child as a
separate entity. She is filled with wonder and perhaps
concern over the changes taking place in her body. The
fetus becomes her major focus. She experiences
feelings of love and attachment and enjoys fantasizing
about her new role.
Third trimester: She wants the child and is tired of being
pregnant. She has increasing feelings of vulnerability and
often becomes more dependent on her partner during
the last weeks of pregnancy.
Acceptance of the First trimester: Acceptance of the pregnancy by herself
Infant by Others and others. Securing acceptance is a process that
continues throughout pregnancy.
Second trimester: The family needs to relate to the fetus
as a member. Acceptance from her mother is very
important; many expectant women experience an
increased closeness with their mothers during
pregnancy. A mother’s reaction to her daughter’s
pregnancy signifies her acceptance of the grandchild and
of her daughter.
Third trimester: The critical issue is the unconditional
acceptance of the child; conditional acceptance may
imply rejection by the mother or family members.
Reordering of First trimester: Examines what needs to be given up to
Relationships, Giving of assume a new role.
Self Trade-offs for having the infant.
May grieve the loss of a carefree life.
Second trimester: Identifies with the child, learns how to
delay her own desires.
Third trimester: Has decreased confidence in her ability
to become a good mother to her child.
Ensuring Safe Passage First trimester: Focuses on herself, not on her fetus.
Throughout Pregnancy, Second trimester: Begins to conceptualize the fetus as a
Labor, and Birth separate being; develops an increasing sense of the
value of her infant.
Third trimester: Has concern for herself and her infant as
a unit, shares a symbiotic relationship. At the seventh
month, she is in a state of high vulnerability. At the end of
this trimester, begins to view labor and birth as an “end
point.”
Participating in positive self-care activities (e.g., nutrition,
exercise, stress reduction, and childbirth preparation)
help to accomplish this task.
Source: Adapted from Mattson, S., & Smith, J. E. (2010). Core curriculum for
maternal-newborn nursing (4th ed.). St. Louis, MO: W.B. Saunders.
Acceptance of the Child

Acceptance of the child is critical to a successful adjustment to the
pregnancy. Acceptance must come from the expectant woman as
well as from others. During early pregnancy, announcements are
made to one another and to family and friends. A positive response
from those closest to the pregnant woman helps to foster her
acceptance of the child. There is a great value attached to this
unborn child, and she wants and needs others in the family to accept
the child as well. In the second trimester, the immediate family needs
to exhibit behaviors consistent with relating to the child as a sibling, a
son, or a daughter. In the third trimester, the woman must develop an
unconditional acceptance of the child, or she and others may reject
them for not meeting their expectations.
Reordering Relationships
To facilitate the necessary family transition, the pregnant woman
must reorder her relationships to allow for the child to fit into the
existing family structure and learn to give of herself to the unknown
child. At this time, she becomes reflective and examines what things
in her life may need to be given up or changed for the infant. If this is
her first child, she may grieve the loss of her carefree life. As the
pregnancy progresses, the woman begins to identify with the child
and makes plans for their life together after the birth. During the last
few weeks of the pregnancy, the woman must work through doubts
of her ability to be a good mother. Positive support from family and
friends is essential in boosting her confidence and assisting her in
overcoming these feelings of self-doubt.
Seeking Safe Passage Through Pregnancy, Labor, and Birth

Seeking safe passage through the pregnancy, labor, and birth are
maternal tasks that receive the most attention during the pregnancy.
In the first trimester, the woman focuses on her own discomforts and
places her needs before those of the fetus. Symptoms of fatigue,
nausea, and breast tenderness can be overwhelming during this
often-difficult time. In the second and third trimesters, the woman
develops an increasing sense of the value of her infant. She comes
to conceptualize her fetus as a separate being (fetal distinction), and
she accepts her changing body image. She becomes extremely
vulnerable during her seventh month and increasingly worried about
the impending labor and birth. As the due date approaches, the
woman’s fears about labor may diminish as she begins to view
childbirth as an “end point.” Participation in childbirth preparation
classes can greatly assist the woman and her family in dealing with
the anxiety and fears that often surround labor and birth.
Other developmental tasks take place during the passage of
pregnancy as well. The woman needs to validate the pregnancy, and
initial feelings of uncertainty or ambivalence are normal. When
caring for expectant women, the nurse should never assume that the
pregnancy was planned or wanted. Instead, the nurse should
facilitate discussion of uncertainties or concerns with the patient and
her family to facilitate acceptance of the pregnancy. Many women
fantasize and dream about their pregnancy and how it will change
their lives. The woman must incorporate the fetus into her body
image, a process termed “fetal embodiment.” Accomplishing this
task allows her to accept the changes in her body size and shape as
the pregnancy progresses. The significant other plays an important
role as the woman becomes increasingly dependent on that
individual for helping to meet her daily needs.
As the pregnancy advances, the woman begins to conceptualize
the fetus as a separate individual. She comes to view her changing
body as a “vessel of new life” and often feels closer to her own
mother at this time. This deeper relationship with her mother begins
as one of dependency and progresses to one in which she identifies
with her mother as a peer. If her mother is not available, she may
reach out to another valued maternal figure for identification and
support. As she reaches the end of the third trimester, the woman
begins to give up her symbiotic relationship with the fetus. She
harbors feelings of anxiety about the childbirth process and begins to
gather supplies and prepare for the baby’s entry into the home. This
process is termed “nesting.” At this point in pregnancy, the woman is
often impatient with the awkwardness related to her increasing size
and has a strong desire to see the pregnancy end so that she can
begin her next phase as a mother.
Developmental Tasks and the Pregnant Adolescent

For the pregnant adolescent, ongoing age-related developmental
growth can affect the psychological changes in pregnancy. Typically,
tasks associated with adolescence focus on growth and maturity.
These include developing a personal value system, choosing a
vocation or career, developing personal body image and sexuality,
achieving a stable identity, and attaining independence from parents.
Conflicts may arise when these tasks are overshadowed by the
developmental tasks of pregnancy. The pregnant adolescent may
not be able to readily accept the reality of the unborn child and may
not seek prenatal care until the second or third trimester. The
immediate family may not react positively to the pregnancy, and
acceptance of the pregnancy by self and others may be hindered.
Many times, the adolescent’s parents come to assume the parenting
role for their grandchild. Although this may be helpful at times, this
situation limits the young mother’s involvement with the newborn and
her ability to fully give of herself in her new role.
Readiness for Fatherhood

In preparation for parenthood, the male partner also moves through
a series of developmental tasks. During the first trimester, the father
begins to deal with the reality of the pregnancy. At this time, he may
worry about financial strain and his ability to be a good father.
Feelings of confusion and guilt often surface with the recognition that
he is less excited about the pregnancy than his partner is. Couvade
syndrome, the experience of maternal signs and symptoms, may
develop.
In the second trimester, the pregnancy becomes even more real
for the father. The pregnancy begins to “show,” and he is able to
identify fetal movement through the maternal abdomen. Because
there is an increased paternal willingness to learn about fetal growth
and development during this time, the second trimester is the best
time to provide prenatal education for the expectant couple.
During the third trimester, both parents are preparing for their new
roles. Many of the father’s early concerns regarding financial
demands, personal parenting skills, and partner safety during birth
return during this time. Conflicting feelings may emerge between
excitement over the prospect of a new baby and the major lifestyle
changes that will accompany the presence of a new family member.
Most couples attend prenatal classes in preparation for the birth
experience during the third trimester. The father may fear for the
safety of his partner. How well the couple progresses through the
developmental tasks of pregnancy has a major influence on their
level of adaptation once the baby is born.
PATERNAL ADAPTATION TO PREGNANCY
Pregnancy is psychologically stressful for men. Expectant fathers
may experience a variety of reactions to the pregnancy. Some enjoy
the role of nurturer and marvel in the changes that occur in the
woman. Others feel alienated and begin to stray from the
relationship. Many men view pregnancy as positive proof of their
masculinity and take steps to assume a dominant or more supportive
role in the relationship. Others find no meaning or personal value in
the pregnancy and consequently fail to develop any sense of
responsibility toward the mother or the child.
The father of the baby can also experience specific tasks of
pregnancy that correspond with the trimesters. During the first
trimester, the father is in an “announcement phase.” Similar to the
woman’s experience, the father may be ambivalent at this time. He
must first accept the pregnancy as “real” to begin to incorporate the
future child into his life and assume the expectant father role. In the
second trimester, or “moratorium phase,” the man’s “binding in”
usually takes longer to achieve than the woman’s, and this is related
to his “remoteness” to the fetus. At this time, involvement in prenatal
visits, listening to the baby’s heartbeat, and visualization of the fetus
during ultrasound can make the fetus seem more real to the father.
He begins to accept the woman’s changing body and the reality of
the fetus as a child when he can feel fetal movement.
In the third trimester, the expectant father enters a “focusing
phase.” He negotiates what his role in labor and birth will be;
prepares for the reality of parenthood; alters his self-concept to
reflect that of a more mature, or fatherly figure; becomes involved in
setting up the nursery; and copes with his fears of the mutilation or
death of his partner or child during birth. Fears and concerns are
often lessened somewhat by participation in prenatal and parenting
classes. Problems such as a dysfunctional couple relationship and
sociocultural factors may prevent the man from assuming a paternal
role.
Adaptation of Siblings and Grandparents

The reactions of siblings correlate closely to their age and level of
involvement with the pregnancy. Children may express excitement,
anticipation, anger, or despair. The toddler, characteristically involved
in his own little world, may initially exhibit a reaction of indifference.
However, the parents must be advised about the strong likelihood of
a regression in age-appropriate behavior. For example, the child may
want to nurse, drink from a bottle, or wear a diaper like the baby. The
school-age child usually appears more interested but grasping the
full reality of a baby in the family may not be realistic because the
process of concrete thinking is not fully developed until around age
10. Engaging the child in family discussions about the anticipated
birth, encouraging the child to feel fetal movements and listen to the
fetal heartbeat, sharing age-appropriate educational materials, and
allowing the child to attend sibling preparation classes are strategies
that may help the child to feel that they are sharing in the pregnancy
experience.
When a child reaches early adolescence, there may be changing
attitudes toward a new infant. Parents need to be aware of ways to
cope with potential negative behaviors and recognize that
adolescents often appear to have knowledge and understanding
about pregnancy and birth, but their information may be incorrect
and incomplete. The nurse can suggest that the child attend prenatal
visits to listen to the baby’s heartbeat and, if possible, view the fetus
during ultrasound examinations. Parents should be assisted in
developing other strategies to include the adolescent in the changes
that are taking place during pregnancy and that will occur following
the birth. Older children may benefit from attending prenatal classes
or touring the birthing facility.
Grandparents are very often excited and eagerly await the birth of
a grandchild, although this is not always the case. The grandparents’
age at the time of the birth can exert a positive or a negative effect
on their reactions. For example, if they will become first-time
grandparents during their 30s or 40s, they may be ambivalent or be
unready to assume the grandparent role. Conversely, those who are
already grandparents may be excited with the prospect of another
grandchild. Other factors (e.g., if the pregnancy was unplanned or if
the mother is very young or unwed) may prompt feelings of anger
and disappointment. Along with the woman’s partner, the
grandparents usually harbor concerns about the health and well-
being of the expectant woman and her fetus. They also may be
unsure about the extent to which they should become involved in the
childrearing process.
Maternal Adaptation During Absence of a Significant Other
If the woman has no involved significant other, she will need the
presence of a strong support person to help her adapt to the
pregnancy and the demands of parenting. The future she has
planned for the child, such as the decision to place the child for
adoption, can heavily influence her psychological needs. During
prenatal visits, the nurse should ensure that the woman is given the
opportunity to discuss her future plans for the child. After assessing
the woman’s needs, the nurse can make referrals to appropriate
community resources that may include prenatal classes,
psychological counseling, pastoral care, or social services.
Factors That Interfere With Psychosocial Adaptations During

Pregnancy
Grief and loss during the perinatal period can be triggered by
spontaneous abortion; elective termination; plans to relinquish the
child for adoption or surrogacy; and loss of the person’s idea of
perfect child because of prematurity, illness, deformity, or less-
preferred gender. Parental reactions can produce distance from the
infant and delay attachment, prompt feelings of personal inadequacy
concerning the inability to produce a healthy infant, and alter healthy
methods of relating to the infant.
The importance of prenatal education, labor and birth preparation,
and parenting classes cannot be stressed enough by the nurse.
Many women bypass the courses offered by their health-care
providers or hospitals in lieu of watching birth stories on television or
reading others’ experiences in online forums and communities. This
information must be placed into context by information obtained at
the prenatal visits and during attendance at prenatal and childbirth
education classes taught by nurses and certified personnel.
Nursing Assessment of Psychosocial Changes and Prenatal

Health Education
Nursing assessment of the psychosocial changes that occur during
pregnancy must include a thorough history including the family
background, past obstetric events, and the status of the current
pregnancy. Each prenatal visit provides an opportunity to ask the
patient about her pregnancy experience since the last visit, address
current concerns, and offer anticipatory guidance of what to expect
from the present visit to the next appointment. Based on this
information, the nurse formulates appropriate nursing diagnoses
related to the maternal psychosocial adaptation to pregnancy. Health
education should be focused on the current trimester and evaluated
by the patient’s or couple’s ability to verbalize the content presented,
their efforts to seek assistance and support with psychological
concerns, and indicators of satisfactory coping with the psychological
transitions that are occurring. Pregnancy represents a time of great
physical and emotional change. The woman and her family require
ongoing support and education to ensure that they safely and
successfully move through the stages of pregnancy and in the end
are prepared to welcome the new baby into their lives.
Assessment of Intimate Partner Violence

Intimate partner violence (IPV), formerly known as domestic
violence, is the most common form of violence experienced by
women worldwide. IPV occurs across all socioeconomic status,
races, genders, and cultures. The incidence of IPV during pregnancy
is a serious concern and can result in detrimental consequences to
the mother and growing fetus (Scannell, 2018). In the latest U.S.
data, approximately one of every four women has been a victim of
severe physical violence by an intimate partner (Centers for Disease
Control and Prevention [CDC], 2020).
Research indicates that physical abuse affects about 9% of
pregnant women, although the incidence may be as high as 50% in
women affected by poverty, women of a racial or ethnic minority,
women who are parenting without a partner, and pregnant
adolescents (Alhusen et al, 2015). Populations disproportionately
affected by IPV include people of color, immigrants, homeless
individuals, individuals who have mental or physical disabilities, and
individuals within the lesbian, gay, bisexual, transgender,
queer/questioning, and intersex communities (Scannell, 2018).
IPV may occur for the first time during pregnancy, or the nurse
may identify evidence during the physical examination that is
suspicious of ongoing physical abuse. It is estimated that every day
at least three women in the United States die as a result of IPV.
Femicide, the death of a woman resulting from an act of violence
against that woman, is a surprisingly common cause of death among
pregnant women in the United States.
Every woman should be screened for IPV during the initial visit
and at every prenatal visit throughout the pregnancy. Health-care
providers should be aware of certain red flags that can be signs of
IPV, such as missed prenatal appointments, frequent UTI or STIs,
placental abruption, and any other concerning signs.
NURSING INSIGHT
Long-Term Consequences Associated With Female Sexual Assault
A number of long-term health effects, such as increased patient-reported
symptoms, diminished levels of functional capacity, and diminished overall
quality of life, have been associated with female sexual assault. Victims of
sexual assault can experience acute and long-term physical and psychological
health problems.
All patients should be screened for IPV. A nonthreatening approach is to ask
patients directly whether they feel safe going home and whether they have
been hurt physically, emotionally, or sexually by a past or present partner. If the
partner (male/female) has accompanied the woman to the prenatal visit, these
questions are postponed until the nurse is alone with the patient, for obvious
reasons.
Nurses can also opt to use a standardized form that has valid and reliable
questions concerning IPV. The form could be incorporated into the intake
assessment data obtained from all patients. Women who have been sexually
abused as children are at greater risk of IPV in adult relationships. Sequelae of
abuse include depression, anxiety, substance abuse, and PTSD. As a women’s
advocate, nurses have a duty to be observant, to actively listen, and to use
communication skills to gain clarification and understanding. One serious
concern is strangulation. Strangulation has been recognized as a red flag for
worsening violence. All IPV screening should include asking about
strangulation (Scannell, MacDonald, & Foster, 2017).
Assessment Tools
RADAR for Relationship Violence
The Centers for Disease Control and Prevention (CDC) has adopted the
acronym “RADAR,” a term originally developed by the Massachusetts Medical
Society, to guide nurses as they interview patients about relationship violence:
• Routinely screen every patient
• Ask directly, kindly, and in a nonjudgmental manner
• Document your findings
• Assess the patient’s safety
• Review options and provide referrals
Psychological Assessment
Pregnancy is a time of change, and usually change of any nature is
linked with additional stress. How an individual deals with stress
depends on learned behaviors, coping mechanisms, and support
systems. Pregnancy is a major life change or developmental phase
for all women. Each woman’s approach to her pregnancy
encompasses cultural values and family traditions and beliefs. One’s
status in relation to marriage or partnership, financial security,
career, or educational achievements is influential in shaping the
overall childbearing experience. Past obstetric experiences including
pregnancy outcomes, interactions with care providers, and level of
physical health during and after pregnancy are instrumental in
forming the woman’s attitude toward this pregnancy. The loss of a
previous pregnancy may adversely affect a woman’s ability to bond
with her present pregnancy. Understandably, she may be reluctant to
invest in a pregnancy that she fears may not come to fruition. In
other situations, acceptance of pregnancy may be delayed if it was
unplanned or unwanted. Ambivalence is a normal initial reaction to
pregnancy that usually diminishes as the woman accomplishes the
developmental tasks of pregnancy.
Although the developmental tasks of pregnancy may be reviewed
in a systematic way, it is important to remember that each woman is
an individual who harbors a host of unique medical and
psychological factors. For example, a woman with a history of a
previous eating disorder may experience difficulty maintaining a
healthy diet and achieving appropriate weight gain during pregnancy.
Another woman may have struggled with anxiety and depression,
alcohol or drug use, or issues related to domestic violence before
pregnancy. These are all factors that can have a significant effect on
the prenatal course. Many tools such as “The Edinburgh Postnatal
Depression Scale” are available to guide the nurse in conducting the
prenatal and postpartal psychological assessment.
SCREENING AND DIAGNOSTIC TESTS DURING

PREGNANCY
Before prenatal testing, it is essential to determine the gestational
age accurately because a number of screening and diagnostic tests
have different ranges of normality based on the maturity of the
pregnancy. Before a patient is asked to consent to any investigation,
she should be counseled about the purpose of the test, its reliability,
and the implications of a negative or positive result. The nurse also
needs to explain the difference between a screening test and a
diagnostic test.
Patient Education
Educating Patients About Screening and Diagnostic Tests
To facilitate patient understanding of care options, nurses should explain the
differences between screening and diagnostic tests. A screening test:
• Identifies patients at increased risk for developing a disorder or disease
• Identifies patients who need diagnostic testing A diagnostic test:
• Confirms the presence of a disorder or disease
At the first prenatal visit, venous blood samples are taken so that
abnormal findings can be identified and promptly treated. Blood is
drawn for a number of tests: the patient’s blood group and rhesus
(Rh) factor; antibody screen (Kell, Duffy, rubella, varicella,
toxoplasmosis, and anti-Rh), and RPR/VDRL (rapid plasma
reagent/Venereal Disease Research Laboratory) screen for syphilis.
If the woman has not received the hepatitis B vaccine, she is tested
for hepatitis B surface antigen (HbsAG) and hepatitis B surface
antibody (HbsAB). A complete blood count (CBC) with hemoglobin,
hematocrit, and differential cell count is obtained and assessed using
laboratory values established for pregnancy. Testing for antibody to
HIV is recommended for all pregnant women (Workowski & Bolan,
2015; ACOG, 2011f; CDC, 2011d), and a sickle cell screen is
recommended for women of African, Asian, or Middle Eastern
descent. In the United States, sickle cell anemia is one of the most
common genetic blood disorders and occurs most often in African
American populations (ACOG, 2017). During this visit, a Tine or
purified protein derivative (PPD) tuberculin test may also be
administered to assess for exposure to tuberculosis.
SUMMARY POINTS
■ Estrogen and progesterone are the major hormones produced by the placenta
during pregnancy. Estrogen’s effect is one of “growth”; progesterone’s effect is
one of “maintenance.”
■ The reproductive system undergoes the greatest changes in size and
function, and every organ within this system is affected by or focused on the
needs of the growing fetus.
■ Every system in the body experiences dramatic changes in structure and
function as a result of the hormonal changes of pregnancy.
■ Pregnancy is a time of disruption in the woman’s life that affects her ability to
deal with stress and cope with the changes that will occur over many months.
These changes affect not only the woman but also her partner and the other
family members as well.
■ Ethnocultural, familial, and spiritual beliefs exert a powerful influence on the
woman’s and her family’s progress through the pregnancy and can enhance
or interfere with routine prenatal care.
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Davis Advantage
CHAPTER 5
Promoting a Healthy Pregnancy
CONCEPTS
Female reproduction
Pregnancy
Nursing
KEY WORDS
Preconception
Reproductive life plan (RLP)
Recommended daily allowance (RDA)
Folic acid
Body mass index (BMI)
Pica
Anorexia nervosa
Bulimia nervosa
Teratogen
LEARNING OBJECTIVES

■ Discuss healthy approaches for empowering women in planning for a healthy
pregnancy.
■ Describe factors that must be integrated to achieve optimal nutrition and
weight gain during pregnancy.
■ Develop an exercise plan for women in the first, second, and third trimesters
of pregnancy.
■ Discuss the various methods of childbirth education and assist a pregnant
patient in developing a birth plan.
PICO(T) Questions
chapter.
1. Does (I) changing pregnant women’s diets to avoid peanut consumption (0)
decrease the incidence of peanut allergies (P) in infants?
2. Do (P) women whose pregnancy was not planned have (O) a higher
incidence of (1) clinical depression (C) than women who were actively trying
to conceive?
INTRODUCTION
This chapter focuses on health promotion of childbearing women
during preconception and throughout pregnancy. Topics covered
include counseling as an essential component of preconception
care, health promotion during pregnancy including adequate nutrition
and weight gain, medication safety, lifestyle behaviors, prenatal
education, and childbirth education.
As an integral part of promoting a healthy pregnancy and
incorporating a holistic approach to care, women should be
encouraged to develop a birth plan that includes their preferences for
care during the labor and birth of their child.
CHOOSING A PREGNANCY CARE PROVIDER
One of the first maternal tasks of pregnancy as described by Rubin
(1984) is “Ensuring safe passage.” This stage encompasses the
active lifestyle choices that the woman makes and the behaviors that
she adopts to promote her own and her fetus’s well-being. One of
the early decisions the patient (and partner) makes concerns
choosing a care provider. It is recommended that every patient
arrange an appointment with a chosen care provider (obstetrician,
family practice physician, or certified nurse midwife [CNM]) to
discuss the management of pregnancy and childbirth as early as
possible within the first trimester. The woman may seek childbearing
care from an obstetrician, a family practice physician, or a CNM who
is educated in the disciplines of nursing and midwifery and is
certified by the American College of Nurse Midwives.
Healthy women who choose a CNM are as likely as those who
choose an obstetrician to have an excellent outcome, and they may
also experience fewer medical interventions and a lower rate of
cesarean births. Women who have complications related to the
pregnancy or who are in a high-risk category will often require joint
management or complete transfer of care to that of an obstetrician,
and patients should also plan to meet with a perinatologist. The
perinatologist works closely with the woman’s CNM or obstetrician to
determine the best plan for managing the pregnancy, labor, and
birth.
A woman’s journey through the pregnancy experience can have
long-term effects on her self-perception and self-concept. Thus, it is
especially important that the patient choose a care provider with
whom she can openly relate and who shares the same philosophical
views on the management of pregnancy. Continuity of prenatal care
has been shown to be associated with increased maternal
satisfaction and a need for fewer interventions during labor. The
importance of developing a positive relationship with one’s care
provider and receiving personal, individualized care throughout the
pregnancy is medically and psychologically advantageous.
The provision of prenatal care offers the nurse a unique
opportunity to make a difference not only in the patient’s life but also
in the lives of her family. To truly take advantage of this opportunity,
the nurse needs an expansive array of tools including the ability to
communicate effectively with patients irrespective of cultural
background, educational level, health-care beliefs, or age to
understand family and group dynamics and to accept diversity
without prejudice or bias. Family care during the prenatal period
centers on education and health promotion.
When caring for pregnant women it is critical to consider the
number of issues that can affect a woman’s willingness to use
health-care services. These include personal beliefs about
pregnancy, cultural expectations, previous relationships with past
experience with health-care system and health-care providers, and
perceived benefits of prenatal care, together with the more practical
issues of access to care, medical insurance, and/or financial support.
By using therapeutic communication, the nurse can gain insights into
the patient’s belief system and manage care appropriately.
Maintaining a nonjudgmental attitude is essential, for example, if the
woman is a late recipient of prenatal care. Creating an atmosphere
in which the patient feels accepted and valued for seeking care is a
therapeutic, positive approach and one that will hopefully foster
patient adherence.
Through discussion, the nurse can gain an understanding of the
availability and acceptability of traditional health-care services and
whether they meet the patient’s individual health-care needs. Each
culture embraces different customs and health practices that need to
be respected and, wherever possible, accommodated. These
requirements may relate to the gender of the health-care provider,
the patient’s clothing requirements, diet, and/or food preparation.
The prenatal interview provides an opportunity to develop a positive
relationship with the patient and emphasize the benefits of prenatal
care for her and her unborn child.
In both the local and national arenas, nurses can empower women
and their families by advocating for prenatal care that is readily
available and affordable for all, especially for low-income and
vulnerable populations.
PRECONCEPTION CARE
Preconception is the period of time before pregnancy during which
health-care providers can address family planning with the goal of
health promotion to protect the health of the baby and women for
future pregnancies (Centers for Disease Control and Prevention
[CDC], 2020). Many pregnancies are unintended, so addressing
preconception care allows the practitioner to identify reproductive
goals and interventions to reduce unintended pregnancies.
During preconception, a woman builds the foundation for a healthy
pregnancy long before she may ever even think of becoming
pregnant. Preconception care with the woman’s health-care provider
provides opportunities for the nurse to empower the woman to plan
and carry out a healthy pregnancy and birth.
The purpose of preconception care is to identify conditions,
whether physical, psychological, environmental, or social, that could
adversely affect a future pregnancy. With early identification,
interventions can be initiated to manage, reduce, or prevent potential
complications that may be associated with them. Although certain
conditions cannot be ameliorated, it may be possible to manage or
treat them to minimize the possible effect on future pregnancies.
Each time a woman of childbearing age visits her care provider for
an annual gynecological examination, preconception counseling
should be included, regardless of whether or not the woman is
planning a pregnancy now or at any time in the foreseeable future
(Table 5-1). Use of a tool such as a reproductive life plan (RLP) is
beneficial for couples. The RLP is a reflection of a person’s
intentions about the number and timing of pregnancies in the context
of their personal values and life goals, and it may serve as the
starting point of focused, personalized counseling to directly address
the individual’s plan. Especially useful in populations at risk for
adverse outcomes, the RLP serves as a comprehensive strategy
that can be incorporated into nursing practice at all levels to improve
birth outcomes (Hipp et al, 2019).
PRENATAL CARE
Prenatal care, also known as antenatal care, is a form of preventive
health care a woman receives throughout the pregnancy. It
encompasses routine maternal and fetal assessments, screening
and testing for certain health-care conditions, risk factor
assessments, and education on various aspects of pregnancy
(World Health Organization, 2019). Prenatal care usually begins in
the first trimester of pregnancy, when the patient is seen every 4
weeks until she reaches 28 to 32 weeks’ gestation. At that time, the
appointments are changed to visits every 2 weeks and then occur
weekly from 36 weeks of gestation until birth. If it is a high-risk
pregnancy or the woman or fetus is having complications, the
number of prenatal visits increases, especially toward the end of the
pregnancy where the women and fetus may require close
monitoring. The goals of prenatal care include the following:
■ Ensure specific pregnancy dietary nutrients are met
■ Ensure immunizations are up to date
■ Screen for sexually transmitted infections (STIs), (GBS), hepatitis,
and HIV
■ Monitor and control chronic disease such as diabetes and
hypertension
■ Screen and counsel on cessation of smoking, alcohol, and
recreational substances
■ Attain and/or maintain a healthy weight
■ Assess for discomforts of pregnancy and treat/counsel accordingly
■ Assess for genetic risk factors and test accordingly
■ Refer patients at risk for mental health disorders: depression,
anxiety, or other mental health issues
■ Educate on health-related issues such as oral hygiene and
avoiding exposures to harmful medications and substances
■ Screen for intimate partner violence at every prenatal visit
■ Monitor fetal growth and development
■ Provide individualized, evidence-based care
■ Provide culturally appropriate prenatal education designed to meet
the patient’s learning style and needs
■ Empower women to become actively involved in their pregnancy
by being informed recipients and shared decision makers
TABLE 5-1
Preconception Counseling Items
ASPECTS OF PRENATAL COUNSELING ITEMS
CARE
Family planning Addressing reproductive desires and adequate
contraception to prevent unintended pregnancies
and ensure adequate interval spacing between
pregnancies. Addressing any current issues with
infertility and subfertility to determine need to
additional counseling.
Medical and menstrual A review of the menstrual history to identifying the
history frequency and length of menstrual periods is
essential information for teaching about the fertile
period and how to enhance the likelihood of
conception.
Chronic health-care Chronic health-care conditions that can affect a
conditions adequately pregnancy such as diabetes, thyroid disease,
managed hypertension, seizure disorders, and HIV should be
assessed for management and any complications
that can negatively affect a pregnancy or fetus.
Mental health Assessment of current or past mental health issues
that can exacerbate in the pregnancy or postpartum
period. Include assessment of stress and anxiety
regarding issues of conceiving. Referral to metal
health experts and counseling on anxiety and stress-
reducing techniques.
Vaccinations Immunization status should be updated and
determine the need for vaccinations, as some
vaccines are contraindicated in pregnancy and
should be given preconception.
Medications Review of prescribed medications, over-the-counter
medications, and any herbal supplements that can
cause a teratogenic effect and may need to be
stopped, adjusted, or changed to a nonteratogenic
medication.
Sexuality and sexually Address sexually transmitted disease that should be
transmitted diseases assessed and tested for during preconception care
as well as the need for prevention. Address safe
sexual practices and determine any additional
sexuality needs.
Genetic testing Genetic history should be assessed to determine
need for genetic testing. Genetic testing should be
guided by local or state guidelines as well as any
racial, ethnic, or family history that indicates a higher
risk for certain fetal or pregnancy issues related to
genetics.
Nutrition Folic acid supplement of 400 mcg encouraged for all
women of childbearing age to prevent neural tube
defects in pregnancies that are intended and those
unintended.
Dental Women considering pregnancy should be counseled
to undergo a dental examination. This health-
promoting strategy offers the opportunity for the
identification and treatment of dental conditions
associated with adverse pregnancy outcomes.
Weight Address BMI and counsel on methods to meet BMI.
Overweight and obese women should be counseled
on nutrition and exercise. Underweight women
should be counseled on adequate weight and
nutrition. Referral to nutritionists to help meet the
BMI goals may be necessary.
Environmental Parental exposure to various environmental
contaminants contaminants in the home, work, and community
(e.g., metals, solvents, petrochemicals, and
pesticides) may be associated with a plethora of
adverse reproductive effects (e.g., infertility and
spontaneous abortion) and genetic damage in the
fetus.
Domestic violence or Screen all women for domestic violence or
interpersonal violence interpersonal violence. Address any concerning red
flags that can endanger women’s safety.
Exposures to recent Address any recent exposure to infections, diseases,
infections or areas where there are outbreaks that can be
detrimental to a pregnancy or fetus (Zika virus,
Epstein bar, or Cytomegalovirus) to determine
possible risk.
Lifestyle behaviors Address smoking, alcohol, and recreational drug use
and the need for abstinence and cessation. Referrals
and interventions should be targeted to the individual
to help meet their goals of abstinence and cessation
for the particular substance.
Sources: (Academy of Nutrition and Dietetics, 2019; American College of Nurse
Midwives, 2017a; ACOG, 2020; CDC, 2020c; Office on Women’s Health, 2019)
The First Prenatal Visit

The first prenatal visit is an extremely important one and should take
place as early in pregnancy as possible. Before meeting the patient
for the first time, it is helpful for the nurse to review the paperwork to
prepare to take a comprehensive health history and ask appropriate,
relevant questions. The initial interview with the patient should be
used to build a positive, nonthreatening relationship and to gain her
confidence. Useful strategies include active listening, validating
responses when needed, maintaining eye-to-eye contact, and using
humor as appropriate to relax the patient. Honesty is essential for
effective communication. When uncertain of the answer to a
question, the nurse should make a note to find the answer and report
back to the patient at the end of the interview.
Therapeutic communication skills are of paramount importance
when obtaining prenatal history. The information requested can often
be of a very personal nature, and it may be difficult for patients to
disclose certain aspects of their past histories. Therefore, care must
be taken to manage the environment to promote privacy and provide
the patient with psychological and physical comfort. Use openended
questions to encourage the patient to discuss and share information
rather than closed-ended questions that require only a “yes” or “no”
response. The value the patient places on the care she receives and
her interactions with personnel will determine whether she returns for
subsequent prenatal care. Therefore, the prenatal team’s objective is
to provide a user-friendly service that is efficient, effective, caring,
and patient centered. One major goal for this first visit is to explain
the purpose of prenatal care and to establish specific goals. Care
goals are determined through shared decision making with the
patient and should focus on promoting maternal and fetal health
through assessment, education, screening, diagnosis, and
treatment.
Biographical Data
One of the first aspects of the prenatal visit is obtaining a complete
health history, including the patient’s biographical data, medical
history, and psychosocial history. A medical examination is also an
essential component of the first visit. A risk assessment form allows
for the collection of information relating to the patient’s pregnancy
history, medical history, nutritional and exercise patterns, financial
income, vocational and educational goals, living arrangements,
psychosocial history (includes depression and past suicidal
tendencies), and lifestyle choices. It also provides an opportunity for
the patient to request educational information on a variety of topics.
Completing the prenatal history form with the patient enables the
nurse to provide personalized education that focuses on risk factors
pertinent to that individual. For example, it may be appropriate to
discuss the maternal and fetal effects of environmental substances
to which the woman is exposed at home and in the workplace.
Common offenders include exposure to cigarette smoke (either
directly or passively), alcohol consumption, recreational drugs, poor
or inadequate diet, pollutants, viruses, and occupational hazards.
Current Pregnancy
When obtaining the medical history, the nurse should begin with the
events of the current pregnancy. For the woman, her pregnancy is of
primary importance at this time and is the reason she came to the
office for prenatal care. The nurse gathers information to confirm the
pregnancy and determine the estimated date of birth. It is usually
possible to determine from the patient’s responses whether this was
a planned or unexpected pregnancy. “Unexpected” does not
necessarily mean “unwanted.” Instead, this term refers to the fact
that the pregnancy occurred when the couple was not actively trying
to conceive. Often, pregnancy comes as a complete surprise when
the menstrual period is missed or other signs of pregnancy appear.
The diagnosis of pregnancy is based on the patient’s reported
symptoms and the presence of objective signs elicited by the health-
care provider. The signs and symptoms are traditionally divided into
three classifications: presumptive (experienced by the patient),
probable (observed by the examiner), and positive (attributable only
to the presence of the fetus).
Medical History
To provide the patient with appropriate care to meet medical needs
during pregnancy, it is essential to obtain a detailed medical history
with a complete assessment of the individual’s past medical,
surgical, and reproductive history. This should include allergies,
current prescription and over-the-counter (OTC) medications, and
immunization status. This information gives insights into the patient’s
past and present health status and use of preventive services.
Medical history should include all medical conditions since childhood
and resolution or management of these conditions, including
evaluation of oral hygiene.
Vaccination History
Obtaining information on vaccination history is important to the
pregnancy and developing fetus. Patients should be asked regarding
vaccination history, which will help to determine if they are up-to-date
with vaccinations and an opportunity to identify vaccines the patient
may need during pregnancy or after the pregnancy. Vaccines can
help prevent diseases during pregnancy which can be detrimental to
the health of the women or fetus. In addition, some vaccines can be
harmful, and those will need to wait until after the pregnancy to
receive.
Varicella (chickenpox) is another common childhood disease that
may cause problems in the developing embryo and fetus. At present,
an immunization for chickenpox is available and given to most
children. If a woman presents for a preconception visit and her
history reveals no prior chickenpox infection, she should be
immunized before attempting pregnancy. Pregnant women should be
questioned about childhood chickenpox, and a varicella titer may be
obtained to confirm immunity. If nonimmune, the patient should be
advised to avoid children who could potentially expose her to the
chickenpox virus.
Seasonal influenza can be a serious illness in pregnancy leading
to significant adverse pregnancy and fetal outcomes. Influenza
vaccine is safe in pregnancy and recommended to administer to all
pregnant women during pregnancy.
Lastly tetanus, diphtheria, and pertussis vaccine should also be
safe in pregnancy and is recommended in the third trimester to allow
for passive immunity to the fetus, who will then have protection
against this disease. Many fetal deaths due to pertussis occur before
2 months of age (American College of Nurse Midwives, 2017a).
Recently, concerns over the COVID-19 vaccine have emerged.
COVID-19 is a newer virus that has resulted in worsening clinical
outcomes for pregnant women as well as risk of preterm labor. One
vital component in reducing the spread and minimizing the
consequence of COVID-19 is with the COVID-19 vaccine.
Unfortunately, pregnant women were excluded for the initial research
of this vaccine, leaving this population with limited information on
recommendations. As evidence has emerged, recommendations for
receiving the COVID-19 vaccine have included for pregnant women
to receive the vaccine especially for those who are at a high risk for
contracting the virus, such as those who work with COVID-19
populations such as health-care workers (CDC, 2021).
Obstetrical History
One of the first steps in the prenatal interview process is to obtain an
accurate and detailed obstetric history that provides the interviewer
with essential information so that questions can be formulated and
asked in a manner that respects and acknowledges the patient’s
past experiences with pregnancy. The history should cover the
current pregnancy and all previous pregnancies and their outcomes
because complications experienced in a prior pregnancy often
reoccur in subsequent pregnancies, such as miscarriage, pre-
eclampsia, and preterm birth.
Pregnancy Classification System

The Pregnancy Classification System should be conducted for each
patient. This is a standard method to document previous
pregnancies. Another important task is to determine the patient’s
gravidity and parity. Gravid is the state of being pregnant; a gravida
is a pregnant woman. Gravidity relates to the number of times that a
woman has been pregnant, irrespective of the outcome. The term
nulligravida is used to describe a woman who has never experienced
a pregnancy. A primigravida is a woman pregnant for the first time,
and a secundigravida is a woman pregnant for a second time.
Although officially correct, this term is seldom used and instead the
term multigravida is used in its place. A multigravida describes a
woman who is pregnant for the third time (or more times).
Parity refers to the number of pregnancies carried to a point of
viability (generally accepted as 24 weeks of gestation), regardless of
the outcome. For example, “para 1” indicates that one pregnancy
reached the age of viability. A para 2 means that two pregnancies
reached the age of viability. It is important to note that the term parity
(or “para”) denotes the number of pregnancies, not the number of
fetuses/babies, and does not reflect whether the fetuses/babies were
born alive or stillborn. Some facilities use a digital system (i.e.,
GTPAL) for recording the number of pregnancies and their
outcomes.
G Gravida
T Number of Term pregnancies
P Number of Preterm deliveries
A Number of Abortions, both spontaneous and induced
L Number of Living children
Family History
A family history is health information of immediate parents,
grandparents, siblings, and children that is essential to obtain as it
can help identify possible hereditary risks and complications that
may arise in the current or future pregnancies. The CDC
recommends a family history to include an assessment of both
maternal and paternal family history with respect to hereditary
conditions and disabilities. This information allows the health-care
provider to assess for these conditions and make early referrals for
care (CDC, 2019).
Women should be questioned about the possibility that their
mothers or grandmothers had a possible exposure to
diethylstilbestrol (DES) during pregnancy. DES is a nonsteroidal
synthetic estrogen several times more potent than natural estrogens.
In the United States, DES was widely prescribed from the late 1930s
until the early 1970s to reduce the likelihood of spontaneous abortion
(miscarriage) or preterm delivery. Exposure to DES during
intrauterine development produces both structural and functional
gynecological abnormalities that are associated with numerous
problems including infertility, increased incidence of ectopic
pregnancies, preterm labor and birth, and vaginal adenocarcinoma.
Male offspring may be at an increased risk of testicular and prostate
cancer. Second generational effects of in utero DES exposure
include an increased incidence of ovarian cancer (granddaughters)
and uterine anomalies causing significant reproductive and
obstetrical complications.
Environmental Health Assessment

Conducting an assessment on a women’s environmental history is a
critical aspect of prenatal care given the detrimental effects that
environmental toxins can have on reproductive health, pregnancy,
and the growing fetus. The American College of Nurse Midwives
developed a position statement recognizing the ethical and
professional responsibilities health-care providers have in
addressing environmental health among patients (The American
College of Nurse Midwives, 2015). Health-care professionals can
help to minimize environmental exposures by first identifying
potential exposures, then educating patients on reducing exposures.
A full assessment should be conducted of the home, community, and
work environment to determine risk of exposure to harmful toxins.
Essential components of an assessment should include the level of
the toxin present, the frequency of exposure to the toxin, and the
degree of toxicity. Certain chemicals that have little effect on a
person who is not pregnant can cause serious, permanent disability
and injury to the fetus when a pregnant woman is exposed.
Examples of common chemical exposures include garden
pesticides, cleaning chemicals, lead, and asbestos.
What to Say
Asking About Potential for Toxic Exposure
It is essential for nurses to assess every prenatal patient for the potential for
pesticide exposures. Environmental exposure questions should be included in
the comprehensive patient health history. To elicit the information, the nurse
may wish to ask questions such as the following:
“Do you use pesticides in your home, lawn, workplace, or on your pets?”
“When was your house built and could there be lead paint?”
“What type of drinking/cooking water do you use and where does it come
from?”
“Do you live near or need to commute by hazardous waste sites?
“Are you handling hazardous chemicals at work?”
Air pollution, including secondhand smoke, is one of the most

common concerns for maternal and newborn health. Most people
spend up to 90% of their time indoors, where air pollutants are up to
five times more concentrated than they are outdoors. Adverse birth
outcomes including congenital anomalies, intrauterine growth
restriction, and preterm birth have been linked to in utero exposure
to air pollutants.
The nurse should also encourage the woman to consider toxin
exposure at the workplace. She may work with chemicals that
appear safe and use all safety precautions established by regulatory
agencies, but these precautions may not consider pregnancy. She
may need to avoid or significantly limit possible exposure. Other
industrial compounds (e.g., polychlorinated biphenyl [PCB], a
substance widely used as a coolant and lubricant in transformers,
capacitors, and other electrical equipment) can accumulate in
maternal adipose tissue and possibly be transmitted to the infant via
breast milk. These chemicals can cause distribution in the fetal
endocrine system leading to complications in childhood.
Nurses can help educate patients on the risk factors and help
implement interventions to reduce exposure. For example, if a
patient has to walk near waste sites or farmland that uses pesticides,
she should take off her shoes before entering the home to minimize
transfer of toxins. Another strategy is to avoid using plastic to heat
up food in the microwave to avoid transfer of chemicals from the
food container.
Social History
A social history includes education level, work history, living
arrangements, and history of smoking and substance use. This helps
identify aspects that place a patient at risk for future complications
and problems that require early interventions such as alcohol or
substance use. Several factors related to lifestyle choices have
detrimental effects on the developing fetus, so early assessment is
essential to promote a healthy pregnancy and fetus.
TOBACCO
Smoking during pregnancy causes a plethora of problems for the
woman and the developing fetus. Carbon monoxide in cigarette
smoke binds more readily than oxygen to hemoglobin, decreasing
the oxygen-carrying capacity of the red blood cells. This decreases
the amount of oxygen traveling to the placenta, limiting the amount
of oxygen available to the fetus for growth and development of
tissues and organs.
The nicotine in cigarette smoke also poses a significant risk to the
developing fetus. Depending on the amount and the frequency of
smoking, nicotine can act as either a stimulant or a relaxant. Nicotine
causes the release of epinephrine, stimulating the “fight or flight”
response that results in tachycardia, hypertension, and tachypnea.
This response occurs in both the woman and her fetus. The
stimulation of the sympathetic nervous system also prompts the
release of cortisol from the adrenal glands, increasing blood glucose
levels and altering the body’s immune response. Vasoconstriction
results from stimulation of the sympathetic nervous system, causing
decreased blood flow through the arteries and decreased oxygen
transport to the placenta and the developing fetus. Smoking is
associated with spontaneous abortion, low birth weight, intrauterine
growth restriction, preterm labor and birth, placenta previa, placental
abruption, premature rupture of the membranes, and sudden infant
death (Office on Women’s Health, 2019).
Pregnancy is an ideal time to offer smoking cessation
interventions because, during the prenatal period, women generally
have an increased concern for their fetus as well as for themselves
and are more likely to adopt a healthy lifestyle during this period,
including smoking cessation.
ALCOHOL
Alcohol consumption during pregnancy can cause physical and
mental abnormalities in the developing fetus. The current
recommendation is that no alcohol consumption during pregnancy is
safe because no safe level has been determined.
Alcohol passes quickly through the placenta and reaches the fetal
bloodstream much more rapidly than it does in adults. Fetal body
system functions are immature and unable to metabolize alcohol,
resulting in elevated alcohol levels and damage to developing
organs and tissues. The resulting problems are manifested in the
facial features associated with fetal alcohol syndrome (FAS): a low
nasal bridge, short nose, flat midface, and short palpebral fissures.
FAS is one of the most common causes of intellectual disability.
Body organs affected include the heart and the brain. Children born
with lesser damage are diagnosed with fetal alcohol effects (FAEs),
fetal alcohol spectrum disorder (FASD), or alcohol-related birth
defects (ARBDs).
The American College of Nurse Midwives recommends universal
screening for alcohol at the first prenatal visit and at least once
during each trimester. This allows healthcare providers to address
issues that may have been present before pregnancy as well as
during the pregnancy. Healthcare professionals should inform
patients of available resources in abstaining from alcohol and
educate patients on the risk of alcohol consumption and the effects
on the fetus. Women who are consuming alcohol may need close
follow-up and referral to additional services to help implement a plan
of care on abstinence (American College of Nurse Midwives, 2017b).
CANNABIS
Cannabis consumption may be associated with adverse effects on
neonatal neurobehavior, producing symptoms such as
hyperirritability, tremors, and photosensitivity. Also, women who use
marijuana may engage in other high-risk behaviors (e.g., alcohol and
tobacco use), and the combination of effects may be associated with
poor fetal outcomes.
COCAINE
It is difficult to determine the effects of cocaine use in pregnancy
because of the high potential that the woman may be using other
drugs and engaging in additional high-risk behaviors. Fetal exposure
to cocaine is associated with an increased risk for congenital
anomalies that involve the brain, skull, face, eyes, heart, limbs,
intestines, genitals, and urinary tract. The pregnant woman who uses
cocaine is at risk for pregnancy complications that include stillbirth,
abruptio placentae, preterm labor, preterm birth, and giving birth to
an infant who is small for gestational age (SGA).
Exposure to Sexually Transmitted Infections

Sexually transmitted infections (STIs) may cause maternal and fetal
complications during pregnancy. Routine screening for STIs aids in
early detection and treatment. The Venereal Disease Research
Laboratory (VDRL) test is a screening titer for syphilis that measures
antibodies produced in mid-disease, but it can produce a false
positive result in women who are pregnant or who have rheumatoid
arthritis or systemic lupus erythematosus. For these patients, a rapid
plasma reagin (RPR) screening test may be used to confirm the
presence of antibodies. In the event of a positive result, further
testing is needed to confirm the findings and to determine whether
the infection is in an active or latent phase.
In addition to screening for syphilis, all women should be screened
for HIV as early as possible during each pregnancy. If positive,
therapy can be initiated to decrease the likelihood of transplacental
viral transmission to the fetus. An important nursing role includes
educating all women about HIV and the methods for decreasing the
risk of infection.
Gonorrhea and chlamydia are cervical infections that can ascend
through the cervix and increase the risk of premature rupture of the
membranes and preterm labor. A cervical sample obtained during a
speculum examination can be tested to determine whether either of
the pathogens is present. If no speculum examination is performed,
chlamydia testing may be conducted via urine specimen (Scannell,
2020).
Hepatitis B virus (HBV) is a bloodborne infection that is acquired
primarily by sexual contact or through exposure to infected blood.
The hepatitis B surface antigen (HBsAg) is used to screen for this
infection. If the screening test is positive, further testing is indicated.
Genetic Testing
During the patient’s first interview and visit, the nurse should ask
questions that relate to the patient’s and family’s genetic history.
Depending on the information gained, further blood work and testing
may be indicated. For example, a positive family history of sickle cell
disease or trait should be followed up with a maternal hemoglobin
electrophoresis. If the patient tests positive, her partner should also
be tested.
All women should be offered screening with ultrasonography and
maternal serum markers. Several different tests are available, such
as pregnancy associated plasma protein-A (PAPP-A) and free (3-
human chorionic gonadotropin (free (3-hCG) during the first
trimester, and the triple screen and the quadruple screen during the
second trimester. Depending on the specific test, biochemical
markers (e.g., maternal serum alpha-fetoprotein [MSAFP],
unconjugated estradiol [uE3], and free (3-human chorionic
gonadotropin [(3-hCG]) are measured to screen for potential neural
tube defects (NTDs), trisomy 13, trisomy 18, and trisomy 21. If the
screen is positive, the woman should be referred to a genetics
specialist for counseling, and further testing, such as chorionic villus
sampling (CVS) or amniocentesis, should be performed
Although it is not possible to inquire about every inheritable
disease or disorder, those most frequently encountered are
addressed in Table 5-2.
Optimizing Outcomes
Prenatal Genetic Testing
Prenatal nursing care is enhanced with the implementation of interventions for
early diagnosis and treatment for the prevention of complications related to birth
defects. It is essential that nurses provide prenatal interventions, including folic
acid supplementation for all women of reproductive age, rubella screening and
immunization, teaching women to avoid alcohol consumption during
preconception and pregnancy, screening and detection of prenatal genetic
disorders and early treatment of disorders when possible, and offering
termination of pregnancy for severe defects.
TABLE 5-2
Genetics Screening During Pregnancy
DISORDER POPULATION PATHOLOGY PREGNANCY
AFFECTED AND NEWBORN
COMPLICATIONS
Sickle cell disease African Americans • Autosomal • Spontaneous
Persons of recessive abortion
Mediterranean hemolytic disease
descent
• Involves an • Preterm labor
abnormal
substitution of an
amino acid in the
structure of
hemoglobin
• Red blood cells • Intrauterine
assume growth restriction
abnormal, sickle
shape in response
to triggers,
including hypoxia,
infection,
dehydration
• Results in inability • Stillbirth
to oxygenate
tissues
• Leads to
occlusion and
rupture of blood
vessels
Tay-Sachs disease Ashkenazi Jews • Lipid storage • Infants appear
disorder that normal at birth,
results from a until about 3–6
deficiency in the months of age
enzyme beta-
hexosaminidase A
(necessary for the
biodegradation of
acidic fatty
materials known
as “gangliosides”)
Jewish people from • Both parents must • Nerve cells
eastern or central carry and pass on become distended
Europe the trait to the with fatty material;
child muscles atrophy;
neurological
system
deteriorates
French Canadians • Death usually
Cajuns occurs between
the ages of 2 and
4 years
Thalassemia Greeks • Disorder of • Children appear
hemoglobin normal at birth
synthesis
Italians • Thalassemia • During first 2
minor: person is years, become
heterozygous for pale, lethargic,
the trait; and develop
experiences fewer jaundice
symptoms
Southeast Asians • Thalassemia • Results in
major: person is enlarged liver,
homozygous for spleen, and heart
the trait;
experiences more
severe symptoms
Filipinos • Death results from
heart failure and
infection
Hemophilia Males affected • Mutation in the • Males can have
gene for excessive
coagulation factor bleeding when
VIII circumcised
Females are • Causes a defect • Increased
carriers in blood clotting incidence of
intracranial
hemorrhage
• Leads to frequent • Easy bruising and
bleeding episodes bleeding with
and hemorrhage injuries
Glucose-6- African Americans • Causes drug- • Increased
phosphate Seen mostly in induced incidence of
dehydrogenase males destruction of red pathological
(G6PD) deficiency blood cells when jaundice or
taking certain hyperbilirubinemia
medications (e.g., caused by
sulfonamides) destruction of red
blood cells
Cystic fibrosis Caucasians • Autosomal • Results in chronic
recessive genetic obstructive lung
disorder disease from thick
mucus secretions
in the lungs
• Causes exocrine • Frequent lung
gland dysfunction infections occur
• Causes a
deficiency in
pancreatic
enzymes that
prevents normal
digestion
Sources: Data from: Cunningham, Leveno, Bloom, Spong, & Dashe (2014);
National Institutes of Health (NIH) (2011); U.S. National Library of Medicine (2012).
The Prenatal Physical Examination

During the first prenatal visit, women should expect a visit with their
health-care provider to last approximately 1 hour. This appointment
will include a complete physical and head-to-toe examination
including pelvic examination and, depending on the gestational age,
fetal heart tones (FHT), fundal height and gestational age, specific
assessments, vital signs, and weight. All subsequent visits will be
shorter (approximately 15 minutes) and have more focused
assessments, including vital signs, weight, common discomforts,
problems, fundal height, fetal heart rate (FHR), weight, and in some
places, urine dipstick.
For the physical examination, the patient should be given
adequate private time to prepare for the examination and
encouraged to void if the visit requires a urine specimen. Before the
examination begins, the patient should receive an explanation of
what the examination will involve and what she is expected to do.
Obtain her consent to be examined. During a physical examination,
the patient is usually scantily clothed and must remain on her back in
a vulnerable position for the majority of the time. Gaining permission
from the patient before proceeding gives her control, as she allows
the examiner to continue. This action is especially important for
women with a history of abuse, particularly sexual abuse. Actively
engaging the patient through dialogue during the examination
process provides an excellent opportunity for teaching. Also, ongoing
interaction while describing the findings and their relevance
empowers the patient and dispels the oft-experienced feeling that
something is being “done” to her. Before beginning the physical
examination, the nurse should collect all necessary equipment and
teaching literature that the patient should receive. It does not inspire
confidence or relieve the patient’s anxiety if the nurse is constantly
leaving the room to retrieve forgotten items.
The physical examination should proceed in the same order each
time (preferably head to toe) to reduce the likelihood of
unintentionally omitting any component. The examination should be
organized in a manner that reduces the movements the patient must
make. Also, it is less threatening to the patient when less invasive
procedures are performed first. Throughout the examination, it is
essential for the nurse to use good communication skills and to
advocate for and treat the patient with respect. These actions
empower patients to participate actively in health-care decisions.
The time before, during, and after the examination provides the
nurse with an excellent opportunity to develop a good rapport while
enhancing the patient’s comfort level. Proper management of the
clinical environment plays an important role in facilitating the
patient’s feelings of safety, privacy, and security.
Performing the General Assessment

The general assessment begins by simply observing the woman.
Information that can be obtained includes her overall
health/nutritional status; posture; ease of movement and gait;
appearance (includes clothing and cleanliness); affect and speech
pattern; eye contact; and general orientation to place, person, and
time. As the pregnancy advances, changes in maternal gait become
apparent because of increasing lordosis (curvature of the spine) in
response to the increasing weight and size of the gravid uterus that
changes the woman’s center of gravity.
The nurse then obtains anthropometric measurements. When
obtaining the weight, it is valuable to ask the patient what her normal
prepregnant weight was and to document this information (Fig. 5-1).
The prepregnant weight gives an indication of how the patient is
adapting to pregnancy. A dramatic, unintended weight loss can be
indicative of severe nausea and vomiting (hyperemesis gravidarum).
The height and weight are also recorded and used to calculate the
patient’s body mass index (BMI) and to determine nutritional
needs. The BMI can be used to calculate whether the maternal
weight is appropriate for height. Women who are underweight before
pregnancy and have a low weight gain during the pregnancy are at a
greater risk for preterm labor.
FIGURE 5-1 The weight is recorded and tracked throughout the

pregnancy.
The Focused Obstetric Examination
HEAD, NECK, AND LUNGS
With the patient in a sitting position, the physical examination
proceeds in a head-to-toe fashion beginning with a general
evaluation of the skin and hair. Many women notice that their hair is
healthier and more luxurious during pregnancy. Hair loss, common
during the postpartum period, can be indicative of a vitamin or
mineral deficiency. Increased levels of estrogen are responsible for a
number of objective and subjective changes such as hypertrophy of
the gingival tissue, nasal stuffiness, and an increased tendency for
nosebleeds.
The thyroid gland is palpated while the patient remains in a sitting
position. Enlargement is common during pregnancy because of
increased vascularity and hyperplasia of the glandular tissue. The
size and position of the thyroid are documented along with the
presence of nodules or swelling. Anterior and posterior lung sounds
are auscultated, and the cardiac rhythm and rate are evaluated for
adventitious sounds. During pregnancy, approximately 90% of
women exhibit systolic heart murmurs because of an increase in
blood volume. The systolic murmur may be clearer when the woman
holds her breath. Heart sounds should be evaluated with the woman
in both a sitting and lying position. Beginning late in the second
trimester, the gravid uterus causes an upward and lateral
displacement of the heart and the point of maximal impulse. Also, as
pregnancy advances, the patient’s breathing becomes thoracic in
nature (rather than abdominal) because of the enlarged uterus.
THE SKIN
Assessment of the skin may reveal pregnancy-associated
changes such as chloasma (the mask of pregnancy) and
hyperpigmentation of the areolae, vulva, abdomen, and linea (linea
nigra). The skin is evaluated for color consistent with the woman’s
ethnic background and for the presence of lesions or indicators of
drug abuse (e.g., skin scratches, bruising or track marks, nasal
discharge or irritated mucosa, and constricted or dilated pupils).
THE BREASTS
The patient is assisted to a recumbent position for the breast
examination. Depending on the gestational age, the nurse may place
a wedge under one of her hips to prevent compression of the vena
cava from the gravid uterus (supine hypotension syndrome).
Inspection of the breasts usually reveals pregnancy-related changes
including nodularity, striae, and enlargement and hyperpigmentation
of the nipples and Montgomery tubercles. Areas of indentation or
skin puckering are not normal findings. Colostrum, a precursor to
breast milk, may be expressed from the nipples as early as the first
trimester of pregnancy. The lymph nodes should not be palpable.
Patient Education
Promoting Breast Comfort During Pregnancy
As a component of health teaching during pregnancy, the nurse should
encourage patients to wear a firm, supporting bra. Some women may need a
professional fitting by a brassiere specialist to find a style that promotes both
comfort and support. As the breasts increase in weight, bras with wider straps
may be more comfortable. Some women choose to wear a “sleeping” bra
during the night for added comfort.
THE ABDOMEN
The obstetric abdominal examination focuses on recognizing signs
and changes associated with pregnancy. It is not intended to replace
a comprehensive abdominal examination. The patient should be
appropriately draped to maintain her privacy, comfort, and body
temperature. The abdominal shape is assessed and inspected for
the presence of scars (previous surgery should be documented),
linea nigra, striae gravidarum, or signs of injury (e.g., bruising). As
the pregnancy advances, visual inspection of the abdominal shape
may reveal the fetal position, especially if transverse. Also, it may be
possible to observe and palpate fetal movements. Patients generally
become aware of fetal movements around the 16th to 20th week of
pregnancy. A primigravida is usually able to identify fetal movements
around 18 to 20 weeks; a multigravida may notice fetal movements
as early as 16 weeks. This difference in awareness of fetal activity is
most likely because of past experience in recognizing the
movements along with a decrease in maternal abdominal muscle
tone.
UTERINE SIZE AND FETAL POSITION
Abdominal palpation is used to evaluate the uterine size, to
determine fetal position, and later in pregnancy, to determine
whether the presenting part has engaged in the maternal pelvis.
Fundal height is an indication of uterine size; periodic measurements
of the fundal height should correlate strongly with fetal growth (Fig.
5-2). The relationship of the fundus (top part) of the uterus to specific
maternal abdominal landmarks is used throughout pregnancy as a
gauge to assess fetal growth. The fundal height measurement
correlates to the weeks of gestation from approximately 22 to 34
weeks of gestation.
At 12 weeks of gestation, the fundus should be at the level of the
symphysis pubis; at 20 weeks, the fundus should be at the
umbilicus. The fundal height can be measured by using a tape
measure or finger-breadths in combination with known maternal
landmarks. For example, two finger-breadths above the umbilicus
would be equivalent to approximately 24 weeks of gestation.
Although convenient, using finger-breadths as a measuring tool is
subject to variations in finger size among different examiners.
Most often, the fundal height is measured with a tape measure.
This method is usually initiated at around 22 weeks of gestation. The
end of the measuring tape with the zero mark is held on the superior
border of the symphysis pubis. Using the abdominal midline as
guide, the tape is stretched over the contour of the abdomen to the
top of the fundus. The measurement (in centimeters) is recorded and
equals the weeks of gestation. For example, at 28 weeks of
gestation, the fundal height should be approximately 11 inches (28
cm).
FIGURE 5-2 Obtaining the fundal height measurement.
LEOPOLD MANEUVERS
The next step in abdominal palpation involves the use of Leopold
maneuvers, a four-part clinical assessment method of observation
and palpation to determine the lie, presentation, and position of the
fetus (see Procedure: Performing Leopold Maneuvers).
FETAL HEART AUSCULTATION
The information obtained during fetal palpation includes fetal
presentation, lie, position, and engagement status. Determining the
fetal presentation facilitates fetal heart auscultation. The FHR is
heard most clearly directly over the fetal upper back (the maternal
right or left lower abdominal quadrants) in a vertex presentation. The
intensity of the FHTs varies according to the fetal position (Fig. 5-3).
With a breech presentation, the FHTs may be best heard in the
patient’s right or left upper abdominal quadrants. If FHTs are
auscultated most clearly in that location, the patient’s care provider
should be advised because further assessment may be indicated to
confirm the fetal presentation. This is especially important when the
patient is in labor. However, before approximately 32 weeks of
pregnancy, it is not uncommon for the fetus to be in a breech
presentation. In most instances, by 36 to 37 weeks of gestation, the
majority of fetuses will have spontaneously converted to a vertex
(head down) presentation.
The normal heart rate for a fetus is approximately 110 to 160 beats
per minute (bpm). If a slower heart rate is detected, the maternal
pulse should first be evaluated to determine whether the two heart
rates are synchronous. If they are synchronous, the maternal pulse
has inadvertently been auscultated through the abdomen and an
attempt should be made to locate the fetal pulse. If the two pulses
differ, the nurse should position the patient on her left side and seek
assistance. Oxygen may be administered by mask and the patient
should be instructed to take slow deep breaths. The nurse should
continue to monitor the FHR and provide explanations and
reassurance to the patient.
The fetal heart can be auscultated using a number of different
devices. The least intrusive method involves the use of a Pinard
stethoscope or a fetoscope (Fig. 5-4). Both of these devices are
used without any additional equipment. However, they do require the
examiner’s ability to palpate the woman’s abdomen accurately to
determine the fetal position and locate the fetal shoulder to ascertain
the correct location for placement of the stethoscope. This method of
fetal heart auscultation is ideal if the patient has expressed a desire
to avoid an ultrasound (Doppler) stethoscope.
Following the invention of the Doppler ultrasound stethoscope, use
of the fetoscope and Pinard stethoscopes in clinical practice has
decreased. The Doppler ultrasound stethoscope is a handheld
device that uses ultrasound to locate fetal heart sounds (Fig. 5-5).
Use of the Doppler stethoscope to auscultate FHTs is simple and
requires no special skills because placement of the instrument in the
general vicinity of the fetal heart will most likely produce audible
heart tones. Although this approach may provide an easy, quick
assessment, the nurse who uses this method may not be performing
a detailed patient examination and may miss vital information. With
the Doppler stethoscope, FHT may be auscultated by 10 to 12
weeks or by 17 to 19 weeks with the fetal stethoscope.
Some sophisticated Doppler models provide a printout similar to
those of the more conventional FHR monitors. Beginning in the later
weeks of the second trimester, standard electronic fetal monitors
may be used to record the FHR in conjunction with uterine activity.
Electronic fetal monitoring during the prenatal period is generally
limited to pregnancies designated as high-risk because of maternal
or fetal factors. In these situations, a nonstress test (NST) may be
ordered to provide an evaluation of the FHR in response to fetal
movement and/or uterine activity. A reactive test (the desirable
result) is one in which the heart rate accelerates by at least 15 bpm
for at least 15 seconds, with at least three “acceleration episodes” in
a 20-minute period of monitoring. It is important to remember that a
reactive NST is only an indicator of the fetus’s present condition
rather than a test that can be used to predict future fetal well-being.
PROCEDURE ■ Performing Leopold

Maneuvers
PURPOSE
To determine the lie, presentation, and position of the fetus and to aid in
locating fetal heart sounds.
Equipment
• Gloves
Steps
Prepare the Patient:
1. Wash and dry hands and explain the procedure and purpose of the
examination to the patient, noting what she will experience and what the
results will indicate.
RATIONALE: Hand washing helps to prevent the spread of microorganisms.
Explanations help to decrease anxiety and promote patient understanding
and cooperation.
2. Ask the patient to empty her bladder.
RATIONALE: An empty bladder facilitates the examination (e.g., the fetal
contour will not be obscured by distention of the maternal bladder) and
enhances patient comfort.
3. Assess for latex allergies.
RATIONALE: To prevent injury from latex exposure; if the patient has a latex
allergy, use nonlatex gloves.
4. Don gloves, as indicated.
RATIONALE: When indicated, to avoid contact with the patient’s body
secretions.
5. Assist the patient to assume a supine position with the knees slightly flexed.
Place a pillow under her head and a small rolled towel under one hip.
RATIONALE: To enhance patient comfort, to relax the abdominal muscles,
and to prevent supine hypotension syndrome.
6. Stand beside the patient, facing her head, and observe her abdomen for the
longest fetal diameter and the presence of fetal movement.
RATIONALE: The longest fetal diameter, or axis, is the length of the fetus.
The relationship of the long axis of the woman to the long axis of the fetus is
known as the lie. The location of fetal movement most likely reflects the
position of the fetal feet.
7. Perform the first maneuver (fundal grip) to determine which fetal body part
(head or breech [buttocks]) occupies the uterine fundus.
Using the palmar surfaces of the hands, gently palpate the fundal region
of the uterus. The breech feels soft, broad, and poorly defined. Unlike the
head, the breech moves with the trunk. The head feels hard, firm, and
round and moves independently of the trunk.
8. Perform the second maneuver (umbilical grip) to determine the location of
the fetal back.
Using the palmar surface of the hands, palpate the sides of the uterus.
Hold the left hand steady on one side of the uterus while using the right
hand to palpate the opposite side of the uterus to determine which side the
fetal back is on and which side the fetal small parts (i.e., arms and legs) are
on. Repeat the palpation holding the right hand steady while palpating the
opposite side of the uterus with the left hand. The fetal back feels like a firm,
continuous, smooth, convex structure. The fetal arms and legs feel nodular
and may move during the palpation.
9. Perform the third maneuver (“Pawlick’s grip”) to confirm the presentation

noted in the first maneuver and to determine whether the presenting part is
engaged. Engagement has occurred when the largest diameter of the
presenting part reaches or passes through the maternal pelvic inlet.
With the right hand, gently grasp the lower portion of the maternal
abdomen just above the symphysis pubis between the thumb and index
finger and attempt to press the thumb and finger together. If the presenting
part moves upward so that the examiner’s fingers can be pressed together,
the presenting part is not engaged (i.e., it is not firmly settled into the
maternal pelvis). If the presenting part is fixed, engagement has occurred.
With the first pregnancy, engagement occurs around 37 weeks of gestation;
with subsequent pregnancies, engagement may not occur until labor has
begun. If the presenting part is firm, it is the head; if it is soft, it is the
breech.
10. Perform the fourth maneuver (pelvic or inguinal grip) to determine the fetal
attitude (relationship of the fetal parts to one another) and degree of fetal
extension into the maternal pelvis.
Clinical Judgment Alert: Omit the fourth maneuver if the fetus is in a breech
presentation; this maneuver is performed only to determine whether the fetal
head is flexed.
Turn to face the patient’s feet. Using both hands, outline the fetal head
with the palmar surface of the fingertips pointed toward the pelvic inlet to
determine whether the head is flexed (vertex) or extended (face). Gently
slide the hands downward on each side of the uterus. On one side, the
fingers easily slide to the upper edge of the maternal symphysis pubis. On
the other side, the fingers meet an obstruction (i.e., the cephalic
prominence). If the head is flexed, the cephalic prominence is palpated on
the opposite side from the fetal back. If the head is extended, the cephalic
prominence is palpated on the same side as the fetal back.
11. Assist the patient to a sitting position and wash and dry hands.
12. Document the findings on the patient’s medical record.
13. Inform the patient of the findings.
FIGURE 5-3 Fetal heart tone intensity varies according to the fetal
position. RSA = right sacrum anterior; LSA = left sacrum anterior;
ROP = right occipitoposterior; LOP = left occipitoposterior; RMA =
right mentum anterior; LMA = left mentum anterior; ROA = right
occipitoanterior; LOA = left occipitoanterior.
FIGURE 5-4 Auscultating the fetal heart tones with a fetoscope.

FIGURE 5-5 Auscultating the fetal heart tones with a Doppler
ultrasound stethoscope.
Nurses must be cautious not to rely too heavily on technology.

Instead, nurses should use clinical skills coupled with evidence-
based theory to transition from novice to expert practitioner. To attain
this level of expertise, it is essential to maintain hands-on patient
care. Experienced clinical nurses attain a sixth sense, or “specialty
intuition,” that enables them to quickly recognize deviations from
normal and provide expert care in a timely manner. With regard to
electronic fetal monitoring and other high-tech modalities, the nurse
must be careful not to rely on imperfect tools and instead use sound
clinical judgment and decision making.
THE VAGINA AND PELVIS

A vaginal examination is usually performed at the initial prenatal
visit following assessment of the maternal abdomen. Most women
find this part of the examination to be intrusive and may fear being
exposed, hurt, or embarrassed. An essential component of the
nurse’s role is to explain to the patient what to expect and help her to
verbalize any fears. The patient’s permission to conduct a vaginal
assessment must always be obtained before proceeding.
Demonstrating awareness of the patient’s feelings can be conveyed
by simple strategies: remaining gentle and respectful, showing
equipment that will be used with a demonstration of how it works,
and ensuring privacy with appropriate drapes. Eyeto-eye contact
maintains a connection between the nurse and the patient and
allows the nurse to be aware of nonverbal communication. Some
women feel less anxious if they are actively involved in the
examination. For example, a mirror can be placed so that the patient
can view her cervix or be shown changes such as Chadwick’s sign.
The examination essentially has four components, beginning with
an assessment of the external genitalia (Fig. 5-6). Information can be
obtained regarding secondary sexual characteristics by observing
the pattern of hair growth. This is also an ideal time to check for the
presence of pediculosis, or pubic lice. Signs of vaginal infection
include redness, edema, discolored vaginal discharge, or an
offensive vaginal discharge. The presence of lesions, condylomata,
vesicles ulcerations, or inflammation needs to be recognized and
investigated. Bruising or tenderness may be present as a result of
trauma or abuse. Observation of the perineal body may show
evidence of a previous episiotomy or perineal tear. Women who
have been subjected to female circumcision show varying degrees of
genital mutilation. Women from cultures that support this practice
may prefer to have a female care provider.
The second part of the examination includes visual inspection of
the vaginal mucosa and cervix along with the collection of specimens
such as the Papanicolaou test (Pap test), cultures for gonorrhea or
chlamydia, and if indicated, wet smear slides to determine the cause
of vaginal discharge. The examiner selects an appropriate-size
speculum. Specula may be constructed of metal or plastic and are
generally available in two types: the Graves’ speculum, useful for
examining multiparous women; and the narrower, flat Pedersen
speculum, commonly used for children, women who have never
been sexually active, nulliparous women, and some postmenopausal
women. The speculum is inserted into the vagina at an oblique
angle, then rotated to a horizontal angle and gently advanced
downward against the posterior vaginal wall. Once in position, the
speculum blades are opened to allow visualization of the cervix (Fig.
5-7).
The cervix and vaginal mucosa are inspected for color and for the
presence of inflammation, lesions, ulcerations, or erosion. The cervix
is usually about 1 inch (2.5 cm) in length and the external cervical os
is round in women who have never given birth (nulliparous) and
appears “slit-shaped” in the multigravida (Fig. 5-8).
FIGURE 5-6 A, The vaginal examination begins with a visual

inspection of the external genitalia. B, The fingers are used to
separate the labia minora.
FIGURE 5-7 A, Inserting the speculum. B, Opening the speculum. C,
Proper position of speculum in the vagina. D, View through the
speculum.
The remaining part of the assessment includes clinical pelvimetry
and the bimanual examination. Bimanual examination is an
evaluation of uterine shape, position, and size (Fig. 5-9). The uterus
is normally anteverted (tipped forward). As it enlarges during
pregnancy, the uterus becomes more midline and globular in shape.
The size of the pregnant uterus should be equal to the estimated
weeks of gestation. A larger-than-anticipated uterus may be
associated with a number of factors including miscalculation of the
date of conception, multiple pregnancy, hydatidiform mole, uterine
fibroid tumors, or later in pregnancy, a condition known as
hydramnios (an increase in the volume of amniotic fluid). A uterus
smaller than expected may indicate miscalculation of dates or a
missed abortion. The manual examination provides an ideal time to
evaluate vaginal and perineal muscle tone and to determine the
presence of a cystocele (bladder prolapse), urethrocele (urethral
prolapse), or rectocele (rectal prolapse). Women should be reminded
to practice Kegel exercises to help maintain perineal muscle tone.
The rectovaginal examination is performed after completion of the
bimanual examination. The examiner removes his or her hand from
the vagina and dons a clean pair of gloves. A water-based lubricant
is applied to the fingertips of the dominant hand. The index finger is
reinserted into the vagina; the middle finger is inserted into the
rectum. The rectal finger is advanced forward as the abdomen is
depressed with the nondominant hand. Palpation of the tissue
between the examining fingers allows for assessment of the strength
and irregularity of the posterior vaginal wall. The fingers are
withdrawn and any stool present on the glove may be tested for
occult blood.
FIGURE 5-8 A, Circular cervical opening: nulliparous. B, Slit-shaped
cervical opening: multiparous.
FIGURE 5-9 A, Palpating the uterus. B, Palpating the ovaries.
The final component of the physical examination involves the

clinical evaluation of the pelvis, also known as clinical pelvimetry.
The goal of this assessment is to recognize any abnormality in
shape or size that may be associated with a difficult or traumatic
vaginal birth. The four basic pelvic types include the gynecoid, found
in more than 40% of women; the android (male); the anthropoid
(most common in non-Caucasian races); and the platypelloid, which
is the rarest type found in fewer than 3% of women. The internal
pelvic measurements provide the diameters of the inlet and outlet
through which the fetus must pass during birth. The measurements
most commonly made include the diagonal conjugate, the true
conjugate (conjugate vera), and the ischial tuberosity diameter.
Clinical pelvimetry is performed by the physician, nurse midwife, or
advanced practice nurse; it is generally not repeated in women who
have previously given birth to an infant weighing 7 lb or more (3.18
kg) unless there is a history of pelvic trauma in the intervening period
between pregnancies.
The diagonal conjugate is the distance between the anterior
surface of the sacral prominence and the anterior surface of the
inferior margin of the symphysis pubis. This measurement,
performed with the patient in a lithotomy position, indicates the
anteroposterior diameter of the pelvic inlet—the narrowest diameter
and the one most likely to create a problem with misfit of the fetal
head. If the diagonal conjugate is greater than 12.5 cm, the pelvic
inlet is considered to be adequate for childbirth (Fig. 5-10).
The true conjugate (conjugate vera) is the measurement between
the anterior surface of the sacral prominence and the posterior
surface of the inferior margin of the symphysis pubis. This
measurement is estimated from the dimension made of the diagonal
conjugate. It cannot be measured directly. The true conjugate is the
actual diameter of the pelvic inlet through which the fetal head will
pass. On average, the diameter of the true conjugate ranges from
4.1 to 4.3 inches (10.5 to 11 cm).
FIGURE 5-10 A, The diagonal conjugate and the true conjugate
(conjugate vera). B, Use of a pelvimeter to measure the ischial
tuberosity diameter.
The ischial tuberosity diameter (also known as the intertuberous or

biischial diameter) is a measurement of the distance between the
ischial tuberosities (e.g., the transverse diameter of the outlet). Often
assessed with a pelvimeter (a special device for measuring the
pelvis), the diameter can also be measured with a ruler or with the
examiner’s clenched fist or hand span (the exact measurements of
the fist and hand must be known). A diameter of 11 cm is considered
adequate for passage of the widest diameter of the fetal head
through the pelvic outlet. Using palpation, the examiner assesses the
coccyx for mobility. A mobile nonprominent coccyx allows for some
flexibility of the pelvic outlet during birth.
Subsequent Prenatal Examinations

The plan of care for the first prenatal visit should be amended to
meet each individual woman’s needs based on medical, social,
cultural, and individual factors. Subsequent prenatal visits are
usually not as in-depth but should be designed to recognize any
deviations from normal so that appropriate investigations can be
ordered and care managed accordingly. Normally, patients are seen
at a frequency of every 4 weeks until 28 to 32 weeks of pregnancy,
then every 2 weeks until 36 weeks, and then weekly until childbirth.
At each visit, standard of care includes an evaluation of the maternal
weight gain, blood pressure, urine (for glucose and protein), uterine
growth, FHTs, fetal movements, and presentation (Box 5-1). The
patient is also assessed for the presence of edema. Each prenatal
appointment provides an ideal opportunity for education related to
the patient’s particular stage of pregnancy and what to expect before
the next visit. A review of the warning signs of pregnancy is also
essential, and the nurse should confirm that the woman is able to
verbalize when and how to seek professional assistance.
Evaluation of fetal well-being includes documentation of the
patient’s perception of fetal movements. Depending on the
circumstances, fetal evaluation may also include electronic heart rate
monitoring, ultrasonography to monitor growth patterns and/or
placental aging, and a biophysical profile. In addition, the patient
may be offered various screening tests during pregnancy to detect
fetal genetic or structural abnormalities.
BOX 5-1
Essential Components of Subsequent Prenatal

Visits
REVIEW THE WOMAN’S OVERALL HEALTH STATUS
• Signs/symptoms of pregnancy
• Discomforts of pregnancy
• Changes in medications/over-the-counter/herbal/homeopathic
• Psychological assessment (emotional or psychological distress) including
factors such as affect, sleep patterns, and diet
MATERNAL WELL-BEING
• Record vital signs.
• Ensure blood pressure is recorded using an appropriately sized cuff and
under the same conditions each visit (e.g., maternal position).
• Record maternal weight.
• Weight gain is usually 1 pound per week during the second and third
trimesters.
• Excessive weight gain may be indicative of fluid retention and requires
investigation.
• Weight loss may be because of maternal disease or inadequate dietary
intake: nursing assessment needed.
• Evaluate for edema: dependent edema, especially in hot weather and at the
end of the day, is a normal finding.
• Where indicated, assess reflexes and check for clonus.
• Assess for any signs of preterm labor such as uterine contractions or
backache.
• Ensure patient knows indicators of preterm labor and knows how to seek
medical advice.
• Assess for any signs of domestic/intimate partner abuse.
EVALUATE FETAL WELL-BEING
Listen to fetal heart tones, usually can be heard from approximately 12–14
weeks’ gestation with a Doppler stethoscope: normal rate is 110–160 bpm.
• Discuss pattern and frequency of fetal movements.
• Encourage patient to monitor and record fetal movements daily.
• Educate patient on the importance of fetal movements as an indicator of
general fetal well-being.
• Ensure the patient knows to immediately report a decrease in fetal
movements.
• Evaluate uterine growth.
• Measure fundal height.
• Document findings and evaluate pattern of growth.
• Weeks of gestation are equivalent to measurement in centimeters:
McDonald Method (measure from the top of the symphysis pubis to
fundus, from approximately 24–34 weeks’ gestation)—for example, at 30
weeks’ gestation the fundal height should be 11.8 inches (30 cm).
• Measurement less than expected could indicate intrauterine growth
restriction, oligohydramnios, or incorrect dates.
• Measurement greater than expected could indicate multiple pregnancy,
macrosomic infant, hydramnios, or incorrect dates.
PATIENT TEACHING
• Provide education related to stage of pregnancy (e.g., what physical changes
to expect or danger signs that need to be reported, such as vaginal bleeding
or fluid loss, abdominal pain, or visual disturbances).
• Encourage attendance in prenatal education classes.
• Encourage tour of facility where patient intends to give birth.
• Later in pregnancy, focus of education needs to include fetal kick counts,
preparation for breastfeeding, care of the newborn (e.g., car seats, male
circumcision, and immunizations) so that parents can make informed
decisions. Screening and laboratory testing may include:
Ultrasound Some health-care providers offer routine
Prenatal screening ultrasound examinations in the first trimester of
pregnancy to confirm dates and ensure single
pregnancy; may be repeated later in pregnancy.
May be performed first trimester and/or second
trimester.
Screening for Offered around 24–28 weeks’ gestation.
gestational
diabetes
Patient drinks solution containing 50 g of
glucose and then has blood drawn 1 hour later—
results should be below 140 mg/dL.
Rh screening Rh(D)-negative woman: Check for Rh antibodies
and if negative, 300 mcg of Rho(D) immune
globulin (RhoGAM) is prescribed at 28–32
weeks’ gestation.
Hemoglobin/hematocrit Usually repeated midpregnancy and then as
indicated.
Group B Normally offered at 37 weeks’ gestation to
Streptococcus determine whether antibiotic coverage is needed
screening during labor.
Confirm the patient’s contact information (address and telephone numbers)

and ensure she has a scheduled return appointment. Always provide time for
the patient to ask questions and confirm her understanding and that she has no
other concerns that need to be addressed.
Some health-care providers offer routine ultrasound examinations in the first
trimester of pregnancy to confirm dates and ensure single pregnancy; may be
repeated later in pregnancy.
Labs
Prenatal Labs
In addition to obtaining a human chorionic gonadotropin (hCH) to confirm
pregnancy, every pregnant woman who presents for prenatal care is tested for
various potential problems during the first visit and periodically throughout the
antepartal period. The complete blood count (CBC) serves as the primary test
for anemia via analysis of the hemoglobin and hematocrit. If the woman is
anemic, the indices can aid in identifying the type of anemia (e.g., iron
deficiency, etc.). The patient can also be screened for infection by the white
blood cell (WBC) count. If the WBCs are elevated, more information can be
ascertained via a differential analysis. Platelets, essential components of the
clotting mechanism, are also evaluated in a CBC.
Blood is also drawn for the identification of the woman’s blood type, Rh
status, and the presence of irregular antibodies. The blood type and Rh status
are important in determining whether the woman is at risk for developing
isoimmunization during her pregnancy. This problem can occur if the woman’s
blood is Rh(D)-negative and the fetus she is carrying is Rh(D)-positive.
Screening identifies the presence of antibodies that have been produced in
response to exposure to fetal blood or other irregular antibodies that could
potentially cause problems.
Other prenatal laboratory testing includes STIs (including HIV), urine
analysis and cultures, chemistry panel, and other blood work to determine a
history of exposures to various diseases and illnesses. See Table 5-3 for
information about routine laboratory tests in pregnancy.
Additional testing is often done based on a patient’s past medical history or
risk factor for specific diseases based on genetics or ethnicity such as
hemoglobin electrophoresis, which measures different types of hemoglobin
cells and helps to determine risk for specific diseases such as sickle cell.
Some routine maternal laboratory tests screen for childhood diseases
known to cause congenital anomalies or other pregnancy complications if
contracted during early pregnancy. Rubella, or German measles, was once a
common childhood disease. Today, most women of childbearing age received
rubella immunization during childhood. When contracted during the first
trimester, rubella causes a number of fetal deformities. Therefore, all pregnant
women are screened for rubella. A positive rubella screening test is indicative
of immunity, and the woman cannot contract the disease. If the screening test
is negative, the patient is advised to stay away from children who could
possibly have the disease, and she is immunized for rubella after the infant is
born.
NUTRITION
Nutrition and weight management play an essential role in
pregnancy for fetal growth. Patients need to understand the essential
nutritional elements and be able to assess and modify their diet for
the developing fetus and their own nutritional maintenance. The
nutritional assessment allows the health-care practitioner to
determine whether the woman has adequate intake of calories,
minerals, and nutrients. To facilitate this process, it is the nurse’s
responsibility to provide education and counseling concerning dietary
intake, weight management, and potentially harmful nutritional
practices.
One of the first items a nurse should complete is a nutritional
history on all pregnant patients and patients of childbearing age
when they present for care. A general nutritional screening should
include questions regarding eating patterns; changes in appetite,
chewing, swallowing, and taste; presence of vomiting, diarrhea, or
constipation; food allergies and intolerances; dietary restrictions or
intolerances, and self-care behaviors. Health-care practitioners can
complete a 24-hour dietary recall in which the patient lists all foods
consumed in a 24-hour period. This recall can provide insight into
the patient’s dietary needs. For some women, this may be a
reduction in nonnutritional foods such as candy, while other women
may require more foods rich in iron or protein. In addition, the nurse
should ask specific questions to determine nutrition status, including:
■ Foods preferred during pregnancy, which may provide information
about cultural and environmental dietary factors
■ Special diets, which will assist the nurse in planning for education
or interventions for risk factors associated with current diet so that
it meets adequate nutritional requirements
■ Use of nutritional supplements, such as vitamins and minerals as
well as other items such as protein bars or sport drinks
■ Cravings or aversions to specific foods
■ Considerations that can affect caloric needs such as currently
breastfeeding and level of exercise
■ Pregnancy-specific concerns, multiple pregnancy, nutritional
concerns in previous pregnancies, i.e., anemia, gestational
diabetes, or pre-eclampsia
TABLE 5-3
Routine Laboratory Tests During Pregnancy
LABORATORY PURPOSE WHEN PERFORMED
Blood
Complete blood count Assesses for anemia, infections, First and third trimester
(HGB, HCT, WBC, and and clotting disorders
PLT)
Blood type, Rh, and Determines blood type and risk First trimester
antibody for fetus developing fetalis or
hyperbilirubin and need for
Rhogam
Chemistry (Bun, Determines renal function and First trimester
creatinine, sodium, baseline glucose for those
potassium, chloride, undiagnosed with
and glucose) hyperglycemia or diabetes
Rubella titer Determines immunity to rubella First trimester
HIV testing Detects HIV antibodies and HIV First trimester
status
VDRL or RPR Determines active syphilis First trimester
HSV Determines herpes infections First trimester
(can be latent)
Hepatitis B and Detects active disease and First trimester
Hepatitis B antibody HbSag detects immunity to
surface antigen Hepatitis B
(HbsAg)
Rubella titer Detects immunity to Rubella First trimester
Glucose screening Detects risk for gestational 24-28 weeks of
diabetes gestation
Urine
Urinalysis Determines urine infections, First trimester
proteinuria, hematuria, glucose,
and ketones in urine
Urine culture Determines specific bacterial First trimester
organisms in cases of infection
Cervical/Vaginal culture
Cervical smears Detects abnormalities in cervical First trimester
cells
Gonorrhea and Detects active infection of First trimester
chlamydia Gonorrhea and Chlamydia
Group Beta Strep Detects GBS and need for Third trimester
antibiotics in labor
Skin
Tuberculosis Determines exposure to First trimester
tuberculosis
Important Nutritional Elements

Many elements combine to facilitate a healthy pregnancy.
Practitioners must evaluate the amount as well as the nutritional
value of the food consumed. Calories are an important consideration
when planning the patient’s daily food intake and assessing a
balanced diet that meets their nutritional needs. Other essential
nutritional elements are lean protein, water, iron, folic acid, calcium,
and healthy fats (Academy of Nutrition and Dietetics, 2019).
Calories
The recommended daily allowance (RDA) for caloric intake for
nonpregnant women ranges from 1,200 to 2,400 kcal/day depending
on activity level. During pregnancy, the RDA for caloric intake
increases only slightly, generally requiring a 300 kcal/day increase
from prepregnant needs. Growth during the first and second
trimesters occurs primarily in the maternal tissues; during the third
trimester, growth occurs mostly in the fetal tissues. An increase in
maternal caloric intake is most important during the second and third
trimesters. In the first trimester, the average maternal weight gain is
1 to 2.5 kg, and thereafter the recommended weight gain for a
woman of normal weight is approximately 0.4 kg per week. For
overweight women, the recommended weekly weight gain during the
second and third trimesters is 0.3 kg; for underweight women, it is
0.5 kg.
Pregnant women should be counseled about healthy ways to
incorporate the additional 300 kcal needed in their daily diets. For
example, adding an additional serving from each of the major food
groups (skim milk, yogurt, or cheese; fruits; vegetables; and bread,
cereal, rice, or pasta) meets this need.
Protein
Protein is necessary for tissue growth and repair. For pregnant
women, protein is important for growth of maternal tissues, including
the uterus and the breasts, and for development of fetal tissues and
organs. Only a modest increase in protein is required; increasing
intake of milk and dairy products by one or two servings per day
meets the daily requirement for protein.
Protein is typically found in animal sources, specifically in meat,
poultry, and fish, and women should be encouraged to eat lean
meats whenever possible. Other protein sources include dairy
products such as milk, cheese, and yogurt. For women who avoid
dairy or are lactose-intolerant, soy milk and soy cheese are available
as protein-rich substitutes. In addition, beans and legumes add a rich
source of protein and fiber to the diet and can be substituted for
protein servings in many meals. Peanut butter is another source rich
in protein but often high in fat.
Water
All persons should consume 6 to 8 (8-oz) glasses of fluid daily;
however, pregnant women should have an intake of 8 to 10 (8-oz)
glasses of fluid per day. The increased amount needed during
pregnancy is necessary to meet the changing physiology of the
maternal cardiovascular system and to maintain adequate blood flow
to the fetus.
Water intake can be in the form of many different types of fluids,
including fruit juice and vegetable juice. However, at least four to six
glasses of the fluid consumed each day should be water. Patients
should be cautioned to consume certain beverages, such as diet
sodas (high in sodium and contain artificial sweeteners) and
caffeinated drinks (promote diuresis) in moderation. Alcohol should
be avoided entirely throughout the pregnancy because no safe
amount has been determined.
Prenatal Vitamins
During pregnancy, the need for vitamins and minerals increases.
Prenatal vitamins are recommended by health practitioners for the
positive effects they have on a pregnancy, not for increasing the
likelihood of conceiving. The United States Department of Agriculture
(USDA) has established daily vitamin and mineral recommendations
used as guidelines for the types of prenatal vitamins recommended
for women before and during pregnancy. Many commercial brands of
prenatal vitamins contain the daily recommended vitamins and
minerals for pregnant women. However, different vitamin formulas
contain different amounts of vitamins and minerals. For example,
some prenatal vitamins contain a higher level of folic acid, which
may be beneficial for women with histories of infants with neural tube
anomalies. Some prenatal vitamins contain iron, which is beneficial
for women with a history of anemia. Not all women will want to take a
prenatal vitamin. Sometimes, vitamin intake may cause or contribute
to morning sickness. In these cases, nurses should be aware of and
educate the patient on the vitamin and mineral requirements for
pregnant women so they can strive to get the necessary intake
through food.
Women who eat a balanced diet that includes recommended
servings and serving sizes may meet the recommended nutritional
needs during pregnancy without vitamin supplementation. However,
the need for an increased intake of specific nutrients must be taken
into consideration as the pregnant woman plans her diet.
Specifically, the daily intake of calcium, iron, and folic acid must be
adequate to meet the maternal-fetal needs for adequate growth and
development.
CALCIUM AND VITAMIN D
The United States Food and Drug Administration (FDA)
recommends the RDA for calcium is 1,300 mg/day in pregnant and
lactating women (FDA, 2016). Without supplementation, most
women fail to consume adequate amounts of dietary calcium.
Calcium is essential for maintaining bone and tooth mineralization
and calcification. During pregnancy, calcium must be available to the
fetus for the growth and development of the skeleton and teeth.
Dairy products, especially milk and milk products, are the best
nutritional sources of calcium. Three daily servings of dairy products
are recommended for women; one to two additional daily servings of
milk are recommended during pregnancy. Other rich sources of
calcium include legumes, dark green leafy vegetables, dried fruits,
and nuts.
Vitamin D, a fat-soluble vitamin obtained largely from consuming
fortified milk or juice, fish oils, and dietary supplements, is important
in the absorption and metabolism of calcium. During pregnancy and
lactation, the RDA for vitamin D is 600 IU (15 mcg)/day (FDA, 2016).
Severe maternal vitamin D deficiency has been associated with
biochemical evidence of disordered skeletal homeostasis, congenital
rickets, and fractures in the neonate. Although there is insufficient
evidence for the recommendation for screening all pregnant women
for vitamin D deficiency, it is important to educate women about the
need for fortified foods or supplements. Fortified milk and ready-to-
eat cereals constitute the major food sources of vitamin D, which is
also produced in the skin by the action of sunlight. Women who do
not include milk in their diets should be taught about other vitamin D
sources in such as fortified cereals, soy milk, juices, and other
animal products such as egg yolks, liver, and fatty fish such as
salmon, sardines, and trout.
IRON AND VITAMIN C
As blood volume increases during pregnancy, the number of
circulating red blood cells also increases. Maternal iron intake must
be increased to maintain the oxygen-carrying capacity of the blood
and to provide an adequate number of red blood cells. Fetal iron
needs are increased during the last trimester. At this time, iron is
stored in the immature liver for use during the first 4 months of life
while the liver matures and liver enzymes are being produced. The
newborn uses the stored iron to compensate for insufficient amounts
of iron in the breast milk and in noniron-fortified infant formula.
The iron RDA for pregnant and lactating women is 27 mg/day
(FDA, 2016). Iron can be found in a variety of food sources. Many
individuals may not be aware that adequate amounts of iron are
found in fortified ready-to-eat cereals, white beans, lentils, spinach,
kidney beans, lima beans, soybeans, shrimp, and prune juice. Red
meats, including beef, duck, and lamb, contain moderate amounts of
iron as well. Some of the best food sources for iron include oysters,
organ meats (e.g., liver and giblets), and fortified instant cooked
cereals. Interestingly, canned, drained clams provide the highest
amount of iron per serving, with 23.8 mg of iron in each 3-ounce
serving. Cooking in cast iron can also increase iron sources.
Although most other necessary nutrients can be met through a
balanced diet, it is almost impossible to meet the maternal daily
requirements for iron without a dietary supplement. Consideration
must be given, however, to the gastrointestinal side effects of
supplemental iron, which include constipation, black tarry stools,
nausea, and abdominal cramping. These side effects may
exacerbate other pregnancy-related gastrointestinal discomforts.
Daily iron supplementation is often initiated at around 12 weeks of
gestation to avoid compounding the nausea commonly prevalent
during the first trimester. Adequate water intake helps to decrease
constipation, and patients may take iron at bedtime if abdominal
discomfort is experienced when taking iron between meals.
Patient Education
Teaching About Iron Supplements
Nurses can teach patients about substances known to decrease the absorption
of iron. Women should be taught to avoid consuming bran, tea, coffee, milk,
oxylates (found in Swiss chard and spinach), and egg yolk at the same time
they take the iron supplement. Also, iron is best absorbed when taken between
meals with a beverage other than tea, coffee, or milk.
Vitamin C (ascorbic acid), important in tissue formation, also

enhances the absorption of iron. Women who take iron supplements
should consume foods or beverages that contain vitamin C. Food
sources rich in vitamin C include red and green sweet peppers,
oranges, kiwi fruit, grapefruit, strawberries, Brussels sprouts,
cantaloupe, broccoli, sweet potatoes, tomato juice, cauliflower,
pineapple, and kale. Most pregnant women are able to meet the
RDA (120 mg) by including at least one daily serving of citrus fruit or
juice or vitamin C-rich food source, although women who smoke
need more (FDA, 2016).
MEDICATION: Ferrous Sulfate (fer-us sul-fate)
Pregnancy Category: B
Indications: Prevention/treatment of iron-deficiency anemia
Actions: An essential mineral found in hemoglobin, myoglobin, and many
enzymes. Prevents iron deficiency.
Therapeutic Effects: Prevents/treats iron deficiency
Pharmacokinetics:
ABSORPTION: Therapeutically administered PO iron may be 60% absorbed;
absorption is an active and passive transport process.
Contraindications and Precautions:
Use cautiously in peptic ulcer, ulcerative colitis; indiscriminate chronic use may
lead to iron overload.
Adverse Reactions and Side Effects: Constipation, dark stools, diarrhea,
epigastric pain, gastrointestinal bleeding
Route and Dosage:
(for vitamin/mineral supplementation during pregnancy/lactation): 325 mg orally
once a day
Nursing Implications:
1. Assess nutritional status and dietary history to determine possible cause of
anemia and need for patient teaching.
2. Assess bowel function for constipation or diarrhea; notify care provider and
use appropriate nursing measures if these symptoms occur (Vallerand,
2018).
FOLIC ACID
Vitamin B9, or folic acid (folate), is a water-soluble vitamin that is
closely related to iron. Working with vitamin B12, folic acid helps to
regulate red blood cell development and facilitates the oxygen-
carrying capacity of the blood.
Folic acid deficiency is primarily responsible for the development
of NTDs, including spina bifida, cleft lip and palate, and anencephaly.
Folic acid is essential in the early days of pregnancy and
prepregnancy to prevent NTD. During the early developmental
weeks of pregnancy, the majority of women do not yet know that
they have conceived, and it is during this time that folic acid
supplementation is important for the growing fetus. For this reason,
adequate folic acid intake is important for all women of childbearing
age. The CDC recommends that all women of childbearing age
consume 0.4 mg (400 mcg) of synthetic folic acid daily, from
supplements and/or fortified foods, to reduce NTD risk. During
pregnancy, a minimum of 800 mcg/day of folic acid is recommended,
and this amount is usually provided through supplementation.
Childbearing-aged women who have previously given birth to an
infant with a NTD should consume 0.4 mg of folic acid daily when not
planning to become pregnant and during if they become pregnant or
desire a pregnancy. They are often advised to consume large
amounts of folic acid, 4,000 mcg daily, beginning 1 month before
attempting conception and continuing through the first 3 months of
pregnancy (CDC, 2020a).
Foods that are rich in folic acid include eggs, dark leafy greens,
asparagus, broccoli, citrus fruits, beans, peas and lentils, avocado,
okra, Brussels sprouts, seeds and nuts, fortified breakfast cereals,
and calf liver. In 1998, the FDA mandated the addition of 140 mcg of
folic acid to every 100 grams of certain grain products, such as flour,
breakfast cereals, and pasta. Current recommendations include
consuming folic acid with vitamin C to enhance the absorption of iron
and folic acid.
Prevention of Foodborne Illness

It is important for nurses to educate pregnant women about
strategies to prevent foodborne illness, which occurs as a result of
the consumption of microorganisms (bacteria, parasites, and
viruses) or chemical contaminants found in some foods and drinking
water. Different types of foodborne illness that can cause significant
pregnancy complications include E. coli, Salmonella, Campylobacter,
or Toxoplasma gondii. Listeriosis is a serious foodborne illness
caused by the bacteria Listeria monocytogenes and can be passed
from a pregnant woman to the growing fetus, causing negative
outcomes such as stillbirth, miscarriage, and premature birth. The
bacteria are often found in raw or unpasteurized dairy products such
as milk, cheese, and yogurt, as well as partially cooked eggs. Meat,
poultry, fish, and eggs should be thoroughly cooked and
temperature-checked with a food thermometer. Deli meats, luncheon
meats, and frankfurters should be heated before consumption.
Foods must be stored properly at 40°F or below, and prepared foods
should be eaten within 4 days.
Patient Education
Hand Hygiene and Food Safety Practices
Patients and others who prepare foods for pregnant women must be properly
educated on the following safe hand hygiene and food safety practices:
• Consistent, thorough hand washing before and after food preparation and
between handling different foods is paramount to the prevention of foodborne
infection.
• Cook meat, seafood, and eggs to proper safety levels.
• Reheat all deli meats and hot dogs.
• Avoid raw or unpasteurized foods or drinks.
• Avoid raw or smoked meats and fish.
• Clean and disinfect all food preparation areas and surfaces including cutting
boards, knives, and other utensils used to prepare foods after use.
• Wash fruits and vegetables before consumption.
• Refrigerate perishable foods as soon as possible or within 2 hours.
Nurses who work with women of childbearing age are perfectly positioned to
educate them about the risks of certain seafoods and counsel patients on the
types of seafood with lower levels of mercury. In 2019 the FDA issued updated
recommendations to indicate recommended types of seafood for pregnant
women, available at https://www.fda.gov/food/consumers/advice-about-eating-
fish.
Mercury Exposure
Methylmercury is a known neurotoxin that is especially harmful to the
developing fetus, infants, and children. Exposure to methylmercury
can cause permanent central nervous system (CNS) damage
leading to lower IQ as well as memory, attention, language,
behavioral, and cognitive problems. Methylmercury can be found in
the environment; however, most exposure is through ingested foods,
mostly in seafoods. Seafood with the highest concentrations include
those in the larger fish group such as swordfish, shark, king
mackerel, marlin, ahi tuna, and tilefish (FDA, 2019). Fish
consumption is the primary source of exposure to methylmercury,
and the FDA recommends for pregnant women to avoid the larger
fish and to consume 8 to 12 ounces of a variety of seafood from
ones that are lower in mercury (FDA, 2019).
Caffeine
Caffeine acts as a CNS stimulant, causing tachycardia and
hypertension. Because caffeine readily passes through the placenta
to the fetus, it affects FHR and movement. High caffeine intake
during pregnancy may increase the rate of miscarriage, stress the
fetus’s immature metabolic system, and decrease blood flow to the
placenta. The recommendation for caffeine consumption is 200 mg
per day, approximately 12 ounces of coffee. Sources of caffeine for
most pregnant women include coffee, tea, and soda. Health-care
providers should assess if the patient is consuming caffeine from
other sources. Energy drinks, the latest fad in the caffeine market,
are loaded with caffeine and sugar and infused with herbal additives.
Ingredients added to energy drinks may include ginseng, guarana,
bitter orange, and taurine. Other lesser known sources include
chocolate, OTC medications that contain caffeine as an ingredient,
and dietary supplements. Women should be counseled that coffee
and tea labeled “caffeine-free” still contain small amounts of caffeine.
Artificial Sweeteners
Aspartame (NutraSweet, Equal), acesulfame potassium (Sunett),
and sucralose (Splenda) have not been shown to have any negative
effects associated with the developing fetus. However, because
aspartame consists of two naturally occurring amino acids, women
who have phenylketonuria (PKU) should not use this product.
Saccharin, another artificial sweetener, is considered unsafe for use
during pregnancy and should be avoided altogether.
Weight Gain During Pregnancy

Weight gain is expected during pregnancy and results from a
combination of maternal physiological changes and fetal growth.
During early pregnancy, maternal weight gain is related to increased
blood volume, necessary to supply the enlarging uterus and support
fetal growth and development. Dilation of the renal pelvis and ureters
from increased blood flow adds volume to the bladder and results in
an increased production of urine. Essential nutrients provided
through the maternal blood supply enable fetal growth and
development. As the pregnancy progresses, enlargement of the
placenta and fetal body add to the woman’s increase in weight.
An adverse outcome may result when the woman gains too much
or too little weight during her pregnancy. Health-care providers need
to assess the patient’s weight during the first prenatal visit and
monitor weight gain closely throughout the pregnancy to reduce
complications associated with low and high BMI. Obesity is a risk
factor for a number of pregnancy complications such as gestational
diabetes mellitus, hypertension, congenital anomalies, fetal
macrosomia, adverse birth outcomes, and low Apgar scores. As BMI
increases, the risk for cesarean delivery increases and the recovery
period can be complicated with postpartum infections.
Weight Management During Pregnancy

Classification of weight is often based on body mass index (BMI),
which is a method of evaluating the appropriateness of weight for
height (Table 5-4). The BMI is calculated using the formula:
where the weight is recorded in kilograms and the height is in

meters. For example, the calculated BMI for a woman who weighed
52 kg before pregnancy and is 1.58 m tall is:
Ideally, weight management begins before the pregnancy with the

goal of achieving a healthy BMI before conception, as both high BMI
and low BMI are associated with maternal fetal complications. At the
preconception visit, women should be screened for height and
weight, with the BMI calculated as a beginning point for determining
an appropriate weight gain during pregnancy. The BMI and weight
are then monitored at each prenatal visit. Throughout the pregnancy,
counseling and education on nutrition occur to meet the nutritional
needs of the woman. Gestational weight gain recommendations
should be individualized, according to BMI, additional medical
concerns (diabetes), and for those with special diets and/or
restrictions.
TABLE 5-4
Recommended Weight Gain in Pregnancy
PREPREGNANCY WEIGHT RECOMMENDED WEIGHT GAIN
Underweight 28-40 pounds
BMI less than 18.5
Normal Weight BMI 18.5–24.9 25-35 pounds
Overweight 15-25 pounds
BMI 25.0–29.9
Obese 11- 20 pounds
BMI greater than or equal
to 30.0
Source: Centers for Disease Control and Prevention (2019), Weight Gain in
Pregnancy, Reproductive Health
Prenatal Care After Bariatric Surgery

With the national increase in obesity, many more individuals undergo
surgical bariatric procedures. Many bariatric procedures require
patients to consume additional nutrients as they have lost some of
their ability to absorb these vitamins and minerals. Nurses should be
aware that following bariatric surgery for weight loss, pregnant
patients might experience perinatal complications associated with
decreased nutrition intake. Some bariatric procedures involve
sectioning off a small area of the stomach and reconnecting it to the
jejunum, where the absorption of important nutrients (i.e., iron,
calcium, vitamin A, vitamin B, vitamin K, and folate) occurs. Refer
this patient for a consultation with a registered dietitian or health-care
provider who specializes in bariatric surgery. He or she can offer
specific advice about supplementation. An important nursing role
centers on determining the patient’s level of compliance with the
nutritional plan (Ciangura et al, 2020).
Planning Daily Food Intake

Although planning daily food intake is based on individual
preferences, consideration must be given to ensure that adequate
nutrients are provided without an excessive increase in caloric
intake. Guidelines from the U.S. Department of Health and Human
Services indicate strategies for daily food consumption. The primary
recommendations include:
■ Eating a variety of nutrient-dense foods and fluids while limiting
saturated and trans fats, cholesterol, excessive sugar, salt, and
alcohol.
■ Developing a balanced daily eating pattern.
Specific recommendations for women who are capable of
becoming pregnant incorporate the following strategies:
■ Eating foods that supply heme iron and iron-fortified foods
■ Including vitamin C-rich foods to enhance the absorption of iron
■ Consuming 400 mcg per day of synthetic folic acid through
consumption of fortified foods and/or supplements in addition to
food forms of folate from a varied diet
■ Consuming 8 to 12 ounces of seafood per week (women who are
pregnant or breastfeeding), while limiting white (albacore) tuna to 6
ounces per week and avoiding tilefish, shark, swordfish, and king
mackerel (because of their methylmercury content)
The USDA Food Guide visualized by the new ChooseMy-Plate,
which replaces the Food Pyramid, is based on individual factors,
including age, gender, and activity level. The Daily Food Plan for
Moms is based on the guiding principles of overall health, up-to-date
research, total diet, usefulness, realism, flexibility, practicality, and
evolution. This easy-to-use tool shows the foods and amounts that
are recommended for each stage of pregnancy and during the
breastfeeding period. An added feature is the SuperTracker’s
MyPlan, which focuses the patient on developing an individual
approach to daily dietary planning. The USDA Web site provides
more information to develop a personalized nutrition and physical
activity plan.
Factors Affecting Nutrition During Pregnancy

Several additional factors affect nutrition during pregnancy and may
lead to potentially adverse effects.
Eating Disorders
PICA
Pica, the consumption of nonnutritive substances, can affect
pregnant women. Substances that are most often ingested include
clay, dirt, cornstarch, and ice (Fig. 5-11). Some individuals engage in
poly pica, the practice of consuming more than one of the
nonnutritive substances. Causes of pica are believed to include
nutritional deficiencies, cultural and familial factors, stress, low
socioeconomic status, and biochemical disorders. Specific nutritional
deficiencies associated with pica include deficiencies in iron,
calcium, zinc, thiamine, niacin, vitamin C, and vitamin D.
Treatment of pica focuses on the diagnosis and treatment of
underlying nutritional deficiencies. The practice usually subsides
after the birth of the baby.
FIGURE 5-11 Common sources of pica.
ANOREXIA NERVOSA AND BULIMIA NERVOSA
Anorexia nervosa and bulimia nervosa are conditions
characterized by a distorted body image. Both involve an intense
fear of becoming obese and can have a major effect on the person’s
physical and psychological well-being. Patients with anorexia
nervosa lose weight either by excessive dieting or by purging
themselves of calories they have ingested. Patients with bulimia
nervosa engage in recurrent episodes of binge eating, self-induced
vomiting and diarrhea, excessive exercise, strict dieting, or fasting
and display an exaggerated concern about body shape and weight
(Venes, 2021).
Both eating disorders pose potentially harmful effects on the
woman and the developing fetus because nutrients are either not
consumed or are quickly eliminated from the body. The health-care
practitioner needs to address the nutritional history of patients with
these disorders and work closely with them and other appropriate
resources to achieve a healthy pregnancy. Prenatal care should
center on a team approach that includes nutritional counseling,
psychological counseling, stress management, and active
participation in support groups for individuals with eating disorders.
Vegetarian Diets
Most vegetarian diets include vegetables, fruits, legumes, nuts,
seeds, and grains. However, there are many variations. For
example, semivegetarian diets include fish, poultry, eggs, and dairy
products but no beef or pork, and ovolactovegetarians consume
plant and dairy products. Pregnant women who adhere to these diets
may consume inadequate amounts of iron and zinc. Because strict
vegetarians (vegans) consume only plant products, their diets are
deficient in vitamin B12, found only in foods of animal origin.
Pregnant women who are strict vegetarians should be counseled to
regularly consume vitamin B12-fortified foods such as soy milk or to
take a vitamin B12 supplement. Other essential elements that may be
deficient in women on this diet include iron, calcium, zinc, vitamin B6,
calories, and protein. Nutritional counseling along with ongoing
assessment of maternal weight gain and laboratory testing for
evidence of anemia are important strategies in ensuring optimal
maternal-fetal well-being.
Patient Education
Teaching About Vitamin B12 Deficiency
When counseling patients who are vegetarians, nurses should educate them
about vitamin B12 deficiency. Vitamin B12 deficiency is associated with
maternal problems that include megaloblastic anemia, glossitis, and
neurological deficits. Infants born to mothers with vitamin B12 deficiency are
also more likely to have megaloblastic anemia and to exhibit
neurodevelopmental delays.
Oral Health
Periodontal disease in pregnancy can lead to adverse pregnancy
outcomes such as preterm birth and low birth weight infants
(Corbella et al, 2016). Good oral health and oral health hygiene are
essential to prevent these complications. In the first trimester, many
women experience nausea, vomiting, and acid reflux, which can
cause acid to coat the teeth and break down the enamel, leading to
decay and cavities. In addition, women even go on to develop
swollen gums or gingivitis (inflammation) during the second
trimester. Gingivitis causes bleeding while brushing the teeth,
infections, and pain. Prenatal visits should include assessment of
oral health and education regarding oral hygiene (American College
of Obstetricians and Gynecologists, 2017). In some cases,
worsening disease may require evaluation by a dentist and possible
oral rinses throughout and even after the pregnancy until symptoms
resolve.
Optimizing Outcomes
Promoting Dental Health During Pregnancy

• Encourage regular dental examinations.
• Promote twice-daily brushing and flossing.
• Recommend the use of a fluoride toothpaste.
• Encourage a healthy diet.
• Encourage chewing gum containing xylitol after meals.
EXERCISE, TRAVEL, WORK, AND REST DURING

PREGNANCY
The demands of daily life can create significant stressors during
pregnancy as well as opportunities for incorporating facets of health
promotion into a woman’s life. Balancing these demands requires an
understanding of the physical and emotional changes that occur
during pregnancy and developing strategies to relieve the stress that
may result from these changes. Activity and exercise benefit both the
mother and her fetus, but consideration must be given to the current
level of activity and precautions that are required as a result of the
pregnancy. Work demands often create additional stress during a
woman’s pregnancy, requiring decisions of employment versus
unemployment and maternity leave. For women not employed
outside the home, responsibilities of caring for the home and family
must also be balanced. Rest becomes an important component of
managing a healthy pregnancy, and patients need to understand
how fatigue will affect their daily life and how to manage this fatigue
throughout the pregnancy.
Exercise
Exercise can provide many benefits, both for women who are just
beginning to exercise to facilitate a healthy pregnancy and those
who are already active in an exercise program. Unless there are
absolute contraindications to aerobic exercise, pregnant women
should be encouraged to engage in regular, moderate-intensity
physical activity for 30 minutes or more each day. The exercises
practiced during pregnancy should focus on strengthening muscles
without vigorous aerobic activity that may cause complications. As
long as basic safety guidelines are followed, muscle strengthening
will benefit the woman as she copes with the physical changes of
pregnancy, including weight gain and postural changes, and will
decrease the chances of ligament and joint injury (Box 5-2).
Pregnant women gain many additional benefits from exercise such
as an increased energy level, improved posture, relief from back
pain, enhanced circulation, increased endurance, decreased muscle
tension, increased feelings of well-being, strengthened muscles to
prepare for birth, and a lower risk of gestational diabetes,
hypertensive disorders, preterm births, and cesarean births.
According to the Physical Activity Guidelines for Americans
(USDHHS, 2018), pregnant women who are not already highly active
should get at least 150 minutes of moderate-intensity aerobic activity
per week during pregnancy. Participation in vigorous-intensity
exercise is not recommended for previously inactive women or
women who engage in only moderate-intensity exercise. Women
who are currently vigorously active may continue this level of activity
during pregnancy according to the guidelines.
General Safety Guidelines for Exercise

Although exercise provides significant benefits during pregnancy,
women should adhere to some basic safety guidelines when
formulating the exercise program. The most important consideration
involves monitoring the breathing rate and ensuring that the ability to
walk and talk comfortably is maintained during physical activity.
Exercise should consist of 30 minutes of moderate exercise daily,
and the woman should never exercise to the point of exhaustion.
Exercises that can cause any degree of trauma to the abdomen or
those that include rigorous bouncing, arching of the back, or bending
beyond a 45-degree angle should be avoided, especially in the
second and third trimester when the uterus has risen out of the
pelvis and is an abdominal organ. Adequate fluid intake must be
maintained before, during, and after exercise to prevent dehydration.
Activities that require balance and coordination such as ice skating
should also be avoided, especially during later pregnancy when the
center of gravity shifts and the joints and ligaments soften and relax,
increasing the risk for falls. Exercise that can also cause injury to the
growing fetus should be avoided, such as horseback riding, soccer,
and downhill skiing (USDHHS, 2018).
BOX 5-2
Safety Guidelines for Muscle Strengthening

Exercise During Pregnancy
• Drink water before, during, and after exercising.
• Use lighter weights and more repetitions (heavy weights may overload the
“loosened” joints).
• Avoid walking lunges (lunges may injure connective tissue in the pelvic area).
• Use caution with free weights, to avoid hitting the abdomen (use resistance
bands instead).
• Avoid lifting from a supine position (to prevent vena caval syndrome and
decreased placental perfusion—tilt the bench to an incline).
• Avoid the Valsalva maneuver (may decrease placental perfusion).
• Avoid heavy weightlifting and reduce the frequency of workouts if fatigue or
muscle strain develops.
• Avoid getting overheated or exercising in hot humid weather.
• Never exercise to the point of exhaustion.
Limiting strenuous aerobic exercise and engaging in low-impact

aerobics, swimming, and cycling are strategies to ensure protection
against increased metabolism and overheating. Increased maternal
body temperature can cause reduced oxygen saturation and is
associated with the development of fetal NTDs during early
pregnancy. Decreased oxygen saturation in the maternal circulation
directly affects fetal blood flow and oxygenation and can result in
delayed or improper growth and development. Also, as the pregnant
woman’s body temperature increases, the fetal body temperature
increases as well. The fetus is unable to reduce body temperature
through perspiration or other means and instead must rely on the
mother’s body for temperature regulation. Other adverse effects that
may result from maternal overheating during exercise include
spontaneous abortion, preterm labor, and fetal distress. Women may
need to be counseled on the importance of not overheating and to
avoid things such as saunas and hot tubs when they are pregnant.
Basic Prenatal Exercises

Women who are pregnant can safely engage in several basic
prenatal exercises designed to generate energy, improve balance,
and increase flexibility. These exercises can be accomplished in as
little as 10 minutes each day (Box 5-3).
Travel
Traveling is completely safe throughout most of a pregnancy,
especially during the first trimester. However, during the second and
third trimester traveling can lead to health concerns or stress. Due to
the high risk of deep vein thrombosis, pregnant women may want to
avoid travel that involves long periods of sitting. When long-distance
plane or car travel is inevitable, the pregnant woman should plan
periods of activity combined with rest and a period of ambulating to
improve circulation of blood. While sitting, the woman can engage in
slow, deep breathing, make circling motions with her feet, and
practice alternately contracting and relaxing different muscle groups.
Seat belt safety is another concern, as incorrect use of seat belt or
nonuse of a seat belt can lead to serious traumatic consequences for
the mother and fetus (Scannell, 2018). Patients should always be
assessed for proper use of a seat belt during pregnancy. Educate
patients to place the shoulder harness above the gravid uterus and
below the neck to avoid irritation. The woman should assume an
upright position and ensure the headrest is properly aligned to avoid
a whiplash injury (Fig. 5-12).
Occasional air travel is generally safe but is not recommended at
any time during pregnancy for women who have medical or obstetric
conditions that may be exacerbated by flight or that could require
emergency care. Most commercial airlines allow pregnant women to
fly up to 36 weeks of gestation. The metal detectors used at security
checkpoints are not harmful to the fetus. Because the airline cabin
humidity is typically maintained at a low level, the nurse should
advise the pregnant woman to drink plenty of water to remain
hydrated throughout the flight. Also, the use of support stockings,
periodic movement of the lower extremities, avoidance of restrictive
clothing, and occasional ambulation are important strategies to
minimize the risk of superficial and deep vein thrombophlebitis.
Late in pregnancy, women may want to avoid traveling far from
their health-care provider and place of delivery. When travel cannot
be avoided, the women should travel with her obstetrical medical
record in case she has to deliver somewhere else. Patients should
also be counseled if traveling to places where they may need
additional immunizations because of a high prevalence of a
contagious infection that poses a risk to the pregnancy or fetus.
BOX 5-3
Basic Prenatal Exercises

Basic prenatal exercises to help generate energy, diminish discomfort, and
improve balance and stamina:
• Arm and upper back stretch: Raise your arms above your head, keeping the
elbows straight, palms facing one another and hold for 20 seconds. Lower
your arms to your sides. Bring the backs of your hands together behind your
back and stretch.
• Pelvic tilt: Lie on your back with your knees slightly bent. Inhale through your
nose while tightening your stomach muscles and buttocks. Flatten your back
against the floor and tilt your pelvis slightly upward. Slowly exhale through
your mouth while counting to 5. Relax.
• Sit-ups: Lie on your back with your knees slightly bent. Inhale through your
nose. While breathing out slowly through pursed lips, raise your head with
your hands placed behind your head. Tuck your chin toward your chest and
slightly lift your shoulders off the floor.
• Kegels: Before beginning this exercise for the first time, isolate the
pubococcygeal (PC) muscle, which is the muscle used to start and stop the
flow of urine. Practice stopping the flow of urine a few times; do not continue
to do this as this may lead to a urinary tract infection. If you have difficulty
isolating the muscle in this fashion, insert a clean finger into the vaginal
opening and squeeze. This is the muscle that will tighten as the exercise is
done properly. Kegel exercises will help to support the growing baby by
strengthening the pelvic floor, assist during the birth process, decrease
urinary problems during postpartum, and help to prevent hemorrhoids.
• Squeeze the PC muscle for 5 seconds, then relax for 5 seconds. Repeat for
a total of 10 repetitions each day.
• Squeeze and release the PC muscle as rapidly as possible for a total of 10
times.
• Increase this exercise up to 100 repetitions each day.
• Squatting: Move to a squatting position, with the knees located directly over
the toes. Keeping your heels flat on the floor, stretch the back of the thighs.
Hold for 20 to 30 seconds. Increase time to 60 to 90 seconds. Remember to
keep your head and arms relaxed during this exercise.
• Calf stretch: Lean against a wall or flat surface with your hands against the
surface. Move one leg behind you, keeping your heel flat on the floor. Lean
into the wall to stretch the calf muscles. Hold for 20 to 30 seconds. Repeat
with the other leg. This exercise will help to reduce leg cramps experienced
during pregnancy.
Figure 5-12 Proper use of the seat belt and headrest during
pregnancy.
Work
Many women who work outside the home discover rather early in the
pregnancy that they must make decisions regarding the continuation
of employment, the safety of the workplace, the demands of the work
environment, and plans for maternity leave. The majority of
employed women continue to work as long as they remain healthy
and free of any pregnancy-related complications. Some factors that
women need to consider, in consultation with the health-care
provider, include general health and well-being, the overall
progression of the pregnancy, present age, prior pregnancy
complications, the type of work performed, the number of hours
worked, and the environmental and safety risk factors associated
with the workplace. Health-care providers need to assess for
possible environmental exposure that can be detrimental to a
growing fetus so that risk reduction and risk elimination strategies
can be employed. To date, there are no safe exposure levels for
certain chemicals, and women who work in areas such as nail
salons, manufacturing industries, funeral homes, agriculture, and
those working with pesticide may need to be educated on the risk
and need for assistance in how to reduce/eliminate such risk.
Evaluation of Work and Its Effect on the Pregnancy

The pregnant woman may be advised to reduce the number of hours
worked if the job requires heavy lifting, prolonged standing,
extensive walking, or physical exertion. When the nature of the work
is physically demanding, safety concerns may require that she stop
working altogether. The potential for maternal exposure to toxic
substances such as chemotherapeutic agents, lead, and ionizing
radiation (found in laboratories and health-care facilities) or heavy
machinery and other hazardous equipment should prompt
reassignment to a different work area. If reassignment is not
possible, the woman may need to stop working until after recovering
from birth. Women who are currently experiencing pregnancy
complications and those who have a history of pregnancy
complications or other pre-existing health disorders may be required
to reduce their hours or stop working as well. Examples of problems
and pregnancy complications that may necessitate a change in work
hours include diabetes, kidney disease, heart disease, back
problems, hypertension, and a history of spontaneous abortion or
preterm labor.
Planning for Maternity Leave

Maternity leave provides the woman with time off from work during
the pregnancy and after the birth of the child. Although some
companies may allow up to 6 weeks of paid time off, other
companies may require that their pregnant employees use a
combination of short-term disability, vacation time, sick time, and
unpaid leave time. Health-care providers can help women plan how
much time they may need or wish to be away from work and provide
them with information about available options. All women who are
employed outside the home should be encouraged to meet with their
employers to discuss the options that are provided by the workplace
and to determine a satisfactory plan for their leave.
The Family and Medical Leave Act of 1993 (U.S. Department of
Labor, 1995) guarantees most women, as well as men, 12 weeks of
unpaid family leave following the birth or adoption of a child. By law,
the employer is required to allow the family member to return to his
or her job or a similar job with the same salary and benefits without a
reduction in seniority. Family members qualify for this benefit if they
work for the federal, state, or local government or if the company has
50 or more employees working within 75 miles of the workplace. In
addition, the family member must have worked for the employer at
least 12 months or for at least 1,250 hours in the previous year.
Rest
Fatigue and tiredness are common symptoms associated with
pregnancy. As the pregnancy progresses from one trimester to the
next, the woman’s level of fatigue changes along with the need for
rest. An understanding of the expected alterations in maternal
anatomy and physiology empowers the woman to anticipate and
make changes in her daily routine to accommodate the necessary
rest. Nurses should provide education about the anticipated need for
additional rest and suggest strategies for managing fatigue and for
promoting rest and relaxation.
Contributors to Fatigue During the First Trimester

During the first trimester, the woman’s body begins to undergo
changes that will support the developing fetus. One of the major
changes is an increase in the production of progesterone, a hormone
that causes increased fatigue and feelings of tiredness, especially
during the day. The maternal blood volume also begins to increase
and frequently results in physiological anemia. Women with
decreased iron stores may develop “true” (iron-deficiency) anemia.
As the fetus grows, oxygen requirements increase and cause an
increased workload on the woman’s body systems. These changes,
along with the emotional stress often associated with adjustment to
the news of the pregnancy, combine to produce fatigue. Strategies
for coping with pregnancy-related fatigue should routinely be
discussed with patients early in the pregnancy.
Contributors to Fatigue During the Second Trimester

During the second trimester the rapid physiological changes that
occurred in the first trimester come into balance with the body’s
workload demands. Pregnant women experience increased energy
and endurance during this time and are able to focus more on
planning for the upcoming birth. Some women, however, may
continue to experience fatigue that persists into the second trimester.
Potential causes of the fatigue include depression, external
stressors, and anemia. Other underlying medical causes may also
be a factor and should be investigated by the woman’s health-care
provider.
Contributors to Fatigue During the Third Trimester

The pregnant woman’s level of fatigue increases as the fetus
continues to grow and develop. The maternal weight-bearing load
associated with the fetus is compounded by a corresponding
increase in extracellular fluid and blood volume, maternal reserves,
placental mass, and amniotic fluid. The enlarging fetus causes the
maternal diaphragm to be upwardly displaced, decreasing lung
expansion. Increased bladder pressure from the gravid uterus
causes increased voiding, especially at night when the woman is
trying to sleep. Each of these factors plays a role in the
overwhelming fatigue common during the third trimester.
Through education, the health-care provider can empower the
expectant mother throughout the pregnancy to better manage her
rest demands and cope with fatigue. Planning and making healthy
choices concerning rest enables the woman to feel more relaxed,
energetic, and better able to cope with and manage this common
discomfort of pregnancy.
MEDICATIONS
Medication use during pregnancy must be handled very carefully,
and the needs of the patient and her fetus should always be
considered on an individual basis. Nurses need to be aware that
their patients may be taking prescribed OTC medications, vitamins,
and/or herbal preparations and often do not readily report this
information during the prenatal interview. Thus, the nurse should ask
specific questions regarding all medications, as many medications
can pose a risk to the pregnancy or growing fetus.
FDA Classification System for Medications Used During

Pregnancy
To determine the safety of medication use during pregnancy, the
FDA devised a classification system according to known fetal risk
based on research findings. See Table 3-4 in Chapter 3 for the
categories and associated fetal risk.
A teratogen is anything that adversely affects the normal cellular
development in the embryo or fetus (Venes, 2021). Although some
medications are safe, others are known teratogens or the safety of
their use during pregnancy has not been demonstrated. The fetus is
most vulnerable to the effects of teratogens from the third week of
gestation through the third month. However, the risk for fetal
developmental anomalies continues to exist throughout the
pregnancy. The third trimester is the most vulnerable time for
cognitive impairment from a teratogenic insult.
Over-the-Counter Medications
Nonprescription medications such as acetaminophen (Tylenol) and
guaifenesin (Robitussin) are often taken for minor problems such as
headaches, coughs, and colds. It is commonly assumed that a
medication that requires no prescription must be safe to take.
However, all medications, whether available by prescription or over
the counter, have side effects, and many have adverse effects. The
nurse needs to counsel women who are planning to become
pregnant and those who are already pregnant not to take any
medications (prescription or nonprescription) without first consulting
with the primary health-care provider. The provider will make a
determination regarding the safety and necessity of the medication in
case there is a pregnancy or plan to become pregnant.
Prescription Medications
Certain prescription medications may be necessary during
preconception and pregnancy. Women who suffer from life-
threatening illnesses such as seizure disorders, heart disease,
respiratory disorders, or infections need to continue or initiate
treatment to maintain their own health and safety. The health-care
practitioner must be aware of all prescription medications currently
being taken to evaluate the safety of their continued use. In some
instances, dosages can be adjusted, or the medications can be
replaced with safer medications.
Certain prescription medications must be avoided completely.
Isotretinoin (Accutane), prescribed primarily for the treatment of
acne, is associated with spontaneous abortions and congenital
anomalies when taken early in pregnancy. Some antimicrobials
cause altered fetal growth and development and should be avoided
during the later months of gestation. Sulfonamides, for example, are
associated with delayed fetal skeletal development, while prenatal
exposure to tetracycline causes staining of the child’s teeth. Table 5-
5 lists commonly prescribed teratogenic medications.
Herbal and Homeopathic Preparations

One of the most important facts about herbal and homeopathic
preparations is that the FDA has not approved these drugs and does
not regulate or control them. Furthermore, there are major
drawbacks to the use of these substances. There is no regulation
that controls product development, the dosages are not consistent
between brands, and additives used in their composition may differ
in type and amount. Also, because herbal and homeopathic products
have not been subjected to rigorous research to determine their
efficacy, effectiveness, side effects, therapeutic dosages, and
adverse effects, there is no guarantee that the claims made about
them are true. Although herbal and homeopathic treatments are
considered “natural” because they have been developed from plants
and other natural sources, many of these products are dangerous,
toxic, and may cause as-yet undiscovered effects.
Several herbal products are recognized as dangerous during
pregnancy; others are known to have specific teratogenic effects.
These substances need to be completely avoided during the periods
of preconception and pregnancy. Nurses should warn patients about
the use of these products, provide written information that can be
taken home, and reinforce the teaching at each visit.
TABLE 5-5
Commonly Prescribed Teratogenic Medications
MEDICATION EFFECTS ON PREGNANCY
Thalidomide During pregnancy, there is a risk of fatal birth defects,
most notably shortened limbs, with bone absence,
hypoplastcity, reduced or absent external auditory
meatus, phocomelia, amelia, facial nerve palsy,
anopthalamos (absence of eyes), micropthalamos
(small-sized eyes), and cardiac defects.
Warfarin During pregnancy, can result in CNS defects,
spontaneous abortion, stillbirths, postpartum
hemorrhage, and ocular abnormalities.
Isotretinoin During pregnancy, can lead to facial, ocular, otologic, and
skull abnormalities. It has also been shown to cause
CNS and cardiac defects along with hormonal
abnormalities. Cases of low IQ after isotretinoin use have
also been reported.
Phenytoin During pregnancy, can result in fetal hydantoin
syndrome, which is characterized by cranial, facial, and
limb defects, as well as cleft lip or palate, abnormal head
size, low IQ, distal phalangeal hypoplasia, reduced size
or absence of nails, and abnormal palmar creases.
Lithium During pregnancy, has been related to bipolar disorder in
the newborn. It can also lead to congenital cardiac
defects, particularly Ebstein’s anomaly, cyanosis in
newborns, hypotonia, atrial flutter, and bradycardia.
FOCUS ON SAFETY
Common Herbs to Avoid During Preconception and Pregnancy
During preconception counseling and pregnancy, nurses should educate
couples to avoid the following common herbs:
• Uterine stimulants that may cause preterm labor
• Barberry
• Black cohosh
• Feverfew
• Goldenseal
• Mugwort
• Pennyroyal leaf
• Yarrow root
• Blood thinners and anticoagulants that may cause miscarriage
• Dong quai
• Laxatives that may overstimulate digestion and metabolism and cause fluid
and electrolyte imbalance
• Blessed thistle
• Cascara sagrada
• Drug aloe
• Senna
• Cardiovascular stimulants that may elevate blood pressure or cause
abnormal heart rhythms
• Ephedra
• Licorice root
• Others that may damage the fetus during development
• Gotu kola
• Juniper berries
What to Say
Sexual Activity During Pregnancy
Couples have many questions regarding sexual activity during pregnancy.
These questions relate to the safety of sexual intercourse, potential
complications, when to stop having intercourse, and sexual positions that
facilitate comfort. It is important for the health-care provider to address sexual
activity early in the pregnancy in an honest, open manner and to encourage the
couple to communicate with each other. The nurse can address the couple’s
concerns with the following statements:
“It is perfectly safe to continue sexual activity throughout your pregnancy
unless your doctor or nurse midwife identifies risk factors that may preclude
your activity (e.g., a risk for preterm labor). With no risk factors, sexual activity
is safe for you and your baby as long as you continue to practice safe sex
behaviors as you would if you were not pregnant. As you gain pregnancy
weight, some sexual positions may be less comfortable; for comfort, you can
try woman on top and side-lying positions. A sexual activity to avoid during
pregnancy includes oral sex during which water or air is placed in the vagina.”
USING A PREGNANCY MAP TO GUIDE

PRENATAL VISITS
A prenatal care map that includes a timetable for prenatal visits
helps to ensure consistency of care, especially when many health-
care professionals are involved in the woman’s care. The care map
can be placed in the patient’s chart during the initial visit, and an
abbreviated version that outlines the schedule for prenatal care visits
may be given to the patient. Some facilities add a grid that provides
additional space for entering scheduled appointment dates. An
example of a prenatal care map is presented in Table 5-6. In other
institutions, the care map consists of a comprehensive guide with
check boxes and identifies counseling and education needs
throughout pregnancy and during the postpartum period.
TABLE 5-6
Example of a Prenatal Care Map
TRIMESTER SCHEDULE FOR COMPONENTS LABORATORY
RETURN VISITS OF THE NURSING TESTS TO BE
INTERVIEW AND OBTAINED
NURSING CARE
First Every 4 weeks • Reason for • CBC with
seeking care differential
Vital signs and • Blood type and Rh
weight Fundal (antibody screen
height and FHR (if for Rh-)
able) Tuberculosis
• Presumptive signs screening
• Review of • Rubella titer
systems • VDRL or RPR
• History taking • HbsAG and
including medical, HbsAB if indicated
obstetrical, • STI and HIV
medications, • Hemoglobin
allergies, family, electrophoresis
social, nutrition, (sickle cell,
work, hazard thalassemia)
exposures • Urinalysis and
Assessment of culture including
abuse risk GBS
• Support system • Pap test
Common
• Nuchal
pregnancy
translucency test
discomforts Danger
or combined
signs to report
screening
Second Every 4 weeks • Summary of • Hematocrit
relative events • Urinalysis
since last visit • Urine culture
• General emotional • Triple screen or
state quadruple screen
• Common
pregnancy
discomforts
• Vital signs and
weight
Fundal height and
FHR (if able)
• Presence of
edema or other
signs of pre-
eclampsia
Assessment of
abuse risk
Danger signs to
report
Third Every 4 weeks • Primary concerns • Hematocrit
through weeks 28– • Attendance at • Urinalysis
32 childbirth • Urine culture
Every 2 weeks education classes • Glucose tolerance
through week 36 • Physical test
Every week assessment GBS culture
thereafter • Psychosocial • Repeat, if needed:
responses VDRL or RPR,
Fundal height and HIV, CBC, vaginal
FHR (if able) smears
• Vital signs and
weight
• Fetal kick counts
Leopold’s
maneuver Signs of
labor
• Presence of
edema or other
signs of pre-
eclampsia
• Confirmation of
gestational age
Assessment of
abuse risk
Birth preparation
and support system
Danger signs to
report
Prenatal Care Coordination
Prenatal Care Coordination (PNCC), a benefit of the federal Medicaid program,
assists women perceived to be at highest risk for poor birth outcomes with
accessing prenatal care and obtaining health information to improve their
pregnancy outcomes. PNCC services are delivered based on a mutually
created care plan and may include interventions such as strategies to diminish
barriers associated with prenatal care attendance, support for continued
education or job training, strategies to reduce the use of tobacco or other
substances, and referral to other community resources (e.g., the Special
Supplemental Nutrition Program for Women, Infants, and Children [WIC]).
Assessment Tools
Pregnancy Risk Assessment Monitoring Tool (PRAMS)

The CDC and local state health departments have recognized a need for health
assessment in pregnancy and developed an assessment tool called Pregnancy
Risk Assessment Monitoring Tool (PRAMS). The goal of PRAMS is to improve
the health outcomes of mothers and infants and reduce adverse health
outcomes. Information is collected by health-care professionals and entered
into a database. Collected information is related to health behaviors, attitudes,
and experiences that occurred before, during, and after the birth. Questions
range from specific medical conditions, to substance use, to questions about
previous health-care providers and care delivered to the patient. Information is
then analyzed to assess where improvements, programs, and policy
interventions need to be targeted to reduce adverse health outcomes. In
addition, the PRAMS assessment allows for state and national health experts
to monitor for changes both positive and negative in specific health outcomes
allowing for timely evaluations of any intervention, program, or policy that was
implemented. Information on PRAMS can be found at
https://www.cdc.gov/prams/index.htm (CDC, 2020c).
CHILDBIRTH EDUCATION TO PROMOTE A

POSITIVE CHILDBEARING EXPERIENCE
Childbirth education provides a wealth of information to parents who
are having a baby for the first time as well as parents who have
already experienced childbirth. Traditionally, childbirth education
focused on managing labor and birth. Contemporary classes focus
on a wide variety of topics, with the primary goal centered on
facilitating a positive childbearing experience, including pregnancy,
childbirth, postpartum care, and newborn care. Topics typically
discussed in childbirth classes include anatomy and physiology
related to pregnancy; comfort measures during each trimester of
pregnancy; the labor and birth process; relaxation and pain
management, including pharmacological and nonpharmacological
measures; complications related to pregnancy, labor, and birth;
vaginal and cesarean births; postpartum care; newborn care; and
newborn feeding, including bottle feeding and breastfeeding (Fig. 5-
13).
Finding Information on Childbirth Education

There are many ways that expectant mothers and their partners can
locate information on childbirth education. The best strategy is to
begin with the health-care provider, who can offer information about
potential birth locations and childbirth education provided by the
individual facilities. Internet sources can also assist couples in
finding classes that are available nearby or online. Expectant
mothers and couples can engage in different childbirth education
classes to meet their specific needs.
FIGURE 5-13 Childbirth education classes help to prepare the

expectant couple for many aspects of the childbearing year.
In determining the childbirth preparation class that will meet the
individual needs of the parents, the following questions should be
considered:
■ Who sponsors the class?
■ How many classes will we be expected to attend?
■ How many couples are in the class?
■ Can I bring more than one support person to the class?
■ What types of teaching and learning strategies are used?
■ What topics are covered in the course?
■ Where will the classes be held?
■ Is there a cost involved?
With the abundance of childbirth methods available and the
different certifications that exist for childbirth educators, it is
important for expectant parents to identify the approaches and
methods that best meet their needs to make the childbirth
experience as meaningful as possible to them. It is helpful not only to
examine the questions previously listed but also to consider what the
most important factors are with regard to personal values and
beliefs. Using the following list, nurses can direct parents to the
appropriate education program to meet their needs. The woman
should identify which four of the following factors are most important
in selecting a childbirth education class:
■ Familiarize me with hospital routines
■ Prepare me for a natural, nonmedicated birth
■ Teach me breathing patterns and distraction techniques
■ Give my partner the skills necessary to be an active and informed
labor coach
■ Teach us as parents to be childbirth consumers and to take
responsibility for our child’s birth
■ Follow current medical policies
■ Represent the most common type of childbirth education class in
our area
■ Teach relaxation and natural breathing
■ Stress good nutrition and exercise
■ Discuss medication options without making value judgments
■ Address patient specific needs such as adolescent classes or
cesarean birth classes
Methods of Childbirth Preparation

Some childbirth classes follow a prescribed curriculum with
foundations in different philosophical views. Ideally, patients choose
a class in harmony with their beliefs and values about the
childbearing experience so they can engage in the educational
process without reservation and with complete commitment. For
many expectant parents, the experience of childbearing is more than
just a physical and biological one; the experience can have
emotional, mental, and spiritual meaning. This holistic approach to
having a child allows the parents to assimilate all aspects of the
experience to be prepared physically and mentally for becoming a
parent.
Many childbirth education programs in the community combine
aspects from the traditional stand-alone methods of childbirth
preparation. Combining philosophies and activities into the classes
allows the couple to identify more strongly with features that fit their
individual and collective needs. The most common childbirth
methods include the Lamaze and Bradley methods of natural
childbirth; however, there are several different childbirth education
programs. Table 5-7 describes the different types of childbirth
classes.
TABLE 5-7
Types of Childbirth Classes
CHILDBIRTH CLASS DESCRIPTION
Lamaze Most popular and widely used childbirth classes in the
United States. The foundation of the Lamaze method is
empowerment, recognizing the woman’s innate ability to
give birth, while finding strength and support from her
family and the members of the health-care team during
the labor and birth process. Historically, Lamaze focuses
on breathing techniques during labor and birth, as well as
education on movement and position, massage,
relaxation, and use of heat and cold in addition to the
traditional focused-breathing techniques.
Bradley Method Bradley method uses techniques that focus the woman
on inward relaxation, by means of breathing control,
abdominal breathing, and general relaxation. The partner
facilitates the implementation of these techniques
through coaching, giving rise to the term “husband-
coached childbirth.” To assist the partner in coaching the
laboring woman to relax, there is an emphasis on
darkness, solitude, and quiet to reduce stimulation and
enhance the calm and comfort needed to conserve
energy that will be required for birth and to decrease
anxiety and tension in the woman.
Hypnobirthing Classes focus on relaxation techniques to eliminate the
pain associated with the fear and tension. Deep and slow
breathing for total relaxation. When in a relaxed state the
muscles of the uterus work in harmony and release
endorphins as a natural pain relief. Deepening
techniques for transition and breathing the baby down.
LeBoyer Method Using this method, the baby is born in a dimly lit room
that is conducive to relaxation and facilitates a tranquil
entrance into the world. Immediately after birth, the
newborn is placed in a warm water bath to enhance the
transition from the intrauterine to the extrauterine
environment. The infant is then moved to the mother’s
abdomen to initiate bonding. Through the gentle handling
and the quiet, smooth transition, the newborn is able to
open her eyes and breathe with minimal external
stimulation.
Birthing From Within This method views childbirth as a rite of passage for
parents and their infant. The underpinnings of this
method focus on the psychological and spiritual aspects
of birth, using art, writing, painting, and sculpting to
encourage self-discovery. The focus is not on the birth
process but on the experience of birth.
During early pregnancy, the woman focuses mainly on the

developing pregnancy. In the latter part of pregnancy, she will start to
prepare for labor, birth, and becoming a parent. Prenatal visits will
change focus to ensure the women has adequate knowledge to
prepare for what is to come.
Birth Plans
Engaging women in developing birth plans is a great way to have
patients participate in their care and establish goals of care. A birth
plan is a guide that helps the women and her partner express their
feelings, wishes, expectations, and desires for the pregnancy as well
as during labor and birth. The birth plan helps the woman to identify
her priorities for this process and will reflect her culture and personal
values and beliefs. During the pregnancy, the patient should be
encouraged to write out her plan for review with the health-care
provider at a subsequent visit. This will help the health-care provider
set goals and determine early if aspects of the patient’s birth plan are
unrealistic. For some women, having a birth plan increases
satisfaction with the birth process and helps them gain a sense of
control. Birth plans should always start with natural methods and end
with interventions the women will consider if natural methods are
unavailable or ineffective. This approach will enable each woman to
control and shape her birth experience. An example of a birth plan
appears in Box 5-4.
BOX 5-4
Birth Plan Topics

LABOR AND BIRTH CONSIDERATIONS
Support persons I want with me in labor include (note their relationship to you
and how you would like them to be addressed):
Support persons I want in the birthing process include (note their relationship
to you and how you would like them to be addressed):
Things that will make me more comfortable in labor (for example, music, dim
lighting, noise level, clothing):
Equipment I would like available (shower, tub, birthing ball, birthing
stool/chair, mirror):
Pain management in labor (natural, alternative methods, medications or
epidural):
Pushing positions (supine, squatting, hands or knees, or whatever feels
best):
For hydration and nutrition, I would like: If necessary, to have a c-section I
would like: My plan for cord blood is: My greatest concern in labor or birth is:
NEWBORN CONSIDERATIONS
When the baby is born, I would like:
For all newborn procedures I would like to:
Do not give my newborn (for example, formula, sucrose, pacifier):
I plan to feed by baby by:
Male circumcision:
My greatest concern for my newborn is:
ADDITIONAL CONSIDERATIONS
Hospital health-care providers could help me by:
I would like my health-care provider to be aware of my cultural practices of:
I would like my health-care provider to be aware of gender identity
disclosures of:
I would like my health-care provider to also be aware of:
Key word or phrase for when you want to speak privately with your health-
care provider:
Source: Expecting and Beyond. (2020). Making a Birth Plan. From

https://expectinfo.com/labor-and-birth/birth-plans/
Breastfeeding
During pregnancy, the nurse should start the conversation about
breastfeeding and assess the patient’s willingness to breastfeed.
Patients may be apprehensive, and a prenatal visit offers the health-
care provider an opportune time to address these concerns. During
prenatal breastfeeding education, the health-care provider will review
basic components of breastfeeding and answer the patient’s
questions. Referral to local breastfeeding community support groups
can supplement the patient’s learning. The Academy of
Breastfeeding Medicine (2015) has developed a protocol for health-
care professionals on the prenatal preparation of breastfeeding.
In addition to providing education, nurses can provide a
breastfeeding-friendly environment in the office space that promotes
breastfeeding, offer support and resources for patients by connecting
them with lactation specialists and consultants, arrange group
prenatal care with other patients who can share breastfeeding
experiences, and incorporate breastfeeding as an essential element
in the breast examination.
Prenatal breastfeeding preparation should include the following
topics:
■ How culture affects the decision to breastfeed
■ Economic or work-related barriers to breastfeeding
■ Community support services
■ Feeding cues, positions for breastfeeding, physiology of lactation,
and skin-to-skin contact
■ Plans for returning to work
■ How and when to use a breast pump
■ Support systems and resources
■ Complications such as engorgement, cracked nipples, and breast
tenderness
Patient Education
Kick Counts
Counting fetal movements, or “kick counts,” is an essential aspect of prenatal
care and an indicator of fetal well-being that has been proposed as a primary
method of fetal surveillance for all pregnancies (Fig. 5-14). This method is
taught at around 28 weeks when the woman can detect identifiable fetal
movements. Before 28 weeks, movement is harder to identify. Kick counts are
easy to perform, readily available, and free of associated costs. The patient is
instructed to lie on her side and count the number of times that she feels the
fetus move. Many variations have been developed, but there are two major
methods for performing kick counts:
• The first method is done while the woman lies on her side. She counts and
records 10 distinct movements in a period of up to 2 hours. Once 10
movements have been perceived, the count may be discontinued.
• With the second method, the patient counts and records fetal movements for
1 hour three times per week. The count is to be considered reassuring if it
equals or exceeds the woman’s previously established baseline.
FIGURE 5-14 Counting fetal movements is easy to perform and

constitutes an important method of fetal surveillance.
SUMMARY POINTS
■ Preconception counseling empowers families to plan for pregnancy and

develop healthy bodies and minds to optimize birth outcomes.
■ Nurses and other health-care providers must collaboratively provide families
with prenatal education and incorporate interventions for a holistic approach
to pregnancy.
■ A balance of diet and nutrition, exercise, work, and rest enhance the
development of a healthy pregnancy.
■ To determine safety of use during pregnancy, all medications, including
prescription, OTC, and herbal preparations, must be carefully evaluated. It is
essential that the nurse obtain a comprehensive medication history during
each prenatal visit.
■ Ongoing prenatal education regarding pregnancy danger signs and symptoms
and appropriate home interventions is key in reducing complications.
■ Nurses can help to empower families by providing information about childbirth
education programs and other community resources.
■ A holistic approach to a healthy pregnancy and birth includes all members of
the family and the healthcare team. Encouraging the family to develop a birth
plan is an important step in helping to create a positive, satisfying birth
experience.
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Davis Advantage
CHAPTER 6
Caring for the Woman Experiencing

Complications During Pregnancy
CONCEPTS
Female reproduction
Pregnancy
Nursing
Family
KEY WORDS
salpingectomy
laparotomy
laparoscopy
salpingostomy
complete abortion
incomplete abortion
inevitable abortion
threatened abortion
missed abortion
septic abortion
recurrent abortion
elective or therapeutic abortion
cerclage
complete (total) placenta previa
partial placenta previa
marginal placenta previa
Kleihauer–Betke
abruptio placentae
tocolysis
oligohydramnios
pre-eclampsia
eclampsia
scotomata
disseminated intravascular coagulopathy
erythroblastosis fetalis
direct Coombs’
indirect Coombs’
glycosylated hemoglobin A1c
biophysical profile
contraction stress test (CST)
LEARNING OBJECTIVES
■ Plan nursing assessments and interventions for the woman experiencing
complications of pregnancy.
■ Discuss the importance of complete and accurate documentation in caring for
the patient experiencing an obstetric emergency.
■ Identify complications of pregnancy that require fetal and/or maternal
surveillance.
PICO(T)Questions
Use these PICO(T) questions to spark your thinking as you read the chapter.
1. Are (P) women with multifetal pregnancies (I) at greater risk for (O) gestational
diabetes than (C) women who are pregnant with a single fetus?
2. Are (P) women who have a miscarriage with their first pregnancy (I) more likely
to (O) have another miscarriage (C) than women who have a miscarriage with
their second pregnancy?
INTRODUCTION
Complications during pregnancy can arise during any gestational age.
Some complications occur early on and others arise in the later stages
of pregnancy. Understanding complications allows nurses to provide
care that can optimize health outcomes for both the woman and fetus.
The nurse must apply skills, knowledge, and expertise combined with
the nursing process to identify the pregnant patient at risk and then
formulate, implement, and evaluate an appropriate, holistic plan of
care. Identification and activation of appropriate community resources
are also essential components of the care plan. Throughout the entire
process, the nurse must remain cognizant of the unique individuality of
the patient and her family and deliver care that is respectful of their
diversity and culture. This chapter describes pregnancy complications
and how nurses can deliver appropriate care.
BLEEDING COMPLICATIONS IN PREGNANCY

Early Pregnancy Complications
Three of the most common pregnancy complications in the first
trimester are ectopic pregnancy, gestational trophoblastic disease, and
spontaneous abortion (miscarriage). Outcomes of these complications
can affect the health of the woman and pregnancy. Not all bleeding in
early pregnancy indicates a complication; however, women who have
this symptom must be evaluated and, depending on the diagnosis,
may require extensive work-up, treatment, and follow-up throughout
the pregnancy.
Ectopic Pregnancy
An ectopic pregnancy occurs when the fertilized egg implants outside
the uterine cavity. Implantation may occur in the fallopian tube (99%),
on the ovary, on the cervix, on the outside of the fallopian tube, on the
abdominal wall, or on the bowel (Fig. 6-1). Patients who present with
unilateral abdominal pain, vaginal bleeding, a missed period, or
abdominal tenderness should always be evaluated for an ectopic
pregnancy. The hallmark sign of an ectopic pregnancy is unilateral
stabbing pain in the lower quadrant, caused by the growing pregnancy
in the fallopian tube. Referred pain can also occur in the shoulder due
to a rupture ectopic pregnancy and the diaphragmatic irritation of the
phrenic nerve caused by blood in the peritoneal cavity. Ectopic
pregnancy, especially a ruptured ectopic pregnancy, can lead to
extreme blood loss, shock, and death. All women who have shock
symptoms, including tachycardia, hypotension, faintness, and
dizziness, should be thoroughly assessed. Significant vaginal bleeding
may or may not occur, as the woman may experience a large volume
of internal bleeding.
A number of factors place a woman at risk for experiencing an
ectopic pregnancy. These include past and current medical and
gynecological problems such as:
■ History of sexually transmitted infections or pelvic inflammatory
disease
■ Prior ectopic pregnancy
■ Previous tubal, pelvic, or abdominal surgery
■ Endometriosis
■ Current use of exogenous hormones (e.g., estrogen and
progesterone)
■ Use of an intrauterine device
■ In-vitro fertilization or other method of assisted reproduction
■ In-utero diethylstilbestrol (DES) exposure with abnormalities of the
reproductive organs
A ruptured ectopic pregnancy is an emergency and must be
diagnosed before the onset of hypotension, bleeding, pain, and overt
rupture to prevent major morbidity and death. The patient’s history can
often indicate signs of an ectopic pregnancy that warrant immediate
evaluation, such as unilateral, bilateral, or diffuse abdominal pain and
missed period. During the physical examination, a palpable mass is
present on bimanual examination in approximately 50% of women.
Active bleeding is associated with rupture; other symptoms of this
complication may include hypotension, tachycardia, vertigo, unilateral
lower abdominal pain, and shoulder pain. Women may also have
referred shoulder pain on the side of the ectopic pregnancy due to
irritation of the phrenic nerve.
FIGURE 6-1 Ectopic pregnancy.
Labs
Work-Up for Ectopic Pregnancy
Women receiving blood work for ectopic pregnancy will need repeated labs in
subsequent days to monitor for worsening of the condition.
• Beta-human chorionic gonadotropin (β-hCG) that is low for gestational age
should be monitored. (Because an ectopic pregnancy has a poorly implanted
placenta, the level of β-hCG does not double every 48 hours as in normal
implantation.) β-hCG will be taken every 2 days to monitor for effectiveness of
treatment.
• Type is completed in cases of rupture, ectopic, and/or need for operative
surgical removal or a blood transfusion.
• Rh is completed to determine Rh factor and the woman will need Rhogam if
she is Rh-negative.
• Complete blood count is performed to assess the degree of vaginal bleeding or
internal bleeding and level of hemorrhage and a white blood count (WBC) that
can range from normal to 15,000/mm3.
Diagnostic Tools
Diagnosis of an ectopic pregnancy is typically performed by ultrasound that will
indicate where the pregnancy has implanted.
• Transvaginal ultrasonography should be performed to confirm intrauterine or
tubal pregnancy. Ultrasonographic identification of an intrauterine pregnancy
rules out the presence of an ectopic pregnancy in most women. Location of the
pregnancy outside the uterus is considered ectopic.
• In cases where ultrasound is inconclusive, serial BhCG will be conducted. The
woman may need a later follow-up ultrasound.
• In the early work-up stage the woman may undergo a pelvic examination to
confirm an adnexal mass. If an ectopic pregnancy is suspected the examination
should be conducted gently so as not to rupture the mass. Once a mass or
ectopic pregnancy is diagnosed, pelvic examinations are avoided due to the risk
of rupture.
MANAGEMENT
Salpingectomy (removal of the ruptured fallopian tube) by
laparotomy involves abdominal surgery with a traditional incision
(Venes, 2021). Current clinical emphasis is not only preventing
maternal death but also promptly restoring health through a rapid
recovery with preservation of fertility. To achieve this goal,
laparoscopy (visualization of the reproductive organs using a
laparoscope inserted into the pelvic cavity through a small incision in
the abdomen), salpingostomy (incision into the fallopian tube to
remove the pregnancy), and partial salpingectomy are replacing
laparotomy as the treatment modes of choice. At present, laparotomy
is performed only when a laparoscopic approach is too difficult, the
surgeon is not trained in operative laparoscopy, or the patient is
hemodynamically unstable.
Methotrexate is a chemotherapeutic drug and folic acid inhibitor that
stops all rapid cell production, inhibiting the growth of the embryo and
destroying remaining trophoblastic tissue. Methotrexate treatment is
used in the management of uncomplicated, non-life-threatening ectopic
pregnancies. Patients are considered eligible for methotrexate therapy
if the ectopic mass is unruptured and measures 1.6 in. (4 cm) or less
on ultrasound examination. Patients with larger ectopic masses,
embryonic cardiac activity, or clinical evidence of acute intra-abdominal
bleeding (acute tender abdomen, hypotension, or falling hematocrit)
are not eligible for this mode of treatment.
Patient Education
Methotrexate
Patients receiving methotrexate should have comprehensive patient education on
the chemotherapeutic medication so that the patient and family members can stay
safe and healthy. Educational points include:
• Information on side effects such as nausea and vomiting
• Discontinuation of prenatal vitamins and other folic acid supplements, which can
act as antagonists
• The need for alcohol abstinence
• Avoidance of NSAIDs, which can precipitate gastric bleeding
• The need for sunscreen and protective clothing to prevent photosensitivity
• Required follow-up laboratory work to monitor hCG levels and other side effects
Ectopic pregnancy can be a life-threatening complication of

pregnancy. Depending on the type of treatment, patients should have a
low threshold for returning to their healthcare providers. If a woman
exhibits additional or worsening symptoms such as abdominal pain or
vaginal bleeding, she should seek immediate emergency treatment in
case of ruptured ectopic pregnancy. The women and family may
benefit from psychosocial support and/or therapy due to the loss of a
pregnancy. In addition, depending on the extent of the ectopic
pregnancy and treatment, future pregnancies may also be
compromised, resulting in further grieving, which the woman may
experience at a later time.
Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD), otherwise known as
hydatidiform mole or molar pregnancy, can have different pathologies
including locally invasive mole, metastatic mole, and choriocarcinoma.
GTD is characterized by an abnormal placental development that
results in the production of fluid-filled grapelike clusters (instead of
normal placental tissue) and a vast proliferation of trophoblastic tissue
(Fig. 6-2). It is associated with loss of the pregnancy and, rarely, the
development of cancer. GTD occurs in 1 in 1,000 pregnancies. The
incidence of hydatidiform mole increases with maternal age (especially
in women 45 or older) and in those with a history of a previous molar
pregnancy. Other risk factors include blood types A and AB and
becoming pregnant accidentally while on birth control. Women with a
history of a molar pregnancy have a 1% to 2% risk for a second molar
pregnancy in subsequent pregnancies (American Cancer Society,
2017).
Figure 6-2 A hydatidiform mole pregnancy is one in which the

chorionic villi degenerate into a mass of fluid-filled grapelike clusters.
PATHOPHYSIOLOGY
The cause of molar pregnancy is unknown, but it is thought that
complete moles result from the fertilization of an empty ovum (one
whose nucleus is missing or nonfunctional) by a normal sperm. A
complete mole is characterized by trophoblastic proliferation and the
absence of fetal parts. Incomplete moles often appear with a
coexistent fetus that has a triploid genotype (69 chromosomes) and
multiple anomalies. Incomplete moles are almost always benign and
have a much lower malignancy potential than complete moles. An
invasive mole is similar to a complete mole but has invaded the
myometrium layer of the uterus. Invasive moles rarely metastasize.
Choriocarcinoma is an invasive, malignant trophoblastic disease that is
usually metastatic and can be fatal (American Cancer Society, 2017).
SIGNS AND SYMPTOMS

Clinical and laboratory findings include an absence of fetal heart
sounds, a markedly elevated quantitative serum hCG (may be greater
than 100,000 mIU/mL), and very low levels of maternal serum α-
fetoprotein (MSAFP). More than 95% of patients experience vaginal
bleeding that may be scant or profuse and ranges in color from dark
brown to bright red. Some women may pass part of the molar
pregnancy with tissue that resembles grapes. In early pregnancy, there
is often a discrepancy between uterine size and dates with larger than
expected size. The patient may complain of excessive nausea and
vomiting (hyperemesis gravidarum) and abdominal pain caused by
uterine distention. Pre-eclampsia may occur earlier in pregnancy,
usually between 9 and 12 weeks of gestation, but any symptoms of
gestational hypertension before 24 weeks of gestation may be
indicative of hydatidiform mole (American Cancer Society, 2017).
MANAGEMENT
Clinical management involves removal of the uterine contents with
meticulous follow-up. If the GTD is in the early stages, then suction
dilation and curettage may be the first option. Depending on the size
and invasiveness of the GTD, some women may need hysterectomy.
Chemotherapy is initiated immediately if the hCG titer rises or plateaus
during follow-up or if metastases (movement of cancer cells from the
original site to another site) are detected at any time. Surgery may be
indicated if chemotherapy is not successful or for patients who have
completed their childbearing. Radiation therapy is usually reserved for
treating brain and liver metastases (American Cancer Society, 2017).
Follow-up will include serial hCG levels. A sensitive marker, hCG is
secreted by the molar cells. The amount of this hormone measured in
maternal serum is directly related to the number of molar cells. The
hCG levels should be assessed every 1 to 2 weeks until hCG is
undetectable on two consecutive determinations. Thereafter, hCG
should be measured every 1 to 2 months for at least a year.
PATIENT EDUCATION
Patient education must include the need to avoid pregnancy for at
least 1 year following GTD.
Effective contraception is needed during this time to prevent
pregnancy and the resulting confusion about the cause of changes in
the hCG levels. In addition, pregnancy could mask an hCG rise
associated with malignant GTD. The nurse should carefully counsel
the patient about different methods of contraception and stress the
importance of avoiding pregnancy for a year. During a subsequent
pregnancy, first trimester sonography should be performed to confirm
that the pregnancy is normal.
Spontaneous Abortions
A spontaneous abortion (SAB) or miscarriage is the loss of a
pregnancy before age of viability or fetus less than 500 g (Venes,
2021). Of all clinically recognized pregnancies, approximately 10%
result in SAB, with 80% occurring within the first trimester (American
College of Obstetricians and Gynecologists, 2018a). These
percentages underestimate the exact number due to undiagnosed
SAB, and very early miscarriages can be mistaken for menses. By
definition, an early pregnancy loss occurs before 12 weeks of
gestation; a late pregnancy loss occurs between 12 and 20 weeks of
gestation. First-trimester SABs are associated with chromosomal
abnormalities due to a faulty embryo development or placenta.
Infections (e.g., listeriosis, toxoplasmosis, and C trachomatis),
maternal anatomical defects, and immunological and endocrine factors
have also been identified as causes of early pregnancy loss, although
many have no obvious cause. Second-trimester SABs (12 to 20
weeks) have been linked to chronic infection, recreational drug use,
maternal uterine or cervical anatomical defects, maternal systemic
disease, exposure to fetotoxic agents, and trauma and shock.
The type of SAB that occurs is defined by whether any or all
products of conception (POC) have been passed and whether the
cervix is dilated.
Terminology/classifications associated with SABs include the
following:
■ Complete abortion: Complete expulsion of all POC before 20
weeks of gestation.
■ Incomplete abortion: Partial expulsion of some but not all POC
before 20 weeks of gestation.
■ Inevitable abortion: No expulsion of products, but bleeding and
dilation of the cervix has occurred and expulsion of POC cannot be
halted. Threatened abortion: Signs of SAB are present with
intrauterine bleeding before 20 weeks of gestation, without dilation of
the cervix; fetus is still alive and attached to the uterus.
■ Missed abortion: Death of the embryo or fetus before 20 weeks of
gestation with complete retention of the POC; these often proceed to
a complete abortion within 1 to 3 weeks, but occasionally they are
retained up to 8 weeks.
■ Septic abortion: POC and/or uterus become infected during the
abortion process.
■ Recurrent abortion: Three or more pregnancies that have ended in
SAB, often due to genetic, chromosomal, or anatomical irregularities.
■ Elective or therapeutic abortion: The POC are removed for
medical reasons in which the fetus has a condition incompatible with
life, when the woman’s health is in danger, or for personal reasons.
A woman experiencing an SAB usually presents with bleeding and
may also complain of cramping, abdominal pain, and decreased
symptoms of pregnancy; cervical changes (dilation) may be present on
vaginal examination. An ultrasound is performed for placental
evaluation and to determine fetal viability and/or degree of retained
POC. Laboratory tests include a quantitative level of ß-hCG, which
should show a lower value than when associated with a viable
pregnancy (Fig. 6-3); hemoglobin and hematocrit levels; blood type
and Rh status determination; and indirect Coombs’ screen. A
progesterone level may also be warranted in some cases to help
determine the viability of pregnancy, especially in cases of threatened
abortions.
MANAGEMENT
Management of SAB starts with an assessment and history taking.
Assessment includes obtaining vital signs, gestational age, and Rh
status. Symptom assessment should include time of onset of vaginal
bleeding or pain, character and amount of vaginal bleeding, and the
passing of tissue (any tissue should be preserved and sent to the
laboratory for examination). Assessment should also include
evaluation for serious complications such as shock, sepsis, and
disseminated intravascular coagulations (DIC). Mental health
assessment should also be a priority as the patient may experience a
range of emotions including grief, anger, guilt, sadness, depression,
relief, and sometimes happiness in cases of unwanted pregnancies
(Venes, 2021).
Incomplete, inevitable, and missed abortions are usually managed
via a dilation and curettage (D and C). With this procedure, the cervix
is dilated and a curette is inserted to scrape the uterine walls and
remove the uterine contents. In the case of an incompetent cervix, an
emergent cerclage (placement of ligature to close the cervix) may be
performed. An unsensitized, Rh(D)-negative woman should be given
Rho(D)-immune globulin (RhoGAM) to prevent antibody formation.
(See discussion later in this chapter.) Another option may be expectant
management for women who prefer to allow for the natural progression
of the abortion and expulsion of uterine contents. Candidates include
women who have inevitable abortion, complete abortion, and
sometimes missed abortion depending on how far along the pregnancy
is and when the abortion occurred.
FIGURE 6-3 hCG levels.
Depending on the circumstances, the nurse can provide counseling

or make an appropriate referral. Not all women who suffer a pregnancy
loss require formal assessment, but all women should be offered an
evaluation after several losses. The nurse should also allow the family
to express as much grief as they are feeling at the moment and are
willing to share; allow them to talk freely of what their hopes and
expectations had been for this new life, and acknowledge that this is a
very difficult time for them. The nurse may offer to enlist the assistance
of social services, a chaplain, a rabbi, or appropriate support groups if
they so desire.
Optimizing Outcomes
Follow-up for Habitual SAB
Habitual (three or more) abortions may occur due to medical or genetic conditions.
Women affected often benefit from genetic counseling and further testing to
include:
• A karyotype obtained from the POC and from both parents
• Examination of maternal anatomy, beginning with a hysterosalpingogram; if
abnormal, hysteroscopy or laparoscopy. Assessment of the reproductive tract to
determine anomalies such as a bicornuate uterus, which is a congenital
condition resulting in abnormal uterus shape often appearing as two separate
horns
• Screening tests for endocrine disorders as well as hypothyroidism, diabetes
mellitus, antiphospholipid syndrome (APS; an acquired hypercoagulable state
that involves venous and arteriole thrombosis) and systemic lupus
erythematosus (SLE)
• Serum progesterone level during the luteal phase of the menstrual cycle
• Cultures of the cervix, vagina, and endometrium
Cervical Insufficiency
Cervical insufficiency is the structural inability of the uterine cervix to
remain closed and support a growing pregnancy in the absence of
preterm labor (PTL). Cervical insufficiency is associated with recurrent
abortions and/or preterm births and is often seen in women who have
experienced cervical trauma, had cervical procedures such as a loop
electrosurgical excision procedure (LEEP), or have a family history of
DES exposure (Venes, 2021). Approximately 1% of women have
cervical insufficiency (Brown et al, 2019).
MANAGEMENT
Management may include placement of a cerclage, or purse string
suture, beneath the cervical mucosa either at the cervical-vaginal
junction (a McDonald cerclage) (Fig. 6-4) or at the internal cervical os
(a Shirodkar cerclage). The intent of the cerclage is to close the cervix.
Sometimes a cerclage is placed via an abdominal incision. It may be
placed electively before pregnancy, at 12 to 14 weeks of gestation, or
as an emergency procedure. The cerclage is usually removed in the
office or clinic at 37 weeks of gestation to facilitate vaginal birth. A new
cerclage will need to be placed with subsequent pregnancies. The
cerclage may also be left in place, necessitating a cesarean delivery.
FIGURE 6-4 Cerclage.
Hyperemesis Gravidarum
Hyperemesis gravidarum is characterized by extreme persistent,
continuous nausea and vomiting in pregnancy. This is one of the most
common reasons for hospitalizations in pregnancy, occurring in 2 out
of every 1,000 pregnant women. Adverse outcomes of hyperemesis
gravidarum include electrolyte imbalance, dehydration, alkalosis,
ketonuria, and some discrete weight loss, most often 5% of the
prepregnancy weight. Many women also experience a mental health
effect and can develop symptoms of post-traumatic stress disorder
(London et al, 2017). Risk to the fetus includes growth restriction in
cases that are persistent and severe as well as risk of PTL.
According to Erick et al (2018) and London et al (2017), risk factors
include:
■ Increased placental mass
■ Multiple fetus pregnancy
■ Increase in hormones, including serum hCG, progesterone, and
estrogen
■ History of hyperemesis in previous pregnancy
■ Pregnancy complications including multiple gestation and molar
pregnancy
■ Deficiency in thiamine and vitamin B1
■ Familial history of hyperemesis gravidarum, including daughters and
sisters; women who are pregnant with a female child are also
considered to be at risk
■ Fetus with chromosomal abnormality
MANAGEMENT
Women with a history of nausea and vomiting in a previous
pregnancy are advised to regularly take multivitamins before the next
conception. Rest is encouraged. The nurse should counsel the woman
to avoid foods and sensory stimuli
that provoke symptoms (e.g., some women become nauseous when
they smell certain foods being prepared). She should eat small
frequent meals of dry, bland foods, and high-protein snacks. Spicy
foods should be avoided. Eating crackers before arising in the morning
may help alleviate symptoms. Nonpharmacological management can
include ginger capsules 250 mg four times daily and the use of P6
acupressure with wrist bands (Erick et al, 2018). If the patient requires
hospitalization, IV fluids containing dextrose and vitamins are given,
and the patient is placed on a nothing by mouth status and treated with
antiemetics (Box 6-1). Parenteral or enteral feedings may be ordered if
the patient is unable to take oral nourishment and if normal weight gain
parameters for the gestation of pregnancy are not being achieved
(Erick et al, 2018).
Bleeding Disorders Later in Pregnancy

Hemorrhagic disorders constitute an obstetric emergency and are a
leading cause of maternal death in the United States. Third-trimester
vaginal bleeding occurs in 3% to 4% of all pregnancies and may be
obstetric or nonobstetric in nature (Cunningham et al, 2018). Examples
of nonobstetric causes include severe cervicitis, benign and malignant
neoplasms, lacerations, and varices.
Clinical Judgment Alert
Early Identification of Maternal Hemorrhage

During pregnancy, the woman’s blood volume increases 50%, and in the case of
multiple gestation, it increases as much as 100%. Because of this expanded blood
volume, the patient may be asymptomatic and exhibit vital signs that remain within
normal parameters despite a large amount of blood loss. Blood pressure is a very
poor indicator of blood volume deficit. The maternal pulse (tachycardia) and/or
fetal heart rate (FHR; bradycardia or tachycardia) may be the first indicators of
maternal instability.
BOX 6-1
Common Medications for Nausea and Vomiting of

Pregnancy
Pyridoxine (vitamin B6), 25–75 mg (orally) per day, used alone or in combination
with doxylamine (Unisom), 25 mg (orally) per day
*Doxylamine succinate and pyridoxine hydrochloride (Diclegis) delayed release
tablets 10 mg/10 mg; 2 tablets (orally) at bedtime (day 1); may be increased as
needed to maximum recommended dose of 4 tablets/day. (Note: The
medication is taken as a daily prescription and not on an as-needed basis to
help control symptoms throughout the day.)
Promethazine (Phenergan) 12.5–25 mg (IV, intramuscularly, orally, or rectally)
every 4 hours
Dimenhydrinate (Dramamine) 50–100 mg (orally or rectally) every 4–6 hours or
50 mg IV (in 50 mL of saline run over 20 minutes) every 4–6 hours
Metoclopramide (Reglan) 5–10 mg (IV, intramuscularly, or orally) every 8 hours
*FDA-approved in 2013
Placental Causes of Vaginal Bleeding

PLACENTA PREVIA
Placenta previa is an implantation of the placenta in the lower
uterine segment, near or over the internal cervical os. This condition
occurs in 1 of every 200 pregnancies. There are three recognized
variations of placenta previa. With a complete (total) placenta previa,
the placenta covers the entire cervical os. Because it is associated with
the greatest amount of blood loss, a complete placenta previa presents
the most serious risk. A partial placenta previa describes a placenta
that partially occludes the cervical os. A marginal placenta previa is
characterized by the encroachment of the placenta to the margin of the
cervical os, and a low-lying placenta is one that is implanted in the
lower uterine segment in proximity to the internal cervical os (Fig. 6-5).
Placenta previa may be associated with conditions that cause
scarring of the uterus, such as a prior cesarean birth or previous
abortions with curettage. A placenta previa may also occur with a large
placental mass as seen in multiple gestations, diabetes, and
erythroblastosis fetalis. Other risk factors include smoking, cocaine
use, a prior history of placenta previa, previous abortion, closely
spaced pregnancies, grand multiparity, and maternal age greater than
40 years (Abduljabbar et al, 2016). Abnormal placental adherence
often occurs with placenta previa in which the placenta abnormally
attaches to the uterine wall. Placenta accreta, placenta percreta, and
placenta increta are the most common placenta abnormalities involving
adhesion, each invading different uterine layers of the muscles. There
is a high risk of bleeding in labor, and treatment often involves a
hysterectomy.
Signs and Symptoms
The most common symptom is painless bright red vaginal bleeding,
believed to occur from small disruptions in the placental attachment
during normal development and the subsequent stretching and
thinning of the lower uterine segment during the third trimester. Initially,
the bleeding is usually a small amount that stops as the uterus
contracts to close the open blood vessels. However, bleeding can
reoccur at any time and may be associated with profuse hemorrhage
especially if the cervix is dilating and the placental is pulling away from
the uterine wall cervix.
VASA PREVIA
With vasa previa, the umbilical vessels are not supported by the cord
and the vessels traverse within the membranes and cross the cervical
os before reaching the placenta. The umbilical blood vessels are at risk
for laceration, which can cause significant hemorrhage. The
appearance of bright red blood at the time of rupture of the membranes
(ROM) should alert the nurse to the possibility of a vasa previa.
Maternal risks associated with vasa previa are in vitro fertilization
(IVF), placenta previa, fetal anomalies (spina bifida, single umbilical
artery, exomphalos, prematurity, antepartum hemorrhage, and fetal
growth restriction (Gagnon, 2017).
Today most cases of placenta previa are detected antenatally before
the onset of significant bleeding. Although diagnosis typically occurs in
the second trimester, these cases tend to resolve as the uterus
enlarges. The placenta can shift with the uterus and can migrate
upward and off the cervix.
Management of the pregnant woman who is experiencing active
bleeding associated with placenta previa requires astute assessment
skills to avoid a delay in treatment. Delay can mean the difference
between an optimal or poor outcome for the patient and her fetus.
Stabilization involves the administration of IV fluids and a laboratory
work-up that includes a complete blood count, prothrombin time, partial
thromboplastin time, fibrin split products, and fibrinogen. A blood type
and crossmatch should be obtained in anticipation of the need for a
transfusion. A maternal Kleihauer-Betke blood test may be ordered to
determine whether there has been a transfer of fetal blood cells into
the maternal circulation and treatment with RhoGam should be
administered. The patient is placed on bedrest and the fetus is
continuously assessed by electronic fetal monitoring (EFM). If time
permits, betamethasone (a long-acting corticosteroid) may be
administered to promote fetal lung maturity if the woman is preterm.
Vaginal examinations should be avoided at all times, and if labor
cannot be halted, fetal compromise, and life-threatening maternal
hemorrhage are indications for immediate delivery (often by c-section)
regardless of gestational age.
PLACENTAL ABRUPTION
Placental abruption (abruptio placentae) is the premature
separation (partial or complete) of a normally implanted placenta from
the decidual lining of the uterus. This condition occurs in 0.3–1 in every
100 births (Venes, 2021) (Ananth et al, 2015).
Risk Factors and Classifications
Bleeding can be either concealed (internal) or revealed (apparent
vaginal bleeding). A concealed hemorrhage occurs in 20% of cases
and describes an abruption in which the bleeding is confined within the
uterine cavity. The most common abruption is associated with a
revealed or external hemorrhage, in which the blood dissects
downward toward the cervix (Fig. 6-6).
FIGURE 6-5 Placenta previa. A, Complete (Total). B, Partial. C,

Marginal/Low lying.
Experiencing domestic violence in pregnancy is a major risk factor

for placental abruption. Other risk factors include maternal
hypertension (chronic, gestational, pre-eclampsia/eclampsia), cigarette
smoking, multiparity, abortions (spontaneous, elective), illicit drug use
(cocaine, methamphetamine), short fetal umbilical cord, maternal
abdominal trauma, ROM, and uterine leiomyoma (fibroids) located
behind the placenta. Placental abruption may be broadly classified into
three grades that correlate with clinical and laboratory findings (Box 6-
2).
Perinatal and Maternal Morbidity and Mortality
Maternal mortality from abruptio placentae varies from 0.5% to 5%.
The degree of hemorrhage that results from the torn placental vessels
can vary from maternal anemia in mild cases to shock, acute renal
failure, and maternal death in severe cases. Thirty-five percent of
infants whose mothers require an antepartal transfusion will
themselves be anemic and require a transfusion after birth. Fetal
mortality occurs in about 35% of all placental abruptions and can be as
high as 50% to 80% when associated with severe placental abruption.
Death results from hypoxia that is related to the decreased placental
surface area and maternal hemorrhage (Cunningham et al, 2018).
Signs and Symptoms
The classic presenting sign is third-trimester bleeding associated
with severe abdominal pain. Other signs include uterine tenderness
and abdominal or back pain, a board-like abdomen and no vaginal
bleeding, abnormal contractions and increased uterine tone, fetal
compromise as evidenced by late FHR decelerations, bradycardia and
lack of variability on the electronic fetal monitor, and fetal demise.
Vaginal bleeding in the third trimester of pregnancy is the hallmark of
placental abruption or placenta previa and should always prompt an
investigation to determine its etiology. Diagnosis is made by clinical
findings and, when available, ultrasound examination. However, during
the acute phase of placental abruption, ultrasound findings may not be
reliable, so a thorough clinical evaluation of any pregnant woman who
presents with bleeding or acute abdominal pain is always indicated
(Cunningham et al, 2018).
Management will depend on the degree of the placenta abruption.
The potential for rapid deterioration (hemorrhage, DIC, fetal hypoxia)
necessitates delivery in some cases of placental abruption. However,
most abruptions are small and noncatastrophic and therefore do not
necessitate immediate delivery. Certain actions, including
hospitalization, laboratory studies, continuous monitoring, and ongoing
patient support should be initiated when placental abruption is
suspected (Box 6-3).
FIGURE 6-6 Abruptio placentae.
BOX 6-2
Classifications of Abruptio Placentae
Grade 1: Slight vaginal bleeding and some uterine irritability are usually present.
Maternal blood pressure is unaffected, and the maternal fibrinogen level is
normal. The fetal heart rate pattern is normal.
Grade 2: External uterine bleeding is absent to moderate. The uterus is irritable
and tetanic, or very frequent contractions may be present. Maternal blood
pressure is maintained, but the pulse rate may be elevated and postural blood
volume deficits may be present. The fibrinogen level may be decreased. The
fetal heart rate pattern often shows signs of fetal compromise.
Grade 3: Bleeding is moderate to severe but may be concealed. The uterus is
tetanic and painful. Maternal hypotension is frequently present, and fetal death
has occurred. Fibrinogen levels are often reduced or are less than 150 mg/dL;
other coagulation abnormalities (e.g., thrombocytopenia and factor depletion)
are present.
Source: Cunningham et al. (2018).
BOX 6-3
Care for the Patient Experiencing an Abruptio

Placentae
• Hospitalization.
• IV placement with a large-bore catheter (16-gauge).
• Labwork: Includes CBC, coagulation studies (fibrinogen, PT, PTT, platelet count,
and fibrin degradation products), type and screen for 4 units of blood, Kleihauer-
Betke for Rh(D)-negative patients. A “clot test” may be performed: A red top
tube of blood is drawn, set aside, and checked for clotting. If a clot does not
form within 6 minutes or if it forms and lyses within 30 minutes, a coagulation
defect is probably present and the fibrinogen level is less than 150 mg/dL.
• Betamethasone may be given to the woman to promote fetal lung maturity when
delivery is not imminent.
• Rh(D)-negative patients should receive RhoGAM to prevent isoimmunization.
• Continuous evaluation of intake and output.
• Continuous electronic fetal monitoring.
• Delivery (cesarean or vaginal birth) may be initiated depending on the status of
the mother and the fetus.
• Nursing care is centered on continuous maternal-fetal assessment with ongoing
information and emotional support for the patient and her family.
Source: Cunningham et al. (2018).
PRETERM LABOR
Preterm labor is defined as cervical changes and regular uterine
contractions occurring between 20 and 37 weeks of pregnancy. Many
patients present with preterm contractions, but only those who
demonstrate changes in the cervix are diagnosed with PTL (Venes,
2021). Preterm birth, the number one complication of PTL, is
considered a significant acute health problem in maternal-child health.
(Fig. 6-7). The sequelae of preterm birth have a profound effect on the
survival and health of about 1 in every 10 infants born in the United
States (Centers for Disease Control and Prevention, 2019b)
FIGURE 6-7 Premature infant in the neonatal intensive care unit

(NICU).
Morbidity and Mortality

As a result of high-tech neonatal intensive care, advanced technology,
and improved medications, the morbidity of babies born after 34 to 35
weeks has decreased. With appropriate medical care, neonatal
survival dramatically improves as gestational age increases. Short-
term neonatal morbidities associated with preterm birth are numerous
and include respiratory distress syndrome, intraventricular
hemorrhage, periventricular leukomalacia, necrotizing enterocolitis,
bronchopulmonary dysplasia, sepsis, and patent ductus arteriosus.
Long-term morbidities include cerebral palsy, intellectual and
developmental disabilities, and retinopathy of prematurity. The risk of
these morbidities is directly related to the infant’s gestational age and
birth weight.
Etiology and Risk Factors

The defining physiological mechanism that triggers the onset of PTL is
largely unknown but may include decidual hemorrhage (abruption),
mechanical factors (uterine overdistention or cervical incompetence),
hormonal changes (perhaps mediated by fetal or maternal stress), and
bacterial infections (American College of Obstetricians and
Gynecologists, 2020a). However, a number of risk factors have been
associated with PTL (Box 6-4).
Labs
Fetal Fibronectin Testing
Fetal fibronectin (fFN) is a glycoprotein produced by the fetal membranes. It is
normally present in the cervicovaginal fluid until 16 to 20 weeks of gestation.
Fetal fibronectin may be described as the “glue” that attaches the fetal
membranes to the underlying uterine decidua and not present again in vaginal
secretion until just before delivery. Negative results predict that pregnancy will
continue for another 14 days. However, positive results indicate that labor may
start within 7 to 14 days. Keep in mind that this test must be interpreted with
caution as a positive test can also be caused by other factors, such as vaginal
bleeding or infection. Fetal fibronectin testing is done when the membranes are
not ruptured, and the patient is not bleeding. The patient should not have had a
pelvic examination, vaginal ultrasound, or vaginal intercourse within the 24 hours
before collection. To test for the presence of fFN, a sterile cotton-tipped swab is
placed in the posterior vaginal fornix or in the ectocervical region of the external
cervical os for a minimum of 10 seconds. The collection swab is then removed,
placed in a manufacturer-supplied medium, and sent to a laboratory that
performs the test with results reported in 24 to 48 hours (Van Leeuwen & Bladh,
2021).
Assessment of Cervical Length and Funneling

Determining the cervical length (CL) can play a crucial part in the
prevention of PTL as there is an association of cervical shortening of
less than 25 mm with preterm birth (Butt et al, 2019). Average CL at
term is 35–40 mm (Venes, 2021). Cervical length measurements are
performed, preferably with transvaginal ultrasound (TVU) or with the
FDA-approved CervilLenz CL measuring device. The risk of preterm
delivery increases as the CL in the second trimester declines. When a
short CL is detected during transabdominal ultrasound scanning of the
lower uterine segment, a subsequent transvaginal confirmatory
ultrasound examination should be performed. If short CL is present,
the patient’s risk factors for preterm birth should be reviewed to
determine appropriate clinical management.
BOX 6-4
Various Risk Factors Associated With Preterm

Labor and Birth
SOCIAL, PERSONAL, AND ECONOMIC CHARACTERISTICS
• Maternal age extremes (i.e., less than 16 years or greater than 40 years)
• Teens and women over age 35
• Black race
• Women with low socioeconomic status
• Women in intimate partner violence relationships
PREGNANCY AND MEDICAL CONDITIONS
• Prior preterm birth
• Preterm premature rupture of the membranes (PPROM)
• Shorten cervical length
• Infections of the urinary or reproductive tract
• Placenta previa or abruptio placenta
• Uterine or cervical anomalies
• Bacterial infections (e.g., sexually transmitted infections, asymptomatic
bacteriuria)
• Hypertensive disorders of pregnancy
• Diabetes mellitus
• Thyroid disease
• Clotting disorders
• Periodontal disease
FETAL CONDITIONS
• Fetal anomalies
• Multiple pregnancy (twins, triplets, or more)
BEHAVIORAL
• Tobacco use
• Alcohol or substance use
• Stress
• Later or lack of adequate prenatal care
• Poor nutrition
• Low prepregnancy weight
Sources: American College of Obstetricians and Gynecologists (2016); Butt et al

(2019); Centers for Disease Control and Prevention (2019b); Cunningham et al.
(2018).
In addition to CL assessment, other lower uterine segment and
cervical characteristics can be assessed by midtrimester ultrasound.
One of these is the presence of cervical funnel, defined as protrusion
of the amniotic membranes greater than 5 mm into the internal os. It
has been demonstrated that the presence of funneling is a significant
risk factor for an adverse perinatal outcome, and it is best measured as
either “present” or “absent.” Methods of cervical funneling assessment
include observation of the shape of the funnel (U or V), percentage of
funneling, and the depth and width of the funnel. In high-risk women
with a prior spontaneous preterm birth and short cervix, the
progression to a U-shaped funnel has been associated with an
increased risk of preterm delivery.
Optimizing Outcomes
Interventions to Prevent Preterm Labor

Research has demonstrated that the following interventions appear to be
beneficial in decreasing the risk of PTL: preconception control of chronic medical
conditions (e.g., diabetes, seizures, asthma, and hypertension); smoking
cessation; routine prenatal screening and treatment for asymptomatic bacteriuria;
and the use of laminaria for women undergoing second trimester pregnancy
termination via dilation and evacuation. Progesterone supplements have been also
shown to decrease the risk of PTL. Women at risk for PTL may benefit from
progesterone supplementation. Micronized progesterone vaginal gel or
suppositories (every night from weeks 16 to 20 through 36) may reduce PTL,
especially in women with a history of preterm birth and a short CL. Oral
progesterone has shown to significantly reduce the risk of PTL and improve infant
morbidity and mortality (Boelig et al, 2019). Weekly injections of 17-α-
hydroxyprogesterone caproate (17P) significantly reduced the risk of preterm birth
before 32 weeks.
The diagnosis of PTL can be very challenging because many of the

symptoms are subtle and common during pregnancy. For example,
women experiencing PTL may complain of backache, pelvic aching,
menstrual-like cramps, increased vaginal discharge, pelvic pressure,
urinary frequency, and intestinal cramping with or without diarrhea.
A diagnosis of PTL is made when findings include regular uterine
contraction and cervical dilation or regular contractions and at least 2
cm dilation upon presentation for evaluation (American College of
Obstetricians and Gynecologists, 2020a).
Infection has been implicated as a contributing factor in PTL.
Prostaglandin production by the amnion, chorion, and decidua is
stimulated by cytokines (extracellular factors) that are released by
activated macrophages. Group B streptococci, chlamydia, and
gonorrhea have been associated with PTL and preterm premature
ROM (PROM) (Cunningham et al, 2018). It is always prudent for the
nurse to obtain a clean-catch, midstream, or catheterized urine
specimen to identify and treat infection if the patient presents with
signs of PTL or preterm PROM.
Signs of PTL include:
■ Contractions that may be painful or painless
■ Lower back pain
■ Gastrointestinal (GI) upset, cramping, or diarrhea
■ Pelvic pressure or fullness
■ Vaginal discharge/bloody show
■ Vaginal discomfort pressure
Management
The two major goals in the management of PTL are to inhibit or reduce
the strength and frequency of contractions, thus delaying the time of
delivery, and to optimize the fetal status before preterm delivery
(American College of Obstetricians and Gynecologists, 2020a).
Tocolysis is the use of medications (tocolytics) to inhibit uterine
contractions. It is important to note that no medication has been
identified to effectively stop PTL, and no one drug is approved in the
United States or has been proven superior as a tocolytic agent.
Medication selection is individualized based on efficacy, risks,
contraindications (Box 6-5), and side effects. Tocolytic therapy
generally is effective for up to 48 hours, and only women whose
fetuses would benefit from a 48-hour delay in delivery should receive
tocolytic therapy. In general, tocolytics are not indicated for use before
neonatal viability (the upper limit for use is 34 weeks of gestation), fetal
demise, severe pre-eclampsia, preterm premature rupture of
membranes (PPROM), nonreassuring fetal status, and maternal
contraindications (American College of Obstetricians and
Gynecologists, 2020a).
Optimizing Outcomes
Antenatal Corticosteroids to Improve Neonatal Outcomes

The administration of antenatal corticosteroids is the most beneficial intervention
for improvement of neonatal outcomes among women who give birth preterm. A
single course of corticosteroids is recommended for pregnant women between 24
and 34 weeks of gestation who are at risk of preterm delivery within 7 days. A
single course of antenatal corticosteroids should also be administered to women
with PROM before 32 weeks of gestation. Neonates whose mothers receive
antenatal corticosteroids have significantly lower severity, frequency, or both, of
respiratory distress syndrome, intracranial hemorrhage, necrotizing enterocolitis,
and death.
According to ACOG (2020), evidence supports the use of first-line

tocolytic treatment with beta-adrenergic receptor agonists, nonsteroidal
anti-inflammatory drugs (e.g., indomethacin), and calcium channel
blockers within 48 hours of pregnancy, with the goal to delay birth and
for the woman to receive corticosteroids to accelerate fetal lung
maturity. This is to help prevent respiratory complication of the
newborn born with fetal lungs not fully developed. In addition, delaying
the birth provides an opportunity of time for the safe transfer of the
woman to a facility equipped with a neonatal intensive care unit.
BOX 6-5
Contraindications to the Use of Tocolytics in

Preterm Labor
• Pre-eclampsia with severe features or eclampsia
• Maternal bleeding with hemodynamic instability
• Maternal contraindications to tocolysis (agent specific)
• Nonreassuring fetal status
• Fetal demise or lethal anomaly
• Chorioamnionitis
• Preterm premature rupture of the membranes
• In the absence of infection, tocolytics may be considered for the purposes of
maternal transport, steroid administration, or both
Sources: American College of Obstetricians and Gynecologists (2020); Cunningham
et al (2018).
Magnesium sulfate (MgSO4), a central nervous system depressant,
is often used in PTL. Magnesium sulfate has limited effect as a
tocolytic agent and is associated with severe maternal risk factors
including pulmonary edema and cardiovascular problems. However,
MgSO4 may exert a neuroprotective benefit, protecting the brain of the
very preterm infant by possibly reducing the risk of cerebral palsy
(ACOG, 2020). Long-term maintenance therapy with any tocolytic
medication is ineffective for preventing preterm birth and improving
neonatal outcomes and is not recommended for this purpose. Caring
for the patient receiving tocolytic therapy requires the nurse to be
cognizant of not only the safety aspects of administering the
medication to the pregnant woman but also to the emotional needs of
the patient as attempts to halt the PTL are being made (Box 6-6).
Nifedipine Medication Interactions

Nifedipine, a calcium channel blocker used to inhibit PTL, works primarily by
blocking the flow of calcium ions through the cell membrane (thereby decreasing
the activation of smooth muscle contractile proteins). If nifedipine is given with
magnesium sulfate or erythromycin, sudden cardiac arrest can occur (Vallerand &
Sanoski, 2021).
Patient Education
Preventing Preterm Birth
Perinatal nurses must be proactive by educating women and their families about
PTL, teaching them to recognize warning signs and symptoms, and explaining
actions to take if symptoms occur. Nurses should take time to ensure that patients
have information on concerning symptoms that may indicate PTL:
• Uterine contractions (can be mild), cramping, or low-back pain
• Painless contractions with regular abdominal tightening
• Ruptured membranes
• A feeling of pelvic fullness, pressure, or pain
• A change in the amount or character of vaginal discharge (such as bloody or
mucus discharge)
• GI symptoms: nausea, vomiting, diarrhea
• A general sense of discomfort or unease
If patients believe they are having PTL, they should call the health-care provider
or go to the hospital for further evaluation of symptoms.
BOX 6-6
Nursing Care of the Patient Receiving Tocolytic

Therapy
• Explore the woman’s understanding of what is taking place.
• Include the woman’s partner in all discussions about medications and their
effects.
• Provide anticipatory guidance regarding what is likely to happen during
medication administration.
• Position the woman on her side for better placental perfusion.
• Explain the side effects and contraindications of the medication(s).
• Assess blood pressure, pulse, and respirations regularly according to hospital
policies (in many institutions every 15 minutes).
• Notify the health-care provider if systolic blood pressure is greater than 140 mm
Hg or less than 90 mm Hg.
• Notify the health-care provider if diastolic blood pressure is greater than 90 mm
Hg or less than 50 mm Hg.
• Assess for signs of pulmonary edema (chest pain and shortness of breath).
• Assess for the presence of DTRs.
• Monitor intake and output; avoid volume overload.
• Provide continuous external fetal monitoring for FHR pattern and frequency,
duration, and approximate intensity of uterine contractions.
• Palpate the maternal abdomen to assess strength of uterine contractions.
• Provide psychosocial support and opportunities for the patient to express
anxiety.
• Administer tocolytic therapy as ordered to delay delivery long enough to
administer therapy: corticosteroids to accelerate fetal lung maturity; complete
maternal transport to a Level III center before delivery; maternal antibiotic
therapy to prevent neonatal Group B streptococcus (GBS) infection.
Source: Gilbert (2011)
PREMATURE RUPTURE OF THE MEMBRANES

To facilitate an understanding of premature rupture of the membranes
(PROM), it is helpful to first define the various terms used:
■ Premature rupture of the membranes is defined as rupture of the
membranes before the onset of labor at any gestational age.
■ Preterm ROM is defined as rupture of the membranes before 37
completed weeks of gestation and is a common cause of PTL,
preterm delivery, and chorioamnionitis.
■ Preterm premature rupture of the membranes is defined as a
combination of both terms. Rupture occurs before the 37th
completed week of gestation and in the absence of labor.
One of the most common causes of PROM is infection or bacteria in
the genital tract that causes an inflammatory process, enabling the
weakening of the amnionic sac. Most often, the patient reports a gush
or leakage of fluid from the vagina. However, any increased vaginal
discharge should be evaluated. The diagnosis is based on the patient’s
history of leaking vaginal fluid and the finding of a pooling of fluid on
sterile speculum examination. The nitrazine, AmniSure, or fern test can
confirm the diagnosis of PROM. Easily performed, these tests
discriminate between vaginal discharge and amniotic fluid. Ultrasound
examination of amniotic fluid volume may be useful in documenting
oligohydramnios (decreased amniotic fluid) but is not considered
diagnostic.
Management
The risk of perinatal complications changes dramatically according to
the gestational age when ROM occurs. Clinical practice varies and, at
present, considerable controversy exists concerning the optimal
management of PPROM. However, there is consensus about the
following factors:
■ Gestational age should be established based on clinical history and
prior ultrasound assessment when available.
■ Ultrasound should be performed to assess fetal growth, position, and
residual amniotic fluid.
■ The woman should be assessed for evidence of advanced labor,
chorioamnionitis (intrauterine infection), abruptio placentae, and fetal
distress.
■ Patients with advanced labor, intrauterine infection, significant
vaginal bleeding, or nonreassuring fetal testing are best delivered
promptly, regardless of gestational age.
Conservative management includes inpatient observation unless the
membranes reseal and the leakage of fluid stops. This approach
initially consists of prolonged continuous fetal and maternal monitoring
combined with modified bedrest to promote amniotic fluid
reaccumulation and spontaneous membrane sealing. Delivery of the
fetus should be accomplished if signs of infection are present: maternal
temperature of 100.4°F (38°C) or greater, foul-smelling vaginal
discharge, elevated WBC, uterine tenderness, and maternal and/or
fetal tachycardia.
Without intervention, approximately 50% of patients who have ROM
will go into labor within 33 hours, and up to 95% will do so within 94–
107 hours (American College of Obstetricians and Gynecologists,
2020c). Although maintaining the pregnancy to gain further fetal
maturity can be beneficial, prolonged PPROM has been correlated with
an increased risk of chorioamnionitis, placental abruption, and cord
prolapse.
The nurse’s role in caring for the patient with PPROM includes
explaining to the patient that she will be on full or modified bedrest and
her vital signs will be checked at least every 4 hours to detect early
signs of a developing infection. If the patient does not exhibit signs of
labor, intermittent fetal monitoring is appropriate. Frequent ultrasound
examinations are performed to assess amniotic fluid levels. An
important component of the nursing care plan centers on providing
emotional support to the patient who is understandably worried about
the outcome for her baby. The nurse should encourage the woman and
her family members to ask questions and express fears and concerns.
Patient Education
For the woman with uncomplicated PROM, discharge home may be
appropriate with close follow-up. The nurse should provide education
on staying hydrated, monitor temperature, monitor vaginal discharge.
The woman will also need to abstain from intercourse, inserting any
items into the vagina, avoid taking baths, and should abstain from
smoking or using other substances. Routine fetal kick counts should be
conducted on a daily basis and promptly report any concerning
changes or worsening symptoms to the health-care provider.
HYPERTENSIVE DISORDERS OF PREGNANCY

Hypertensive disorders is one of the common medical complications,
the second leading cause of death in pregnancy, and has been
identified as a preventable condition in pregnancy (Centers for Disease
Control and Prevention, 2018). The incidence of hypertensive
disorders is between 8% and 10% of pregnancies (U.S. National
Library of Medicine, 2018; Webster et al, 2019). Hypertensive
disorders contribute significantly to adverse outcomes for the
pregnancy including placental abruption, preterm birth, and results in
adverse infant outcomes including low birth weight, poor fetal growth,
and even increasing the risk for stillbirth (U.S. National Library of
Medicine, 2018). For the mother, hypertension can result in cerebral
hemorrhage, HELLP syndrome, DIC, hepatic failure, acute renal
failure, and a higher risk of cardiovascular disease later in life (U.S.
National Library of Medicine, 2018; Webster et al., 2019).
Classifications and Definitions

The terminology used to describe hypertensive disorders covers an
array of different types of disorders from the following classifications:
■ Chronic hypertension is present and observable before pregnancy or
diagnosed before the 20th week of gestation. Hypertension is
defined as a systolic pressure greater than or equal to 140 mm Hg
and a diastolic pressure greater than or equal to 90 mm Hg.
■ Gestational hypertension is the development of new onset of
hypertension after 20 weeks of gestation without proteinuria.
■ Pre-eclampsia is a pregnancy-specific systemic syndrome clinically
defined as an increase in blood pressure (i.e., systolic and diastolic
blood pressures greater than or equal to 140 and greater than or
equal to 90 mm Hg, respectively, occurring twice, 4 hours apart) after
20 weeks’ gestation accompanied by proteinuria (excretion of greater
than or equal to 300 mg protein/24 hours or 1 + dipstick).
■ Eclampsia is the presence of new-onset grand mal seizures in a
woman with pre-eclampsia who has no other cause for seizure
(Centers for Disease Control and Prevention, 2018; Croke, 2019;
U.S. National Library of Medicine, 2018; Webster et al, 2019).
Pre-eclampsia
Pathophysiology
The normal physiological adaptations to pregnancy are altered in the
woman who develops pre-eclampsia. Pre-eclampsia is a multisystem,
vasopressive disease process that targets the cardiovascular,
hematological, hepatic, renal, and central nervous systems.
Pre-eclampsia is associated with a clinical spectrum of events that
range from mild to severe with a potential endpoint of eclampsia.
Patients do not suddenly “catch” severe pre-eclampsia or develop
eclampsia but rather progress in a predictable course through the
clinical spectrum. In most cases, the progression is relatively slow, and
the disorder may remain mild. In other situations, the disease can
progress more rapidly and change from a mild to a severe form in a
matter of days or weeks. In the most serious cases, the progression
can be rapid: Mild disease at the time of diagnosis evolves to pre-
eclampsia with severe features or eclampsia over hours or days
(Lavallee, 2015). Hence, the nurse must alert the patient to signs and
symptoms that signal a worsening condition and continuously assess
the patient for any change.
Although the pathophysiology is poorly understood, it is clear that
the blueprint for its development is laid down early in pregnancy. Pre-
eclampsia is a disease of the placenta because it has been
documented in pregnancies that involve trophoblastic tissue but no
fetus (i.e., a molar pregnancy). In a normal pregnancy, the
endovascular trophoblast cells of the placenta transform uterine spiral
arteries to accommodate an increased blood flow. In the presence of
pre-eclampsia, the arterial transformation is incomplete. Women with
preeclampsia have a distinctive lesion in the placenta termed acute
atherosis (fat accumulation in the placental arteries). Their placentas
also exhibit a greater degree of infarction (necrosis related to
decreased blood supply) than is found in placentas of normotensive
women. These pathological changes can lead to decreased placental
perfusion and placental hypoxia (Lavallee, 2015; Cunningham et al,
2018).
Vasospasm and endothelial cell damage are the major underlying
pathophysiological events in pre-eclampsia. Vasospasm may be
associated with an elevation in arterial blood pressure and resistance
to blood flow. It is unclear whether vasospasm produces damage to the
vessels or if damage to the vessels produces vasospasm. Regardless,
the restriction of blood flow is associated with endothelial cell damage,
and this tissue insult prompts the systemic utilization of platelets and
fibrinogen. The widespread vascular changes alter blood flow and
result in hypoxic damage to vulnerable organs. Over time, the
alterations produce widespread maternal vasospasm that results in
decreased perfusion to virtually all organs, including the placenta.
Associated physiological events include decreased plasma volume,
activation of the coagulation cascade, and alterations in the glomerular
endothelium. The increased platelet activation and markers of
endothelial activation can predate clinically evident pre-eclampsia by
weeks or even months and can lead to HELLP syndrome (Lavallee,
2015; Cunningham et al, 2018) (Fig. 6-8).
Assessment Tools
SPASMS: A Memory Enhancer When Caring for a Pre-eclampsia Patient
S Significant blood pressure changes may occur without warning.
P Proteinuria is a serious sign of renal involvement.
A Arterioles are affected by vasospasms that result in endothelial damage and
leakage of intravascular fluid into the interstitial spaces. Edema results.
S Significant laboratory changes (most notably, liver function tests [LFTs] and
the platelet count) signal worsening of the disease.
M Multiple organ systems can be involved: cardiovascular, hematological,
hepatic, renal, and central nervous system.
S Symptoms appear after 20 weeks of gestation.
Risk Factors
In the United States, the incidence of pre-eclampsia is rising, most
likely caused by an increased prevalence of predisposing disorders
such as obesity, diabetes, and chronic hypertension.
Risk factors associated with pre-eclampsia are presented in Box 6-7.
Classification of Pre-eclampsia and Maternal and Fetal Morbidity

and Mortality
A number of maternal and fetal complications are likely to develop as
the condition worsens. Signs of severe disease include any of the
following:
■ Systolic BP greater than or equal to 160 mm Hg or diastolic BP
greater than or equal to 110 mm Hg on two occasions at least 4
hours apart while the patient is on bedrest
■ Thrombocytopenia (platelets less than 100 × 109/L)
■ Impaired liver function, as indicated by abnormally elevated blood
concentrations of liver enzymes (to twice normal concentration)
and/or severe, persistent right upper quadrant (RUQ) or epigastric
pain unresponsive to medication and not accounted for by alternative
diagnoses
BOX 6-7
Risk Factors for Pre-eclampsia

• Primigravida (6–8 times greater risk)
• Age extremes (less than 19 years and greater than 40 years)
• Pregestational diabetes
• Pre-existing hypertension, renal disease, or collagen disease
• Multiple gestation (5 times greater risk)
• Fetal hydrops (10 times greater risk)
• Hydatidiform mole (10 times greater risk)
• Pre-eclampsia in a previous pregnancy
• Family history
• Obesity
• Periodontal disease
• Antiphospholipid antibody syndrome
• Rh incompatibility
• African American ethnicity
• Pregnancies that result from donor insemination, oocyte donation, or embryo
donation
CDC (2018), Croke (2019), Cunningham et al (2018)
■ Progressive renal insufficiency (serum creatinine concentration

greater than 1.1 mg/dL or a doubling of the serum creatinine
concentration in the absence of other renal disease
■ Pulmonary edema
■ New-onset visual or central nervous system (CNS) disturbances
FIGURE 6-8 Pathophysiological changes of pre-eclampsia.
The maternal complications associated with pre-eclampsia are

related to the widespread arteriolar vasoconstriction that affects the
brain (seizure and stroke), kidneys (oliguria and renal failure), liver
(edema and subcapsular hematoma), and small blood vessels (small
ruptures within the walls of the vessels use up large amounts of
platelets in an effort to correct the bleeding). This results in
thrombocytopenia and DIC.
The perinatal outcome in pre-eclampsia is dependent on one or
more of the following factors: the gestational age at the onset of the
disease process, the presence of a multiple gestation, and the
presence of underlying maternal hypertension or renal disease. In
patients with pre-eclampsia without severe features at term, the
perinatal mortality, incidence of fetal growth restriction, and neonatal
morbidity are similar to those associated with normotensive
pregnancies. In contrast, both perinatal and maternal morbidity are
increased when the disease is severe, particularly when disease
develops in the second trimester, and the fetus is quite immature.
Maternal death and severe complication rates from pre-eclampsia are
also lowest among women who receive regular prenatal care and are
managed by experienced physicians in tertiary centers (Croke, 2019).
Management of Pre-eclampsia/Eclampsia
Once the diagnosis of pre-eclampsia has been made, delivery of the
fetus is the only cure. The primary considerations of therapy must
always be the safety of the patient and the delivery of a live, mature
newborn who will not require intensive and prolonged neonatal care.
According to ACOG, preeclampsia without severe features, which
presents as a maternal blood pressure of greater than or equal to 140
mm Hg systolic or greater than or equal to 90 mm Hg diastolic (on two
occasions at least 4 hours apart after 20 weeks of gestation) and
proteinuria (greater than or equal to 300 mg/24 hours or
protein/creatinine ratio greater than or equal to 0.3 or dipstick reading
greater than or equal to 1 +), can often be managed at home after the
patient has had a careful assessment of her signs and symptoms, a
physical examination, laboratory tests, and evaluation of fetal well-
being (Croke, 2019).
For patients with new-onset pre-eclampsia, the initial examination
must be performed in the hospital. Ongoing education (e.g., rationales
for various tests and instructions for fetal activity monitoring) and the
provision of a supportive environment are important nursing
interventions at this time. If the woman’s blood pressure and laboratory
test results indicate that her care may be safely managed at home, the
nurse must make certain that the patient fully understands the signs
and symptoms associated with a worsening of the condition and report
promptly to their health-care provider (Fig. 6-9).
Patient Education
Home Management of the Pregnant Patient With a Hypertensive Disorder
Before discharge, it is important to ascertain that the home environment is
conducive to recovery and the patient will be able to rest frequently throughout the
day. It is essential that the patient can verbalize understanding of the importance
of keeping all prenatal appointments and that she must immediately notify her
physician or midwife at the first appearance of:
• Blood pressure values greater than those at the time of hospital discharge—MD
or certified nurse-midwife should provide parameters
• Visual changes
• Epigastric pain
• Nausea and vomiting
• Bleeding gums
• Headaches
• Increasing edema, especially of the hands and face
• Decreasing urinary output
• Decreased fetal movement
• “Just not feeling right”
Promoting Rest at Home
Obtaining an adequate amount of rest is not always easy, especially for women
who have other children at home and no extended family to help. The nurse may
offer suggestions for getting adequate rest, such as lying down and resting while
the other children nap, bringing young children into bed and reading them a story,
or asking a neighbor to watch the children. The woman’s partner should also be
involved in formulating a plan to help facilitate rest. Church groups may be able to
help out with child care, running errands, or preparing meals for the family. When
friends ask what they can do to help, suggest that the woman have a prepared list
of specific actions that would make it easier for her to maintain a calm, restful
home environment. The hospital’s social services department should also be
contacted and asked for assistance. They are a useful resource that can share
information about organizations that can be called on to help.
FIGURE 6-9 Nurse provides discharge teaching to a patient with pre-
eclampsia.
Because lying in the lateral side position decreases pressure on the

vena cava, the woman is instructed to maintain this position as much
as possible. This position also increases venous return, circulatory
volume, and placental and renal perfusion. Improving renal blood flow
helps decrease angiotensin II levels, promotes diuresis, and lowers
blood pressure. Antihypertensive medications have not been shown to
improve perinatal outcomes in pre-eclampsia without severe features
and should not be routinely prescribed.
The clinical course of pre-eclampsia with severe features may be
characterized by a progressive deterioration in both maternal and fetal
conditions. Pregnancies complicated by pre-eclampsia with severe
features have been associated with increased rates of perinatal
mortality and significant risks for maternal morbidity and mortality.
Because of this, there is universal agreement that delivery should be
prompt if the disease develops after 34 weeks’ gestation or earlier if
there is evidence of maternal or fetal compromise. Management of pre-
eclampsia with severe features includes the following clinical actions:
1. Seizure prophylaxis with magnesium sulfate, which has been
universally accepted as the drug of choice because of its CNS-
depressant action.
2. Antihypertensive medications (Table 6-1 and 6-2). The use of
antihypertensive agents in severe pre-eclampsia is generally
indicated when diastolic blood pressures reach or exceed 110 mm
Hg. The goal of therapy is to reduce the risk of cerebral vascular
accident while maintaining uteroplacental perfusion. A decrease in
the diastolic pressure to less than 90 mm Hg in the patient with
severe hypertension will decrease placental blood flow, often with a
decrease in the FHR. Management is directed at reducing the
diastolic blood pressure to a value of less than 110 mm Hg but
greater than 95 to 100 mm Hg.
TABLE 6-1
Medications Used to Treat Chronic Severe Hypertension in Pregnancy
AGENT (TRADE CLASS DOSE MATERNAL BREASTFEEDING
NAME) ADVERSE
EFFECTS
Alpha-methyldopa Central 0.5–3.0 g Sedation, elevated Safe
alpha- PO per day liver function tests,
adrenergic in 2–3 depression, dry
inhibitor divided mouth, lethargy,
doses hemolytic anemia
Labetalol Alpha-/beta- 200–2,400 Headache, Safe
(Trandate) adrenergic mg PO per dizziness,
blocker day in 2–3 orthostatic
divided hypotension,
doses nausea/vomiting,
sweating,
bronchospasm,
dyspnea, scalp
tingling,
tremulousness,
flushing
Nifedipine (Adalat, Calcium 30–120 mg Headache, Safe
Procardia) channel PO per day orthostatic
blocker of a slow- hypotension,
release flushing,
preparation tachycardia
Adjunctive Agents
Hydralazine Peripheral 50–300 mg Tachycardia, Safe
hydrochloride arteriolar PO per day dizziness,
vasodilator in 2–4 headache,
divided palpitations. Use
doses with methyldopa or
labetalol to prevent
reflex tachycardia;
risk of neonatal
thrombocytopenia
Hydrochlorothiazide Loop 12.5–50 Dizziness, Risk is remote, but
diuretic mg PO per drowsiness, there are concerns
day lethargy, weakness, about potential
hypotension, thrombocytopenia
volume depletion, in infants
electrolyte
disorders (e.g.,
hypokalemia,
hypercalcemia,
hypomagnesemia,
hyponatremia,
hypophosphatemia)
Sources: Vallerand & Sanoski (2021), King et al (2016), Webster et al (2019),

Cunningham et al (2018)
TABLE 6-2
Medications Used for Urgent Control of Severe Acute Hypertension in
Pregnancy
AGENT CLASS DOSAGE MATERNAL ADVERSE
(TRADE EFFECTS
NAME)
Labetalol Alpha-/beta- 20 mg IV, then 20–80 Lower risk of
hydrochloride adrenergic mg every 5–15 minutes, tachycardia and
(Normodyne, blocker up to a maximum of 300 arrhythmia than with
Trandate) mg; or constant infusion other vasodilators;
of 1–2 mg/min increasingly preferred
as first-line agent. May
cause neonatal
bradycardia and should
be avoided in women
with asthma or heart
failure.
Hydralazine Peripheral/arterial 5 mg IV or IM, then 5– Long experience of
vasodilator 10 mg every 20–40 safety and efficacy; risk
minutes; or constant of delayed maternal
infusion of 0.5–10 mg/hr hypotension (systolic
BP ≤ 90 mm Hg) and
fetal bradycardia.
Considered a first-line
agent.
Nifedipine Calcium channel 10–30 mg PO, repeat in See hydralazine.
(Adalat, blocker 45 minutes if needed Possible interference
Procardia) with labor; use caution if
the patient is also
receiving magnesium
sulfate.
Sodium Vasodilator 0.25 mcg/kg/min Should be reserved for
nitroprusside (increase by 0.25 extreme emergencies
(Nitropress) mcg/kg/min every 5 and used for the
minutes) to a maximum shortest amount of time
of 5 mcg/kg/min possible because of
concerns about cyanide
and thiocyanate toxicity
in the mother and fetus
or newborn and of
cerebral edema in the
mother.
Source: Vallerand & Sanoski (2021).

3. Invasive hemodynamic monitoring may be required if any of the
following are present:
■ Oliguria unresponsive to a fluid challenge
■ Pulmonary edema
■ Hypertensive crisis refractory to conventional therapy
■ Cerebral edema
■ DIC
■ Multisystem organ failure
Nursing Assessments
Nursing care centers on extremely accurate, astute observations and
assessments. An in-depth understanding of the pharmacological
regimens, management plans, and potential complications associated
with this disease is also essential. The clinical manifestations of pre-
eclampsia are directly related to the presence of vascular vasospasms.
Vasospasms cause endothelial injury, red blood cell (RBC) destruction,
platelet aggregation, increased capillary permeability, increased
systemic vascular resistance, and renal and hepatic dysfunction.
MEDICATION: Magnesium Sulfate (mag-nee-

zhum sul-fate)
Pregnancy Category: D
Indications: Anticonvulsant in severe pre-eclampsia or eclampsia
Unlabeled Use: Preterm labor
(Note: Magnesium sulfate is not FDA-approved for the treatment of PTL)
Actions: Plays an important role in neurotransmission and muscular excitability
Therapeutic Effects: Resolution of eclampsia
Pharmacokinetics:
ABSORPTION: IV administration results in complete bioavailability; well absorbed
from IM sites
DISTRIBUTION: Widely distributed; crosses the placenta and is present in breast
milk
METABOLISM AND EXCRETION: Excreted primarily by the kidneys
HALF-LIFE: Unknown
CONTRAINDICATED IN: Hypermagnesemia/hypocalcemia/anuria/heart block/active
labor or within 2 hours of labor (unless used for pre-eclampsia or eclampsia)
USE CAUTIOUSLY IN: Any degree of renal insufficiency
Adverse Reactions and Side Effects:
Central nervous system: Drowsiness
Respiratory system: Decreased respirations
Cardiovascular system: Arrhythmias, hypotension, bradycardia
Gastrointestinal system: Diarrhea
Dermatology system: Flushing, sweating
Metabolic: Hypothermia
Interactions: Potentiates neuromuscular blocking agents
Route and Dosage (Eclampsia/Pre-eclampsia):
Piggyback a solution of 40 g of magnesium sulfate in 1,000 mL of lactated
Ringer’s solution—use an infusion control device at the ordered rates: loading
dose, initial bolus of 4 to 6 g over 15 to 30 min; maintenance dose, 1 to 3 g/hr.
IM: 4 to 5 g given in each buttock; can be repeated at 4-hour intervals; use Z-track
technique. (Note: IM route rarely used because the absorption rate cannot be
controlled and injections are painful and may result in tissue necrosis.)
Time/Action Profile for Anticonvulsant Effect:
IM: Onset is 60 minutes with peak unknown, and duration is 3 to 4 hours; IV:
Onset is immediate with peak unknown and duration is 30 minutes.
Nursing Implications: Remember that this is a very potent, high-alert drug!
1. Explain purpose and side effects of the medication to the patient and her
companion.
2. Explain that she may feel very warm, become flushed, and experience nausea
and vomiting, visual blurring, and headaches.
3. Magnesium sulfate must never be abbreviated and requires a written order by
the physician for administration.
4. Always use an infusion pump for administration and run the medication
piggyback, not as the main line.
5. Monitor pulse, blood pressure, respirations, and ECG frequently throughout
parenteral administration. Respirations should be at least 16/min before each
dose.
6. Monitor neurological status before and throughout therapy.
7. Institute seizure precautions.
8. Keep the room quiet and darkened to decrease the likelihood of triggering
seizure activity.
9. Patellar reflexes should be tested before each parenteral dose of magnesium
sulfate. If absent, no additional dose should be administered until a positive
response returns.
10. Monitor intake and output. Urine output should be maintained at a level of at
least 100 mL/4 hr.
11. Serum magnesium levels and renal function should be monitored periodically
throughout administration of parenteral magnesium sulfate (Box 6-8).
12. Have 10% calcium gluconate available should toxicity occur. Administer 10 mL
IV over 1 to 3 minutes until signs and symptoms are reversed.
13. After delivery, monitor the newborn for hypotension, hyporeflexia, and
respiratory depression.
Source: Data from Vallerand, A. H., & Sanoski, C. A. (2021). Davis’s drug guide
for nurses (17th ed.). Philadelphia: F.A. Davis.
Preventing Magnesium Sulfate Accidents

Accidental overdose of magnesium sulfate administration can pose a significant
risk to both mother and newborn. Current recommendations to prevent
magnesium sulfate accidents include the following:
• A standardized unit protocol should be consistent and include standing orders
addressing the initial bolus and maintenance dose to be administered, how the
pump should be programmed, the maintenance IV solutions that will be used,
and the frequency that the fetus and mother will be assessed.
• Administer IV magnesium sulfate (including the initial bolus) only through a
controlled infusion device with free-flow protection.
• Use universal standardized dose prepackaged magnesium sulfate.
• Have a second nurse check the initial magnesium sulfate IV bag and pump
settings (and every magnesium sulfate IV bag that is added and each
subsequent rate change).
• Use a 100-mL (4 g) or 150-mL (6 g) IV piggyback for the initial bolus instead of
bolusing from the main bag with a rate change on the pump.
• Use color-coded tags on the lines as they go into the pumps and into the IV
ports.
• Provide 1:1 nursing care for women in labor who are receiving magnesium
sulfate.
• When care is transferred to another nurse, have both nurses together at the
bedside to review the pump settings for both the magnesium sulfate and
mainline IV fluids and to review written physician orders for magnesium sulfate
infusion orders.
• Implement periodic magnesium sulfate overdose drills with airway management
and calcium administration with the physician and nurse team members
participating together.
• Maintain the calcium antidote in the patient’s room in a locked box.
Optimizing Outcomes
Daily Assessment for Patients Who Have Pre-eclampsia

During the assessment, the nurse should include the following parameters:
• Auscultation of heart sounds, lungs, and breath sounds
• Presence and degree of edema
• Early signs or symptoms of pulmonary edema, such as tachycardia and
tachypnea
• Daily weight taken at the same time of the day and on the same scale
• Skin color, temperature, and turgor
• Capillary refill, which may indicate decreased perfusion or vasoconstriction if
greater than 3 seconds
BOX 6-8
Serum Magnesium Levels

Serum Magnesium Levels (mEq/L)
Normal 1.5–2
Therapeutic 4–7
ECG changes 5–10
Loss of reflexes 8–12
Respiratory distress 15
Cardiac arrest 25
Sources: Vallerand & Sanoski (2021).
SIGNIFICANCE OF PROTEINURIA
Proteinuria is defined as the excretion of 300 mg or more of protein
every 24 hours. If 24-hour urine samples are not available, proteinuria
is defined as a protein concentration of 300 mg/L or more (greater than
or equal to 1 + on dipstick) in at least two random urine samples taken
at least 4 to 6 hours apart and no more than 7 days apart. As an
important component of hospital care, the nurse assesses urine output
every 1 to 4 hours to confirm adequate renal perfusion and
oxygenation. A urine output of 25 to 30 mL/hr or 100 mL/4 hr is normal;
a downward trend in output should be reported immediately. A urimeter
attached to the Foley catheter tubing is useful in the accurate
assessment of the hourly urine output. A 24-hour urine test for total
protein may be ordered to monitor for an increase in the excretion of
protein, a finding indicative of increasing kidney impairment. The nurse
should be aware that if the 24-hour urine specimen (for total protein)
shows the presence of protein, a dipstick is not appropriate. Once
protein is evident in a 24-hour urine collection, protein will always be
present when the urine is tested by the dipstick. Therefore, no new
information is obtained. The 24-hour urine sample yields more
accurate information because it shows whether or not the urine protein
is increasing, decreasing, or remaining the same. When indicated, a
high-protein diet may be needed to replace the protein excreted in the
urine.
ASSESSING EDEMA
At one time, edema was an important component of the triad
considered along with hypertension and proteinuria to diagnose pre-
eclampsia. However, edema is a common finding in pregnancy.
Dependent edema in the absence of hypertension or proteinuria is
generally related to changes in the interstitial and intravascular
hydrostatic pressures that facilitate the movement of intravascular fluid
into the tissues. When pre-eclampsia is present, continuous capillary
leakage combined with a decreased colloidal pressure can lead to
pulmonary edema. In this situation, intravascular fluid leaks out
through holes (caused by vasospasms) in the endothelial lining of the
blood vessels. Pulmonary edema can occur very suddenly, especially if
the patient receives an overload of IV fluid. Because of the potential for
rapid development of this life-threatening complication, the nurse must
frequently perform a careful assessment of the patient’s pulmonary
status and meticulously monitor the total intake and output.
CENTRAL NERVOUS SYSTEM ALTERATIONS
Pre-eclampsia may quickly develop into eclampsia, the convulsive
phase of pre-eclampsia. Before the onset of seizure activity, the patient
may complain of headaches, visual disturbances, blurred vision,
scotomata (blind spots, specks or spots in the vision), and in rare
cases, cortical blindness. These symptoms can be indicators of
increased CNS irritability that precedes the onset of seizures. A retinal
examination often reveals vascular constriction and narrowing of the
small arteries. These changes are reflective of the widespread
vasoconstriction occurring throughout the body. Deep tendon reflexes
(DTRs) are also routinely assessed for evidence of irritability and
clonus (rapidly alternating muscle contraction and relaxation), two
additional signs of increased CNS irritability with pre-eclampsia, and
there will be reflexes on the brisker side (Sommers, 2019). Other
nursing interventions include maintaining a quiet, darkened
environment, reducing stimuli that may result in hypertension and
seizures. Ensure that seizure precautions (e.g., suction equipment,
oxygen administration equipment, and emergency medication tray) are
in place (Figs. 6-10 and 6-11).
Optimizing Outcomes
Grading Reflexes and Checking for Clonus

During the assessment, grade maternal reflexes on a 0 to 4 + scale:
4 + Very brisk, hyperactive; often indicative of disease; often associated with
clonus
3 + Brisker than average; possibly but not necessarily indicative of disease
2 + Average; normal
1 + Somewhat diminished
0 No response
Procedure
If the reflexes are hyperactive, test for ankle clonus. Clonus is a spasmodic
reaction to the stretching of a muscle. Support the knee in a partly flexed position.
With your other hand, dorsiflex and plantar flex the foot a few times while
encouraging the patient to relax, and then sharply dorsiflex the foot and maintain it
in dorsiflexion. Look and feel for rhythmic oscillations between dorsiflexion and
plantar flexion. Normal is no reaction to this stimulus. Sustained clonus indicates
upper motor neuron disease. The ankle plantar flexes and dorsiflexes repetitively
and rhythmically (see Fig. 6-11) (Sommers, 2019). Clonus is usually noted as
“absent” or “present” but it may be rated as:
• Mild (2 movements)
• Moderate (3 to 5 movements)
• Severe (6 or more movements)
FIGURE 6-10 Assessing deep tendon reflexes.
FIGURE 6-11 Testing for clonus.
Eclampsia
Eclampsia is the occurrence of grand mal seizures in women who have
either gestational hypertension or pre-eclampsia and is considered an
obstetrical emergency (Lavallee, 2015). It is the most common CNS
complication of hypertension, and most maternal deaths attributable to
hypertension occur in women with eclampsia. Although patients with
severe pre-eclampsia are at the greatest risk for developing seizures,
eclampsia-related seizures have been reported in women with pre-
eclampsia without severe features. Women developing eclampsia
exhibit a wide spectrum of signs and symptoms, ranging from
extremely high blood pressure, 4 + proteinuria, generalized edema,
and 4 + patellar reflexes to minimal blood pressure elevation, no
proteinuria or edema, and normal reflexes.
Maternal complications of eclampsia include cerebral hemorrhage,
aspiration pneumonia, hypoxic encephalopathy, coma, thromboembolic
events, and maternal death (incidence 0.4% to 14%). The perinatal
death rate in pregnancies complicated by eclampsia is 9% to 23%.
Perinatal deaths are closely related to gestational age and most often
result from premature delivery, abruptio placentae, and intrauterine
asphyxia (Cunningham et al, 2018). Eclampsia is a serious condition,
and anyone who is pregnant and having a seizure must be considered
eclamptic until proven otherwise.
FOCUS ON SAFETY
Care of the Seizing Pregnant Patient
Seizures are an obstetrical emergency. Nurses caring for a patient who is having
a seizure or is postseizure must activate the code team and call for help. Patient
safety is paramount and a nurse must stay with the patient during the seizure.
Actions to take include the following:
• Do not attempt to shorten or abolish the initial seizure.
• Secure the patient airway, maintain adequate oxygenation; administer oxygen
via face mask at 10 L/min.
• Minimize the risk of aspiration. Suction equipment should be ready and
working.
• Assess circulation and for pulse. Activate an arrest code if no pulse.
• Place patient on left side to prevent aortic compression.
• Monitor vital signs frequently.
• Obtain intravenous access.
• Obtain blood work and pre-eclampsia panel for monitoring.
• Give adequate magnesium sulfate to control seizures. As soon as possible
following the seizure, venous access should be secured with a 4- to 6-g loading
bolus of magnesium sulfate given over 15 to 20 minutes. If the patient seizes
following the loading dose, another 2-g bolus may be given IV over 3 to 5
minutes.
• Correct maternal acidemia. Blood gas analysis allows monitoring of
oxygenation and pH status. Respiratory acidemia is possible after a seizure.
• Avoid polytherapy. Maternal respiratory depression, respiratory arrest, or
cardiopulmonary arrest is more likely in women who receive polytherapy to
arrest a seizure. Remember that anticonvulsants are respiratory depressants
and may interact.
• Monitor the fetus after a seizure. Fetal monitor tracing may show loss of FHR
variability and bradycardia.
• Assess for ruptured membranes, contractions, cervical dilation, and signs of
placental abruption.
• Prepare for delivery as indicated.
• Support the patient and her family. This is a very frightening event for them, and
they will need reassurance and to be kept aware of the plan of care and the
well-being of their baby (Lavallee, 2015; Phillips & Boyd, 2016).
CASE STUDY
Rosa Garcia
Rosa Garcia is a 25-year-old married Mexican immigrant who is pregnant with her
first child. Rosa’s family practice physician has been caring for her since her first
prenatal visit at 114/7 weeks’ gestation. During the initial prenatal visit, the
following data were obtained:
Vital signs: temperature: 98.6°F (37.0°C); pulse: 78 beats/min; respirations: 20
breaths/min; blood pressure: 110/70; weight: 146 lb (66.4 kg)
A complete physical examination was performed with normal findings, and
prenatal labs including a thyroid-stimulating hormone level (TSH; because of a
positive family history for hypothyroidism) were drawn. During the interview, the
nurse inquired about any other family medical problems. Rosa reported that both
her sister and her mother had experienced pre-eclampsia during pregnancy.
An ultrasound was ordered for pregnancy dating because Rosa had
experienced irregular menstrual periods since discontinuing oral contraceptives.
Rosa kept her regular prenatal appointments every 4 weeks and the pregnancy
progressed uneventfully until 4 months later, when she presented to the office with
increased blood pressure and swollen legs. Rosa had noticed an increased
swelling that extended up to the knees of both legs. She denied hand or facial
swelling, headaches, visual problems, or RUQ pain. Her sister, a chiropractor, had
been checking her blood pressure and noted it to be as high as 160 to 170/100 to
110 mm Hg. At this prenatal visit, the following data were obtained:
Blood pressure: 144/96 (sitting). Repeat on left side: 140/90. Weight: 172.5 lb
(78.4 kg)
Urine dipstick reading: 1 +
Physical examination: General—in no acute distress; abdomen: nontender
fundus at 28–11.8 in. (30 cm) above the symphysis pubis; FHR 150 bpm;
cardiovascular: 1 + pedal edema; neurological: reflexes 3 + with no clonus.
Assessment: Pre-eclampsia without severe features.
The following laboratory tests were ordered: CBC with platelet count, liver
enzyme determination (AST, ALT, LDH), alkaline phosphatase (ALP), prothrombin
time (PT), a chemistry panel (electrolytes: Na+, K+, Cl–, HCO3–, Ca2+, Mg2+),
blood urea nitrogen (BUN), creatinine (Cr), uric acid, and a 24-hour urine collection
for protein and creatinine clearance. A sonogram (ultrasound) was also ordered to
monitor the status of the fetus.
Rosa was instructed to go home, rest on her left side as much as possible, and
call the nurse if she experienced increased edema, headaches, visual
disturbances, or RUQ pain. She was told to continue with fetal kick counts and
twice daily blood pressure monitoring, record all findings and symptoms, and
return to the office in 1 week.
On her next office visit 8 days later, Rosa reported that she had been adhering
to frequent rest periods at home and had noticed that her leg edema was
improved. She exclaimed: “I can see my ankle bones again!” Her sister had
continued to monitor the blood pressure. According to the blood pressure log,
Rosa’s systolic blood pressure measurements had been in the 160s and the
diastolic measurements were in the 80 to 90 range. Rosa denied headaches,
visual disturbances, or abdominal pain and remarked that the fetus had been
active. At this visit, the following data were obtained:
Blood pressure: 160/98 (sitting); 162/100 (left side); weight: 160 lb (72.7 kg);
fundal height: 27 cm; FHR: 150 to 170 bpm; reflexes: 3 to 4 + with no clonus;
urinary protein: 4 + (2,000 + mg/dL) on dipstick
Assessment: Pre-eclampsia with severe features at 294/7 weeks’ gestational
age
At this point, Rosa’s physician consulted with a maternal fetal medicine
specialist, who advised transferring Rosa to a tertiary care center 50 miles away.
Rosa was promptly transferred to the tertiary care center and admitted to the
obstetric service.
CRITICAL THINKING QUESTIONS
1. What are Rosa’s risk factors for developing pre-eclampsia?

2. Why did the nurse ask Rosa about headaches, blurred vision, and RUQ pain?
3. What signs and symptoms prompted Rosa’s physician to consult with the
maternal–fetal specialist and arrange for a transfer to a tertiary care center?
HELLP Syndrome
HELLP is an acronym for Hemolysis and Elevated Liver enzymes and
Low Platelet levels. As a result of the arteriolar vasospasms in the
cardiovascular system that occur in pre-eclampsia, the circulating
RBCs are destroyed as they try to navigate through the constricted
vessels (Hemolysis). Vasospasms decrease blood flow to the liver,
resulting in tissue ischemia and hemorrhagic necrosis (Elevated Liver
enzyme level). In response to the endothelial damage caused by the
vasospasms (small openings develop in the vessels), platelets
aggregate at the site and a fibrin network is set up, leading to a
decrease in the circulating platelets (Low Platelet level).
HELLP syndrome is a rare and life-threatening condition that arises
as a serious complication of pre-eclampsia in approximately 1 to 2 of
every 1,000 pregnancies (Sommers, 2019; Venes, 2021). It can
manifest itself at any time during pregnancy and the puerperium, but
like pre-eclampsia, it is rare before 20 weeks’ gestation.
HELLP syndrome consists of a combination of laboratory anomalies.
The primary presentation of patients often have pre-eclampsia
symptoms of nausea, vomiting, epigastric pain, headache, vision
problems, hepatic dysfunction leading to liver failure, acute renal
failure, DIC, respiratory failure, and/multiple organ failure (Sommers,
2019).
Therapy for HELLP syndrome centers on improving the platelet
count by transfusion of fresh-frozen plasma or platelets and delivery as
soon as feasible by vaginal or cesarean birth. Intrapartum nursing care
involves continuous maternal-fetal monitoring. Measurement of central
venous pressure or pulmonary arterial wedge pressure (Swan-Ganz
catheter) may be required to monitor fluid status accurately when
pulmonary edema or acute renal failure is present.
DISSEMINATED INTRAVASCULAR
COAGULOPATHY
Disseminated intravascular coagulopathy (DIC) is a hematological
disorder characterized by a pathological form of clotting that is diffuse
and consumes large amounts of clotting factors. DIC causes
widespread external or internal bleeding or both (Cunningham et al,
2018). The most common causes of DIC in pregnancy are excessive
blood loss with inadequate blood component replacement, placental
abruption, amniotic fluid embolism, and severe pre-eclampsia/HELLP
syndrome. DIC is a consumptive coagulopathy that results in depletion
of the platelets and clotting factors. Early diagnosis and prompt and
appropriate management are critical in reducing maternal and perinatal
death and complication rates (Sommers, 2019).
Nursing Care
Nursing care includes continued meticulous assessment for signs of
bleeding (e.g., petechiae, oozing from injection sites, and hematuria).
Amount of blood loss should be calculated in cases of vaginal bleeding
and detailed assessments of any bruises or hematomas in terms of
size, shape, color, and assessment time to monitor for worsening
bleeding. Use of an indwelling catheter for monitoring urinary output
and assessment of hematuria is essential because renal failure is a
potential consequence of DIC. Vital signs and fetal assessments are
monitored frequently, and the patient is maintained in a side-lying tilt to
enhance blood flow to the uterus. Oxygen may be administered
through a rebreathing mask at 8 to 10 L/min, and blood and blood
products are administered according to physician orders (Sommers,
2019). The patient and her family are emotionally supported and kept
informed about the maternal-fetal status.
MULTIPLE GESTATION
Multiple gestation refers to a pregnancy in which two or more fetuses
are present in the uterus, most commonly twins. In 2018 there were
123,536 twin births, 3,400 triplet births, and 115 quadruplet births
(Centers for Disease Control and Prevention, 2019e). Twinning occurs
when ovulation produces two separate ova and each is fertilized
(dizygotic, or fraternal twins), or if a single fertilized ovum (zygote)
splits early in pregnancy and develops into two fetuses (monozygotic
or identical twins) (Fig. 6-12). Assisted reproductive technologies such
as assisted embryo hatching and intracytoplasmic sperm injection
have resulted in increased monozygotic twinning by as much as
eightfold; monozygotic pregnancies account for only 30% of
spontaneously conceived twins.
■ Dichorionic/diamniotic: Two chorions (outer membrane) and two
amnions (inner membrane); division of the embryo takes place
during the first 3 days of development; occurs in approximately 25%
to 30% of monozygotic twins.
■ Monochorionic/diamniotic: One chorion (outer membrane) and two
amnions (inner membrane) and a single, shared placenta. Division of
the embryo takes place between 4 to 8 days of development; occurs
in approximately 70% to 75% of monozygotic twins. Each twin has its
own amnion, but the fetuses are surrounded by one chorion.
■ Monochorionic/monoamniotic: One chorion and one amnion—the
fetuses share the same living quarters. The zygotic division occurs
later than the first week of development. Associated with a very high
(40% to 60%) mortality rate as a result of cord accidents from
entanglement.
■ Conjoined twins: Conjoined twins are identical twins, whose bodies
are joined in utero. The twins share a common chorion, amnion, and
placenta. The level of degree they can be conjoined can be a small
shared area to a large shared area, which can affect survival.
FIGURE 6-12 Multiple gestations. A, Monozygotic twins with one
placenta, one chorion, and two amnions. B, Dizygotic twins with two
placentas, two chorions, and two amnions.
Associated Complications
Multiple gestations are high-risk pregnancies associated with a number
of maternal and fetal complications. Complications may occur during
the antepartal, intrapartal, or postpartal period. Preterm labor often
results from uterine overdistention and frequently necessitates an early
operative delivery. Other complications include PTL, gestational
diabetes, increased urinary tract infections (UTIs), pre-
eclampsia/eclampsia, acute fatty liver, pulmonary embolism, placenta
previa, fetal intrauterine growth restriction (IUGR), abnormal
presentation, and umbilical cord prolapse (Cunningham et al, 2018).
Determination of Chorionicity
A positive diagnosis of a multiple gestation can be confirmed by
ultrasound examination. Sonography reveals multiple gestational sacs
with yolk sacs by 5 weeks of gestation and multiple embryos with
cardiac activity by 6 weeks of gestation. Rapid uterine growth,
excessive maternal weight gain, or palpation of three or more fetal
large parts (cranium and breech) on Leopold maneuvers are clinical
findings suggestive of multiple gestation. Laboratory tests show
elevated levels of human chorionic gonadotropin (hCG), human
placental lactogen (hPL), and MSAFP (Cunningham et al, 2018).
Ultrasound determination of chorionicity (an examination of the
chorion), best performed around 10 to 13 weeks’ gestation, constitutes
an important component of modern management. The presence of
placental tissue between the layers of the intervening twin membrane
near the placenta is indicative of a dichorionic/diamniotic (DC/DA)
gestation, whereas the absence of intervening placental tissue
between the membranes is indicative of a single chorion (a
monochorionic/diamniotic [MC/DA] twin gestation). As a group, twins
contribute disproportionately to the overall perinatal morbidity/mortality
rate, and MC/DA twins demonstrate higher mortality rates than DC/DA
twins.
Twin-to-twin transfusion syndrome, a complication of monochorionic
twins, results from vascular connections or anastomoses (i.e., artery-
to-vein, artery-to-artery, vein-to-vein) within the single, monochorionic
placenta. In most cases, the vessels carry blood from one fetus to the
other without creating an imbalance of flow. However, if an imbalance
of blood flow occurs, one fetus receives a reduced blood volume
(eventually leading to oligohydramnios) while the other twin receives
an increased blood volume (eventually leading to polyhydramnios).
Without intervention, fetal death occurs 90% of the time in one or both
fetuses (Stagnati et al, 2017). Selective IUGR and twin-reversed
arterial perfusion sequence are other complications that may affect
monochorionic twins; management depends on the underlying cause
and the gestational age at the time of diagnosis.
Multiple gestation pregnancies are considered high risk; ideally an
appropriately trained specialist should manage the obstetric care.
Delivery should be planned to take place at a Level III facility that has
trained personnel who are prepared to deal with maternal or neonatal
complications. When a pregnancy is complicated by a multiple
gestation, the normal maternal physiological adaptations to pregnancy
are heightened. Complications that are associated with these changes
help to guide the clinical management. Consideration of maternal-fetal
physiological parameters along with ongoing surveillance is essential
in developing an appropriate plan of care.
Caring for the patient with a multiple gestation pregnancy can be
challenging, especially when complications arise. Hospitalization may
be needed because of the increased risk of complications, and the
nurse needs to remain cognizant of this. There is an increased risk of
pulmonary edema caused by the expanded plasma volume and
increased cardiac output. Also, nutritional requirements are increased.
Maternal caloric needs increase; in a singleton pregnancy a woman
needs to increase their caloric intake by 300 calories, but with twins
and triplets they need to increase by 600 and 900 per day (American
College of Obstetricians and Gynecologists, 2020b). Early in the
pregnancy, the patient may suffer from severe hyperemesis
gravidarum as a result of higher levels of pregnancy hormones found
in multiple pregnancies compared with singleton pregnancies. This
condition can lead to dehydration and poor nutrient intake and require
hospitalization for rehydration. At this time, the nurse can refer the
patient to a nutritionist and also review foods that might be more
appealing to the patient. Providing ongoing counseling about the
importance of regular prenatal care and the identification of signs and
symptoms of PTL and other complications constitutes a critical nursing
action throughout the pregnancy.
The nurse must also remain aware that the patients being cared for
are the woman (the primary patient) as well as each individual fetus.
Serial ultrasounds, nonstress tests (NSTs), and biophysical profiles
(BPPs) will be part of the ongoing assessment for fetal well-being and
growth. Fetal surveillance with EFM may be difficult, especially with
more than two fetuses. Triplet monitors are available that allow for the
tracing of three separate FHRs on a single channel, or two heart rate
tracings and a digital readout for the third fetus. It is best to monitor all
fetuses simultaneously, and the nurse should label which line
corresponds to which ultrasound transducer so that it is clear which
fetus is being monitored. The presenting twin is always “A,” with the
remaining fetuses (“B,” “C,” etc.) identified by relative ascending
positions. Although not common, late pregnancy changes in fetal
positions (e.g., male fetus B now in the position of female fetus A)
should be noted in the patient record. If no recent ultrasound has been
obtained, the nurse should identify each FHR by the appropriate
abdominal quadrant.
A multifetal pregnancy can cause many concerns for the family.
They often fear for the well-being of the babies, especially because
PTL is a major complication with multiples. The thought of the
everyday rigors of caring for several newborns at one time can
constitute another major cause of stress. If there are other children in
the household, the expectant couple may question how they are going
to be able to give the older siblings the care and time they will also
need. Family finances can be a great concern as well as the
affordability of child care when it is necessary for the mother to return
to work. The nurse can be supportive in encouraging families to voice
their concerns and address them as appropriately as possible. Helping
the family to prepare for the birth of the babies can be of great benefit.
The nurse may offer suggestions that include giving the older children
household chores appropriate for their age; alerting the partner’s
employer of a potential need to adjust the work schedule to help out at
home; or finding someone to help with housekeeping, grocery
shopping, laundry, cleaning, and/or child care. Other team members
such as social services can also provide valuable solutions to these
concerns. Referring the couple to a support group may also be
appropriate and welcomed.
INFECTIONS
Urinary Tract Infection
Urinary tract infection is the most common bacterial infection in
pregnancy. The three most common clinical syndromes associated
with UTI are asymptomatic bacteriuria, acute cystitis, and acute
pyelonephritis.
The physiological dilation of the urinary collecting system that occurs
normally during pregnancy is associated with an increase in ascending
urinary infections. Mechanical and hormonal changes may lead to
hydroureter, decreased peristalsis, bladder distention, and incomplete
emptying. These events can result in urine stasis or reflux in the
bladder and ureters (Cunningham et al, 2018).
The most common infecting organism is Escherichia coli (E coli);
other bacteria include Staphylococcus aureus, Klebsiella, Proteus,
Pseudomonas, Chlamydia, Enterobacter, Group B streptococcus
(GBS), and coagulase-negative staphylococci (Derese et al, 2016).
Bacteriuria in pregnancy predisposes the patient to the development of
acute pyelonephritis, a condition that poses significant risk to the
woman and her fetus. Asymptomatic and untreated bacteriuria has
been associated with a number of complications during pregnancy
including low birthweight, intrauterine death, pre-eclampsia, and
maternal anemia.
Asymptomatic bacteriuria is defined as the presence of at least 105
colony-forming units of bacteria per milliliter of clean, voided,
midstream urine in specimens obtained on two separate occasions. As
the name implies, the patient does not express any symptoms of a
UTI. Asymptomatic bacteriuria occurs in 2% to 11% of pregnancies (T.
L. King et al, 2018). Screening women for asymptomatic bacteriuria on
the first prenatal visit constitutes a standard of obstetric care (Derese
et al, 2016)). Treatment should be based on culture sensitivity so that
the correct antibiotic therapy can be initiated.
Optimizing Outcomes
When Caring for the Patient With an UTI

During pregnancy, a urine specimen is more likely to be contaminated by bacteria
that originate in the urethra, vagina, or perineum. This occurs because of a change
in pH during pregnancy. The urine becomes more alkaline as a result of the
maternal excretion of bicarbonate; the vagina also becomes alkaline and the
vaginal secretions have increased glycogen content, which aids bacterial growth.
Before collecting a midstream specimen, the nurse should instruct the patient
about the importance of proper cleansing.
A urinalysis and urine culture and sensitivity should be obtained on all patients
who present with signs of PTL, and the nurse must remember that signs of UTI
often mimic normal pregnancy complaints (i.e., urgency, frequency). It is important
to remind the patient to take all the medication that has been prescribed, even if
the symptoms subside and she feels better. A repeat urine test to evaluate
whether bacteria are still present should be obtained once the treatment has been
completed.
Group B Streptococcal Infection

Group B streptococcus is a common infection in which many women
do not show an active infection and have no symptoms. Women harbor
GBS as part of the normal fecal and vaginal flora and typically remain
asymptomatic and infection-free (Centers for Disease Control and
Prevention, 2019a). However, they can still colonize these bacteria in
the reproductive tract, frequently causing UTIs and chorioamnionitis
during pregnancy as well as endometritis postpartum. Unfortunately,
GBS can cause significant infections including sepsis and 4% to 6% of
newborns who have GBS infection will die. Newborns are at risk of
coming into contact of GBS when there is a vaginal birth and the
woman is GBS positive. The newborn will come in direct contact with
GBS, which can lead to early onset GBS infection. Late-onset GBS is
community acquired (the route of transmission is less clear and can be
nosocomial [acquired while in the hospital], environmental, or
maternal) and presents more than a week after birth.
To protect infants from GBS infections, recommended screening is
universal for maternal GBS infection. This includes obtaining vaginal
and rectal cultures from all pregnant women between 36 and 37 weeks
of pregnancy (American College of Nurse Midwives, 2019). Women
with positive cultures and those with unknown GBS status at the onset
of labor and any of the following: delivery at less than 37 weeks of
gestation; ruptured membranes greater than or equal to 18 hours; or
an intrapartum temperature greater than or equal to 100.4°F (38.0°C)
are treated with a penicillin-based anti-infective agent.
TORCH Infections
TORCH refers to a group of maternal infectious diseases that cause
harm to the embryo-fetus (Table 6-3). The TORCH acronym stands for
Toxoplasmosis, Rubella, Cytomegalovirus (CMV), and Herpes simplex
virus type 2 (HSV-2). Some sources identify the “O” as “other”
infections, such as hepatitis B, syphilis, and HIV. Maternal exposure to
the TORCH infections during the first 12 weeks of gestation is
associated with fetal developmental anomalies.
HIV and AIDS

HIV infection causes a slow but relentless destruction of the immune
system that ultimately results in AIDS. HIV is an increasing problem
among women of childbearing age as it can be transmitted in
pregnancy to the newborn, known as perinatal transmission. The risk
of perinatal transmission can be reduced if the woman complies with
their antiviral medication and the newborn completes a 4-6 week
course of postexposure HIV antiviral medications (Centers for Disease
Control and Prevention, 2020b).
Ideally, universal HIV screening should be offered before conception;
if not, testing should take place as early in the pregnancy as possible.
Women with HIV should be counseled in the preconceptional, prenatal,
and postpartum periods about appropriate antiviral medications and
risks (American College of Nurse Midwives, 2017). Screening with a
rapid HIV test is recommended for women who present in labor with an
unknown HIV status; if reactive, immediate antiretroviral prophylaxis
should be recommended.
TABLE 6-3
TORCH Infections
INFECTION/AGENT/TRANSMISSION DETECTION MATERNAL
EFFECTS
Toxoplasmosis Toxoplasma gondii Serological antibody Most infections are
Single-celled protozoan parasite. testing IgM-specific asymptomatic but
Transmitted transplacentally. antibody IgG may cause fatigue,
seroconversion from muscle pains,
negative to positive. pneumonitis,
Active infection myocarditis, and
indicated by a rise in lymphadenopathy.
IgG titer in two
appropriately spaced
tests. After 20 weeks
of gestation, fetal
blood samples can be
tested for the presence
of specific IgM.
Ultrasonography can
demonstrate severe
congenital
toxoplasmosis (e.g.,
ventriculomegaly,
intracranial
calcifications,
microcephaly, ascites,
hepatosplenomegaly,
intrauterine growth
restriction).
Other Hepatitis B DNA virus HBsAG identified 7–14 Course of the
Transmitted via direct contact with days after exposure; disease is not altered
blood or body fluids from an HBsAb present with during the
infected person. HBsAG indicates pregnancy, and
noninfectious stage 30%–50% of infected
women are
asymptomatic. When
present, symptoms
include low-grade
fever, nausea,
anorexia, jaundice,
hepatomegaly,
malaise, preterm
labor, and preterm
birth.
Rubella (German measles) Caused Rubella-specific IgM Erythematous
by the rubella virus. Transmitted via antibodies maculopapular rash
nasopharyngeal secretions; also Rubella antibody titer on face, neck, arms,
transplacentally of 1:8 or more and legs lasting 3
indicates immune days.
status Also, lymph node
enlargement, slight
fever, malaise,
headache, and
arthralgia.
Cytomegalovirus DNA virus of the Serology of CMV- Most infections are
herpes group. Transmitted by specific IgM antibody asymptomatic, but
droplet infection and contact with when present (15%
infected secretions (saliva, urine, of adults) include a
breast milk, cervical mucus, mononucleosis-like
semen); also transplacentally syndrome (e.g.,
fever, pharyngitis,
lymphadenopathy,
polyarthritis).
Severity varies with gestational age Pregnant women who Teach women: avoid
(i.e., the earlier the fetus is infected, acquire toxoplasmosis consuming raw or
the more severe the disease); should be treated with poorly cooked meat,
congenital infection can result if acute spiramycin. If fetal especially pork,
toxoplasmosis occurs during infection is lamb, or venison and
pregnancy (especially likely in third established, treatment do not touch the
trimester). Can cause spontaneous consists of a hands or mouth after
abortion, low birth weight, combination of handling
hepatosplenomegaly, icterus, anemia, pyrimethamine, undercooked meat;
neurological disease, and sulfadiazine, and avoid contact with
chorioretinitis folinic acid, alternating cat feces; peel or
with spiramycin to thoroughly wash
eradicate parasites in fruits and
the placenta and in the vegetables.
fetus. Approximately 50%
of adults have an
antibody to this
organism.
Stillbirth Mother: Women at risk
Neonates may be infected following No specific treatment, include:
exposure to maternal blood, genital but may include Pregnant women
secretions at birth. 1 in 1,000–8,000 bedrest and a high- from China,
infants have a 90% chance of protein, low-fat diet Southeast Asia,
becoming chronically infected, HBV Infant: HBIG
carrier and a 25% risk of developing HBV vaccine Africa, Philippines,
significant liver disease; recommended (three and Indonesia
95% can be prevented with doses) Eskimos
prophylaxis at birth; Prostitutes
90%–95% of those infected are Homosexuals
symptomatic and become chronic IV drug users
hepatitis B carriers Hemophiliacs
Transfusion
recipients
People with other
sexually transmitted
diseases or multiple
sex partners
CDC recommends
universal screening
of all prenatal
patients.
Hepatitis B vaccine
can be safely given
in pregnancy at 0, 1,
and 6 months
(standard schedule),
or at 0, 1, and 4
months (accelerated
schedule).
Mother-to-child
transmission of HBV
occurs in 10%–20%
of women who are
seropositive for
HBsAG and in 90%
of women who are
seropositive for both
HBsAG and HBcAg.
Overall risk of congenital rubella Women with rubella Occurs most often in
syndrome is 20% for primary maternal require no special the springtime, and
infection in the first trimester; 50% if therapy other than mild an estimated
maternal infection occurs during the analgesics and rest. 6%-25% of women
first 4 weeks of gestation; and 25% if Infants born with are susceptible.
the infection occurs in the 2nd 4-week congenital rubella may Inquire about history
period after conception. shed virus for many of exposure 3 weeks
Congenital spectrum anomalies months and thus be a earlier.
include: threat to other infants, Vaccine is
Deafness (60%–75%) contraindicated
Eye defects (10%–30%) as well as to during pregnancy.
CNS anomalies (10%–25%) susceptible adults. Patient counseling: If
Cardiac malformation (10%–20%) nonimmune (i.e.,
absence of rubella
antibody), she
should be vaccinated
immediately
postpartum and use
contraception for a
minimum of 1 month
after vaccination.
Infection to fetus most likely with Mother: treat Factors associated
primary maternal infection and timing: symptoms with increased risk of
first and second trimester exposure Infant: no satisfactory maternal infection
associated with more severe effects: treatment is available; include history of
low birth weight, IUGR, microcephaly isolate the infant. abnormal cervical
CNS abnormalities, mental and motor Ganciclovir may cytology, lower
retardation, intracranial calcifications, prevent hearing loss socioeconomic
sensorineural deafness, blindness with and developmental status, birth outside
chorioretinitis, intellectual and outcomes in infants North America, first
developmental disabilities, born with symptomatic pregnancy at
hepatosplenomegaly, jaundice congenital CMV younger than 15
infection with CNS years, and history of
involvement, but this STI. Day care
antiviral medication centers can be a
has serious side common source of
effects. infection.
Counsel patients at
high risk (e.g., those
with young children
or who work with
young children):
carefully handle
potentially infected
articles (e.g.,
diapers), practice
safe-handling
techniques such as
rigorous hand
washing and the use
of latex gloves, avoid
high risk behaviors
(e.g., IV drug use,
sharing of needles),
use condoms.
Maternal immunity
does not eliminate
the possibility of fetal
infection.
Vaccine is available
but more research is
needed.
Counsel patients:
maintain rigorous
personal hygiene
throughout
pregnancy.
Herpes simplex virus (HSV) Double- Tissue culture (swab Painful genital
stranded DNA virus, associated specimen from vesicle lesions
with chronic infection. Transmitted vesicles) (may be present on
via viral exposure at time of birth Immunofluorescent the cervix, vagina, or
and ascending infection, also staining of the cell can external genitalia).
transplacental transmission is differentiate HSV-1 The primary infection
possible if initial infection occurs from HSV-2 is commonly
during pregnancy. associated with
fever, malaise and
myalgia, numbness,
tingling, burning,
itching, and pain.
May also have
lymphadenopathy
and urinary retention.
Sources: CDC (2018), CDC (2020b), Croke (2019), Cunningham et al (2018), King et
al (2018)
The risk of perinatal transmission (vertical transmission) to the fetus
or newborn is proportional to the concentration of virus in maternal
plasma (viral load). Vertical transmission occurs antepartally when the
virus crosses the placenta, intrapartally when it travels (via the
bloodstream) from the vagina up into the uterus during labor or
following ROM, or postpartally through transfer in the breast milk.
Transmission of HIV to the fetus or infant is believed to most often
occur late in pregnancy or during labor and birth. Increased rates of
transmission also occur with advanced maternal disease and ruptured
membranes and after events during labor and delivery that increase
fetal exposure to maternal blood.
SYSTEMIC LUPUS ERYTHEMATOSUS

Systemic lupus erythematosus is a chronic multisystem inflammatory
disorder. It is characterized by an autoimmune antibody production that
results in an inflammation of the connective tissue in various organs or
systems in the body. The disease tends to affect young women in the
second, third, and fourth decades of life but may occur in any age-
group. The prevalence of SLE is approximately 1 per 1,000 in the
general population, and 90% of cases.
The immune system is composed of specialized cells that destroy
invading organisms by phagocytosis and antibody and lymphocyte
production. When a foreign organism or antigen enters the body, it is
consumed by macrophages and then passed on to lymphokines, which
present the antigens to the T and B lymphocytes. The B lymphocytes
are activated, resulting in the production of an increased number of
circulating antibodies that target their specific antigen. The antigen-
antibody complex either promotes destruction of the antigen or
activates the normal inactive proteins in the complement system. With
SLE, the body fails to recognize its own proteins. The clinical
manifestations result from inflammation of multiple organ systems,
especially the joints, skin, kidneys, nervous system, and serous
membranes.
Adverse pregnancy outcomes are more common in SLE than in any
other rheumatic disease. In the presteroid era, it was common practice
to terminate pregnancy in patients with active SLE. However, with
successful treatment of active disease with corticosteroids, this
practice has become less frequent. Patients are more likely to have
inactive SLE at the onset of pregnancy because of earlier disease
diagnosis and more effective prepregnancy therapy, as well as
appropriate prepregnancy counseling. Recommendations for
pregnancy include inactive disease state for at least 6 months
depending on the degree of known organ damage (Petri, 2020).
Pregnancy outcome is improved in the following circumstances: SLE
has been in remission for at least 6 months; there is no active renal
involvement; superimposed pre-eclampsia does not develop; and there
is no evidence of antiphospholipid antibody activity (Cunningham et al,
2018).
The patient with SLE should be seen frequently by both an internist-
rheumatologist and a perinatologist specializing in high-risk cases.
Assessment of the signs and symptoms of an impending SLE flare-up
should be elicited on the patient’s history and physical examination,
and blood samples should be obtained for serological evaluation. A
rise in the anti-dsDNA antibody titer and a decrease in complement
may be predictive of an exacerbation of SLE. The onset of edema and
hypertension in pregnancy in these patients is characteristic of both
pre-eclampsia and active SLE-associated nephritis. Because the
treatment of these conditions is very different, the importance of an
accurate diagnosis is essential. When SLE complicates the pregnancy,
there is an increased risk of SAB, PROM, PTL, preterm birth,
intrauterine growth restriction (IUGR), stillbirth, neonatal lupus, and
neonatal death (Petri, 2020).
Management of SLE is aggressive and includes immunosuppression
of lupus flare with corticosteroid therapy, nonsteroidal anti-
inflammatory drugs, antimalarial agents, azathioprine, and careful fetal
surveillance. If the disease flares during the pregnancy, treatment must
be implemented as quickly as possible. The physician assesses the
manifestations and extent of the disease exacerbation and selects the
safest, most effective therapy. The patient’s health must be deemed
the first priority, and the treatment is planned accordingly. When caring
for patients with SLE, nurses should offer support and remain alert for
early indicators of SLE exacerbation and pregnancy complications.
Patients and their families should be educated about the plan of care,
the need for close surveillance, and the importance of effective family
planning after the birth.
RHO(D) ISOIMMUNIZATION
Hemolytic disease of the fetus and newborn is a condition in which the
life span of the fetal or neonatal RBCs is shortened by the action of
maternal antibodies against antigens present on the fetal and neonatal
RBCs. Antigens provoke an immune reaction if an incompatible blood
cell enters the circulation. The RBCs are agglutinated and destroyed.
The two most problematic types are those of the rhesus (Rh) system
and the ABO system. Maternal antibodies form in the Rh(D)-negative
mother after exposure to Rh(D)-positive fetal blood. Theoretically, no
mixing of fetal and maternal blood occurs during pregnancy and
childbirth. In reality, however, drops of fetal blood most likely enter the
maternal circulation after small placental “accidents.” The development
of maternal antibodies, which destroy the fetus’ Rh(D)-positive blood,
is termed isoimmunization, alloimmunization, or sensitization. In
addition to the Rh system, there are more than 400 different antigens
found on the surface of RBCs. The incidence of hemolytic disease in
the newborn has dramatically declined with the advent of Rho(D)
immune globulin (RhoGAM).
Pathophysiology
For Rh(D) maternal isoimmunization to occur, at least three
circumstances must exist:
■ The fetus must have Rh(D)-positive erythrocytes, and the mother
must have Rh(D)-negative erythrocytes.
■ A sufficient number of fetal erythrocytes must gain access to the
maternal circulation. This amount can be as little as 0.1 mL.
■ The mother must have the immunogenic capacity to produce
antibodies directed against the D antigen.
Fetal RBCs gain access to the maternal circulation during
pregnancy, childbirth, and in the immediate postpartum period. Clinical
factors such as cesarean birth, multiple gestation, bleeding placenta
previa or abruption, manual removal of the placenta, and intrauterine
manipulation may increase the chance of substantial hemorrhage.
Rho(D) immune globulin (such as RhoGAM) works by coating and
destroying fetal cells in the maternal circulation. Rho(D) immune
globulin must be given within 72 hours, and its effects last for 3
months. To ensure that the correct amount of Rho(D) immune globulin
(sometimes more than one 300-mcg vial is required) is given to the
patient, a fetal screen or Kleihauer-Betke blood test is performed on
the woman’s blood after it has been determined that the baby is Rh(D)-
positive. This test estimates the number of fetal RBCs in the mother’s
circulation. In most situations, exposure of maternal blood to fetal
blood occurs during the third stage of labor at the time of placental
separation. The woman’s first child is usually unaffected because the
maternal antibodies form after the infant’s birth. However, subsequent
Rh(D)-positive fetuses may be affected unless the woman receives
Rho(D) immune globulin to prevent antibody formation. Rho(D) immune
globulin must be given after the birth of every Rh(D)-positive infant
(Fig. 6-13). The information presented in Box 6-9 helps to simplify what
can be a very confusing clinical situation.
When antibodies to the Rh factor are present in the pregnant
patient’s blood (i.e., the woman is sensitized), they freely cross the
placenta and destroy the RBCs of the Rh(D)-positive fetus. Over time,
the fetus develops an RBC deficiency, the fetal bilirubin levels rise
(“icterus gravis”), and severe neurological disease (“bilirubin
encephalopathy”) may result. In the fetus, this pathological process
triggers a rapid production of erythroblasts (immature RBCs) that are
unable to carry oxygen. The syndrome associated with this hemolytic
process is termed erythroblastosis fetalis. Fetal anemia and
generalized edema (“hydrops fetalis”) develop and lead to fetal
congestive heart failure.
Figure 6-13 The Rh isoimmunization sequence. Rh+ father and Rh-

mother; Rh+ fetus. During pregnancy or childbirth, a small amount of
fetal blood enters the mother’s circulation. The mother’s immune
system produces anti-Rho(D) antibodies (triangles). In subsequent
pregnancies with an Rh+ fetus, the antibodies cross the placenta,
enter the fetal circulation, and attack the fetal red blood cells, causing
hemolysis.
BOX 6-9
Simplifying and Understanding the Rh Factor
RH FACTOR
Rh(D)-positive: Persons who have the D genotype: The Rh antigen is present on
their erythrocytes
Rh(D)-negative: Persons who DO NOT possess the antigen on their RBCs
Anti-Rh antibodies do not spontaneously occur and are only formed if there is
sensitization by Rh(D)-positive cells entering the circulation of the Rh(D)-negative
person. The Rh(D)-negative person develops antibodies against the Rh(D)-
positive cells. This is why the first pregnancy is not affected, UNLESS the mother
was previously sensitized during a miscarriage, amniocentesis, or antepartum
hemorrhage.
EXAMPLE
Rh(D)-negative mother gives birth to an Rh(D)-positive baby and some of the
baby’s blood enters the mother’s system at the time of delivery. (It takes only 0.1
mL.) Mother develops antibodies against any future Rh(D)-positive babies.
During the prenatal period, all Rh(D)-negative women receive an

antibody titer (indirect Coombs’ test) to determine whether they are
sensitized from a previous exposure to Rh(D)-positive blood. If the test
is negative, another antibody titer is obtained at 28 weeks of gestation
to rule out sensitization that may have occurred later in the pregnancy.
If the woman remains unsensitized, Rho(D) immune globulin is given
as a preventive measure to prevent formation of active antibodies
during the remainder of pregnancy. After birth, if the infant is Rh(D)-
positive, another dose of Rho(D) immune globulin is administered. If
the infant is Rh(D)-negative, no Rho(D) immune globulin is necessary.
If the prenatal patient’s indirect Coombs’ test is positive, sensitization
has occurred and antibodies against Rh(D)-positive erythrocytes are
present in the maternal circulation. In this situation, the patient’s
antibody titer is repeated frequently throughout pregnancy to identify a
rising level. A rise in the maternal antibody titer is indicative of ongoing
antibody formation and an increased likelihood of fetal erythrocyte
destruction.
MEDICATION: Rho(D) Immune Globulin
(RhoGAM, HypRho-D, BayRho-D, Gamulin Rh,
Rhophylac)
(arr aych oh dee im-yoon glob-yoo-lin)
Pregnancy Category: C
Indications: Administered to Rh(D)-negative women who have been exposed to
Rh(D)-positive blood by:
Delivering an Rh(D)-positive infant
Aborting an Rh(D)-positive fetus
Having chorionic villus sampling (CVS), amniocentesis, or intra-abdominal
trauma while carrying an Rh(D)-positive fetus
Accidental transfusion of Rh(D)-positive blood
Action: Prevents production of anti-Rho(D) antibodies in Rh(D)-negative patients
who were exposed to Rh(D)-positive blood by suppressing the immune reaction of
the Rh(D)-negative woman to the antigen in the Rh(D)-positive blood.
Therapeutic Effects: Prevents antibody response and subsequently prevents
hemolytic disease of the newborn (erythroblastosis fetalis) in future pregnancies
of women who have conceived an Rh(D)-positive fetus. Prevention of Rho(D)
sensitization following transfusion accident.
Pharmacokinetics:
ABSORPTION: Well absorbed from IM sites.
CONTRAINDICATED IN: Rho(D)- or Du-positive patients; patients previously
sensitized to Rho(D) or Du.
Adverse Reactions and Side Effects: Pain at IM site
Route and Dosage: One vial standard dose (300 mcg) administered IM:
• At 28 weeks of pregnancy and within 72 hours of delivery.
• Within 72 hours after the termination of a pregnancy of 13 weeks or more of
gestation.
• After an accidental transfusion, dosage is calculated based on the volume of
blood that was erroneously administered.
One vial MICRhoGAM (microdose) (50 mcg) within 72 hours after CVS or the
termination of a pregnancy of less than 13 weeks of gestation.
Note: (l) More than 300 mcg of RhoGAM may be indicated after a large
transplacental hemorrhage or after a mismatched blood transfusion; (2)
Rhophylac can be given IM or IV (prefilled syringes are available).
1. Do not give to infant, to Rh(D)-positive individual, or to Rh(D)-negative
individual previously sensitized to the Rho(D) antigen. Note: There is no more
risk than when given to a woman who is not sensitized—if in doubt, administer
Rho(D) immune globulin.
2. Administer into the deltoid muscle. Should be given within 3 hours but may be
given up to 72 hours after delivery, miscarriage, abortion, or transfusion.
3. Explain to the patient the purpose of this medication to protect future Rh(D)-
positive infants; before administering, obtain a signed consent form if required
by the agency.
4. Special considerations may be indicated for women who are members of
Jehovah’s Witnesses because this medication is made from human plasma.
Source: Data from Vallerand, A. H., & Sanoski, C. A. (2021). Davis’s drug guide
for nurses (17th ed.). Philadelphia, PA: F.A. Davis.
Management
Prevention of isoimmunization (a rising anti-Rh antibody titer in an
Rh(D)-negative woman) is the goal throughout pregnancy. All pregnant
women should be tested for ABO and Rho(D) type along with an
antibody screen during their first prenatal visit. It is essential that these
determinations be made during each subsequent pregnancy, as
previous maternal antibody screening is not an adequate assessment.
Rho(D) immune globulin (RhoGAM) should also be given at any time
during the pregnancy when a possibility exists that a patient may be
exposed to fetal blood (e.g., CVS, amniocentesis, miscarriage, vaginal
bleeding, abortion, and ectopic pregnancy).
Optimizing Outcomes
Safe Administration of Rh (D) Immune Globulin (RhoGAM)
In an Rh(D)-negative woman who is nonsensitized, RhoGAM should be given after
delivery of an Rh(D)-positive infant. In the United States, the standard dose is 300
mcg given within 72 hours of delivery. Remember to educate your patient as to the
reason she is receiving RhoGAM.
Be sure to give your patient documentation that she has received RhoGAM.
Never give RhoGAM to:
• An Rh(D)-positive woman
• A sensitized Rh(D)-negative woman
• An Rh(D)-negative woman who has given birth to an Rh(D)-negative baby
• The baby or father of the baby
ABO
In this condition the mother is blood group O, and the baby is either A
or B. This form of blood incompatibility is unrelated to the Rh factor. It
is important for nurses to remember that blood group O carries no
antigens; group A carries A antigen, and group B carries B antigen.
Because the mother already has anti-A and anti-B antibodies present
during the first pregnancy, the first child may be affected. IgG
antibodies (immunoglobulins that respond to a specific antigen, in this
case, A or B) can cross the placenta and cause hemolysis of the fetal
RBCs.
The Coombs’ test is performed on the baby’s cord blood obtained at
the time of birth. A direct Coombs’ test identifies the presence of
maternal antibodies in the neonate’s blood and hemolysis or lysis of
RBCs, whereas the indirect Coombs’ test detects antibodies against
RBCs in the maternal serum. The results are reported as either
positive or negative. A positive direct Coombs’ test must be reported to
the pediatrician.
RESPIRATORY COMPLICATIONS
Pulmonary diseases have become more prevalent in the general
population and therefore in pregnant women. The normal physiological
changes of pregnancy can cause a woman with a history of
compromised respirations to develop significant problems. The
outcome for a pregnant woman with respiratory complications depends
on the adequacy of ventilation and oxygenation and the early detection
of respiratory compromise. Hypoxia poses a major threat to the fetus.
Asthma
Asthma is the most common form of lung disease that affects
pregnancy, characterized by limited airflow that is generally more
marked during expiration than during inspiration. Asthma
exacerbations occur in approximately 45% of pregnant women with
asthma (Murphy, 2015). Asthma is associated with significant risks for
both the fetus. There is little risk to the fetus with well-controlled
maternal asthma, and it is safer for pregnant asthmatics to be treated
with appropriate medications than to have asthma symptoms and
exacerbations. Exacerbations that cause hypoxia and decreased
uterine blood flow increase the incidence of IUGR, preterm birth, and
neonatal mortality.
Management
Careful monitoring and appropriate adjustments in therapy may be
required to maintain maternal lung function and ensure an adequate
oxygen supply to the fetus. Guidelines for asthma management have
been developed to help ensure maternal-fetal safety and well-being
during pregnancy. Goals of therapy include optimal control of asthma
symptoms, attainment of normal pulmonary function, prevention and
reversal of asthma attacks, and prevention of maternal and fetal
complications. Asthma therapy is based on a stepwise classification
system designed to control symptoms, avoid acute attacks, and help
patients achieve unhampered lifestyles (Murphy, 2015).
Medications currently used for asthma are generally well tolerated
during pregnancy and appear to be safe for the fetus. Therefore, the
management of asthma in the pregnant woman differs little from
management in the nonpregnant patient. It is also widely accepted that
the fetal risk is higher with poorly controlled maternal asthma than with
medications necessary to gain optimal symptom control. Research has
shown poor compliance with medications, making patient education
regarding the need for adherence a critical aspect in controlling and
preventing asthma exacerbations (Murphy, 2015)
DIABETES IN PREGNANCY
Diabetes during pregnancy encompasses a range of disease entities,
including gestational diabetes mellitus (GDM) and overt diabetes
mellitus. Diabetes complicates approximately 2% to 10% of all
pregnancies each year in the United States (Centers for Disease
Control and Prevention, 2020a). Diabetes is a complex health-care
problem that requires a comprehensive, multidisciplinary approach to
ensure positive outcomes for both the patient and her infant. When
working with this population, perinatal nurses are challenged to provide
care and education that incorporates diabetes management principles
into obstetric care during all phases of childbearing, from
preconception through the postpartum period.
Definition and Classification of Diabetes Mellitus

Pregestational Diabetes Mellitus
Pregestational diabetes mellitus is a chronic metabolic disease
characterized by hyperglycemia that results from limited or absent
insulin production, deficient insulin action, or a combination of the two.
Diabetes is divided into two broad categories—type 1 and type 2—that
are differentiated according to the primary underlying etiology. Type 1
diabetes (formerly termed “insulin-dependent diabetes mellitus”) is
characterized by an autoimmunity directed at the pancreatic beta cells.
With type 1 diabetes, there is an absolute insulin deficiency, requiring
the patient to have insulin treatment and management.
Optimizing Outcomes
Preconception Care for Pregestational Diabetes Mellitus
Nurses who care for childbearing-age women with diabetes mellitus are perfectly
positioned to offer preconceptional counseling during every patient contact.
Women should be taught about the adverse obstetric and maternal outcomes that
may result from poorly controlled diabetes and the importance of euglycemic
control before pregnancy. Depending on the situation, testing to assess for
vascular changes may include a retinal examination, 24-hour urine collection for
protein excretion and creatinine clearance, and electrocardiography. Thyroid
function studies may also be indicated, and all women who contemplate
pregnancy should receive a multivitamin containing at least 400 mcg of folic acid,
especially important in women with diabetes, who have an increased risk for
offspring with neural tube defects (ACOG Practice Bulletin No. 201: Pregestational
Diabetes Mellitus, 2018).
Gestational Diabetes Mellitus

Gestational diabetes mellitus is an impairment in carbohydrate
metabolism that first manifests during pregnancy. Changes in
carbohydrate, protein, and fat metabolism in normal pregnancy are
profound, mediated in part by the developing fetus and the production
of placental hormones. The first half of pregnancy is considered an
anabolic phase. It is associated with an increased storage of fat and
protein, along with an increase in the secretion of estrogen and
progesterone. These physiological events lead to maternal hyperplasia
and hyperinsulinemia. The increased insulin production prompts an
increased tissue response to insulin and the increased uptake and
storage of glycogen and fat in the liver and tissues.
The second half of pregnancy is characterized by a catabolic phase
associated with the breakdown of protein and fat. During this time
there is also an increased insulin resistance caused by the heightened
production of placental hormones (insulinase and hPL), cortisol, and
growth hormones. These hormones are diabetogenic and act as insulin
antagonists. In women who cannot meet the increasing needs for
insulin production, this change leads to an altered carbohydrate
metabolism and progressive hyperglycemia.
During this time, the developing fetus continuously removes glucose
and amino acids, substances that can easily cross the placenta, from
the maternal circulation. Because insulin does not cross the placenta,
the fetus must increase its own insulin production. Fetal
hyperinsulinemia develops and acts as a growth hormone that
contributes to an increase in fetal size (macrosomia) and a decrease in
pulmonary surfactant production. Macrosomia occurs in 20% to 25% of
diabetic pregnancies. When the pregnant woman’s blood glucose
levels remain abnormally elevated, there is a constant transport of
maternal glucose across the placenta. This “glucose load” prompts the
fetus to produce insulin at a greater rate to use the glucose.
During the first trimester, maternal blood glucose levels are normally
reduced and the insulin response to glucose is enhanced. The woman
with well-controlled pregestational diabetes may need a decrease in
her insulin dosage to avoid hypoglycemia. During the second and third
trimesters, as the insulin requirements steadily increase, the insulin
dosage must be adjusted to prevent hyperglycemia. Maternal insulin
resistance begins around 14 weeks of gestation and continues to
increase until it stabilizes during the final weeks of pregnancy.
These factors increase a woman’s risk of developing gestational
diabetes:
■ Age older than 25
■ Obesity
■ Insulin resistance
■ Polycystic ovary syndrome
■ History of pregnancy-related diabetes mellitus
■ History of a large for gestational age infant
■ Hydramnios
■ Stillbirth, miscarriage, or an infant with congenital anomalies during a
previous pregnancy
■ Family history of type 2 diabetes (first-degree relative)
■ Ethnicity
Maternal and Perinatal Morbidity and Mortality

The changes in the maternal milieu that characterize the diabetic state
can have profound effects on the growth and development of the fetus,
increase the risk of perinatal morbidity and mortality, and exert adverse
effects throughout life. The physiological adaptations induced by
pregnancy can unmask latent maternal diabetes or result in transient
worsening of pre-existing vascular compromise. Diabetic women are
four times more likely to develop pre-eclampsia or eclampsia, require a
C-section, and develop diabetes later in life (American College of
Obstetricians and Gynecologists, 2018b). The rates of infection,
hydramnios, postpartum hemorrhage, and cesarean birth increase. In
the long term, GDM is also associated with impaired insulin tolerance
and the manifestation of diabetes in later life (Centers for Disease
Control and Prevention, 2020a).
Major fetal effects associated with diabetes include a fivefold
increase in perinatal death and a two- to threefold increase in the rate
of congenital malformations. Early in pregnancy, the fetus is at risk for
congenital malformations and poor fetal growth. Congenital defects
result from the teratogenic effects of hyperglycemia during the time of
organogenesis during the early gestational weeks. Late in pregnancy,
the fetus is at risk for growth abnormalities and sudden intrauterine
death. Macrosomia can also occur in the fetus, thereby increasing the
risk of dystocia and hypoglycemia.
Control of maternal glucose levels is an important factor in
determining fetal outcome. The glycosylated hemoglobin A (HbA1c)
level is commonly assessed to guide adjustments in the treatment plan
throughout pregnancy. Because the maternal serum HbA1c reflects the
degree of glycemic control during the preceding 5 to 6 weeks, the test
is repeated every trimester. Good diabetic control is reflected by an
HbA value of 2.5% to 5.9%; an HbA value greater than 8% is indicative
of poor diabetic control. In the absence of prepregnancy and prenatal
care, the rate of perinatal mortality for the diabetic patient and her fetus
may be as high as 40%. However, with close, meticulous care, the
perinatal mortality rate can be reduced.
What to Say
Teaching Patients About Hypoglycemia
Hypoglycemia occurs more frequently in pregnancy than at other times, especially
in patients with type 1 pregestational diabetes mellitus. When teaching about
hypoglycemia, the nurse should include the following information:
• Hypoglycemia is a condition that occurs when your blood sugar levels decrease
to less than 60 mg/dL.
• It is more common during pregnancy.
• Symptoms include light-headedness, shaking, headache, sweating, confusion,
hot flashes, nervous and anxiety attacks, intense hunger, sudden irritability, and
changes in vision.
• It is important that you and your family are able to immediately recognize and
respond to hypoglycemia.
• Drinking a glass of milk is better than a glass of juice that contains high levels of
glucose.
• Always keep glucagon on hand for severe hypoglycemia or loss of
consciousness.
Diagnostic Tools
Screening Pregnant Women for GDM
According to ACOG, all pregnant women should be screened for GDM, whether
by patient history, clinical risk factors, or a 50-g, 1-hour loading test to determine
blood glucose levels at 24 to 28 weeks of gestation. Women with high risk factors
(previous medical history of GDM, known impaired glucose metabolism, obesity
[body mass index greater than or equal to 30]) should be screened earlier in
pregnancy; if diabetes mellitus is not diagnosed, blood glucose testing should be
repeated at 24 to 28 weeks of gestation (American College of Obstetricians and
Gynecologists, 2018b).
In the United States, most centers use the following diagnostic
recommendations and criteria established by the National Diabetes Data Group:
• The Glucose Challenge Test (Glucola screening): A 50-g oral glucose solution is
administered to the woman and a blood sample is taken 1 hour after it is
consumed. Patients with a 1-hour plasma glucose value that exceeds 130 to
140 mg/dL (depending on the laboratory used) should be further evaluated with
the formal 3-hour oral glucose tolerance test (OGTT).
• The 3-hour OGTT requires the fasting patient to ingest 100 g of glucose with
blood drawn at 1-hour intervals. Before the test, the woman should avoid
caffeine (it may increase glucose levels) and refrain from smoking at least 12
hours before and during the test. The diagnosis of GDM is made when two
values or more of the threshold are above the norm. The normal plasma values
are:
Fasting blood sugar <95 mg/dL
1 hour <180 mg/dL
2 hour <155 mg/dL
3 hour <140 mg/dL
Management
The goal of modern glycemic management during the diabetic
pregnancy is to maintain blood glucose levels as close to normal
(euglycemia) as possible. Metabolic monitoring during pregnancy is
directed at detecting hyperglycemia and making all necessary
pharmacological, dietary, or activity adjustments to minimize any
adverse effects to the fetus. Home blood glucose monitoring with a
glucose reflectance meter or biosensor monitor is a widely accepted
method for monitoring blood glucose levels and an essential tool for
helping the woman to assess her degree of blood glucose control (Fig.
6-14). Patients monitor their blood glucose levels daily, record the
findings, and bring their blood glucose logs with them to each prenatal
appointment.
Continuous Blood Glucose Monitors

Self-monitoring of blood glucose (SMBG) via the intermittent
monitoring of capillary blood has brought significant improvements to
the care of patients with diabetes. Recently, continuous glucose
monitoring (CGM) has become available. This modality, which provides
real-time glucose data, offers patients and providers a tool to use along
with SBGM to achieve a more complete picture of 24-hour blood
glucose patterns. CGM can identify sudden blood glucose drops,
hyperglycemia, and postprandial changes in glucose levels that cannot
be identified with intermittent glucose monitoring. Pregnant women
may especially benefit from this added information because glycemic
goals during pregnancy are more stringent.
Figure 6-14 Blood glucose monitoring is an essential component of

care for the pregnant patient with diabetes.
Fetal Surveillance
Ongoing fetal surveillance is of utmost importance. Maternal care requires the
cooperative efforts of a clinical team that includes the obstetrician, internist,
endocrinologist, diabetes educator, neonatologist, dietitian, and nurse. Ultrasound
examinations throughout the pregnancy are useful in determining viability and
accurately establishing the gestational age early in pregnancy, diagnosing fetal
complications and macrosomia. Patient education is essential to ensure that the
woman understands her diabetic state and the need to adhere to treatment so
that an optimal outcome is achieved. Social services, home nursing visitation, and
spiritual support are often involved as well.
Insulin and Oral Hypoglycemic Therapy

Optimal glycemic goals for GDM include a fasting venous plasma
glucose concentration less than or equal to 95 mg/dL and a 1-hour
postprandial plasma glucose of less than or equal to 140 mg/dL. Blood
glucose self-monitoring is recommended. Although diet and exercise
are the mainstays of care for the woman with GDM, up to 20% will
require insulin during pregnancy to maintain euglycemia. If fasting
blood glucose levels exceed 105 mg/dL, insulin therapy is initiated.
Most insulin used to treat pregestational diabetes mellitus is
biosynthetic human insulin such as lispro or aspart, which are short- or
rapid-acting insulin analogs that mimic physiological insulin action. The
analogs can be given closer to a meal (i.e., 5–10 minutes vs. 30–45
minutes) than regular insulin, but patients must be warned that
significant hypoglycemia can occur if they do not eat promptly after
administering the medication. Often, a four-dose regimen that
combines a short-acting (preprandial) with a long-acting (bedtime
dosing) insulin is used. Patients who are highly motivated and
compliant may wish to use an insulin pump, which delivers a
continuous subcutaneous infusion of a rapid-acting insulin such as
lispro, which has been shown to be more effective in maintaining
desired glucose levels and in reducing the risk of fetal macrosomia
(ACOG, 2018; Hurst, 2011).
Oral hypoglycemic agents, which cross the placenta and have not
been well studied in pregnancy, are generally not used. However,
glyburide (Glynase, Micronase), a second generation oral sulfonylurea,
does not cross the placenta and has been used to treat GDM.
Glyburide has been found to be comparable to insulin in improving
glucose control without evidence of adverse maternal and neonatal
complications. According to ACOG (2018), the use of oral agents for
the control of type 2 diabetes mellitus during pregnancy should be
limited and individualized until the safety and efficacy of these
medications have been confirmed.
THE THYROID GLAND AND PREGNANCY

Thyroid disorders are relatively common among pregnant women. The
hormonal changes and increasing metabolic demands of pregnancy
bring about complex compensatory alterations in maternal thyroid
function. Human chorionic gonadotropin, which is at its highest levels
in early pregnancy, possesses intrinsic, weak thyroid-stimulating
activity. Thyroid-stimulating hormone levels fall during the first
trimester, and this decrease parallels the rise in the production of hCG.
Thyroid disease in pregnancy has serious adverse consequences,
including increased risk of miscarriage, gestational hypertension,
placental abruption, postpartum hemorrhage, low birth weight infants,
and negative cognitive development (Gorringe, 2019).
Hyperthyroidism
Hyperthyroidism occurs when there is excessive levels of the thyroid
hormone thyroxine (T4) and triiodothyronine (T3) (Venes, 2021). The
signs and symptoms of mild to moderate hyperthyroidism are common
during pregnancy (heat intolerance, diaphoresis, fatigue, anxiety,
emotional lability, tachycardia, insomnia, and a wide pulse pressure).
However, weight loss, tachycardia greater than 100 beats per minute,
and diffuse goiter (enlargement of the thyroid gland) are clinical
features suggestive of hyperthyroidism. Gastrointestinal symptoms
(i.e., severe nausea, excessive vomiting, and diarrhea),
cardiomyopathy, lymphadenopathy, and congestive heart failure can
also accompany thyrotoxicosis (excessive thyroid activity) in
pregnancy. Establishing a diagnosis of maternal hyperthyroidism can
be challenging because of the myriad of metabolic and hormonal
changes that normally take place during pregnancy. However, a
depressed maternal serum TSH concentration and an elevated T4 and
T3 level are useful in confirming the diagnosis. Early treatment of
hyperthyroidism is imperative because of the potential for serious
maternal and fetal complications including low birth weight infants,
preterm delivery, and pre-eclampsia (King et al, 2016).
Treatment
Treatment for hyperthyroidism includes the use of antithyroid
medications such as the thioamides, propyl-thiouracil (PTU—the drug
of choice), or methimazole (Tapazole). Treatment often depends on the
gestational age. In the first trimester the woman will receive PTU,
changed to methimazole in the second trimester due to the
hepatotoxicity of long-term PTU and avoidance of methimazole in the
first trimester during organogenesis. Symptomatic improvement usually
occurs within 2 weeks after the initiation of therapy and repeat
laboratory work should be obtained to determine efficacy (King et al,
2016).
Patient Education
Patient education should focus on complications of antithyroid therapy
(i.e., purpuric skin rash, pruritus, fever, and nausea) and dietary needs
(i.e., increased calories and protein)
Hypothyroidism
Symptoms
Caused by an inadequate production of thyroid hormone, the
symptoms of hypothyroidism are insidious and can be masked by the
hypermetabolic state associated with pregnancy. Maternal symptoms
can include modest weight gain, a decrease in exercise capacity,
lethargy, cold intolerance, constipation, hoarseness, hair loss, brittle
nails, and dry skin. Laboratory confirmation is made from an elevated
TSH level and low to normal T3 and T4 values.
Treatment
During early gestation, thyroid hormones cross the placenta in small
amounts. The fetus is dependent on the hormones until fetal
production begins at 12 weeks. Maternal hypothyroidism must be
treated promptly, because there is an increased risk for pre-eclampsia,
placental abruption, preterm birth, low birth weight, and stillbirth. Fetal
neurological development can be severely affected by decreased
levels of thyroid hormone. Treatment involves the use of a thyroid
hormone supplement (e.g., levothyroxine [Synthroid]) with the dose
adjusted every 4 weeks until the TSH level reaches the lower end of
the normal range for pregnancy. Radioactive iodine (131I) is
contraindicated in pregnancy (Cunningham, 2018).
VENOUS THROMBOSIS AND PULMONARY

EMBOLISM
Venous thromboembolic diseases, which complicate approximately 1
to 2 in 1,000 births, include superficial and deep vein thrombophlebitis
(DVT), pulmonary embolus (PE), septic pelvic thrombophlebitis, and
thrombosis (Royal College of Obstetricians and Gynaecologists, 2015).
These conditions account for one-half of all obstetric morbidity.
Pulmonary embolism is the leading cause of maternal mortality. The
most common form of thrombosis that occurs during pregnancy
involves the veins of the calf, thigh, and pelvis. The most important
aspect of lower extremity and pelvic venous thrombosis is that it can
lead to pulmonary embolism, which poses a major threat to the
pregnant woman.
Thrombosis is thought to result from alterations in the vessel wall,
slowing of blood flow (or stasis), and changes in blood components.
Pregnancy presents the ideal state in which all three of these
components may exist. Trauma to the vessel wall may occur during
childbirth with alterations in the clot-inhibiting endothelial surface.
Blood flow from the legs and pelvic veins are slowed during pregnancy
because of pressure exerted on the iliac veins by the gravid uterus and
by the relaxation of the smooth muscles in response to increased
progesterone.
The most important individual risk factor for venous
thromboembolism in pregnancy is a personal history of thrombosis.
Other factors include history of hemoglobinopathies, obesity,
hypertension, overweight, smoking, advanced age, increased parity,
sedentary or limited mobility, and pregnancy complications (e.g., pre-
eclampsia and multiple gestation) (Royal College of Obstetricians and
Gynaecologists, 2015).
When assessing the pregnant patient, the nurse must be aware of
the characteristic signs associated with thromboembolic disease. The
diagnosis can be very challenging because some of the symptoms are
normal during pregnancy (e.g., lower extremity edema). Doppler
ultrasound technique has become the diagnostic study of choice in
cases of proximal vein occlusion. When results are negative and iliac
vein thrombosis is suspected, confirmatory imaging with magnetic
resonance imaging (MRI) is recommended. If there is a suspicion of
PE, ventilation-perfusion scanning or computed tomographic (CT)
angiography results in minimal radiation exposure to the fetus.
Management involves a combination of strategies including
medications (i.e., anticoagulant therapy with heparin), bedrest with
elevation of the involved extremity, and the application of warm, moist
heat.
During the examination, the nurse assesses for the presence of the
following signs and symptoms that may be indicative of
thromboembolism:
■ Pain, tenderness, and/or warmth.
■ Swelling of the lower extremity, which is asymmetric with a difference
greater than 0.8 in. (2 cm) between the normal and affected leg.
Swelling of the thigh is especially relevant because the risk of
pulmonary embolism is associated with femoral or iliac phlebitis.
■ Color change, especially in the left leg.
■ A palpable cord underlying the region of pain and tenderness.
Symptoms of a pulmonary embolism:
■ Tachypnea
■ Dyspnea
■ Pleuritic chest pain
■ Atelectatic rales
■ Cough
■ Fever
■ Diaphoresis
■ Tachycardia
■ Hemoptysis
■ Cyanosis
■ Heart gallop or murmur
■ Anxiety
■ Apprehension
PSYCHIATRIC COMPLICATIONS DURING

PREGNANCY
The recognition and management of depression and psychoses during
pregnancy and the puerperium are of critical importance. Particularly in
the United States, these disorders often are underrecognized and
undertreated, and this factor potentially contributes to the likelihood of
devastating effects on the child, the mother, the family, and society.
Consulting With the Pregnant Psychiatric Patient

Psychiatric complications during pregnancy can represent an
exacerbation of an ongoing psychiatric disorder, a resurgence of
previously remitted symptoms, or the onset of a new illness. Prenatal
counseling should include a mental health history to determine any
previous or past psychiatric disorders during pregnancy and the
potential associated with fetal exposure to psychotropic agents and/or
maternal mental illness.
Consultations with pregnant women who suffer from a psychiatric
disorder should include discussion of the following:
■ Psychoactive medications readily cross the placenta.
■ Risks associated with untreated maternal psychiatric illness and
exposure to psychotropic medications may include poor attention to
prenatal care, substance abuse, and deliberate self-harm.
■ Risk of experiencing relapse or worsening symptoms if
pharmacological treatment is not continued or instituted when
necessary. Maternal anxiety and stress have been shown to have
adverse effects on pregnancy outcome, infant/child
neurodevelopment, and maternal postnatal mental health.
■ Use of a single medication at a higher dose is preferable to the use
of multiple medications for the treatment of psychiatric illness during
pregnancy. Changing medication increases the exposure to the
fetus.
■ Patient care is optimized when provided by a multidisciplinary team
composed of the obstetrician, mental health clinician, primary health-
care provider, and pediatrician.
Depression
The incidence of depression during pregnancy is estimated to be 7% to
20% (Biaggi et al, 2016). Women at risk for antepartum depression are
those with a personal or family history of affective disorders (unipolar
and bipolar), depression in a previous pregnancy, unplanned
pregnancy, young age, few social supports or isolation, high
psychosocial stress, intimate partner violence (IPV), marital conflict,
significant life events, and cessation of antidepressant medications.
Signs and symptom of antenatal depression include:
■ Lack of interest in pregnancy
■ Lasting sadness, tearfulness, anxiety, or emotional detachment
■ Feelings of hopelessness or pessimism
■ Feelings of guilt, worthlessness, or helplessness
■ Feelings of irritability or restlessness
■ Loss of energy
■ Poor concentrating or memory
■ Difficulty making decisions
■ Difficulty falling asleep or sleeping too much
■ Overeating or loss of appetite
■ Suicidal thoughts or suicide attempts
■ Lack of interest in sex
Antenatal depression can have detrimental health outcomes
including increase risk of preterm birth, low birth weight, and abnormal
stress responses in offspring. Women with antenatal depression are
also at risk for postpartum depression (Biaggi et al, 2016). Treatment
for depression may include psychotherapeutic counseling, talk therapy,
peer support groups as well as regular exercise for some women with
mild depression symptoms (Centers for Disease Control and
Prevention, 2019c; U.S. Department of Health & Human Services,
2018).
Medications prescribed for depression include selective serotonin
reuptake inhibitors (SSRIs), such as fluvoxamine, sertraline,
citalopram, and fluoxetine, and tricyclic antidepressants (TCAs)
including amitriptyline, clomipramine, doxepin, and protriptyline.
Presently, there are conflicting data regarding SSRI exposure and the
risk for fetal malformations such as heart defects, encephalopathy,
gastroschisis, and omphalocele. Health-care providers need to
carefully discuss the risk and benefits of all treatments to patients so
they can discuss what is best for their pregnancy (Centers for Disease
Control and Prevention, 2019d).
Bipolar Disorder
Bipolar disorder is commonly characterized by distinct periods of
abnormally and persistently elevated, expansive, or irritable mood and
separate distinct periods of depressed mood or anhedonia (inability to
gain pleasure from normally pleasurable experiences). The course of
bipolar disorder is particularly unpredictable during pregnancy and
some women can experience relief of symptoms during pregnancy
(U.S. Department of Health & Human Services, 2018). However,
despite relief of symptoms many women need to continue mood-
stabilizer medications so that they don’t relapse. The health-care
provider needs to work in collaboration with the mental health team to
determine any at-risk behavior, such a noncompliance with medication,
severity of disease, lack of support systems, and other compounding
factors such as medical or living arrangement to help guide a plan of
care.
Early prenatal exposure to mood stabilizers such as lithium and
lamotrigine can cause congenital cardiac malformations.
Anticonvulsants including valproate and carbamazepine are also used
in the treatment of bipolar disorder; however, they are associated with
significant adverse effects when used during pregnancy and should be
avoided, especially during the first trimester (Boyce & Buist, 2016).
Schizophrenia
Schizophrenia is a psychotic disorder that consists of delusions,
hallucinations, disorganized speech, grossly disorganized or bizarre
behavior, and symptoms involving loss of behaviors, lack of motivation,
empty verbal response, inappropriate affect, anhedonia, dysphoric
mood, abnormal psychomotor activity, slow reaction time, dysfunctional
interpersonal relations, and/or dysfunctional self-care (Venes, 2021).
During pregnancy, women often experience worsening symptoms, and
because of the potential teratogenic effects on the fetus, the prescribed
psychotropic medication may need to be discontinued or changed. No
significant teratogenic or toxic effects have been documented with
typical antipsychotic drugs, including haloperidol, perphenazine, and
chlorpromazine. However, reproductive safety data on the commonly
used atypical antipsychotics such as olanzapine are extremely limited,
and the routine use of the atypical antipsychotics should be used with
caution during pregnancy (Teodorescu et al, 2017).
Maternal high-risk symptoms of schizophrenia include psychotic
denial of pregnancy (the woman denies she is pregnant despite clear
evidence that she is), self-mutilation, fetal abuse, and neonaticide.
Nurses caring for pregnant women with schizophrenia should assess
for delusions and coexisting health problems such as depression,
eating disorders, sexually transmitted infections, alcohol or drug abuse,
and compliance with treatment of coexisting chronic conditions,
including diabetes mellitus and hypertension.
Anxiety Disorders
Anxiety disorders including panic disorder, generalized anxiety
disorder, obsessive-compulsive disorder (OCD), and post-traumatic
stress disorder (PTSD) are common during the childbearing years.
Childbearing has been associated with the onset or worsening of panic
disorder or OCD, and women are at greatest risk for exacerbation of
both disorders during the postpartum period. Risk factors for anxiety
disorders in pregnancy include history of depression or anxiety, use of
alcohol or smoking, child abuse, parenting style that includes low care
or high control, and lack of partner, marital, or social supports (Biaggi
et al, 2016).
Eating Disorders
Eating disorders in pregnant women have both physiological and
psychological effects on the outcome of the pregnancy and on
subsequent infant development, including miscarriages, premature
birth, and low birth weight. Anorexia nervosa has been associated with
higher rates of perinatal mortality, obstetric complications, and
congenital anomalies. Bulimia nervosa has been associated with
extreme maternal weight gain, pre-eclampsia, and eclampsia. Women
with a history of eating disorders need to be monitored for relapses so
that intervention can occur in a timely manner (U.S. Department of
Health & Human Services, 2018/2018).
Management
The importance of the detection of mental health disorders in the
pregnant population cannot be overemphasized. The health and
welfare of not only the mother but also that of the entire family is at
stake. Nurses are often the first care providers to recognize indicators
of psychiatric difficulties in their patients. Strategies to help identify
mental health problems during pregnancy may include:
■ Placing psychoeducational materials throughout all patient areas
■ Routinely inquiring about the patient’s and her family’s psychiatric
history during the initial interview
■ Using a standard screening tool to assess for depression at least
once during the perinatal period
■ Assessing the woman’s access to social and family supports
■ Referring the woman to community resources such as home health
visitation and the local mental health agency
ASSESSMENT AND DIAGNOSTIC TOOLS TO

DETERMINE FETAL WELL-BEING
Doppler Ultrasound Blood Flow Studies (Velocimetry)
Doppler ultrasound is used to study blood flow in the umbilical vessels
of the fetus, placental circulation, fetal cardiac motion, and maternal
uterine circulation. This technology is useful in managing pregnancies
at risk because of hypertension, diabetes mellitus, IUGR, multiple
fetuses, or PTL. A noninvasive Doppler wave measures the velocity of
RBC movement through the uterine and fetal vessels. Assessment of
the blood flow through the uterine vessels is useful in determining
vascular resistance in women at risk for developing placental
insufficiency. Decreased velocity is associated with poor neonatal
outcome.

The fetal biophysical profile is a noninvasive fetal physical
examination that is more accurate in predicting fetal well-being than
any single assessment. It combines electronic FHR monitoring with
ultrasonography measures to evaluate fetal well-being. The fetus
responds to central hypoxia by alterations in movement, muscle tone,
breathing, and heart rate patterns. A finding of normal fetal biophysical
parameters indicates that the CNS is functional and therefore the fetus
is not hypoxemic. The BPP comprises the following five components
and is based on a 30-minute time period (Table 6-4). Findings on the
BPP are scored with a normal finding receiving a 2 and anything
abnormal receiving a 0. Scores of 8 to 10 with normal amniotic fluid
volume and a reactive NST indicate satisfactory fetal status. A score of
6 with normal amniotic fluid volume requires reassessment of a
preterm fetus within 24 hours of delivery. Scores of less than 6 or a
nonreactive NST indicate fetal compromise and require prompt
delivery (Venes, 2021).
Sonographic methods for determining amniotic fluid volume include
subjective assessment, three-dimensional techniques with
ultrasonography or MRI, and measurement of amniotic fluid pockets
(known as amniotic fluid index [AFI]). Amniotic fluid index is calculated
by summing the deepest vertical amniotic fluid pockets in each of four
quadrants of the uterus. At term, an AFI less than 5 cm has been used
as a common cutoff value to define oligohydramnios, and hydramnios
occurs when there is an AFI of greater than 24 cm or maximal vertical
pocket greater than 8 cm.
Each of the five BPP components is assigned a score of 2 (normal
or present) or 0 (abnormal). A score of 8 to 10 is reassuring whereas a
score of 6 is considered “equivocal,” and the test should be repeated
within 24 hours in the case of a preterm infant; the term infant should
be promptly delivered. A score of 0 to 4/10 strongly suggests fetal
asphyxia and indicates a need for consideration for early or immediate
delivery (Van Leeuwen & Bladh, 2021).
Nonstress Test
The NST is one of the most common methods of antenatal screening
that assesses for fetal well-being (Venes, 2021). It involves the use of
EFM for approximately 20 minutes. An NST monitors both the FHR
and uterine activity or contractions. The NST is based on the premise
that a normal fetus moves at various intervals and that the CNS and
myocardium responds to movement. The response is demonstrated by
an acceleration of the FHR. Loss of heart rate reactivity is associated
most commonly with a fetal sleep cycle but may result from any cause
of CNS depression, including fetal hypoxia, acidosis, and some
congenital anomalies. Reactivity is also based on gestational age; 32
to 34 weeks is considered the appropriate age for reactivity to occur.
Before this gestational age, a very large percentage of fetuses will not
meet the acceptable criteria and results of the NST need to account for
variations due to gestational age. Nonstress testing is performed once
or twice weekly for women with certain risk factors (Table 6-5).
TABLE 6-4
COMPONENT SCORE 2 SCORE 0
Nonstress test At least 2 or more 0 or only 1 acceleration in a
accelerations greater or time frame of 20–40
equal to 15 bpm lasting for minutes
at least 15 or more
seconds in a time frame of
20–40 minutes
Fetal breathing 1 or more episode of Less than 30 seconds of
rhythmic breathing lasting rhythmic breathing in a time
30 or more seconds in a frame of 30 minutes
time frame of 30 minute
Fetal movement 3 or more discrete body or Less than 3 discrete body
limb movements in a time or limb movements in a time
frame of 30 minutes frame of 30 minutes
Fetal tone 1 or more episode of No movements of extension
extremity or extension and and flexion movements
subsequent return to
flexion
Amniotic fluid volume Single vertical pocket of at Largest single vertical
least 2 cm of fluid or more pockets less than 2 cm
Contraction Stress Test

The contraction stress test (CST) evaluates the FHR response to
uterine contractions. The CST is based on the premise that fetal
oxygenation that is only marginally adequate with the uterus at rest is
transiently worsened by uterine contractions. The nurse uses the
electronic fetal monitor to obtain a baseline FHR tracing for 20
minutes. If spontaneous uterine contractions do not occur during this
time, uterine stimulation is produced through IV oxytocin infusion
(beginning with 0.5 milliunits/min and increasing the dose by 0.5
milliunits/min at 15- to 30-minute intervals) until three contractions of at
least 40 seconds’ duration occur within a 10-minute time frame. CSTs
are evaluated according to the presence or absence of late FHR
decelerations. A late deceleration, associated with fetal hypoxia, is one
that begins at the peak of the contraction and persists after the
conclusion of the contraction. Episodic patterns (i.e., accelerations,
variable decelerations, and prolonged decelerations) are FHR patterns
that do not have a direct relation to uterine contractions (Venes, 2021).
The test is considered negative (normal) if there is no evidence of
late or significant variable decelerations. A positive CST (abnormal) is
one in which there are late decelerations with 50% of contractions,
even if the frequency is less than three in 10 minutes. An
equivocal/suspicious result indicates the presence of either intermittent
late decelerations or significant (severe) variable decelerations (Venes,
2021).

Electronic fetal heart rate monitoring (EFM) uses electronic techniques
to give an ongoing assessment of fetal well-being. EFM provides
information related to the response of the FHR in the presence or
absence of uterine contractions. Electronic monitoring of the FHR can
be accomplished by either external or internal means.
TABLE 6-5
Selected Indications for Nonstress Testing/Biophysical Profile
MATERNAL PREGNANCY-RELATED
Hyperthyroidism (poorly controlled) Intrauterine growth restriction
Trauma/motor vehicle accident, improper seat belt Polyhydramnios
use
Injury/Intimate partner violence
Gestational diabetes, or diabetes mellitus (type 1 Oligohydramnios
or type 2)
Chronic renal disease Multiple gestation
Prior stillbirth or intrauterine fetal demise (IUFD) Isoimmunization
Hemoglobinopathies (Hgb SS, SC, S-thalassemia) Post-term gestation (greater than
cyanotic heart disease 42 weeks)
Systemic lupus erythematosus Decreased fetal movement
Hypertensive disorders Placental abnormality
Significant illness/septic shock Previous pregnancy loss/stillbirth
Premature rupture of
membraness
Decreased fetal movement
PROCEDURE ■ Performing an NST

To prepare the patient for an NST, the nurse explains the procedure and asks her
to void. The patient is then assisted into a semi-Fowler’s or lateral tilt position, and
the nurse performs Leopold maneuvers to determine fetal position and to guide
proper placement of the external fetal heart ultrasound transducer (U/S) and
tocodynamometer (toco), a pressure-sensitive device. Next, the nurse applies the
external U/S and toco on the maternal abdomen (Fig. 6-15) and obtains baseline
maternal vital signs. The tracing is then observed for evidence of FHR
accelerations of at least 15 bpm above the baseline heart rate. During this time,
the patient may or may not be aware of fetal movement.
In a term fetus, at least two FHR accelerations sustained for at least 15
seconds (from beginning to end of the acceleration) should occur over a 20-
minute time period. If these criteria are met, the test is considered normal or
reassuring and is termed a “reactive test.” The test may be extended for another
20 to 40 minutes if needed. If the reactive criteria are not met (i.e., no FHR
accelerations or the accelerations do not reach 15 bpm or do not last for 15
seconds) over a 20- to 40-minute period in a term fetus, the test is considered to
be “nonreactive.” Depending on the fetal age, a nonreactive NST result should be
followed by another NST a few hours later or contraction stress test or a BPP
(Venes, 2021).
FIGURE 6-15 Placement of the fetal heart ultrasound transducer and

tocodynamometer for a nonstress test.
SPECIAL CONDITIONS AND CIRCUMSTANCES
THAT MAY COMPLICATE PREGNANCY
The Pregnant Woman Who Requires Bedrest
The patient whose antenatal course is compromised by medical or
obstetric complications that require bedrest faces even more
challenges. Maloni has written extensively about the deleterious effects
of bedrest on body systems and addresses problems such as muscle
wasting, bone loss, failure to gain weight, and cardiovascular and
psychological difficulties. Lack of weight-bearing and inactivity make
muscles weak. Dizziness, difficulty regulating blood pressure, and
fainting are common symptoms in the patient confined to bedrest.
In most situations, regular home visitation by a community health
nurse is an important component of care (Fig. 6-16). Referral to social
services and other community resources may be helpful in assisting
the couple with financial matters and other aspects of home care.
Nursing interventions that can be instituted to help the family adjust
to the stress of a complicated pregnancy include the involvement of
high-risk pregnancy or other specialty support groups, professional
counseling when appropriate, and religious support when desired. The
educational needs of the pregnant woman who is experiencing a high-
risk pregnancy are essentially the same as those of any childbearing
woman. Whenever possible, nurses should encourage their patients to
participate in prenatal classes, seek lactation counseling, learn about
infant care, and attend self-care classes. The nurse may arrange for
the couple to attend childbirth education classes in either a group or
private setting. For most, participating in a group promotes a feeling of
normalcy. Family members, particularly the woman’s partner, should be
included, because they can share infant care responsibilities and
provide emotional support.
The recognition that high-risk couples may have depleted their
coping skills as a result of perinatal complications constitutes an
important nursing issue, especially during the intrapartal period. The
nurse needs to be aware that the anxiety and stress of labor may be
extremely difficult for the couple. The nurse can assist and empower
the patient and her partner by encouraging them to express their
emotional concerns, keeping them informed of changes in the
woman’s condition, and encouraging them to ask questions.
FIGURE 6-16 Visiting patients confined to bedrest at home is an
important nursing intervention.
The Adolescent Pregnant Patient

Although teen pregnancies have been decreasing steadily during the
past decade, the United States still has one of the highest teen
pregnancy rates among developed countries. Pregnancy complications
are the leading cause of death for girls ages 15 to 19 years old (World
Health Organization, 2020).
Prenatal medical and behavioral risk factors can severely complicate
adolescent pregnancy and result in poor birth outcomes, particularly
when late or inadequate prenatal care occurs. Prenatal medical and
behavioral risks for the adolescent population include:
■ PTL and birth, especially when combined with low socioeconomic
status, single parent, smoker, illicit drug use, prepregnant weight less
than 100 lb (45.5 kg), poor weight gain during pregnancy, and
inadequate prenatal care
■ Anemia
■ Pre-eclampsia/eclampsia
■ Repeated exposure to sexually transmitted infections
■ Chronic or asymptomatic UTIs
■ Acute pyelonephritis
■ IUGR/low birth weight infants (less than 2,500 g)
■ Social issues: poverty, unmarried status, low educational levels,
smoking, and drug use
The nurse’s need for good communication skills when working with
adolescents cannot be overstated, because these young women often
lack trust in medical personnel and fear that their behaviors might be
judged. Without good communication, the nurse is unable to make an
accurate assessment of the adolescent’s knowledge about the
importance of quality, consistent prenatal care.
The Advanced Age Pregnant Patient

Many women are now choosing to delay childbirth until later years. The
implementation of infertility technology has broadened the boundaries
of the reproductive age. Both socioeconomic circumstances and the
nature of the older mother have changed with time. The older maternity
patient today is at significantly lower risk than her contemporary of two
decades ago, who tended to be the mother of many children, having
commenced childbearing many years earlier. However, the nurse must
be aware of special considerations such as an increased likelihood of
chronic diseases (e.g., diabetes and hypertension) when planning care
for the woman who has become pregnant after age 35.
The Pregnant Patient Who Has Suffered Trauma

Trauma is the fourth leading cause of death worldwide and the leading
nonobstetric cause of maternal death during pregnancy. Motor vehicle
accidents account for more than one-half of maternal trauma incidents.
About 50% of fetal deaths result from maternal trauma, and most of
these result from motor vehicle accidents with many of them related to
improper seat belt use (Royal College of Obstetricians and
Gynaecologists, 2015; Scannell, 2018a). Blunt trauma is caused by the
following conditions:
■ Motor vehicle collisions in which force is applied to the abdomen
from direct impact or as a result of secondary injury from abdominal
organs. Abruption of the placenta and/or PTL may result from the
trauma.
■ Accidental falls, usually more common in the third trimester as the
woman’s center of gravity becomes increasingly displaced.
■ Assaults involving IPV (the incidence increases during pregnancy)
and gunshot and stabbing wounds.
Optimizing Outcomes
Considerations When Caring for the Obstetric Trauma Patient

Maternal stabilization is the initial goal in resuscitation. Resuscitation during
pregnancy proceeds as with any other trauma. Trauma in pregnancy involves at
least two patients (more in the case of multiple gestation). Minor injuries in the
woman may cause significant or fatal injury to the fetus. Maternal outcome in
trauma corresponds to the injury; fetal outcome depends on the injury and the
maternal physiological response. The FHR is often the first vital sign to change. All
pregnant trauma patients need continuous fetal monitoring. Risk factors predictive
of fetal death include ejection during an automobile crash (preventable with proper
seat belt use), motorcycle and pedestrian collisions, abnormal heart FHR patterns,
maternal tachycardia, and maternal death (Scannell, 2018a).
Intimate Partner Violence During Pregnancy

Intimate partner violence, family violence, battering, and spousal abuse
are all terms used to describe a pattern of assaultive and coercive
behaviors. The effects of IPV during pregnancy can have serious
consequences for the woman and the growing fetus. Pregnant women
are likely to have more multiple injury sites than nonpregnant women,
and the abuse is often directed to the breasts, genitalia, and abdomen.
The risk of injury to the fetus is very high because of the chance of
placental injury that can result in an abruption. Women in IPV
relationships are also more often at risk for physical injuries, sexually
transmitted infection, urinary infections, mental health disorders
including suicide, and inadequate prenatal care. The effects on the
pregnancy and fetus include PTL, placenta previa, miscarriages,
IUGR, prenatal distress, and stillbirth (Scannell, 2018b). Pregnancy is
often the trigger for the beginning or escalation of violence in a
relationship, and many chronically abused women report an increase
in violence directed at them during pregnancy.
Pregnant teenagers are particularly vulnerable because of their need
to rely on others for the basics of life. Often those whom they rely on
are their abusers. Incest, rape, child abuse, gang (group) fighting,
stalking, and IPV from both male and female partners have been
described. Nurses can help teenagers with violence only if they know
that the teenagers are experiencing it. Thus, nurses need to be able to
gain their young patients’ trust and confidence so that they feel
comfortable sharing their problems. Assessment, safety planning,
documentation, and follow-up are all essential components of providing
care for women who are experiencing violence, no matter what their
age. The medical record is often the source of information that can
raise suspicions of abuse, and a number of assessment forms
specifically designed to elicit information regarding patterns of abuse
have been developed.
SUMMARY POINTS
■ Complications that arise during pregnancy are often challenging and demand
the perinatal nurse’s skills, knowledge, and expertise, combined with the nursing
process, to first identify the pregnant patient at risk and then formulate,
implement, and evaluate an appropriate, holistic plan of care.
■ Anticipatory nursing care is invaluable in preventing a complication from
becoming a major health crisis.
■ Alterations of signs and symptoms from the expected clinical progression during
pregnancy must be immediately conveyed to the primary health-care provider so
that an appropriate management plan may be activated.
■ The nurse must always remain cognizant of the important role the patient’s
family, culture, language, and religious beliefs play in her adjustment to
motherhood and overall well-being.
■ By providing culturally competent care to childbearing families, many potential
complications can be identified in a timely manner to allow for effective treatment
and improved outcomes.
■ Meticulous documentation of the patient’s plan of care and response to the plan
of care cannot be overemphasized.
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To explore learning resources for this chapter, go to Davis

Advantage
UNIT 4

CHAPTER 7
The Process of Labor and Birth
CONCEPTS
Pregnancy
Nursing
KEY WORDS
tocodynamometer
effacement
dilation
fontanelles
fetal lie
fetal attitude
fetal presentation
cephalic presentation
breech
engagement
station
position
amniotomy
baseline fetal heart rate
tachycardia
bradycardia
hyperstimulation
nuchal cord
amnioinfusion
uteroplacental insufficiency
visceral pain
referred pain
somatic pain
analgesia
anesthesia
cardinal movements
Schultze mechanism
Duncan mechanism
LEARNING OBJECTIVES
■ Discuss the onset of labor and describe signs and symptoms of impending
labor.
■ Describe the “5 Ps” and how each influences labor and birth.
■ Differentiate among the four stages of labor according to the duration and
work accomplished, contraction patterns, and maternal behaviors.
■ Identify nonpharmacological methods to promote comfort during labor and
birth.
■ Compare pharmacological interventions used for discomfort and pain during
different stages of labor.
■ Discuss the nurse’s role in ensuring maternal-fetal safety while promoting
comfort during labor and birth.
PICO(T) Questions
chapter.
1. Are (P) women older than age 30 (O) at a higher risk of (I) uterine
hemorrhage in the fourth stage of labor (C) than women younger than age
30?
2. In the absence of known risks, do more (P) women in active labor (O) prefer
(I) intermittent auscultation (IA) of the fetal heart rate (C) or continuous
electronic fetal monitoring (EFM)?
INTRODUCTION
The journey from conception to birth is one of ongoing development
and adaptation for the woman, the fetus, and the family.
Physiological, psychological, and emotional changes that take place
during pregnancy help prepare the woman for labor and birth. Near
the end of the pregnancy, the fetus continues to develop
physiological abilities that facilitate successful adaptation for the
transition from in utero life to the outside environment.
Each woman’s labor and birth experience is uniquely shaped by
myriad factors. Throughout this journey, the actions of nurses play a
vital role in supporting the patient, the fetus, and the family. This
chapter presents the processes of labor and birth and the important
roles of nurses during each stage.
THE ONSET OF LABOR

For most women, the onset of labor occurs between the 38th and
42nd weeks of pregnancy. For most of the pregnancy, the uterus
stays in a relaxed state and the cervix remains closed and firm to
maintain the pregnancy. Toward the end of pregnancy, a complete
reversal occurs in which the uterus becomes more excitable and
cervical softening (ripening) occurs. The cervical changes result from
the breakdown of collagen fibers, which produce a decrease in the
binding capacity. This change, coupled with an increase in cervical
water content, causes weakening and softening. Although many
theories regarding the origin of labor have been proposed, no one
theory can account for the onset of labor in all women. Instead, a
combination of maternal and fetal factors most likely interacts to
bring about the initiation of labor (Box 7-1).
THE PROCESS OF LABOR AND BIRTH

A number of forces affect the progress of labor and help to bring
about childbirth. These critical factors are often referred to as the
“Ps” of labor:
■ Powers (physiological forces)
■ Passageway (maternal pelvis)
■ Passenger (fetus and placenta)
■ Passageway + Passenger and their relationship (engagement,
attitude, position)
■ Psychosocial influences (previous experiences, emotional status)
Position of the laboring patient is sometimes designated as a
separate critical “P.” In this chapter, maternal positions to facilitate
labor and enhance comfort are included in the discussion under
promoting comfort during labor. The coordination of the various
factors that affect labor is essential for the labor and birth to progress
in a successful manner.
Powers
The powers are the physiological forces of labor and birth that
include the uterine contractions (UC) and the maternal pushing
efforts. The uterine muscular contractions, primarily responsible for
causing cervical effacement and dilation, also move the fetus down
toward the birth canal during the first stage of labor. Uterine
contractions are considered the primary force of labor. Once the
cervix is fully dilated, the maternal pushing efforts serve as an
additional force. During the second stage of labor, use of the
maternal abdominal muscles for pushing (the secondary force of
labor) adds to the primary force to facilitate childbirth.
Characteristics of Uterine Contractions

Contractions are a rhythmic tightening of the uterus that occur
intermittently. Over time, this action shortens the individual uterine
muscle fibers and aids in the process of cervical effacement and
dilation, birth, and postpartal involution (the reduction in uterine size
after birth). Each contraction consists of three distinct components:
the increment (building of the contraction), the acme (peak of the
contraction), and the decrement (decrease in the contraction).
Between contractions, the uterus normally returns to a state of
complete relaxation. This rest period allows the uterine muscles to
relax and provides the woman with a short recovery period that helps
her to avoid exhaustion. In addition, uterine relaxation between
contractions is important for fetal oxygenation that allows for blood to
flow easily from the uterus to the placenta to be restored.
Contractions inhibit this process.
Contractions bring about changes in the uterine musculature. The
upper portion of the uterus becomes thicker and more active. The
lower uterine segment becomes thin-walled and passive. The
boundary between the upper and lower uterine segments becomes
marked by a ridge on the inner uterine surface, known as the
“physiological retraction ring.”
With each contraction, the uterus elongates. Elongation causes a
straightening of the fetal body so that the upper body is pressed
against the fundus and the lower, presenting part is pushed toward
the lower uterine segment and the cervix. The pressure exerted by
the fetus is called the fetal axis pressure. As the uterus elongates,
the longitudinal muscle fibers are stretched upward over the
presenting part. This force, along with the hydrostatic pressure of the
fetal membranes, causes the cervix to dilate (open).
Assessment of Uterine Contractions

Contractions are often described in terms of their frequency,
duration, and intensity. The frequency of a contraction is measured
from the beginning of one contraction to the beginning of the next
contraction. The duration of a contraction is measured from the start
of one contraction to the end of the same contraction. The intensity
of a contraction is most frequently measured by uterine palpation
and is described in terms of mild, moderate, and strong (Fig. 7-1).
BOX 7-1
Theories Regarding the Onset of Labor

MATERNAL FACTORS
• Uterine muscle stretching, which causes a release of prostaglandins.
• Pressure on the cervix, which stimulates the release of oxytocin by the
maternal posterior pituitary gland.
• Oxytocin stimulation increases significantly during labor and works together
with prostaglandins to activate UC. Endogenous oxytocin, a neuropeptide
released from the posterior pituitary, is also synthesized locally by the
amnion, chorion, and decidua. Shortly before the onset of labor, the uterus is
primed with a dramatic increase in the number of oxytocin receptors, which
causes it to become markedly sensitive to increases in endogenous oxytocin
that normally occur during spontaneous labor.
• Increase in the ratio of estrogen to progesterone: As term approaches,
biochemical changes cause a decreased availability of progesterone (relaxes
smooth muscle) to the uterine myometrial cells. With rising estrogen levels,
the uterus becomes more excitable and contractions begin.
FETAL FACTORS
• Placental aging and deterioration trigger the initiation of contractions.
• Fetal cortisol concentration increases. This results in a decrease in the
production of placental progesterone and an increase in the release of
prostaglandins.
• Fetal membranes produce prostaglandins, which aid in the stimulation of UC.
Palpation is a noninvasive procedure that requires the nurse to

place the fingertips of one hand on the fundus of the uterus where
most contractions can be felt. The nurse applies gentle pressure and
keeps the hand in the same place. Moving the hand over the uterus
may stimulate additional contractions, interfering with the ability to
accurately assess labor progress. Gentle palpation of the uterine
fundus can determine the firmness of the uterus by whether the
nurse can indent the uterus at the acme (peak) of the contraction.
Palpating the intensity of contractions is often compared with
palpating one’s nose (mild intensity), chin (moderate intensity), or
forehead (strong intensity). When the uterine fundus remains soft at
the acme of a contraction, the contraction intensity is described as
“mild.” Conversely, when there is an inability to indent the uterus at
the acme of a contraction, the contraction intensity is described as
“strong.” “Moderate” contraction intensity falls somewhere in
between and is characterized by a firm fundus that is difficult to
indent with the fingertips. Several contractions must be evaluated to
accurately determine the frequency, duration, and intensity.
Contractions may also be measured via electronic monitoring.
Monitoring may be external or internal, and this modality can provide
a continuous assessment of uterine activity. External contraction
monitoring uses a tocodynamometer, a pressure-sensitive device
that is applied against the uterine fundus. When the uterus contracts,
the pressure that is exerted against the “toco” is measured and
recorded on graph paper. External monitoring may be continuous or
intermittent. It provides information about the frequency and duration
of contractions. However, it may not give accurate data regarding the
intensity of contractions because many variables (e.g., maternal
position, obesity, and the placement of the monitor on the uterus)
can affect the tracing. Contraction intensity is best assessed with
palpation.
An invasive procedure to measure the intensity of UCs involves
the use of an internal monitor called an intrauterine pressure
catheter (IUPC). An IUPC can only be used if the amniotic
membranes have ruptured. If they have not ruptured spontaneously,
they will first need to be ruptured artificially. Next, an internal
pressure catheter is inserted through the cervix and into the uterus to
measure the internal pressure generated during the contraction.
Normally, resting pressure (or resting tone) in the uterus is 10 to 12
mm Hg. During the acme, contraction intensity ranges from 25 to 40
mm Hg during early labor, 50 to 70 mm Hg during active labor, 70 to
90 mm Hg during transition, and 70 to 100 mm Hg during maternal
pushing in the second stage. Internal uterine pressure monitoring is
most often used with high-risk pregnancies when accurate
measurement of uterine activity is required. Internal monitoring is
considered an invasive procedure, and patients should be aware that
there is a slight risk of infection.
Uterine contractions also bring about changes in the pelvic floor
musculature. The forces of labor cause the levator ani muscles and
fascia of the pelvic floor to draw the rectum and vagina upward and
forward. During descent, the fetal head exerts increasing pressure
and causes thinning of the perineal body with continued pressure
causing the maternal anus to evert, and the interior rectal wall is
exposed as the fetal head descends forward.
The coordinated efforts of the contractions help to bring about
effacement and dilation of the cervix. Effacement is the process of
shortening and thinning of the cervix. As contractions occur, the
cervix becomes progressively shorter until the cervical canal
eventually disappears. The amount of cervical effacement is usually
expressed as a percentage related to the length of the cervical
canal, compared with a noneffaced cervix. For example, if a cervix
has thinned to half the normal length of a cervix, it is considered 50%
effaced. Dilation is the opening and enlargement of the cervix that
progressively occurs throughout the first stage of labor. Cervical
dilation is expressed in centimeters, and full dilation is approximately
10 cm. With continued UC, the cervix eventually opens enough to
allow the fetal head to come through. At this point, the cervix is
considered fully dilated, or completely dilated, and measures 10 cm
(Fig. 7-2).
FIGURE 7-1 Counting contractions. Contraction frequency is the
time from the beginning of one contraction to the beginning of the
next contraction. Contraction duration is the time from the beginning
to the end of the same contraction.
Maternal Pushing Efforts

After the cervix becomes fully dilated, the laboring woman usually
experiences an involuntary “bearing-down” sensation that assists
with the expulsion of the fetus. At this time, the woman can use her
abdominal muscles to aid in the expulsion. It is important to
remember that the cervix must be fully dilated before the patient is
encouraged to push. Bearing down on a partially dilated cervix can
cause cervical edema and damage, adversely affecting the progress
of the labor. For most women, the urge to bear down generally
occurs when the fetal head reaches the pelvic floor. Women who
have a strong urge to push often do so more effectively than women
who force themselves to push without experiencing any sensations
of pressure.
Passageway
The passageway consists of the maternal pelvis and the soft tissues.
The bony pelvis through which the fetus must pass is divided into
three sections: the inlet, midpelvis (pelvic cavity), and outlet. Each of
these pelvic components has a unique shape and dimension through
which the fetus must maneuver to be born vaginally. In human
females, the four classic types of pelvis are the gynecoid, android,
platypelloid, and anthropoid.
Passenger
The passenger comprises the fetus and the fetal membranes. In the
majority (94%) of pregnancies, the fetus presents in a head-first
position and is the optimal position of the passenger for birth
(Australian Institute of Health and Welfare, 2020). Other positions for
the fetus, such as breech or transverse position, result in a more
difficult birth.
The Fetal Skull

The fetal skull, usually the largest body structure, is also the least
flexible part of the fetus. However, the sutures and fontanelles in the
skull allow some flexibility. These structures let the cranial bones
move and overlap in response to the powers of labor. The
overlapping or overriding of the cranial bones is called molding. The
fetal skull consists of three major components: the face, the base of
the skull, and the vault of the cranium (roof). The cranium is
composed of five bones: two frontal bones, two parietal bones, and
the occipital bone. These bones, which are not fused, meet at the
sutures. The sutures of the fetal skull are composed of strong but
flexible connective tissue that fills the spaces that lie between the
cranial bones.
Two membrane-filled spaces are present where the suture lines
meet. These spaces are referred to as the anterior and posterior
fontanelles. The anterior fontanelle is the larger of the two and
measures approximately 0.8 to 1.2 inches (2 to 3 cm). It is diamond-
shaped and positioned where the sagittal, frontal, and coronal
sutures intersect. The anterior fontanelle remains open until
approximately 18 months of age to allow normal brain growth to
occur. The posterior fontanelle is triangular and much smaller than
the anterior fontanelle. It measures approximately 0.8 inch (2 cm) at
its widest point. The posterior fontanelle is positioned where the
lambdoidal and sagittal sutures meet. Shaped like a small triangle, it
closes at approximately 6 to 8 weeks after birth. The location of the
fontanelles assists the examiner in determining the position of the
fetal skull during a vaginal examination. Important landmarks of the
fetal skull are presented in Figure 7-3.
The fetal skull contains several important landmarks (Box 7-2).
Skull diameters display significant variation. As molding occurs
during labor, some skull diameters shorten while others lengthen.
The head diameters are measured between the various skull
landmarks. Most fetuses enter the maternal pelvis in the cephalic
presentation, but a number of positional variations are possible. The
biparietal diameter is the major transverse diameter of the fetal head.
It is measured between the two parietal bones and averages 3.7
inches (9.5 cm) in a term fetus. The anteroposterior diameter of the
fetal head varies according to the degree of flexion. During labor, the
most favorable situation occurs when the head becomes fully flexed
and the anteroposterior diameter is the suboccipitobregmatic, which
averages 3.7 inches (9.5 cm).
FIGURE 7-2 Cervical effacement and dilation. The membranes are
intact. A, Before labor. B, Early effacement. C, Complete (100%)
effacement; the fetal head is well applied to the cervix. D, Complete
dilation (10 cm); note overlapping of the cranial bones.
FIGURE 7-3 Bones, fontanelles, and sutures of the fetal head. An
understanding of the placement and relationships of these structures
is essential in making an accurate assessment during the labor
process.
BOX 7-2
Landmarks of the Fetal Skull

Mentum: fetal chin
Sinciput: Anterior area known as the “brow”
Bregma: Large, diamond-shaped anterior fontanelle
Vertex: The area between the anterior and the posterior fontanelles
Posterior fontanelle: The intersection between the posterior cranial sutures
Occiput: The area of the fetal skull that is occupied by the occipital bone,
beneath the posterior fontanelle (Fig. 7-3).
FIGURE 7-4 The fetal lie refers to the relationship of the long axis of
the woman to the long axis of the fetus. A, Longitudinal lie. B,
Transverse lie. C, Oblique lie.
Fetal Lie
The fetal lie refers to the relationship of the long axis of the woman
to the long axis of the fetus (Fig. 7-4). If the head to tailbone axis of
the fetus is the same as the woman’s, the fetus is in a longitudinal
lie. In the longitudinal lie, either the fetal head or the fetal buttocks
enter the pelvis first. If the head to tailbone axis of the fetus is at a
90-degree angle to the woman, the fetus is in a transverse
(horizontal) lie. A transverse lie occurs in fewer than 1% of
pregnancies. An oblique lie is one that is at some angle between the
longitudinal and the transverse lie.
Fetal Attitude
The fetal attitude describes the relationship of the fetus’s body parts
to one another. The fetus normally assumes an attitude of flexion. In
this attitude, the fetal head is flexed so that the chin touches the
chest, the arms are flexed and folded across the chest, the thighs
are flexed on the abdomen, and the calves are flexed against the
posterior aspects of the thighs. This is commonly referred to as the
“fetal position.”
In moderate flexion, the fetal chin is not touching the chest but is in
an alert or “military” position. This position causes the occipital
frontal diameter to present to the birth canal. An attitude of moderate
flexion usually does not interfere with labor because during descent
and flexion the fetal head flexes fully. The fetus in partial extension
presents the brow or face of the head to the birth canal.
Flexion of the fetal head (in which the chin touches the chest) is
the preferred position for birth because it allows the smallest
anteroposterior diameter of the fetal skull to enter the maternal
pelvis. Any other position of the fetal head (other than that of
complete flexion) will present with a larger anteroposterior diameter,
which can ultimately contribute to a longer, more difficult labor (Fig.
7-5).
Fetal Presentation
The fetal presentation refers to the fetal part that enters the pelvic
inlet first and leads through the birth canal during labor. The fetal
presentation may be cephalic, breech, or shoulder. The part of the
fetal body first felt by the examining finger during a vaginal
examination is the “presenting part.” The presenting part is
determined by the fetal lie and attitude.
CEPHALIC PRESENTATION
A cephalic presentation identifies that the fetal head will be first
to come into contact with the maternal cervix. The following
advantages are associated with a cephalic presentation:
■ The fetal head is usually the largest part of the infant. Once the
fetal head is born, the rest of the body usually delivers without
complications.
■ The fetal head is capable of molding. There is sufficient time
during labor and descent for molding to occur. Molding helps the
fetus maneuver through the maternal birth passage.
■ The fetal head is smooth and round, which is the optimal shape to
apply pressure to the cervix and aid in dilation.
FIGURE 7-5 The fetal attitude describes the relationship of the fetal
body parts to one another. A, Flexion (vertex). B, Moderate flexion
(military). C, Extension.
There are four types of cephalic presentations: vertex, military,

brow, and face (Fig. 7-6). Other presentations (e.g., breech and
shoulder) are associated with difficult, prolonged labor and often
require cesarean births. They are called malpresentations.
Vertex
The fetal head presents fully flexed. This is the most frequent and
optimal presentation that enables the smallest suboccipitalbregmatic
diameter to present first into the vaginal canal and is called a “vertex
presentation.”
Military
In the military position, the fetal head presents in a neutral
position, which is neither flexed nor extended. The occipitofrontal
diameter presents to the maternal pelvis, and the top of the head is
the presenting part.
Brow
In the brow position, the fetal head is partly extended. This is an
unstable presentation that converts to a vertex if the head flexes or
to a face presentation if the head extends. The occipitomental
diameter (the largest anteroposterior diameter) presents to the
maternal pelvis, and the sinciput (fore and upper part of the cranium)
is the presenting part.
Face
In the face presentation, the fetal head is fully extended, and the
occiput is near the fetal spine. The submentobregmatic diameter
presents to the maternal pelvis, and the face is the presenting part.
BREECH PRESENTATION
A breech presentation occurs when the fetal buttocks enter the
maternal pelvis first. Breech presentations occur in approximately
4.6% of births and are classified according to the attitude of the fetal
hips and knees (Australian Institute of Health and Welfare, 2020).
Breech presentations are more likely to occur in preterm births or in
the presence of a fetal abnormality such as hydrocephaly (head
enlargement caused by fluid) that prevents the head from entering
the pelvis. They are also associated with abnormalities of the
maternal uterus or pelvis. Because many factors can compromise
the normal labor and birth process associated with breech
presentations, delivery is usually accomplished via cesarean section.
Several disadvantages are associated with a breech presentation:
FIGURE 7-6 There are four types of cephalic presentation; the

vertex presentation with complete flexion is optimal. Fetal
presentation refers to the fetal body part that first enters the maternal
pelvis.
■ An increased risk for umbilical cord prolapse because the

presenting part may not be covering the cervix (i.e., footling
breech)
■ The presenting part (buttocks or feet) is not as smooth and hard as
the fetal head and is less effective in dilating the cervix.
■ Once the fetal body (abdomen) is delivered, the umbilical cord can
become compressed. The fetus must then be delivered
expeditiously to prevent hypoxia. Rapid delivery may be difficult
because the fetal head is usually the largest body part, and in this
situation, there is no time to allow for molding.
There are three types of breech presentations: frank, complete
(full), and footling (Fig. 7-7):
Frank
The frank breech is the most common of breech presentations. In
the frank breech position, the fetal legs are completely extended up
toward the fetal shoulders. The hips are flexed, the knees are
extended, and the fetal buttocks present first in the maternal pelvis.
Complete (Full)
The complete or full breech position is the same as the flexed
position with the fetal buttocks presenting first. The legs are typically
flexed. Essentially, this position is a reversal of the common cephalic
presentation.
Footling
In the footling breech position, one or both of the fetal legs are
extended with one foot (“single footling”) or both feet (“double
footling”) presenting first into the maternal pelvis.
FIGURE 7-7 There are three types of breech presentation. A, Frank.
B, Complete or full. C, Footling (single). D, Footling (double).
SHOULDER PRESENTATION
The shoulder presentation is a transverse lie (Fig. 7-8). This
presentation is rare and occurs in fewer than 1% of births. When a
transverse lie is present, the maternal abdomen appears large from
side to side rather than vertically. In addition, the woman may
demonstrate a lower than expected fundal height measurement for
the gestational age. Although the shoulder is usually the presenting
part, the fetal arm, back, abdomen, or side may present in a
transverse lie. This presentation occurs most often with preterm
birth, high parity, prematurely ruptured membranes, hydramnios, and
placenta previa. It is important for the nurse to promptly identify a
transverse lie or shoulder presentation because the infant will almost
always require a cesarean birth.
Passageway + Passenger
The next “P” is the relationship between the passageway (maternal
pelvis) and the passenger (fetus and membranes). The nurse
assesses the relationship between the two when determining the
engagement, station, and fetal position.
Engagement
Engagement occurs when the widest diameter of the fetal
presenting part has passed through the pelvic inlet. In a cephalic
presentation, the largest diameter is the biparietal; in breech
presentations, it is the intertrochanteric diameter. Engagement can
be determined by external palpation or by vaginal examination. In
primigravidas, engagement usually occurs approximately 2 weeks
before the due date. In multiparas, engagement may occur many
weeks before the onset of labor or it may take place during labor.
Although engagement confirms the adequacy of the pelvic inlet, it is
not an indicator of the adequacy of the midpelvis and outlet.
Station
Station refers to the level of the presenting part in relation to the
maternal ischial spines. In the normal female pelvis, the ischial
spines represent the narrowest diameter through which the fetus
must pass. The ischial spines, blunted prominences located in the
midpelvis, have been designated as a landmark to identify station
zero. To visualize the location of station zero, an imaginary line may
be drawn between the ischial spines. Engagement has occurred
when the presenting part is at station zero. When the presenting part
lies above the maternal ischial spines, it is at a minus station.
Therefore, a station of minus 5 (–5) cm indicates that the presenting
part is at the pelvic inlet. Positive numbers indicate that the
presenting part has descended past the ischial spines. A presenting
part below the level of the ischial spines is considered a positive
station. A station of +4 cm indicates that the presenting part is at the
pelvic outlet (Fig. 7-9). During labor, the presenting part should
continue to descend into the pelvis, indicating labor progress. As
labor advances and the presenting part descends, the station should
also progress to a numerically higher positive station. If the station
does not change in the presence of strong, regular contractions, this
may indicate a problem with the relationship between the maternal
pelvis and the fetus (“cephalopelvic disproportion”).
FIGURE 7-8 Shoulder presentation.
Position
Position refers to the location of a fixed reference point on the fetal
presenting part in relation to a specific quadrant of the maternal
pelvis (Fig. 7-10). The presenting part can be right anterior, left
anterior, right posterior, and left posterior. These four quadrants
designate whether the presenting part is directed toward the front,
back, right, or left of the passageway.
Four landmarks of the fetus are used to describe the relationship
of the presenting part to the maternal pelvis. In a vertex presentation,
the occiput (O) is used. For a face presentation, the chin (M for
mentum) is used. In a breech presentation, the sacrum (S) is used,
and for a shoulder presentation, an acromion process (A) of the
shoulder is used. Fetal position may be described as:
■ Right (R) or left (L) side of the maternal pelvis
■ The landmark of the presenting part: occiput (O), mentum (M),
sacrum (S), or acromion process (A)
■ Anterior (A), posterior (P), transverse (T): This designation
depends on whether the landmark is in the front, back, or side of
the maternal pelvis
It is important for the nurse to identify whether the fetus is in an
optimal position for a vaginal birth. To do so, the nurse uses
inspection and palpation of the maternal abdomen and vaginal
examination. Use of the abbreviated notations listed earlier helps
convey essential information to other members of the health-care
team. For example, when the fetal occiput is directed toward the
maternal back (a posterior lie) and to the right of the birth
passageway, the nurse would chart “ROP,” to indicate right occiput-
posterior. The fetal position most common, and most favorable for
birth, is the right occiput-anterior (ROA). Identification of a
malpresentation such as a footling breech or transverse lie is
important because the presence of a malpresentation may signal the
need for a cesarean delivery. Identification of a posterior lie may
identify the potential for a longer labor because the fetus may
attempt to rotate to an OA position. In addition, the nurse must be
aware that the fetal position will vary as the fetus changes position to
move through the different diameters of the maternal pelvis.
FIGURE 7-9 Station.
In some situations, the physician may attempt a fetal rotation.

Prenatally, an external cephalic version may be performed to try to
rotate an identified breech presentation. A forceps rotation from a
transverse or posterior position to an anterior position may also be
indicated during a prolonged second stage of labor. However, as with
any procedure, these maneuvers are associated with risks and
benefits that must be presented to the patient for informed consent.
Psychosocial Influences
The first four Ps discussed the physical forces of labor. The last “P”
(psychosocial influences) acknowledges the many other critical
factors that have an effect on parents such as their emotional
readiness for labor and birth, level of educational preparedness,
previous experience with labor and birth, cultural influences, and
ethnicity. Transition into the maternal role, and most likely also into
the paternal role, is facilitated by a positive childbirth experience. A
number of internal and external influences can affect the woman’s
psychological well-being during labor and birth.
Culturally oriented views of childbirth help shape the woman’s
expectations and ongoing perceptions of the birth experience. The
nurse’s understanding of the cultural values and expectations
attached to childbirth provide a meaningful framework on which to
plan and deliver sensitive, appropriate care. Cultural considerations
for the laboring woman encompass many elements of the birth
experience including choice of a birth support person, strategies for
coping with contractions, pain expression and relief, and food
preferences.
Emotional factors can have physiological implications as well.
Maternal catecholamines (chemicals that affect the nervous and
cardiovascular systems, metabolic rate, temperature, and smooth
muscle) are often stimulated as a response to anxiety and fear and
can inhibit UCs and impede placental blood flow. During labor, the
nurse’s ongoing assessment of the maternal psyche along with
appropriate interventions can help facilitate therapeutic
communication to decrease or eliminate anxiety and fear through
discussion and support.
SIGNS AND SYMPTOMS OF IMPENDING LABOR

Energy Spurt
Toward the end of the pregnancy, some women experience a
sudden increase in energy coupled with a desire to complete
household preparations for the new baby. Some refer to this energy
spurt as “nesting.” The energy spurt may be related to an increase in
the hormone adrenaline, which is needed to support the woman
during the work of labor. Women should be cautioned not to
overexert themselves doing household chores and instead to “store
up” their energy for the childbirth process.
FIGURE 7-10 Fetal presentations and positions. The position refers

to how the presenting fetal part is positioned in relation to a specific
quadrant of the maternal pelvis: front, back, or side.
Distinguishing True Labor From False Labor

Recognizing the difference between true and false labor is important
for the pregnant woman and her nurse (Table 7-1). True labor
contractions lead to progressive dilation and effacement of the
cervix. They occur with regularity and increase in frequency,
duration, and intensity. The pain of true labor usually begins in the
woman’s lower back region and radiates to the abdomen. The pain
often intensifies with activity such as walking. In contrast, false labor
contractions are irregular and usually do not change in intensity and
duration. False labor does not lead to dilation and effacement of the
cervix. The pain of false labor is usually felt in the abdominal region
and often stops with activities such as walking, position changes,
and hot showers or other comfort measures.
Before the onset of labor, a number of physiological changes
occur that signal the readiness for labor and birth. These changes
are usually noted by the primigravid woman at about 38 weeks of
gestation. In multigravidas, they may not take place until labor
begins.
Patient Education
Teaching the Signs of Impending Labor
It is important for nurses to empower pregnant women and their families by
teaching them about the signs and symptoms of impending labor. Providing
guidelines about when to contact the health-care provider or come to the birth
facility helps to demystify the sometimes confusing events that surround birth
and lessen the anxieties that can accompany the onset of labor.
Lightening
At about 38 weeks in the primigravid pregnancy, the presenting part
(usually the fetal head) settles downward into the pelvic cavity,
causing the uterus to move downward as well. This process, called
lightening, marks the beginning of engagement. As the uterus moves
downward, the woman may state that her baby has “dropped.” She
may also report changes in the appearance of her abdomen such as
a flattening of the upper area and an enhanced protrusion of the
lower area. This downward settling of the uterus may decrease the
upward pressure on the diaphragm and result in easier breathing.
The downward settling may also lead to the following maternal
symptoms:
■ Leg cramps or pains
■ Increased pelvic pressure
TABLE 7-1
Distinguishing True From False Labor
TRUE LABOR FALSE LABOR
• Contractions are at regular intervals. • Contractions are irregular.
• Contractions increase in frequency, • Usually there is no increase in
duration, and intensity. frequency, duration, or intensity of
contractions.
• Pains usually begin in lower back, • Pains usually occur in the abdominal
radiating to the abdomen. region.
• Dilation and effacement of the cervix • There is no change in the cervix.
are progressive.
• Activity such as walking usually • Walking may lessen the pain.
increases labor pains.
■ Increased urinary frequency

■ Increased venous stasis, causing edema in the lower extremities
■ Increased vaginal secretions because of congestion in the vaginal
mucosa
Braxton Hicks Contractions

As the pregnancy approaches term, most women become more
aware of irregular contractions called Braxton Hicks contractions. As
the contractions increase in frequency (they may occur as often as
every 10 to 20 minutes), they may be associated with increased
discomfort. Braxton Hicks contractions are usually felt in the
abdomen or groin region, and patients may mistake them for true
labor. It is believed that these contractions contribute to the
preparation of the cervix and uterus for the advent of true labor.
Braxton Hicks contractions do not lead to dilation or effacement of
the cervix and thus are often termed “false labor.”
Cervical Changes
In the nonpregnant woman, the cervix is normally rigid. In
preparation for passage of the fetus, the cervix undergoes many
physiological changes. The cervix softens (“cervical ripening”),
stretches, thins, and eventually is taken up into the lower segment of
the uterus. This softening and thinning is called cervical effacement.
Bloody Show
During pregnancy the cervix is plugged with mucus. The mucus plug
acts as a protective barrier for the uterus and its contents throughout
the pregnancy. As the cervix begins to soften, stretch, and thin
through effacement, the small cervical capillaries may rupture. The
added pressure created by engagement of the presenting part may
lead to the expulsion of a blood-tinged mucus plug, called bloody
show. Its presence often indicates that labor will begin within 24 to
48 hours. Late in pregnancy, vaginal examination that involves
cervical manipulation may also produce a bloody discharge that can
be confused with bloody show.
Rupture of the Membranes

About 12% of pregnant women experience spontaneous rupture of
the amniotic sac (“ruptured membranes” or “ruptured bag of waters”)
before the onset of labor (ACOG, 2018). In the majority of
pregnancies, the amniotic membranes rupture once labor is well
established, either spontaneously or by amniotomy, the artificial
rupture of the membranes by the provider. Rupture of the
membranes is a critical event in pregnancy. Assessment by the
woman if rupture occurs at home, or by the nurse if it occurs in the
birthing unit, is essential. If the membranes do rupture at home, the
woman should be taught to immediately contact the nurse at the
provider’s office or at the birthing center who will advise her to report
for an examination. It is important for the woman to note the color,
amount, and odor of the amniotic fluid. The fluid should be clear and
odorless. Often it contains white specks (vernix caseosa) and fetal
hair (lanugo). A yellow-green-tinged amniotic fluid may indicate
infection or fetal passage of meconium, and this finding always
signals the need for further assessment and fetal heart rate (FHR)
monitoring. Urinary incontinence (frequently associated with urgency,
coughing, and sneezing) is sometimes confused with ruptured
membranes.
Diagnostic Tools
Detecting Amniotic Fluid
Three tests may be used to detect amniotic fluid: the Nitrazine tape test, the
AmniSure test, and the fern test. The Nitrazine tape tests the pH of fluids. If
amniotic fluid is present, the tape will turn a blue color, indicating a pH of 6.5–
7.5. Another test for amniotic fluid is called the fern test. A small fluid sample is
collected and placed on a microscope slide and set aside to dry. Once it is
dried, the slide is placed under a microscope, where a fern-like appearance
indicates amniotic fluid. The AmniSure test detects trace amounts of placental
alpha-1-microglobulin (PAMG-1), one of the amniotic fluid proteins that appears
in vaginal discharge after rupture of the membranes (Venes, 2021).
CHILDBIRTH SETTINGS AND LABOR SUPPORT

The decision about where to give birth is influenced by several
factors: geographical location, socioeconomic status, the patient’s
preference, and the absence or presence of pregnancy
complications. The size of the community often dictates the type and
number of maternity health-care facilities and the available primary
care providers who may include family physicians, obstetricians, and
certified nurse midwives (CNMs).
Large urban centers have hospitals with birthing units or birthing
centers. Some of the units may offer labor options such as whirlpool
baths. Other settings may provide a homelike environment for the
expectant couple. Taking a tour of the available birth settings as part
of prenatal education classes can help the pregnant woman and her
partner develop an understanding of what to expect during the
childbirth experience.
PROCEDURE ■ Assessing for Amniotic

Fluid
PURPOSE
To confirm the presence of amniotic fluid in cases of spontaneous
rupture of membranes (SROM)
Equipment
• Nitrazine test tape or the AmniSure kit (contains the test strip, sterile swab,
and test vial)
• Sterile gloves
• Sterile speculum
• Sterile cotton swab and glass slide
• Microscope
Steps
1. Gather the necessary supplies. Explain the procedure and purpose of the
examination to the patient. Ensure privacy. Wash and dry hands, and
position the patient in a dorsal lithotomy position.
2. Ask the patient if she has noticed any leakage of fluid from her vagina.
3. Assess for the presence of amniotic fluid before other tests that require the
use of lubricant (such as vaginal examination).
RATIONALE: Lubricant may alter the pH of amniotic fluid and contaminate
the test result.
4. Don sterile gloves. With one hand, spread the labia to expose the vaginal
opening.
For the Nitrazine tape test:
With the other hand, place a 2-inch (5-cm) piece of Nitrazine tape against
the vaginal opening, ensuring contact with enough fluid to wet the tape.
Alternately, a sterile cotton-tipped applicator may be used to obtain fluid
from the vagina. The applicator is then touched to the Nitrazine tape.
5. Remove the tape. Compare the color of the tape with the color guide on the
Nitrazine tape container. If the tape turns blue-green, gray, or deep blue,
amniotic fluid is present. If the tape remains beige, no amniotic fluid has
been detected.
RATIONALE: Amniotic fluid is alkaline, with a pH of 6.5 to 7.5. Urine and
vaginal secretions are usually acidic and have a lower pH.
Caution: Blood, Trichomonas vaginalis, and other substances may also
turn the Nitrazine test strip alkaline or blue.
For the AmniSure test:
a. Hold the cap secure on the solvent vial and shake it to ensure that all the
liquid in the vial has reached the bottom.
b. Remove the cap and place the vial upright on a flat, secure surface.
c. Carefully remove the sterile swab from the package.
d. Grasp the swab in the middle of the stick and insert the swab tip into the
vagina until the fingers contact the patient’s skin (no more than 2 to 3 inches
[5 to 7 cm]).
e. Hold the swab in the vagina for 1 minute and then remove it.
f. Carefully place the tip of the swab in the vial and rotate it in the solvent for 1
minute to ensure that the vaginal secretions are thoroughly mixed with the
solvent.
g. Remove the swab and discard it in an appropriate receptacle.
h. Open the foil packet containing the test strip.
i. Insert the white end of the test strip into the vial with the solvent, making sure
the arrows are within the solvent. Hold the test strip in the solvent for no less
than 5 minutes and no more than 10 minutes.
j. Remove the test strip from the vial if two stripes appear clearly on the strip
(no earlier than 5 minutes) or after exactly 10 minutes.
k. Place the test strip on a clean, dry, flat surface to read the result.
1. If only one line (a “control line”) is visible, there is no rupture of
membranes (negative result).
2. If two lines (“control line” and “test line”) are visible, rupture of
membranes has occurred (positive result).
3. If no lines are visible, the test result is invalid and may need to be
repeated.
For the fern test:
l. When the Nitrazine tape or AmniSure tests are unavailable or have not
confirmed the presence of amniotic fluid, the nurse may insert a speculum
and sterile cotton swab to collect a sample of fluid from the posterior vagina.
The swab is smeared on a glass slide and allowed to dry. The glass slide is
then placed on the microscope. The presence of a ferning pattern confirms
the presence of amniotic fluid. The fern test is often indicated if premature
rupture of the membranes (PROM) is suspected.
m. Document the findings on the admission or labor record.
n. Inform the patient of the findings.
The patient usually determines whether a support person or team

accompanies them to the birthing unit and remains throughout the
labor and birth. This decision is based on personal preferences and
may reflect cultural, religious, sexual, or gender preferences. The
woman’s partner or the baby’s father is the most common labor
support person, although the woman’s mother or friend may also
serve as a support person. Nurses also need to be considerate of
patients’ sexual and gender preferences. In some situations, the
support person may not be the father but the mother’s wife,
girlfriend, or partner. The nurse can identify the patient’s preference
for a support person by asking a question such as, “Who is the main
person whom you want to stay with you during labor?”
In some centers, women may use a doula as a labor support
person. The doula is a woman who has received professional
training and is experienced in childbirth. The doula’s role is to
provide continuous information and physical and emotional support
to the woman and her partner before, during, and immediately after
the birth. She does not function in a clinical role but instead
specializes in providing comfort measures to decrease the woman’s
anxiety. Breathing techniques, application of hot and cold, and
massage are strategies often used to enhance comfort and the
progress of labor.
In some cases, home births may be an acceptable option for
women with low-risk pregnancies. Home births allow for the comforts
of the home and already established support systems. Women have
many potential reasons for choosing home birth such as cultural,
location, and personal preference. A recent increase in home births
due to the COVID-19 pandemic has occurred as individuals weigh
the risks of a home birth against the risks of potential virus exposure
in a hospital setting.
Routine Hospital and Birth Center Procedures

In the third trimester it is important for the prenatal care nurse to
explain the differences between true and false labor and to teach the
patient about when to go to the birthing center. Table 7-2
summarizes the circumstances that warrant a visit to the birthing
center. The nurse should reinforce this information during each
prenatal visit.
Once the woman arrives at the birthing center, the role of the
nurse is twofold: to establish a positive relationship with the patient,
her family, and support person and to assess the status of the
patient and her fetus.
Establishing a Positive Relationship

To foster a positive and therapeutic relationship, the health-care
professional must create a patient-centered atmosphere that
encourages asking questions and sharing information. Some women
have prepared written childbirth plans that describe their
expectations of the experience. If the patient doesn’t have a birth
plan, the nurse may wish to use a template with simple questions
about her preferences to guide care. Getting to know each patient’s
expectations for her childbirth experience constitutes an important
element in the nurse relationship. Understanding and supporting the
birth plan fosters patient autonomy and may lead to enhanced
satisfaction with the childbirth experience as well as identify any
unrealistic plans so that education can occur before the laboring
process.
TABLE 7-2
Providing Patient Guidelines for Reporting to the Birthing Center
QUESTIONS TO ASK THE PATIENT GUIDELINES FOR ADMISSION
Describe your contractions: frequency, Primigravida: Contractions are regular,
duration, and intensity? occur about every 5 minutes for at least
1 hour. Multipara: Contractions are
regular, occur about every 10 minutes
for at least 1 hour.
Have your membranes ruptured? Any gush of fluid needs to be evaluated,

even if there are no contractions.
Is there any vaginal bleeding? The mucus plug or “bloody show” is

usually pink or dark red. Any bright red
bleeding requires immediate evaluation.
Has there been a decrease in the Any decrease in fetal movement signals
movement of the baby? the need to report to the birthing center.
Has there been any change in your Any cause for worry or anxiety in the
health? pregnant woman needs to be explored
by the nurse and may lead to admission.
Collecting Admission Data

The admission interview provides the nurse with information about
the woman’s reason for coming to the birthing center, her
understanding and expectations of the labor and birth process, her
subjective experience of the labor, and psychosocial and cultural
factors that can affect her birth experience. The nurse uses multiple
sources and data collection methods to compile a comprehensive
database to plan and deliver individualized care to the woman in
labor. Measurements such as maternal vital signs, weight gain,
fundal height, and FHR patterns should be performed shortly after
arrival, as abnormal findings may change the course of the labor.
The fetal assessment, including presentation, FHR, and
movement, provides essential data regarding fetal well-being.
Maternal vital signs, particularly blood pressure and temperature,
and the assessment of current labor status (UC patterns, cervical
dilation and effacement, fetal station, and rupture of membranes)
provide important baseline labor data.
Initial Admission Assessments

For women who have received prenatal care, the care record is sent
to the birthing center before the expected due date. The information
is stored and readily available when the laboring patient reports
there for care. Women without a prenatal care record require a more
extensive assessment upon admission to the birth setting.
The Focused Assessment

On admission to the birthing unit, the nurse initiates a focused
assessment to determine the condition of the mother and fetus and
the progression of the labor. The data collected answer these critical
questions and help the nurse to establish priorities for care:
■ Is this true labor, and if so, is birth imminent?
■ Are there any factors that increase risk to the mother or fetus?
The nurse assesses the fetus’ well-being by recording the FHR
and noting it in response to UC. Uterine contractions are quantified
as the number of contractions present in a 10-minute window
averaged over 30 minutes, with notes about other factors such as
duration, intensity, and relaxation time between the contractions. The
nurse also assesses fetal movement. If the woman reports that her
membranes have ruptured, the nurse validates the presence of
amniotic fluid and examines the amniotic fluid for color and odor. The
nurse assesses the patient’s vital signs to establish a baseline for
comparison during the labor and birth. The nurse also assesses the
progression of the labor by monitoring the pattern of UCs for
frequency, duration, and intensity. The nurse further assesses the
labor status by evaluating cervical dilation and effacement and fetal
station, presentation, and position.
A patient who states “I feel like pushing” may be indicating that the
birth is imminent. Important questions to ask this patient upon
admission include the following:
■ What is your name? Your support person’s name?
■ Have you received prenatal care? Who is your care provider?
■ How many pregnancies and births have you had? Were the
deliveries vaginal or cesarean? Were there any difficulties with
previous deliveries?
■ What is your due date? When was your last normal menstrual
period?
■ Have your membranes ruptured? What time? Describe the fluid.
■ Have you had any complications with this pregnancy?
■ Do you have any allergies?
■ Describe your contractions—mild, moderate, or intense. When did
your contractions begin? How are you coping? Are you taking any
medications—prescribed and/or over-the-counter? Do you use
illegal/street drugs? Do you smoke? Do you drink alcoholic
beverages?
■ When did you last eat or drink anything and what was it?
■ Have you prepared a birth plan? Do you have any cultural
preferences related to your labor and birth?
If the nurse determines that the fetal or maternal assessments are
not normal or that the birth is imminent, the physician or primary care
provider is notified immediately. If the assessments are normal and
birth does not appear to be imminent, the nurse can complete a
more thorough admission assessment, which would include a
systematic physical assessment.
The Psychosocial Assessment

An important yet sometimes challenging part of the data collection is
the psychosocial assessment. Understanding the woman’s
behavioral responses to the pregnancy and childbirth experience
allows the nurse to support and strengthen the identified coping
mechanisms. Obtaining information that addresses questions such
as “What was the previous birth experience like?” “How is the patient
handling the labor pain?” and “Who is providing labor support for
her?” helps the nurse to better meet the patient’s and her support
person’s needs.
The nurse completes a social assessment, collecting information
about the woman’s family and support systems and living conditions.
Questions about family violence can be particularly difficult. If the
nurse suspects partner abuse, the patient should be interviewed
alone in a private place where she feels safe.
Assessing the woman’s social and lifestyle habits can also be
difficult. Questions about drug and alcohol use and sexually
transmitted infections are often embarrassing. The nurse can
facilitate the sharing of this information through the establishment of
a caring and nonjudgmental relationship with the patient.
What to Say
Asking the Difficult Questions
Asking closed-ended questions such as “Do you drink alcohol?” may elicit a
quick “No” response. Asking more directed and open questions such as “How
many drinks do you have each day?” may encourage a more detailed
response. The nurse should remember that a caring and nonjudgmental
attitude, in a private, nonthreatening environment, helps to foster a trusting
nurse-patient relationship.
Laboratory Tests
Laboratory testing is a routine component of the admission process.
Tests for blood type and Rh factor, complete blood count,
hemoglobin and hematocrit, and blood glucose are generally
obtained. Blood tests for syphilis, hepatitis B, and HIV are also
collected. The urine specimen is tested for the presence of white
blood cells, protein, glucose, and ketones.
Documentation of Admission
Each birth setting has documentation forms and set protocols to be
completed with patient admissions (Figs. 7-11 and 7-12). Collecting
a complete health and childbirth history and performing a physical
examination of the patient and her fetus provide an essential
foundation for the care and support to be given during labor and
birth. Once the admission assessments have been completed, the
nurse documents the information using the birth setting’s recording
procedures, notifies the patient’s primary care provider of the
admission status, and receives orders. Critical information to relay to
the physician or nurse-midwife includes:
■ Patient’s name and age
■ Gravidity and parity
■ Gestational age and estimated date of delivery
■ Labor status: pattern of contractions, cervical dilation and
effacement, and fetal presentation and station
■ Status of membranes
■ FHR and response to contractions
■ Patient’s vital signs, especially blood pressure and temperature
■ Any identified risk to maternal or fetal well-being
■ Patient’s coping ability in response to labor
After admission, the patient and her fetus are assessed frequently
to monitor both the progression of labor and their responses to the
labor. Throughout each stage of labor, ongoing maternal
assessments include vital signs, intake and output, pattern of
contractions, cervical dilation and effacement, and response to labor.
Fetal assessments, which primarily center on the response to labor,
involve intermittent or continuous FHR monitoring.
ASSESSMENT OF THE FETUS DURING LABOR

AND BIRTH
Assessment of the fetus during labor and birth is a fundamental
component of caring for a woman in labor. Intrapartal assessment of
the fetus should be included in the maternal assessments at
admission and remain ongoing throughout the intrapartal period.
Fetal assessments include the identification of fetal position and
presentation and the evaluation of fetal status. A healthy fetus is able
to withstand the mechanical and hemodynamic changes that occur
during normal labor without adverse effects. Various fetal
physiological responses to labor are presented in Box 7-3.
FIGURE 7-11 Labor and delivery admission record.
FIGURE 7-12 Labor documentation record.
BOX 7-3
Various Fetal Physiological Responses to Labor

CHANGES IN HEART RATE
• Decelerations may occur with increased intracranial pressure as the head
presses against the maternal cervix. The early decelerations are thought to
result from hypoxic depression of the central nervous system, which is under
vagal control.
CHANGES IN ACID-BASE STATUS
• Decreased fetal blood flow, which occurs at the peak of the contraction, leads
to a slow decrease in pH.
• This process is accelerated during the second stage of labor, as a result of
longer, stronger contractions and maternal pushing efforts.
CHANGES IN HEMODYNAMIC STATUS
• Fetal blood pressure, necessary for the adequate exchange of nutrients and
gases in the fetal capillaries and intervillous spaces, protects the fetus during
the anoxic periods that normally occur during UC.
AWARENESS OF SENSATION
• By 37 weeks, the fetus is able to experience sensations of light, sound, and
touch.
• During labor, the term fetus is aware of pressure sensations (e.g., head
pressure during contractions and vaginal examination).
NURSING INSIGHT
The Role of Astute Observation
Nurses use a variety of assessment techniques including observation,
palpation, and auscultation. When assessing a woman in labor, the nurse must
use observation and interview skills from the moment the woman comes
through the door. Astute observation assists the nurse in assessing the
patient’s level of pain, her coping abilities, her contraction frequency, and the
effectiveness of her support person. However, the nurse is unable to use direct
observation skills to assess the status of the fetus. Therefore, it is critical that
fetal assessment be a priority when the patient enters the intrapartal unit.
Fetal Position
The nurse may attempt to identify the fetal presentation in the
following ways:
■ Abdominal palpation (Leopold maneuvers)
■ Location of the point of auscultation of the FHR
■ Vaginal examination
■ Ultrasound
Some methods are more accurate than others.
Leopold Maneuvers and Point of FHR Auscultation

Leopold maneuvers are a systematic way of palpating the maternal
abdomen to assess the fetal position. Through the identification of
fetal position, Leopold maneuvers can also assist the nurse to
identify the location to auscultate the fetal heart tones. Performing
Leopold maneuvers is a skill that requires practice and is not always
accurate in identifying fetal position. Factors such as maternal
obesity, hydramnios, and multiple gestation can increase the
difficulty of identifying fetal position by Leopold maneuvers. (See
Chapter 6 for further discussion.)
FOCUS ON SAFETY
Prevent Supine Hypotension
Much of the fetal assessment involves the maternal abdomen. Avoid
positioning the patient flat on her back. In this position the fetus is directly
pressing of the vena cava, which affects both fetal and maternal blood flow.
The nurse should slightly elevate the head of the bed or place a wedge under
the patient’s right hip to prevent compression of the maternal vena cava
caused by the gravid uterus.
Vaginal Examination
Another method of assessing the fetal position is by vaginal
examination. The examiner may be able to palpate the fontanelles or
cranial suture to identify that the fetus is in a cephalic presentation.
The landmarks may also be used to further identify the degree of
flexion and the specific presentation such as vertex. If the
membranes are intact or if the cervix is minimally dilated, the
examiner may not be able to identify the position of the fetus.
Abdominal Ultrasound
Ultrasound may be used when the practitioner is unable to identify
the position by abdominal palpation or when it is necessary to
determine the fetal position with the most accuracy. If a breech
presentation is suspected during labor, an ultrasound examination
may be performed to confirm the fetal presentation before
performing a cesarean section.
Assessment of the Fetal Heart Rate

Much debate exists regarding the optimal method for evaluating the
FHR in labor with the use of continuous or intermittent electronic
fetal monitoring (EFM) and intermittent auscultation (IA). Intermittent
auscultation, which promotes the “high touch, low-tech” approach to
care, has been found to be as effective as the electronic method for
fetal surveillance, and research evidence supports the use of IA for
low-risk pregnant women. However, in practice, many low-risk
women continue to be electronically monitored during labor. The use
of continuous EFM has been shown to increase the rate of cesarean
deliveries and operative vaginal deliveries (ACOG, 2019).
Variations in Practice Environments for Perinatal Nurses
Because diverse policies are found in different practice environments, nurses
are encouraged to seek relevant policies and procedures within their individual
health-care organizations to guide their practices. It is important that the nurse
practice within the standards set by the employer institution. The nurse is
professionally accountable and has a legal responsibility to be knowledgeable
of the current standards that affect practice. Perinatal nurses should be fully
cognizant of the institutional policies concerning fetal heart surveillance during
labor. Pertinent information generally includes the method of assessment,
qualifications for those performing the technique, nurse-to-patient ratio,
frequency and duration of assessment for specific stages of labor and defined
risk categories, indications for specific methods, when to notify the primary care
provider, and documentation.
Auscultation of Fetal Heart Sounds
Fetal heart sounds are best heard over the fetal back when the fetus
is in the flexed position because this is the part in closest contact
with the uterine wall. Where to auscultate the fetal heart sounds
depends on the fetal position (e.g., back to maternal left or right side
and breech versus cephalic) (Fig. 7-13). Finding the best location to
auscultate fetal heart sounds facilitates another method to identify or
confirm fetal position. Typically, with a cephalic presentation, the fetal
heart sounds are heard below the level of the maternal umbilicus. In
an ROA position, the heart sounds are heard loudest in the right
lower quadrant. Conversely, with a breech presentation, the fetal
heart sounds are often auscultated above the level of the umbilicus.
In an LSA position, the fetal heart sounds should be heard loudest in
the upper left quadrant.
FIGURE 7-13 Location of fetal heart sounds on the maternal

abdomen.
Regardless of the method used to assess fetal well-being in labor,

nurses need to be extremely attentive to the fetal heart sounds. In
addition, nurses must be knowledgeable regarding the identification
of various FHR patterns and the appropriate interventions that may
be required.
INTERMITTENT AUSCULTATION
Intermittent auscultation of the FHR is frequently the
recommended method for evaluating fetal status in women who have
been identified as low risk. The FHR can be auscultated with a
fetoscope or Doppler instrument and should be assessed for the
baseline FHR, regular or irregular rhythm pattern, and the presence
of accelerations. IA requires 1:1 care, and the health-care
professional should be able to identify normal and abnormal FHR
patterns and recognize the implications and interventions that may
be required. Intermittent auscultation is conducted using a fetoscope
or Doppler instrument. Intermittent auscultation does not provide a
continuous printout of information on the FHR, and the health-care
provider who is performing the FHR needs to document findings
frequently according to hospital policy. Although this method is more
involved, research has demonstrated its efficacy in monitoring FHR
in labor. Intermittent auscultation results in less-frequent cesarean
section compared with continuous EFM (American College of
Obstetricians and Gynecologists [ACOG], 2019). In a normal healthy
pregnancy when no risk factors are present, the suggested
frequencies for FHR auscultation are within the range of every 60
minutes during the latent phase of labor, every 15 minutes during the
active phase, and every 5 minutes during the second stage of labor.

Electronic fetal monitoring may be conducted on an intermittent or
continuous basis. Electronic fetal monitoring, compared with IA, has
not been associated with a decrease in neonatal mortality or
morbidity although it has been associated with increased rates of
cesarean section, operative vaginal birth, and the use of obstetric
anesthesia. Despite recommendations from professional
organizations, approximately 3.4 million low-risk laboring women in
the United States are monitored electronically for at least part of their
labor.
The situations in which EFM is recommended continuously for
assessing fetal well-being include history of a stillbirth (in utero fetal
death at greater than or equal to 38 weeks’ gestation), the presence
of a complication of pregnancy (e.g., pre-eclampsia-eclampsia,
placenta previa, abruptio placentae, multiple gestation, and
prolonged or PROM), induction of labor with oxytocin, when IA
identifies a need for more detailed information about the FHR, or if
the institution is unable to provide IA. Electronic fetal monitoring can
be performed externally or internally. The external EFM involves a
process that is very similar to the nonstress test (NST). The external
monitor is composed of a Doppler ultrasound transducer and
tocodynanometer that is applied to the maternal abdomen to monitor
and display the FHR and contractions (Fig. 7-14). Although the use
of an external transducer requires that the woman remain confined
to a bed or chair, portable telemetry units allow patients to ambulate
during electronic monitoring. The nurse is able to observe the FHR
and UC patterns at a centrally located electronic display station.
Some facilities are equipped with monitoring units that can be used
when the woman is submerged in water.
The internal fetal monitor is composed of a spiral electrode (fetal
spiral electrode, or FSE) that must be inserted into the fetal scalp or
presenting part during a vaginal examination (Fig. 7-15). The cardiac
signal is transmitted through the spiral electrode and a fetal
electrocardiogram tracing is produced. Uterine activity is assessed
by a solid or fluid-filled IUPC that is introduced into the uterine cavity.
The IUPC can measure contraction frequency, duration, and
intensity. The internal method is a more accurate form of fetal
monitoring. However, because of the invasive nature of the
procedure, internal EFM is often reserved for high-risk pregnancies
(situations in which external fetal monitoring is insufficient in
obtaining the FHR or in situations in which there is evidence of a
nonreassuring FHR). The application of an internal electrode
requires that the membranes be ruptured and that the cervix has
sufficiently dilated.
The interpretation of the FHR pattern requires a holistic
assessment of the maternal risk factors, uterine activity, and FHR
patterns including baseline, variability and the presence of
accelerations, and the identification of any decelerations. The
primary objective of intrapartal FHR monitoring interpretation is to
assess the adequacy of fetal oxygenation during labor. An
understanding of FHR physiology and the various influences on the
FHR is useful in interpreting FHR patterns (Box 7-4). Members of the
obstetric team must maintain close communication and reach mutual
consensus regarding interpretation of fetal heart patterns. Often,
nurses who practice in labor and delivery units obtain advanced
training and education regarding fetal monitoring to aid in accurate
interpretation.
PROCEDURE ■ Auscultating the Fetal Heart

Tones During Labor
PURPOSE
Auscultation, an auditory method of monitoring the fetal heart tones, is
performed intermittently during labor to assess the fetus. Auscultation allows
the laboring woman greater freedom because she is not attached to a machine
and does not have to wear belts to secure the ultrasound transducer and the
tocotransducer. Intermittent auscultation does not provide a printed record of
the FHR for other members of the health-care team to review. Auscultation also
does not provide an assessment of FHR variability or of other subtle changes
in the FHR.
Equipment
• Fetoscope or handheld Doppler ultrasound with gel (“Doppler”)
• Disposable wipes Steps
a. Wash and dry hands and explain procedure and purpose of the examination
to the patient.
and cooperation.
b. Help the patient assume a comfortable position that provides access to the
abdomen.
c. Palpate the maternal abdomen using Leopold maneuvers to identify the fetal
position to aid in obtaining the location of the fetal heart tones. Note that the
fetal heart tones are heard most loudly over the fetal back.
d. Palpate the fundus of the uterus for the presence of UC. At the end of a UC,
place the fetoscope or Doppler over the location of the fetal back. Adjust the
fetoscope or Doppler if necessary to obtain a clearly audible FHR.
Depending on fetal position, the fetal heart sounds may be soft and muffled
or loud and clear.
e. Listen for audible fetal heart sounds. Note that two distinctly different sounds
can be heard: fetal heart tones that result from blood moving through the
placenta and umbilical cord (funic soufflé) and the uterine soufflé, which is
the same rate as the maternal pulse.
f. Palpate the maternal radial pulse to ensure that the auscultated fetal heart
sounds are at a different rate than the maternal pulse.
g. Auscultate the fetal heart sounds for the rate and rhythm. The greatest
accuracy for assessment of the FHR occurs when listening for 1 minute.
Note: During active labor, 30-second intervals may be more feasible.
h. Count the FHR for 30–60 seconds between contractions to determine the
baseline rate.
RATIONALE: The baseline rate can be assessed only during the absence of
uterine activity.
i. Interpret the FHR: Is the baseline normal between 110 and 160 beats per
minute (bpm)? Is there tachycardia (baseline greater than 160 [MR7] bpm)
or bradycardia (baseline less than 110 bpm)? Is the rhythm regular or
irregular? Can you note the presence of accelerations or decelerations?
j. Repeat the procedure as indicated according to agency policy.
k. Inform the patient of the findings. l. Document the FHR according to agency
policy.
What If?
What if you have carefully applied the Doppler in several locations over the
area of the fetal back, yet you are unable to hear any fetal heart tones?
Immediately notify the primary care provider, who will most likely perform an
ultrasound assessment.
Documentation
5/5/09 1030: FHR obtained by fetoscope at 144 bpm and regular. Acceleration
of the FHR noted. Patient coping well in active labor. Contractions 3 min apart,
60-second duration with moderate intensity.
—L. Lopez, RN
FIGURE 7-14 External fetal monitor.

FIGURE 7-15 Internal fetal monitor.
BOX 7-4
Various Influences on the Fetal Heart Rate

UTEROPLACENTAL UNIT
• Transfer of oxygen and carbon dioxide between the maternal and fetal
circulation (depends on adequate uterine blood flow, sufficient functional
placental mass, and umbilical cord patency)
• Adequate fetal oxygenation (depends on adequate maternal oxygenation,
placental blood flow, uteroplacental circulation, umbilical circulation, and
innate ability of the fetus to initiate compensatory mechanisms to regulate the
FHR)
• Other fetal environmental factors that influence oxygenation (uteroplacental
function, uterine activity, umbilical cord patency, and maternal physiological
functioning)
• Adequate placental reserve (reserve oxygen available to the fetus to
withstand the transient changes in blood flow and oxygen during labor)
• The placenta normally provides oxygen and nutrients over and above fetal
baseline needs
• In periods of decreased oxygen, blood flow is deferred to vital fetal organs
(heart, brain, and adrenal glands) to compensate
• If placental reserves are decreased or depleted, the fetus may not be able to
adapt to or tolerate the decreased oxygen that occurs during a UC
• The fetus adapts to the stresses of labor through homeostatic mechanisms
AUTONOMIC NERVOUS SYSTEM
PARASYMPATHETIC NERVOUS SYSTEM
• Primarily mediated by the vagus nerve innervating the sinoatrial (SA) and
atrioventricular (AV) nodes in the heart
• Parasympathetic stimulation decreases the heart rate
• Stimulation of the vagus nerve slows the FHR and helps to maintain variability
(develops around 28–30 weeks of gestation)
SYMPATHETIC NERVOUS SYSTEM (SNS)
• SNS stimulation increases the FHR
• Stimulation of nerves (located throughout the fetal heart) produces an
increase in the strength of the fetal heart contraction
• SNS is responsible for long-term baseline variability
• Action occurs through the release of norepinephrine
• SNS may be stimulated during periods of fetal hypoxemia
BARORECEPTORS
• Stretch receptors present in the aortic arch and the carotid arch; detect
pressure changes
• Maintain homeostasis: Regulate the heart rate by stimulating a vagal
response and decreasing the FHR, fetal blood pressure, and cardiac output
CENTRAL NERVOUS SYSTEM (CNS)
• The integrative center responsible for variations in the FHR and baseline
variability related to fetal activity
• Regulates and coordinates autonomic activities
• Mediates cardiac and vasomotor reflexes
• Responds to fetal movement
CHEMORECEPTORS
• Located in the aortic arch and the CNS
• Respond to changes in fetal O2, CO2 and pH levels: Decreased O and
increased CO cause peripheral chemoreceptors to stimulate the vagal nerve
and slow the FHR; central chemoreceptors respond to an increased FHR and
an increased blood pressure
HORMONAL REGULATION
• The fetus responds to a decrease in O2 or in uteroplacental blood flow by
releasing hormones that maximize blood flow to vital organs (heart, brain, and
adrenal glands)
• Epinephrine, norepinephrine, catecholamines, and vasopressin prompt
hemodynamic changes in response to changes in fetal oxygenation; fetal
hypoxia triggers a release of epinephrine and norepinephrine that increases
FHR and blood pressure
• Renin-angiotensin (secreted by the kidneys) produce vasoconstriction in
response to fetal hypovolemia
Baseline Fetal Heart Rate
The baseline fetal heart rate (FHR) is referred to as the average
FHR observed between contractions over a 10-minute period (Fig. 7-
16). The recorded baseline excludes periodic FHR changes that are
evidenced by increased variability or accelerations. The normal
baseline FHR at term is 110 to 160 bpm. There are two abnormal
variations of the baseline: tachycardia (baseline above 160 bpm) and
bradycardia (baseline below 110 bpm).
TACHYCARDIA
Tachycardia is generally defined as a sustained baseline FHR
greater than 160 bpm for a duration of 10 minutes or longer (Fig. 7-
17). A number of conditions are associated with fetal tachycardia.
■ Fetal anemia: In response to a decrease in hemoglobin, the FHR
increases to compensate and improve tissue metabolism.
■ Fetal hypoxia: The fetus attempts to compensate for reduced
blood flow by increasing the heart rate to perfuse organs.
■ Maternal fever: An increase in maternal temperature accelerates
fetal metabolism, thus increasing the FHR. This situation may be
seen in a laboring woman who becomes dehydrated or has an
increased temperature following prolonged exposure in a warm
bath or whirlpool.
■ Maternal dehydration: FHR will increase in the setting of maternal
dehydration to compensate for low volume.
■ Maternal medications: Both parasympathetic drugs (e.g., atropine
and scopolamine) and beta-sympathetic drugs (tocolytic drugs
used to halt contractions) can have a stimulant effect and increase
the FHR.
■ Infection: Tachycardia may be an initial sign of uterine infection
(amnionitis) and may precede an increased maternal temperature
by 1 to 2 hours.
■ Maternal hyperthyroidism: Thyroid-stimulating hormone (TSH) may
cross the placenta and stimulate the FHR.
■ Maternal substance use: FHR increases due to illicit substances
that can increase heart rate such as cocaine and
methamphetamines.
FIGURE 7-16 The normal baseline fetal heart rate at term is 110 to
160 bpm (Top: fetal heart rate; Bottom: uterine contractions).
FIGURE 7-17 Fetal tachycardia.
FIGURE 7-18 Fetal bradycardia.
BRADYCARDIA
Bradycardia is defined as a sustained (greater than 10 minutes)
baseline FHR of less than 110 bpm (Fig. 7-18). Fetal bradycardia
may be associated with the following:
■ Medications: Beta-adrenergic blocking drugs (e.g., propranolol
[Inderal])
■ Maternal hypotension: Results in decreased blood flow to the fetus
and can lower the FHR. Maternal hypotension can result from
positioning (i.e., supine hypotension) and is a common side effect
associated with an epidural or spinal anesthetic.
■ Maternal or fetal hypoglycemia, hypothermia, and dehydration.
■ Prolonged umbilical cord compression or prolapse
■ Fetal heart failure or complete heart block, which may cause an
FHR baseline as low as 70 to 90 bpm
■ Uterine tachysystole (hyperstimulation)
■ Abruptio placentae
■ Uterine rupture or vasa previa
■ Vagal stimulation during the second stage (fetal recovery is
possible because this condition does not involve hypoxia)
■ Chronic fetal head compression
When bradycardia is observed, the nurse first confirms that the
EFM is monitoring the FHR rather than the maternal heart rate. If the
woman is on a uterotonic such as Pitocin, the first response should
be to shut the medication off and turn the mother to the left side-lying
position. Assess for fetal movement and response to fetal scalp
stimulation (performed when the FHR is between contractions). A
vaginal examination is performed to assess for umbilical cord
prolapse. Assessment of maternal vital signs and hydration status
with prn fluid administration may be useful in reducing contractions
and in promoting fetal oxygenation. Depending on other parameters
(e.g., FHR variability), other actions that may be appropriate include
administering oxygen (8–10 L/min by mask), modifying the patient’s
pushing pattern, and notifying the primary care provider.
Hyperstimulation, also known as uterine tachysystole, is a
condition of excessively frequent contractions with the following
characteristics: greater than five UCs in 10 minutes (averaged over a
30-minute window) with contractions occurring within 1 minute of
each other, and a uterine resting tone greater than 20 to 25 mm Hg
with a peak pressure greater than 80 mm Hg (Fig. 7-19).
Tachysystole may occur in spontaneous or stimulated labor and is
most commonly caused by cervical ripening agents, induction, and
augmentation of labor. Medical management centers on addressing
the cause of tachysystole (e.g., discontinuing oxytocin or removing
cervical ripening medication). Nursing interventions center on
reducing uterine activity with intrauterine resuscitative actions such
as maternal position change, increasing hydration, relieving maternal
anxiety and pain, and administering a tocolytic medication as
ordered.
Baseline Variability
Variability of the FHR is manifested by fluctuations in the baseline
FHR observed on the fetal monitor. The pattern denotes an irregular,
changing FHR rather than a straight line that indicates few changes
in the rate. The variability of the FHR is a result of the interplay (a
“push and pull” effect) between the fetal sympathetic nervous
system, which assists to increase the heart rate, and the
parasympathetic nervous system, which acts to decrease the heart
rate. Baseline variability, the fluctuations in the baseline FHR that are
irregular in amplitude and frequency, is the most important predictor
of adequate fetal oxygenation during labor. Reduced variability is the
best single predictor for determining fetal compromise. The
fluctuations are visually quantified as the amplitude of the peak and
trough in bpm.
FIGURE 7-19 Tachysystole (inadequate interval of resting tone

between UC).
The presence of variability is reflective of a well-functioning and

well-oxygenated fetal autonomic nervous system and confirms that
the fetus is not experiencing metabolic acidosis. Short-term
variability, the beat-to-beat changes in the FHR, is most accurately
assessed with an internal fetal scalp electrode. Long-term variability
refers to the changes in FHR over a longer period, such as 1 minute.
The absence of or undetected variability is considered a warning
sign of nonreassuring fetal status. Reduced variability may be
associated with fetal dysrhythmias or anomalies affecting the heart,
central nervous system (CNS), or autonomic nervous system, a
previous neurological insult, tachycardia, or prematurity (less than 32
weeks’ gestation). If decreased variability is noted with an external
modality, application of an internal fetal scalp electrode should be
considered to obtain more accurate information. Variability may be
described as absent, minimal, moderate, or marked (Table 7-3)
(Figs. 7-20 to 7-23).
The presence of adequate (moderate) variability is an important
indicator of fetal well-being. Fetal heart rate variability is indicative of
an adequately oxygenated neurological pathway in which impulses
are transmitted from the fetal brain to the cardiac conduction system.
An electronic fetal monitor tracing that records the FHR as a
changing, jagged line is reflective of an adequately oxygenated,
responsive fetal brain and fetal heart.
Conversely, the absence of variability may indicate normal
variations such as fetal sleep (the sleep state should not last longer
than 30 minutes), a response to certain drugs that depress the CNS
(e.g., analgesics: meperidine [Demerol]; tranquilizers: diazepam
[Valium]; barbiturates: secobarbital [Seconal] and pentobarbital
[Nembutal]; and ataractics: promethazine [Phenergan]), general
anesthetics or a pathological condition such as hypoxia, a CNS
abnormality, or acidemia.
Periodic and Episodic Changes

Periodic changes are accelerations and decelerations in the FHR
that occur in relation to UCs and persist over time. Periodic changes
include FHR accelerations and four types of FHR decelerations:
early, variable, late, and prolonged.
Episodic changes are FHR acceleration and deceleration patterns
that are not associated with UCs. Fetal heart rate accelerations are
the most common episodic change.
ACCELERATIONS
An acceleration is defined as an increase in the FHR of 15 bpm
above the fetal heart baseline that lasts for at least 15 seconds to
less than 2 minutes. Accelerations are visually abrupt and transient
—the onset to peak is less than 30 seconds. Before 32 weeks of
gestation, accelerations are defined as an acceleration greater than
or equal to 10 bpm over the baseline FHR for greater than or equal
to 10 seconds. A prolonged acceleration is greater than or equal to 2
minutes but less than or equal to 10 minutes. Accelerations are
considered a sign of fetal well-being when they accompany fetal
movement. Thus, when a fetus is active in utero, accelerations
(caused by a sympathetic response to fetal movement) are normally
present. Consequently, when the fetus is sleeping or not moving,
limited FHR accelerations may be noted.
When contractions are present, accelerations are often noted as a
response to the contraction. This type of periodic FHR acceleration
with contractions is thought to be a compensatory accelerative
response to a transient decrease in blood flow (e.g., umbilical vein
compression) to the fetus. Accelerations may occur before, during,
or after a contraction. Accelerations are often associated with a
normal FHR baseline and normal variability (Fig. 7-24). The
presence of FHR accelerations should be recorded in the patient’s
labor chart.
DECELERATIONS
Decelerations are defined as any decrease in FHR below the
baseline FHR. They are classified according to their shape, timing,
and duration in relation to the UC. Recurrent decelerations occur
with at least 50% of UCs over a 20-minute period. Intermittent
decelerations occur with fewer than 50% of UCs over a 20-minute
period. Decelerations are further defined according to their onset and
are characterized as early, variable, late, and prolonged (Fig. 7-25).
Appropriate nursing actions for variable, late, and prolonged
decelerations are presented in Table 7-4.
TABLE 7-3
Classifications of FHR Variability and Possible Causes
VARIABILITY AMPLITUDE OF FHR CAUSES
CHANGES
Absent Undetectable May represent fetal cerebral asphyxia.
Warrants immediate evaluation.
Minimal >2–<5 beats per minute May be related to narcotics,

(bpm) tranquilizers, magnesium sulfate,
barbiturates, anesthetic agents, supine
hypotension, cord compression, uterine
tachysystole, prematurity, or fetal sleep.
Moderate 6–25 bpm Indicative of fetal well-being.
Marked <25 bpm Marked variability is believed to be a

less common response to fetal hypoxia.
FIGURE 7-20 Absent variability.
FIGURE 7-21 Minimal variability.
FIGURE 7-22 Moderate variability.

FIGURE 7-23 Marked variability.
FIGURE 7-24 FHR accelerations.
Early Decelerations
An early deceleration is defined as a visually apparent, usually
symmetrical, gradual decrease and return of the FHR associated
with a UC. Early decelerations are characterized by a deceleration in
the FHR that resembles a mirror image to the contraction. Therefore,
the onset of the deceleration begins near the onset of the
contraction, the lowest part of the deceleration (nadir) occurs at the
peak of contraction, and the FHR returns to baseline by the end of
the contraction. Early decelerations are usually repetitive and are
commonly observed during active labor and descent of the fetus
(Fig. 7-26).
Early decelerations are considered benign and are usually well
tolerated by the fetus. They are believed to be related to transient
fetal head compression and the resulting vagal stimulation that slows
the FHR. When present, early decelerations usually occur during the
first stage of labor. They may also occur during vaginal examinations
as a result of fundal pressure and during placement of the internal
mode of fetal monitoring. Early decelerations are viewed as an
indicator of fetal well-being and adequate oxygen reserve and no
nursing intervention is needed.
FIGURE 7-25 Causes and examples of periodic decelerations.
TABLE 7-4
Nursing Actions for Variable, Late, and Prolonged FHR Decelerations
DECELERATION NURSING ACTIONS
PATTERN
Variable decelerations: Explain finding and offer support to patient and her birth
Normal (transient) partner to decrease anxiety or pain, and to enhance
(duration less than 60 uterine blood flow and fetal oxygenation.
seconds, rapid return to
baseline, normal
baseline and variability)
Variable decelerations: Change the maternal position (side to side, knee chest)
Indeterminate or to minimize or correct cord compression and promote
abnormal (prolonged fetal oxygenation.
return to baseline, Decrease or discontinue oxytocin if infusing to decrease
persistence to less than uterine contractions. Note: A tocolytic (e.g., terbutaline)
60 bpm and greater may be given to promote uterine relaxation.
than 60 seconds, Administer oxygen at 8 to 10 L/min (via tight face mask)
presence of overshoots to improve fetal oxygenation.
tachycardia, repetitive Assist with/perform sterile vaginal examination to assess
overshoots, and absent for umbilical cord prolapse, to assess labor progress, and
variability) to perform fetal scalp stimulation.
Assist with amnioinfusion (if ordered) to alleviate
umbilical cord compression by increasing the intrauterine
fluid volume.
Alter the maternal pushing technique (open glottis,
shorter duration of pushes) to enhance uteroplacental
blood flow.
Consider internal monitoring to obtain a more accurate
fetal and uterine assessment. Explain finding and offer
support to the patient and her birth partner.
Prepare for birth: If FHR pattern cannot be corrected,
expect cesarean or operative vaginal delivery (e.g.,
forceps, vacuum extraction).
Late decelerations Position patient on her side.

Assess for maternal hypotension; to correct—increase
IVF rate, administer an IVF bolus (at least 500 mL
Ringer’s lactate), elevate maternal legs to increase blood
volume and raise the blood pressure.
Continue adequate maternal hydration (IVF—normal
saline or Ringer’s lactate) to maximize maternal
intravascular volume and enhance uteroplacental
perfusion.
Palpate the uterus to assess for tachysystole.
Discontinue oxytocin if infusing and late decelerations
persist. Note: Terbutaline may be ordered. Administer
oxygen at 8 to 10 L/min (via tight face mask).
Assess labor progress (cervical dilation, fetal station);
consider internal monitoring.
Consider fetal scalp stimulation or vibroacoustic
stimulation to assess fetal status.
Explain finding and offer support to the patient and her
birth partner.
Prepare for birth – expect cesarean or operative vaginal
delivery (e.g., forceps, vacuum extraction) if FHR pattern
cannot be corrected.
Prolonged Assess baseline variability preceding and following the

decelerations deceleration to observe for accompanying FHR pattern
changes.
Assist patient into a position that improves FHR pattern.
Discontinue oxytocin if infusing (terbutaline may be
ordered). Administer oxygen at 8 to 10 L/min (via tight
face mask).
Increase IVF rate prn; consider administering an IVF
bolus (500 mL Ringer’s lactate). Assist with/perform
sterile vaginal examination and fetal scalp stimulation.
Assist with amnioinfusion (if ordered). Consider internal
monitoring.
Explain finding and offer support to the patient and her
birth partner.
Prepare for birth—expect cesarean or operative vaginal
delivery (e.g., forceps, vacuum extraction) if FHR pattern
cannot be corrected.
FIGURE 7-26 Early decelerations.
NURSING INSIGHT
Repetitive Early Decelerations
Repetitive early decelerations may signal advanced cervical dilation or the
beginning of the second stage of labor. When the EFM strip shows recurring
early decelerations, the nurse should inquire about sensations of pressure.
Pressure that occurs only during contractions is indicative of advanced cervical
dilation, while intense, unremitting pressure may signal the beginning of the
second stage. A vaginal examination may be performed to confirm the cervical
status.
Variable Decelerations
Variable decelerations are variable in terms of their onset,
frequency, duration, and intensity. The visually abrupt decrease in
FHR below the baseline is 15 bpm or more, lasts at least 15
seconds, and returns to the baseline in less than 2 minutes from the
time of onset (Fig. 7-27). Variable decelerations occur at any time
during the uterine contracting phase and may appear in the shape of
a “U,” “W,” or “V.”
Variable decelerations, the most common deceleration pattern
seen in labor, are thought to result from umbilical cord compression,
which triggers a vagal response that slows the FHR. Umbilical vein
compression is accompanied by decreased Po2 and chemoreceptor
stimulation, then compression of the more muscular umbilical
arteries. Thus, the degree by which the cord is compressed (partially
versus completely) can affect the severity of the deceleration. For
example, a cord that is briefly compressed by the fetus may manifest
as a very abrupt decrease in the FHR with a rapid return to baseline.
Conversely, a cord that is tightly wrapped around the fetal neck
(nuchal cord) progressively becomes more compressed as the
fetus descends into the maternal pelvis. This situation is most likely
to result in longer, more severe decelerations. In general, brief,
occasional variable decelerations are often considered benign,
whereas repetitive, worsening variable decelerations are cause for
concern and always warrant further investigation (see Table 7-4).
FIGURE 7-27 Variable decelerations.
Optimizing Outcomes
Amnioinfusion to Relieve Cord Compression
Amnioinfusion is the transcervical instillation of warmed normal saline that is
infused by a sterile catheter inserted into the vagina, through the cervix, and
into the uterus. It is required that the membranes be ruptured so that the
catheter can be placed into the uterus (Venes, 2021). The infusion of saline
provides additional intra-amniotic fluid to cushion the umbilical cord and help
lessen cord compression and may be used in an attempt to reduce the severity
of repetitive and several variable decelerations (Venes, 2021).
Late Decelerations
A late deceleration of the FHR is a visually apparent, gradual
decrease in and return to baseline FHR associated with UC. The
patterns of late decelerations typically mirror the contraction, and this
characteristic is similar in appearance to early decelerations. With
late decelerations, the deceleration has a late onset and begins
around the peak of the contraction (Fig. 7-28). This type of
deceleration does not resolve until after the contraction has ended.
Late decelerations indicate the presence of uteroplacental
insufficiency, a decline in placental function. Normally, the fetus can
withstand repeated contractions with sufficient oxygenation.
However, in this circumstance a decrease in blood flow from the
uterus to the placenta results in fetal hypoxia and late decelerations.
Late decelerations require prompt attention and reporting. The
presence of persistent and repetitive late decelerations is usually
indicative of fetal hypoxemia that may progress to hypoxia and
metabolic acidemia. The longer the late decelerations persist, the
more serious they become. Immediate attempts should be made to
correct the cause of the late decelerations if possible. For example,
late decelerations in the presence of an oxytocin infusion may signal
a need to immediately discontinue the oxytocin infusion, especially if
uterine hyperstimulation is suspected. Nursing interventions that
should be implemented immediately center on intrauterine
resuscitation. It is important to note that late decelerations can
present very obviously or very subtly. In addition, late decelerations
are often accompanied by other nonreassuring fetal heart patterns
such as a loss of or decrease in variability.
Prolonged Decelerations
A prolonged deceleration is an abrupt decrease in the FHR below
the baseline that is greater than or equal to 15 bpm and lasts greater
than or equal to 2 minutes but less than 10 minutes (Fig. 7-29).
Prolonged decelerations may be abrupt or gradual, and when they
are nonrecurrent and preceded and followed by normal baseline and
moderate variability, prolonged decelerations are not associated with
fetal hypoxemia. The following events can cause prolonged
decelerations: any mechanism that produces a profound change in
the fetal O2, interruption of uteroplacental perfusion (e.g.,
tachysystole [hyperstimulation, maternal hypotension, or abruptio
placentae]), interruption of umbilical blood flow (e.g., cord
compression or cord prolapse), or vagal stimulation (e.g., profound
head compression or rapid fetal descent). If prolonged decelerations
are observed, the nurse must immediately initiate appropriate
interventions (see Table 7-4) and promptly notify the primary care
provider.
FIGURE 7-28 Late decelerations.
FIGURE 7-29 Prolonged decelerations.

Interpretation of FHR Tracings
A systematic approach to the interpretation of FHR tracings ensures
that all possibilities are considered. When assessing FHR tracings,
nurses should consider factors such as contraction frequency and
intensity, stage of labor, and the earlier FHR pattern. Most
institutions have established protocols to guide electronic fetal heart
monitoring methods and to maintain consistency in the interpretation
of FHR patterns.
A “Three-Tier Fetal Heart Rate Interpretation System” is the
recommended method in interpreting FHR patterns (Box 7-5). A
schema to guide decision making in FHR assessment is presented
in Figure 7-30.
BOX 7-5
Fetal Heart Rate Terms and Interpretation of

FHR Patterns
Normal: Less than or equal to five contractions in 10 minutes, averaged over a
30-minute window.
Tachysystole: Greater than five contractions in 10 minutes, averaged over a 30-
minute window.
• Tachysystole should always be qualified as to the presence or absence of
associated FHR decelerations.
• The term “tachysystole” applies to both spontaneous and stimulated labor.
• The terms “hyperstimulation” and “hypercontractility” are not defined and
should be abandoned.
• Categorization of FHR patterns: Three-Tier Fetal Heart Rate Interpretation
System
CATEGORY I: NORMAL AND PREDICTIVE OF NORMAL ACID-BASE, NO
ACTIONS REQUIRED
Category 1 fetal heart rate tracings include all of the following:
• Baseline rate: 110–160 beats per minute (bpm)
• Moderate baseline FHR variability
• Late or variable decelerations are absent
• Early decelerations may be present or absent
• Accelerations may be present or absent
Category I FHR tracings are normal and strongly predictive of normal fetal
acid-base status at the time of observation. Category I FHR tracings may be
followed in a routine manner and no specific action is required.
CATEGORY II: INTERMEDIATE AND NOT PREDICTIVE OF NORMAL OR
ABNORMAL AND REQUIRE CONTINUOUS SURVEILLANCE AND
MONITORING
Category II FHR tracings include all FHR tracings not categorized as Category I
or Category III. Category II tracings may represent an appreciable fraction of
those encountered in clinical care. Examples of Category II FHR tracings
include any of the following:
BASELINE RATE
• Bradycardia not accompanied by absent baseline variability
• Tachycardia
BASELINE FHR VARIABILITY
• Minimal baseline variability
• Absent baseline variability not accompanied by recurrent decelerations
• Marked baseline variability
ACCELERATIONS
• Absence of induced accelerations after fetal stimulation
PERIODIC OR EPISODIC DECELERATIONS
• Recurrent variable decelerations accompanied by minimal or moderate
baseline variability
• Prolonged deceleration greater than or equal to 2 minutes but less than 10
minutes
• Recurrent late decelerations with moderate baseline variability
• Variable decelerations with other characteristics, such as slow return to
baseline, “overshoots,” or “shoulders”
Category II FHR tracings are indeterminate. Category II FHR tracings are not
predictive of abnormal fetal acid-base status; there is a lack of adequate
evidence to classify these tracings as Category I or Category III. Category II
FHR tracings require evaluation and continued surveillance and reevaluation,
taking into account the entire associated clinical circumstances.
CATEGORY III: ABNORMAL AND PREDICTIVE OF ABNORMAL ACID-
BASE BALANCE REQUIRE PROMPT EVALUATION
Category III FHR tracings include either:
• Absent baseline FHR variability and any of the following:
• Recurrent late decelerations
• Recurrent variable decelerations
• Bradycardia
• Sinusoidal pattern
Source: American College of Obstetricians and Gynecologists, 2019.

FIGURE 7-30 Decision making in FHR assessment.
Assessment Tools
Interpreting Fetal Monitor Tracings
To aid in the interpretation of EFM tracings, the nurse should consider the
following parameters:
• Uterine activity: What is the frequency, duration, and intensity of
contractions?
• Labor progress: What is the stage of labor? What is the dilation, effacement,
station, presentation, and position?
• Baseline FHR: What is the baseline FHR? Is tachycardia or bradycardia
present?
• Baseline variability: What is the variability of the FHR (absent, minimal,
moderate, marked, or other)?
• Periodic changes in FHR: Are there any FHR changes from the baseline?
Are accelerations present? Are any decelerations present? If decelerations
are present, are they early, variable, late, or prolonged?
• Maternal history and condition: Are there any pre-existing conditions that
increase risk for this pregnancy? Are there any intrapartal high-risk factors
(e.g., meconium) that should be noted?
Fetal monitoring documentation, usually recorded on a standard form, should
include all the critical elements including characteristics of the FHR, UC, and
monitor mode (Fig. 7-31).
FIGURE 7-31 Example of FHR documentation.
FOCUS ON SAFETY
Communicating About FHR patterns
In clinical practice, various guidelines exist concerning the management of
FHR tracings. Accurate, consistent, and timely communication among health-
care providers is crucial in addressing clinical concerns about the patient and
her fetus. The Situation-Background-Assessment-Recommendation (SBAR)
tool can be used to efficiently convey key information:
• Situation (what is happening with the patient now?)
• Background (what is the clinical background or context?)
• Assessment (what is the problem?)
• Recommendation (what can be done to correct it?)
Additional Methods of Fetal Assessment

Other methods of fetal assessment have been developed to use in
conjunction with EFM to provide additional information about the
fetal status when nonreassuring FHR patterns are observed. These
methods include FHR response to stimulation, fetal scalp blood
sampling, and umbilical cord acid-base sampling (performed in the
neonate).
Fetal Heart Rate Response to Stimulation

Fetal scalp stimulation is a technique performed to elicit an
acceleration of the FHR of 15 bpm for at least 15 seconds and/or to
improve FHR variability. Presently, two methods of fetal stimulation
are in practice: scalp stimulation (the use of digital pressure during a
vaginal examination) and vibroacoustic stimulation (the use of an
artificial device [artificial larynx or fetal acoustic stimulation device]
positioned over the fetal head for 1 to 2 seconds). Fetal stimulation
procedures may be performed with or without ruptured membranes.
Acceleration of the FHR is usually indicative of fetal well-being;
absence of an acceleration can indicate interuterine and/or fetal
complication and warrants a need to conduct further fetal evaluation.
Fetal Scalp Blood Sampling

Fetal scalp blood sampling is a process of sampling a small amount
of blood from the fetal scalp to determine the pH. A sample of fetal
scalp blood is obtained through the dilated cervix after rupture of the
membranes. Seldom used in the United States, this procedure is
associated with many limiting factors: the requirement for cervical
dilation and membrane rupture, the technical difficulty of the
procedure, the need for repeated pH determinations, and the
uncertainty surrounding the interpretation and application of results.
Normal finding for fetal pH is at or above 7.25. Findings between
7.20 and 7.24 indicate a preacidotic state; if the pH is below 7.20,
acidosis is present and intervention is required (Venes, 2021).
Umbilical Cord Acid-Base Assessment

During the immediate assessment of the newborn, a sample of cord
blood is a useful adjunct to the Apgar score. Blood is withdrawn from
the umbilical artery and tested for pH, Pco2, and Po2. Arterial values
are reflective of the fetal condition; venous blood values are
reflective of placental function. Umbilical cord gas measurements
reflect the acid-base status of the neonate at birth; if acidemia is
present, the type (respiratory, metabolic, or mixed) is determined by
an analysis of the blood gas values. The normal fetal blood pH level
is 7.25. Levels between 7.20 and 7.24 reflect a preacidotic state;
levels below 7.20 indicate acidosis (Venes, 2021).
Early decelerations are considered benign, and no action is
necessary. However, it is important to identify them so that they can
be differentiated from variable or late decelerations. Depending on
the cause, interventions for variable and late decelerations include
lateral position changes (to displace the weight of the gravid uterus
off the inferior vena cava), oxygen administration at 8 to 10 L per
minute by face mask, palpation of the uterus for hyperstimulation
(excessive uterine activity, also referred to as tachysystole),
discontinuation of oxytocin if infusing, increasing the rate of the
maintenance intravenous solution, and assisting with fetal oxygen
saturation monitoring if ordered.
FIRST STAGE OF LABOR

The first stage of labor is often referred to as the stage of dilation.
This stage begins with the onset of regular UCs and ends with
complete dilation of the cervix. The onset of labor is often made
retrospectively because the woman may not always recognize when
true labor actually begins. The contractions often start slowly and are
fairly tolerable. Over time, contractions tend to increase in frequency,
duration, and intensity as the first stage of labor progresses. The first
stage of labor is most often the longest stage, and its duration can
vary considerably among women. This stage is divided into three
distinct phases: latent, active, and transition. Multiparous women
tend to progress through the childbirth process much more rapidly
than do nulliparous women. Factors such as analgesia, maternal and
fetal position, the woman’s body size, and her level of physical
fitness can also affect the length of labor.
Latent Phase
The latent phase of labor begins with the establishment of regular
contractions (labor pains). Labor pains are often initially felt as
sensations similar to painful menstrual cramping and are usually
accompanied by low back pain. Contractions during this phase are
typically about 5 minutes apart, last 30 to 45 seconds, and are
considered mild. During this phase, the woman is usually excited
about labor commencing, and she remains chatty and sociable.
Often this phase of labor is completed at home. During the latent
phase cervical effacement and early dilation (0 to 3 cm) occur. The
latent phase of labor can last as long as 10 to 14 hours because the
contractions are mild and cervical changes occur slowly.
Active Phase
The active phase of labor is characterized by more active
contractions. The contractions become more frequent (every 3 to 5
minutes), last longer (60 seconds), and are of moderate to strong
intensity. During the active labor phase, the woman becomes more
focused on each contraction and tends to draw inward to cope with
the increasing demands of the labor. Cervical dilation during this
phase advances more quickly because the contractions are often
more efficient. While the length of the active phase is variable,
nulliparous women generally progress at an average speed of 1 cm
of dilation per hour and multiparas at 1.5 cm of cervical dilation per
hour.
PROCEDURE ■ Performing the Intrapartal

Vaginal Examination
PURPOSE
Vaginal examination may be performed during the intrapartal period for many
reasons including assessment of cervical dilation, effacement and station, fetal
position and presentation, rupture of the membranes, prolapse of the umbilical
cord, and to perform fetal scalp stimulation. This is often a sensitive
examination and asking the patient if she wants any visitors to leave may be
preferred to ensure privacy.
Equipment
• Sterile examination gloves (clean gloves may be used if the membranes are
intact)
• Sterile lubricant
• Antiseptic solution and light source (if required)
• Disposable wipes
Steps
1. Wash and dry your hands. Explain the procedure and purpose of the
examination to the patient.
2. Assemble necessary equipment including clean gloves (if the membranes
are intact) or sterile examination gloves (if the membranes are ruptured),
sterile lubricant, and antiseptic solution (if required).
3. Position the patient in a supine position with a small pillow or towel under her
hip to prevent supine hypotension. Instruct the patient to relax and position
herself with her thighs flexed and abducted.
RATIONALE: Relaxation decreases muscle tension and enhances patient
comfort. Proper positioning facilitates the examination by providing access
to the perineum.
4. Don sterile gloves (clean gloves may be used if the membranes are intact).
5. Inspect the perineum for any redness, irritation, or vesicles.
6. Using the nondominant hand, spread the labia majora and continue
assessment of the genitalia. Note the presence of any discharge including
blood or amniotic fluid.
RATIONALE: Positioning the hand in this manner facilitates good
visualization of the perineum. The presence of lesions may be indicative of
an infection and possibly preclude a vaginal birth. The presence of amniotic
fluid implies that the membranes have ruptured. Bleeding may be a sign of
placenta previa. Do not perform a vaginal examination if a placenta previa is
suspected.
7. Gently insert the lubricated gloved index and third fingers into the vagina in
the direction of the posterior wall until they touch the cervix. The uterus may
be stabilized by placing the nondominant hand on the woman’s abdomen.
8. Assess the cervix for effacement and the amount of dilation.
9. Assess for intact membranes; if fluid is expressed, test for amniotic fluid.
10. Palpate the presenting part.
RATIONALE: It is necessary to determine the presenting part to assess fetal
position and evaluate fetal descent.
11. Assess fetal descent and station by identifying the position of the posterior
fontanelle.
12. Withdraw the fingers. Assist the patient in wiping her perineum from front to
back to remove lubricant or secretions. Help her to resume a comfortable
position.
13. Inform the patient of the findings from the examination.
14. Wash hands.
15. Document the procedure on the patient’s chart and on the fetal monitor strip
(if a fetal monitor is being used). Include the assessment findings and the
patient’s tolerance of the procedure.
Transition Phase
The transition phase is the most intense phase of labor. Transition is
characterized by frequent, strong contractions that occur every 2 to 3
minutes and last 60 to 90 seconds on average. Fortunately, this
phase often does not take long because dilation usually progresses
at a pace equal to or faster than active labor (1 cm/hr for a nullipara
and 1.5 cm/hr for a multipara). During the transition phase, the
laboring woman may feel that she can no longer continue or she
may question her ability to cope with much more. Other sensations
that a woman may feel during transition include rectal pressure, an
increased urge to bear down, an increase in bloody show, and
spontaneous rupture of the membranes (if they have not already
ruptured). Table 7-5 presents a summary of the characteristics of the
first and second stages of labor.
Assessment Tools
Friedman Curve
A labor curve assessment tool, often referred to as a “Friedman curve,” is a
graph used to help identify whether a patient’s labor is progressing in a normal
pattern (Fig. 7-32). Composite normal labor patterns are graphically presented
for the multiparous and nulliparous patient. The labor curve assessment tool
contains categories that include the time of day, amount of cervical dilation and
effacement, and hours of labor that have elapsed. The patient’s own labor
progress is plotted on the graph to allow a comparison between her progress
and the norm.
TABLE 7-5
Characteristics of the First and Second Stages of Labor
FIRST STAGE SECOND STAGE
Definition Commences with the onset of regular Begins with full dilation
contractions and ends with full dilation of the cervix (10 cm)
(10 cm) of the cervix. and ends with the
expulsion (birth) of the
fetus.
Contractions Latent: 5–10 minutes, may be irregular Contractions continue

in frequency, duration 30–40 seconds, at a similar rate as
mild to moderate strength. Active: during the transition
Regular pattern established (2–5 phase; 2–3 minutes
minutes apart), 40–60 seconds duration apart lasting 60
and moderate to strong by palpation. seconds and strong by
Transition: 2–3 minutes apart lasting 60– palpation.
90 seconds, strong by palpation.
Dilation Latent: 0–3 cm Active: 4–7 cm Fully dilated
Transition: 8–10 cm
Physical Latent: Contractions often begin as May have an urge to

discomforts painful menstrual-like cramps or low push that increases as
backache. Active: Increasing discomfort the fetal head
as contractions become stronger and descends. Many
more regular. May have backache. women prefer to push
Transition: Increasing discomfort so that they can use the
because contractions are very strong contractions and work
with little time for relaxation in between. with them. When head
As the fetal head descends there may is crowning may feel
be an increase in rectal pressure and intense pain, burning.
the urge to push.
Maternal Latent: Pain often well controlled; Often during this stage
behaviors various behaviors may be present: many women get a
excited, talkative, confident, anxious, “second wind” as they
withdrawn. Stage may be completed at see that they are
home. Active: Needs to focus more on making progress and
staying in control and managing the are embarking on a new
pain; often requires coaching at this (labor) phase. Intense
stage; quieter and more inwardly concentration with
focused. Transition: Most intense phase. pushing efforts.
Often difficult to cope; may experience
various emotions: irritable, agitated,
hopeless (“can’t do it”); tired (sleeps
between contractions).
FIGURE 7-32 A labor curve assessment tool, often referred to as a

“Friedman Curve,” helps to identify whether a patient’s labor is
progressing in a normal pattern.
Nursing Care During the First Stage of Labor

There are several key roles for the nurse who is providing care for
the woman in early labor. It is essential that the nurse continually
assess the patient and her fetus to ensure a safe delivery, facilitate a
positive birth experience, assist in the satisfactory management of
pain, and advocate for the patient’s needs. It is important to
remember that nursing interventions must first be safe and
consistent with the current standard of care. Interventions are also
tailored to meet the individual needs and preferences of the woman
in labor. The patient’s needs may quickly change throughout the
process of labor. For example, during early labor the woman may be
very independent and in little need of assistance. During active labor
or transition, the needs often become very different. Research has
shown that, during labor, support by nurses has a positive effect on
maternal and fetal outcomes.
Labor Support
Whenever possible, women in labor should receive continuous
support. Providing this level of care has been associated with
positive outcomes for mothers and infants, and there have been no
documented harmful or adverse effects. Continuous labor support
can be provided by professional nurses or by lay people. In 2018,
the Association of Women’s Health, Obstetric and Neonatal Nurses
(AWHONN) published a position statement, Continuous Labor
Support for Every Woman, which underscores the importance of
continuously available labor support from a registered nurse in
helping to achieve improved birth outcomes. According to AWHONN,
labor care and labor support are powerful nursing functions that
should include assessment and management of the physiological
and psychological processes of labor, facilitation of normal
physiological processes, provision of physical comfort measures,
emotional support, instruction, role modeling and advocacy,
evaluation of fetal well-being, and direct collaboration with other
members of the health-care team (AWHONN, 2018).
Spirituality
Spirituality, religion, or faith may serve as a source of inner strength
and comfort for the laboring woman. The nurse can support the
patient by providing spiritual care that may include prayer,
meditation, chanting, reading or reciting from scriptures, and the use
of rituals or sacraments. Creating a serene, respectful environment
is conducive to prayer or meditation, and, depending on the woman’s
wishes, the nurse can offer to read scripture or prayers or seek the
assistance of clergy who typically administer rituals or sacraments
or, in other cases, assist with creating an environment with dim
lighting or soothing music to help achieve an environment that will
help promote spirituality, religion, or faith. Providing nursing that
fosters the patient’s spirituality, religion, or faith aligns with
fundamental aspects of patient-centered care, recognizing the
patients’ values in providing care.
Promotion of Comfort
POSITION CHANGES
In labor, frequent position changes are beneficial in helping to
promote the descent of the fetus and has been recognized as a
method that can help limit interventions (ACOG, 2017). The nurse
may assist the laboring woman to various positions and activities
such as walking, standing, sitting, squatting, leaning over a piece of
furniture, or assuming a hands and knees position (Fig. 7-33).
Maternal preferences can guide the nurse in assessing which
positions or activities the woman finds most comfortable. Each
position is associated with advantages and disadvantages (Box 7-6).
During early labor, women are often encouraged to remain
ambulatory because activity has been shown to enhance the normal
progression of labor (Fig. 7-34).
FIGURE 7-33 Various positions for labor and birth.
BOX 7-6
Advantages and Disadvantages of Various

Positions for Labor
WALKING/STANDING
Uses gravity, facilitates descent, places fetus in alignment with pelvis, may
decrease the length of labor by enhancing the effect of contractions.
May be tiring, requires telemetry for continuous EFM, may not be possible
with regional anesthesia.
SITTING
Uses gravity, increases pelvic diameter, shortens second-stage labor, avoids
supine hypotension syndrome, decreases back pain, enhances communication
with partner, and allows for ready access to back and sacrum for massage and
counterpressure.
Labor may be slowed if not alternated with other positions, and may intensify
suprapubic pain and cause edema of the vulva or cervix.
HANDS AND KNEES POSITION
Stimulates rotation of fetus from a posterior to an anterior position, relieves
backache and rectal pressure, facilitates pelvic rocking and pelvic mobility.
May be tiring or embarrassing, difficult to keep external fetal monitor in place,
may not be possible with regional anesthesia.
SQUATTING
Uses gravity, increases pelvic diameter, relieves backache, promotes fetal
descent and rotation, facilitates second-stage pushing.
May impede descent before engagement has occurred, may be tiring,
uncomfortable, or embarrassing, may increase perineal and cervical edema.
As labor advances, the woman may feel tired and in need of some
relaxation between contractions. Sitting in a chair and reclining on
the side are two positions that often bring comfort. Changes in the
patient’s status such as continuous fetal monitoring, PROM, or
epidural analgesia may necessitate a need for bedrest. In these
situations, the nurse should encourage the laboring woman to rest
on her left side to facilitate optimal uteroplacental blood flow. In
addition, position changes should be encouraged even if the woman
must remain in bed. If bedrest is necessary, the nurse may be able
to assist the woman into a variety of positions in bed. Sitting, getting
on hands and knees, or resting on alternate sides may be desirable,
depending on the patient’s condition and preferences. It is important
to avoid the supine position because the pressure of the uterus on
the maternal spine can cause compression of the inferior vena cava
and lead to decreased blood pressure and diminished uteroplacental
blood flow.
PAIN MANAGEMENT
When a laboring woman experiences discomfort and pain, nurses
can implement many interventions to help reduce anxiety and
promote comfort. There is an increasingly accepted perspective that
certain physiological processes are normally associated with a
certain level of pain and that the pain serves a useful purpose.
Becoming familiar with strategies for managing or diminishing the
pain of childbirth empowers the laboring woman to make informed
decisions about the various pain management measures she will
use.
The pain experienced during childbirth is an unpleasant sensation
that is usually localized to the back and the abdomen. For most,
labor pain intensifies an already highly emotional experience for both
the laboring woman and her support person. How well the laboring
woman is able to cope with her pain significantly affects the overall
birth experience.
FIGURE 7-34 Laboring woman walking with her nurse.

During the assessment, the nurse may identify physiological and
psychological changes that are indicative of maternal pain. These
include an increased pulse rate and blood pressure, changes in
mood, increased anxiety and stress, marked agitation, confusion,
decreased urine output, decreased intestinal motility, and guarding of
the target area of discomfort. Pain affects the patient’s physiological,
behavioral, sensory, and cognitive responses. It is frequently
intensified by fear, anxiety, and fatigue.
When caring for laboring women, nurses must recognize that,
unlike other sources of pain, childbirth pain:
■ Is part of a normal process (not associated with illness or injury)
■ Can be anticipated and thus prepared for (through childbirth
education and the practice of distraction techniques and comfort
measures)
■ Has an end point (the baby’s birth brings relief on a physical and
emotional level)
PAIN NEUROLOGY
The pain associated with labor and birth has both visceral and
somatic origins. Uterine contractions during the first stage of labor
bring about cervical dilation and effacement. During each
contraction, arteries that supply the myometrium are compressed,
causing uterine ischemia (oxygen deficit that results from decreased
blood flow). During the first stage of labor, pain impulses are
transmitted via the T11 and T12 spinal nerve segments and
accessory lower thoracic and upper lumbar sympathetic nerves.
These nerves originate in the uterus. According to the gate-control
theory, pain sensations travel along sensory nerve pathways to the
brain, but only a certain number of sensations, or “messages,” can
pass through the nerve pathways at one time. Methods of distraction
learned and practiced in prepared childbirth classes such as
breathing patterns, massage, music, and the use of focal points and
imagery reduce or completely block the capacity of the nerve
pathways to transmit pain. It is believed that these physical and
psychological distractions work by “shutting the gate” in the spinal
cord so that pain signals are unable to reach the brain.
When the laboring woman is actively involved in neuromuscular
and motor activity, an increase in spinal cord activity further modifies
the transmission of pain. For example, the cognitive effort channeled
into concentration on breathing patterns, focal points, and imagery
requires selective and directed cortical activity that activates and
closes the gating mechanism. The gate-control theory helps to
explain how methods such as hypnosis and the various pain relief
techniques taught in childbirth education classes help to diminish the
laboring woman’s perception of pain.
TYPES OF PAIN
Visceral pain describes the predominant discomfort experienced
during the first stage of labor. It is related to changes in the cervix
(i.e., dilation and effacement), distention of the lower uterine
segment, and uterine ischemia. Visceral pain is a slow, deep, poorly
localized pain that occurs over the lower abdomen. It is commonly
described as a dull, aching pain.
Laboring women may also experience referred pain. Referred
pain describes pain that originates in the uterus and then radiates to
the abdominal wall, the lumbosacral area of the back, the iliac crests,
the gluteus maximus, and down the thighs. Usually, the discomfort is
felt only during contractions. A period of pain relief occurs between
contractions although some women report continued unremitting
pain even during the interval between contractions.
Somatic pain, a faster, well-localized intense, sharp, burning,
prickling pain, occurs during the second stage of labor. Somatic pain
is associated with stretching and distention of the perineal body to
allow for birth. It is also related to distention and traction placed on
the peritoneum and uterocervical supportive tissue during
contractions and can result from soft tissue lacerations that
frequently occur in the cervix, vagina, or perineum. Somatic pain
may also occur from the maternal expulsive forces during the
second, or “pushing,” stage of labor or by fetal pressure on the
bladder, bowel, or other pelvic structures. During the second stage of
labor, pain impulses are transmitted via the pudendal nerve through
S2 to S4 spinal nerve segments and the parasympathetic system.
Pain is expressed in a number of physiological and affective ways.
During labor and childbirth, the sympathetic nervous system
responds to pain with increased levels of catecholamines (e.g.,
epinephrine and norepinephrine—biologically active substances that
produce a marked effect on the nervous and cardiovascular
systems, metabolic rate, temperature, and smooth muscle). There is
a rise in blood pressure and heart rate. Increased maternal oxygen
consumption results in an altered respiratory pattern that may
produce hyperventilation and respiratory alkalosis. The woman may
become diaphoretic, and nausea and vomiting are common during
the active phase of labor. Throughout this process, decreased
placental perfusion and uterine activity can potentially prolong labor
and adversely affect fetal well-being.
NONPHARMACOLOGICAL COMFORT MEASURES
Music
Music can help create a relaxing environment and boost spirits.
During labor, music provides comfort and decreases maternal
anxiety by stimulating the release of endorphins. For some patients,
music during labor promotes maternal relaxation, thereby increasing
oxygen intake. Music has been shown to lower pain intensity when
used during the latent phase of labor (Smith et al, 2018).
Relaxation
Various relaxation techniques are used to help decrease anxiety
during labor. When the nurse, patient, and her labor support
person(s) are successful in diminishing the patient’s level of anxiety,
stress and tension are also reduced. When tension is reduced, the
woman breathes more deeply, resulting in improved maternal and
fetal oxygenation. When the laboring woman experiences increased
anxiety, stress levels and tension build and trigger a cascade of
events that heighten the sensation of pain. Pain also impedes the
patient’s ability to relax. The nurse’s ongoing assessment of
maternal pain should be conducted throughout labor and birth. The
use of a standardized pain assessment tool facilitates the evaluation
and allows for an easy reassessment of pain following therapeutic
interventions.
Focusing Strategies
Guided imagery is a state of intense, focused concentration that
one uses to create persuasive mental images. Guided imagery
distracts the laboring woman and transports her to a place that is
special to her. The nurse or labor support person assists with guided
imagery by asking the laboring woman to focus on a place where
she likes to be. Many patients choose the beach or the mountains as
their special locale. Next, the nurse or the labor support person
verbalizes sights and sounds of that unique place in an attempt to
relax and distract the patient. Often, the labor support person can
describe the special place in a meaningful, calming way.
Massage and Touch
Massage and touch techniques have long been used to facilitate
comfort and relaxation during labor. The patient’s labor support
person or nurse can perform simple hand massage to help decrease
tension and improve labor. Back massage is especially beneficial for
the discomfort of back labor. Current evidence suggests that
massage may be beneficial in reducing labor pain and reducing labor
time (Gonenc & Terzioglu, 2020).
Effleurage, taken from the French word effleurer (to touch lightly),
is a gentle stroking technique performed in rhythm with contractions.
The patient or her labor support person massages the abdomen
using light circular motions. Effleurage is helpful in distracting the
patient from her contractions. Massage of the hands, feet, and back
may be effective in diminishing tension and in enhancing comfort.
Throughout the labor experience, patients and their partners should
be encouraged to experiment with various techniques to determine
what methods work best for them.
Counterpressure is often effective in enhancing the woman’s
ability to cope with discomfort from internal pressure and lower back
pain. This technique involves use of the labor support person’s fist or
heel of the hand to apply steady pressure to the sacral area.
Counterpressure is especially helpful when maternal back pain
results from pressure of the occiput against spinal nerves when the
fetal head is in a posterior position. This technique has shown to
significantly reduce pain in labor (Santiasari et al, 2018).
Therapeutic touch is based on the use of “prana,” the body’s
energy fields. Prana is believed to be deficient in some individuals
who experience pain. Specially trained persons use laying-on of
hands to provide therapeutic touch to redirect the energy fields
thought to be associated with the pain (Venes, 2021).
Hydrotherapy (water therapy) is the use of warm water to promote
comfort and relaxation (U.S. Department of Health & Human
Services, 2018). Hydrotherapy may involve showering or soaking in
a regular tub or whirlpool bath. When showering is the selected
method of hydrotherapy, the patient stands in a warm shower and
allows the water to gently glide over her abdomen. Alternatively, she
may wish to sit in a shower chair. The nurse or labor coach may use
a handheld sprayer to direct a steady stream of water over the
abdomen or back. The flow of warm water enhances feelings of
relaxation and helps to decrease muscle tension.
Immersion in a tub of warm water filled up to shoulder level is also
beneficial in promoting comfort and relaxation. For most, the
buoyancy provided by the water provides welcomed relief from labor
discomfort and pain. The production of maternal catecholamines is
decreased, prompting an increase in the release of oxytocin
(stimulates UC) and endorphins (reduces the perception of pain). If
the woman is experiencing “back labor” from a fetal occiput posterior
or transverse position, she may be assisted into a side-lying or
hands-and-knees position in the tub. These positions enhance
comfort and help to facilitate fetal rotation into an occiput anterior
position. To avoid overheating, the water temperature should be
maintained at 96.8°F to 100.4°F (36°C to 38°C).
Hypnotherapy
Hypnotherapy is a structured technique that enables the patient to
achieve a state of heightened awareness and focused concentration
that can be used to alter the perception of pain. Hypnotherapy
involves the induction of a state of great mental and physical
relaxation that can be therapeutic in the management of pain control.
With this modality, emphasis is placed on promoting maternal
relaxation and a sense of safety while decreasing fear, anxiety, and
the perception of pain. To accomplish this, the woman may be given
direct suggestions about pain relief or indirect suggestions that she
is experiencing decreased discomfort (Azizmohammadi &
Azizmohammadi, 2019).
Aromatherapy is the use of essential oils derived from plants,
flowers, herbs, and trees whose aroma is thought to have a
therapeutic effect in treating illnesses and promoting health and well-
being. The fragrances of rose, lavender, frankincense, and bergamot
oils are believed to promote comfort and relaxation and decrease
pain. Patients may use the scented oils by adding a few drops to a
warm tub bath, to body compresses and massage lotions, or to an
aromatherapy lamp used to add fragrance to the room. Drops of
lavender and other essential oils may also be massaged into the
woman’s temples or forehead or placed on a pillow to induce
relaxation (Venes, 2021).
Yoga
Prenatal yoga classes, which focus on breathing techniques and
enhanced relaxation, are becoming increasingly popular.
Physiologically, yoga increases the efficiency of the heart, slows the
respiratory rate, and lowers blood pressure. For many, yoga helps
decrease stress and anxiety during the prenatal period and provides
coping strategies that can be used during labor. The practice of yoga
during pregnancy helps women learn to decrease the urge to tighten
muscles in response to pain. This response promotes the release of
oxytocin to enhance the progress of labor. Poses used in prenatal
yoga also facilitate the descent of the fetus and often decrease back
pain. Yoga in labor has been shown to lower pain intensity and
provide greater satisfaction of pain relief and of the childbirth
experience (Smith et al, 2018).
Application of Heat and Cold
The application of heat and cold can promote comfort and
decrease pain during labor and birth. The two modalities may be
used alternately to enhance their effects. Heat exerts a therapeutic
effect by relieving muscle ischemia and increasing blood flow to the
area of discomfort. Warm washcloths applied to the perineum help to
relieve the discomfort associated with stretching and may also help
prevent tearing during the second stage of labor. Cold washcloths or
ice packs placed on the forehead, chest, or face may be comforting
to laboring women who feel warm (Fig. 7-35). Cold packs may also
be applied to areas of pain where they exert a therapeutic effect by
reducing muscle temperature and relieving muscle spasms.
Biofeedback
Biofeedback has been used for many years to enhance relaxation
and help patients gain control over their pain. It is based on the
concept that the mind controls the body: If one can recognize
physical signals, certain internal physiological events can be
changed. During the prenatal period, the woman is taught body
awareness, how to recognize responses to stimuli, and various
relaxation techniques. She practices using strategies such as
concentration, focal points, and breathing to control her response to
uncomfortable stimuli. The labor partner learns to recognize cues
(e.g., grimacing, tensing, frowning, moaning, and breath holding) that
indicate pain and uses verbal feedback and touch to help the woman
to achieve relaxation. Formal biofeedback, which involves the use of
a recording device to measure physiological responses, requires
special training by a skilled biofeedback therapist. Body signals (e.g.,
skin temperature, blood flow, and muscle tension) that indicate pain
and stress are sent via attached electrodes back to the biofeedback
unit. The unit then alerts the patient who uses various techniques to
decrease the tension and discomfort.
FIGURE 7-35 A cool washcloth placed on the forehead provides

comfort during labor.
Transcutaneous Electrical Nerve Stimulation
Transcutaneous electrical nerve stimulation (TENS) involves the
delivery of an electric current through electrodes that are applied to
the skin over the painful region of a peripheral nerve (Venes, 2021).
The TENS unit relieves pain by producing counterirritation on the
nociceptors. Normally, two pairs of flat electrodes are placed on
either side of the patient’s thoracic and sacral spine. Continuous low-
intensity electrical impulses are delivered through a battery-operated
device. During a contraction, patients are instructed to turn the knobs
on the unit to increase the degree of stimulation from a low intensity
to a high intensity. TENS works by interfering with the transmission
of painful stimuli (Venes, 2021).
Intradermal Water Block
Intradermal water block is a technique that involves the use of a
small (e.g., 25-gauge) needle to inject small amounts (e.g., 0.05 to
0.1 mL) of sterile water into four locations (two over each posterior
superior iliac spine and two 3 cm below and 1 cm medial to each of
the first sites) on the patient’s lower back to relieve back pain (Fig. 7-
36). Preferably, two people perform the injections simultaneously (to
decrease the pain of the injections). This method may be used
during early labor to delay the initiation of pharmacological pain relief
methods. Patients experience a brief, intense stinging sensation
immediately after the injections, but the back pain is generally
relieved for 45 minutes to 2 hours. Although the mechanism of action
is not fully understood, the technique is believed to work by
producing counterirritation (pain in one specific area is reduced while
skin in proximity is irritated), gate control, or by increasing circulating
endorphins. Intradermal water blocks have been shown to decrease
pain and improve maternal satisfaction (Koyucu et al, 2018).
FIGURE 7-36 Intradermal water block involves the intracutaneous
injection of sterile water into four locations on the lower back; four
small blebs should be formed.
Acupressure
This type of therapy involves the application of pressure, or heat or
cold to identified acupuncture points to decrease the sensation of
pain. The points contain an increased density of neuroreceptors and
increased electrical conductivity. It is believed that the technique’s
effectiveness is related to the gate-control theory of pain and an
increased release of endorphins. Pressure may be applied by the
support person’s hands, tennis balls, or by the application of
pressure bands—cloth-covered elastic bands that contain rigid
plastic inserts—to provide the pressure. During labor, pressure is
applied to various acupressure points, which are located on the
neck, shoulders, wrists, lower back, hips, area below the kneecaps,
ankles, toenails, and soles of the feet.
PHARMACOLOGICAL PAIN RELIEF MEASURES
During early labor, nonpharmacological methods alone are often
satisfactory for relaxation and pain relief. As labor progresses,
contractions and discomfort intensify, often necessitating the addition
of pharmacological agents for pain control. Nonpharmacological
measures promote relaxation and often potentiate the effects of
analgesic agents, often decreasing the need for pharmacological
intervention. A range of different pharmacological measures with
different properties have different effects on the mother and infant.
The safest and most effective form of pharmacological pain relief
depends on the stage of labor, progress of labor, medical status of
the mother and infant, and the patient’s preference.
Sedatives and Antiemetics
Sedatives are agents that relieve anxiety and induce sleep. They
are primarily used during the early latent phase of labor, when the
cervix is long, closed, and thick and rest has been prescribed for the
patient. Sedatives may also be used to augment analgesics and
reduce nausea after the administration of opioids. Sedatives induce
sleep for a few hours. Once the woman awakens, either the
contractions have ceased (i.e., the patient had experienced false
labor) or regular, effective contractions that produce cervical change
occur. Sedatives should not be used during active labor because
they can cause respiratory depression in the neonate.
Barbiturates
Secobarbital sodium (Seconal) is one of the most commonly used
barbiturates during early or latent labor and most often given for
relaxation and sleep. It is a fast-acting oral agent that produces mild
sedation within 15 minutes after administration; its effects last for 3
to 4 hours. Undesirable effects include maternal drowsiness and
neonatal respiratory and vasomotor depression, and this medication
should be avoided if birth is anticipated. These effects are intensified
if a barbiturate is administered with another CNS depressant.
However, when given without an analgesic, the woman will be
drowsy but still experience pain, which may intensify.
Benzodiazepines
Benzodiazepines are agents primarily used to treat anxiety (e.g.,
diazepam [Valium] and lorazepam [Ativan]) in early labor. Their
mechanism of action is similar to that of barbiturates. When given
with an opioid analgesic, benzodiazepines enhance pain relief and
decrease nausea and vomiting, although some have an amnesic
effect that may be unacceptable for women in labor.
H-Receptor Antagonists
H1-receptor antagonists are medications that block the action of
histamines at the receptor sites. These medications produce
sedative, anti-Parkinson, and antiemetic effects. They cause
drowsiness and are often used during early labor to promote sleep
and decrease anxiety. During labor, the H1-receptor antagonists
commonly used include promethazine (Phenergan), hydroxyzine
(Vistaril), and diphenhydramine (Benadryl).
Differentiating Analgesia From Anesthesia
To enhance understanding of the pharmacological methods of pain
relief, it is important to distinguish between the concepts of analgesia
and anesthesia. Analgesia is relief, to some degree, from pain. Pain
may be eliminated or only lessened. Analgesia may be
accomplished via many methods, including medications, the
application of heat or cold, massage, or electrical stimulation.
Anesthesia is the partial or complete loss of sensation with or
without the loss of consciousness. There are many types of
analgesia and anesthesia and a number of methods for
administering them. The analgesic or anesthetic selected is
determined, to some degree, by the patient’s stage of labor and by
the method of birth anticipated (Boxes 7-7 and 7-8). When given too
early, analgesia may prolong the labor and cause fetal depression.
When administered too late, analgesia provides no benefit to the
woman and may cause depression in the neonate.
The nurse’s role involves continuous patient assessment to
monitor the progress of labor and to identify cues that indicate that
the patient would benefit from the administration of analgesic
medications prescribed by the physician, CNM, or certified registered
nurse-anesthetist (CRNA). Depending on institutional policy, the
CNM or physician may evaluate the woman in the birthing facility or
rely on the nurse’s assessment and instruct the nurse to administer
the ordered medications. In most facilities, the CRNA monitors
analgesia-related complications and conducts continuous monitoring
for patients who receive epidural anesthesia. In some institutions, an
anesthesiologist is available to provide these services.
BOX 7-7
Pharmacological Interventions for Intrapartal
Pain Control According to Stage of Labor
FIRST STAGE OF LABOR
SYSTEMIC ANALGESIA
Opioid agonists (e.g., hydromorphone hydrochloride [Dilaudid]; meperidine
hydrochloride [Demerol]; fentanyl citrate [Sublimaze]; sufentanil citrate
[Sufenta])
Opioid agonist-antagonists (e.g., butorphanol [Stadol]; nalbuphine [Nubain])
NERVE BLOCK ANALGESIA
Epidural
Combined spinal-epidural
SECOND STAGE OF LABOR
NERVE BLOCK ANALGESIA AND ANESTHESIA
Local infiltration
Pudendal block
Spinal block
Epidural block
Combined spinal-epidural
BOX 7-8
Pharmacological Interventions for Intrapartal

Pain Control According to Birth Method
VAGINAL BIRTH
• Local infiltration anesthesia
• Pudendal block
• Epidural block analgesia/anesthesia
• Spinal block anesthesia
• Combined spinal-epidural analgesia/anesthesia
CESAREAN BIRTH
• Spinal block anesthesia
• Epidural block anesthesia
• General anesthesia
Systemic analgesia
Systemic analgesic agents provide central analgesia to the patient
and fetus because they readily cross the placenta. Although this
method of pain control during labor has declined, it is still used in
facilities where specialists trained in administering regional analgesia
(e.g., epidural analgesia) are not available. Fetal-neonatal effects
include respiratory depression, decreased alertness, and delayed
sucking, depending on the agent used, the dosage given, and the
route and timing of administration. Intravenous administration is
preferred over intramuscular injection because the onset of action is
more rapid and predictable, pain relief is obtained with smaller doses
of the drug, and the duration of the effect is more predictable
(ACOG, 2019). The medication is administered into the intravenous
tubing port nearest the patient while the IV solution is stopped.
Optimizing Outcomes
When Administering Intravenous Medications During Labor

Intravenous analgesics are given slowly in small doses during a contraction.
When necessary, the medication may be given over a period of four to five
consecutive contractions to complete the dose. Administering the medication
during a contraction decreases fetal exposure to the drug because uterine blood
vessels are constricted during contractions and the medication remains in the
maternal vascular system for several seconds before the uterine blood vessels
reopen.
In many institutions, patient-controlled analgesia (PCA) is available. The
laboring woman self-administers small amounts of an opioid analgesic using a
pump previously programmed for dose and frequency. As a result, a smaller
amount of medication is required, and women are generally pleased with the
level of pain control achieved. Analgesic agents available for the intrapartum
period include opioid (narcotic) agonists and opioid (narcotic) agonist–
antagonists (ACOG, 2019).
Opioid agonist analgesics

Opioid agonist analgesics include hydromorphone hydrochloride
(Dilaudid), meperidine hydrochloride (Demerol), fentanyl citrate
(Sublimaze), and sufentanil citrate (Sufenta) (Table 7-6). These
agents work by stimulating the major opioid receptors mu and kappa.
They promote feelings of euphoria and exert no amnesic effects.
These medications cause a delay in gastric emptying time and can
result in nausea, vomiting, and aspiration. Common side effects
include sedation, drowsiness, altered mental status, tachycardia, and
respiratory depression. Bladder and bowel elimination may also be
diminished. Fetal effects include decrease in FHR variability and
respiratory depression. Ideally, opioid agonist analgesics should be
given either less than 1 hour or greater than 4 hours before birth to
minimize neonatal depression. Fentanyl citrate and sufentanil citrate
require more frequent administration because of their relatively short
duration of action (30 to 60 minutes, compared with 2 to 4 hours for
hydromorphone hydrochloride and meperidine hydrochloride).
Consequently, these agents are often administered intrathecally or
epidurally, alone or in combination with a local anesthetic
medication.
FOCUS ON SAFETY
Safety Measures for Women Who Receive Opioid Analgesics
Opioid analgesics may cause bradycardia/tachycardia, hypotension, and
respiratory depression and should be administered cautiously in women with
respiratory or cardiovascular disorders. Consultations to an anesthesiologist
may be appropriate in cases where medical complications can arise with
opioids such as difficult airway, malformation, obesity, and other risk factors for
anesthetic complications (ACOG, 2019).
TABLE 7-6
Opioid Agonist Analgesics
OPIOID-AGONIST ROUTE AND DOSAGE NURSING CONSIDERATIONS
ANALGESIC
Hydromorphone IV: 1 mg q3h prn Monitor vital signs, FHR pattern
hydrochloride (Dilaudid) IM: 1–2 mg q3–6h prn and uterine activity before and
during administration; observe
for maternal respiratory
depression; encourage voiding
q2h, palpate for bladder
distention; if birth occurs within
1–4 hours after administration,
observe neonate for respiratory
depression
Meperidine IV: 25 mg q1-3h prn Common side effects include

hydrochloride (Demerol) IM: 50–100 mg q1-3h pruritus, dizziness, sedation,
prn nausea, constipation
Fentanyl citrate IV: 25–50 mcg Contraindications:

(Sublimaze) IM: 50–100 mcg Hypersensitivity to the drug,
Epidural: 1–2 mcg with convulsive disorders
0.125%
bupivacaine at a rate of
8–10 mL/hr
Sufentanil (Sufenta) Epidural: 1 mcg with

0.125% bupivacaine at
a rate of 10 mL/hr
Opioid agonist-antagonist analgesics

Opioid agonist-antagonist agents include butorphanol (Stadol) and
nalbuphine (Nubain), which are agonists at kappa opioid receptors
and either antagonists or weak agonists at mu opioid receptors.
During labor, these medications provide satisfactory pain control;
their incidence of respiratory depression is lower compared with
other analgesics. They are also associated with less nausea and
vomiting and are used more often during labor than the opioid
agonist analgesics. They may be administered intravenously or
intramuscularly or subcutaneously. Opioid agonist–antagonists
should not be given to women with an opioid dependence because
the antagonist activity may precipitate maternal/neonatal withdrawal
symptoms (ACOG, 2019).
MEDICATION: Butorphanol (Stadol) (byoo-tor-

fa-nole)
Schedule IV Pregnancy Category: C
Indications: Moderate to severe labor pain; postoperative pain after cesarean
birth
Actions: Stimulates kappa opioid receptors and blocks or weakly stimulates
mu opioid receptors; alters pain perception, produces generalized CNS
depression
Therapeutic Effects: Decreased severity of pain
CONTRAINDICATED IN: Hypersensitivity; patients dependent on opioids (may
precipitate withdrawal), women with chronic hypertension, pre-eclampsia
Adverse Reactions and Side Effects: Confusion, drowsiness, sedation,
blurred vision, headache, dizziness, dysphoria, hallucinations, hypotension,
hypertension, sweating, maternal palpitations/tachycardia or bradycardia,
respiratory depression, transient nonpathological sinusoidal-like FHR rhythm,
urinary retention, and urgency
Route and Dosage: 2 mg (range 1–4 mg) IM every 3 to 4 hours as needed; 1
mg (range 0.5–2 mg) IV every 3 to 4 hours as needed
Nursing Implications: May precipitate withdrawal symptoms in
woman/neonate. Protect medication from light and store at room temperature.
Source: Adapted from Vallerand, A. H., & Sanoski, C. A. (2021).
Nitrous Oxide
Nitrous oxide (N2O) is a colorless, nearly odorless and tasteless
gas made for inhalation and is self-administered by the patient.
Nitrous oxide is provided in a 50-50 blend of nitrous oxide and
oxygen that allows the laboring women to experience pain relief,
decreased anxiety, and euphoria while remaining awake and alert,
with complete motor and sensory function throughout its use.
Maternal adverse effects include nausea and vomiting, restlessness,
anxiety, and feelings of unpleasantness; in the neonate, N2O is
associated with neither CNS nor respiratory depression, and the
effect of N2O is eliminated rapidly once the neonate begins breathing
(ACOG, 2019).
Nerve Block Analgesia and Anesthesia
Local anesthetics used in obstetrics may produce regional
analgesia, which provides some degree of pain relief and motor
block, and anesthesia, which provides complete pain relief and
motor block. Regional analgesia may be obtained by the injection of
a narcotic agent such as fentanyl along with a small amount of a
local anesthetic agent. Regional anesthesia, a temporary and
reversible loss of sensation, is produced by the injection of an
anesthetic agent (a local anesthetic) into an area that brings the
medication into direct contact with nervous tissue. Regional
anesthetic agents block sodium and potassium transport in the nerve
membrane, causing stabilization of the nerve(s) in a polarized resting
state, which prevents the initiation and transmission of nerve
impulses. Rarely, serious reactions (e.g., respiratory depression and
hypotension) to local anesthesia may occur from one or more
anesthetic agents. The nurse should ensure that emergency
measures, including epinephrine, antihistamines, and oxygen, are
readily available in all patient areas where these medications are
used. When caring for patients receiving analgesia/anesthesia by
catheter, nurses must be aware of institutional policy and national
standards.
Epidural blocks may be administered for analgesia during labor
and vaginal birth and for anesthesia during cesarean birth.
Alternately, a combined epidural-spinal block may be used—the
epidural provides analgesia for labor, and the spinal provides
anesthesia for birth or analgesia after the birth. During the first stage
of labor, an epidural relieves pain by blocking the sensory nerves
that supply the uterus. Pain experienced during the second stage of
labor and with birth can be alleviated with epidural, combined
epidural-spinal, and pudendal blocks. A summary of commonly used
regional blocks is presented in Table 7-7.
Pudendal Nerve Block
A pudendal nerve block provides pain relief in the lower vagina,
vulva, and perineum (ACOG, 2019) (Fig. 7-37). It should be
administered 10 to 20 minutes before perineal anesthesia is needed
and may be used late in the second stage of labor if an episiotomy is
to be performed or if forceps or vacuum extraction will be used to
facilitate birth. The anesthetic effect diminishes or completely
removes the maternal bearing-down reflex. It may also be used
during the third stage of labor for laceration repair.
TABLE 7-7
Commonly Used Regional Blocks for Labor and Birth
TYPE OF BLOCK; AREAS WHEN USED DURING NURSING
AFFECTED LABOR AND BIRTH IMPLICATIONS
Local Perineal Infiltration Immediately before birth for Assess patient’s
Affected area: Perineum episiotomy; after birth for knowledge and
repair of lacerations. understanding; provide
information as needed.
Observe perineum for
bruising, discoloration,
hematoma, or signs of
infection during the
recovery period.
Pudendal Nerve Block Late in the second stage for Assess patient’s level of
Affected areas: Perineum episiotomy, forceps, or knowledge and
and lower vagina vacuum extraction; during understanding; provide
third stage for repair of additional information
episiotomy or lacerations. as needed. Monitor for
signs of infection,
urinary retention.
Spinal Anesthesia Block First stage for both elective Assess patient’s level of
Affected areas: Uterus, and emergent cesarean knowledge and
cervix, vagina, and births; low spinal anesthesia understanding and level
perineum block may be used for of pain relief; provide
vaginal birth—not suitable additional information
for labor. as needed. Monitor
maternal vital signs
(hypotension most
common complication)
and FHR status. Assess
for urinary retention,
itching, nausea,
vomiting, headache.
Monitor site for leakage
of spinal fluid or
development of a
hematoma.
Lumbar Epidural Block First and second stages. Assess patient’s level of
Affected areas: Uterus, knowledge and
cervix, vagina, and understanding and level
perineum
of pain relief; provide
additional information
as needed. Monitor
maternal blood
pressure—major
complication is
hypotension—and FHR
status. Provide ongoing
support. Assess for
urinary retention,
itching, nausea,
vomiting, headache.
Combined Spinal– Spinal analgesia may be Perform patient

Epidural Affected areas: administered during the assessments as listed
Uterus, cervix, vagina, latent phase for pain relief. previously for spinal
and perineum Epidural is given when and epidural
active labor begins. anesthesia.
FIGURE 7-37 A, Administration of a pudendal block. B, The areas of

the perineum affected by a pudendal block.
Spinal Anesthesia Block
Spinal anesthesia block involves the injection of a solution
containing a single local anesthetic or an anesthetic combined with
fentanyl through the third, fourth, or fifth lumbar interspace into the
subarachnoid space, where it mixes with cerebrospinal fluid (CSF).
The subarachnoid space is a fluid-filled area located between the
dura mater and the spinal cord. Used for elective or emergent
cesarean births, the differences in the levels of spinal anesthesia for
vaginal and cesarean birth are created by the dosage of the
anesthetic agent administered and the position of the patient after
placement of the medication in the dural sac. For vaginal birth, a low
spinal anesthesia block provides anesthesia from level T10 (hips) to
the feet; patients remain in a sitting position for a brief period of 1 to
2 minutes after administration to facilitate downward migration of the
anesthetic solution toward the sacral area. For cesarean birth, the
level of anesthesia coverage extends from the nipples (T6) to the
feet; after administration of the anesthetic solution, patients are
immediately assisted to a supine position with a left lateral tilt to
enhance a cephalad spread of the anesthesia (and a higher level of
sensory blockade). The anesthetic agent may be “weighted” with
glucose to make it heavier than CSF. This prevents the medication
from rising too high in the spinal canal and interfering with motor
control of the uterus or with the maternal respiratory muscles (Fig. 7-
38).
Spinal anesthesia block has several advantages: It is easy to
administer, has an immediate onset of anesthesia, requires a smaller
volume of medication, produces excellent muscular relaxation,
allows for maintenance of maternal consciousness, and is
associated with minimal blood loss. However, because UC sensation
is lost, the patient must be instructed when to bear down during a
vaginal birth. Because voluntary maternal expulsive efforts are
compromised, there is an increased likelihood of an operative (e.g.,
episiotomy, forceps-assisted, or vacuum-assisted) birth. After
childbirth, there is an increased incidence of bladder and uterine
atony and postdural puncture headache.
Nursing care during administration of a spinal anesthesia block
includes proper positioning of the patient in a lateral or sitting
position with the back curved outward to widen the intervertebral
space (Fig. 7-39). After injection of the anesthetic solution, the
patient is positioned upright to allow downward flow of the solution to
provide a lower level of anesthesia suitable for a vaginal birth. For a
cesarean birth, the patient is placed in a supine position with the
head and shoulders slightly elevated with a wedge placed under one
of the hips to displace the uterus (to obtain a higher level of
anesthesia coverage). Effects from the anesthesia occur within 1 to
2 minutes after injection and last 1 to 3 hours, depending on the
anesthetic agent used.
Complications that may occur with spinal anesthesia block include
maternal hypotension, decreased placental perfusion, and an
ineffective breathing pattern. Before administration, the patient’s fluid
balance is assessed and intravenous fluids are administered to
reduce the potential for sympathetic blockade (decreased cardiac
output that results from vasodilation with pooling of blood in the
lower extremities). After administration of the anesthetic, the
patient’s blood pressure, pulse, respirations, and FHR must be taken
and documented every 5 to 10 minutes. If indicators of severe
maternal hypotension (e.g., a drop in the baseline blood pressure of
more than 20%) or fetal compromise (e.g., bradycardia, decreased
variability, or late decelerations) develop, emergency measures must
be instituted.
FIGURE 7-38 A, The spinal column: levels of the sacral, lumbar, and
thoracic nerves. B, Levels of anesthesia necessary for vaginal and
cesarean births.
FIGURE 7-39 A, Lateral position for spinal and epidural blocks. B,
Sitting position for spinal and epidural block.
FOCUS ON SAFETY
In the event of severe maternal hypotension, the nurse takes the
following actions:
• Place the patient in a lateral position or use a wedge under the hip to
displace the uterus; elevate the legs.
• Maintain or increase the IV infusion rate, according to institution protocol.
• Administer oxygen by face mask at 10 to 12 L/min or according to institution
protocol.
• Alert the primary care provider, anesthesiologist, or nurse anesthetist.
• Administer an IV vasopressor (e.g., ephedrine 5–10 mg) according to
institutional protocol, if the previous measures are ineffective.
• Remain calm, offer reassurance, and continue to assess maternal blood
pressure and FHR every 5 minutes until stable or per order from the primary
care provider.
Postdural puncture headache, a complication that may develop

within 48 hours after the puncture, is believed to occur from leakage
of CSF from the puncture site in the dura mater. Typically, the
headache is intensified when the patient assumes an upright position
and relieved when she assumes a supine position. Accompanying
symptoms include auditory (tinnitus) and visual (blurred vision or
photophobia) problems. Interventions usually center on oral
analgesics, bedrest in a darkened room, caffeine, and hydration. If
these measures are not effective, an autologous epidural blood
patch may be administered. Approximately 10 to 20 mL of the
patient’s blood is slowly injected into the lumbar epidural space. A
clot forms in the tear or hole in the dura mater around the spinal
cord, effectively sealing the area from further CSF leakage (Fig. 7-
40).
Epidural Anesthesia or Analgesia Block
Injection of a local anesthetic such as bupivacaine, an opioid
analgesic such as fentanyl or sufentanil, or both into the epidural
space (between L4 and L5) provides pain relief from UCs and
vaginal or cesarean birth. The degree of analgesic or anesthetic
effect obtained is related to the specific medication used. Combining
an opioid with a local anesthetic agent reduces the total amount of
anesthetic required, thereby reducing adverse effects and preserving
a greater amount of maternal motor function (ACOG, 2019).
The epidural space
The nerves located in the spinal cord are covered and protected
by several tissue layers. The pia mater is the membrane that
adheres to the nerve fibers. It is surrounded by CSF. The next layer
is the arachnoid membrane; the dura mater is the protective covering
that lies outside this membrane. An anesthetic agent administered
into the CSF in the subarachnoid space is called spinal anesthesia.
The epidural space is a vacant space located outside the dura
mater; beyond the epidural space, the ligamentum flavum, which
extends from the base of the skull to the end of the sacral canal,
provides another protective layer. With epidural anesthesia, an
anesthetic agent is placed just inside the ligamentum flavum in the
epidural space (Figs. 7-41 and 7-42).
Lumbar Epidural Anesthesia and Analgesia Block
The lumbar epidural anesthesia and analgesia block is the most
commonly used method of pain control during labor; nearly two-
thirds of women in the United States incorporate this intervention for
discomfort and pain into their birth plan. Advantages of this method
include maternal relaxation, enhanced comfort and pain relief, and
an ability to remain alert and participate in the birth. Also, there is
little blood loss, the respiratory reflexes remain intact, there is no
delay in gastric emptying, and only a partial degree of motor
paralysis occurs. Fetal complications are rare and are related to
maternal hypotension or effects from the rapid absorption of the
medication. Postdural puncture headaches, caused by leakage of
CSF, rarely occur because, with epidural anesthesia, the CSF space
is not entered.
FIGURE 7-40 Autologous epidural blood patch.

FIGURE 7-41 The epidural space is located between the dura mater
and the ligamentum flavum.
PROCEDURE ■ Assisting With the

Administration of Spinal Anesthesia
PURPOSE
To facilitate administration of a spinal anesthesia block for the relief of pain
during labor and birth.
Equipment
• Blood pressure cuff
• Stethoscope
• Fetal monitor
Steps
2. Assist the patient to a sitting position on the edge of the bed or operating
table (as directed by the nurse anesthetist or anesthesiologist).
3. Provide support, promote comfort, and limit motion during the procedure.
RATIONALE: Proper positioning (e.g., head bowed so that the back arches
outward to widen the intervertebral space) and restricted movement are
essential to successful anesthesia administration. Support prevents the
patient from falling forward (she is “top heavy” from the gravid uterus).
4. Check the intravenous infusion for patency.
RATIONALE: Hypotension from sympathetic blockage in the lower
extremities may occur immediately after anesthesia administration. For this
reason, IV fluids such as lactated Ringer’s solution (500–1,000 mL) are
usually given before the injection to ensure maternal hydration; confirming
the patency of IV tubing ensures that the fluid is infusing well before the
anesthesia is administered and facilitates the rapid infusion of fluids if
needed for postadministration hypotension.
5. Assist the patient to lie down on her back after anesthesia administration (as
directed by the nurse anesthetist or anesthesiologist).
6. Place a pillow under her head and a wedge under her right hip.
RATIONALE: Remaining in an upright position for too long prevents the
anesthetic from rising high enough up the spinal canal to achieve pain relief.
Conversely, lying down too soon allows the anesthetic to rise too high in the
spinal canal. Lying with a pillow under the head helps to ensure that the
anesthesia will be confined to the lower spinal canal. A wedge placed under
the right hip displaces the uterus and helps to prevent compression of the
vena cava.
7. Monitor the pulse, blood pressure, and respirations every 1 to 2 minutes for
the first 10 minutes, then every 5 to 10 minutes. Use electronic monitoring to
continuously monitor the FHR.
RATIONALE: Frequent assessment of maternal vital signs is essential for
recognizing hypotension (from sympathetic blockage in the lower
extremities) or an adverse reaction. Ongoing assessment of the FHR and
pattern provides evidence of fetal well-being.
8. Document the procedure on the patient’s chart.
RATIONALE: Documentation provides a record for communication and
evaluation of patient care.
Nursing Consideration
The nurse informs the nurse anesthetist or anesthesiologist when a contraction
is beginning so that the anesthetic will not be administered during a
contraction.
What If?
What if you detect a drop in the FHR while the anesthesiologist is administering
the spinal anesthesia? You should take the following steps:
• Immediately alert the anesthesiologist.
• Immediately alert the obstetrician or certified nurse midwife.
• Assist the patient into a left side-lying position.
• Administer oxygen at 10 L by face mask.
• Increase the IV fluid rate.
• Continuously monitor the FHR.
• Provide information to the woman and her support person.
• Prepare for birth.
FIGURE 7-42 The spinal canal: injection sites for regional

anesthesia.
Epidural blocks are advantageous for patients with diabetes, heart
disease, pulmonary disease, and, in some cases, gestational
hypertension because they essentially eliminate the pain associated
with labor and thus reduce the maternal stress associated with labor
discomfort. The patient’s energy level is preserved because she
does not feel the contractions. Epidural blocks may be used with
preterm pregnancies because there is minimal effect on the fetus. A
gentle, controlled birth is associated with minimal trauma to the
immature fetal skull, and there are no systemic narcotic analgesics
to cause depression in the premature neonate.
Maternal hypotension is the most common complication of
epidural anesthesia. Preloading the patient with a rapid infusion of
intravenous fluids, which increases the blood volume and cardiac
output, can usually prevent this complication. Intravenous fluids are
then infused continuously. Most institutions use dextrose-free
solutions because dextrose can cause fetal hyperglycemia with
rebound hypoglycemia during the first several hours after birth. The
nurse should be in continuous attendance after administration of an
epidural anesthetic. To detect hypotension, blood pressure should be
continuously monitored for at least the first 20 minutes and after
each new injection of the anesthetic. Blood pressure should be
monitored during the entire time the anesthetic is in effect to ensure
that the systolic pressure does not fall below 100 mm Hg or
decrease 20 mm Hg in a hypertensive patient. A drop greater than
this may be life-threatening to the fetus unless effective interventions
(e.g., maternal position change or administration of antihypotensive
agents) are instituted.
Other disadvantages include lengthened duration of labor,
increased requirements for oxygen and oxytocin, and limited mobility
because of medical interventions such as the intravenous infusion
and electronic monitoring equipment. Patients may experience
orthostatic hypotension, dizziness, sedation, and lower extremity
weakness. The accidental injection of a local anesthetic into a blood
vessel can cause CNS effects including bizarre behavior,
disorientation, excitation, and convulsions. Severe maternal
hypotension resulting from sympathetic blockade can cause a
significant decrease in uteroplacental perfusion and the delivery of
oxygen to the fetus (ACOG, 2019; U.S. Department of Health &
Human Services, 2018).
NURSING INSIGHT
Shiver Response After Epidural Block Administration
The patient may exhibit a shiver response after administration of epidural block
anesthesia. This physiological reaction can result from heat loss related to
increased peripheral blood flow. It may also be related to an alteration of
thermal input to the CNS when warm but not cold sensations have been
suppressed. Essentially, the body believes that the temperature is lower than
the true temperature and raises the “thermostat” to generate heat by shivering.
The nurse should apply warm blankets for comfort and offer reassurance.
The nurse must perform frequent assessments of the maternal bladder to
avoid bladder distention. Although the patient may be unable to void and
require catheterization, the bedpan should always be offered initially to
minimize the potential for a urinary tract infection. Nursing actions to facilitate
voiding include assisting the patient to an upright position on the bedpan,
raising the head of the bed to support the back, and providing privacy. Urinary
retention and stress incontinence may also occur immediately postpartum.
Intense pruritus is a common side effect of opioid use; this symptom is usually
treated with diphenhydramine (Benadryl), 25 mg IV or 50 mg IM. A temporary
elevation in temperature may occur after administration of epidural anesthesia.
Optimizing Outcomes
After an Epidural Block

The patient who has received an epidural block may require assistance with
pushing because of an inability to feel the contractions or experience the urge to
push. She may also need someone to hold or control her legs to push. After
birth, the nurse must ensure that full sensation has returned and the patient is
able to control her legs before ambulation is permitted. Depending on the agent
used and the dose administered, this may take several hours.
For relief of labor pain and a vaginal birth, a block from T10 to S5
is performed, usually when the cervix has dilated to 5 to 6 cm. For a
cesarean birth, a block from T8 to S1 is required. The patient is
positioned on her side with her legs slightly flexed, or she is asked to
sit on the edge of the bed. She is instructed to drop her shoulders,
round out the small of her back (“arch the back like a cat”), and put
her chin into her chest. The medication is injected between
contractions to minimize the risk of tachycardia that can occur if the
drug is unintentionally injected directly into a vessel. The diffusion of
the epidural anesthesia is dependent on the placement of the
catheter tip, the dose and volume of medication used, and the
patient’s position (e.g., horizontal or upright). Once the epidural has
been administered, a side-lying position (alternating sides each hour)
is maintained to prevent compression of the vena cava. Depending
on the degree of motor impairment, ambulation may be encouraged.
Most often, a continuous epidural anesthesia block, a method
achieved by the use of a pump to infuse solution into an indwelling
catheter, is used. In many areas, patients are allowed to control the
dosing with a programmed pump (patient-controlled epidural
analgesia [PCEA]). This method empowers the patient to achieve
some degree of control over her labor comfort and has been shown
to decrease the total amount of medication needed. A lock-out
period after each self-administration prevents overdosage. Less
commonly, an intermittent block that relies on repeated injections of
anesthetic solution is performed.
Combined Spinal-Epidural Analgesia
A combination of spinal-epidural analgesia may be used to block
pain transmission without interfering with motor ability. Pain relief is
immediate, unlike the 20- to 30-minute delay associated with an
epidural alone. With the combined approach, an opioid such as
fentanyl or sufentanil is injected into the subarachnoid space to
rapidly activate the opioid receptors. A catheter inserted in the
epidural space extends the duration of the analgesia by using a
lower dose of a local anesthetic agent alone or in combination with
an opioid agonist analgesic. Although patients may ambulate, they
often choose not to do so because of fatigue, sensations of
weakness in the legs, and a fear of falling. They should be
encouraged to change positions frequently and assisted to an
upright position to enhance bearing-down efforts. Because this
method is associated with puncture of the dura and placement of a
catheter in the epidural space, there is a greater risk for infection and
postdural puncture headache (ACOG, 2019). A combined spinal-
epidural block may be used for both labor analgesia and for
cesarean birth; the anesthetic and analgesic agents used vary
according to the purpose of the procedure. Additional medication
may be added to increase its effectiveness or if an instrument-
assisted or cesarean birth is needed.
Epidural and Intrathecal Opioids
Another approach for nerve block analgesia/anesthesia involves
the use of opioids alone. This method eliminates the effects of a
local anesthetic. Epidural or intrathecal (injected into the
subarachnoid space) opioids without local anesthetics have several
advantages. They do not cause maternal hypotension or alteration in
vital signs. The patient is aware of contractions but does not feel
pain. Thus, she can bear down during the second stage of labor and
her motor power remains intact.
Optimizing Outcomes
When Epidural and Intrathecal Opioids Are Administered

The nurse should monitor and record the patient’s respiratory rate every hour
for 24 hours (or per institutional protocol) after administration of epidural or
intrathecal opioids. Naloxone (Narcan) should be administered if the maternal
respiratory rate decreases to less than 10 breaths per minute or if the maternal
oxygen saturation rate decreases to less than 89%. Oxygen may be
administered by face mask and the anesthesiologist should be notified.
General Anesthesia
General anesthesia (induced unconsciousness) may be used for
unplanned, rapid (emergency) cesarean birth, when there are
contraindications to an epidural or spinal block, or when surgical
intervention is required for certain obstetric complications (Box 7-9).
The major risks associated with general anesthesia administered for
childbirth are increased maternal blood loss related to uterine
relaxation, hypoxia, and the possible inhalation of vomitus during
administration. Pregnant women are particularly prone to gastric
reflux because of increased stomach pressure from the gravid uterus
beneath it. In addition, the gastroesophageal valve may be
displaced, allowing the upward passage of stomach contents. The
aspiration of stomach contents that have an acid pH may cause
chemical pneumonitis and secondary infection of the respiratory tract
(ACOG, 2019).
Fetal depression is directly related to the depth and duration of the
anesthesia. Most general anesthetic agents reach the fetus in
approximately 2 minutes. General anesthesia is not recommended
when the fetus is considered to be high risk, especially in preterm
birth. Measures to reduce respiratory depression in the neonate
include reducing the time from induction of the anesthesia until the
umbilical cord is clamped and using a minimum of sedating drugs
and anesthetics until after the cord has been clamped.
BOX 7-9
Contraindications to Spinal/Epidural Block

ANESTHESIA
• Maternal refusal
• Local or systemic infection
• Coagulation disorders
• Actual or anticipated maternal hemorrhage
• Allergy to specific anesthetic agents
• Lack of trained staff available
Source: Cunningham et al, 2014.

To prepare the patient for general anesthesia, the nurse ensures
that an IV infusion is in place, and if time permits, premedicates her
with an oral antacid (e.g., sodium citrate, citric acid/sodium citrate, or
effervescent aspirin/citric acid) to neutralize the acidic contents of the
stomach. Some anesthesiologists order ranitidine hydrochloride
(Zantac) IV or cimetidine (Tagamet) to decrease the production of
stomach acid; metoclopramide (Reglan) may also be prescribed to
increase gastric emptying (Vallerand, 2018). Before administration of
the anesthesia, a wedge is placed under the right hip to displace the
uterus (to prevent aortocaval compression and decreased placental
perfusion). When possible, the patient is preoxygenated with 3 to 5
minutes of 100% oxygen.
Thiopental sodium (Pentothal), an ultrashort-acting barbiturate, is
usually given. This agent causes rapid induction of anesthesia and
minimal postpartal bleeding. Succinyl choline (Anectine) is a muscle
relaxant used to facilitate passage of the endotracheal tube. To
prevent gastric reflux and aspiration before the woman fully loses
consciousness, the nurse may be asked to assist with applying
cricoid pressure. This maneuver seals off the esophagus by
compressing it between the cricoid cartilage and the cervical
vertebrae. The cricoid ring, which is the only tracheal cartilage that
forms a complete ring, is located immediately above the thyroid
isthmus. The cricoid cartilage is depressed 2 to 3 cm posteriorly, and
pressure is maintained until the cuffed endotracheal tube is securely
in place (Fig. 7-43). While applying pressure, the nurse should use
the other hand to support the patient’s neck.
Recovery room care is focused on maintenance of an open
airway, continuous monitoring of cardiopulmonary function, and the
prevention of postpartum hemorrhage. Postpartal care should be
arranged to facilitate parent-infant bonding as soon as possible. The
nurse offers emotional support, answers questions concerning the
birth, provides updates regarding maternal/neonatal status, and
assesses the patient’s readiness to interact with her newborn.
FIGURE 7-43 Correct position for applying cricoid pressure until
endotracheal tube placement has been completed.
Caring for the Birth Partner

Obviously, most of the nurse’s attention focuses on the woman in
labor. Efforts also should be made to help the support person feel
welcome and included whenever possible according to the woman’s
wishes. Awareness of the support person’s emotional status and
taking action to help reduce stress (e.g., offering information about
labor progress and demonstrating supportive measures) is import
ant in alleviating maternal stress. Labor support behaviors include
expressions of encouragement, praise, reassurance, and nursing
providing a supportive presence.
Assessment of the degree of involvement the support person
would like to assume is also important. It is helpful to determine
whether the patient and labor partner have attended childbirth
preparation classes and give respect to the support person for
identified wishes and limitations.
SECOND STAGE OF LABOR

The second stage of labor commences with full dilation of the cervix
and ends with the birth of the infant. Often the woman or nurse may
suspect that the woman has entered the second stage of labor
because of the patient’s urge to push or the presence of involuntary
bearing-down efforts. The contractions often remain very similar to
those experienced during the transition stage. They continue to
occur frequently and are very intense. The woman may exhibit
varying emotions during the second stage. Some patients may get a
spurt of energy or a “second wind” to help them get through the
second stage. Others may be nervous or fearful of the new
sensations that they are feeling. Encouragement and support from
the labor nurse and support person are crucial at this stage. The
woman is not to be left alone during this time, and continuous
support should be provided. It is important to encourage the patient
to rest between pushing to maintain her energy throughout the
second stage.
Promoting Effective Pushing

Women push most effectively when they experience the urge to bear
down and push. The urge to push is believed to be stimulated by the
Ferguson reflex as the presenting part stretches the pelvic floor
muscles. Thus, the maternal urge to push may be more related to
the station of the presenting part rather than to the dilation of the
cervix.
Differing practices exist regarding the promotion of pushing during
the second stage. Many practitioners believe that pushing should be
encouraged only when the woman has the urge to push instead of
when full cervical dilation has been reached. Some women (e.g.,
those with an epidural analgesia or other types of anesthesia) may
have no urge to bear down. When this situation occurs, a process
called “laboring down” may be used. “Laboring down” allows the
woman to rest as the fetus descends. Newer research has
demonstrated adverse maternal outcomes when “laboring down”
occurs for more than 1 to 2 hours: there is an increase in second
stage of labor, increase in c-sections, and postpartum hemorrhage
and infection, and ACOG recommends pushing at the beginning of
second stage (ACOG, 2017).
There are generally two methods of pushing during the second stage
of labor: closed-glottis and open-glottis pushing. With closed-glottis
pushing, also referred to as “directed pushing,” the woman begins
pushing at full cervical dilation regardless of the urge to bear down.
Open-glottis pushing is also referred to as “involuntary pushing.”
With this technique, air is released during pushing so that no
intrathoracic pressure builds up. The laboring woman is encouraged
to hold her breath for only 5 to 6 seconds during pushing and to take
several breaths between each bearing-down effort. In addition,
women are allowed to exhale throughout the bearing-down attempts.
These pushing methods are comparable in terms of maternal and
fetal outcomes, and preference for one over the other is usually
determined from the health-care professional preference (ACOG,
2017; de Tayrac & Letouzey, 2016).
Achieving a Position of Comfort

During the second stage, comfort measures remain equally
important, and many of the interventions and positioning identified
for the first stage of labor can be implemented during the second
stage as well. Many factors (e.g., the woman’s personal preferences,
the use of analgesia or anesthesia, the preferences of the health-
care practitioner, and the imminence of birth) have an influence on
the optimal maternal position during this stage. When pushing,
women are encouraged whenever possible to maintain an upright or
semiupright position, such as squatting, sitting, standing, kneeling,
on all fours, or sitting on the toilet.
Pushing when in an upright position allows the use of gravity to
promote fetal descent and has been associated with a shortened
labor. Positions such as squatting and kneeling may also help to
increase the dimensions of the maternal pelvis. Assuming a hands
and knees position or leaning over a table or chair helps to take
pressure off the maternal spine and often reduces backache
commonly associated with a fetal occipital–posterior position (see
Fig. 7-14).
Preparation for the Birth

As the fetus descends, the woman experiences an increasing urge
to bear down because of pressure of the fetal head on the sacral and
obturator nerves. As the patient pushes, contraction of the
abdominal muscles exerts intra-abdominal pressure. With the
maternal bearing-down efforts and further descent of the fetus, the
nurse may notice bulging of the perineum and rectum. As the fetal
head progresses downward, the perineum begins to stretch, thin out,
and move anteriorly. The amount of bloody show may increase at
this time, and the labia begin to part with each contraction. The fetal
head, which may be observable at the vaginal introitus, often
appears to recede between contractions. As the contractions and
maternal pushing efforts continue, the presenting part descends
farther.
Crowning, which means that birth is imminent, occurs when the
fetal head is encircled by the vaginal introitus (Fig. 7-44). Some
women may complain of a burning sensation as the perineum is
stretched. This experience can be frightening for the woman, and it
is important for the nurse to identify it as a normal sensation. The
woman may also feel intense pressure in the rectum and a need to
evacuate her bowels. Again, the nurse should confirm the normalcy
of these sensations and continue to offer encouragement and
support. If the woman does pass stool, she should be cleaned in a
timely manner. Some women may feel as though they are losing
control, and a variety of emotions (e.g., irritability, fear,
embarrassment, and helplessness) may be displayed. These
behaviors also can be frightening to the support person. The nurse
needs to continue to encourage and reinforce to the woman and her
support person that these reactions are normal and that progress is
being made.
FIGURE 7-44 Crowning.

Lacerations
Every birth is associated with damage to the soft tissues of the
vagina and adjacent structures. Nulliparous women tend to
experience more pronounced damage because the tissues are
firmer and more resistant than those of multiparous women.
Lacerations may occur in the cervix, vagina, and perineum. Perineal
lacerations, which usually occur when the fetal head is being born,
are defined in terms of their depth:
■ First degree—involve the perineal skin and vaginal mucous
membrane
■ Second degree—involve the skin, mucous membrane, and fascia
of the perineal body
■ Third degree—involve the skin, mucous membrane, and muscle of
the perineal body and extend to the rectal sphincter
■ Fourth degree—extend into the rectal mucosa and expose the
lumen of the rectum
Immediately after birth, the cervix, vagina, and perineum are
carefully inspected to assess for tissue damage. Rapid repair
promotes healing and comfort, limits residual damage (e.g., fistulas,
dyspareunia, cystocele, and rectocele), and decreases the possibility
of infection.
Episiotomy
Episiotomy is a surgical incision of the perineum performed to
enlarge the vaginal orifice during the second stage of labor. The
frequency of routine episiotomy has decreased over the last 20
years because of notable risks such as cystocele, rectocele,
dyspareunia, and uterine prolapse.
Two different methods are used for episiotomy. The most common
method is the midline or median episiotomy. An incision is made
from the vaginal opening downward toward the rectum. A midline
episiotomy is considered a second-degree laceration, which is easily
repaired and heals quickly. However, it is associated with a higher
risk of an adverse third-degree or fourth-degree laceration. The
mediolateral episiotomy is less common. An incision is made from
the vagina to the 5 o’clock or 7 o’clock position (the maternal left
mediolateral or right mediolateral position). Compared with a midline
incision, the mediolateral episiotomy is associated with a smaller risk
of fourth-degree lacerations although third-degree lacerations may
occur. The amount of blood loss is usually greater, the surgical repair
is more difficult, and there is increased pain postpartum (Fig. 7-45).
Optimizing Outcomes
Methods to Decrease Perineal Trauma

Various strategies to decrease the risk of perineal trauma during the second
stage of labor have been implemented and evaluated. These include perineal
massage (antenatal and intrapartal), application of warm compresses, use of
lubricating oils, and manual support. However, research has demonstrated
variable results, with vaginal massage demonstrating most effective in reducing
the need for an episiotomy and perineal trauma that requires suturing. Nurses
should be aware of the potential benefits and risks associated with various
techniques intended to help minimize perineal trauma. It is important for nurses
to remain open-minded, encouraging, and supportive of patients who wish to
use alternate methods to help facilitate perineal stretching.
Birth
As the fetal head is crowning, the perineum is stretched very thin
and the anus stretches and protrudes. With continued maternal
pushing efforts, the fetal head extends under the symphysis pubis
and is born. The practitioner assisting at the birth may prefer to
coach the patient regarding pushing and breathing because the birth
of the head should occur in a controlled manner in an attempt to limit
injury to the perineum. Once the anterior shoulder reaches the pelvic
outlet, it rotates to the midline and is delivered from under the pubic
arch. The posterior shoulder is guided over the perineum, and the
body follows.
FIGURE 7-45 An episiotomy is a surgical incision of the perineum
that is performed to facilitate birth. The most common method is the
midline or median episiotomy—an incision is made from the vaginal
opening downward toward the rectum.
The Cardinal Movements

The cardinal movements, or mechanisms of labor, have been used
to describe how the fetus (in a vertex presentation) passes through
the birth canal and the positional changes required to facilitate birth
(Fig. 7-46). The cardinal movements are presented in the order in
which they occur.
DESCENT
Four forces facilitate descent, which is the progression of the fetal
head into the maternal pelvis: (1) pressure of the amniotic fluid, (2)
direct pressure of the uterine fundus on the fetal breech, (3)
contraction of the maternal abdominal muscles, and (4) extension
and straightening of the fetal body. The fetal head enters the
maternal inlet in the occiput transverse or the oblique position
because the pelvic inlet is widest from side to side. The sagittal
suture is equidistant from the maternal symphysis pubis and sacral
promontory. The degree of fetal descent is measured by stations.
FLEXION
Flexion occurs as the fetal head descends and comes into contact
with the soft tissues of the pelvis, the muscles of the maternal pelvic
floor, and the cervix. The resistance encountered with these
structures causes the fetal chin to flex downward onto the chest.
This position allows the smallest fetal diameters to enter the
maternal pelvis.
INTERNAL ROTATION
To fit into the maternal pelvic cavity, which is widest in the
anteroposterior diameter, the fetal head must rotate. As the occiput
of the fetal head comes into contact with the levator ani muscles and
surrounding fascia, it meets with resistance. This causes the occiput
to rotate, usually from left to right, and the sagittal suture aligns with
the long axis of the maternal pelvis (the anteroposterior pelvic
diameter).
EXTENSION
As the fetal head passes under the maternal symphysis pubis, it
meets with resistance from the pelvic floor. The head pivots and
extends with each maternal pushing effort. The head is born in
extension as the occiput slides under the symphysis and the face is
directed toward the rectum. The fetal brow, nose, and chin then
emerge.
FIGURE 7-46 The cardinal movements, or mechanisms of labor.
RESTITUTION
Internal rotation causes the fetal shoulders to enter the maternal
pelvis in an oblique position. After the head is delivered in the
extended position, it rotates briefly to the position it occupied when it
was engaged in the inlet. This movement is termed restitution. The
45-degree turn of the fetal head facilitates realignment with the long
axis of the body.
EXTERNAL ROTATION
As restitution continues, the shoulders align in the anteroposterior
diameter, causing the head to continue to turn farther to one side
(external rotation). The fetal trunk moves through the pelvis with the
anterior shoulders descending first.
EXPULSION
After external rotation, maternal pushing efforts bring the anterior
shoulder under the symphysis pubis. Lateral flexion of the shoulder
and head occurs and the anterior, then posterior, shoulder is born.
Once the shoulders are delivered, the rest of the body quickly
follows.
Clamping the Umbilical Cord

Much controversy exists concerning the issue of when and how to
clamp the umbilical cord. When the newborn is held above the level
of the placenta, a transfer of blood occurs from the newborn back to
the placenta. Conversely, delaying the umbilical cord clamping and
holding the newborn below the level of the placenta can result in a
transfer of 50 to 100 mL of blood from the placenta to the newborn.
The additional blood may be beneficial in reducing infant iron
deficiency anemia and improved hematocrit and ferritin levels for up
to 6 months. For the term infant, clamping should be delayed for at
least 60 seconds, probably for 120 seconds, or until cord pulsation
ceases. For the preterm infant, especially one who does not require
resuscitation in the first minute, delaying cord clamping from 60 to
120 seconds is beneficial in improving circulatory and respiratory
function and in reducing the need for blood transfusion and the risk
for intraventricular hemorrhage. However, with delayed cord cutting
there is an increase in hematocrit, which can result in polycythemia
and hyperbilirubinemia, leading to the need for phototherapy. For this
reason, the practice is usually not a standard in care (Fogarty et al,
2018).
The primary care provider places two Kelly clamps on the
umbilical cord and may invite the father or birth support person to cut
the cord between the two clamps. Either the primary care provider or
the nurse then places a plastic clamp on the umbilical cord
approximately 0.5 to 1 inch (1.2 to 2.5 cm) from the newborn’s
abdomen, being careful to not catch the abdominal skin in the clamp.
The nurse observes the cut cord for the presence of three blood
vessels: two arteries and one vein. Samples of cord blood are
collected for laboratory analysis. Some parents request to have their
newborn’s cord blood “banked” in the event that the stem cells in the
cord blood may be required in the future for the treatment of a family
illness. A vaginal birth sequence is presented in Figure 7-47.
THIRD AND FOURTH STAGES OF LABOR

Nursing care during the third and fourth stages of labor is focused on
providing immediate care for the newborn in the adjustment to
extrauterine life, assisting with the delivery of the placenta,
monitoring and assisting the mother with the physiological
adjustments of labor and birth, and facilitating the attachment
between the mother and baby. Characteristics of the third and fourth
stages of labor are presented in Table 7-8.
Third Stage of Labor

The third stage of labor is the period of time from the birth of the
baby to the complete delivery of the placenta. This stage usually
lasts 5 to 10 minutes and may last up to 30 minutes. Once the baby
is born, the uterine cavity immediately becomes smaller. The change
in the interior dimension of the uterus results in a reduction in the
size of the placental attachment site. This event leads to the
separation of the placenta from the uterus. The following clinical
indicators signal that separation of the placenta from the uterus has
occurred:
■ The uterus becomes spherical in shape.
■ The uterus rises upward in the abdomen as a result of the descent
of the placenta into the vagina.
■ The umbilical cord descends farther through the vagina.
■ A gush of blood occurs once the placenta detaches from the
uterus.
The placenta is expelled in either the Schultze or Duncan manner
(Fig. 7-48). The Schultze mechanism “shiny Schultze” occurs when
the placenta separates from the inside to the outer margins with the
shiny, fetal side of the placenta presenting first. It is the most
common method of placental expulsion. The Duncan mechanism
occurs when the placenta separates from the outer margins inward,
rolls up, and presents sideways. Because the placental surface is
rough, the Duncan mechanism is commonly called “dirty
Duncan” (Fig. 7-49).
As the placenta separates from the uterine wall, it is important that
the uterus continues to contract. The contractions minimize the
bleeding that results from the open blood vessels left at the placental
attachment site. Failure of the uterus to contract adequately with
separation of the placenta can result in excessive blood loss or
hemorrhage. To enhance the UCs after expulsion of the placenta,
oxytocic medications are often given. Oxytocin is administered either
by IV or IM.
Nursing Care of the Mother During the Third Stage of Labor

After the birth of the infant, the nurse observes for signs that the
placenta has separated from the wall of the uterus. The uterus is
palpated to determine the rise upward and the characteristic change
in shape from one resembling a disk to that of a globe. The nurse
may ask the woman to push again to facilitate in the delivery of the
placenta. If 30 minutes have elapsed from completion of the second
stage of labor and the placenta has not yet been expelled, it is
considered “retained.”
FIGURE 7-47 Vaginal birth sequence. A, Pushing in an upright
position allows the use of gravity to promote fetal descent. B,
Crowning. C. Birth of the head. D, Birth of the shoulders. E, The
infant is shown to the new parents. F, The baby’s father cuts the
cord.
TABLE 7-8
Characteristics of the Third and Fourth Stages of Labor
THIRD STAGE FOURTH STAGE
Description Begins with the birth of the A time of physiological adaptation
infant and ends with the that begins following delivery of the
delivery of the placenta. placenta and lasts 1–2 hours.
Usually takes 5–10 minutes
and may take up to 30
minutes.
Contractions The uterus should be firmly The uterus should be firmly

contracted. contracted.
Assessment Uterus becomes globelike. Uterus remains firmly contracted.
Uterus rises upward. Lochia rubra, bright red blood flow

with occasional small clots.
Umbilical cord descends Vital signs return to prelabor values.

farther.
Gush of blood as placenta

detaches.
Physical Some discomfort or Some women experience perineal

discomforts cramping as the placenta is discomfort usually related to trauma
expelled. from the episiotomy or tearing, or
hemorrhoids.
Maternal Focus on infant well-being. Excited, tired.

behaviors
Crying common. Bonding and attachment with infant.

Expressions of relief.
Culturally influenced. Initiation of breastfeeding.
Culturally influenced.
FIGURE 7-48 Third stage of labor: separation and expulsion of the
placenta. A, Schultze mechanism. B, Duncan mechanism.
FIGURE 7-49 The delivered placenta. A, Fetal side. B, Maternal

side.
Oxytocic medications such as Pitocin and Syntocinon are often

administered at the time of the delivery of the placenta. These drugs
are used to stimulate UCs, thereby minimizing the bleeding from the
placental attachment site and reducing the risk of postpartum
hemorrhage. The nurse administers oxytocic medications according
to institutional protocol. If a peripheral intravenous infusion has been
established, oxytocin 10 to 20 units may be added to the intravenous
infusion. If no intravenous infusion is present, 10 units of oxytocin
may be administered intramuscularly. In situations where there is
excessive blood loss, the physician may order up to 40 units of
oxytocin per liter of intravenous infusion fluid. Other medications
such as methylergonovine maleate (Methergine) or carboprost
tromethamine (Hemabate) may be given intramuscularly to control
blood loss. During this time, the nurse continues to assess the
volume of blood loss and monitor the patient’s vital signs, paying
close attention to the blood pressure and heart rate.
MEDICATION: Oxytocin (Pitocin, Syntocinon)

(ox-i-toe-sin)
Pregnancy Category: X
Indications:
IV: Induction of labor at term
IV: Facilitation of threatened abortion
IV, IM: Control of postpartum bleeding after expulsion of placenta
Actions: Stimulates uterine smooth muscle producing UCs similar to those in
spontaneous labor (administered intravenously). Stimulates mammary gland
smooth muscle facilitating lactation (administered intranasally). Has
vasopressor and diuretic effects.
Therapeutic Effects: Induces labor. Reduces postpartum bleeding. Induces
breast milk letdown.
Pharmacokinetics:
ABSORPTION: Well absorbed from the nasal mucosa when administered
intranasally.
DISTRIBUTION: Through extracellular fluid. Small amounts reach fetal
circulation.
METABOLISM: Metabolized rapidly in kidneys and liver. EXCRETION: Small
amounts excreted in urine; half-life 3 to 9 minutes.
CONTRAINDICATED IN: CPD or deliveries that require conversion (e.g.,
transverse lie). Use with caution in first and second stages of labor.
Maternal adverse reactions are associated with IV use only. Painful
contractions and increased uterine motility most common. May contribute to
maternal coma, seizures, and hypotension. May contribute to fetal asphyxia or
arrhythmias.
Route and Dosage:
May be added to IV for labor induction or given IV or IM to control postpartum
bleeding (do not administer IM and IV routes simultaneously).
1. Fetal maturity, presentation, and maternal pelvic adequacy should be
assessed before administration to induce labor.
2. Monitor contractions and resting uterine tone frequently.
3. Monitor maternal BP and pulse frequently and FHR continuously throughout
administration.
4. Monitor uterus for firmness and early detection of bogginess.
5. Monitor lochia for signs of excessive bleeding.
6. Monitor patient for signs and symptoms of water intoxication (drowsiness,
listlessness, confusion, headache, and anuria) and monitor electrolyte
(hypochloremia and hyponatremia) status.
Once the placenta has been delivered, the nurse carefully

examines it to ensure that all cotyledons are intact (Fig. 7-50). If any
part of the placenta is missing, the nurse immediately reports this
finding to the attending physician. Because retained placental
fragments can contribute to postpartum hemorrhage or infection, the
physician may perform a manual exploration of the uterus to remove
any remaining placental tissue.
EMOTIONAL SUPPORT
The birth of the newborn is an emotional experience for the patient
and her support person. Hearing the infant’s first cry can evoke
tears, laughter, and feelings of relief, accomplishment, and
amazement. The nurse can support the mother and her birth partner
by promoting contact with the infant. The stable newborn can be
placed on the maternal abdomen, and as soon as possible, the
nurse can help the mother into a comfortable position to hold the
infant.
FIGURE 7-50 Examination of the placenta.
CASE STUDY
The Birth Experience of a Multigravida
Tina Sanchez is a 26-year-old Mexican American gravida 2 para 1 who comes
to the birthing unit with her husband Jose. On arrival, Tina describes her
contractions as starting approximately 2 hours earlier, regular and of moderate
strength. You note that while she is walking to her room, she has two
contractions that are approximately 4 minutes apart and 60 seconds long. Tina
is coping well with the contractions. Between contractions, she tells you that
with her first baby 3 years ago she was induced and confined to bed with an
electronic monitor and does not want that constraint this time if at all possible.
1. What type of information do you need to obtain from Tina and her husband?
2. What are your priority nursing assessments?
3. How would you respond to Tina’s request not to be confined to bed?
The nurse completes the assessment of Tina and the admission history
between contractions. Tina has experienced a healthy pregnancy and is
considered low risk. The institution policy promotes IA for low-risk patients in
active labor. Tina’s contractions are growing longer in duration and becoming
stronger in intensity. Tina states: “I don’t know how long I am going to be able to
do this, it is getting harder.”
4. What evaluation of the FHR would you make during IA?
5. How would you respond to Tina, considering that at this time she appears to
be coping well?
6. What type of comfort measures could you suggest?
While ambulating in the room, Tina experiences a large gush of greenish-
brown fluid from her vagina.
7. What are your priority nursing assessments?
8. Are these findings normal or pathological? What further interventions are
required?
Thirty minutes later Tina is fully dilated and begins to push with each
contraction. The FHR is now decreasing with each contraction and resembles
the mirror image of the contraction.
9. What stage of labor has Tina now entered?
10. What is your interpretation of the FHR at this time?
11. What type of nursing interventions would you anticipate for Tina?
Tina gives birth to a healthy baby girl 20 minutes later. The infant is suctioned
well at the perineum and examined by the pediatrician because of the presence
of meconium in the amniotic fluid. The infant is pink with acrocyanosis, does not
demonstrate any signs of respiratory difficulties, and is quickly returned to the
proud parents.
13. What are your priority nursing interventions for the newborn, Tina, and the
family?
SUMMARY POINTS
■ Each patient’s labor and birth experience is unique, and nurses play a vital
role in facilitating a positive outcome for the patient, infant, and family.
■ Nurses recognize that the labor and birth experience is influenced by a myriad
of factors such as maternal age and well-being, social support, and cultural
and religious beliefs and practices.
■ Nurses need a strong knowledge base about the physiological processes of
labor and birth to provide safe and effective care.
■ In each of the four stages of labor, the nurse uses well-developed assessment
skills to recognize the normal progression of labor, identify potential risks to
the patient and fetus, and identify how and when to intervene and consult with
other health-care providers.
■ The overall goal of intrapartal nursing care is to promote comfort and safety of
the patient, the fetus, and the newborn infant.
■ A positive nurse-patient relationship in which the woman feels cared for and
informed will empower her in coping with her labor.
■ Nurses include the patient and her support person(s) in the planning and
delivery of care.
■ The nursing care given throughout labor and birth is an important determinant
of the woman’s overall perception of her childbirth experience.
■ Pain during labor is unique in that it is normal, can be anticipated and
prepared for, and ends with a birth.
■ Although a universal phenomenon, every individual perceives pain differently.
■ The better prepared a woman is for childbirth, the less likely is the need for
analgesia and anesthesia.
■ Relaxation, massage, breathing techniques, and other nonpharmacological
strategies should be encouraged in conjunction with prescribed analgesics.
■ The type of analgesic or anesthetic to be used depends, in part, on the stage
of labor and the method of birth.
REFERENCES
American College of Obstetricians and Gynecologists. (2017). Committee opinion
no. 687: Approaches to limit intervention during labor and birth. Obstetrical
Gynecology, 129(2), e20-e28.
American College of Obstetricians and Gynecologists (2018). Prelabor rupture of
membranes. Practice Bulletin. Obstetrics and Gynecology, 131(1), e1–e14.
https://doi.org/10.1097/AOG.0000000000002455
American College of Obstetricians and Gynecologists. (2019). Intrapartum fetal
heart rate monitoring: Nomenclature, interpretation, and general management
principles; ACOG practice bulletin no. 106. Obstet Gynecol, 114(1), 192–202.
Association of Women’s Health, Obstetric and Neonatal Nurses. (2018). Position
statements. Continuous labor support for every woman. Journal of Obstetrical
Gynecological & Neonatal Nursing, 47(1), 73.
Australian Institute of Health and Welfare. (2020). Australia’s mothers and babies
2018 in brief. Perinatal statistics series no. 36. Cat. no. PER 108.
https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies-
2017-data-visualisations/contents/labour-and-birth/presentation
Azizmohammadi, S., & Azizmohammadi, S. (2019). Hypnotherapy in management
of delivery pain: A review. European Journal of Translational Myology, 29(3).
Chapman, L., & Durham, R. (2014). Maternal-newborn nursing: The critical
components of nursing care. (2nd ed.). Philadelphia: F.A. Davis.
de Tayrac, R., & Letouzey, V. (2016). Methods of pushing during vaginal delivery
and pelvic floor and perineal outcomes: A review. Current Opinion in Obstetrics
and Gynecology, 28(6), 470–476.
Fogarty, M., Osborn, D. A., Askie, L., Seidler, A. L., Hunter, K., Lui, K., Simes, J., &
Tarnow-Mordi, W. (2018). Delayed vs early umbilical cord clamping for preterm
infants: A systematic review and meta-analysis. American Journal of Obstetrics
Gaiser, R. (2012). Anesthesia for cesarean delivery. In B. A. Bucklin, D. R.
Gambling, & D. Wlody (Eds.). A practical approach to obstetric anesthesia (pp.
185–208). Philadelphia: Lippincott Williams & Wilkins.
Gönenç, I. M., & Terzioğlu, F. (2020). Effects of massage and acupressure on
relieving labor pain, reducing labor time, and increasing delivery. The Journal of
Nursing Research: JNR, 28(1), e68.
Koyucu, R. G., Demirci, N., Yumru, A. E., Salman, S., Ayanoğlu, Y. T., Tosun, Y., &
Tayfur, C. (2018). Effects of intradermal sterile water injections in women with
low back pain in labor: A randomized, controlled, clinical trial. Balkan Medical
Journal, 35(2), 148.
Santiasari, R. N., Nurdiati, D. S., Lismidiati, W., & Saudah, N. (2018).
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Davis.
F.A. Davis.

Davis Advantage
CHAPTER 8
Caring for the Woman Experiencing

Complications During Labor and Birth
CONCEPTS
Female Reproduction
Pregnancy
Nursing
Assessment
KEY WORDS
dystocia
hypertonic labor
hypotonic labor
macrosomia
precipitous labor
Bandl ring
trial of labor
induction
Bishop score tool
augmentation of labor
cephalopelvic disproportion
asynclitism
version
McRoberts maneuver
oligohydramnios
hydramnios
meconium
Couvelaire uterus
uterine inversion
vasa previa
perinatal loss
LEARNING OBJECTIVES
■ Differentiate critical factors associated with nursing care of women
experiencing dysfunctional labor patterns.
■ Discuss collaborative care of the woman experiencing an induction of labor.
■ Describe the management of selected maternal complications during the
intrapartal period.
■ Describe emergency nursing care for various uterine, placental, umbilical, and
amniotic complications during labor and birth.
■ Plan appropriate nursing care for a family experiencing a fetal loss.
■ Discuss maternal and fetal factors associated with cesarean birth.
PICO(T) Questions
chapter.
1. Do (P) infants (I) delivered with forceps assistance (O) have a higher rate of
injury at birth (C) than infants delivered with vacuum assistance?
2. What (I) nursing interventions do (P) parents who experience perinatal fetal
loss say are (O) most meaningful in coping with this event?
INTRODUCTION
The nurse who cares for women and their families experiencing
complications during labor and birth is responsible for creating a
supportive environment that facilitates complex nursing care. Under
normal circumstances, labor and birth place stress on the family unit,
so problems that arise during this time add another layer of
complexity. The woman often needs to respond rapidly to changing
health conditions and may be unprepared. The nurse must be
proactive and reassuring in support of the woman and her family
unit. It is critical to empower the woman and encourage her to take
control as much as possible. The nurse acts as her advocate in
collaborative care when the woman is unable to express her voice.
Complications arise from a variety of factors including:
■ Problems with uterine dysfunction caused by the powers of labor
■ Malpresentation and position of the fetus
■ Multiple fetuses
■ Placenta obstruction or an inadequate bony pelvis
■ Medical emergencies and complications from maternal disease
Cesarean or operative birth is one of the outcomes associated
with a complicated labor. In the United States, the cesarean birth
rate has steadily increased. Cesarean birth is a major abdominal
surgery that places the women at risk for complications.
The nurse serves in many capacities when managing the care of a
patient experiencing complicated labor and birth. Use of the nursing
process combined with a strong theoretical background provides a
foundation for the critical decision making that exists in the clinical
unit. The nurse has the unique opportunity to empower the woman
and assist her in taking control as much as possible in these difficult
situations. The nurse must constantly examine practice and promote
research initiatives that give evidence to optimal outcomes in
complex perinatal care.
DYSTOCIA
Dystocia, defined as a long, difficult or abnormal labor, is a term
used to identify poor labor progression. Dystocia may arise from any
of the three major components of the labor process—the powers
(uterine contractions), the passenger (fetus), or the passageway
(maternal pelvis). In addition, various medical interventions used
during labor and birth may create problems that complicate the birth
process.
Dystocia may be related to maternal positioning during labor, fetal
malpresentation, anomalies, macrosomia, and multiple gestation.
Also, maternal psychological responses to the labor, especially
anxiety and fear, may affect the normal progress of labor (Alijahan &
Kordi, 2014).
Dysfunctional Labor Patterns

Dysfunctional labor patterns are deviations from the normal pattern
of labor. Labor alterations occur more frequently during the first
stage of labor (cervical dilation and effacement) than during the
second stage (maternal expulsive efforts). Nulliparous women have
a higher incidence of abnormalities than do multiparous women.
Dysfunctional labor is the fourth most common complication of labor
and birth, and several factors may increase a woman’s risk for
dystocia (Box 8-1). There are two general types of labor dysfunction:
hypertonic and hypotonic (Fig. 8-1). These contraction patterns are
classified according to when they occur in labor and the nature of the
uterine contractions.
Hypertonic Labor
Hypertonic labor contractions are strong and often painful but do
not effectively produce cervical effacement and dilation. An increase
in maternal catecholamine release (e.g., epinephrine and
norepinephrine) can result in poor uterine contractility. Uterine
pacemakers (the initiation of the energy source of contractions
located in the smooth muscle of the uterine wall) do not initiate a
good myometrial response needed for progressive cervical change
(Parkington et al, 2018). Instead, irregular spasmodic episodes occur
that do not result in effective contractions or help bring the fetus into
a more favorable downward position. Maternal anxiety can play a
significant role in hypertonic labor. Anxiety is known to produce high
levels of catecholamines. Many factors contribute to a woman’s fear
related to labor and birth, such as:
BOX 8-1
Factors Associated With an Increased Risk for

Uterine Dystocia
• Uterine abnormalities, such as congenital malformations and overdistention
(e.g., hydramnios and multiple gestation)
• Fetus in the occipito-posterior position in second stage
• Fetal malpresentation or malposition
• Cephalopelvic disproportion (CPD)
• Maternal body build (greater than BMI of 30)
• Maternal anxiety and fear
Sources: Alijahan & Kordi (2014); Hautakangas et al (2018).
FIGURE 8-1 Uterine contraction patterns. A, Normal uterine

contraction pattern. B, Hypertonic uterine contraction pattern. C,
Hypotonic uterine contraction pattern.
■ Primiparous labor
■ Loss of control
■ Sexual abuse or previous trauma
■ Lack of support
■ Cultural differences
■ Fear of pain
Although the management of hypertonic labor contractions varies,
in general, the emphasis is on establishing a more effective labor
pattern. Rest, hydration, and sedation reduce the irritability of the
uterus and help to diminish ineffective contractions. Medications that
may be prescribed to induce therapeutic rest include acetaminophen
with Benadryl, meperidine (Demerol), hydromorphone (Dilaudid),
and morphine. Natural labor with effective contractions often
resumes after this simple intervention. Nonpharmacological
techniques to reduce anxiety, such as relaxation techniques,
massage, a warm shower or tub bath, and increased emotional
support, are also helpful for some women.
One common reason for hypertonic contraction is occiput-posterior
position. For a woman whose fetus is in an occiput-posterior
position, the major goal of care is to facilitate rotation of the fetal
head into a more favorable position. The nurse can encourage the
laboring woman to walk and change positions frequently throughout
the course of labor. The descent of the fetus into an anterior lie
creates a better environment for normal labor progression.
Nursing care begins with a thorough assessment. It is critical to
identify factors that contribute to increased maternal anxiety. Careful
monitoring of contractions may provide early information regarding
poor labor progression and lead to timely interventions. While
frequent checks for cervical dilation are not advisable, this
assessment, when performed at proper intervals, provides a strong
indicator of labor progression. Along with continued assessment of
the contraction pattern, the nurse can use this information to validate
the finding of hypertonic labor. Once any intervention has occurred,
the nurse evaluates the plan of care and, depending on the results,
initiates appropriate measures.
Hypotonic Labor
Hypotonic labor is a more common type of uterine dysfunctional
pattern that contributes to poor labor progression. With hypotonic
dystocia, the uterine contractions decrease in frequency and
intensity. A hypotonic labor pattern usually occurs during the active
phase of labor. It is defined as fewer than two to three contractions
during a 10-minute period. The uterus can be easily indented, even
at the peak of the contraction, and the intrauterine pressure (IUP) is
insufficient for the progression of cervical effacement and dilation.
Hypotonic labor may be associated with a number of maternal and
fetal factors that produce excessive uterine stretching and
overdistention. For example, fetal macrosomia, anomalies,
malpresentation, multiple gestation, and hydramnios are all risk
factors for hypotonic labor. Grand multiparity may also be a
contributing cause (Venes, 2021).
Fetal macrosomia occurs in 10% of all pregnancies in the United
States (Araujo Júnior et al, 2017). Macrosomia, defined as a fetus
whose birth weight is above the 90th percentile on an intrauterine
growth chart for that gestational age, often results from a fetal
imbalance between glucose and insulin in women diagnosed with
any type of diabetes. Over time, as increased amounts of glucose
are absorbed from the mother, the fetus produces pancreatic insulin,
which results in an increase in fat deposits.
Maternal obesity unaccompanied by diabetes also contributes to a
larger fetus. Direct links between maternal obesity and fetal
macrosomia have been established, and other obesity-related
peripartum complications include shoulder dystocia, high cesarean
birth rates, and postpartum infection (Hautakangas et al, 2018).
Pharmacological agents used to alleviate pain during labor may
also contribute to the risk of uterine hypotonia. If a labor pattern is
not well established, these medications often halt or significantly
slow down the progress of labor. After administration of epidural
anesthesia, some women may experience a longer second stage of
labor. The effects of the epidural may make it difficult for the patient
to identify when to push and how long to push because the
contractions are not always detected.
Depending on the cause, labor hypotonia is managed in different
ways. Careful, ongoing assessments are key. Walking and position
changes in labor assist in fetal descent through the maternal pelvis
and therefore need to be encouraged. The use of relaxation
techniques, massage, and water treatments can decrease the need
for pharmacological agents for pain.
Augmentation of labor contractions is considered when either the
natural measures are unsuccessful or when it is deemed the best
approach. At certain points in the labor, an amniotomy, or artificial
rupture of the membranes (AROM), may be successful in increasing
uterine contractility. Other measures to enhance the progress of
labor include membrane stripping, nipple stimulation, and oxytocin
infusion. Maternal and fetal assessments including vital signs,
contraction patterns, and cervical changes must be regularly
documented.
Precipitous Labor and Birth

Contrary to both hypertonic and hypotonic labor, precipitous labor
contractions produce very rapid, intense contractions. By definition, a
precipitous labor lasts less than 3 hours from the beginning of
contractions to birth. Multiparous women with little soft tissue
resistance are at the greatest risk for this labor pattern. Patients
often progress through the first stage of labor with little or no pain
and may present to the birth setting already advanced into the
second stage. Precipitous labor may result from hypertonic uterine
contractions that are tetanic in their intensity (Borhart & Voss, 2019)
(Fig. 8-2).
Complications from a precipitous labor pattern result from trauma
to maternal tissue and to the fetus because of the rapid descent.
Hemorrhage may occur from uterine rupture and vaginal lacerations.
Most women are ill-prepared for the rapid advancement of labor and
become alarmed, highly anxious, and fearful. The fetus may suffer
from hypoxia related to the decreased periods of uterine relaxation
between the contractions and intracranial hemorrhage related to the
rapid birth.
Initial assessments are paramount to establishing the pattern of
precipitous labor. A multiparous patient with a previous history of
rapid labor must alert her physician or certified nurse midwife (CNM)
as soon as she recognizes any signs of labor. Her prenatal record
should include this information and be readily accessible to nursing
personnel managing her care. Often, plans are made to induce a
woman who has had a previous precipitous birth 1 week sooner than
the gestational age of the precipitous so that the birth can occur in a
controlled environment. In a nulliparous patient, careful examination
for cervical dilation and effacement is required. This woman’s
previous labor pattern is an unknown and the nurse must be alert in
recognizing signs of abnormally rapid cervical dilation.
FIGURE 8-2 Tetanic uterine contractions.
The woman and her support person need reassurance throughout

the rapidly advancing labor. Breathing and relaxation techniques are
helpful tools that the nurse can use to assist the woman to cope with
labor. Precipitous labor is an anxiety-producing situation that can be
compounded by the woman’s inability to understand what is
happening to her body. Although some precipitous labors occur with
little or no pain, the patient is nevertheless aware of contractions that
are occurring more quickly than normal. Continuous surveillance,
frequent updates on her status, and reassurance about her condition
can help to allay the patient’s anxiety. Medical management includes
readiness on the part of the entire health team for the birth,
particularly when the patient has a history of rapid labor.
The nurse can assist the woman in breathing through her
contractions to avoid pushing and to help prevent tearing. If the
nurse is alone with the patient during a precipitous delivery, the
nurse follows delivery protocols when assisting in the birth of the
infant and alerts nearby health-care professionals of the imminent
birth.
After birth, whether assisted by the nurse or physician, the
maternal soft tissue and placenta need to be carefully examined.
The patient may require suturing of the cervix or vagina for
lacerations. During the immediate postpartum period, the woman
must be continuously monitored for hemorrhage. Providing ongoing
information and support assists the patient and helps her support
person cope with this unexpected event.
FOCUS ON SAFETY
Assisting With a Precipitous Birth
The nurse who assists with a precipitous birth should take the following
actions:
• Assist the laboring woman to breathe through each contraction to prevent
pushing.
• Provide continuous emotional support.
• Provide perineal support with warm cloths.
• Frequently monitor the maternal and fetal vital signs and immediately report
any abnormal findings to the physician or CNM.
• After birth, carefully monitor the patient for signs of hemorrhage; assess for
trauma to the perineum.
• Assess the neonate for evidence of trauma and report and document all
findings.
Pelvic Structure Alterations
Pelvic Dystocia
Pelvic dystocia occurs when the pelvic bones, bony pelvis,
midpelvis, or outlet has limited capacity. The fetus is either too large
to fit in the pelvis or enters the pelvis in malpresentation, preventing
passage through the birth canal. Contractures of the maternal pelvis
may result from malnutrition, tumors, neoplasms, congenital
abnormalities, traumatic spinal injury, or spinal disorders. In addition,
immaturity of the pelvis may predispose some adolescent mothers to
pelvic dystocia. Fetal causes include large infant, malpositions such
as breech, transverse, face, or brow presentation. During labor,
contractures of the inlet, midplane, or outlet can cause interference
in engagement and fetal descent, necessitating cesarean birth
(Borhart & Voss, 2019; Venes, 2021).
Soft Tissue Dystocia

Soft tissue dystocia occurs when the birth passage is obstructed by
an anatomical abnormality other than the bony pelvis. The
obstruction, which prevents the fetus from entering the bony pelvis,
may be caused by placenta previa, uterine fibroid tumors
(leiomyomas), ovarian tumors, or a full bladder or rectum. Bandl
ring is a pathological retraction ring that develops between the upper
and lower uterine segments (Venes, 2021). It is associated with
protracted labor, prolonged ROM, and an increased risk of uterine
rupture.
Trial of Labor
A trial of labor (TOL) is the surveillance of a woman and her fetus
for a set amount of time (usually 4 to 6 hours) during spontaneous
active labor to assess the safety of a vaginal birth. Indications for a
TOL include situations when the maternal pelvis is of questionable
size or shape, when the fetus is in an abnormal presentation, and
when the woman desires to have a vaginal birth after a previous
(low-segment transverse) cesarean birth. Before the TOL, an
assessment of the adequacy of the maternal pelvis for vaginal birth
(to rule out cephalopelvic disproportion [CPD]) is conducted with
sonography or maternal pelvimetry. The cervix must be favorable
(soft, dilatable), and throughout the TOL, the woman is assessed for
the presence of adequate contractions, engagement and descent of
the fetal presenting part, and cervical dilation and effacement.
Amniotomy
Amniotomy, or AROM, is a nonpharmacological intervention that
may be done to augment or induce labor or to facilitate the
placement of internal monitors during labor. AROM involves the
insertion of an Amnihook or other sharp instrument into the lower
segment of the fetal membranes; following rupture, the fluid is
allowed to drain slowly (Fig. 8-3). Before AROM is performed, the
nurse or health-care provider should assess the fetal heart rate
(FHR) and characteristics, perform a vaginal examination to palpate
for umbilical cord, and determine fetal station and presentation. The
presenting part must be engaged and well applied to the cervix and
there should be no evidence of active infection of the genital tract
(e.g., herpes) or HIV infection. The ROM causes a release of
arachidonic acid, which converts to prostaglandins, known inducers
of labor through the stimulation of oxytocin in the uterus. Labor
usually commences within 12 hours after artificial rupture. However,
if labor does not ensue, there is an increased risk of infection; other
risks include fetal injury and umbilical cord prolapse. Due to risk for
infection, amniotomy is frequently used in combination with oxytocin
induction to facilitate delivery in effectors to enhance the labor
process.
The nurse carefully monitors the patient who will undergo an
amniotomy. After an amniotomy is performed, assessment of FHR is
a priority to detect significant complications such as cord
compression or umbilical cord prolapse (protrusion of the umbilical
cord in advance of the presenting part). FHR patterns such as
bradycardia and variable decelerations may be indicative of cord
compression or prolapse. The nurse observes and documents the
FHR and pattern of the fluid, along with its color, odor, consistency,
clarity, and amount. This may augment labor and contractions may
be more painful, and the patient may request analgesia or epidural
anesthesia before the procedure. Maternal vital signs, cervical
effacement and dilation, station of the presenting part, and
contractions should also be documented.
INDUCTION OF LABOR
Indications for Induction
Induction of labor describes the use of chemical or mechanical
modalities to initiate uterine contractions before their spontaneous
onset to bring about childbirth. Induction of labor is considered when
an existing maternal or fetal condition dictates the need for medical
intervention in the labor process. The American College of Nurse
Midwives recommends the induction of labor when medically
indicated as an evidence-based practice when the benefits outweigh
the risks of spontaneous birth (American College of Nurse Midwives,
2016). Labor induction often leads to an increase in interventionist
care including the use of intravenous therapy, amniotomy, internal
monitoring, epidural anesthesia, and a longer stay in the labor unit.
Indications for induction:
■ Post-term pregnancy
■ Maternal medical conditions (e.g., diabetes mellitus, renal disease,
chronic pulmonary disease, chronic hypertension, or
antiphospholipid syndrome) Gestational hypertension
■ Fetal demise
■ Chorioamnionitis
■ Premature rupture of membranes (ROM)
■ Placental abruption
■ Fetal compromise (e.g., severe fetal growth restriction,
isoimmunization, or oligohydramnios)
■ Pre-eclampsia, eclampsia
Because induction carries certain risks, it is not performed without
careful consideration and evaluation of the maternal-fetal status.
However, because of the rise in the U.S. cesarean rate over the last
two decades, medical management of labor is commonly practiced
in many hospitals to prevent the need for surgical delivery. This
practice often involves admission of the patient with complete
cervical effacement, ROM, or expulsion of the mucus plug, which is
begun on a series of protocols that frequently include amniotomy
combined with oxytocin infusion.
FIGURE 8-3 A, An Amnihook. B, An Amnihook is used to rupture the
membranes.
Assessment Tools
The Bishop Score Tool
One method to assess if induction of labor will be more successful is to utilize
the Bishop scoring tool. The Bishop score tool is a rating system that may be
used to determine the level of cervical inducibility. Induction of labor is more
successful when the cervix has begun some of the physiological changes that
occur before delivery and is termed “favorable,” or inducible.
A series of points is awarded to cervical dilation, effacement, station,
consistency, and position (Table 8-1). In general, labor induction is more likely
to be successful with a higher score (Bishop, 1964; Venes, 2021).
TABLE 8-1
The Bishop Score
COMPONENT SCORE
0 1 2 3
Dilation 0 1–2 cm 3–4 cm >5cm
Effacement 0%-30% 40%-50% 60%-70% >80%
Station –3 –2 –1 to 0 + 1, + 2
Cervical Firm Medium Soft

consistency
Cervical Posterior Midposition Anterior

position
Each component is given a score of 0–2 or 0–3; the highest possible score is 13.
MEDICATION: Cervical Ripening Agents

If it is determined that the cervix is not favorable for oxytocin induction, a
chemical cervical ripening agent using prostaglandin E1 (PGE1 (Misoprostol)
or prostaglandin E2 (PGE2) (Dinoprostone) may be prescribed (Table 8-2).
These agents are most beneficial when the patient’s Bishop score is greater
than 6, although they are commonly used when the Bishop score is 4 or less.
Before administration, informed consent may be required according to
agency protocol.
Misoprostol (Cytotec), an analogue of PGE1, can be administered
intravaginally, orally, or sublingually and is used for both cervical ripening and
induction of labor. In 2002, the U.S. Food and Drug Administration (FDA)
approved a new label for the use of misoprostol during pregnancy for cervical
ripening (effacement and dilation) and the induction of labor. The labeling
does not contain claims regarding the efficacy or safety of the medication. At
least 4 hours after the last dose, oxytocin may be initiated for the induction of
labor if cervical ripening has occurred and labor has not begun.
Two FDA-approved PGE2 preparations are commercially available for
cervical ripening in women at or near term: dinoprostone vaginal gel (Prepidil
and Prostin E2), available in a 2.5 mL syringe containing 0.5 mg, 10 mg, and
20 mg of dinoprostone, and dinoprostone vaginal insert (Cervidil), which
contains 10 mg of dinoprostone. The vaginal insert releases prostaglandins
at a slower rate than the gel. The gel is refrigerated and should be brought to
room temperature before insertion. Cervical ripening agents make the cervix
softer, causing it to dilate and efface, stimulating uterine contractions. PGE2
is used for preinduction cervical ripening when the Bishop score is 4 or less.
The dinoprostone vaginal insert is applied into the posterior vaginal fornix;
the dinoprostone gel is inserted through a syringe into the cervical canal just
below the internal cervical os or into the posterior fornix. Uterine contractions
usually begin in 5 to 7 hours after administration. When necessary, oxytocin
induction can be initiated 30 to 60 minutes after removal of the dinoprostone
insert. When using Prepidil gel, oxytocin induction must be delayed until 6 to
12 hours after the last administration of the medication. Cervidil has an
added advantage—the insert can be removed if uterine tachysystole occurs.
Patients who receive Cervidil should be monitored for fever, which can occur
within 15-45 minutes after insertion (Vallerand, 2021).
Contraindications to the PGE1 and PGE2 cervical ripening agents include the
presence of a nonreassuring FHR or pattern, maternal fever, infection,
vaginal bleeding, hypersensitivity, regular progressive uterine contractions,
and a history of cesarean birth or uterine scar. The medications should be
cautiously used in women with a history of asthma, glaucoma, or renal,
hepatic, or cardiovascular disorders. After insertion, the nurse should clearly
document all assessment findings and administration procedures.
TABLE 8-2
Cervical Ripening Agents
MEDICATION ACTION ADVERSE DOSAGE
EFFECTS
Prostaglandin E1 Ripens the cervix Diarrhea, nausea Intravaginally: 25 to
misoprostol (causes softening and vomiting, 50 mcg—repeat
(Cytotec) and initiates dilation headaches, fever, every 3 to 6 hours
and effacement). tachysystole (>5 (maximum of 300 to
Stimulates uterine uterine contractions 400 mcg in a 24-
contractions. in 10 minutes hour period) until
averaged over a Bishop score
30-minute window equals 8 or greater.
without alteration of The tablet is placed
FHR or pattern), into the posterior
uterine fornix using the tips
hyperstimulation of the index and
(tachysystole with middle fingers; no
nonreassuring FHR lubricant is used.
or patterns), fetal Note: Misoprostol is
passage of available as a 100-
meconium. mcg tablet. One-
quarter of an
unscored 100-mcg
tablet is considered
the initial dose for
cervical ripening
and labor induction.
The tablet must be
cut in the pharmacy
to ensure dosing
accuracy.
Prostaglandin E2 Ripens the cervix Diarrhea, nausea Prepidil Gel: (2.5-
dinoprostone gel (causes softening and vomiting, mL syringe
(Prepidil Gel; and initiates dilation headache, back containing 0.5 mg
Prostin E2) and effacement). pain, fever, of dinoprostone).
dinoprostone Stimulates uterine hypotension, Repeat gel
vaginal insert contractions. tachysystole (>5 insertion in 6 hours
(Cervidil) uterine contractions as needed
in 10 minutes (maximum = 1.5 mg
averaged over a or 3 doses/24 hr).
30-minute window Allow gel to reach
without alteration of room temperature
FHR or pattern), before
uterine administration; do
hyperstimulation not heat. Continue
(tachysystole with administration until
nonreassuring fetal maximum dose is
heart rate or reached, or uterine
patterns), fetal contractions are
passage of established (3/10
meconium. min), or Bishop
Adverse effects are score equals 8 or
more common with greater or adverse
intracervical reactions occur.
administration. Cervidil Insert: (10
mg dinoprostone
gradually released
over 12 hours).
Remove after 12
hours or at labor
onset. Keep insert
frozen until ready to
use.
Source: Vallerand (2021).
Patient Education
Cervical Ripening Agents
• Assess the patient’s understanding and knowledge of the medication. The
patient should be taught about the common reactions to the medication and
be knowledgeable about both normal and abnormal effects.
• Explain the purpose of medication and potential adverse side effects. Cervical
ripening agents soften the cervix, can induce contractions, and in some cases
cause hyperstimulation requiring immediate medical attention.
• Explain that the patient will be unable to leave the maternity unit while being
monitored for 2 hours postadministration.
• Discuss comfort options to offset side effects. The medication can cause a
warm sensation in the vagina that may be uncomfortable for some women.
• Instruct the patient to void before insertion.
• Instruct the patient to maintain a supine position with a lateral tilt or side-lying
position for 30 minutes to 2 hours (depending on medication used) after
insertion. During this time the patient is often monitored and instructed to limit
ambulation to allow maximum effect of medication.
• Patients should be aware of concerning signs and report immediately to the
nurse or health-care provider if prolonged contractions or more than three
contractions in 10 minutes occur.
• Patients should also be instructed that if the cervical ripening doesn’t work, a
second dose may be inserted. Some patients may be able to go home and
return when labor begins or consider other methods of induction.
Administration of Cervical Ripening Agents

Before administration of a prostaglandin cervical ripening agent, the
nurse explains the procedure to the woman and her support person,
ensures that informed consent has been obtained per institutional
policy, and asks her to void. Maternal vital signs and FHR and
pattern are assessed before each medication insertion and
periodically throughout treatment, according to agency protocol.
After placement of the medication, the nurse assists the woman to
maintain a supine position with lateral tilt or a side-lying position (30
to 40 minutes after misoprostol; 30 to 60 minutes after dinoprostone
gel; 2 hours after placement of dinoprostone insert). In the event of
adverse reactions, the nurse uses saline-soaked gauze wrapped
around the fingers to swab the vagina (or grasps the pull string
attached to the insert) to remove remaining medication and prepares
to administer terbutaline, 0.25 mg subcutaneously or intravenously.
Mechanical Methods
Mechanical methods provide another approach to cervical ripening.
Dilators placed in the cervix cause cervical ripening by stimulating
the release of endogenous prostaglandins. A balloon catheter (e.g.,
Foley) placed into the intracervical canal causes cervical ripening by
increasing pressure exerted on the lower uterine segment.
Hydroscopic dilators (those that enlarge as they absorb moisture
from the surrounding tissue) such as laminaria tents (made from
desiccated seaweed) and synthetic dilators containing magnesium
sulfate (Lamicel) may be inserted into the endocervix without
rupturing the membranes. The dilators remain in place for 6 to 12
hours before removal for assessment of cervical dilation. Fresh
dilators may then be inserted if necessary. Nursing care includes
careful documentation of the number of dilators inserted (and later
removed) and assessment for contractions, urinary retention, ROM,
uterine tenderness and contractions, vaginal bleeding, fever, and
fetal distress (Simpson, 2020).
With membrane stripping or sweeping, the physician or midwife
inserts a gloved finger into the internal cervical os and rotates it 360
degrees to gently “strip” or separate the amniotic membranes in the
lower uterine segment. This allows the release of prostaglandins that
help ripen the cervix. This membrane sweeping often occurs weeks
before delivery among women who are at term with low-risk
pregnancies (Avdiyovski & Haith-Cooper, 2019).
Oxytocin
Oxytocin, a hormone produced by the pituitary gland, stimulates
uterine contractions. It can be used to induce labor or augment a
labor that is progressing slowly because of ineffective uterine
contractions. Oxytocin is considered a high-alert medication that can
cause significant harm if administered incorrectly (Association of
Women’s Health, Obstetric and Neonatal Nurses, 2015).
Administration of the medication (via electronic infusion device) is
closely monitored according to institutional protocols; use of a
checklist-driven protocol for the monitoring of oxytocin infusion
improves patient safety. Some institutions have established low- and
high-dose regimens for oxytocin infusion:
■ Low-dose oxytocin regimen
■ Begin at 2 milliunits per minute
■ Increase by 2 milliunits per minute every 30 minutes until less
than or equal to five contractions lasting 45 to 90 seconds in 10
minutes averaged over 30 minutes
■ Maximum dose is 20 milliunits per minute
■ High-dose oxytocin regimen:
■ Begin at 4 milliunits per minute
■ Increase by 4 milliunits per minute every 30 minutes until less
than or equal to five contractions lasting 45 to 90 seconds in 10
minutes averaged over 30 minutes
■ Maximum dose is 20 milliunits per minute
The patient should be re-evaluated if the dose reaches 20 milliunits

per minute; oxytocin may exceed 20 milliunits per minute with
provider discretion and documentation of rationale for exceeding the
protocol.
MEDICATION: Safe Administration of Oxytocin

First, the patient’s primary health-care provider writes an order for oxytocin for
labor induction or augmentation. After an explanation and assessment of the
patient’s level of understanding, the nurse assists the woman to a side-lying or
upright position. Assessment of the patient and fetus is conducted and
documented. The solution is prepared and administered with a pump delivery
system according to the prescribed orders. The piggyback solution is flagged
with a medication label and connected to the intravenous infusion at the port
nearest the point of venous insertion (Fig. 8-4). The medication is administered
as ordered; ongoing assessments are conducted according to institutional
protocol. The nurse documents the medication (kind, amount, time of beginning
infusion, increasing the dose, maintaining the dose, and discontinuing the
infusion), maternal–fetal reactions (FHR and pattern, maternal vital signs,
pattern and progress of labor, nursing interventions, and maternal response),
and when notification of the primary health-care provider takes place.
Oxytocin acts on receptors in the myometrium to increase the

strength, duration, and frequency of the contractions. These same
receptors are susceptible to uterine tachysystole (sometimes
referred to as hyperstimulation), which constitutes a major risk
associated with the medication. Signs of uterine hyperstimulation
include the following:
■ Uterine contractions that last greater than 90 seconds and occur
more frequently than every 2 minutes
■ Uterine resting tone greater than 20 to 25 mm Hg with a peak
pressure greater than 80 mm Hg
FIGURE 8-4 Administration of intravenous oxytocin.
■ Nonreassuring FHR and pattern (baseline less than 100 or greater

than 160 beats per minute; absent variability; repeated late
decelerations or prolonged decelerations)
Higher doses are associated with an increased incidence of uterine
tachysystole; however, low dosages result in an increased rate of
cesarean births because of failure of labor progression. Uterine
tachysystole causes reduced blood flow through the placenta and
results in FHR decelerations, fetal asphyxia, and neonatal hypoxia.
Contraindications to the Use of Oxytocin to Stimulate Labor

Nurses should be aware of contraindications to labor induction, which include,
but are not limited to, the following:
• Vasa previa or complete placenta previa
• Transverse fetal lie
• Umbilical cord prolapse
• Previous classical cesarean delivery
• Active genital herpes infection
• Previous myomectomy (surgical excision of a fibroid) entering the
endometrial cavity
Conditions that necessitate special precaution during oxytocin

administration include:
• Breech presentation
• Multifetal pregnancy
• Presenting part above the pelvic inlet
• Severe hypertension
• Maternal heart disease
• Polyhydramnios
• One or more previous low-transverse cesarean deliveries
• Abnormal FHR patterns not necessitating emergent delivery
Augmentation of labor is used to stimulate uterine contractions

after labor has begun spontaneously but is not progressing
satisfactorily. It is most commonly indicated for the management of
hypotonic uterine dysfunction. Labor augmentation may be
accomplished with amniotomy, oxytocin infusion, and nipple
stimulation. Noninvasive approaches include ambulation, hydration,
relaxation, and hydrotherapy, and these methods should be
attempted before the initiation of invasive measures.
Nonpharmacological Methods for Induction of Labor

Several nonpharmacological methods have been used to induce
labor. Herbal remedies such as black haw, primrose oil, black and
blue cohosh, chamomile, and red raspberry leaves are prescribed as
labor inducers in some cultures. Technically these substances are
medicinal agents with some properties similar to those of oxytocin.
Use of these agents creates problems because of the lack of
scientific research and validation of their effectiveness. Much of the
information about how they work is anecdotal, which also makes it
difficult to evaluate the risks and the benefits, critical information for
patients and their health-care providers. Non-herbal methods such
as acupuncture have increased the rates of spontaneous delivery,
thereby reducing the need for pharmacological induction (Neri et al,
2018). Castor oil laxative has been a traditional method of induction
of labor in uncomplicated pregnancy. Although the exact method of
labor is unclear, castor oil stimulates the bowls and induces labor
(Gilad et al, 2018).
Nipple stimulation has been used for labor augmentation and
induction. The action of nipple rolling produces an increase in the
release of oxytocin from the anterior pituitary gland. The nurse
instructs the woman to roll her nipple through her clothing for 10
minutes on one side and then proceed to the other side, resting
during a contraction. A breast pump may also be used. Nipple
stimulation rarely causes uterine tachysystole. However, the results
of nipple stimulation are less predictable than the administration of
specified dosages of oxytocin. Sexual intercourse has also been
helpful as a method of induction because semen contains
prostaglandins. Both these methods require additional evidence-
based research before their endorsement as viable alternatives for
labor induction.
The nurse’s responsibilities during labor induction or augmentation
begin with obtaining informed consent for the procedure. Patient
education regarding the procedure and its consequences is critical.
Monitoring of labor is essential because uterine tachysystole may
lead to uterine rupture. Oxytocin protocols in many institutions
require a 1-to-1 nurse-to-patient ratio. The nurse must remain at the
patient’s bedside at all times for careful surveillance. The following
data should be placed on a flow sheet in the patient record:
■ Patient’s vital signs (blood pressure, pulse, and respirations every
30 to 60 minutes and with every increment in medication dose)
■ FHR (via electronic monitoring)
■ Frequency, duration, and strength of contractions (note contraction
pattern and uterine resting tone every 15 minutes and with every
increment in medication dose during first stage; then monitor every
5 minutes during second stage)
■ Cervical effacement and dilation
■ Fetal station and lie
■ Rate of oxytocin infusion
■ Intake and urine output (limit intravenous fluid intake to 1,000 mL/8
hr; output should be 120 mL or more every 4 hours)
■ Any side effects or adverse effects of the medication administration
(nausea, vomiting, headache, or hypotension)
■ Psychological response of the patient
FOCUS ON SAFETY
Recognizing and Responding to Problems During Labor Induction With
Oxytocin
Patients receiving the high-alert medication oxytocin should have a 1:1 nurse-
to-patient ratio. During induction of labor with oxytocin, the nurse remains
critically alert to signs indicative of complications such as uterine tachysystole,
especially when coupled with a nonreassuring FHR pattern, and suspected
uterine rupture. Management of tachysystole generally involves efforts to
reduce uterine activity to minimize the risk of evolving fetal hypoxemia or
acidemia. Immediate emergency measures include discontinuing the oxytocin
per institutional protocol, positioning the patient on her side, IV fluid bolus
and/or increasing the primary IV rate up to 200 mL/hr (unless there is
evidence of water intoxication—in this situation, the rate is decreased to one
that keeps the vein open), administering oxygen by face mask at 8 to 10 L/min
or per physician order or institutional protocol, and preparing to administer
tocolytic medications (e.g., terbutaline) per physician order or institutional
protocol.
The nurse needs to discuss pain relief options with the patient
before oxytocin administration. The information presented should
include prescribed medications as well as natural options. If the
woman declines pharmacological analgesia or anesthesia, the nurse
must work closely with her and her support person in the effective
use of relaxation and breathing techniques. The woman placed on
bedrest as a result of the induction needs frequent position changes.
Massage may enhance her comfort during the procedure. The nurse
should keep the patient and her support person informed of her
progress because this information reassures the patient and gives
her confidence.
ASSISTED OPERATIVE/VAGINAL DELIVERY

Forceps and vacuum extraction are used to decrease the length of
the second stage of labor when indicated because of maternal
exhaustion or epidural anesthesia, suspected fetal distress, and the
need to rotate the fetal head. In the United States, there has been a
decrease in the overall use of instrumentation as a birth assist while
there has been an increase in operative deliveries. The following
indications for operative vaginal delivery apply when the fetal head is
engaged and the cervix is fully dilated.
■ Prolonged second stage:
■ Nulliparous women: Lack of continuing progress for 3 hours with
regional anesthesia or 2 hours without regional anesthesia
■ Multiparous women: Lack of continuing progress for 2 hours with
regional anesthesia or 1 hour without regional anesthesia
■ Suspicion of immediate or potential fetal compromise
■ Shortening of the second stage for maternal benefit
Forceps-Assisted Birth
A forceps-assisted birth is one in which a steel instrument with two
curved blades is used to facilitate the birth of the infant’s head.
Forceps is an instrument consisting of cephalic-curved blades similar
to the shape of the fetal head (Fig. 8-5). The two blades slide
together at the shaft to form a handle. The first blade is inserted into
the maternal vagina next to the fetal head. The second blade is then
inserted and applied to the opposite side of the fetal head. The
shafts of the forceps are brought together in the midline and secured
to form a handle. Forceps prevent pressure from being exerted on
the fetal head and facilitate birth.
Maternal indications for a forceps-assisted birth include a need to
shorten the second stage of labor for the following reasons: dystocia,
an inability to push with contractions (e.g., because of exhaustion,
spinal or epidural anesthesia, or spinal cord injury), and to prevent
worsening of serious medical complications such as cardiac
compensation. Fetal indications include an abnormal presentation,
arrest of rotation, immaturity, and distress from a complication such
as prolapsed cord.
There are various applications and several different types of
forceps for forceps-assisted birth. Outlet forceps are used when the
fetal scalp is visible on the maternal perineum without manual
separation of the labia. Low forceps are used when the fetal head is
at a + 2 station or more. Midforceps are used when the fetal head is
engaged but at less than a + 2 station. Because birth trauma has
been associated with the use of midforceps, this procedure has been
largely replaced by cesarean birth, which poses less risk to the fetus.
Forceps are never applied to an unengaged presenting part. Piper
forceps are used to facilitate delivery of the head in a breech birth.
Some form of anesthesia is administered before forceps application
to achieve pelvic relaxation and decrease pain. An episiotomy is
usually performed to prevent perineal tearing. Before forceps
application, the following criteria must be met:
■ The cervix must be fully dilated, bladder empty, and presenting
part engaged.
■ The membranes must be ruptured.
FIGURE 8-5 Forceps are instruments with curved blades that are
used to facilitate the birth of the fetal head.
■ Cephalopelvic disproportion must not be present.

■ Informed consent must be obtained.
FHR and pattern are assessed and recorded before the forceps
application. When the forceps are applied, there is a danger of
compression of the cord between the fetal head and the forceps
blade. Cord compression causes a decrease in FHR. Therefore,
assess and record the FHR and pattern again immediately after the
forceps application.
Perineal trauma is one of the major complications associated with
the use of forceps, resulting in second and third degree tears and
episiotomy extensions (Biru et al, 2019). Hemorrhage may result
from cervical lacerations or perineal tearing, requiring close
observation during the postpartum period. To rule out maternal
bladder injury, the nurse documents the time and amount of the first
postbirth voiding. Some women have reported fecal incontinence
following forceps injury. Women who experience forceps-related
problems may suffer fear and anxiety regarding the birth experience
in subsequent pregnancies.
Vacuum-Assisted Birth
Vacuum-assisted birth, also termed vacuum extraction, is an
alternative method used in an assisted vaginal delivery. The vacuum
extractor consists of a soft plastic cup that is attached to the fetal
head over the posterior fontanelle and a suction apparatus that uses
negative pressure to facilitate the birth of the head (Fig. 8-6). This
procedure is used for a patient whose labor has completely stalled,
has an arrest of labor, cannot push effectively, or needs expedited or
emergency labor because of fetal distress. The same conditions
apply to the use of the vacuum as for forceps: vertex presentation,
ruptured membranes, and absence of CPD. Vacuum-assisted birth
has certain advantages over forceps-assisted birth: little anesthesia
is required (the fetus is less depressed at birth), and it is associated
with fewer lacerations of the maternal birth canal. Vacuum extraction
should not be used following fetal scalp blood sampling. The suction
pressure can cause excessive bleeding at the sampling site. It is
also not recommended for preterm fetuses whose skulls are
extremely soft.
To prepare the patient for a vacuum-assisted birth, the nurse
provides education and support and encourages the woman’s
continued participation in childbirth by pushing during contractions.
The FHR and pattern are assessed before and throughout the
procedure. The nurse assists the woman to a lithotomy position to
allow sufficient traction. The primary care provider applies the cup to
the fetal head, and a caput (swelling of the soft tissue) develops
inside the cup as the pressure is initiated (Fig. 8-7). Gentle traction is
applied to facilitate descent of the fetal head. An episiotomy may be
performed as the head crowns.
The nurse is responsible for patient education and support during
a vacuum-assisted procedure. The perinatal team must
communicate frequently during the procedure as they each assess
progress or the lack of progress. The nurse, following protocols, can
advocate for cesarean birth if maternal exhaustion and/or failure of
descent indicates that the vacuum assistance is not effective. If the
nurse fails to communicate concerns and there is an untoward event,
the nurse can be held liable. Liability is also incurred if the nurse fails
to document a detailed sequence of events (e.g., number of
applications, number of pulls, occurrence of pop-offs, and maximum
amount of suction applied) during the vacuum assistance along with
the maternal-fetal response. After an assisted birth, the nurse who
assesses the neonate is also liable with regard to the documentation
of vital signs and the neonatal assessment.
FIGURE 8-6 Vacuum device.

FIGURE 8-7 A, Vacuum extractor is applied with a downward and
outward traction. B, A caput succedaneum, or chignon, is formed
from the suction cup.
MATERNAL CONDITIONS THAT COMPLICATE

CHILDBIRTH
Management of hypertensive disorders during parturition is based on
two goals: preventing further deterioration of affected organs and
fostering a positive maternal-infant outcome. Women who have been
diagnosed with severe preeclampsia or HELLP syndrome
(Hemolysis, Elevated Liver enzymes, and Low Platelets) may be
placed in an obstetric critical care unit or a medical intensive care
unit for hemodynamic monitoring. Maternal vital signs, FHR, urine
output, deep tendon reflexes, level of edema, and mental orientation
and neurological status are assessed. Maternal-fetal factors that
may necessitate immediate interventions to facilitate birth are
presented in Box 8-2.
The nurse manages the care for the woman with preeclampsia
during the intrapartal period. Careful assessments are critical. The
nurse plans and evaluates all interventions on a continuous basis.
The patient with severe pre-eclampsia is in an extremely fragile
condition. Any change in condition may require an emergency
intervention, and the nurse must be prepared to provide the
necessary care immediately. The nurse is responsible for the
continuous monitoring of several key parameters (Box 8-3).
Labs
Pre-eclampsia Labs
Monitoring laboratory results is a key aspect of care for the pre-eclampsia
patient, as worsening labs can indicate the severity of disease that may
require immediate intervention. The following labs are done for suspected and
known patients with pre-eclampsia. While in the hospital they may have
repeated blood work every day or every 12 hours or sooner in cases that
require close and frequent monitoring.
• Complete blood count (CBC) with platelets
• Coagulation profile to assess for disseminated intravascular coagulation
(DIC)
• Metabolic studies for determination of liver enzymes (aspartate
aminotransferase [AST], alanine aminotransferase [ALT], and lactate
dehydrogenase [LDH]) and bilirubin
• Uric acid to assess kidney functioning
• Electrolyte studies to establish renal function
• 24-hour urine test for protein and creatinine
The nurse must also monitor the laboratory values for impending HELLP
syndrome during labor. The nurse follows the plan of care for the patient with
severe pre-eclampsia.
Cardiac Disease
Recent years have shown a decline in the traditional causes of
maternal death (hemorrhage, hypertension, and pulmonary
embolism) but an ominous increase in cardiac-related deaths. Heart
disease now complicates an estimated 1% to 4% of pregnancies and
is the leading cause of indirect maternal deaths. This trend is most
likely related to several factors: the dramatic improvement in survival
of young girls who were born with congenital heart disease and are
now of reproductive age; advanced maternal age (older than 40);
and associated health risks such as diabetes, hypertension, and
obesity (Elkayam et al, 2016).
BOX 8-2
Factors That May Necessitate Immediate

Intervention to Facilitate Birth in Patients With
• Uncontrolled severe hypertension
• Eclampsia
• Persistent oliguria (greater than 500 mL/24 hr)
• Abruptio placentae
• Platelet count less than 100,000/mm3
• Elevated liver enzyme levels with epigastric pain or right upper quadrant
tenderness
• Pulmonary edema
• Persistent severe headache or visual changes
• Spontaneous labor
• Fetal death
• Rupture of the membranes
• Gestational age less than 34 weeks (an observational period may be initially
attempted as a conservative management approach)
• Evidence of fetal compromise
The physiological demands that accompany normal intrapartum

events make this an especially critical time for patients with cardiac
disease. During labor, pain and anxiety combined with uterine
contractions result in further increases in maternal heart rate, stroke
volume, cardiac output, and blood pressure. Due to the risk of vena
cava compression and decreased venous return from the weight of
the gravid uterus, nurses should avoid placing the patient in a supine
position for procedures such as cervical examinations or bladder
catheterization. Increased hemodynamic and oxidative cardiac
stress occur during the second stage of labor, and the 500 mL
maternal auto-transfusion that occurs after delivery of the placenta
may not be tolerated (Elkayam et al, 2016). As a result, the patient’s
fluid balance must be closely monitored during the immediate
postpartum period, which frequently is a time of acute
decompensation.
Diabetes Mellitus
Women with the metabolic disorder of diabetes mellitus that is under
control may safely give birth spontaneously at term provided there
are no indications of severe cephalopelvic disproportion (CPD).
When a possibility of CPD exists, the diabetic woman may be given
a TOL. The physician may also plan an elective induction of labor
between 38 and 40 weeks of gestation.
Intrapartum management for the woman with pregestational
diabetes centers on the close surveillance of maternal hydration and
blood glucose levels to prevent complications associated with
dehydration, hypoglycemia, and hyperglycemia. An intravenous
infusion of a maintenance fluid such as lactated Ringer’s solution or
5% dextrose in lactated Ringer’s solution may be ordered. Insulin is
usually administered by continuous infusion; only regular insulin may
be administered intravenously. In some situations, patients who use
continuous subcutaneous insulin infusion (insulin pump) are closely
monitored and allowed to continue the therapy throughout labor and
birth. Blood glucose levels are assessed every hour and fluid/insulin
adjustments are made as needed to maintain maternal blood
glucose levels between 80 and 120 mg/dL. It is essential that
maternal hyperglycemia during the intrapartal period be avoided to
prevent neonatal metabolic problems such as hypoglycemia.
PROCEDURE ■ Checking for Patellar Deep
Tendon Reflexes and Clonus
PURPOSE
Checking for deep tendon reflexes is part of the assessment for pre-eclampsia.
Hyperactive reflex is indicative of pre-eclampsia.
EQUIPMENT
• Reflex Hammer
STEPS
and cooperation.
2. Assemble necessary equipment including clean gloves.
3. Position the patient in a seated position with knees freely dangling off the
edge.
RATIONALE: The tendon you are assessing needs to be in a flexed and
neutral position and able to freely move so that it is not artificially stopped
from moving when you assess the tendon so that you can obtain an
accurate reflex.
4. Instruct the patient to hold hands together and pull against each hand while
looking straight ahead.
RATIONALE: For a reflex to be assessed, the patient needs to be relaxed.
Having the patent hold their hands together and pull against each hand
enables a distraction and causes relaxation of the patent’s counter muscles
and allows the health-care provider to elicit reflex.
5. Locate the patella tendon, located below the patella bone.
6. Tap the patella tendon directly with the pointed end of the reflex hammer.
7. Assess for the reaction of the reflex.
8. Perform the assessment on the other extremity and note any differences in
symmetry.
9. Document findings.
• 0 indicates absent reflex
• 1 + indicates slight response but diminished
• 2 + indicates normal response
• 3 + indicates brisk or exaggerate response
• 4 + indicates abnormal response, and repetitive tapping response indicates
clonus
When severe pre-eclampsia is diagnosed at less than 34 weeks’ gestation,
the approach to care may include an observational period and conservative
management. If the gestational age is 32 to 35 weeks, induction of labor is
usually initiated. Vaginal birth is considered safer than cesarean birth and is
attempted if cervical favorability is present. Antenatal glucocorticoids such as
betamethasone may be given (12 mg IM 24 hours apart) to promote lung
maturity if the gestational age is less than 34 weeks and delivery can be
delayed for 48 hours.
BOX 8-3
Intrapartal Nursing Care for Patients With Pre-

eclampsia
BLOOD PRESSURE
The blood pressure is taken every 4 hours or more frequently according to
physician orders or institutional protocol. Blood pressure should be taken in the
same arm at each assessment. Encourage the patient to assume a side-lying
position to enhance uterine perfusion. Record the data. Notify the health-care
provider of an increase in blood pressure.
WEIGHT
Daily weights need to be performed to assess fluid retention.
MEDICATION ADMINISTRATION
Administer medication as ordered and evaluate its effect. Adhere to hospital
protocol for magnesium sulfate infusion. Magnesium sulfate infusions require
close monitoring of maternal vital signs, FHR and pattern, urine output, deep
tendon reflexes (DTRs), IV flow rate, and serum magnesium levels to assess
for magnesium sulfate toxicity (e.g., depressed respirations, hyporeflexia,
sudden onset of hypotension, oliguria, and indicators of fetal compromise).
Administer calcium gluconate (the antidote for magnesium sulfate toxicity) for
respirations below 12 breaths/min and discontinue the magnesium sulfate
infusion.
RENAL BALANCE
Edema is rated on a scale of 1 to 4. A score of 4 is generalized massive edema
that includes the face, abdomen, and sacrum. Assess and record urinary
output. An indwelling urinary catheter may be inserted to more accurately
measure urinary output. A urine output less than 30 mL/hr is indicative of
oliguria, and the physician must be notified. A dipstick measurement is
performed every 4 hours or more frequently to assess urinary protein on a
scale of 1–4. A dipstick reading over 2 + is indicative of a worsening condition.
NEUROLOGICAL STATUS
DTRs are assessed every 4 hours (or more frequently) and rated on a scale of
1 to 4. Reflexes greater than 2 + signify worsening status. If dorsiflexion of the
foot produces clonus (convulsive spasm), this finding provides an additional
indication of a deteriorating maternal condition. Assessment of headache,
visual disturbances, and altered sensorium can be indicated of worsening
conditions.
PULMONARY STATUS
Auscultation of the lungs is performed every 4 hours (or more frequently) to
assess for dyspnea, crackles, and diminished breath sounds, which may be
indicative of pulmonary edema. Patients who are receiving magnesium sulfate
require more frequent respiratory assessments because a respiratory rate
below 12 is an indicator of magnesium toxicity.
ADVANCING SYMPTOMS
Headaches, blurred vision, severe right upper quadrant epigastric pain, and
restlessness are all indicators of impending eclampsia. Prepare for immediate
delivery.
SEIZURES
Protect the patient. Keep the airway patent; turn head to one side and place a
pillow or folded linen under one shoulder or back. Call for assistance. Ensure
that the side rails have been raised. Observe and document all seizure activity.
Notify the physician and prepare for delivery. Administer oxygen.
FETAL STATUS
Monitor the FHR and pattern every 4 hours or more frequently as indicated.
Assess fetal movements. Notify the physician if indicators of fetal compromise
are noted.
The laboring patient is maintained in an upright or side-lying

position with continuous FHR monitoring. Nursing care involves
close surveillance for indicators of normal labor progression along
with a stable maternal-fetal unit. Failure to progress may be related
to fetal macrosomia or CPD and necessitate a cesarean birth.
Diabetes-related complications such as hyperglycemia, ketosis, and
ketoacidosis may develop and must be promptly managed. Shoulder
dystocia associated with fetal macrosomia may complicate the
second stage of labor. A team that consists of the obstetrician and
neonatologist, pediatrician, or neonatal nurse practitioner should
attend the birth to provide immediate neonatal assessment and care.
When a cesarean birth has been planned, the surgery is
scheduled for the early morning to achieve optimal glycemic control.
Depending on physician orders, the nurse may be instructed to
withhold the morning insulin. Other protocols allow administration of
an intermediate-acting insulin in the morning and every 8 hours until
surgery. The patient is allowed nothing by mouth. Epidural
anesthesia is preferred because hypoglycemia can be detected
earlier if the woman remains awake. After the surgery, maternal
blood glucose levels are assessed at least every 2 hours; target
plasma levels are between 80 and 160 mg/dL.
The first 24 hours postpartum are remarkable for the dramatic
decrease in insulin requirements that occurs after removal of the
placenta. Depending on the amount of food consumed, women with
type 1 diabetes may require only one-fourth to one-third of the
prenatal insulin dose. Some women may not require insulin for 24 to
72 hours postpartum. Throughout the postpartal period, blood
glucose levels continue to be monitored, and insulin dosage
adjustments are made as needed, often using a sliding scale.
Women whose pregnancies have been complicated by diabetes
have an increased risk for complications such as pre-
eclampsia/eclampsia, hemorrhage, and infection (e.g., endometritis)
during the postpartal period. Hemorrhage is more likely if the uterus
was overdistended because of fetal macrosomia or hydramnios.
The nurse should encourage mothers with pregestational and
gestational diabetes to breastfeed. However, because glucose levels
are lower, especially during early postpartum, breastfeeding women
are at an increased risk for hypoglycemia. Also, the mother with poor
metabolic control may have a delay in lactogenesis that results in
decreased milk production.
Discharge planning for women with diabetes should include
discussion about contraceptive information as appropriate. Because
women with gestational diabetes are at increased risk for developing
diabetes later in life, the nurse should counsel them about the
importance of maintaining a healthy weight and undergoing glucose
testing during routine health maintenance visits.
Preterm Labor and Birth

Preterm labor (PTL) occurs after 20 weeks’ gestational age and
before 37 weeks’ gestational age (American College of Obstetricians
and Gynecologists [ACOG], 2016). In the United States, preterm
birth has increased over the last decade despite the use of
preventive pharmacological therapies. Approximately 12% of all live
births are preterm and result in the highest cause of infant morbidity
and mortality (Sommers, 2019).
The causes for preterm birth are often a series of overlapping
conditions such as premature ROM combined with cervical
insufficiency. Other conditions that increase the risk for PTL include
placenta previa or abruption, distended uterus, maternal infection,
abdominal surgery during pregnancy, multiple gestation, fetal
anomalies, and behavioral factors such as smoking, alcohol, and
drug use during pregnancy. Maternal medical history of previous PTL
can also predispose the mother to have subsequent PTL (Sommers,
2019).
Signs of PTL include:
■ Contractions that may be painful or painless
■ Lower back pain
■ GI upset, cramping, or diarrhea
■ Pelvic pressure or fullness
■ Vaginal discharge/bloody show
■ Vaginal discomfort pressure
Key treatment for PTL includes delaying birth until term or long
enough so that the fetal lungs are mature. Initial interventions,
including bedrest, hydration, and tocolytic therapy (for up to 48 hours
to allow for administration of antenatal steroids), are used to inhibit
contractions (Table 8-3). Tocolytics are recommended for short
duration use for up to 48 hours in efforts to prolong the pregnancy to
enable a dose of steroids (ACOG, 2016).
In many situations, if the woman’s membranes have ruptured or if
the cervix is greater than 50% effaced and 3 to 4 cm dilated, it is
unlikely that the labor can be stopped. If the fetus is very immature
and birth is deemed to be inevitable, a cesarean birth may be
planned to reduce pressure on the fetal head and decrease the
possibility of a subdural or intraventricular hemorrhage.
Labs
Diagnosing the Risk of Preterm Delivery
Laboratory and diagnostic tests are performed to determine the possibility of
delivering early:
• Fetal fibronectin: Vaginal swab to detect the presence of the protein
fibronectin, which is found before delivery. If detected at 22-34 weeks,
fibronectin may indicate preterm delivery.
• Transvaginal ultrasound: Performed to assess cervical effacement. Less than
25 mm effacement or evidence of funnel increase the risk of preterm
delivery.
TABLE 8-3
Medications for Preterm Labor
MEDICATION DOSAGE DESCRIPTION SIDE
EFFECTS/NURSING
CONSIDERATIONS
Nifedipine 30-mg loading Calcium channel Maternal flushing,
dose; 10-30 mg blocker, inhibits peripheral edema,
every 4–6 hrs calcium into the dizziness,
smooth muscle headaches, and
thereby inhibiting nausea.
contractions Lowers blood
pressure so there is
a need to monitor
blood pressure
frequently. Patients
may develop
orthostatic
hypertension, and
patients need to
slowly change
positions. Should not
be given with
magnesium sulfate or
immediately after
terbutaline.
Indomethacin 100 mg PR, then Nonsteroidal anti- Maternal dizziness,

PO every 6–8 hrs inflammatory drug drowsiness,
that reduces headaches, psychic
prostaglandins, disturbances, GI
which then reduces upset. Caution in
contractions. patients with history
of asthma and aspirin
induced allergy,
which can increase
the risk of developing
reactions.
Magnesium Sulfate 4–6 g IV loading Central nervous Assess for

dose, 1–4g/hr for system depressant; magnesium toxicity:
IV maintenance decreases depression of DTR,
contractions of decrease in
smooth muscles. respirations, blood
pressure, and/or
urinary output,
cardiac arrhythmias,
muscle weakness,
flushing, and
hypothermia.
Observe for
respiratory distress
and pulmonary
edema.
Terbutaline 2.5 mch/min, Beta-adrenergic; Maternal

increase to max of relaxes smooth restlessness,
20 mcg/min or 0.25 muscles, inhibiting nervousness, tremor,
mg sc every 20 uterine headaches, angina,
min X 3, then Q 3 contractions. hypertension,
hours. nausea, vomiting,
hypokalemia.
Betamethasone 12 mg IM every 24 Given if delivery is

hours X 2 Doses or anticipated to
6 mg IM every 6 expedite fetal lung
hours maturity and
surfactant
production.
Sources: American College of Obstetricians and Gynecologists (2016); Vallerand

(2021).
In addition to careful maternal monitoring, FHR monitoring is one of
the most important nursing responsibilities when caring for a patient
in PTL. A number of perinatal complications such as pre-eclampsia,
intra-amniotic infection, oligohydramnios, umbilical cord
compression, placental abruption, intrauterine growth restriction,
uteroplacental insufficiency, and multiple gestation occur more often
with PTL. This combination of complications may result in FHR
patterns that differ from the norm. Due to the increased incidence of
neurological deficits in premature infants, it is essential that the
nurse be able to identify and report data suggestive of hypoxia as
early as possible.
Optimizing Outcomes
Providing Pain Relief During Preterm Labor and Birth

The length of the first stage of labor for a woman who is preterm is essentially
the same as for a woman with a full-term gestation, although the second stage
may be shorter since the smaller fetal size can be pushed through the dilated
cervix more easily. Maternal analgesia is used cautiously because of the
immaturity of the fetus, who may have considerable difficulty breathing without
the additional burden of sedative effects from maternal analgesic agents. If the
patient desires analgesia, the nurse can explain why epidural pain relief is most
likely preferable. An episiotomy is often performed at the time of birth to lessen
trauma on the fragile fetal head; forceps may also be used.
Because of the patient’s medical complications and related fetal

issues, she and her support person often experience increased
anxiety and fear during the labor and birth. The nurse is there to offer
clinical expertise; provide a calming presence; and inform, support,
and assist the patient and her partner throughout the birth
experience. A careful assessment of the patient’s psychological
status can help direct the care. Expressions of caring coupled with
dialog that includes specific questions help to identify the patient’s
main concerns.
COMPLICATIONS OF LABOR AND BIRTH

ASSOCIATED WITH THE FETUS
Fetal Malpresentation
Malpresentations are all presentations of the fetus other than vertex.
Fetal malpresentation is the second most commonly reported
complication of labor and birth. The fetal occiput is the most
favorable presenting part for a vaginal birth, and in most situations,
the fetal head engages in the occipital-anterior position. Face, brow,
shoulder, compound, and breech constitute malpresentations. A
breech presentation in which the buttocks or legs present first occurs
in approximately 3% of all births and is considered the most common
malpresentation. It is important that these conditions be identified
during the antepartum period because a malpresentation may place
the woman and fetus at risk for complications during labor and birth.
Diagnosis is made by abdominal palpation (i.e., Leopold maneuvers)
and vaginal examination and is usually confirmed by
ultrasonography.
During labor, descent of the fetus in a breech presentation may be
slow (Fig. 8-8). This is because the breech is not as effective as a
dilating wedge as the fetal head. There is an increased risk of
prolapsed cord if the membranes rupture during early labor.
NURSING INSIGHT
Breech Presentation and Meconium in the Amniotic Fluid
When the fetus is in a breech presentation, the presence of meconium in the
amniotic fluid may not be indicative of fetal distress. Pressure exerted on the
fetal abdomen during the birth process may cause the passage of meconium. It
is important to assess the FHR and pattern to ensure there are changes
indicative of fetal hypoxia. When the fetus is in a breech position, the FHR is
best auscultated at or above the maternal umbilicus.
During the vaginal birth of a fetus in a breech presentation, the

physician uses labor mechanisms that manipulate the buttocks and
lower extremities. Piper forceps are sometimes applied to facilitate
delivery of the head. Before the birth, the physician may attempt an
external cephalic version (ECV) to rotate the fetus to a vertex
presentation. Cesarean birth is commonly performed when the
following circumstances exist: The fetus is estimated to be larger
than 3,800 g or smaller than 1,500 g, the labor is ineffective, this is
the woman’s first pregnancy, or there are additional maternal-fetal
complications.
Face and brow presentations are examples of asynclitism (the
fetal head is presenting at a different angle than expected). Face and
brow presentations hyperextend the neck and increase the overall
circumference of the presenting part. These presentations are
uncommon and usually associated with fetal anomalies (e.g.,
anencephaly), macrosomia, CPD, and contractures of the maternal
pelvis. Vaginal birth may be accomplished if the fetus flexes to a
vertex presentation. Forceps are often used. Cesarean birth is
indicated if the presentation persists, if there is evidence of fetal
compromise, or if there is an arrest in the progression of labor.
Shoulder and compound presentations (e.g., a hand combined with
the head) contribute to fetal and vaginal trauma and usually require
cesarean birth.
Version
Version (turning of a fetus from one presentation to another) may be
done either externally or internally by the physician.
FIGURE 8-8 The mechanisms of labor in a breech presentation—the
aftercoming fetal head delivers last.
EXTERNAL CEPHALIC VERSION
An ECV is used as an attempt to turn the fetus from a breech
presentation to a vertex presentation to allow a vaginal birth (Fig. 8-
9). Because cesarean birth is a major surgical procedure associated
with numerous maternal and fetal risks, ECV may offer an alternative
to surgery. The procedure, performed in a birth unit, may be
attempted after 37 weeks of gestation. Contraindications to ECV
include previous cesarean birth, uterine anomalies, CPD, placenta
previa/abruption, multifetal gestation, oligohydramnios,
nonreassuring fetal monitoring, and significant fetal or uterine
anomalies. Risk of ECV includes placental abruption/hemorrhage,
umbilical cord prolapse, ROM, stillbirth, and fetomaternal
hemorrhage (ACOG Committee on Practice Bulletins-Obstetrics,
2016).
Before the version, informed consent should be completed and
include benefits and risk of the procedure. An ultrasonography is
obtained to confirm the fetal position; locate the umbilical cord; rule
out placenta previa/abruption; and assess the maternal pelvic
dimensions and the amniotic fluid volume, fetal size and gestational
age, and the presence of anomalies. Before the version, a nonstress
test (NST) is performed to confirm fetal well-being, or the FHR and
pattern may be electronically monitored for a brief period (e.g., 10–
20 minutes). Some experts have proposed the use of regional
anesthesia, which relaxes the maternal abdominal wall and improves
maternal tolerance of the procedure, to enhance the success of
ECV. Ultrasound guidance is used as the physician slowly applies
gentle, steady pressure over the fetal head and buttocks to rotate the
position.
The procedure of rotating the fetus (version) requires uterine
relaxation. Tocolytic agents such as magnesium sulfate or terbutaline
are used to facilitate this process.
Optimizing Outcomes
Assisting With ECV

The nurse is responsible for obtaining written informed consent from the patient
after physician explanation, providing teaching regarding the procedure,
administering medications as ordered, and conducting constant surveillance of
the maternal-infant dyad. The patient needs to know not only that the version
attempt might not be successful but also be aware of the associated
complications that may occur such as ROM, fetal bradycardia, and discomfort.
During the version, if there is any indication of significant fetal or maternal
compromise, the nurse prepares the woman for a cesarean birth. Women who
are Rh(D)-negative are given Rho(D) immune globulin because the
manipulation may cause fetomaternal bleeding (ACOG Committee on Practice
Bulletins-Obstetrics, 2016).
INTERNAL VERSION
With internal version, the physician rotates the fetus by inserting a
hand into the uterus and changes the fetal presentation to cephalic
(head) or podalic (foot). Internal version is used with multifetal
gestations to deliver the second fetus. However, the safety of this
procedure has not been documented. Cesarean birth is usually
performed for malpresentation in multiple gestations. Nursing
responsibilities center on maternal-fetal monitoring and providing
support to the woman.
Shoulder Dystocia
Shoulder dystocia is an uncommon obstetric emergency that occurs
in 0.2% to 3.0% of all births. It occurs when the fetal head is born,
but the anterior shoulder cannot pass under the maternal pubic arch
and becomes stuck. The problem is often not identified until the head
is born. Risk factors for shoulder dystocia include maternal pelvic
abnormalities or CPD, a history of shoulder dystocia in a previous
pregnancy, obesity, excessive weight gain, diabetes, prolonged
labor, precipitous labor, instrument delivery, arrest of dilation,
postdate pregnancy, and fetal macrosomia (greater than 4,000 g)
(Borhart & Voss, 2019; Hill & Cohen, 2016; Menticoglou, 2018).
FIGURE 8-9 External cephalic version is a maneuver performed
through the maternal abdominal wall in an attempt to change the
fetal position from a breech to a cephalic presentation.
Although there are no methods to predict or prevent shoulder

dystocia, the nurse should be alert to clinical indicators: slowed labor
progression and formation of a caput succedaneum that increases in
size. When the fetal head emerges on the perineum (crowning), it
retracts instead of protruding with subsequent contractions (termed
the turtle sign), and external rotation does not occur. Fetal/neonatal
injuries are related to birth asphyxia, damage to the brachial plexus
(e.g., Duchenne-Erb paralysis or Klumpke’s paralysis), and fractures,
usually of the humerus or clavicle. Maternal injury is most commonly
associated with excessive blood loss that results from uterine atony
or rupture; other risks include lacerations, extension of the
episiotomy, rectovaginal fistula, symphyseal separation, and
postpartum endometritis. Shoulder dystocia is an emergency that
requires a team effort. Once the nurse suspects shoulder dystocia,
he or she must summon help to assist with the different maneuvers
to deliver the infant.
A number of maneuvers may be attempted to free up the anterior
shoulder and facilitate delivery. The McRoberts maneuver is often
the first maneuver after a diagnosis of shoulder dystocia is made.
The woman is placed in a dorsal lithotomy position, and her thighs
are sharply flexed on her abdomen. This position increases the
angle between the symphysis pubis and the sacral promontory,
allowing for greater room in fetal descent (Hill & Cohen, 2016;
Menticoglou, 2018). Suprapubic pressure applied immediately above
the symphysis pubis may be needed along with the McRoberts
maneuver to loosen the trapped shoulders (Fig. 8-10). When this
maneuver is unsuccessful, the health-care provider performs a
Zavanelli maneuver, attempting to place the head back into the
uterus and perform an emergent cesarean section (Venes, 2021).
Other methods of delivery assistance for shoulder dystocia center
on maternal positional changes: a hands-and-knees position, a
squatting position, or a lateral recumbent position. The use of fundal
pressure is contraindicated in shoulder dystocia. In other cases, the
Woods maneuver or corkscrew maneuver can be performed. This is
a rotational maneuver in which the health-care provider attempts to
rotate the posterior shoulder into the anterior position, the anterior
shoulder into the posterior position, the infant rotates 180 degrees,
and then delivery is attempted (Hill & Cohen, 2016; Menticoglou,
2018).
Cephalopelvic Disproportion
Although there are true problems that create issues between the
head of the fetus and the pelvis of the mother, in the United States,
CPD (sometimes termed fetopelvic disproportion) is often used to
describe unsuccessful attempts at vaginal birth. When CPD is
present, the fetus cannot fit through the maternal pelvis to allow a
vaginal birth. CPD is often related to excessive fetal size
(macrosomia), a condition that may be associated with maternal
diabetes mellitus, obesity, and multiparity. A macrosomic infant (birth
weight greater than 4,000 g) is likely to have a large head that can
prevent descent into the mother’s pelvis.
Despite ultrasound evaluation, it is difficult to predict the safest
mode of birth for the macrosomic infant. A TOL is suggested if the
woman is nulliparous. Women with a previous history of cesarean
birth for CPD may also be offered a TOL, although a prompt
cesarean birth is recommended at the earliest sign of maternal or
fetal compromise.
FIGURE 8-10 Methods to relieve shoulder dystocia. A, Pressure is

applied immediately above the maternal symphysis pubis to push the
fetal anterior shoulder downward. B, McRoberts maneuver: The
woman’s thighs are sharply flexed on her abdomen to straighten the
pelvic curve. C, Angle of pelvis before maneuver. D, Angle of pelvis
after maneuver.
The maternal pelvis is assessed before the onset of labor to

determine type and size. A gynecoid pelvis is considered the most
common female pelvic type and most amenable to vaginal birth,
although markedly small dimensions may preclude a vaginal birth.
Other pelvic types are the android, anthropoid, and platypelloid.
Although the other types of pelvises may not contraindicate a TOL,
vaginal birth may not be possible for the woman with a platypelloid
pelvis because its markedly shortened anterior-posterior diameter
prevents fetal descent (Cunningham et al, 2014).
Nursing Care
A thorough nursing assessment including a review of present and
past pregnancies is important in guiding care. Women with a history
of CPD are at increased risk during the present labor. Slow
progression of effacement and dilation, lack of fetal descent, and
excessive pain are all possible indicators of CPD. Nursing
interventions such as maternal position changes, particularly to an
upright posture (e.g., sitting or squatting) to widen the pelvic girdle,
relaxation, and water therapy are strategies to facilitate labor
progression. The use of analgesic agents may alleviate pain-creating
tension that is interfering with fetal descent. Supportive care includes
information related to labor status and encouragement when
progress has been made.
Multiple Gestation
Managing the births of more than one fetus is complex and requires
the expert collaboration of medical and nursing personnel. The
gestational age, number, health, and presentation of the fetuses
determine the mode of birth, whether vaginal or cesarean.
Multiple births are associated with more complications than
singleton births. The woman’s health status may be compromised by
problems such as gestational hypertension, pregnancy, anemia, or
gestational diabetes. She is also at increased risk for hemorrhage
related to atony from uterine overdistention, abruptio placentae, and
multiple or adherent placenta. With multiple pregnancies, the vast
majority of women (60% to 100%) will have spontaneous labor
before 37 weeks’ gestation (National Institute for Health and Care
Excellence, 2019). Abnormal fetal presentation often occurs with
multiple fetuses. Increased fetal/newborn complications are related
primarily to problems associated with low-birth-weight infants
because of preterm birth and intrauterine growth restriction.
Intrapartal fetal distress may result from cord prolapse and the onset
of placental separation after the birth of the first fetus. This leads to a
greater risk of cerebral palsy and other birth-related injuries with
multiple births.
Women who present at 38 weeks with a twin pregnancy are less
likely to experience fetal morbidity and mortality than women with
higher-order multiples and may be appropriate candidates for a
vaginal birth. It is recommended, although not always possible, that
women with a multiple gestation, particularly triplets or higher-order
multiples, deliver at a tertiary care center where facilities have a
neonatal intensive care unit and are available in the event of an
emergency. Birthing centers must have transport ready for infant
transfer to neonatal intensive care units. Patients who will undergo
labor or a TOL require careful monitoring. Ultrasound is used to
determine position and presentation of the fetal parts. Electronic fetal
monitoring (EFM) is applied. It is important to identify each of the
individual FHRs, and the use of a separate monitor for each fetus is
preferable. Interventions, such as analgesia, anesthesia, and
intravenous infusions, are determined on a case-by-case basis. For
many women, an epidural for pain management is recommended
both to provide pain control during the delivery and allow for quicker
outcomes if the second infant needs an external version or an
emergency c-section. The stimulation of labor with oxytocin and
epidural anesthesia, forceps, vacuum assistance, and fetal version
may all be used to facilitate the vaginal birth of twins. Women in
good health and with no evidence of fetal distress should be given
the opportunity to participate in medical decision management.
When the woman is fully dilated and ready to push, she is moved
to the birthing suite or the operating suite, where personnel,
equipment, and supplies are readily available in the event there is a
need for a cesarean birth. The woman may safely give birth in a
labor, delivery, recovery, postpartum (LDRP) suite provided there is
quick access to the surgical area. The nurse prepares the woman
and her support for the possibility that she may experience both a
vaginal and a cesarean birth depending on the fetal presentation.
The nurse also explains the external version procedure in case this
intervention is necessary.
Most vertex twins are delivered with success vaginally. The first
infant born is identified as “A” and neonatal care is initiated. In some
settings, each infant has its own team of neonatal care providers
present at the birth. In the vertex breech presentation, an external
version of the second twin is attempted provided that the conditions
are favorable. If the second fetus is a footling breech, has a
hyperextended head, or exhibits signs of compromise, a cesarean
birth is considered the better option. The birth of the second twin
normally occurs within 15 minutes of the birth of the first twin and is
identified as twin “B” (Cheng et al, 2017). The nurse documents the
time of birth for the first infant and all subsequent infants.
For patients who choose midwifery care, twin pregnancy often
requires collaboration with an obstetrician, especially in cases with
additional risk factors. The midwife may be able to manage prenatal
care and the deliveries, but because this is a high-risk pregnancy,
complications can still result. Having a collaborative practice with an
obstetrician typically results in the patient receiving care from both
providers with an understanding that care may be transferred to the
obstetrician in cases if significant complications arise, such as the
need for an external version or c-section. Triplets and higher-order
multiples generally require a cesarean birth. The vast majority of
women with triplets or higher multiples will go into spontaneous labor
before 35 weeks, and a planned c-section for 35 weeks is
recommended (National Institute for Health and Care Excellence,
2019). This mode of birth decreases the risk that the second fetus
will experience anoxia as well as other complications such as cord
entanglement and premature placental separation. While there are
reports of triplet vaginal births, these successes are tempered with
the strong possibility that both the second and third neonates may be
in breech presentations and require operative interventions.
Nonreassuring FHR Patterns

Fetal heart monitoring is one type of assessment that provides the
nurse, the patient, and her support(s) feedback concerning the well-
being of the fetus. Families often request to increase the volume of
the fetal monitor so that they hear the reassurance of a strong
heartbeat. It is essential that the nurse understand actions that
should be taken when decelerations or other ominous FHR patterns
are detected.
Depending on the situation, watchful waiting with continuous
monitoring conducted by the nurse may provide the best option for
assessment of fetal well-being. Because nonreassuring FHR
patterns constitute a risk indicator for cesarean birth, the nurse and
all members of the health-care team must always be ready for this
outcome. It is important to provide ongoing support for the laboring
woman and keep her informed of her labor progress and fetal status.
What to Say
When a Nonreassuring FHR Pattern Is Detected
When electronic monitoring reveals a nonreassuring FHR pattern, the nurse
needs to maintain a calming presence and offer factual, simple explanations for
all actions. For example, the nurse may say:
“We are concerned about your baby’s heart rate pattern.”
“I am going to change your position to your side to increase oxygen flow to
your baby.”
“I am also going to place this oxygen mask on your face to increase the
oxygen flow to you and to your baby and increase your IV rate.”
“Do you have any questions?”
“I am here to help in any way, and I will stay here with you. Please let me
know what concerns you have.”
Nuchal Cord
Nuchal cord (a cord that is wrapped around the infant’s neck) and
cords with true knots are observed in approximately 10% to 29% of
births (Peesay, 2017). Nuchal cord, which rarely causes hypoxia,
occurs most often in fetuses with long umbilical cords and occur
more frequently with advancing gestational age. When a tight knot is
present in the cord, variable heart rate decelerations associated with
fetal asphyxia may be noted on EFM. Nursing interventions follow
protocols used for other abnormal variations of the fetal heart
tracing. Tight nuchal cords can compromise fetal circulation,
resulting in adverse outcomes such as asphyxia, facial petechial,
subconjunctival hemorrhage, facial duskiness, markings around the
neck, and anemia (Peesay, 2017).
Once the head is born, gentle palpation is used to feel for the cord.
If the cord is present, it is loosened and carefully slipped over the
head. If it is too tightly coiled to allow this intervention, the cord is
clamped twice, cut between the clamps, and unwound from around
the neck before the shoulders are delivered. Otherwise, the cord
could tear and interfere with the fetal oxygen supply.
Diagnostic Tools
Nuchal Cord Diagnosis
Diagnosis of a nuchal cord is done by ultrasound. Use of ultrasound and color
Doppler diagnose a nuchal cord by the presence of a circular indentation of the
fetal nuchal skin. Diagnosis of nuchal cord warrants close fetal heart monitoring
and helps to decrease morbidity and mortality associated with nuchal cord
(Peesay, 2017).
AMNIOTIC FLUID COMPLICATIONS

Oligohydramnios (less than 300 mL of amniotic fluid), hydramnios
(polyhydramnios) (greater than 2 L of amniotic fluid), and the
presence of meconium (the first stools of the infant) in the amniotic
fluid complicate labor and birth.
Oligohydramnios
Oligohydramnios may result from fetal renal abnormalities, poor
placental perfusion, or premature ROM. During labor, the absence of
the amniotic fluid buffer may lead to cord compression during
contractions and decreased fetal blood flow as evidenced by variable
heart rate decelerations. Women with pregnancies complicated by
oligohydramnios require careful nursing and medical surveillance;
amnioinfusion may be indicated to replace the cushion of fluid for the
cord and relieve the frequency and intensity of variable
decelerations.
Hydramnios
Hydramnios occurs in multiple gestations, fetal anomalies, and as a
complication of maternal disease such as diabetes. During labor, the
nurse needs to be aware that the excessive volume of fluid may
obscure the fetal heart tracings. Hydramnios can cause fetal
malpresentation because of the extra uterine space that it provides
for the fetus to turn. The mother is also at risk for prolapse of the
umbilical cord because the increased amount of fluid pushes the
fetus high into the uterine cavity. Preterm ROM, another complication
associated with hydramnios, increases the risks of both infection and
prolapsed cord.
Meconium
Meconium-stained amniotic fluid during the intrapartal period is an
indication for careful fetal surveillance by EFM and possibly fetal
scalp blood sampling. Although not always a sign of fetal distress, its
presence, which occurs during fetal loss of sphincter control, is
highly correlated with its occurrence. Reasons for the passage of
meconium during labor include:
■ Hypoxia-related peristalsis and sphincter relaxation
■ Breech presentation or normal physiological function that occurs
with fetal maturity
■ Following umbilical cord compression-induced vagal stimulation in
the mature fetus
Meconium staining, which occurs in approximately 17% to 40% of
births, is observed more frequently in prolonged pregnancies (Addisu
et al, 2018; Robillard et al, 2019). A decrease in amniotic fluid
(oligohydramnios) increases the viscosity of the meconium and the
risk of neonatal aspiration during delivery. The nurse must carefully
document the presence of meconium-stained fluid at the time of
ROM. In addition, the nurse should note the occurrence of variable
decelerations and immediately notify the physician or CNM
regardless of whether meconium is present. Amnioinfusion has been
shown to be effective in decreasing the fetal mortality associated
with variable FHR decelerations.
Chorioamnionitis
Chorioamnionitis is a maternal infection of the amniotic membranes
resulting in an inflammatory response of the amniotic fluid, placenta,
fetus, fetal membranes, or decidua (College of Obstetricians and
Gynecologists, 2017). It occurs in approximately 2% to 4% of
pregnancies, with an increase in incidence in later gestations.
Bacteria (often normal flora) in the vagina ascends to the uterus and
amniotic cavity causing an infection. Risk factors for chorioamnionitis
includes ROM and long interval time for labor, multiple vaginal
examinations, pre-existing infection, untreated GBS in labor, use of
internal FHR and IUP catheter, and preterm premature ROM. Other
maternal risk factors include young maternal age, poor maternal
nutrition, and nulliparity (Sommers, 2019). Diagnosis is often based
on clinical symptoms of maternal fever of 100.4°F (38°C) or higher,
fetal tachycardia, uterine tenderness, and foul-smelling amniotic
fluid.
Chorioamnionitis leads to significant maternal sepsis and neonatal
morbidity leading to pneumonia, meningitis, sepsis, and mortality
with rates of fetal demise of 1% to 4% in term infants and 10% in
preterm infants (College of Obstetricians and Gynecologists, 2017;
Sommers, 2019). Treatment includes delivery of the infant (even if
preterm) and antibiotics. Nursing considerations include frequent
vital signs, close fetal monitoring, uterine activity, response to
antibiotics, vaginal discharge, and abdominal tenderness. Antibiotics
typically commence and continue throughout labor into the
postpartum period, including Ampicillin (or amoxycillin) 2 g IV every 6
hours and Gentamicin 5 mg/kg IV daily (College of Obstetricians and
Gynecologists, 2017).
COMPLICATIONS ASSOCIATED WITH THE

PLACENTA
Critical nursing actions are required when the woman’s intrapartum
course is complicated by bleeding related to placenta previa (a low
implantation of the placenta) or abruptio placentae (a premature
separation of the placenta). Either condition places the woman at
risk for hemorrhage and shock. A deteriorating physiological status
of the mother impacts the fetus and often results in hypoxia. The
nurse faces the challenge of helping to manage this intrapartal
emergency. Guidelines for nursing care of the patient experiencing
an intrapartal hemorrhage are presented in Table 8-4.
TABLE 8-4
Care of the Patient Experiencing an Intrapartal Hemorrhage
ASSESSMENT PLAN INTERVENTION EVALUATION
Vital signs Establish Take every 5 minutes if Vital signs are
maternal unstable, or every 15 within normal
stability. minutes if stable. range.
Use pulse oximetry. Pulse is between

60 and 120
beats/min.
Auscultate respirations. Respirations are

between 14 and 26
breaths/min.
Temperature is less
than 100.4°F
(38.0°C).
Blood pressure is
greater than 90/60
mm Hg.
Bleeding Resolve Start two large-bore IV Bleeding is

hemorrhage. sites. minimized.
Prevent shock. Infuse normal saline and Homeostasis is

lactated Ringer’s solution. established.
Estimate blood loss
(l g = l mL) for replacement.
Infuse blood products as
necessary.
Monitor circulatory volume
using CVP/Swan-Ganz
catheter as needed for
extreme bleeding.
Send blood sample to
laboratory for analysis of
gases.
Document blood loss.
Intake/Output Prevent volume Insert indwelling urinary Urine output will be
depletion. catheter. Measure and greater than 30
record output every hour. mL/hr.
Measure and record input
every hour.
Fetal status Prevent fetal Continuous electronic fetal FHR tracings

injury. monitoring. remain between
120 and 160
beats/min. No
evidence of
abnormal FHR
tracings.
Emotional Assist patient to Educate the patient Patient verbalizes

response cope with regarding all procedures. an understanding of
condition. her condition.
Inform the patient of her Face displays no

status throughout the grimace.
bleeding crisis.
Provide relaxation and Muscles remain

breathing techniques. relaxed.
Provide spiritual support as

necessary.
Pain Reduce pain. Provide relaxation and Patient reports pain

breathing techniques. on a scale of 1–10
Use guided imagery. as between 3 and
Offer massage. 5.
Monitor contractions.
Offer limited pain
medication as ordered.
Placenta Previa
With placenta previa, bleeding occurs when the lower uterine
segment begins to differentiate from the upper segment late in
pregnancy and the cervix begins to dilate. If the bleeding has
stopped, the maternal vital signs are stable, the fetal heart sounds
are of good quality, and the fetus has not yet reached 36 weeks, the
woman is usually managed by expectant watching. If the woman is
near term (greater than 37 weeks of gestation) and in labor or
bleeding persistently, immediate birth by cesarean is almost always
indicated. Women diagnosed with partial or marginal placenta previa
who have no bleeding or minimal bleeding may be allowed to
attempt a vaginal birth.
Prenatal Planning for Patients Likely to Hemorrhage
Advanced planning and interdisciplinary collaboration are essential for the
management of patients who are at risk for intrapartal hemorrhage. Women
with placenta previa, placenta accreta, or significant leiomyomas (fibroids)
should be started on prenatal iron and folic acid as needed to maintain normal
hemoglobin values, and, ideally, referred to a tertiary care center with
capacities (e.g., maternal-fetal medicine, general surgery, urology, vascular
surgery, and neonatology) to care for them. When cesarean birth is planned,
nursing responsibilities include continuous maternal-fetal assessment while
preparing the woman for surgery. Maternal vital signs are assessed for
indicators of hemorrhage (decreasing blood pressure, tachycardia, changes in
the level of consciousness [LOC], and oliguria). Continuous EFM is used to
assess the fetus for signs of hypoxia.
There is an increased risk for postpartal hemorrhage because the

placental site is in the lower uterine segment, which does not
contract as efficiently as the upper segment. Also, because the
uterine blood supply is less in the lower uterine segment, the
placenta tends to grow larger than when implanted in the upper
segment. Thus, a larger denuded surface area is exposed after
removal of the placenta. Nursing care throughout the intrapartal
course centers on providing emotional support for the woman and
her family and collaborating with and supporting medical
management.
Placental Abruption
Placental abruption (abruptio placentae), which tends to occur in late
pregnancy, may occur as late as the first or second stage of labor.
Although the primary cause of premature placental separation is
unknown, predisposing factors include maternal hypertension,
cocaine use (associated with vasoconstriction), direct trauma, and a
history or previous placental abruption.
Treatment for abruptio placentae depends on the severity of
maternal blood loss and the fetal maturity and status. If the abruption
is mild and the fetus is less than 36 weeks and not in distress,
expectant management may be implemented. When the fetus is at
term gestation or if the bleeding is moderate to severe and the
woman or fetus is in jeopardy, delivery is facilitated. Nursing care
includes continuous maternal-fetal monitoring and emotional
support. The patient is maintained in a lateral position to prevent
pressure on the vena cava and to facilitate placental blood flow. To
avoid further damage to the injured placenta, no vaginal or pelvic
examinations are performed and no enemas are administered.
Blood and fluid volume replacement are implemented to maintain
the urine output (assessed by indwelling Foley catheter) at 30 mL/hr
or more and the hematocrit at 30% or more. Hemodynamic
monitoring may be necessary. If the premature placental separation
occurs during active labor, the physician may elect to rupture the
membranes or augment the labor with intravenous oxytocin to
hasten birth. Rupturing the membranes prevents large amounts of
blood from collecting in the myometrium, which can interfere with
uterine contractions. Artificial rupture of the membranes allows a
slow, steady escape of amniotic fluid, preventing a sudden change in
IUP that may encourage further placental separation. Vaginal birth is
desirable, especially in cases of fetal death. If birth does not appear
to be imminent, a cesarean birth is the delivery method of choice.
However, cesarean birth should be reserved for cases of fetal
distress or other obstetric indications and should not be attempted if
the woman has severe and uncorrected coagulopathy (e.g., DIC).
The patient with unresolved bleeding from a placental abruption is
most vulnerable to severe complications. Maternal problems
resulting from abruptio placentae include a Couvelaire uterus (the
accumulation of blood between the separated placenta and the
uterine wall) and DIC. Although a Couvelaire uterus is rare, its
implications are severe. The uterus takes on a bluish tinge as blood
extravasates from the clot into the myometrium. Contractility is lost.
The condition is so severe that a hysterectomy may be necessary to
control the bleeding.
If DIC has developed, surgery poses a major maternal risk
because of the possibility of hemorrhage during surgery and later
from the incisional site. The administration of intravenous fibrinogen
or cryoprecipitate (which contains fibrinogen) may be given to
increase the maternal fibrinogen level.
The maternal prognosis depends on how quickly interventions are
initiated and how effective they are in halting the hemorrhage. Death
can occur from massive hemorrhage that leads to shock or renal
failure from circulatory collapse. The fetal prognosis depends on the
extent of the abruption and the severity of the accompanying
hypoxia.
CASE STUDY
A Pregnant Adolescent in the Emergency Department
Maria Selles is a 14-year-old Latina who arrives in the emergency department
(ED) complaining of severe abdominal pain. She is pale and diaphoretic. A
small amount of bright red blood is slowly trickling from her vagina. On
assessment, her blood pressure is 120/70; pulse, 100; respirations 22
breaths/minute; temperature 99°F (37.2°C). Her physical examination reveals
an enlarged abdomen, which is rigid and boardlike with extreme tenderness.
Maria is known to the ED because of a history of repeated drug abuse including
cocaine. She has been living on the street since she was kicked out of her
house several months ago.
1. Based on this initial information, what is the nurse’s assessment of the

possible problem?
2. Because Maria is in such extreme distress, the nurse is aware of a need to
limit the number of questions asked. What critical questions should be asked
at this point?
3. What laboratory tests would be important to check?
The nurse’s further assessment reveals dark red vaginal bleeding and clinical
signs consistent with pregnancy (the presence of abdominal enlargement,
deeply pigmented areolae, linea nigra, and striae gravidarum). The young
patient has said very little in response to the questions, but Maria does admit to
sexual intercourse and no recent menstrual periods.
Given this information, the nurse formulates the care priorities for Maria.
Although her physical condition and that of the fetus warrant immediate priority,
the nurse needs to support this young girl psychologically to proceed with any
plan. Any support people who have come with her to the ED should be
identified. If there is no one with her, the nurse explains the plan of care and
describes what she should expect. The nurse places Maria on the electronic
fetal monitor and immediately notifies the physician of her condition. Because
cocaine is associated with placental abruption, the nurse must identify any
recent drug use. The care plan should be developmentally oriented. The nurse
implements strategies to keep Maria warm, provides emotional support and a
calming presence, and continues to monitor her vital signs and her vaginal flow
until the physician arrives.

Disseminated intravascular coagulation is an acquired disorder of
blood clotting. Affected individuals can experience widespread
internal and external bleeding and clotting. Clinical symptoms may
include easy bruising, the appearance of multiple petechiae, and
bleeding from intravenous sites (Table 8-5). DIC is most often
triggered by the release of large amounts of tissue thromboplastin,
which occurs in abruptio placentae and stillbirth in which there is a
prolonged retained fetus (Venes, 2021).
TABLE 8-5
Diagnostic Highlights of DIC
TEST NORMAL ABNORMALITY EXPLANATION
RESULT WITH
CONDITION
Antithrombin III 0.15–0.2 Decreased Irreversible complexing of
mg/mL thrombin and circulating
coagulation factors with
antithrombin lower this level
D-dimer 0–0.5 mcg/mL Elevated >500 Fibrin degradation fragment;

fibrinogen mcg/mL FEU measured amount of clot
equivalent units indicates DIC breakdown products specific
(FEU) for cross-linked fragments
derived from fibrin; in DIC,
extensive fibrinolysis occurs
FDPs <5 mcg/mL Elevated н40 Seven split products are

mcg/mL formed from splitting fibrin as a
indicates DIC result of plasmin during
dissolution of fibrin clots; FDP
quantifies amount of split
products present in blood; in
DIC, extensive breakdown of
clots occurs
Fibrinogen 200–400 mg/dL Decreased <50 Decreased levels of fibrinogen

mg/dL (factor I) occur due to depletion
of clotting factors
Partial Varies by Prolonged; may Indicates how long it takes for

thromboplastin laboratory; be prolonged recalcified, citrated plasma to
time (activated; generally 25– >80 sec clot after partial thromboplastin
APTT) 35 sec is added; screens for
deficiencies in all factors
except VII and XIII; factors are
depleted, causing prolonged
APTT
Platelet count 150,000– >100,000/mm3 Platelets are consumed during

450,000/mm3 clot formation
Prothrombin Varies by Prolonged н15 Prothrombin is a vitamin K–

time (PT) laboratory; sec dependent glycoprotein
generally 10– necessary for firm clot
13 sec formation; converts to thrombin
in clotting cascade; in DIC,
clotting factors are depleted
and PT is prolonged
Other Tests: INR (international normalized ratio): Standardizes the PT ratio by

allowing laboratories to compare values with an international standard provided by
the World Health Organization. Formula is patient’s PT in seconds/mean normal
PT in seconds. In DIC, INR is elevated from a normal value of 1.3 to 1.6.
Therapeutic range for INR is 2 to 3 for people on warfarin. Factors: Decrease in
factors II, V, and VIII; prothrombin fragments 1 and 2 and fibrinopeptide A (through
enzyme-linked immunosorbent assay). A DIC risk assessment has been
developed by the International Society on Thrombosis and Haemostasis. The
scale involves calculating a score based on the laboratory coagulation tests:
Platelet count, D-dimer, FDP, fibrinogen, PT, and APTT. The scoring is as follows:
Platelet count: н100 = 0 points, <100 = 1 point, <50 = 2 points; Elevated fibrin
marker: No elevation = 0 points, moderate increase = 2 points, strong increase =
3 points; Prolonged PT: <3 seconds = 0 points, н3 to <6 = 1 point, н6 = 2 points;
Fibrinogen level: н1 g/L = 0 points, <1 = 1 point. A score greater than or equal to 5
is compatible with overt DIC, and a score less than 5 suggests nonovert DIC. The
patient should also be assessed to determine whether an underlying disorder
such as trauma or sepsis exists.
Source: Sommers (2019).
Optimizing Outcomes
Prompt Identification of Clinical DIC Symptoms

When conducting a physical assessment of the pregnant woman at risk for DIC,
the nurse must be alert to the following clinical signs:
• Bleeding from multiple sites (e.g., intravenous access site, venipuncture
site, and site of urinary catheter insertion)
• Spontaneous bleeding from the gums and nose
• Widespread petechiae and bruising
• Gastrointestinal bleeding
• Tachycardia
• Diaphoresis
With DIC, the anticoagulation and procoagulation factors are
activated simultaneously. Thromboplastin (a clotting factor) is
released into the maternal circulation as a result of placental
bleeding and the consequent clot formation. Circulating levels of
thromboplastin activate widespread clotting throughout the
microcirculation. This process consumes, or uses up, other clotting
factors such as fibrinogen and platelets. The condition is complicated
further by the activation of the fibrinolytic system to lyse (destroy) the
clots. As a result, there is a simultaneous decrease in clotting factors
and an increase in circulating anticoagulants, leaving the circulating
blood unable to clot. Laboratory results reveal low hemoglobin,
hematocrit, platelets, and fibrinogen and elevated fibrin
split/degradation products.
The priority in treatment of DIC is to correct the underlying cause
and replace fluids and essential clotting factors. When premature
placental separation has triggered the coagulopathy, delivery of the
fetus and placenta must be accomplished so that the production of
thromboplastin, which is driving the process, is halted. This is
accomplished with intravenous administration of heparin to stop the
clotting cascade (Table 8-6). Heparin is cautiously given close to the
time of birth to decrease the likelihood of postpartum hemorrhage
after the delivery of the placenta. The administration of blood and
platelets is usually delayed until after completion of the heparin
therapy so that the newly infused blood factors are not consumed by
the widespread coagulation process. Depending on the clinical
setting, antithrombin III factor, fibrinogen, cryoprecipitate fresh frozen
plasma, packed red blood cells, and/or platelets may also be used to
restore blood clotting (Venes, 2021).
Nursing care includes continuous maternal–fetal assessment;
administering the prescribed fluids, blood, and blood products; and
assessing for signs of complications from the replacement products.
The woman is positioned in a side-lying tilt to maximize placental
perfusion, and oxygen may be administered via rebreathing mask at
8 to 10 L/min or according to physician or institutional protocol.
Renal failure may result from DIC, and urinary output is closely
monitored; it should be maintained at more than 30 mL/hr. Serial
blood studies are performed, and frequent assessments on
venipuncture sites for bleeding should be routine. Due to the high
risk of bleeding, vaginal discharge and abdominal girth should be
assessed and measured every 2-4 hours if abdominal or vaginal
bleeding is suspected. The patient and her family should be provided
with ongoing information and emotional support (Venes, 2021).
Rupture of the Uterus

Rupture of the uterus during labor is a rare but life-threatening
obstetric complication that occurs in 0.2% to 1% of births, with higher
rates in less developed countries (Motomura et al, 2017) (Fig. 8-11).
It is most often associated with the tearing of a uterine scar (usually
from a previous classic cesarean birth), uterine trauma (e.g.,
accidents or surgery), and a congenital uterine anomaly. Rupture of
the uterus occurs more often in multigravidas than in primigravidas.
Intrapartal uterine rupture may result from overdistention (e.g.,
multiple gestation), tachysystole (e.g., oxytocin and prostaglandin),
external or internal version, malpresentation, or a difficult forceps-
assisted birth (Motomura et al, 2017).
TABLE 8-6
Pharmacological Highlights of DIC
MEDICATION DOSAGE DESCRIPTION RATIONALE
OR DRUG
CLASS
Heparin Varies with patient; patient- Anticoagulant Inactivates
based dosing is common, thrombin and
with a starting bolus of 80 factors X and IX by
units/kg and an infusion of antithrombin III;
18 units/kg per hr. Then note that use is
dosage is calculated based controversial but
on APTT results. experts generally
agree it is indicated
for obvious
thromboembolic
events or with fibrin
deposition
Antithrombin III Total doses equals: (desired Anticoagulant Replacement; used

level – initial level) × (0.6 × for moderately
total body weight kg) IV q 8 severe to severe
hr with a desired level DIC; increases
>125% loading dose of 100 effects of heparin
units/kg IV over 3 hr
followed by continuous
infusion of 100 units/kg per
day
Drotrecogin alfa 24 mcg/kg per hr IV by Recombinant Antithrombotic

activated continuous infusion over 96 form of human effect; inhibits
(Xigris); hr APC factors Va and VIIIa
activated with indirect
protein C (APC) profibrinolytic
activity
Analgesics Varies with drug Narcotics such Relieve pain of

as morphine hemarthrosis
and fentanyl
Other Drugs: Tissue factor pathway inhibitor
Source: Sommers (2019).

FIGURE 8-11 Rupture of the uterus in the lower uterine segment.
Uterine rupture may be classified as complete or incomplete (also

known as uterine scar dehiscence; occurs when a previous scar
begins to separate). A complete rupture extends through the
endometrium, myometrium, and peritoneum. When this occurs,
uterine contractions stop. The woman complains of sudden, severe
abdominal pain during a strong contraction followed by cessation of
the pain. There is bleeding into the abdominal cavity and possibly
into the vagina and protrusion of fetal parts and/or placenta into the
abdominal cavity. An incomplete rupture (scar dehiscence) extends
into the peritoneum but not into the peritoneal cavity or broad
ligament. Bleeding is usually internal, and the woman may be
asymptomatic (a “silent” rupture) or complain of localized tenderness
and aching pain over the lower uterine segment.
Changes in fetal heart tracings such as sudden bradycardia or
prolonged late or variable decelerations are the most common signs
and symptoms and frequently precede the onset of abdominal pain
or bleeding. Maternal signs and symptoms may include faintness,
vomiting, abdominal tenderness, hypotonic uterine contractions, and
lack of labor progress. As blood loss continues, the woman may
exhibit signs of hypovolemic shock (hypotension; tachypnea; pallor;
and cool, clammy skin). Fetal parts may be readily palpable through
the abdomen.
Rupture of the uterus constitutes an obstetric emergency; the type
of medical management depends on the severity. A small rupture
may be safely managed with a laparotomy and birth of the infant,
repair of the tear, and volume replacement with fluids and blood
transfusions if needed. A complete uterine rupture requires
hysterectomy and blood replacement.
Uterine Inversion
Uterine inversion (uterus is turned inside out) is a rare but
potentially life-threatening complication that most often results from
excessive pulling on the umbilical cord in an attempt to hasten the
third stage of delivery (Venes, 2021). Other contributing factors
include fundal implantation of the placenta, vigorous fundal pressure,
uterine atony, macrosomic infants, magnesium sulfate, precipitous
labor, congenital uterine structural anomalies and malformations,
abnormally adherent placental tissue, short umbilical cord, and
connective tissue disorders (Wendel et al, 2018). When complete
inversion occurs, a large, red, globular mass (that may contain the
still-attached placenta) protrudes 20 to 30 cm outside the vaginal
introitus. A partial or incomplete inversion is not visible; instead, a
smooth mass is palpated through the dilated cervix and the fundus
will not be palpated in the correct position.
Maternal symptoms include pain and large hemorrhage with
hypovolemic shock. Management involves manual replacement of
the fundus immediately, usually under general anesthesia by the
physician, followed by oxytocin to facilitate uterine contractions and
antibiotic therapy to prevent infection. In cases of severe blood loss
and hypovolemic shock, patients require fluid resuscitation and blood
transfusions. Prevention (by not pulling strongly on the cord until the
placenta has fully separated) is the safest and most effective
therapy.
Umbilical Cord Prolapse

Umbilical cord prolapse is an emergency condition occurring in 2 out
of 1,000 births (Venes, 2021). Umbilical cord prolapse happens
when a loop of the umbilical cord slips down below the presenting
part of the fetus (Fig. 8-12). Prolapse of the umbilical cord may be
occult (hidden; not visible) at any time during labor whether the
membranes have ruptured—the cord lies beside the presenting part
in the pelvic inlet. With a complete cord prolapse, the cord descends
into the vagina and can be felt as a pulsating mass on vaginal
examination. It may or may not be seen. Frank (visible) prolapse
most commonly occurs immediately after ROM (spontaneously and
artificially) as gravity washes the cord in front of the presenting part.
Risk factors associated with cord prolapse include malpresentation
(e.g., breech), transverse lie, polyhydramnios, preterm or low-birth-
weight infant, multiple gestation, an unengaged presenting part,
male infant, AROM or SROM, ECV, and placement of cervical
ripening balloon or IUP catheter (Sayed, Ahmed, & Hamdy, 2018). If
the presenting part does not fit snugly into the lower uterine
segment, the sudden gush of amniotic fluid that accompanies ROM
may displace the cord downward.
FIGURE 8-12 Umbilical cord prolapse. A, Occult—the cord cannot

be seen or felt during a vaginal examination. B, Complete—during a
vaginal examination, the cord is felt as a pulsating mass. C, Frank—
the cord precedes the fetal head or feet and can be seen protruding
from the vagina.
Optimizing Outcomes
Actions to Reduce the Risk of Umbilical Cord Prolapse
If spontaneous rupture of the membranes (SROM) has occurred, the woman
should be kept on bedrest until the fetal presenting part is engaged. Artificial
rupture of the membranes should not be attempted until engagement has
occurred. To rule out umbilical cord prolapse, the nurse should assess the fetal
heart sounds immediately after spontaneous or AROM.
To relieve pressure on the cord, the examiner places a sterile

gloved hand into the vagina and manually lifts the presenting part off
the umbilical cord. The patient is assisted into a position such as a
modified Sims, extreme Trendelenburg, or knee–chest position,
which uses gravity to cause the presenting part to fall back from the
cord (Fig. 8-13). The nurse administers oxygen at 10 L/min by face
mask to improve oxygenation to the fetus; the physician may order
administration of a tocolytic agent to reduce uterine activity and
relieve pressure on the fetus. If the cord is protruding from the
vagina, the exposure to room air will cause drying, which leads to
atrophy of the umbilical vessels. No attempts should be made to
place the cord back into the vagina. Instead, the nurse should cover
the exposed segment of umbilical cord with warm, sterile saline
compresses to prevent drying. Prompt delivery, often with forceps
assistance, is facilitated if the cervix is fully dilated. Otherwise, the
nurse or other care provider continues to manually maintain upward
pressure on the presenting part (using a hand in the vagina) until a
cesarean birth can be accomplished.
NURSING INSIGHT
Signs of Umbilical Cord Prolapse

It is imperative that the nurse recognizes indicators of umbilical cord prolapse:
fetal bradycardia with variable decelerations during contractions, observing or
palpating the cord in the vagina, and the woman’s statement that she “feels the
cord” after membrane rupture. Prolonged cord compression causes fetal
hypoxia; occlusion of blood flow to and from the fetus for greater than 5
minutes is likely to result in central nervous system damage or fetal death.
FIGURE 8-13 Interventions to relieve pressure on a prolapsed
umbilical cord until birth can be effected. A, A gloved hand is placed
in the vagina to lift the presenting part off the cord. B, The maternal
hips are elevated with two pillows; this intervention is often combined
with a Trendelenburg position. C, The knee–chest position uses
gravity to shift the fetus out of the maternal pelvis.
FOCUS ON SAFETY
After Prolapse of the Umbilical Cord
After prolapse of the umbilical cord, immediate nursing interventions are
essential:
• Call for assistance; notify the primary health-care provider.
• Using the gloved examining hand, insert two fingers into the vagina to the
cervix. Place one finger on either side of the cord or both fingers to one side
and quickly exert upward pressure against the presenting part to relieve
compression of the cord.
• Assist the woman into an extreme Trendelenburg, modified Sims, or knee-
chest position.
• If the cord is protruding from the vagina, wrap it loosely in a sterile towel
saturated with a warmed, sterile normal saline solution.
• Administer oxygen at 10 L/min by face mask.
• Increase the IV fluid rate; administer a tocolytic agent as ordered.
• Continuously monitor the FHR by internal fetal scalp electrode if possible.
• Provide information and support to the woman and her birth partner.
• Prepare for an immediate vaginal birth if the cervix is fully dilated or for
cesarean birth if it is not.
Variations Related to Umbilical Cord Insertion and the Placenta
Velamentous Cord Insertion/Vasa Previa

A velamentous insertion of the umbilical cord occurs when the fetal
vessels separate at the distal end of the cord and insert into the
placenta at a distance away from the margin (Fig. 8-14). The vessels
are not protected by Wharton’s jelly and are subject to compression,
rupture, and thrombosis, which are major complications that may
lead to severe fetal distress and death. This form of cord insertion
most frequently occurs with placenta previa and multiple
pregnancies; it may also be associated with fetal anomalies. Rupture
of the membranes or traction on the umbilical cord may tear the fetal
vessels. This event produces rapid, usually fatal, fetal hemorrhage.
Vasa previa occurs when the unprotected fetal vessels cover the
cervical os and precede the fetus. It is usually seen with a
velamentous insertion of the umbilical cord. The vessels are not
covered with Wharton’s jelly, and the examiner may be able to feel
pulsations of the umbilical cord. Lacerations of the vessels, which
can occur at any time, cause sudden fetal blood loss. The onset of
sudden, painless bleeding at the beginning of cervical dilation or
during ROM may signal the presence of vasa previa; diagnosis may
be confirmed by sonogram (Gagnon, 2017; Matsuzaki & Kimura,
2019).
Circumvallate, Succenturiate, and Battledore Placenta

Other placental variations and problems related to the umbilical cord
insertion site include circumvallate placenta (placenta circumvallata),
succenturiate placenta (placenta succenturiata), and battledore
placenta. These conditions are associated with variations that
occurred during placentation (formation and attachment of the
placenta). The circumvallate placenta has formed a ring composed
of a double fold of amnion and chorion near the fetal surface. This
placental aberration has been reported to be associated with
antepartum hemorrhage, preterm delivery, and fetal malformations.
The succenturiate placenta contains one or two separate lobes, each
with its own circulation. After childbirth, one of the separate lobes
may be retained in the uterus and impede contractions, resulting in
severe maternal hemorrhage. The remaining lobes must be
manually removed from the uterus to prevent hemorrhage.
Battledore insertion of the cord describes a condition in which the
umbilical cord is implanted near the margin of the placenta.
Battledore placenta may be associated with fetal hemorrhage,
especially after marginal separation of the placenta.
FIGURE 8-14 Variations related to umbilical cord insertion on the
placenta. A, Velamentous insertion of the umbilical cord. B,
Circumvallate placenta. C, Succenturiate placenta. D, Battledore
placenta.
Placenta Accreta, Placenta Increta, and Placenta Percreta

Abnormal adherence of the placenta is rare, and its causes are
unknown. After birth, the usual maneuvers to remove the placenta
are unsuccessful, and laceration or perforation of the uterine wall
may result. When this occurs, the woman is at high risk for
hemorrhage and infection. The placental adherence may be partial
or complete. Placenta accreta describes a slight penetration of the
myometrium by the trophoblast. Placenta increta describes a deep
placental penetration of the myometrium, and placenta percreta
describes placental perforation of the uterus. Depending on the
degree of placental adherence (and the severity of the hemorrhage),
the patient will require blood replacement, and a vaginal
hysterectomy may be indicated.
Anaphylactoid Syndrome of Pregnancy

Anaphylactoid syndrome of pregnancy (formerly known as amniotic
fluid embolism; obstruction of a blood vessel by amniotic fluid) is a
rare complication of the intraand postpartum periods that is
associated with a high incidence of maternal and fetal death.
Anaphylactoid syndrome in pregnancy occurs in between 1 in 10,000
and 1 in 100,000 births (Venes, 2021). Historically, mortality rates
were as high as 80%, but with early diagnosis and advanced
treatments fatality rates now range from 13% to 26% (Kaur et al,
2016). The origins of the problem are not clear, but it is hypothesized
that amniotic fluid containing particles of fetal debris (meconium,
hair, vernix, or skin cells) escapes into the maternal circulation and in
certain patients triggers an anaphylactic reaction and the release of
endogenous mediators such as histamine, prostaglandins, and
thromboxane. However, it should be noted that fetal material is not
always found in the maternal circulation in patients with
anaphylactoid syndrome of pregnancy, and material of fetal origin is
often found in women who do not develop the condition. When the
complication does occur, obstruction of the pulmonary vessels leads
to respiratory distress and circulatory collapse. Hemorrhage, DIC,
and pulmonary edema are present to some extent. Anaphylactoid
syndrome of pregnancy is not preventable because it cannot be
predicted, although maternal factors (including advanced age,
multiparity, abruptio placentae, and tumultuous labor), and fetal
problems (including macrosomia, meconium passage, and death)
have been associated with an increased risk for development (Kaur
et al, 2016).
The nurse must recognize the rapidly deteriorating maternal
condition and seek immediate help. Symptoms occur during labor,
delivery (vaginal or cesarean), or within 30 minutes postpartum.
Respiratory compromise is often the first clinical symptom with a
sudden onset of coughing, respiratory distress, and decreased
oxygen saturation, leading to acute hypoxia, respiratory arrest, and
altered mental status. The woman may also exhibit anxiety,
restlessness and dread, acute hypotension or cardiac arrest, and
coagulopathy, DIC, or severe hemorrhage (Kaur et al, 2016; Venes,
2021).
Diagnostic Tools
Criteria to Diagnose Anaphylactoid Syndrome of Pregnancy
The following must be present to diagnose anaphylactoid syndrome of
pregnancy:
1. Acute hypotension or cardiac arrest.
2. Acute hypoxia.
3. Coagulopathy or severe hemorrhage in the absence of other explanations.
4. All of these occurring during labor, cesarean delivery, dilation, and
evacuation, or within 30 minutes postpartum with no other explanation of
findings (Kaur et al, 2016).
FOCUS ON SAFETY
When Anaphylactoid Syndrome of Pregnancy Develops

Immediate management of this condition includes the administration of oxygen
by face mask or cannula at a rate of 8 to 10 L/min or resuscitation bag to
deliver 100% oxygen. Nursing interventions center on support of resuscitation
efforts:
• Prepare for intubation and mechanical ventilation.
• Initiate or assist with cardiopulmonary resuscitation (CPR). Position the
pregnant woman in a 30-degree lateral tilt to displace the uterus.
• Administer intravenous fluids and blood (e.g., packed cells or fresh frozen
plasma); because circulatory collapse is a possibility, consider having two IV
lines in place. Caution: Do not overload with fluids because of the threat of
pulmonary edema resulting from developing adult respiratory distress
syndrome (ARDS).
• Have emergency medications to assist in patient stabilization (e.g.,
dopamine, digoxin, hydrocortisone, and uterotonics).
• Prepare for and assist with placement of a central line.
• Obtain blood work for CBC, DIC panel, arterial blood gases, and blood type.
• Insert indwelling urinary catheter; measure hourly urine output.
• Continuously monitor maternal-fetal status.
• Prepare for emergency birth once the woman is stable.
• Provide ongoing information and emotional support to the woman and her
family.
The maternal prognosis depends on the size of the embolism and

speed and skill of the responding perinatal team. If the woman
survives, she will most likely be transferred to a critical care unit for
hemodynamic monitoring, blood replacement, and coagulopathy
treatment. Although rapid delivery is paramount to save the fetus, a
delay in delivery usually occurs to stabilize the mother. Survival of
the infant is approximately 70%, with rates of survival dependent on
the time of maternal arrest and the delivery of the infant (Kaur et al,
2016).
This type of situation is very difficult for all professionals involved
in the care of the patient. An ethical conflict may arise when the
health of the mother is given consideration over the fetus. While
there are no easy answers to these dilemmas, the nurse can serve
as a leader by organizing regular meetings during which issues of
this nature can be discussed in a calm, open manner. The nurse is in
a key position to help create an environment where health
professionals can resolve or work through difficult dilemmas.
Collaboration During Perinatal Emergencies
Communication is an essential component in all patient environments, but it is
critical in emergency obstetric nursing. Team members need to collaborate to
provide timely interventions that promote patient safety. Learning how to
present information in a nonthreatening but effective way is key to promoting
positive communication patterns. Many hospitals and health-care centers
provide education and training around obstetrical emergencies for
interdisciplinary teams to facilitate communication and collaboration among
disciplines. Teamwork training also stresses effective communication to
improve a culture of safety and encourage health-care professionals to freely
speak about concerns without the fear of retribution (Lyndon et al, 2015).
What to Say
Communicating Concerns With Members of the Health-Care Team
The need for effective communication among the health-care team is critical
especially in times of crisis. Problems in care are encountered when people fail
to collaborate or communicate. Teamwork is enhanced when everyone knows
the expectations of their role in the obstetric emergency (Box 8-4).
Standardization of protocols allows everyone to function more effectively and
prevent poor outcomes.
BOX 8-4
Collaborative Care Principles in Perinatal

Nursing
To facilitate the team process when providing care in emergency situations, the
perinatal nurse should:
• Employ effective communication techniques.
• Advocate for the patient through assertive statements.
• Conduct interdisciplinary reviews of all cases to identify risks.
• Promote team collaboration by rotating leadership roles in the case reviews.
• Assist in the evaluation process of all emergency cases.
• Use outcome measurements to evaluate safe and effective care.
CESAREAN BIRTH
Cesarean birth is the birth of a fetus through an abdominal incision
into the uterus; it is performed to preserve the life of the mother and
her fetus. Today, cesarean delivery is the most common operation in
the United States, and nearly one-third of all births occur in this
manner (Centers for Disease Control and Prevention, 2019). In
1965, the rate of cesarean births in the United States was less than
5%. According to the latest data in 2018, the cesarean section rate is
31.9% (Centers for Disease Control and Prevention, 2019). Although
modern surgical advances and the use of antibiotics have resulted in
a decrease in maternal and fetal morbidity and mortality, cesarean
birth is a major surgical procedure that poses threats to the health of
the mother and her infant.
Indications
Cesarean birth is performed when the health of the mother or her
fetus is jeopardized. Maternal medical risk factors most closely
associated with cesarean birth include hypertensive disorders, active
genital herpes, positive HIV status, and diabetes. Fetal complications
most closely associated with cesarean birth include CPD,
malpresentations (i.e., breech or shoulder), placental abnormalities
(e.g., abruptio previa), dysfunctional labor patterns, fetal distress,
multiple gestation, and umbilical cord prolapse. In actuality, few
absolute indications exist for cesarean birth, and most are primarily
performed for the benefit of the fetus (Hamilton et al, 2011).
Elective cesarean births have been on the rise since 1985. In
contemporary society, women are requesting cesarean births for
reasons other than medical, obstetric, or fetal complications. One
reason is related to a fear of vaginal birth, or tocophobia. Others are
concerned about labor pain, fetal death or injury, and the potential for
future problems with pelvic support or sexual dysfunction related to
perineal or rectal injury. Some women view cesarean birth as an
empowering experience and wish to choose the birth method and
date rather than have it selected for them. At issue is the question of
whether an elective cesarean birth is more beneficial or harmful to a
woman and her baby than a vaginal birth. The Association of
Women’s Health, Obstetric and Neonatal Nurses (AWHONN)
supports the need to learn more about the nature of elective
cesarean birth. AWHONN calls for continued research into strategies
to decrease traumas associated with vaginal birth and subsequently
decrease the need for elective cesarean birth because of maternal
fear. The American College of Nurse-Midwives (ACNM) have
published a statement saying that the practice of elective cesarean
birth for nonmedical reasons is not ethically justified (ACNM, 2016).
Cesarean birth is a major surgical procedure that carries risks and
complications. It is associated with a host of potential postoperative
problems such as hemorrhage, thromboembolism, and infection
during the postpartum period. The surgery can result in chronic pain
from scar tissue, urinary tract injury, adhesions, dehiscence of the
wound, and problems with the placenta in subsequent pregnancies.
Women face a higher incidence of death during a surgical procedure
with the use of general anesthesia and are at greater risk for
intraoperative surgical complications such as lacerations of the
uterus and bladder. In addition, there is a greater likelihood for
hysterectomy associated with cesarean birth than with vaginal birth.
The risk associated with previous cesarean delivery increases as the
number of previous cesarean deliveries rises.
NURSING INSIGHT
Impact of Surgical Adhesions on Subsequent Cesarean Birth
Tissue adhesions, bandlike structures that form as a result of a defect in the
healing process, can lead to significant morbidity, chronic pelvic pain, and
complications of future pregnancies such as cesarean delivery. Maternal
morbidity and neonatal morbidity increase among women with adhesions
(Arlier et al, 2017). Adhesion interference originating from a primary cesarean
birth prolongs repeat cesarean surgery, and the operative time (required for
tissue dissection) is extended with each subsequent birth. Delayed delivery
may negatively impact neonates. Rates of abdominal adhesions increase with
the number of c-sections with 32% of women developing adhesions after the
first c-section and 59% of women developing adhesions after three or more c-
sections (Hesselman et al, 2018). Other risk factors include maternal age
greater than 35, BMI greater than 30, and presence of a postop infection
(Hesselman et al, 2018).
Surgical Procedures
There are two main types of cesarean operations: the classic
(vertical) incision and the lower-segment transverse (LST) incision
(Fig. 8-15). The surgeon chooses the incision type based on the
patient’s condition and the fetal status. Rarely used today, the classic
cesarean incision is reserved for some cases of shoulder
presentation, placenta previa, and when birth must take place
immediately. Because this type of uterine incision is associated with
complications including considerable blood loss, infection, and
uterine rupture with subsequent pregnancies, women who undergo
classic cesarean births may not attempt future vaginal births.
FIGURE 8-15 Abdominal wall and uterine incisions for cesarean

births. A, Skin (abdominal wall) incisions. 1. Vertical, 2. Transverse
(Pfannenstiel). B, Uterine wall incisions. 1. Low transverse, 2. Low
vertical, 3. Classic.
The lower-segment cesarean (preferred by women for cosmetic

reasons) may involve either a vertical or a transverse uterine
incision. The transverse incision, more commonly performed, is
associated with less blood loss, fewer postoperative infections, and a
decreased likelihood of uterine rupture during subsequent
pregnancies. The skin incision made into the abdomen is either
transverse (sometimes called a “Pfannenstiel” or “bikini” incision) or
vertical (sometimes called a “midline” incision). The skin incision may
or may not be the same type of incision that is made into the
abdomen.
After the skin incision, the surgeon carefully moves through the
tissue layers to the uterus. An incision is made into the uterus and
the fetal head is gently elevated through the opening. A patent
airway is established and the rest of the fetus is delivered. The cord
is clamped and the newborn is placed either in the arms of the
parent or in the neonatal warmer depending on the circumstances.
After removal of the placenta, the incision is sutured at each layer,
and a sterile bandage is placed over it (Venes, 2021).
The nurse documents all components of patient care including the
time of birth and offers ongoing encouragement and support to the
mother. Once the birth has taken place, the nurse facilitates
attachment with the new family. Keeping mothers and their newborns
together after cesarean birth promotes family-centered care and is
associated with increased satisfaction among patients, nurses, and
physicians. When keeping the mother and the infant together is not
feasible because of complications, attempts should be made to keep
the infant together with the support person, partner, father of the
baby, or husband. When complications are present, the nurse
provides information including a description of the newborn to the
family. If the newborn requires resuscitation or a transfer to the
neonatal intensive care unit, the family is allowed to view the
neonate in the isolette before transport. When the newborn’s
condition is satisfactory, the newborn is presented to the parent or
support person to hold. Although the mother is restrained by surgical
equipment, the parent or support person can hold the baby close to
the mother’s face so that she can see her child (Fig. 8-16). This
initial bonding experience can usually take place while the surgeon
completes the suturing process. The family is then moved to the
recovery room for postsurgical care.
FIGURE 8-16 Family in cesarean birth.
Nursing Care
In most instances, the patient scheduled for a planned cesarean
birth is admitted on the day of surgery (Fig. 8-17). When the need for
an emergency or unplanned cesarean arises, the patient undergoes
the same procedures but in a timelier manner. Blood work, including
type and crossmatch and a CBC, is obtained before admission, and
the results are entered in the chart. The woman has been instructed
to remain NPO since midnight before admission. The nurse orients
the patient to the unit, reviews the prenatal history, and responds to
any questions or concerns. An informed consent is signed. A fetal
monitor is placed on the patient’s abdomen for a 20- to 30-minute
baseline assessment. Vital signs are taken and charted. In
preparation for the surgery, the abdomen is cleaned and shaved, an
intravenous line is placed, and an indwelling urinary catheter is
inserted to keep the bladder empty during the operation. Medications
are administered according to the physician’s orders. If an epidural
anesthetic is to be used, the nurse properly positions the patient and
supports her during its administration. If a general anesthetic is to be
used, an oral antacid or histamine, H2 receptor antagonist, may be
prescribed to neutralize gastric secretions and reduce the risk of
aspiration pneumonitis. The woman is then transported to the
operative suite (Wilson et al, 2018).
Optimizing Outcomes
Enhancing Maternal Anesthesia Knowledge and Choice

Spinal, epidural, and general anesthesia are used for cesarean births. Although
epidural anesthesia is a popular choice because the woman may remain awake
during the birth experience, the type of anesthesia used depends on factors
such as the maternal medical history, current status, and how quickly the birth
needs to take place. In addition, the woman is a factor—she may harbor fears
about having an anesthetic injected into her back. Patients should be given
information including the risks and benefits associated with the different types of
anesthesia to empower them to make an informed decision whenever there is a
choice.
Surgical Care
The nurse’s role varies during the surgical procedure. Depending on
the hospital setting and protocols, one nurse assists the physician
during the procedure while another nurse circulates. A team
consisting of a neonatal nurse and a neonatologist or nurse skilled in
neonatal resuscitation is in attendance to provide care for the infant.
The patient is placed on the surgical table with a hip wedge to
slightly elevate the hips. The FHR is continuously monitored until the
patient’s abdomen is ready for surgical preparation according to
hospital protocol. The support person, dressed in appropriate
surgical attire, may be present at any point in the process but is
usually asked to wait until the surgical drapes are in place before
being seated by the patient’s head. The anesthesiologist monitors
the maternal vital signs and the intravenous solutions.
When the woman remains awake during the procedure, the nurse
and other members of the care team provide information about the
events taking place and sensations that the woman may be
experiencing. Continued support and explanations help to decrease
anxiety, enhance feelings of comfort, and help the woman to
maintain a sense of control in the unfamiliar and perhaps frightening,
environment. A cesarean birth sequence is presented in Figure 8-18.
Postoperative Care
After the completion of the surgery, the woman is transferred to a
recovery room or to her labor room. According to agency protocol,
the nurse assesses various aspects of the recovery progress,
including effects from the anesthesia, the status of the
postoperative/postbirth uterus, and the degree of pain. If a general
anesthetic was used, special attention is given to maintenance of a
patent airway. The patient is positioned to prevent aspiration, and
vital signs are assessed every 15 minutes for the first 2 hours or until
stable. The nurse frequently inspects the incisional dressing and
assesses the fundus, the amount of lochia, the intravenous infusion,
and the urinary output. The woman is assisted to turn, cough, deep
breathe, and perform leg exercises. Pain medications are
administered as needed.
If the neonate is with the mother and her labor support, time is
provided to facilitate family bonding and attachment. If the woman
wishes to breastfeed, she is encouraged to do so. Patients generally
remain in the recovery area for 1 to 2 hours before transfer to the
postpartum unit for continued care.
FIGURE 8-17 Couple awaiting scheduled cesarean section.
Vaginal Birth After Cesarean

There is an old adage, “once a cesarean, always a cesarean.”
During the 1970s and 1980s, women challenged this rule and fought
for the opportunity to attempt a vaginal birth after a cesarean birth
(VBAC). Research conducted during that time provided evidence
that a VBAC was safe and a more cost-effective birth alternative.
This movement also coincided with the growing concern in the
United States over the dramatic increase in cesarean birth rates,
especially among women requiring a repeat cesarean birth.
In 1988, the ACOG, having concluded that women with a low
transverse incision could safely be allowed a TOL and possible
vaginal birth, released a statement in support of VBAC. The ACOG
endorsed the practice of oxytocin administration, epidural
anesthesia, and early ambulation for women with previous cesarean
births who met certain criteria. A standby team prepared to perform a
cesarean birth in the event of an emergency would be available at all
times. Numerous studies supported the success of VBAC. Safety
concerns arose, although data showed that uterine rupture, the most
serious of complications, was a rare event. In response to these
concerns, physicians began to more closely restrict the types of
patients allowed to attempt a TOL. Criteria for the selection of
candidates for a TOL have been developed (Box 8-5). A critical point
confirmed by the studies was that VBACs needed to be performed in
large hospitals or tertiary level centers because these institutions
offer continued 24-hour anesthesia coverage necessary to prevent
perinatal mortality and morbidity if uterine rupture occurs.
FIGURE 8-18 Cesarean birth. A, Delivery of the head. The nose and
mouth are suctioned. B, Delivery of the shoulders. C, D, Delivery of
the body. E, F, The newborn is presented to her parents.
Current ACOG recommendations state that most women with one

previous cesarean delivery with a low transverse incision are
candidates for and should be counseled about VBAC and offered a
TOL after previous cesarean delivery (TOLAC), that epidural
analgesia may be used as part of TOLAC, and that TOLAC should
be undertaken at facilities capable of emergency deliveries. When
resources for immediate cesarean delivery are not available, health-
care providers and patients should discuss the facility’s resources
and availability of staff (e.g., obstetric, pediatric, anesthetic, and
operating room), and once fully informed, patients should be allowed
to accept increased levels of risk (ACOG, 2019).
To provide safe, effective care, it is essential that nurses who care
for patients in the labor and birth suite have received extensive
training in fetal monitoring interpretation. At the first sign of any
abnormality in the FHR tracing, the nurse must alert the physician or
CNM. Meticulous documentation is critical because it provides
essential information to other members of the health-care team. For
the elective cesarean birth, informed consent is obtained in the
physician’s office before admission, and the nurse confirms this with
the patient. Once patients actually experience labor, it is possible for
them to change their minds, and depending on the circumstances,
they may choose not to have a vaginal birth. As in other situations,
the nurse responds to questions and concerns and ascertains the
patient’s understanding of the associated benefits and risks.
During the entire labor process, the nurse is alert for any changes
in the maternal-fetal condition. The FHR pattern and uterine activity
are usually monitored electronically during the active phase of labor.
Nonreassuring FHR patterns such as prolonged decelerations, late
decelerations, and variable decelerations may precede uterine
rupture or herald its occurrence. The nurse continuously evaluates
the woman’s level of pain. Uterine rupture may be accompanied by
abdominal, shoulder, or back pain even when epidural anesthesia
has been administered. However, the nurse should frequently
palpate the uterus for signs of rigidity because the patient may report
no pain. When present, uterine or abdominal pain most often occurs
in the area of the previous incision and can range from mild to a
“tearing” sensation. Uterine contractions may diminish in intensity
and frequency, accompanied by loss of station of the presenting part.
Vaginal or intra-abdominal bleeding may be accompanied by
symptoms of anxiety, restlessness, weakness, dizziness, and gross
hematuria. Because there is always the possibility of an emergency,
the nurse must be prepared to react in a calm manner. As the labor
progresses, the patient and her support(s) should receive
reassurance and information regarding any change in the plan of
care.
BOX 8-5
Selection Criteria for Vaginal Birth After

Cesarean Birth (VBAC)
• One previous low-transverse cesarean birth (if two prior cesarean births, only
those who have also had a vaginal birth as well should be considered
candidates for a spontaneous labor)
• Clinically adequate pelvis in relation to fetal size
• No other uterine scars, anomalies, or previous rupture
• Physician immediately available throughout active labor capable of monitoring
labor and performing an emergency cesarean birth
• Availability of anesthesia and personnel for emergency cesarean birth
Source: American College of Obstetricians and Gynecologists (2019); Sommers

(2019).
Areas for Continued Research

The rising rate of cesarean births and the decrease in the number of
VBACs are related. The higher the number of first-time mothers who
experience a cesarean delivery, the higher the number of women
who may not have a choice for a vaginal delivery the next time if
their physician is reluctant to attempt a VBAC. Medical studies
currently question the rising cesarean birth rate. The adverse
consequences of higher cesarean birth rates contribute to an
increase in maternal morbidity and mortality. In addition, significant
economic costs are related to the prolonged hospital stays and the
increased need for expensive surgery-related technologies. Although
the greatest concern centers on the health and safety of the mother
and her fetus, burgeoning health-care costs cannot be discounted as
a problem. The National Partnership for Maternal Safety under the
guidance of the Council on Patient Safety in Women’s Health Care
developed a consensus bundle on the primary focus of reducing
primary cesarean sections (Lagrew et al, 2018).
Nurse researchers should continue to examine evidence to
provide a better understanding of the factors that impact the
cesarean birth rate. A few of the modifiable variables include
maternal obesity, fear of labor and delivery, physiological pushing
techniques, fear of injury, and convenience in planning a birth.
Nurses need to engage in clinical research designed to offer
evidence identifying the many factors that contribute to the rise in
cesarean births. Nurse educators in the community can provide
supportive interventions for these issues. Counseling during the
prenatal period to allay anxieties and fears is critical. Families also
need realistic plans for the childbirth along with thorough
explanations of procedures and what they should expect.
Prepared childbirth classes have increased in numbers and variety
in the United States. Although many health educators serve an
important role, the nurse with a clinical practice in obstetrics and
women’s health is in an ideal position to offer constructive guidance
to families. Families need to learn to advocate for themselves
through increased knowledge and understanding of the issues
surrounding operative deliveries. If women’s fears concerning
childbirth are lessened, they become more open to teaching and can
begin to function as collaborators in their own care. For example,
perinatal education and selective tension-reducing labor techniques
may reduce the woman’s fear of labor and birth. Perhaps women
who are able to overcome their fear of labor will choose to attempt
vaginal birth instead of elective cesarean birth. Nurses who serve as
childbirth educators have a unique opportunity to empower women
and their families through education, and this new knowledge and
self-confidence may translate into a reduction in the rate of cesarean
births.
POST-TERM OR PROLONGED PREGNANCY

A post-term pregnancy extends beyond 294 days or 42 weeks past
the first day of the last normal menstrual period (Venes, 2021). A
similar term, postdate, identifies a pregnancy that has gone past the
estimated date of birth. It is estimated that post-term pregnancies
occur in approximately 3% to 12% of all pregnancies.
Prolonged pregnancies are at risk for a number of problems
including fetal macrosomia associated with shoulder dystocia and
fetal injury, oligohydramnios, meconium aspiration, intrapartum fetal
distress, and stillbirth. Neonatal problems may include asphyxia,
meconium aspiration syndrome, hypoglycemia, polycythemia,
respiratory distress, and dysmaturity syndrome.
Maternal risks such as trauma, hemorrhage, infection, and labor
abnormalities are also associated with post-term pregnancy. Labor
interventions, including sweeping membranes, induction with
prostaglandins or oxytocin, forceps-or vacuum-assisted birth,
become more likely, as does cesarean birth (Avdiyovski & Haith-
Cooper, 2019; World Health Organization, 2019).
The exact cause of post-term pregnancy is unknown. However, a
woman with a history of one post-term pregnancy is more likely to
experience another with subsequent pregnancies.
Because the placenta ages rapidly past the 40th week of
gestation, it becomes inefficient and cannot adequately support the
fetus. Areas of infarction coupled with calcium and fibrin deposits
result in reduced placental reserves (Fig. 8-19). The decrease in
oxygen and nutrients results in fetal hypoxic episodes. Hypoxic
events that occur on a regular basis stress the fetus. When labor
commences, the post-term compromised fetus is at a greater risk for
severe distress than the nonstressed term infant.
Antenatal testing combined with careful expectant management is
used to monitor fetal status beyond the 40th week of gestation.
Antenatal testing is not viewed as a predictor of an untoward event
but as a way to identify the fetus that demonstrates signs of
compromise. The antenatal assessments most often obtained
include NSTs, biophysical profiles, amniotic fluid volume
measurements, and maternal daily fetal movement counts. Other
tests include the contraction stress test, which relies on oxytocin-
stimulated contractions to identify FHR decelerations associated with
fetal hypoxia, and Doppler flow measurements. The tests are usually
performed on a weekly or twice-weekly basis (Australian
Government Department of Health, 2019).
FIGURE 8-19 Calcifications appear as white areas in the placenta.
Medical Management
If a woman does not experience spontaneous labor by the 42nd
week (sometimes earlier), induction is considered the primary
medical management choice. Expectant management, including
daily kick counts, weekly monitoring of the amniotic fluid index, and
NST, provide information regarding fetal well-being but are not
always conclusive. If the gestational age is documented by
ultrasound to be beyond 42 weeks and the cervix is favorable, most
physicians and certified nurse midwives proceed with labor
induction. Health risks increase significantly after 42 weeks for both
mother and infant and induction becomes necessary.
Intrapartal nursing care centers on close maternal-fetal surveillance
and continued emotional support. Women should be cared for in an
environment with available emergency care in case of adverse
outcomes from interventions. During labor, the fetus should be
monitored electronically to obtain an accurate assessment of the
FHR and pattern. Umbilical cord compression, which is more likely to
occur in the presence of decreased amniotic fluid, results in fetal
hypoxia. Variable or prolonged deceleration patterns and the
passage of meconium are reflective of fetal hypoxia. If
oligohydramnios is present, amnioinfusion may be performed to
restore the amniotic fluid volume to provide a fluid cushion for the
umbilical cord.
PERINATAL LOSS
Perinatal loss is the death of a fetus or infant that occurs between
the time of conception and the end of the newborn period 28 days
after birth. A perinatal loss can occur during the antepartal,
intrapartal, or postpartum periods. Intrauterine fetal demise (IUFD),
otherwise known as a stillbirth, is the demise of a fetus after the
completion of 20 weeks’ gestation, or a fetus who weighs at least
500 mg when gestational age is unknown. A variety of causes may
lead to the death of the fetus or the newborn, often related to
obstetric complications such as maternal infection, post-term
pregnancy, advanced maternal age, trauma, abruptio placentae,
previous stillbirth, pre-eclampsia, diabetes, placental abnormalities,
neonatal prematurity related to genetic disorders, or congenital
malformations (Sommers, 2019; Venes, 2021). Many believe
perinatal death to be a rare phenomenon, but IUFD occurs in 1% of
pregnancies per year.
One serious clinical symptom of IUFD is a decrease in fetal
movement. A patient who presents a decrease or absence of fetal
movement should have a maternal-fetal evaluation as soon as
possible. The first procedure should be assessment for FHR,
followed by NST if fetal heartbeat is detected. If FHR is not found, an
immediate ultrasound should be done to assess for FHR. If IUFD
has occurred, further assessment should include assessment of
abdomen for rigidity, sepsis, vaginal examination to assess for
prolapsed cord, and full work-up for DIC.
If testing is reassuring for no maternal risks, then treatment will
include an induction of labor within the following days. Some patients
opt for expectant management and will wait for labor to initiate on its
own, while other patients opt to schedule an induction for the IUFD.
Nursing practice has changed over the years with regard to caring
for families who are dealing with a perinatal loss. From the 1960s
through the 1980s, women who experienced a perinatal loss were
often placed on a medical-surgical unit to prevent them from hearing
the sounds of infants crying. However, the most experienced
professionals in perinatal nursing are not located in the medical-
surgical areas. The patient who has suffered a loss still requires all
assessments and interventions involved in normal postpartum care.
A nurse in the perinatal practice area can better focus on therapeutic
interventions to assist the woman and her family in the grieving
process.
The nurse organizes and coordinates a team approach to
bereavement. Different members may participate, but there should
be key individuals such as spiritual or religious representatives,
social workers, and physicians, in addition to the nurse. It is
important to identify which hospital routines associated with perinatal
death might interfere with the family’s ability to make decisions
regarding their infant. As an example, in some cases, the infant’s
body might be moved to the funeral home before the family has had
the opportunity to hold him or her. Many parents wish to hold their
child before an autopsy, and they should be encouraged to do so.
Before presenting the parents with their infant, the nurse should
make certain the infant has been cleaned and is wrapped in a soft
blanket. Some institutions use a commercially developed
presentation/handling system that includes a basket for infant
presentation and a carrier component designed to discreetly
transport the infant to the morgue. Depending on the cause of death,
it may also be prudent to give the parents an idea of their infant’s
appearance. Some families may want to take hair or fingernail
clippings from the infant or follow practices of their culture. These
wishes should be respected and the family should be allowed time
with the infant. Usually, parents’ preconceived perception of how
their infant will look is much worse than the reality. Individuals from
the hospital morgue or a funeral home who are involved with regular
bereavement team meetings can be instrumental in developing a
perinatal bereavement plan grounded in compassion and sensitivity.
When healthy infants are discharged, it is common practice to take
their picture. Photographs should also be taken when an infant has
died. Parents should always be encouraged to view, touch, and hold
the deceased infant. However, if they do not wish to see the infant
while in the hospital, the picture provides a way for them to see their
infant at a future time when they are ready. Photographs can be
stored with the patient’s medical record and given to the parents
upon their request. Use of an experienced photographer is preferred,
because the infant may not always be in the most favorable
condition. The maternity unit should always have a supply of clothing
and new blankets available for these infants.
What to Say
To the Mother Whose Newborn Has Died
When caring for the mother whose infant has died, the nurse conveys
compassion by simply being available. Often, the mother finds comfort in
talking about the birth experience, her infant, and how she will cope with her
loss. The nurse can gain insights into the mother’s support systems by asking
the following questions:
“What are you most worried or fearful about?”
“How supportive is the baby’s father and your family or friends?”
“What coping techniques have been helpful for you in the past?”
A perinatal loss might be the first experience a family has with

death. It is a confusing, anxiety-provoking time that often creates a
fear that it will happen again. Death of a child of any age is also
viewed as unnatural. Parents expect their children to die after them
—not before them. Dreams and expectations for the lost child will
now never be realized. A resource guide given to the family on
discharge is an important tool to help them cope with their loss.
Much of the grieving work occurs after the hospitalization. Family
members need to know where to call for help and should be
provided with resources on discharge or initiate referral before
discharge.
Postpartum care should not be overlooked. Patients will still need
complete postpartum assessments and education on normal
physiological changes and adaptations as well as signs and
symptoms that require prompt evaluation. In addition, women who
have had an IUFD are at a risk of DIC (Sommers, 2019). When an
IUFD has occurred, the by-products of the retained fetus can start to
degenerate. The normal bodily function of elimination of these
products can begin the cascade of events of DIC, a life-threatening
illness. Patients must be educated on signs of DIC so they can be
evaluated and treated immediately.
SUMMARY POINTS
■ The nurse serves in many capacities when managing the care of women
experiencing a complicated labor and birth; a strong theoretical background
provides a foundation for the necessary critical decision making.
■ Dystocia—a long, difficult, or abnormal labor—may arise from any of the three
major components of the labor process: the powers, passenger, or
passageway.
■ During a TOL, nursing responsibilities center on assessment of maternal vital
signs and FHR and pattern.
■ Oxytocin used during labor induction and augmentation should always be
administered as a piggyback solution, and a uterine and FHR monitor should
be used continuously during the infusion.
■ Forceps and vacuum extraction are methods to assist birth; the mother and
the infant require special observation during and after these procedures.
■ The management of hypertensive disorders during intrapartum is focused on
preventing further deterioration of affected organs and fostering a positive
maternal-fetal outcome.
■ Cesarean birth, which may be a scheduled or emergency procedure, is
associated with increased risk for the mother and her infant and should be
undertaken only when medically necessary.
■ Perinatal loss necessitates a collaborative response from all professionals
involved in the care of the patient.
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Davis Advantage
UNIT 5

CHAPTER 9
Physiological Transition of the

Newborn
CONCEPTS
Pregnancy
Nursing
LEARNING OBJECTIVES

■ Explain normal adaptation in the newborn transition.
■ Identify factors that influence the initiation of respirations.
■ Describe normal neonatal patterns of behavior during the first several hours
after birth.
■ Demonstrate how to perform a newborn physical assessment.
■ Identify normal clinical assessment findings.
■ Describe positive bonding between mother and infant.
■ List key items for discharge planning for the newborn.
PICO(T) Questions
chapter.
1. Do (I) initial attempts at breastfeeding (P) infants during the first period of
reactivity following birth (O) result in fewer feeding issues (C) compared with
waiting until the second period of reactivity?
2. Do (P) infants born by cesarean birth (O) have a higher incidence of (I) initial
respiratory problems (C) than infants born by vaginal birth?
KEY WORDS
surfactant
respiratory distress syndrome (RDS)
acrocyanosis
periodic breathing apnea
ligamentum arteriosum
ligamentum venosum
homeothermic
neutral thermal environment (NTE)
nonshivering thermogenesis (NST)
brown adipose tissue (BAT)
conduction
convection
radiation
hyperthermia
hematocrit
polycythemia
glycogenolysis
jaundice
direct bilirubin
active acquired immunity
passive acquired immunity
plethora
petechiae
pustular melanosis
milia
erythema toxicum
nevi
telangiectatic nevus
nevus vasculosus
nevus flammeus
microcephaly
omphalitis
hypospadias
epispadias
INTRODUCTION
The transition from intrauterine to extrauterine life begins with the
birth of the newborn. This transition is an intense and dynamic period
during which a newborn goes from the safety of the life-sustaining
uterus to the world outside. This chapter explores the physiological
changes that take place in the newborn during the process of
transition. Alterations that occur in each major body system are
discussed, with emphasis on nursing assessment and interventions
to facilitate a normal transition.
ADAPTATIONS OF THE RESPIRATORY SYSTEM

Intrapulmonary Fluid, Fetal Breathing Movements, and
Surfactant
After birth, the initiation of respirations is the first important step in
neonatal transition. Many forces that occur during pregnancy and
childbirth facilitate this essential process. Amniotic fluid plays an
important role in fetal lung development. Inhalation of the amniotic
fluid into the lungs helps to promote growth and differentiation of the
lung tissue. Normal pulmonary functioning is dependent on two
factors: the alternating in-and-out fetal breathing movements and the
formation of intrapulmonary fluid.
NURSING INSIGHT
Fetal Breathing Movements

Breathing efforts are first initiated in utero as the fetus spends months
practicing coordinated inhalation and exhalation movements. Fetal breathing
movements can be observed by ultrasonography as early as 11 weeks of
gestation. The breathing movements serve as an important mechanism that
helps to develop the muscles of the chest wall and the diaphragm.
As the fetus approaches term, the secretion of intrapulmonary fluid

decreases. The absorption of fetal lung fluid accelerates during
labor, the birth, and for up to a few hours after birth. This fluid shift is
an important physiological event that assists in reducing the
pulmonary resistance to blood flow (necessary while in utero) and
facilitates the initiation of air breathing. Lung expansion after birth
stimulates the release of surfactant, a slippery, detergent-like
phospholipid that includes lecithin and sphingomyelin. Surfactant
causes a decreased surface tension within the alveoli, which
prevents alveolar collapse and allows for alveolar re-expansion and
gas exchange. Under normal circumstances, by the 35th week of
gestation, surfactant is produced in sufficient amounts to maintain
alveolar stability. Before this, lung maturity is assessed by the
lecithin-to-sphingomyelin (L/S) ratio, which in mature lungs is
produced at a ratio of 2 to 1. Before 35 weeks’ gestation, the lungs
produce less lecithin, indicating immature lungs that would require
maternal steroid administration before birth to improve L/S ratio for
fetal lung development and prevent alveolar collapse (Venes, 2021).
The First Breath

Four factors influence the initiation of the newborn’s first breath.
These include internal stimuli, i.e., the chemical changes, and
external stimuli i.e., the sensory, thermal, and mechanical changes)
(Fig. 9-1). Each factor stimulates the respiratory center located within
the medulla of the brain.
Chemical Factors
Chemical factors that initiate respirations are hypercarbia, acidosis,
and hypoxia. These conditions, brought about by the stress of labor
and birth, stimulate the respiratory center in the brain to initiate
breathing. Hypoxia causes blood oxygen levels (Po2) and pH to
drop. Subsequently, blood carbon dioxide levels (Pco2) begin to rise
and prompt the respiratory center within the medulla to initiate
breathing. This brief period of asphyxia occurs in all newborns during
the birth process. However, prolonged asphyxia that accompanies a
traumatic birth is abnormal and may cause respiratory depression
mediated by the central nervous system.
FIGURE 9-1 Chemical, sensory, thermal, and mechanical factors
involved in the initiation of respirations.
Sensory Factors
The newborn experiences overwhelming stimuli when leaving a
familiar, comfortable, warm environment to enter one filled with a
multitude of tactile, visual, olfactory, and auditory stimuli. These
sensory experiences aid in the initiation of respirations. Some infants
are unresponsive at birth and appear lethargic. They can be
stimulated with vigorous rubbing, which awakens the infant and
initiates respiration.
Thermal Factors
After months of development in a warm (98.6°F [37°C]), fluid-filled
environment, the newborn abruptly enters an environment where
temperatures are often cooler than in utero. The drastic change in
temperature helps stimulate the initiation of respirations. Sensors in
the skin respond to the temperature changes and send signals to the
respiratory system in the brain. Physiological changes in the
newborn’s temperature may occur, and as long as the temperature
remains within the normal range of 97.7°F to 98.6°F (36.5°C-
37.0°C), no problems related to the thermal environment should
develop. However, to prevent cold stress and respiratory depression,
the nurse immediately dries the infant and either places the infant
skin-to-skin with the mother/partner or in a radiant warmer.
Mechanical Factors
Primary mechanical factors involved in the initiation of respirations
include removing fluid from the lungs and replacing it with air. The
fetal chest compression thoracic squeeze that occurs during a
vaginal birth increases intrathoracic pressure and helps to push fluid
out of the lungs. Recoil of the chest wall after the birth of the
newborn’s trunk creates a negative intrathoracic pressure. This
facilitates a small, passive inspiration of air, which replaces the fluid
that has been squeezed out. Infants of cesarean births do not have
the same lung compressions with a vaginal birth and are at a higher
risk for pulmonary transitional difficulties.
Continued respiration occurs when the pressure within the
newborn’s lungs increases and pushes the remaining fetal lung fluid
into the lymphatic and circulatory systems. Most of the fluid is
reabsorbed within the first few hours, but in some infants this
process may take up to 24 hours. The newborn’s lungs may sound
moist during early auscultation but should become clear as the fluid
is absorbed.
Factors That May Interfere With Respiration

A number of factors may interfere with the newborn’s ability to initiate
respirations. Conditions such as prematurity or birth asphyxia can
adversely affect lung compliance (elasticity) and surfactant
production. Childbirth events including trauma, maternal
medications, and the mode of birth can interfere with normal
pulmonary transition.
Infants born before 35 weeks have low levels of surfactant and are
more likely to develop respiratory distress syndrome (RDS). RDS
is a developmental disorder of the respiratory system that begins at
birth or very soon after. It occurs most frequently in infants born with
immature lungs. Lack of adequate surfactant can cause RDS to
progress to atelectasis, loss of functional residual capacity,
alterations in the ventilation perfusion ratio, and poor lung
compliance. Pregnant women who go into labor before the 35th
week will often receive a steroid injection to help the newborn to
produce surfactant to prevent alveolar collapse. (See Chapter 15 for
Cardiopulmonary Transitions
Cardiopulmonary adaptations must also occur during the transition
from fetal to neonatal pulmonary functioning. As air enters the lungs,
the Po2 rises in the alveoli. This normal physiological response
causes pulmonary artery relaxation and results in a decrease in
pulmonary vascular resistance. As the pulmonary vascular
resistance decreases, pulmonary blood flow increases, reaching
100% by the first 24 hours of life. The increased pulmonary blood
volume contributes to the conversion from fetal to newborn
circulation (Fig. 9-2). Once the pulmonary circulation has been
functionally established, blood is distributed throughout the lungs.
Although a variety of hemoglobins (HGBs) are present in the fetus
and newborn, the most significant types are fetal hemoglobin (HbF)
and adult hemoglobin (HbA). HbF has a greater affinity for oxygen
than HbA, and the newborn’s blood oxygen saturation is greater than
that found in adults. However, there is less oxygen available to the
tissues. Before birth, this situation is beneficial—the fetus must
maintain an adequate oxygen uptake despite low oxygen tension
levels because the umbilical venous Po2 cannot exceed the uterine
venous Po2.
Assessment of the newborn’s cardiopulmonary system must occur
immediately after birth. Overall, skin color provides one of the most
important indicators of how well the newborn is making the transition
to extrauterine life. Infants typically exhibit a central pink hue with
acrocyanosis, a bluish coloration of the hands and feet that may
persist for up to 24 hours until peripheral circulation improves. Signs
of cyanosis may be easier to detect on infants with lighter skin tone.
The nurse may notice blueish or purple lips, extremities, or
abdomen. In infants with darker skin tones, the nurse must assess
the mucous membranes for a blue or purple tinge.
The normal respiratory rate for a healthy term newborn is 30 to 60
breaths per minute. The breathing pattern is often shallow,
diaphragmatic, and irregular. Abdominal movements should be
synchronous with chest movements. The breathing pattern may
include brief pauses that last 5 to 15 seconds. Termed periodic
breathing, this pattern is usually not associated with any change in
skin color or heart rate and has no prognostic significance. Apnea is
cessation of breathing that lasts more than 20 seconds. It is
abnormal in the term newborn and may or may not be accompanied
by changes in skin color or a decrease in the heart rate less than
100 beats per minute. Apnea should be reported immediately. Other
indicators of respiratory difficulties include expiratory grunting,
wheezing, nasal flaring, retractions, use of accessory muscles when
the newborn is at rest or in the sniffing position (neutral breathing
position), or a breathing rate that is outside the normal range.
CARDIOVASCULAR ADAPTATION
Changes After Placental Expulsion
Expulsion of the placenta following childbirth triggers important
physiological events in the transition process. In utero, the placenta
serves as the exchange organ for oxygen and nutrients and for the
excretion of fetal waste products such as carbon dioxide. Maternal
oxygenated blood enters the fetal circulation via the umbilical vein.
Approximately 40% to 60% of the blood perfuses the fetal liver while
the remaining volume of blood passes through the ductus venosus
and enters the right atrium via the inferior vena cava.
FIGURE 9-2 Major events that occur during the transition from fetal
to neonatal circulation include closure of the foramen ovale, the
ductus arteriosus, and the ductus venosus.
After placental separation at birth, the umbilical arteries and vein

constrict as the fetal circulatory system is interrupted. Successful
cardiopulmonary adaptation in the newborn involves five major
changes: an increased aortic pressure and decreased venous
pressure; an increased systemic pressure and decreased pulmonary
pressure; and closure of the foramen ovale, the ductus arteriosus,
and the ductus venosus (Fig. 9-3). Table 9-1 presents a summary of
the structural changes in circulation that take place in the newborn.
Closure of the Foramen Ovale

The foramen ovale is a flap in the septum of the fetal heart that
allows blood flow between the right and left atria. Oxygen-rich blood
returning to the heart from the inferior vena cava crosses from the
right atria to the left atria across the foramen ovale. This pathway
allows most of the oxygenated blood to bypass the nonfunctioning
lungs and supply the aorta and vessels of the heart and head with
oxygen.
The right-to-left shunting ceases once the umbilical cord has been
clamped. The ventricular and aortic pressures in the left side of the
heart rise. The systemic vascular resistance increases while
pressure in the right side decreases. The pulmonary blood vessels
respond to the increase in Po2 during lung expansion and aeration
with vasodilation and a decrease in pulmonary vascular resistance.
These changes cause an increase in blood flow through the
pulmonary veins to the left atrium and lead to an increased left atrial
pressure that results in closure of the foramen ovale. The foramen
ovale is only capable of shunting from right to left, and this
physiological event closes the shunt. The foramen ovale then
becomes the fossa ovalis, which should be closed within 1 to 2 hours
after birth. Permanent closure occurs by the sixth month of life. If the
infant experiences difficulties such as asphyxia, acidosis, or cold
stress during the physiological transition period, the shunt may
reopen and allow for continued right to left shunting due to the
increased pressure in the right atria.
Closure of the Ductus Arteriosus

In utero, most of the fetal blood flow occurs across the ductus
arteriosus. This structure functions as the pathway between the
pulmonary artery and the descending aorta. Blood flow through the
ductus arteriosus occurs in a right-to-left direction due to the high
pulmonary vascular resistance and low placental resistance. Once
the umbilical cord is clamped, placental blood flow ceases and there
is an increase in the systemic blood pressure and vascular
resistance. At this point, the lungs oxygenate the blood and the
increased Pao2 stimulates the closure of the ductus arteriosus.
Functional closure of the ductus arteriosus in a term infant typically
occurs within the first 72 hours of life. Before the complete closure, a
small amount of blood flowing through the ductus arteriosus may
produce a soft murmur. When present, it can be auscultated at the
left sternal border in the area of the second intercostal space. Once
permanent closure occurs at 3 to 4 weeks, the structure is termed
the ligamentum arteriosum. Permanent closure results from
endothelial destruction, connective tissue formation, and subintimal
proliferation.
The infant whose birth transition has been complicated by factors
such as asphyxia or prematurity has an increased risk of the ductus
not closing completely. This results from continued blood flow
through the partially opened ductus arteriosus, known as patent
ductus arteriosus (PDA) (Fig. 9-4). Low levels of oxygenated blood
flowing through the shunt cause it to dilate, creating a serious
transitional complication (Durham and Chapman, 2019).
FIGURE 9-3 Neonatal circulation.
TABLE 9-1
Structural Changes in Circulation After Birth
FETUS NEWBORN
Umbilical vein Ligamentum teres
Ductus venosus Ligamentum venosum
Foramen ovale Closed atrial septum
Ductus arteriosus Ligamentum arteriosum
Umbilical artery Superior vesical (bladder) artery Lateral
vesicoumbilical ligaments
Closure of the Ductus Venosus

The ductus venosus links the inferior vena cava with the umbilical
vein. The umbilical vein delivers approximately 50% of the placental
blood flow through the ductus venosus into the inferior vena cava
and then mixes with the systemic venous drainage from the lower
body. Blood flow through the left hepatic vein mixes with blood in the
inferior vena cava and flows toward the foramen ovale. Oxygenated
blood traveling through the umbilical vein enters the left ventricle and
supplies the carotid arteries with oxygen. Once the umbilical cord is
clamped, cessation of umbilical venous blood return, along with
mechanical pressure changes, leads to closure of the ductus
venosus. Closure of the bypass route forces enhanced blood flow to
the liver. Fibrosis occurs in the nonfunctional ductus venosus, and
the structure, which is termed the ligamentum venosum, usually
closes by the end of the first week.
FIGURE 9-4 Patent ductus arteriosus.
THERMOGENIC ADAPTATION
Neonatal thermoregulation is essential for life-sustaining
physiological adaptation. The newborn’s ability to maintain a normal
body temperature after birth is dependent on factors in the external
environment as well as internal physiological processes. Newborns
are characteristically homeothermic—that is, they attempt to
regulate and maintain their internal core temperature regardless of
varying external environmental temperatures.
The Neutral Thermal Environment

Thermogenic adaptation is closely related to the infant’s rate of
oxygen consumption and metabolism. The neutral thermal
environment (NTE) is the range of temperature in which the
newborn’s body temperature can be maintained with minimal
metabolic demands and oxygen consumption. To maintain an NTE,
the newborn may need to make certain vasomotor adjustments,
such as vasoconstriction to conserve heat or vasodilation to release
heat. Most term newborns are able to restore the initial decline in
body temperature when they are born and stabilize at a normal
(axillary) temperature of 97.7°F (36.5°C) to 98.6°F (37°C) within 2 to
3 hours after birth.
The term newborn’s ability to maintain temperature often depends
on the protective subcutaneous fat, which helps to maintain a barrier
for prevention of heat loss; newborns have less than half of the
amount of subcutaneous fat normally present in adults. Preterm
infants are born with very little adipose tissue and lack the muscle
development needed to maintain a flexed position for heat
conservation. Although full-term newborns have a large body area in
relation to the total body mass, their normal position of flexion
facilitates maintenance of body heat. As the newborn transitions to
extrauterine life, their ability to respond to the thermal environment is
delayed for a few weeks and places them at significant risk for cold
stress (Durham & Chapman, 2019).
Physiological Adaptations for Heat Production

When the infant is exposed to a cold environment, several
physiological adaptations help them to increase heat production.
These include increasing the basal metabolic rate and muscle
activity to generate heat, peripheral vasoconstriction to conserve
heat, and nonshivering (or chemical) thermogenesis (NST) (heat
production). Unlike children and adults, newborns are unable to
shiver to generate heat. Instead, they must produce heat via NST,
and this process becomes the key mechanism for maintaining an
NTE.
The sympathetic nervous system responds to skin receptors
programmed to recognize a drop in the environmental temperature.
Once low temperatures are detected, the receptors alert the
sympathetic nervous system. NST uses the newborn’s stores of
brown adipose tissue (BAT) to provide heat in the cold-stressed
newborn. Formation of BAT in the fetus begins at around 26 to 30
weeks of gestation. The deposits of BAT steadily increase until 2 to 5
weeks after birth unless they have been depleted by cold stress.
Stores of BAT are located in the midscapular area, around the neck,
and in the axillae. Deeper deposits are found around the trachea,
esophagus, abdominal aorta, kidneys, and adrenal glands (Fig. 9-5).
BAT, also known as brown fat, is a unique highly vascular fat found
only in newborns. BAT derives its name from the rich abundance of
blood vessels, cells, and nerve endings that cause it to appear dark
in color. The masses of brown fat cells accelerate triglyceride
metabolism, triggering a process that produces heat. Rapid
metabolism, along with the generation of heat, quickly sends heat to
the peripheral circulation. Newborns are only born with a limited
supply of BAT that doesn’t regenerate, and cold stress can rapidly
use up this store, leaving no reserve.
FIGURE 9-5 Sites of brown adipose tissue stores (in yellow) in the
newborn.
Mechanisms for Neonatal Heat Loss

The nurse’s role in preventing neonatal cold stress is critical.
Supporting thermoregulation after birth allows the newborn to have a
successful transition from intrauterine to extrauterine life. Thorough
assessments of all of the newborn’s systems should be aimed at
maintaining an NTE. The newborn has four mechanisms by which
heat is lost after birth: evaporation, conduction, convection, and
radiation (Fig. 9-6).
Evaporation
Evaporation is the loss of heat that occurs when fluids that cover the
body are air-dried and converted into vapor. If not adequately dried
after birth, the newborn loses heat through the evaporation of
amniotic fluid or other fluids on the skin or through insensible fluid
loss, which is a loss of bodily fluids that occur through the skin
(Venes, 2021). Nursing interventions geared toward preventing
evaporative heat loss include thoroughly drying the newborn after
birth, promptly removing wet linens, and immediately placing a hat
on the head to prevent evaporation through the scalp.
Conduction
Conduction is the loss of heat to a cooler surface via direct skin
contact. Conductive heat loss occurs when the infant is placed on a
cold surface, such as a cold scale, mattress, or examining table.
Nursing interventions to minimize conductive heat loss include
placing the infant on a prewarmed radiant warmer, using warmed
blankets, covering scales with blankets before weighing, and
avoiding the use of cold instruments (e.g., stethoscope). The
newborn can also be placed skin-to-skin with the mother to facilitate
body warming and bonding.
FIGURE 9-6 The four mechanisms of heat loss in the newborn. A,

Evaporation. B, Conduction. C, Convection. D, Radiation.
Convection
Convection is the loss of heat from the warm body surface to the
cooler air currents. Convective heat loss occurs when the newborn is
exposed to drafts and cool circulating air. The nurse can help
minimize neonatal heat loss through convection by preventing drafts
in the birth area (e.g., no ceiling fans) and by placing the newborn
away from doors or windows. Also, depending on the environment,
the newborn should be warmly clothed and possibly swaddled to
prevent cooling from air currents.
Radiation
Radiation heat loss occurs when there is a transfer of heat between
objects that are not in direct contact with each other. The walls of the
nursery or the incubator may serve as potential sources of heat loss
through radiation. Nursing interventions to prevent heat loss through
radiation include having a prewarmed radiant warmer present at the
birth, avoiding placement of the crib or incubator by a cold window,
and keeping cold objects well away from the newborn.
Preventing Hyperthermia
It is also important to prevent neonatal hyperthermia (elevated core
body temperature). Although sweating is the full-term infant’s initial
response to elevated body temperature, the sweat glands are not
fully functional until after the first month of life. Before that time, the
body loses heat through peripheral vasodilation and the evaporation
of insensible water loss. An increase in oxygen consumption and the
metabolic rate are associated with hyperthermia, and when severe,
brain damage or death may result.
During the first few minutes of life, neonatal hyperthermia is most
often associated with maternal fever. An elevated core body
temperature can also result from an ambient environment that is too
hot for the newborn to successfully maintain a neutral temperature.
Other causes of hyperthermia include infection, central nervous
system impairment, dehydration, excessive clothing or coverings, an
environment that is too hot, and medications.
Factors Related to Cold Stress

Cold stress is one of the greatest risks to the health of a newborn.
Preventing cold stress is a priority and nurses need to be aware of
the different risks. Exposure to low environmental temperatures,
especially for a prolonged period of time, causes an increase in
oxygen consumption and an increased rate of metabolism. Factors
associated with high risk for cold stress include:
■ Large body area in relation to body mass
■ Limited subcutaneous fat
■ Limited amount of brown fat
■ Limited ability to shiver
■ Thin skin and blood vessels that are closer to the body’s surface
HEMATOPOIETIC ADAPTATION
As with most of the newborn’s other body systems, the
hematopoietic system is not fully mature at birth. Instead, in the days
following birth, the newborn’s hematopoietic system transitions from
an in-utero oxygenation pathway to an extrauterine perfusion
pathway.
Blood Volume
The full-term infant’s average blood volume ranges from 80 to 90
mL/kg of body weight. The newborn’s blood volume is determined in
large part by the timing of umbilical cord clamping. At birth, blood
transfers from the placenta to the newborn. Delayed cord cutting
allows for additional blood transfer from the placenta to the fetus and
can significantly increase blood volume.
Delayed cord cutting reduces risk for anemia and may facilitate an
improved transition because of enhanced pulmonary perfusion and
the gain of additional iron stores. This allows additional blood to
transfer from the placenta to the newborn, resulting in higher rates of
HGB and hematocrit. However, a disadvantage of this practice
concerns the increased risk of jaundice caused by the higher volume
of erythrocytes and possible resultant polycythemia.
Blood Components
Erythrocytes and Hemoglobin
At birth, the newborn has a greater number of erythrocytes and
higher HGB and hematocrit levels than in an adult. During early fetal
development, erythropoiesis (formation of red blood cells [RBCs])
occurs primarily in the liver. At approximately 6 months of gestation,
the bone marrow becomes the site for hematopoiesis (formation of
blood cells). During the later stages of fetal development, HbF is
slowly replaced by HbA. HbF carries more oxygen than HbA.
The process of erythropoiesis is stimulated by the renal hormone
erythropoietin. RBC production increases in response to a rise in
erythropoietin after low fetal oxygen saturation. This physiological
event facilitates adequate tissue perfusion and oxygenation. After
the initiation of normal respirations at birth, the newborn’s oxygen
saturation rises, causing an inhibition in the secretion of
erythropoietin. This event inhibits the production of RBCs.
The newborn’s erythrocytes (fetal RBCs) have a shorter life span
(90 days) than adult RBCs (120 days). As the newborn’s RBC count
decreases from deterioration of the fetal RBCs, physiological anemia
of infancy may develop and persist for 2 to 3 months. The life span
of RBCs in the full-term newborn is 60 to 70 days; for the preterm
newborn, the RBC life span is only 35 to 50 days (Esan, 2016). In
the event of hemolysis, the HGB is broken down and bilirubin is
released into the systemic circulation. If large numbers of RBCs are
involved, blood levels of bilirubin rise, and the newborn becomes
jaundiced. See Chapter 10 for further discussion of jaundice.
Hematocrit
Hematocrit is defined as a percentage of RBCs within a certain unit
volume of blood. Normal neonatal blood values vary according to
gestational age and the volume of placental blood that was
transfused at the time of birth (i.e., delayed cord clamping). A
peripherally drawn hematocrit for a normal infant ranges from 46% to
68%. If the hematocrit drawn from a central site is greater than 65%,
the infant is considered to be polycythemic. Polycythemia, an
abnormally high RBC count, is a condition that can place the infant
at high risk for jaundice and organ damage caused by increased
viscosity of the blood cells. Polycythemic infants are also at an
increased risk for hypoglycemia and respiratory distress. Under
routine circumstances, unless the infant exhibits signs and
symptoms associated with transitional difficulties, hematocrit and
HGB levels are not routinely assessed. Infants who exhibit a ruddy
color or reddish skin color may be a sign of polycythemia, and
assessment for jaundice becomes increasingly important (Van
Leeuwen & Bladh, 2021).
A heel stick blood sample for hematocrit and HGB may be
performed to detect anemia or polycythemia (an excess number of
RBCs). Anemia can result from hypovolemia associated with
complications such as placenta previa, abruptio placentae, or
cesarean birth. Polycythemia may be related to excessive blood flow
from the umbilical cord into the infant at birth. A normal hematocrit at
1 hour of life is 46% to 55%. A normal HGB is 15.2 to 22.5 g/dL.
Early detection of abnormal laboratory results can ensure immediate
treatment.
Labs
Blood Component Normal Range
Albumin 2.6–3.6 g/dL
Bilirubin, total
Newborn Birth-1 day <5.8 mg/dL
1–2 days <8.2mg/dL
3–5 days <11.7 mg/dL
Bleeding time 2 minutes
Arterial blood gases Birth, cord, full- 5 7.11–7.36
term pH
Venous blood gases Birth, cord, full- 7.25–7.45
term pH
Glucose (birth) 30–100 mg/dL
1 Hematocrit 42%-62% (cord blood)
46%-68% (0–1 week)
Hemoglobin 13.5–20.7 g/dL (cord blood)
15.2–23.6 g/dL (0–1 week)
Platelets 150,000–450,000/mm3
Iron 100–250 mcg/dL
IgA 1–4 mg/dL
IgD Greater than 2 mg/dL
IgG 650–1,600 mg/dL
IgM Less than 25 mg/dL
IgE Less than 20 units/mL
Source: Van Leeuwen, A. M, & Bladh, M. L. (Eds.). (2021).
Leukocytes
Leukocytes (white blood cells [WBCs]) serve as the major defense
against infection in the newborn. WBCs are classified into five
categories: neutrophils, eosinophils, basophils, lymphocytes, and
monocytes. Neutrophils act as phagocytes that ingest and destroy
small particles of bacteria and cellular debris. Eosinophils perform
similar duties but are less effective. However, eosinophils survive
longer than neutrophils and act as important mediators in allergic
and anaphylactic responses. Basophils respond to allergic and
inflammatory reactions. Lymphocytes are responsible for making
antibodies to fight infections as well as foreign cells such as cancer.
Monocytes clean up old blood cells and cellular debris and remove
activated clotting factors from the circulation.
An elevated leukocyte count in a normal newborn does not always
indicate infection. During the first 12 hours after birth, the leukocyte
count typically remains elevated before it begins to decline. The
average WBC count in the term newborn ranges from 9,100 to
30,000/mm3, considered within normal limits (Van Leeuwen & Bladh,
2021). Infection is usually associated with a decrease in the
leukocyte count. Neonatal sepsis is accompanied by an increased
number of immature leukocytes along with a decrease in the total
platelet count.
Platelets
Largely due to the absence of vitamin K at birth, the newborn is at
risk for developing a blood-clotting deficiency during the first few
days of life. To facilitate clotting, the following blood factors must be
present: factor II (prothrombin) and factors VII, IX, and X. Vitamin K,
synthesized in the infant’s intestinal tract, is not produced in the
intestines until food and normal intestinal flora are present. The
infant is given an IM injection of vitamin K1 phytonadione
(AquaMEPHYTON) during the initial care and assessment to prevent
hemorrhagic disease of the newborn.
HEPATIC ADAPTATION
The newborn’s liver is a large organ that accounts for about 40% of
the total abdominal area. It is palpable approximately 2 to 3 cm
below the right costal region. The liver is essential for the regulation
of blood glucose, iron storage, bilirubin conjugation, and coagulation
of the blood.
Glycogen and Blood Glucose Maintenance

Throughout pregnancy, the fetus receives glucose by way of the
placenta. During the last 4 to 8 weeks of gestation, the glucose is
stored as glycogen in the fetal liver and skeletal system for use after
birth. Glucose is used more rapidly in the newborn than in the fetus
due to the metabolic demands that occur during transitions. The
newborn requires added energy to accomplish several essential
tasks to offset the stress of birth, initiate breathing, activate muscular
activity, and produce heat.
The stressful events associated with the birth process prompt the
conversion of fats and glycogen to glucose. After the birth, an
increase in circulating catecholamines triggers the release of
glycogen from the newborn’s liver. Glycogen provides a ready
source of glucose to the brain and other vital organs. The liver’s
ability to adequately convert glycogen to glucose for fuel is essential
for a successful physiological transition.
During the first 4 to 6 hours of life, the newborn’s main source of
energy is glucose. The serum blood glucose level drops during the
first 3 hours of life and then gradually rises over the next 3 to 4 hours
to reach a steady state of 40 to 60 mg/dL. Glycogenolysis, the
breakdown of glycogen into the more usable glucose within the body
tissues, occurs if the newborn does not receive any exogenous
glucose before the initial hepatic and skeletal glycogen stores have
been depleted. This process prompts the release of glucose into the
bloodstream as needed to maintain normal blood levels.
Hypoglycemia
Assessment of blood glucose helps prevent newborn injury related to
hypoglycemia. In healthy term infants after an uneventful pregnancy
and birth, blood glucose monitoring often takes place within the first
hour after birth. Normal infant glucose is between 45–65 mg/dL.
During the early newborn period of a term infant, hypoglycemia is
defined as a blood glucose concentration of less than 35 mg/dL or a
plasma concentration of less than 40 mg/dL. Infants with a low blood
glucose level or who exhibit signs and symptoms of hypoglycemia
(jitteriness, apnea, seizures, lethargy, and hypothermia) require
immediate attention to prevent brain cell damage. Hypoglycemia
usually resolves with feeding. If the newborn continues to display
signs and symptoms of hypoglycemia along with low blood glucose
laboratory results, transfer to the neonatal intensive care unit for IV
administration of glucose may be necessary.
Hypoglycemia can occur after stressful events (e.g., hypothermia
or hypoxia) that increase metabolic demands. Hypoglycemia also
occurs more frequently in infants with abnormal growth patterns.
Nurses must be aware of risk factors associated with neonatal
hypoglycemia (Box 9-1).
Iron Storage
During the last few weeks of pregnancy, iron is stored in the fetal
liver. At birth, the newborn’s iron store is proportional to the total
body HGB and length of gestation. As RBCs are destroyed after
birth, the neonatal liver stores additional iron until needed for the
production of new RBCs. At term, the newborn has approximately
270 mg of iron, and of this amount, 140 to 170 mg of iron is
contained in the HGB. Adequate maternal iron intake during
pregnancy ensures that a sufficient amount of iron is available in the
infant to last up to 6 months of age. Term infants who are exclusively
breastfed do not need additional supplemental iron until at least 4
months of age. However, formula-fed infants should be given an
iron-fortified formula, and beginning at 6 months, all infants should
receive iron supplements or iron-rich foods to prevent anemia
(Centers for Disease Control and Prevention, 2019d).
Hyperbilirubinemia
Conjugation of bilirubin is a major function of the newborn’s liver.
Before birth, the fetus does not need to conjugate bilirubin; instead,
unconjugated bilirubin is transferred across the placenta for maternal
excretion. After birth, the newborn’s liver must be able to
satisfactorily conjugate bilirubin. Bilirubin is produced from the
hemolysis (breakdown) of RBCs and HGB. Infants have HbF, which
has a shorter half-life, resulting in a faster breakdown of HGB. In this
state, bilirubin is known as unconjugated or indirect bilirubin.
Box 9-1
Risk Factors for Hypoglycemia in the Newborn
• Prematurity
• Postmaturity
• Intrauterine growth restriction (IUGR)
• Large or small for gestational age (LGA or SGA)
• Asphyxia
• Difficult transition at birth
• Cold stress
• Maternal diabetes mellitus or preeclampsia-eclampsia
• Maternal intake of terbutaline (Brethine)
• Infection
• Congenital malformations
• Seizures
Conjugation is a process that converts the yellow lipid-soluble

(nonexcretable) bilirubin pigment into a water-soluble (excretable)
pigment. Jaundice is a condition characterized by a yellow (icteric)
coloration of the skin, sclera, and oral mucous membranes. Jaundice
results from the accumulation of bile pigments associated with an
excessive amount of bilirubin in the blood. First noticed in the head,
jaundice gradually progresses to the thorax, abdomen, and
extremities. The total serum bilirubin level (TSB) is a measurement
of both the conjugated and unconjugated bilirubin. At birth, the
normal TSB is 3 mg/dL or less. Jaundice is typically evident when
the serum bilirubin levels reach approximately 4 to 6 mg/dL. The
yellow coloration of the body then progresses caudally as the TSB
rises to 6 to 7 mg/dL.
Unconjugated, or “indirect,” bilirubin is fat-soluble and
nonexcretable. The newborn’s liver must be able to convert the fat-
soluble (nonexcretable) bilirubin into a water-soluble (excretable)
form by way of conjugation. Bilirubin is a highly neurotoxic
substance. During this process, the unconjugated bilirubin attaches
to the blood albumin and is transported to the liver. In the liver, the
unconjugated bilirubin detaches from the albumin and is conjugated
with glucuronide in the presence of the enzyme glucuronyl
transferase. This process produces water-soluble direct bilirubin,
which is excreted into the common bile duct and duodenum. Normal
intestinal flora reduces the direct bilirubin into urobilinogen and
stercobilinogen. This product is then excreted as a yellow-brown
pigment in the stools, and a small amount is excreted through the
kidneys. If unconjugated bilirubin cannot be turned into conjugated
bilirubin, then elevated blood levels of unconjugated bilirubin can
result in kernicterus (“yellow nucleus”), which refers to the deposition
of unconjugated bilirubin in the basal ganglia of the brain. This
condition can result in hearing loss, cerebral palsy, and vision and
teeth problems as well as the permanent neurological sequelae such
as intellectual disabilities, seizures, apnea encephalopathy, and
death (Centers for Disease Control and Prevention, 2019a) (Box 9-
2).
The physiological pathway for the excretion of bilirubin is
presented in Figure 9-7. (See Chapter 10 for further discussion.)
BOX 9-2
Factors for Hyperbilirubinemia

• Jaundice within first 24 hours after birth
• A sibling who was jaundiced as a newborn
• Unrecognized hemolysis such as ABO blood type incompatibility or Rh
incompatibility
• Nonoptimal sucking/nursing
• Deficiency in glucose-6-phosphate dehydrogenase, a genetic disorder
• Infection
• Cephalohematomas/bruising
• East Asian or Mediterranean descent
• Family history of jaundice or previous child with jaundice
• Neonatal complications (e.g., asphyxia neonatorum, cold stress, and
hypoglycemia)
Source: Centers for Disease Control and Prevention. (2019a).

FIGURE 9-7 Physiological pathway for the excretion of bilirubin.
GASTROINTESTINAL ADAPTATION
Stomach and Digestive Enzymes
The newborn’s stomach capacity is approximately 6 mL/kg at birth,
and by the end of the first week of life, the capacity has increased to
hold approximately 90 mL. In utero, the fetal gastrointestinal system
reaches maturity around 36 to 38 weeks of gestation when there is
sufficient enzymatic activity for digestion and the transport of
nutrients throughout the body. To nutritionally thrive, newborns must
be able to digest essential carbohydrate disaccharides that include
lactose, maltose, and sucrose. Lactose, the primary carbohydrate in
breast milk, is easily digested and readily absorbed. A deficiency of
pancreatic amylase, the only enzyme lacking at birth and during the
first few months of life, makes it difficult for infants to digest fats
efficiently. Newborns also have a decreased production of pancreatic
lipase and bile acids, which further limits their ability to absorb fats.
Production of pancreatic lipase gradually increases during the first
few weeks of life.
Intestinal Peristalsis
Fetal peristalsis can be influenced by anoxia, which triggers the
expulsion of meconium into the amniotic fluid. Immediately after
birth, air enters the stomach and reaches the small intestine within 2
to 12 hours. Bowel sounds are present within the first 15 to 30
minutes of life due to air that has entered the stomach and small
intestines. The gastrocolic reflex is stimulated when the stomach fills,
and this process helps to enhance intestinal peristalsis. The stomach
empties intermittently, usually at the beginning of a feeding and up
until 2 to 4 hours after a feeding. The salivary glands are immature at
birth; little saliva is produced for the first 3 months of life. The cardiac
sphincter (located between the esophagus and the stomach) is
immature, and it is not unusual for newborns to regurgitate small
amounts following feedings. Compared with the overall body size,
the newborn’s intestines are long, a feature that provides an
increased surface area for the absorption of nutrients. However, if
diarrhea occurs, the additional surface area places the infant at an
increased risk for dehydration and water loss. Infants born at term
generally pass their first meconium stool within 8 to 24 hours of life.
An important nursing function includes documentation of the first
meconium stool. Absence of passage of a bowel movement by 72
hours of age may be indicative of an obstructive bowel problem or an
imperforate anus.
Stools
Meconium is the first stool of a newborn and consists of particles
found in the amniotic fluid such as vernix, skin cells, hair, and cells
that have been shed by the intestinal tract. Meconium stools begin
as a greenish-black, thick, viscous, and sticky substance that
gradually transition to become thinner and greenish-brown or
yellowish-brown. Failure to pass meconium within 48 hours of birth
may indicate obstruction or imperforated anus. The newborn may
pass stools from 1 to 10 times a day over a 24-hour period.
Following the transitional stools, stool appearance and frequency
vary, depending on whether the infant is breast- or bottle-fed.
Kidney Function
In utero, the placenta does the job of the newborn’s kidneys by
removing and excreting waste. After birth, the newborn kidneys start
to function. Three major physiological factors need to occur for the
kidneys to manage bodily fluids, remove waste, and excrete urine:
■ The nephrons are fully functional by 34 to 36 weeks of gestation.
■ The glomerular filtration rate (GFR) is lower than that of the adult.
■ There is a limited capacity for the reabsorption of HCO3– and H+.
Although the fetal kidneys contain working nephrons by 34 to 36
weeks of gestation, the kidneys are not mature and fully functional
until after birth when the newborn becomes responsible for the
elimination of waste products. The newborn’s elevated hematocrit
(related to the high concentration of RBCs) and low blood pressure
may lead to a decreased GFR (the volume of glomerular filtrate that
is formed over a specific period of time). With a low GFR, the
newborn’s kidneys are unable to dispose of fluid rapidly and tend to
reabsorb excess sodium. As the kidneys mature and enlarge, the
GFR rapidly increases during the first 4 months of life. Adult GFR
values are reached around 2 to 3 years of age.
In the newborn, urine-specific gravity normally ranges from 1.002
to 1.010. In the term newborn, the kidney tubules are short and
narrow, which result in the inability to adequately concentrate urine
(reabsorb water back into the blood). This alteration may lead to an
inappropriate loss of substances such as amino acids and glucose.
By 3 months of age, infants are able to fully concentrate their urine.
The following feature presents normal laboratory values for
components in the newborn’s urine.
Labs
Laboratory Values for Urine in the Normal Term Newborn
Urine Component Normal Range
Osmolality (maximum concentration 75–300 mOsm/kg
ability)
pH 4.5–8.0
Phenylketonuria No color changes
Specific gravity 1.001–1.010 (less than an adult)
Protein May be present during the first 2–4
days
Glucose Negative
Blood Negative
Leukocytes Negative
Source: Van Leeuwen, A. M, & Bladh, M. L (Eds.). (2021).
The kidneys perform an important function in helping the body

maintain a normal acid-base balance. Several factors can interfere
with the newborn’s ability to maintain homeostasis in this system.
The limited capacity for tubular reabsorption of HCO3– and H+ can
lead to a loss of essential substances (e.g., amino acids,
bicarbonate, glucose, and sodium) in the filtrate. Newborn are at risk
for acute kidney injury due to the of immaturity of the newborn’s
kidneys with a lower glomerular filtration, high plasma renin activity,
decreased intercortical perfusion, and increased reabsorption of
sodium and secretion (Nada et al, 2017).
Most newborns void immediately after birth or within the first few
hours, although some may not void for up to 24 hours. Normal urine
output for a newborn is 1–2 mL/kg/hr (Van Leeuwen & Bladh, 2021).
If voiding has not occurred by 24 hours of life, the nurse must alert
the pediatrician or neonatal nurse practitioner. The infant may be
experiencing hypovolemia related to an insufficient fluid intake.
Failure to void during the first 24 hours of life may also indicate the
presence of an obstruction in the urinary outflow system, and the
infant should be carefully assessed for bladder distention,
restlessness, and symptoms of pain.
Initially, the newborn’s bladder capacity ranges from 6 to 44 mL of
urine. During the first 2 days of life, infants normally void two to six
times in a 24-hour period, with a total output of 15 to 60 mL of urine
per kilogram per day. Urine output is significantly higher in infants
with edema. By the fourth day, the frequency of voiding should
increase to more than six voids in a 24-hour period. The kidneys
have difficulty concentrating urine and removing waste products from
the blood immediately after birth, and small amounts of protein and
glucose are frequently present in the urine. Urate crystals, which are
pink-red in color, are excreted in the urine and can be mistaken for
blood. The crystals (sometimes referred to as “brick dust spots”)
disappear after the first few days of life as kidney function matures.
During the first 24 to 48 hours, full-term newborns require 60 to 80
mL/kg of fluids to maintain adequate fluid balance. This requirement
increases to 100 to 150 mL/kg per day after the first few days, and
urine output of 1 to 3 mL/kg per hour is indicative of adequate fluid
maintenance. The newborn’s kidneys are unable to tolerate large
changes in volume, so careful monitoring of fluid balance is
essential. Large changes in fluid balance can create a problem if the
infant becomes ill and needs to receive IV fluids.
Assessing the appearance of the newborn’s urine is important
when evaluating genitourinary system function. When necessary, the
nurse may need to apply a urine collection bag to obtain a urine
sample from the infant (Fig. 9-8). After the first voiding, the urine may
be cloudy (from mucus) and contain (innocuous) urate crystals. The
urine should be odorless and straw-colored to clear in appearance
as the newborn’s fluid intake increases.
IMMUNOLOGICAL ADAPTATION
The newborn’s immunological system remains immature after birth
and may not adequately react to an infectious process. Signs of
infection in the newborn can be very subtle and often are not as
obvious as they would be in an older child. The newborn receives
immunity through two types of methods: active acquired immunity
and passive acquired immunity. The pregnant woman’s exposure to
illness and immunizations prompts the development of antibodies in
a process termed active acquired immunity. The infant receives
passive acquired immunity through antibodies that have been
passed through the placenta by way of IgG.
There are three primary immunoglobulins: IgG, IgA, and IgM.
These immunoglobulins, also referred to as humoral antibodies, are
proteins that are synthesized in response to a specific antigen.
Humoral immunity is important in protecting the newborn against
bacterial and viral infections. Low levels of immunoglobulins and
immature leukocytes that destroy pathogens render the newborn
especially vulnerable to infections.
FIGURE 9-8 Urine collection bag.
IgG is the only immunoglobulin able to pass through the placenta

before birth. Placental transfer of this immunoglobulin occurs
primarily during the third trimester. At birth, full-term infants have
already acquired immunity from the mother to many diseases due to
passive immunity from the mother. If the mother has had
immunizations for diseases such as tetanus, diphtheria, smallpox,
measles, mumps, and poliomyelitis, then this will be passed on to
the infant. Passive acquired immunity typically disappears by 6
months of age. The infant continues to develop antibodies by active
acquired immunity either by direct exposure to an infection with the
subsequent development of antibodies or by receiving the mother’s
immunity if she has been immunized.
IgA is important in protecting the infant against many infections.
Colostrum and breast milk are the main sources of IgA. IgA has a
local effect on the intestinal tract and mucosal tract, and only 10% of
IgA in breast milk will enter the infant’s bloodstream (Palmeira &
Carneiro-Sampaio, 2016). IgM immunoglobulins are produced in
response to an infection, pathogen, or virus. This immunoglobulin is
synthesized early in utero, beginning at approximately 10 to 15
weeks of gestation. Detectable levels are reached by 30 weeks of
gestation, and IgM serum concentrations increase rapidly after birth.
Thus, an increased IgM at birth is suggestive of exposure to a
maternal infection and intrauterine infection such as syphilis or
another infection.
PSYCHOSOCIAL ADAPTATION
Early Stages of Activity
Full-term infants experience several “activity” stages during the early
hours after birth. Nurses should educate parents about normal
neonatal behavior during this period and encourage them to enjoy
this opportunity to become acquainted with their newest family
member. An understanding of normal neonatal activities during the
first hours of life provides reassurance and empowers parents to
promptly recognize and seek assistance for any signs of difficulty.
The infant’s psychosocial adaptation begins with two stages of
activity followed by a period of sleep.
The First Period of Reactivity

This stage is the first period of active, alert wakefulness that the
infant displays immediately after birth (Fig. 9-9). It lasts
approximately 30 minutes and the newborn is very alert and
responsive during this stage and moves around energetically while
exploring the environment and taking in the new surroundings. The
heart rate and respirations are rapid and may increase during this
period and then return to baseline. This first period of reactivity is an
opportune time for the mother to initiate breastfeeding as the
newborn may start to exhibit rooting, sucking, and lip smacking.
The Period of Inactivity and Sleep

After the first period of reactivity, the newborn settles into the sleep
phase. At this time, the infant displays decreased muscle activity and
is difficult to awaken, instead resting quietly and recovering from the
stress of birth. The heart rate and respirations return to a normal
baseline range. Central perfusion and general coloring should be
excellent at this time, although acrocyanosis is not unusual. The
sleep period may last from a few minutes to 2 to 4 hours.
FIGURE 9-9 The mother and her newborn become acquainted

during the first period of reactivity.
The Second Period of Reactivity

At this time, the newborn awakens and becomes alert once again.
Most infants show signs of feeding readiness (e.g., sucking and
rooting) and are eager to begin feeding if not previously fed. During
the second period of reactivity, the newborn becomes increasingly
more responsive to exogenous and endogenous stimulation, which
can cause the heart rate to become labile. The infant may exhibit
brief periods of tachycardia, tachypnea, and rapid changes in color
and muscle tone. The nurse needs to be aware of normal newborn
behaviors during this period that may last for minutes up to several
hours. The infant will usually have an increase in mucus secretions,
which can accumulate in the mouth, causing gagging and choking
responses as well as regurgitation. The nurse must employ careful
and ongoing assessments to allows for differentiation between
normal reactions and symptoms that signal difficulty with transition.
NEWBORN BEHAVIORAL STATES

Sleep States
According to Brazelton (2005), newborn behavior can be divided into
the sleep state and the alert state. Two sleep states are exhibited:
the deep or quiet sleep and the period of active rapid eye movement
(REM). REM active and quiet sleep occurs in intervals of
approximately 50 minutes. Approximately one-half of the infant’s
total sleep is “active” sleep. Forty-five percent is “quiet” sleep, and
10% is transitional sleep occurring between the two periods. It has
been suggested that REM sleep is instrumental in promoting growth
of the neural system. As the infant matures, the sleep-wake cycle
adjusts to a diurnal pattern of sleeping during the night and
remaining awake during the day. The periods of alertness are fairly
brief during the first 2 days of life as the infant recovers from the
events associated with birth. After that time, the infant’s alert states
result from choice or necessity. Stimuli that may prompt wakefulness
include hunger, cold, and heat. Once the triggering stimuli are
removed, the infant tends to fall back asleep. The alert state has
been subcategorized into four distinct phases: drowsy or
semidozing, quiet alert or wide-awake, active alert, and crying
(Brazelton, 2005). Table 9-2 lists the infant behavioral states.
TABLE 9-2
Behavioral States
BEHAVIORAL DESCRIPTION
STATES
Sleep States Deep or Quiet During deep sleep, the infant’s eyes are closed,
no eye movements occur, and breathing is
regular and even. Jerky motions are common
although behavioral responses to external stimuli
are delayed and the newborn is often difficult to
arouse.
Active REM During REM sleep, the infant’s respirations are
irregular, the eyes are closed with REMs visible
through closed eyelids, and irregular sucking
motions are common. There is minimal activity.
Environmental and internal stimuli may prompt a
startle reaction and a change of state of
awakeness.
Awake States Drowsy Period of time between sleep and awake.
Physical manifestations include open or closed
eyes; fluttering eyelids; semidozing appearance;
and slow, regular movement of the extremities.
The infant will display a delayed response to
external stimuli and may go to sleep or gradually
awaken.
Quiet alert The infant is alert and follows and fixates on
attractive objects, faces, or auditory stimuli.
During this time the newborn may have an
intense gaze on people, which is an opportune
time to increase bonding. There is minimal motor
activity and a delayed response to external
stimuli. Optimal time to feed a newborn.
Active alert The eyes are open, less fixated on objects,
motor activity is intense, and the infant displays
thrusting movements of the extremities.
Environmental stimuli increase the motor activity.
Crying Often follows active alert if needs are unmet.
Motor activity appears to have jerky movements
accompany intense and continuous crying.
Crying often serves as a distraction from
unpleasant stimuli such as hunger and pain. It
allows the infant to discharge energy and elicits
a helpful response from the parents.
NEWBORN ASSESSMENT
During the transitional period after birth, nursing care focuses
primarily on two goals: to safeguard and support the newborn’s
physical well-being and to promote the establishment of a healthy
family unit. The first goal is met by close observation coupled with
skilled assessment throughout the time the infant remains in the
health-care facility. The second goal is met by observing appropriate
bonding between mother and infant, as well as other family members
and the infant (Fig. 9-10).
Immediate Newborn Assessment

Airway, Breathing, Circulation, and Thermoregulation
AIRWAY
The newborn infant’s physical condition, especially airway,
breathing, and cardiovascular, is assessed immediately at the time of
birth. If there are no imminent airway, breathing, or cardiovascular
concerns, the infant is dried and placed directly on the mother’s
abdomen, allowing for skin-to-skin contact. However, some infants
experience respiratory distress immediately after birth as excessive
fluid/mucus in the upper airway may fully or partially block the
airway. If necessary, suctioning of the oral, pharyngeal, or
endotracheal area is conducted according to the health facility’s
policy, procedure, and protocol. APGARs (appearance, pulse,
grimace, activity, and respiration) are done at 1 minute and 5
minutes after birth unless respiratory difficulties require immediate
attention before the 1-minute APGAR.
FIGURE 9-10 Mother and father bonding with newborn.
BREATHING
After the airway is cleared, then the nurse assesses the breathing.
This assessment begins with assessing for any signs of respiratory
difficulty, such as rib or sternal retractions, “grunting” sounds, or
nasal flaring.
CIRCULATION
To immediately check the heart rate, the nurse places the thumb
and two fingers at the base of the umbilical cord and counts the
pulsations. An apical pulse can also be obtained with a stethoscope;
however, it can be difficult to use this method if the infant is crying.
As the infant cries, the trunk will turn pink, and the extremities may
remain slightly blue (acrocyanosis), a condition related to vasomotor
insufficiency and poor peripheral perfusion. If necessary, respiratory
support is initiated according to hospital protocol. Oxygen may be
administered via bag or mask.
THERMOREGULATION
Immediately after birth, the infant can lose heat from factors such
as wetness and evaporation or the stress from the birth. The nurse
should dry the infant right away, and the infant is either placed
directly on the mother’s abdomen to maintain heat or placed under a
warmer to assess body temperature with an axillary thermometer or
use of a thermoprobe.
APGAR
A numerical expression of the newborn’s well-being, the APGAR
score is assigned at 1 and 5 minutes after birth. This provides an
objective means for assessing the newborn’s immediate adaptation
to extrauterine life. Five categories, including respiratory effort, heart
rate, muscle tone, reflex irritability, and skin color are assessed, and
each component is given a score ranging from 0 to 2. If neonatal
resuscitation is required, it should be initiated before the 1-minute
APGAR score (American College of Obstetricians and
When the APGAR score is less than 9 at 5 minutes of life, it is
important to stabilize the infant rather than allowing them to remain
with the mother in the birthing unit. Other conditions that would
necessitate immediate infant stabilization include observations of
nasal flaring, grunting respirations, rib retractions, heart rate less
than 120 beats per minute or greater than 160 beats per minute,
pallor, serious congenital anomalies (such as a neural tube defect),
preterm birth (less than 38 weeks’ gestational age), infant of a
diabetic mother, or an infant who appears to be small for gestational
age (SGA) (Table 9-3).
Various newborn laboratory tests may be routinely ordered
according to hospital protocol, especially if the APGAR score was
low or in the case of blood-blood incompatibility. A sample of the
cord blood if the mother is Rh (D)-negative or has type O blood
group is often sent to the laboratory for confirmation of the newborn’s
blood type and Rh factor. If the infant’s APGAR score is low, cord
blood gas analysis may be ordered as well.
After the APGAR evaluation, the nurse completes the mother–
infant identification process according to hospital policy. This
procedure usually includes obtaining infant footprints and a
fingerprint and thumbprint of the mother along with appropriate
labeling. Most institutions employ a system of two identifiers such as
name, date-of-birth, or medical record number, using waterproof
matching identification bracelets that show the mother’s name, the
baby’s gender, the name of the physician or nurse-midwife of record,
and the date and time of birth. Two bracelets are worn by the
newborn (one on the wrist and one on the ankle) while the mother
and her partner wear the others. Careful and continuous monitoring
of infants is essential to prevent misidentification, baby switching, or
abduction. Additional security measures such as sensing devices,
video cameras, and door alarms on all mother–baby units as well as
hospital policies on staff identification help allay parents’ concerns
about their infants’ safety.
PROCEDURE ■ Suctioning the Infant’s Oral

and Nasal Passages
PURPOSE
To clear secretions from oral and nasal passages.
EQUIPMENT
• One bulb syringe
• Tissue
STEPS FOR ORAL SUCTIONING
1. Assess the infant for oral secretions.
2. Position the infant’s head to the side or downward if vomiting or gagging
occurs.
3. Compress the bulb syringe.
RATIONALE: Removing the air prevents forcing secretions deeper into the
respiratory tract.
4. Insert the bulb syringe approximately 1 inch into one side of the infant’s
cheek. Avoid contact with the roof of the mouth and the back of the throat.
RATIONALE: To prevent stimulation of the gag reflex.

5. Gently release compression of the bulb syringe and allow it to fill with oral
secretions.
6. Gently remove the bulb syringe; expel drainage into a tissue.
7. Repeat the process on the other side of the infant’s cheek.
8. Repeat as needed.
Clinical Judgment Alert Always suction the mouth before suctioning the
nares. Fluids and secretions that could obstruct the respiratory tract may
be present in the mouth or the nares or both. Placing the syringe in the
nares first may trigger an inspiratory gasp, causing the infant to pull
mucus farther into the respiratory tract.
STEPS FOR NASAL SUCTIONING

1. Assess the infant for nasal congestion.
2. Position the infant’s head to the side or downward if they are vomiting or
gagging.
3. Compress the bulb syringe.
RATIONALE: Removing the air prevents forcing secretions deeper into the
respiratory tract.
4. Insert the bulb syringe into the tip of the infant’s nostril. Avoid obstructing the
nasal passageway.
RATIONALE: To prevent respiratory distress.
5. Gently release the compression of the bulb syringe to allow it to fill with
mucus or nasal drainage.
6. Gently remove the bulb syringe; expel drainage into a tissue.
7. Repeat as needed.
Clinical Judgment Alert An increasing respiratory rate is often the first

sign of respiratory compromise or obstruction. If this occurs, measures
must be initiated to maintain effective ventilation.
TEACH PARENTS
• Proper technique for use of the bulb syringe; ask for return demonstration.
• Proper care of the bulb syringe: wash in warm, soapy water each day and
after each use and allow to air dry.
• Store the bulb syringe at the infant’s bedside.
NOTE
Instruct the parents to position the infant’s head to the side or downward
if they are vomiting or gagging.
Caution: The nurse must emphasize to the parents that the bulb syringe
must be compressed first and then inserted into the infant’s nostril or mouth. If
they insert the bulb syringe and then compress the bulb syringe, they may
actually force secretions further back into the nose or throat and possibly cause
an obstruction.
TABLE 9-3
APGAR Scoring for 1 Minute and 5 Minutes
0 POINT 1 POINT 2 POINTS
Appearance Completely Blue extremities Completely
pale/blue (acrocyanosis), pink perfused/pink body
body (perfused face
and trunk)
Pulse Absent Less than 100 bpm More than 100 bpm
Grimace No response to Grimace, weak or slow Cry is strong, prompt
stimulation response to stimulation response to stimulation
Activity Absent and Some flexion of the Well-flexed arms and
flaccid arms and legs legs with active motion
Respiration Absent Weak, slow, or irregular Vigorous cry
cry
Vital Signs
Routine assessment of the newborn’s vital signs is important before
the physical examination and throughout the infant’s hospital stay. It
is essential that the nurse recognize the normal parameters for
temperature, pulse, respirations, and blood pressure so that any
change in the newborn’s status can be readily identified. Normal
parameters for assessing vital signs appear in Box 9-3.
Length and Weight

The newborn’s weight, recorded in grams, and the length, recorded
in centimeters, are measured in the birthing room and again during
the transitional period (Figs. 9-11 and 9-12). On average, a term
newborn infant weighs 3,400 grams (7.5 lbs), with a normal range of
2,500 grams (5.5 lbs) to 4,300 grams (9.47 lbs). Recumbent length is
a crown-to-heel measurement taken with the infant in a supine
position. The recumbent length is recorded regularly until the infant
reaches 24 months of age. Normal length parameters for newborns
are approximately 18 to 22 inches (45–55 cm).
The nurse also obtains and records the frontal-occipital
circumference (FOC), or head measurement (Fig. 9-13). A paper
tape measure with increments marked in tenths of a centimeter is
used to ensure an accurate measurement. To obtain the head
circumference, the tape measure is placed on the area immediately
above the eyebrows and pinna of the ears and then wrapped around
to the occipital prominence at the back of the head. This location
represents the area of the greatest head circumference. After
obtaining the head measurement three times, the nurse records the
largest finding. The normal head circumference for a full-term
newborn ranges from 13 to 15 inches (33–38 cm). Measurement of
the head circumference is repeated at subsequent physical
examinations until the infant reaches 36 months of age.
FIGURE 9-11 Weighing the infant.
FIGURE 9-12 Measuring the infant’s body length.

FIGURE 9-13 Measuring the head circumference.
BOX 9-3
Assessing Newborn Vital Signs

When assessing newborn vital signs, the nurse must be aware of the following
normal parameters:
TEMPERATURE:
Rectal: 98.6°F to 100.0°F (37.0°C–37.8°C)
Axillary: 97.7°F to 99.3°F (36.5°C–37.4°C)
HEART RATE:
120 to 160 beats per minute (count apical heart rate for 1 full minute)
During sleep, the heart rate can be as low as 80 beats per minute.
During crying the heart rate can be as high as 180 beats per minute.
RESPIRATIONS:
30 to 60 respirations per minute (count respiratory rate for 1 full minute)
Abdominal breathing is normal. Periodic breathing is considered normal and
classified as short pauses in the breathing of the newborn that last only
approximately 3 seconds. Apneic episodes are significant if they last more than
15 to 20 seconds; they may be accompanied by abrupt pallor, hypotonia,
cyanosis, and bradycardia. Apnea must be differentiated from periodic
breathing, which is normal in the newborn.
Caution: Withhold oral feeding if the respiratory rate is greater than 60
respirations per minute.
BLOOD PRESSURE:
Systolic: 60 to 80 mm Hg; diastolic: 40 to 50 mm Hg at birth
Systolic: 95 to 100 mm Hg; diastolic: slight increase at 10 days of age
PROCEDURE ■ Measuring the Newborn’s
Body Length
PURPOSE
To establish and document the newborn’s body length
EQUIPMENT
• Standard paper tape measure
STEPS
1. Place the infant on a paper-covered flat surface.
2. Fully extend the infant’s body by holding the head midline.
RATIONALE: The newborn normally assumes a flexed position and must be
fully extended to obtain an accurate measurement.
3. Gently grasp the knees and place them together.
4. Push down gently on the knees until they are fully extended and flat against
the table surface.
5. Measure the crown-to-heel recumbent length by placing the paper tape
measure beside the infant with the 0 end of the tape at the top of the head.
Keep the infant’s body in alignment and carefully extend one leg. Ensure
that the tape measure remains straight. Note the length and record it in the
infant’s chart. As an alternate measurement method, make a slash mark
with a pen at the end points by the top of the infant’s head and the heels of
the foot. While providing continuous support, gently roll the infant to the side
and measure between the two points with a paper tape measure that has
increments designated in tenths.
RATIONALE: Careful body positioning and use of a tape measure graduated
in tenths ensures an accurate measurement. Measurements are taken and
recorded to note abnormalities and to provide a baseline value. Only paper
tape should be used for measuring, as cloth tape measures can stretch,
resulting in inaccurate data.
To obtain the chest measurement, the paper tape measure is

placed on the nipple line and then wrapped around the entire
thoracic area (Fig. 9-14). The head measurement should be 2 cm
greater than the chest during the first few days of life. Greater than 4
cm may indicate hydrocephalus or increased intracranial pressure
and a smaller measurement may indicate microcephaly. A normal
chest measurement is 30.5 to 33 cm (12 to 13 inches). The
abdominal circumference may be obtained by encircling the infant’s
body with the paper tape measure placed directly above the
umbilicus (Fig. 9-15). The abdomen should be approximately the
same size as the chest.
Once all measurements have been obtained, the nurse plots the
weight, length, and head circumference against the infant’s
gestational age to determine the appropriate size category (Fig. 9-
16). Size categories are SGA below 10% for gestational age,
appropriate for gestational age (AGA), and large for gestational age
(LGA) above the 90% for gestational age. If at any time the physical
measurements fall outside the normal growth parameters, the
physician should be notified. Information concerning normal growth
parameters for infants, children, and adults is available at the CDC
National Center for Health Statistics Web site,
http://www.cdc.gov/growthcharts/.
FIGURE 9-14 Measuring the chest circumference.
FIGURE 9-15 Measuring the abdominal circumference.
LGA means that weight is above the 90th percentile at any week.
AGA means that weight falls between the 10th and 90th percentiles
for the infant’s age. SGA means that weight falls below the 10th
percentile for the infant’s age.
In 1967, the American Academy of Pediatrics recommended that
all newborns be classified by birth weight and gestational age. Since
that time, a scoring system developed by Ballard and colleagues
(1991), which represents a modification of the Dubowitz system, has
been the most commonly used method for determining the
newborn’s gestational age. With this assessment system, the infant
examination yields a score of neuromuscular and physical maturity
that can be extrapolated onto a corresponding age scale to reveal
the infant’s gestational age in weeks. Additional methods used to
determine gestational age are fundal height measurement before the
birth, ultrasonography, and eye lens vascularity. A rough
approximation of the gestational age at birth can be calculated
according to the date of the mother’s last normal menstrual period.
The infant’s weight and length are determined and recorded. Table
9-4 presents normal newborn parameters.
Level of Reactivity
The infant’s reaction to the environment is an important indicator of
the level of neuromuscular development. The nurse routinely
assesses the infant’s state of responsiveness and reactivity. The
neonatal behavioral assessment is an important component of the
overall evaluation and validates a mature neurological–
organizational system that allows the term infant to readily transition
from one behavioral state to another. Certain conditions such as in
utero exposure to cocaine disrupt this normal development; affected
newborns exhibit erratic, disorganized behavior, an excessive
response to stimuli, and lengthy or absent transition periods between
behaviors. (See Chapter 10 for further discussion.)
FIGURE 9-16 Gestational age assessment.
TABLE 9-4
Normal Neonatal Parameters at Birth
PARAMETER NORMAL FINDING
Respirations Rate 30–60 breaths per minute, irregular No retractions
or grunting
Apical pulse Rate 120–160 beats per minute
Temperature 97.7°F-99.3°F (36.5°C-37.4°C)
Skin color Pink body, blue extremities
Umbilical cord Contains two arteries and one vein
Gestational age Full term: >37 completed weeks
Weight 2,500–4,300 grams
Length 45–54 cm
The nurse may assess the infant’s response to voices and

physical presence to confirm the level of responsiveness and
behavioral organization. An infant who displays irritability and an
overreaction to voices, touch, or movement needs to be comforted,
and special care must be taken to provide calming measures such
as swaddling the newborn in blankets, cuddling, rocking, and gentle
holding. It is best to postpone the physical examination,
manipulation, and handling of the newborn as this will most likely
cause further disruption and behavioral disorganization.
Gestational Age
Assessing the gestational age is a critical part of the newborn
examination. Using a maturity rating tool will determine whether the
estimated gestational age conducted with the date of delivery is
accurate. In addition, nurses need to know how to conduct a
gestational age assessment as there may be patients (newborns)
with unknown gestational age, and this may be the only method of
determining the age.
POST-TERM
A post-term newborn is a newborn born after 41 weeks and 6
days. Several significant complications are associated with the post-
term newborn, including microsomia or LGA, dehydration, meconium
aspiration syndrome, persistent pulmonary hypertension, and
postmaturity syndrome. Signs of postmaturity include meconium-
stained skin (due to increased risk of passing meconium in utero),
dry skin with desquamation or peeling of the skin with crackling seen
on the abdomen, extremities, and palms and sole of the feet, with
some muscle wasting. In addition, the fingers may appear long with
long finger- and toenails (Robillard et al, 2019).
Diagnostic Tools
Use of the Ballard Gestational Age by Maturity Rating Tool
The Ballard Gestational Age by Maturity Rating tool includes a neuromuscular
maturity and a physical maturity component (Fig. 9-17) that contains six
characteristics to be assessed and is helpful in determining gestational age. At
the conclusion of the examination, the scores from each component are added
together, then mathematically extrapolated onto the maturity rating scale to
determine the infant’s gestational age by examination. The scoring system is
designed to identify the decreased levels of muscle and joint flexibility
characteristic of the premature infant, as well as the mature term infant’s ability
to return to the original position after movement. The nurse usually performs
this assessment within the first 12 hours of the infant’s life. The Ballard scoring
system is more accurate when conducted on term infants who are between 10
and 36 hours of life. The order in which the assessment is conducted is
unimportant.
Interestingly, gestational age maturity may occur at different rates among the
various categories. For example, a score of 4 (full maturity) in one category
does not indicate that all subsequent categories must also reflect a score of 4.
“Half-scores” are often recorded if the examiner believes that the infant exhibits
a characteristic that falls between two scoring options during the assessment. It
is important to remember that the infant’s maturity scoring does not directly
translate to the gestational age in weeks.
FIGURE 9-17 Ballard Gestational Age Assessment Tool.
NEWBORN METABOLIC SCREENING TESTS

Newborn screening, designed to identify newborns with genetic,
metabolic, and/or infectious conditions, is an essential part of
preventive care. With routine screening, many life-threatening
problems can be detected early enough for effective intervention.
Conditions commonly discovered through early screening include
biotinidase deficiency, hemoglobinopathies, medium-chain acyl Co-A
dehydrogenase deficiency, galactosemia, cystic fibrosis, congenital
adrenal hyperplasia, congenital hypothyroidism, sickle cell anemia,
and phenylketonuria (PKU). PKU, which occurs in approximately 1 in
10,000 to 25,000 births, is a genetic metabolic disorder. It is
characterized by a deficiency of the enzyme phenylalanine
hydroxylase, which the body needs to convert phenylalanine to
tyrosine. A lack of proper conversion results in a buildup of toxic
blood levels of phenylalanine, a condition that causes central
nervous system damage (ACOG, 2017). See Chapter 10 for further
discussion.
Under state law, screening of newborns has been routinely
performed in the United States since the 1960s. However, policies
concerning routine neonatal screening vary from state to state and
are frequently based on local demographics, cost, reimbursement,
politics, and ready availability of resources.
Optimizing Outcomes
Newborn Metabolic Screening

The American College of Obstetricians and Gynecologists, the U.S. Human
Resources and Service Administration, the American College of Medical
Genetics, and the American Academy of Pediatrics stress the importance of
communication about newborn screening at some point during the prenatal
period. An important nursing role centers on understanding the effects of
various disorders detected by metabolic screening and advocating for the
universal routine screening of all newborns. A current list of conditions screened
for in each state is maintained online by the National Newborn Screening and
Genetic Resource Center.
Diagnostic Tools
Newborn Metabolic Screening
Approximately 24 hours after birth, a small sample of blood is taken from the
infant’s heel and placed on special filter paper. The specimen should be
obtained as close to the time of the infant’s hospital discharge as possible and
within no more than 7 days. A blood sample taken before 24 hours of age may
be unreliable in detecting some conditions. However, if the newborn is
discharged from the hospital or birthing center within the first 24 hours of life, a
sample must be obtained and the infant’s parents must be instructed to contact
the physician within 2 weeks to arrange to have another specimen drawn.
Newborns born at home must also be screened for disease. The parents or the
person registering the birth must make the proper arrangements with a doctor
or health-care provider to have the tests completed before completion of the
first week of life. If the 1-week time period is missed, the infant should be tested
so that they can still benefit from early intervention for certain disorders.
HEAD-TO-TOE NEONATAL PHYSICAL

ASSESSMENT
The nurse conducts the neonatal physical examination, which is the
review of systems, within 24 hours of birth. This examination should
not be initiated if the infant is crying or appears upset. Instead,
postpone the assessment until the infant is calm. It is important for
the nurse to adhere to universal precautions and wear gloves if the
newborn has not been bathed.
A Systems Approach to Assessment of the Newborn

The nurse systematically examines each body system, beginning
with the skin and proceeding in a head-to-toe direction. This
assessment may take place in the nursery with the infant resting
comfortably in a crib, under a radiant warmer (to maintain
temperature stability), or if stable, in the mother’s room. Carrying out
the assessment by the mother’s bedside has several advantages.
For most, the bedside is a nonthreatening environment where the
mother and the nurse can “explore” the baby’s special and unique
characteristics. Also, conducting the evaluation in this relaxed setting
gives the nurse an opportunity to observe the mother’s ease in
interacting with and touching and holding her infant.
With the infant in a supine position, the nurse follows the steps of
inspection, light palpation, deep palpation, and auscultation to
facilitate the examination. When assessing the abdomen, the proper
sequence is inspection, auscultation, and light palpation followed by
deep palpation.
Assessment of the Integumentary System

The integumentary assessment begins with the nurse examining the
newborn’s skin, scalp, body hair, and nails for color, texture,
distribution, disruptions, eruptions, and birthmarks. It is important
that the assessment take place in a well-lit room, and additional light
sources may be needed to confirm accuracy of findings. The infant’s
skin should be perfused and pink, a finding that indicates adequate
peripheral cardiac perfusion. Even dark-skinned infants typically
have light skin for the first 3 days after birth. Blanching the skin over
bony prominences should yield a pink-white color before returning to
natural pigmentation.
GENERAL COLOR
One common finding is acrocyanosis, a bluish coloration to the
hands and feet. This condition is normal during the first 24 hours of
life, related to vasomotor instability and poor peripheral circulation
(Fig. 9-18). To differentiate between acrocyanosis and true cyanosis,
the nurse can vigorously rub the sole of the newborn’s foot. If the
sole turns pink, the diagnosis is acrocyanosis. If the sole remains
blue, it is true cyanosis. Also, acrocyanosis disappears when the
infant cries.
Visual inspection of the infant’s mouth, tongue, and gums confirms
the skin color assessment. These areas should be pink-red in color
and darken to bright red with crying. True cyanosis produces a bluish
coloration and pallor (paleness) of the lips and on the area around
the mouth. Newborns with central cyanosis may demonstrate a blue
tint to the lips, gums, tongue, fingertips, toes, and on trunk and body
as well as pallor under the eyes and on the cheeks. These findings
indicate a circulatory problem and warrant immediate investigation
into the suspected cause of the cyanosis. The diagnostic work-up for
infants with central cyanosis may include echocardiography and
cardiac catheterization. Depending on the findings, treatment may
involve medical or surgical intervention.
Infants with congenital heart defects often exhibit skin pallor that
does not improve with time. When stimulated by physical contact,
infants should demonstrate a rapid perfusion or pinking of the skin
that progresses to a reddish color. Observing how long it takes for
the infant to return to the previous skin color after stimulation is an
important component of the nurse’s visual assessment of the
newborn’s cardiovascular system. Other concerning findings include
pallor, plethora (a deep purplish color related to an increased
number of circulating RBCs), petechiae (pinpoint hemorrhagic
areas), or central cyanosis.
JAUNDICE
Jaundice (hyperbilirubinemia), a yellow coloration of the skin, may
be apparent in the newborn. Normally, jaundice develops gradually
over several days in a head-to-toe, or cephalocaudal, pattern. Any
term infant less than 24 hours old who demonstrates visual jaundice
is considered to have “pathological jaundice” or “hemolytic jaundice,”
a condition that most often results from a serious blood
incompatibility between the mother and her newborn. See Chapter
19 for further discussion of physiological and pathological jaundice.
FIGURE 9-18 Acrocyanosis.
When conducting the skin assessment, the nurse must remember

that certain characteristics of the nursery or mother’s postpartum
room can affect the accuracy of the examination. For example, pink
walls and artificial lighting may mask the early detection of jaundice
and interfere with an accurate assessment of the degree of severity
of the condition. It is best to examine the newborn’s skin in natural
daylight, if possible. When jaundice is suspected, the nurse can
readily assess the skin coloring by pressing on the infant’s forehead
or nose with a finger. When blanching occurs, the nurse can observe
for the yellow coloration associated with jaundice. This is helpful with
infants with darker skin tones where jaundice may be more difficult to
detect.
“Physiological jaundice” or “nonhemolytic” jaundice describes the
more common yellowing of the skin in newborns that appears after
the first 24 hours of life and usually peaks by the third to fifth day.
Physiological jaundice often has a nonhemolytic cause and
frequently results from a failure to adequately process bilirubin from
inadequate intake or elimination, birth trauma, or minor blood
incompatibilities.
Breastfed infants may develop early onset or “breastfeeding-
associated jaundice,” which results from insufficient feeding and
infrequent stooling. Because colostrum has a natural laxative effect
that stimulates the passage of meconium, frequent breastfeeding
during the early days of life is beneficial in reducing the newborn’s
serum bilirubin levels. Late-onset or “breast milk jaundice”
sometimes affects breastfed infants during the second week of life.
This type of jaundice usually develops around the fourth day when
the mother’s mature breast milk comes in and peaks around day 10.
Breast milk jaundice may be associated with factors in human milk
that inhibit the conjugation or decrease the excretion of bilirubin.
Although usually no treatment is necessary, some health-care
professionals advise mothers to discontinue breastfeeding for 12 to
24 hours to allow the infant’s bilirubin levels to decrease.
Nurses can implement several actions to decrease the likelihood
of high bilirubin levels in the newborn. Maintaining the infant’s skin
temperature at or greater than 97.7°F (36.5°C) is essential in
avoiding cold stress that can cause acidosis and an elevated serum
bilirubin. Also, careful monitoring of the infant’s intake and output
with special attention to stool characteristics and frequency is
important. Bilirubin is excreted in the feces; inadequate elimination
can result in the reabsorption and recycling of bilirubin. Finally, the
nurse should encourage feedings within the first hour of life when
possible to promote rapid and continuous intestinal evacuation and
provide the calories necessary for the production of hepatic binding
proteins.
Understandably, the presence of jaundice in the infant can be
distressing for parents. Nurses can address these concerns by
providing ongoing emotional support and accurate explanations of
the condition. Parents should be taught about the importance of
adequate hydration and how to assess the infant for signs of
jaundice. If the baby undergoes phototherapy (exposure to high-
intensity lights) for treatment, additional days of hospitalization may
be required, and the mother may have to leave the birth center
without her baby (Fig. 9-19). Newborns treated with phototherapy
should be monitored for dehydration, which can occur due to
insensible water losses associated with the phototherapy or from
water loss due the increase in stooling associated with the
elimination of bilirubin. Newborns should wear eye protection at all
times while under phototherapy to prevent retinal damage. The
nurse should remove protection during feeding to assess the eyes,
promote bonding with the mother, and enhance social stimulation
and visual development. Before placing the eye shield, gently close
the newborn eyelids to prevent excoriation of the corneas. Macular
rashes are a common side effect of phototherapy, and lotions should
be avoided so that symptoms are not exacerbated (Suplee & Janke,
2020)
FIGURE 9-19 The jaundiced infant undergoing phototherapy. The
eyes are covered to prevent retinal damage.
Parents should be encouraged to help meet their infant’s

emotional needs by holding, feeding, touching, and interacting with
the baby. When the mother must leave the hospital without her
infant, the nurse can support the bonding process by providing the
nursery telephone number and name(s) of the baby’s primary
caregiver(s). Mothers should also be encouraged to call for updates
and return for feedings as often as possible. Breastfeeding mothers
may wish to remain in the hospital until the infant is released. In
other situations, initiation of home phototherapy for the jaundiced
infant may be an option. When the infant is treated in the home,
nurses monitor the phototherapy regimen and obtain serum bilirubin
levels as dictated by hospital or agency policy. For more about
phototherapy, see Chapter 10.
Accurately assessing the infant’s true skin color is of paramount
importance when observing for color changes related to pathological
conditions. For the nurse to accurately assess the color of the
newborn’s skin, it is necessary to know the normal range of skin
colors for infants of various races. The nurse should be aware that
many birthmarks, cafe-au-lait spots, and other skin pigment
variations can be very difficult to identify in infants with darker skin
tones, and extra care must be taken when performing the
integumentary system assessment (Scannell & Puka-Beals, 2019).
Skin assessments may be easier to perform within 24 hours after
birth in some cases. Infants who are born to parents with darker skin
tone often are born appearing light-skinned until exposure to sunlight
and melatonin, which fully changes the skin color to a darker skin
tone (Fig. 9-20)
SKIN TURGOR
Skin should appear hydrated without tenting and spring back into
place after a gentle pinch to assess for dehydration. The term
infant’s skin should feel smooth, dry, and soft. Desquamation and
peeling of the skin may be seen in post-term newborns and those
who are a few days old. Lanugo (fine, downy hair) may be noted on
the newborn’s back, shoulders, and head, and vernix caseosa, a
protective thick whitish substance that covers the infant in
intrauterine, may be present in the folds and creases, especially the
axillary and genital areas (Figs. 9-21 and 9-22). An abundance of
vernix caseosa can indicate early gestational age. In the postmature
infant, the skin is often tough and leathery, with cracking and peeling
and without lanugo and vernix caseosa (Venes, 2021). Nurses
should also ask parents about their knowledge of vernix caseosa, as
some parents may want the substance removed from their infant and
other mothers may want to leave the substance to help soften the
skin.
FIGURE 9-20 Newborn of Haitian American parents appears light-
skinned moments after birth.
COMMON INTEGUMENTARY FINDINGS
Infants may be born with pustular melanosis, a condition in
which small pustules form before the birth. As the pustule
disintegrates, a small residue or “scale” in the shape of the pustule is
formed. This lesion later develops into a small (1- to 2-mm) macule,
or flat spot. Macules, which are brown in color, appear similar to
freckles and are frequently located on the chest and extremities.
Although some periauricular papilloma, or skin tags, are benign and
common in some families, they can indicate kidney anomalies. Ears
and kidneys develop at the same time, so skin tags on the ear
require additional assessments.
FIGURE 9-21 Lanugo.
FIGURE 9-22 Vernix caseosa.
Another common skin condition is milia, small white papules or

sebaceous cysts on the infant’s face that resemble pimples (Fig. 9-
23). Milia is a benign condition that will resolve spontaneously within
the first month of life. Inclusion cysts may be seen singularly or in
pairs on the penis or scrotum of male infants or on the areola of
female infants. Acne, a skin condition common in adolescents, may
also be present in newborns and is related to excessive maternal
hormone levels. Over time, neonatal acne disappears spontaneously
from the infant’s cheeks and chest.
Erythema toxicum, a transient rash that covers the face and
chest with spread to the entire body, is the most common normal
skin eruption in term newborns. It is also called “erythema
neonatorum,” “newborn rash,” or “flea bite” dermatitis. Typically, the
rash consists of small, irregular, flat red patches on the cheeks that
develop into singular, small yellow pimples appearing on the chest,
abdomen, and extremities. The cause of this skin condition is
unknown, and it may persist for up to 1 month of life. There is no
treatment available to hasten the resolution of the rash and parents
should be informed that it will resolve spontaneously.
Many neonatal skin variations are characterized by color changes
that are different from normal pigmentation. For example, Mongolian
spots (congenital dermal melanocytosis) are areas that appear gray,
dark blue, or purple and are most commonly located on the back and
buttocks, although they may also be found on the shoulders, wrists,
forearms, and ankles (Fig. 9-24). Mongolian spots are seen most
often in infants who are of Mediterranean, Latin American, Asian,
and/or African ethnicity and in children who have Down syndrome.
Parents can be assured that these skin changes will fade and
disappear as the infant grows older. Mongolian spots can easily be
mistaken for bruises, so it is important that the nurse document
Mongolian spots on the infant’s chart.
FIGURE 9-23 Milia.
Another condition, “cutis marmorata,” or mottling, is common in

newborns and is most often caused by the infant’s vasomotor
response to the lower environmental temperature outside the uterus.
Mottling may also be related to prolonged apnea. Usually, mottling
disappears once the newborn adjusts to the extrauterine
environment. A deepened coloration of the genital skin in males and
females may occur due to the influence of maternal hormones. This
color change also diminishes over time.
BIRTHMARKS
Birthmarks are distinct areas of color that may be tan, brown,
white, or red. Their appearance varies, but generally these lesions
are small and flat. It is important to distinguish birthmarks from skin
lesions that result from birth trauma. The nurse documents the
location, size, and color of the birthmark; if the lesion contains hair or
is located along the anterior or posterior midline, further investigation
is warranted to rule out underlying tissue involvement.
Café-au-lait birthmarks are flat, tan spots that are quite common
and insignificant unless the infant exhibits six or more marks that are
greater than 1 cm in diameter. In this circumstance, the newborn
should be carefully evaluated during infancy for tumors that develop
beneath the skin because they may be at risk for developing type 1
neurofibromatosis.
Brown nevi (from Latin naevi, for “birthmark”) are brown skin
marks whose color can vary from brown to deep black. A nevus may
represent a very early form of a precancerous lesion, and the nurse
should teach parents to routinely check the lesion for changes in
color, shape, size, or elevation from the skin surface. The careful
observation of this skin lesion should be continuous throughout the
child’s lifetime.
A telangiectatic nevus is a red birthmark often seen at the nape
of the neck and is commonly referred to as a “stork bite” or “angel
kiss” (Fig. 9-25). This lesion may also occur on the face between the
eyebrows or on the eyelids, nose, or upper lip. It is usually irregular
in shape and pale red, often turning bright red when the infant cries.
The telangiectatic nevus tends to fade as the infant grows older and
usually disappears by the second birthday.
A nevus vasculosus, or “strawberry mark,” is a red, raised
capillary hemangioma that can occur anywhere on the newborn’s
body. This birthmark usually has sharp borders and a rough surface
that resembles a strawberry. Although often alarming because of its
appearance, the nurse can reassure parents that this lesion will
eventually undergo a process of involution and disappear during the
first year of life. Unless they interfere with a vital organ system or are
located on the face, surgical removal of capillary hemangiomas are
not recommended.
The blue nevus appears as a distinct blue or blue-black birthmark
often found on the buttocks, hands, and feet. Although sometimes
mistaken for a Mongolian spot when it appears on the buttocks,
nurses can differentiate the blue nevus by noting its distinct borders
and brighter color, compared with the Mongolian spot, which covers
a larger area. The blue nevus is usually 1 cm or less in size.
A nevus flammeus, a birthmark often referred to as a “port wine
stain,” is a capillary angioma located directly below the epidermis.
Usually apparent at birth, the nevus flammeus is a nonelevated, red
to purple network of dense capillaries that varies in size, shape, and
location, and is commonly seen on the face. It does not blanch on
pressure, disappear, or grow in size.
FIGURE 9-24 Mongolian spots (congenital dermal melanocytosis).
FIGURE 9-25 Stork bite.
Ongoing observation and assessment of the newborn’s skin allows

the nurse an opportunity to confirm normalcy, identify potential
problems, and prepare for possible interventions. It also provides an
opportunity to educate and reassure parents about normal neonatal
skin characteristics and findings that might indicate problems.
Parents are often fearful about “body marks,” and the nurse can allay
anxieties and stress the importance of conducting routine skin
observations throughout childhood.
BIRTH TRAUMA
Blemishes and other marks on an infant’s skin related to birth
trauma most often mirror the traumatizing instrument such as
forceps or scalp electrodes. Characteristically, the color of these
lesions progresses through the various skin color changes
commonly associated with bruising. When assessing for birth
injuries, the nurse pays close attention to the scalp, face, shoulders,
arms, legs, and feet. Large infants frequently exhibit marks from
trauma sustained during a difficult vaginal birth. Infants born with a
nuchal cord (umbilical cord around the neck) or those who assumed
a face presentation may demonstrate considerable bruising or
petechiae on the head, neck, and face. Also, newborns whose
presenting part was the legs, feet, or buttocks may have extensive
edema or bruising of the lower extremities. Disruptions or breaks in
the skin may be related to electrode marks or lacerations. Infants
delivered by forceps or vacuum extraction may have skin disruptions
or bruising on the scalp and face.
CONCERNING FINDINGS
Findings that need immediate medical attention can be either
obvious or subtle when assessing the newborn. Nurse knowledge
about these findings can potentially detect a serious condition. For
example, widespread petechiae or petechiae unrelated to birth
trauma should be reported immediately. This symptom may be
associated with infection that requires immediate isolation or it may
indicate a serious medical concern such as low platelets that
requires close monitoring and additional laboratory work.
Hypopigmentation refers to a white or pale area of skin. When it
occurs as a single lesion, hypopigmentation is not a cause for worry.
However, if multiple hypopigmented areas are present, including
lesions in a leaf pattern, the infant should be referred for further
evaluation. These lesions, which sometimes appear on the chest,
back, extremities, and axillae, may be associated with tuberous
sclerosis, a neurological condition.
Abnormally pigmented skin lesions and variations in hair patterns
can also signal underlying problems. Infants who exhibit hairy,
pigmented skin lesions containing two distinct areas of color should
be evaluated by a dermatologist. These findings may be related to
an underlying structural defect, and diagnostic ultrasound is often
performed to evaluate the tissue beneath the skin surface. Hairy nevi
contain individual hairs or a full tuft of hair. The presence of hairy
nevi in the posterior midline area near the spinal column may
indicate a vertebral defect. When present, ultrasound examination of
the spinal column is necessary to confirm any defects related to
spina bifida or spina bifida occulta.
Assessment of the Infant’s Head

Following the skin assessment, the infant’s head, eyes, ears, nose,
and throat are evaluated (Fig. 9-26). The nurse should assess the
head for any swelling and edema in the head of the newborn.
Molding may be present, which are changes in the shape of the
newborn head that occur when cranial bones overlap when the
newborns’ head is adapting for passage through the birth canal
(Venes, 2021). Molding is temporary and resolves within a few days.
Next, the nurse carefully palpates the infant’s head to assess the
fontanelles, the cranial suture lines, and the presence of any birth-
related edema. The anterior fontanelle is readily identifiable as a
diamond-shaped open space formed by the anterior-posterior
sagittal and frontal sutures and the lateral coronal suture (Fig. 9-27).
Assessment of the fontanelle includes an estimation of the overall
fontanelle size. The nurse can readily determine this dimension by
palpation of the fontanelle borders with use of the finger for
measurements (the distance from the tip of the finger to the first
finger joint is roughly 1 in., or 2.5 cm). Variations in anterior
fontanelle size are common and range from 0.4 to 2.8 inches (1–7
cm).
The posterior fontanelle, located toward the back of the cranium, is
a small, triangular-shaped space formed by the sagittal suture and
the posterior lateral suture. At its widest point, the posterior
fontanelle is usually only 0.4 inch (1 cm) and may be closed at initial
examination. The anterior fontanelle must remain open during the
first year of life to accommodate skull bone expansion that
accompanies normal brain growth. Open spaces between the suture
lines result from cranial molding during the birth process.
Assessment of the fontanelles for intracranial pressure is an
important component of the examination. Normal intracranial
pressure is characterized by a finding of fontanelle fullness without
bulging, either on visual inspection or palpation. Bulging, tense
fontanelles can indicate infection or hemorrhage as well as
increased intracranial pressure, especially in an infant with a large
head circumference and often associated with hydrocephalus.
Depressed fontanelles can indicate dehydration.
FIGURE 9-26 The face is examined for symmetry, noting placement

of the eyes, nose, lips, mouth, and ears.
FIGURE 9-27 Palpating the fontanelle borders.

The nurse may note the presence of swelling or soft tissue edema
of the head that has resulted from trauma during the birth process.
Caput succedaneum is diffuse edema that crosses the cranial suture
lines and disappears without treatment during the first few days of
life. It is easily observed and is often a soft area that results when
pressure on the presenting part was against the cervix for an
extended period of time or during a vacuum extraction.
Cephalhematoma, a more serious condition, results from a
subperiosteal hemorrhage, which is localized and does not cross the
suture lines (Fig. 9-28). It appears as a localized swelling on one
side of the infant’s head and persists for weeks while the tissue fluid
is slowly broken down and absorbed. During this time, the infant may
exhibit signs of jaundice related to the metabolism of damaged
RBCs from the subperiosteal hemorrhage.
Careful examination of the infant’s hair pattern is another essential
component of the nursing assessment. Special attention should be
paid to the hair texture, color, and distribution, noting disruptions to
the hair distribution or areas of asymmetry on the scalp. Hair that
covers the forehead and creates a shortened distance between the
hairline and the eyebrows may indicate a congenital syndrome. The
nurse notes variations such as hair that is lighter in color than the
surrounding hair or hair that appears to grow in a circular pattern or
whorl. Sections of white hair embedded in darker scalp hair may
indicate an underlying structural defect or the presence of a
congenital syndrome.
Eyes are assessed for shape and size along with assessment for
coordinated movement of the lids. The eyelids are manually opened,
and the iris, sclera, and conjunctiva are examined. Eye color is often
gray or black at birth and should be documented. The pupils should
be assessed of equality of size, reactivity to light, red reflex, and for
any edema and discoloration of the scleral. The sclera should be
assessed for subconjunctival hemorrhages in the outer canthus of
the eyes, which can be caused when there is ocular pressure or
trauma during birth. The nurse uses an ophthalmoscope to check for
bilateral red reflexes and records the findings on the infant’s chart.
Absence of bilateral red reflexes is a medical emergency; this finding
warrants immediate attention. The nurse may assess the infant’s
gross vision by determining the infant’s ability to direct their gaze at
the examiner when positioned approximately 10 inches from the
face. The examiner then moves and notes whether the infant is able
to appropriately readjust the gaze. The lacrimal glands are not fully
developed in a newborn, resulting in a lack of tears that lasts until
approximately 2 months of life and should not be used as a sign of
dehydration.
Nostrils should be open bilaterally, and the nasal bridge should be
centered with no lateral deviations. Assessment of the nose begins
with an observation of its placement, normally located in the middle
of the face. The nurse can draw an imaginary line from the center of
the bridge of the nose downward to the notch of the upper lip. The
nose should lie exactly vertical to this line. Each side of the nose
should be symmetrical. Careful palpation of the nasal bridge should
be performed to determine symmetry and the presence of fracture
that may have occurred during birth. It is important to note any
deviation to one side, as well as asymmetry in relation to the size
and dimensions of the nostrils. Newborns are obligatory nasal
breathers for the first 3 months after birth and will often sneeze to
clear mucus. Blockage of a nostril will result in nasal flaring or
cyanosis, and should be evaluated for choanal atresia, which is a
congenital blockage of the nasal passage.
FIGURE 9-28 A, Normal head. B, Caput succedaneum—localized
soft tissue edema present at birth; does not increase in size; swelling
crosses the suture lines. C, Cephalhematoma—collection of blood
from a subperiosteal hemorrhage, appears after birth; increases in
size; swelling does not cross the suture lines.
The mouth needs to be fully inspected by gently opening the

newborn’s mouth and visually inspecting, then palpating, the gums
for the presence of neonatal teeth above or beneath the gum surface
(Fig. 9-29). Teeth that have emerged through the gums should be
checked for looseness and may need to be extracted due to the risk
of aspiration. The lips are also assessed for movement, which
should be symmetrical. Birth-related damage to the seventh cranial
(facial) nerve can result in findings such as unilateral drooping of the
tongue or mouth, unequal movement of the cheek muscles, or
inappropriate eyelid movement. Lip color should be consistent with
the tongue and buccal mucosa of the mouth. The upper and lower
lips should be approximately uniform in size. The infant’s chin should
be readily apparent when viewed in a profile position.
FIGURE 9-29 Natal teeth.
Epstein pearls, whitish hardened nodules on the gums or roof of

the mouth, may be visualized or palpated (Fig. 9-30). These pearl-
like inclusion cysts are not an unusual finding and disappear within a
few weeks. The presence of the uvula in the midline is noted; a
bivalve or double-lobed uvula may indicate a cleft in the palate. The
infant’s ability to suck can also be assessed during the oral
examination. The nurse inserts a gloved finger into the infant’s
mouth, with the fingernail down to the tongue, and notes and records
the strength of the sucking motion. Also at this time, the hard and
soft palates can be examined for size, shape, and cleft formations.
When present, a cleft defect is felt as an open space or notched
ridge. A high, arched palate may be associated with difficulty
swallowing or with later speech development. The tongue should be
assessed for color and should be pink; a whitish tongue can indicate
thrush, which can be acquired from the vaginal tract during birth. The
tongue should be able to move freely. The nurse should also assess
for ankyloglossia. This condition, which is a shortened frenulum, and
can later affect eating and speech, and may require surgical
correction.
The neck should be assessed by lifting the chin to assess the neck
area, which is short, thick, with skin folds (Fig. 9-31). Webbing of the
neck should not be present, which can indicate a congenital
malformation and require further evaluation. The neck should move
easily side to side, and the nurse checks for neck rotation by
observing the infant’s head movement and by gently turning the
head from side to side. Torticollis is a deviation of the neck to one
side caused by a spasmodic contraction of neck muscles. In the
newborn, a torticollis is apparent when the head is positioned on one
side while the chin points to the opposite side. Torticollis and the
presence of a congenital cervical spine defect are two serious
conditions that may produce limitations in neck movement and
should be reported immediately.
Special attention is paid to the shape, size, and placement of the
ears. Ears placement should be noted in relation to the eyes, and the
top of the ear pinna should be parallel to the outer cantus of the
eyes. Low-set ears that are located below the level of the outer
canthus of the eyes may signal the need for further assessment and
evaluation for chromosomal abnormalities (Fig. 9-32). Placement of
one ear slightly lower than the other is a common finding that
generally has no clinical significance. The ears should be soft and
pliable and when folded and released should recoil easily back in
place. Ear pits, tiny pinholes found near the upper curved border of
the pinna, arise from the imperfect fusion of the tubercles of the first
and second brachial arches during early fetal development. They
may signal a small sinus tract between the skin and underlying
structures and should be evaluated to determine whether a layer of
skin covers the opening or if the pit is open at the bottom. In most
cases preauricular pits are benign and do not warrant further
treatment; however, in some cases they may be a trait of another
syndrome such as a kidney condition, indicating a need for further
evaluation and treatment (U.S. Department of Health and Human
Services, n.d.). The nurse palpates and inspects the newborn’s ears
to determine the thickness of the ear lobe and pinna. Ear tags, fleshy
bulb-shaped growths that project from the surface of the skin, are
benign and can be removed for cosmetic purposes. Hearing is often
present shortly after birth and can be evaluated by noting the
newborn’s response to noise.
FIGURE 9-30 Epstein pearls usually disappear within a few weeks.
FIGURE 9-31 Assessment of the neck.

FIGURE 9-32 To determine ear placement, an imaginary line is
drawn from the inner to the outer canthus of the eye and then to the
ear. A, Normal ear position. B, Low-set ear. C, Slanted low-set ear.
Most U.S. states require routine hearing screening before a

newborn’s discharge from the hospital. The goal of newborn
screening is to identify congenital hearing loss and to refer those
affected for early intervention. Most universal hearing-screening
programs use the otoacoustic emissions test and/or the automated
auditory brainstem response test.
Diagnostic Tools
Newborn Hearing Screening
Otoacoustic emissions (OAEs): This painless test is performed when the
newborn is sleeping and assesses cochlear function for the 500 to 6,000 Hz
frequency range. A tiny, flexible earplug that contains a microphone is inserted
into the infant’s ear and records responses of the outer hair cells of the cochlea
to clicking sounds coming from the microphone. Testing effectiveness is
reduced by ambient noise in the nursery, vernix, blood, and amniotic fluid in the
ear canal or any middle ear pathology.
Automated auditory brainstem response (AABR): This painless test is
performed when the newborn is sleeping and assesses auditory function from
the eighth nerve through the auditory brainstem. Disposable surface electrodes
are placed high on the forehead, on the mastoid, and on the nape of the neck
(Fig. 9-33). The click stimulus is delivered to the newborn’s ear via small
disposable earphones; the test assesses electrical activity of the cochlea,
auditory nerve, and brainstem in response to the sound stimuli and can be
conducted in the presence of background noise.
Infants who do not pass an initial hearing screening at birth should return for
follow-up testing within 1 month.
FIGURE 9-33 Neonatal hearing screening.

Optimizing Outcomes
The Healthy People 2030 Hearing Screening National Objective

The Healthy People 2030 national objective related to newborn hearing
screening states: “Increase the proportion of newborns who are screened for
hearing loss by age 1 month, increase the proportion of infants who didn’t pass
their hearing screening who get evaluated for hearing loss by age 3 months,
and increase the proportion of infants with hearing loss who get intervention
services by age 6 months.” Nurses can help the nation achieve this goal by
educating parents about the importance of newborn hearing screening,
ensuring that newborn hearing screening is completed before hospital
discharge if possible and that appropriate referral is made if indicated, and by
advocating for universal newborn hearing screening.
CONDITIONS THAT MAY WARRANT FURTHER ASSESSMENT

When assessing the head, ears, eyes, nose, and throat, the nurse
is alert to findings of asymmetry, unusual shape or evidence of
defects in underlying structures, or congenital syndromes. Generally,
findings that are immediately apparent to the nurse examiner pose
the greatest problems for the newborn. For example, Down
syndrome is frequently identified during the assessment of the head
when the nurse notes a flattened (instead of round) occiput, a broad
nasal bridge, upward slanted eyes with epicanthal folds, low-set
ears, an enlarged or protruding tongue, high arched palate, and a
small chin. Open separations of the lip, mouth, nose, and hard or
soft palate are indicative of cleft lip or cleft palate.
What to Say
When a Newborn Has a Disfigurement
When a newborn has any type of disfigurement or imperfection, this can cause
a great deal of stress on the parent and family. Nurses need to be extremely
sensitive to the feelings of the parents and other family members who interact
with the newborn. Parents may have a wide range of emotions that they may
show including sadness, fear, concern, guilt, and anxiety. The nurse should
also observe interactions with the mother, partner, and newborn and assess for
bonding issues that may occur. The nurse should consider the parents’ level of
understanding of the disfigurement and may benefit from counseling. This
starting point helps guide the nurse in communicating with the parents and
providing further information and education.
The eye examination may provide an early indicator of several

conditions that can affect the infant’s well-being. For example, sclera,
normally white, may appear blue or yellow. Bluish sclera may signal
a congenital condition known as osteogenesis imperfecta,
characterized by a loss of bone structure and integrity. Infants with
this condition must be handled with extreme gentleness and may
have already suffered fractures during the birth process. Yellowing of
the sclera, related to elevated bilirubin levels, is a late manifestation
of jaundice in the newborn. The nurse should seek immediate
medical assistance for the infant and plan for rapid intervention such
as IV fluids and phototherapy.
A disruption in the iris called a coloboma appears as a keyhole in
the circle of the iris and pupil and will affect vision in that eye.
Congenital cataracts are noted when white or pale-yellow tissue
covers the pupil and iris and occludes the red reflex. This finding
warrants prompt referral. Occasionally, the red reflex (normally red or
reddish orange in color) appears white, a finding that requires
immediate attention and may indicate the presence of a
retinoblastoma. Congenital glaucoma is an ophthalmic emergency
that requires the timely instillation of eye drops to prevent blindness
caused by increased intraocular pressure. This condition is
characterized by protuberant eyes that appear to extend beyond the
orbits and feel firm on gentle palpation.
Careful examination of the infant’s facial features may provide
evidence of birth defects associated with maternal alcohol use.
Characteristic findings include short palpebral fissures; a flattened
nasal bridge with a small, upturned nose; and a flat midface, thin
upper lip, and smooth philtrum. Alcohol-related birth defects (ARBD)
also include poor growth, intellectual disabilities (often associated
with microcephaly, or small head), and small chin (micrognathia).
This condition, also called fetal alcohol syndrome (FAS) or fetal
alcohol effects (FAE), describes the range of physical and mental
effects that are related to the mother’s alcohol use during fetal
growth and development. After birth, affected infants are often jittery,
irritable, and poor feeders. Nursing interventions focus on providing
a calming, quiet, nurturing environment with minimal stimulation. See
Chapter 10 for further discussion.
Assessment of the Respiratory System

When assessing the newborn’s respiratory efforts, the nurse first
observes for symmetry in chest movement and at the same time
notes the placement and size of breast tissue. Enlargement of the
breasts in male infants is common and only a temporary condition
related to maternal hormones. The breast tissue and nipples should
be located in the midclavicular line. This anatomical landmark is an
imaginary line that is one-half of the distance from the midline (the
lower border of the sternum) to the lateral border of the chest wall
formed by the rib cage. If the breast tissue is located between the
midclavicular line and the lateral chest wall, the nurse documents
this finding as “wide-spaced nipples.” The presence of wide-spaced
nipples may signal a congenital syndrome such as Down syndrome.
Extra or “accessory” nipples may be located above or below the
primary nipples. This finding is not associated with a congenital
syndrome, and parents can be assured that the accessory nipples
will not enlarge during puberty and if desired may be safely removed
later.
To assess for nasal patency, the nurse carefully occludes one
naris while the infant’s mouth is closed. A rise in the infant’s chest
confirms that the nasal passageway is open and air has been
inhaled. The assessment may be repeated with the other naris. If the
infant demonstrates difficulty with this maneuver, they may have a
developmental anomaly known as choanal atresia, a malformation of
the bucconasal membrane. When present bilaterally, cyanosis is
noted when the infant’s mouth is closed but disappears when the
mouth is open. An inability to pass a small catheter into the nares
confirms the diagnosis. Because choanal atresia may be associated
with other developmental anomalies, a positive finding should be
reported immediately.
With the infant in a supine position, the nurse can readily assess
their ease with overall breathing efforts. Respirations are counted,
and the pattern and use of accessory muscles are noted. Slight
sternal retractions may occur; this is a normal finding. Prominence of
the xiphoid process is not unusual, and with normal growth and
development, the prominence will diminish.
The lungs are auscultated anteriorly and posteriorly (Fig. 9-34).
Infants may exhibit irregular breathing patterns accompanied by
periods of apnea that can persist for up to 15 to 20 seconds. While
not worrisome, it is important to alert parents that a brief cessation in
respirations is common in newborns. The nurse also teaches the
infant’s caregivers how to recognize signs of respiratory distress:
flaring of the nares, retractions (in-drawing of tissues between the
ribs, below the rib cage, or above the sternum and clavicles),
grunting with expirations, cyanosis, hypotonia, and abnormal
respiratory patterns. For healthy full-term newborns, a respiratory
rate less than 60 breaths per minute is considered normal. To obtain
an accurate respiratory rate, it may be necessary to count the
infant’s respirations at several different times during the physical
assessment. If the respiratory rate remains greater than 60 to 70
breaths per minute during rest, further evaluation is warranted.
If the infant appears to be expending considerable energy to
breathe or shows other signs of breathing difficulty, seek immediate
evaluation of the respiratory system. Signs of respiratory distress
may be manifested by marked sternal or intercostal retractions.
During the assessment, the nurse should gently palpate the anterior
lung field to identify birth injuries, such as fractures of the clavicle or
ribs. These injuries can cause an increased respiratory rate as a
result of pain.
FIGURE 9-34 A, The lungs are auscultated anteriorly. B, The lungs
are auscultated posteriorly.
The nurse next inspects the chest wall to confirm symmetry and
shape. Asymmetry of the chest wall during respirations may also
signal the presence of a rib fracture. Anatomical deformities such as
pectus carinatum (pigeon chest) and pectus excavatum (funnel
chest) arise from abnormal development of the ribs and sternum and
may interfere with normal lung expansion. All lung fields should be
auscultated anteriorly and posteriorly, and the respiratory rate is
counted from the auscultation rather than from observation of
abdominal movements. Auscultation of the infant’s nose can help
differentiate upper airway congestion (from mucus or amniotic fluid)
from lower airway congestion. When the nasal passages, throat, or
upper bronchus is congested, noisy breath sounds are often
detected. Using a bulb syringe, the nurse gently removes fluid and
mucus from the infant’s nasal and throat passages to facilitate easy
respirations. After this intervention, any retractions should disappear.
If the infant continues to exhibit retractions and other signs of
breathing difficulty, prompt investigation is warranted and constitutes
a life-threatening event. Respiratory distress is associated with a
number of heart and lung conditions. Narrowing of the airways
results from many congenital respiratory conditions while congenital
heart defects often interfere with the lungs’ capacity to oxygenate the
blood.
Congenital or acquired infection in the newborn may also cause
respiratory distress. If the infant’s respiratory rate remains elevated
(60–70 breaths per minute) during periods of rest, the nurse must
provide continuous observation. While the increased respiratory rate
may represent a transitional period of adjustment to extrauterine life,
the development of other symptoms such as nasal flaring, grunting,
or intercostal retractions is indicative of respiratory distress. (See
Chapter 10 for further discussion.) To complete the assessment, the
nurse should also note the infant’s skin color and assess the
capillary refill of the extremities, actions that provide additional
information about respiratory system functioning and normal
oxygenation levels.
Patient Education
How to Recognize Breathing Difficulties
As a component of newborn care, the nurse provides the following information
to parents.
Your baby may be experiencing breathing difficulty if they:
• Have faster than normal respirations.
• Have prolonged (greater than 15 seconds) periods of breath holding.
• Show sucking-in and seesaw movements around the rib cage.
• Flare nostrils.
• Make grunting or wheezing sounds.
• Use accessory muscles.
• Appear lethargic or sleepy.
Assessment of the Cardiovascular System
The nurse assesses the newborn’s circulatory system by visual
inspection and auscultation. Careful inspection of the skin, lips,
gums, and buccal mucosa provides reliable evidence of cardiac
perfusion. At rest, the infant’s skin should be pink in color and
progress to red during crying or physical activity. The nurse palpates
the chest to detect any thrills or heaves and the point of maximum
impulse, which is auscultated at the apex of the heart near the third
or fourth left intercostal space (Fig. 9-35). For infants, the normal
heart rate should be between 120 and 160 beats per minute. A heart
rate greater than 160 beats per minute is called tachycardia.
To assess capillary refill in the extremities, the nurse gently
pinches the end of the infant’s finger or toe and then counts the
number of seconds required for the skin to return to its normal color.
The average refill time is 3 seconds. If more than 3 seconds lapse,
there may be shunting of blood from the periphery toward the infant’s
trunk.
The nurse palpates all peripheral pulses for bilateral symmetry,
strength, and rate. The femoral pulses on each side are carefully
checked and compared with the brachial pulses (Fig. 9-36). If a
decrease in the strength of the pulse between the brachial pulses
and femoral pulses is noted, this finding may indicate coarctation of
the aorta, a cardiac condition associated with a narrowing of the
aortic arch. Because the aorta is the main vessel for transporting
oxygenated blood to the upper and lower body, a narrowing of the
aortic arch produces a compromise in blood flow. See Chapter 17 for
further discussion of coarctation of the aorta.
Optimizing Outcomes
Critical Congenital Heart Disease Screening in the Newborn
Critical congenital heart disease (CCHD) is a heterogenous group of disorders
affecting 1.2 infants per 1,000 live births in the United States. With this
condition, surgical or catheter-based therapy within the first year of life is
mandatory for survival. CCHD screening is a safe, simple, noninvasive strategy
for improving early identification of newborns with CCHD. CCHD screening
should be conducted between 24 to 48 hours of life with the use of pulse
oximetry. The pulse oximetry device is applied to the right hand and right foot to
obtain oxygen saturation readings. Results that show oxygenation saturation
less than 90% to 95% in either the hand or the foot or greater than a 3%
difference of oxygen saturations between the hand and the foot warrant
concern. The infant should have this test done an additional two times within the
hour, and if the same concerning results occur, prompt cardiac evaluation
should occur (Suplee & Janke, 2020).
FIGURE 9-35 Auscultating the heart.
FIGURE 9-36 Palpating the femoral pulse.
COMMON FINDINGS
The nurse carefully auscultates all areas of the heart, including the
aortic, pulmonic, tricuspid, and mitral valves, along with the base and
apex. Either condition, if persistent, warrants further investigation.
Heart rate auscultation in the newborn is often difficult because of
the thinness of the chest wall combined with the noisiness of heart
sounds that are often obscured by respirations. The nurse should
listen carefully and take time in counting the heart rate. It is not
uncommon to hear murmurs in infants less than 24 hours old. The
murmurs are characterized by a sound (best heard near the sternal
border at the second or third intercostal space on the left side) that
grows louder during systole. Although a heart sound arising from a
PDA may be heard initially, the sound disappears within 2 to 3 days
when the ductus closes. If a murmur remains audible after the
second day of life and intensifies to a “whoosh” sound, further
investigation is warranted and may indicate the presence of another
type of heart lesion.
Cardiac insufficiency describes a condition that occurs when an
infant cannot adequately oxygenate and circulate blood. This
condition is characterized by pallor, rapid breathing, and cyanosis
around the lips. Pulse oximetry readings should be obtained
immediately. Readings of less than 94% oxygen saturation on room
air are of major concern, and if an infant’s oxygen saturation drops
below 90%, rapid transfer to an intensive care unit for continuous
respiratory and cardiac monitoring should be accomplished. Cardiac
evaluation is carried out, and depending on the findings, treatment
may be medical, surgical, or both.
Infants who demonstrate cardiac instability within the first 2 days
of life are usually those with a genetic karyotype of trisomy (13, 18,
or 21) or have a congenital condition called tetralogy of Fallot.
Tetralogy of Fallot is a congenital malformation of the heart and great
vessels that involves four distinct cardiac anomalies: dextroposition
of the aorta, right ventricular hypertrophy, pulmonary artery stenosis,
and interventricular septal defect (Venes, 2021). Infants born with
tetralogy of Fallot demonstrate no difficulties until the ductus begins
to close after the first 24 hours of life. At that point, the infant
experiences severe cardiac instability and develops central cyanosis.
Transfer to an intensive care unit allows for IV fluids, medications,
and continuous cardiac monitoring to be carried out until surgical and
medical evaluation can take place. (See Chapter 17 for further
discussion.)
HEMORRHAGIC DISEASE OF THE NEWBORN

All infants are at risk for hemorrhagic disease, most often caused
by vitamin K deficient bleeding. During the first few days of life, the
newborn has low levels of vitamin K. Vitamin K is produced through
exposure of bacteria in the gut. A newborn’s gut is considered a
sterile environment at birth and does not contain any bacteria. After
a few days the newborn’s gut is exposed to bacteria through
feedings and sucking on objects. Vitamin K is then produced in the
gastrointestinal tract around day 8. Vitamin K is an essential
component in blood clotting and acts as a catalyst to synthesize
prothrombin, needed for blood clotting. Newborns are at risk for
vitamin K deficiency bleeding such as intracranial hemorrhage due to
a lack of vitamin K, especially during vaginal births that may cause
trauma to the head or skull (Centers for Disease Control and
Prevention, 2018). It is critical that newborns receive vitamin K within
hours of life, either orally or by injection into the muscle. Oral vitamin
K is unreliable as a newborn may spit out the medication and dosage
that is consumed is uncertain. The best and preferred is with a single
dose (0.5–1.0 mg) of vitamin K phytonadione (AquaMEPHYTON),
which is administered via an IM injection in the vastus lateralis
(preferred) or the ventrogluteal muscle.
MEDICATION: AquaMEPHYTON
(Phytonadione, Mephyton, vitamin K)
(fye-toe-na-dye-one)
Classification(s):
THERAPEUTIC: Antidotes, vitamins
PHARMACOLOGICAL: Fat-soluble vitamins
Pregnancy Category: UK
Indications: Prevention and treatment of hypoprothrombinemia, which may be
associated with excessive doses of oral anticoagulants, salicylates, certain anti-
infective agents, nutritional deficiencies, and prolonged total parenteral
nutrition. Prevention of hemorrhagic disease of the newborn.
Action: Required for hepatic synthesis of blood coagulation factors II
(prothrombin), VII, IX, and X.
Therapeutic Effects: Prevention of hypoprothrombinemia bleeding
Pharmacokinetics:
ABSORPTION: Well absorbed after intramuscular administration.
DISTRIBUTION: Crosses the placenta; does not enter breast milk.
METABOLISM AND EXCRETION: Rapidity metabolized in the liver.
HALF-LIFE: Unknown
CONTRAINDICATED IN: Hypersensitivity, hypersensitivity, or intolerance to
benzyl alcohol (injection only).
USE CAUTIOUSLY IN: Impaired liver function
EXERCISE EXTREME CAUTION IN: Severe life-threatening reactions have
occurred after IV administration; use other routes unless IV is justified.
GASTROINTESTINAL: Gastric upset, unusual taste
DERMATOLOGICAL: Flushing, rash, urticaria
HEMATOLOGICAL: Hemolytic anemia
LOCAL: Erythema, pain at injection site, swelling
MISCELLANEOUS: Allergic reactions, hyperbilirubinemia (large doses in very
premature infants), kernicterus
Route and Dosage: IV use of phytonadione should be reserved for
emergencies.
Prevention of Hemorrhagic Disease of the Newborn:
IM (NEWBORNS): 0.5 to 1 mg, given within 1 to 2 hours after birth; may repeat in
6 to 8 hours if needed. May be repeated in 2 to 3 weeks if the mother received
previous anticonvulsant/anticoagulant/anti-infective/antitubercular therapy; 1 to
5 mg may be given IM to the mother 12 to 24 hours before the birth.
1. Inform parents of medication administration; invite them to offer comfort to
their infant.
2. Prepare to administer the injection to the infant within 2 hours after birth;
follow the rights of medication administration (i.e., the right patient, the right
medication, the right dose, the right route, the right time, the right reason,
the right documentation, and the right result) of medication administration.
3. Draw up the medication in a 1-mL syringe.
4. Don gloves; unfasten the diaper to allow full visualization of the leg.
5. Identify the injection site. Children younger than 12 should receive IM
injections halfway down the vastus lateralis on the anterolateral thigh (Fig.
9-37). The anterior thigh should not be used for injections due to
neurovascular structures that are located there and can be damaged.
6. Stabilize the knee with the heel of the hand and grasp the muscle between
the thumb and forefinger.
7. Using a 25-gauge, 5/8-inch to 7/8-inch needle inserted at a 90-degree
angle, slowly administer the medication into the middle third of the vastus
lateralis muscle.
8. After removing the needle, use a dry gauze square to gently rub the
injection site to promote absorption and decrease discomfort. Place a small
dressing over the site and document date, time, and location of the
injection.
9. Report any symptoms of unusual bleeding or bruising (bleeding gums;
nosebleed; black, tarry stools; hematuria; or bleeding from the base of the
umbilical cord or other open wounds) as this may indicate that the dosage
was not effective.
10. A decrease in HGB and hematocrit levels or any bleeding may indicate that
the effects of the medicine have not been achieved and that more vitamin K
may be necessary. Call the physician for further instruction.
Source: (Australian Government Department of Health, 2019; Vallerand, 2021).
Assessment of the Gastrointestinal System

The nurse begins the assessment by placing the infant in a supine
position to facilitate the abdominal inspection. The abdomen should
be round and bilaterally symmetrical. The clamped umbilical cord
should show no evidence of active bleeding or oozing (Fig. 9-38).
The cord is inspected to confirm the presence of three vessels: two
arteries and one vein. If fewer than three vessels are seen, it may be
associated with congenital anomalies that warrant further evaluation.
FIGURE 9-37 IM injection.
Wharton’s jelly, the gelatinous substance that prevents

compression of the blood vessels, can look different and have
different amounts of thickness among newborns. The abdomen may
appear distended because of stool remaining in the bowel. The
nurse carefully auscultates all four quadrants of the abdomen for
bowel sounds (Fig. 9-39). To facilitate thorough auscultation, each
quadrant is divided into small sections to lessen the likelihood that
any one area is overlooked. Bowel obstruction in the newborn is
often first identified by an absence of bowel sounds in a small,
distinct section of the intestines. The nurse completes the
assessment with auscultation of the upper abdomen for the gastric
bubble and the heart sounds of the abdominal aorta.
COMMON FINDINGS
The nurse uses light, then deep, palpation of the abdomen to
assess the structure and contents of the abdomen. Light palpation is
initiated at the lower sternal border and proceeds along the midline
down to the umbilicus. Diastasis rectus, a thinning of the abdominal
wall, may be detected. Diastasis rectus can also be identified by the
presence of a long, raised lump along the midline that becomes
prominent when the infant is crying. The nurse assesses the area
surrounding the umbilicus for the presence of an umbilical hernia.
Using the fingertips to determine the hernia size, the nurse notes
whether it appears to be large or small and documents this
information in the medical record. Small umbilical hernias are
common in newborns and often close without surgical intervention as
the infant grows. The nurse continues palpation along the midline
toward the symphysis pubis to detect any inferior extension of the
hernia. Light palpation from the midline is then extended laterally
toward the rib cage to assess for masses or enlarged organs.
FIGURE 9-38 Assessing the umbilical cord.

FIGURE 9-39 Auscultating bowel sounds.

Findings indicative of a serious abdominal problem in the newborn
include abdominal distention, absence of bowel sounds, discharge
from the umbilical cord or cord site, and palpation of an abdominal
mass. Abdominal distention may involve the entire abdomen or may
be confined to small areas. Abdominal blood vessels may be visible
in the distended abdomen. Abdominal bulging that shifts when the
infant’s position is changed may be indicative of fluid in the
abdomen. Absence of bowel sounds indicates an area of bowel that
is not functioning; this finding must be immediately reported.
Discharge from the umbilical cord or cord site indicates the
presence of infection. Unless a bacteriostatic dye has been used to
paint the area, the cord should be pale yellow in appearance. An
extra clamp may be applied if blood is actively leaking from the
umbilical cord. If meconium was passed in utero, the cord may be
stained a gray-green color. The area around the base of the cord
should be kept clean and dry. During diapering, care must be taken
to prevent stool or urine from coming into contact with the cord or the
cord base. If this occurs, the nurse should carefully clean and dry the
site. The tissue surrounding the base of the cord should be
inspected for redness, a finding that may indicate omphalitis (an
infection that is readily treated with antibiotics).
Palpation to detect an abdominal mass or enlarged organ is
usually facilitated by the infant’s small abdominal girth. Positive
findings require immediate referral for evaluation. Often, an
ultrasound examination is conducted to determine the source of the
clinical findings and guide the management. In infancy, abdominal
masses are frequently neuroblastoma, a type of tumor that is
confirmed by biopsy. The kidneys, liver, and spleen are the organs
most commonly enlarged, and these findings can be confirmed with
ultrasound. Enlargement may result from obstruction or it may be
associated with a congenital malformation such as omphalocele or a
exstrophy of the bladder (see Chapter 10).
Recognizing an acute abdomen in a newborn is a critical part of
the assessment and warrants immediate attention by the doctor.
Symptoms that may indicate acute abdomen include:
■ Rigid, boardlike abdomen
■ Inability to palpate abdominal organs
■ Indicators of pain (continuous crying, facial changes, or gross
motor movements)
Assessment of the Genitourinary System

The nurse begins the assessment by placing the infant in a supine
position with the hips abducted. With the male newborn, the scrotum
is examined to confirm that both testicles have descended. If flat or
depressed areas are identified, this may indicate that a testis has not
descended. Palpation of the scrotum is accomplished by placement
of the examiner’s second finger at the posterior scrotal midline with
the thumb on the anterior midline (Fig. 9-40). Using the index finger
and the thumb, the nurse palpates the left side of the scrotum for the
presence of a testis and then uses the third finger and thumb to
palpate for a testis on the right side of the scrotum. Proceeding in
this pattern helps to ensure that one testis is not mistakenly being
“counted” twice. If a testis is not detected, the nurse can softly stroke
the inguinal canal in an attempt to locate an undescended testis.
Warm soapy water applied to the inguinal area may enhance
testicular prominence and help it be more easily identified. Any infant
older than 35 weeks’ gestation who has undescended testicles
should be referred for a urological consultation.
Inspection of the female genitalia begins with the labia majora.
The extent to which the labia cover the surrounding tissues
corresponds with the developmental maturity of the female newborn.
For most term infants, the borders of the labia majora touch and the
clitoris is covered completely. Occasionally, a full-term infant has
delayed genital development, and on examination, the nurse can
easily view the labia minora and exposed clitoris.
The anus and anal opening are also assessed at this time. While
stooling confirms anal patency, it is beneficial to actually witness the
passage of meconium because it provides an opportunity for the
nurse to confirm that the stool passes through only one opening.
Stool in the vagina indicates the presence of a rectovaginal fistula,
an opening between the rectum and vagina. To palpate the anus, the
nurse gently touches the tissue around the anal opening and
assesses the musculature surrounding the opening. Tiny rectal tears
from the passage of stool in the anal ring are noted, and the anal
wink reflex is assessed. The infant is placed in a prone position and,
using the index finger, the nurse gently strokes the buttocks from
side to side. In response, the buttocks draw together and “wink” at
the point of the anal opening. This response validates the correct
anatomical position of the anal opening. In females, the anal wink
reflex is useful in assessing anal openings positioned less than 1 cm
from the vaginal opening. When the anal opening is too close to the
vaginal opening, proper muscle strength needed to evacuate the
rectum as the child grows older does not develop. The wink reflex is
also useful in facilitating proper placement of the anal opening during
future surgical correction.
FIGURE 9-40 Palpating the scrotum.
COMMON FINDINGS
Careful assessment of genitalia is essential in both males and
females. First, the nurse visually inspects, then palpates, the male
genitalia. Scrotal swelling may interfere with an accurate palpation. If
swelling is present, it is important to auscultate the scrotum to
ensure that it does not hold entrapped bowel. If no bowel sounds are
heard, transillumination can be used to verify the presence of fluid in
the scrotal sac. The nurse secures a penlight or ophthalmoscope,
which will be used as a light source; darkens the room; and gently
presses the light source against the scrotum. Fluid appears as a
reddish yellow reflection. Masses do not transilluminate, and if
detected, must be reported immediately. Scrotal fluid is slowly
reabsorbed during the first weeks of life, and no treatment is
necessary. The nurse can reassure the parents that any swelling will
resolve over time and the scrotum will gradually take on a more
normal appearance.
The penis is palpated to estimate the approximate length. Penile
length in the full-term newborn male is approximately 2 cm. The
nurse gently retracts the prepuce, or foreskin, to inspect the urethral
opening and determine the location of the opening on the glans.
Smegma, a waxy substance, may be present on the glans beneath
the foreskin. Instead of the normal round urethral opening, or
meatus, a vertical opening may be seen. When present on the
ventral (instead of central) surface, this finding is indicative of
hypospadias. Hypospadias requires surgical repair by a physician.
Excess foreskin is used to create a properly positioned meatus,
males with suspected hypospadias should not be circumcised.
Epispadias is a similar condition. When present, the vertical urinary
opening is located on the dorsal surface of the penis instead of on
the glans. Epispadias is also repaired surgically with excess foreskin.
During the inspection of the female genitalia, the nurse may
identify vernix caseosa, a whitish, cheesy substance, covering the
tissue between the labia (Fig. 9-41). This is a normal finding. The
hymenal tag, a small piece of triangle-shaped tissue, may also be
present between the labia. The nurse gently palpates the labia
majora and labia minora, an action that facilitates examination of the
hymenal area. Small amounts of blood and whitish mucoid discharge
(“pseudomenstruation”) related to the maternal hormones may be
noted in the vaginal area. Parents can be assured that this discharge
is normal and will disappear in about a week. Smegma may also be
present between the labia.
FIGURE 9-41 Assessing the female genitalia.

When examining the male genitalia, the nurse may note the
presence of bruising or swelling, especially if the infant was delivered
in a breech presentation. Micropenis, a penis that is less than 2 cm
in length, may be associated with a pituitary tumor.
In the assessment of the female genitalia, most concerns center
around the presence of an enlarged clitoral hood and the finding of
an imperforate hymen. Although maternal hormones may produce
slight clitoral enlargement, a hood-shaped, grossly enlarged clitoris
may be related to excessive androgen production. This condition
may signal congenital adrenal hyperplasia, and further evaluation
and testing should be performed. The infant’s genitalia may also be
edematous from birth trauma, making the examination difficult. The
nurse should gently separate the labia and inspect the area for the
location of the urethral and vaginal openings. Imperforate hymen is
present when tissue obstructs the vaginal opening, necessitating
later surgical correction to allow for the discharge of menstrual blood.
Male and female infants may have anal ring skin tags or an anal
ring that has no opening. The skin tags are hemorrhoid-like tissues
that can cause discomfort or bleeding when the infant stools. The
absence of an opening in the anal ring is a condition known as
imperforate anus.
The finding of imperforate anus is a medical emergency because
the infant is unable to pass stool through the anus. In approximately
half of the infants with this condition, the imperforate anus occurs as
an isolated event unrelated to any congenital syndrome. In the other
half of occurrences, the imperforate anus is a part of a congenital
syndrome associated with anal malformations, called the VATER
association. At least three of the major abnormalities must be
present for diagnosis. The overall prognosis is improved following
the surgical correction of each anomaly. Characteristics of VATER
association in the newborn include:
V = vertebral abnormalities
A = anal abnormalities (imperforate anus)
T = tracheal abnormalities
E = esophageal abnormalities (tracheoesophageal fistulas)
R = renal and radial abnormalities (common occurrence in children
with Down syndrome)
Disorders of Sexual Development
Often, the term “intersex disorders” is used for disorders of sexual
development, which cause degrees of ambiguous genitalia and sex
characteristics (Venes, 2021). For example, this type of condition
can result in male genital structures that mimic labia or female
genitals with a structure similar to a penis. If the definite genitalia
cannot be determined, the infant is referred for genetic studies and
evaluated for adrenal gland insufficiency. Parents are often faced
with stressful decisions regarding assigning and raising the child as
male or female and the need for costly surgery that may cause
economic stress (Bangalore Krishna et al, 2020).
It is important that the nurse approach the parents with sensitivity
and compassion when the health-care team suspects an intersex
disorder. In situations of ambiguous genitalia, the nurse must be
careful not to prematurely label an infant as a “boy” or “girl” to avoid
compounding the parents’ confusion. In addition, some parents may
decide not to choose one sex over the other and raise the child
gender neutral.
What to Say
Infant With Ambiguous Genitalia
Despite the initial birthing room determination of the newborn’s gender, careful
later examination of the genitalia may prompt concerns regarding the true sex
assignment. It is important to promptly alert parents of the need for further
testing for gender determination. The nurse can address the parents’ concerns
with reassuring statements such as:
“There is some question regarding your baby’s sex organs, so the doctor has
asked a specialist to examine your baby. Additional testing may be indicated.
You may want to wait to name your baby until we know for sure. For now, it is
important to spend as much time as possible with the baby as you get to know
one another.”
Assessment of the Musculoskeletal System

The nurse can readily assess the functioning of the musculoskeletal
system by observing the newborn in the crib where they have the
freedom to continue and expand movements first initiated in utero.
By flexing and extending the arms and legs, sucking on the fingers,
and moving the head from side to side, the newborn provides a
visual display of musculoskeletal status. Any compromise in
movement alerts the nurse to the location of possible birth trauma or
other injury. Inspection of the extremities for differences in length or
size is an important component of the assessment. Positive findings
may be indicative of achondroplasia, a congenital condition
characterized by a small thoracic area, an inability to extend the
elbows, and a marked shortening of the femurs and humerus. Often
referred to as “little persons,” individuals with achondroplasia
frequently have neurological and respiratory problems in addition to
their skeletal deformities.
To assess muscle tone and strength, the nurse first places the
infant in a supine position and then in a prone position. If the infant is
unable to move the lower extremities, damage to the spinal cord is
suspected. Asymmetry in movement suggests nerve damage or
fracture related to birth trauma. If the infant does not move or
appears lethargic or limp when repositioned, the nurse suspects
hypotonia, or diminished muscle tone. Hypotonia may be related to
an episode of anoxia, either during birth or while in utero. Increased
muscle tone, or hypertonia, is characterized by muscle tremors,
twitches, or jerkiness, and this finding is often associated with
neonatal abstinence syndrome. Symptoms of drug withdrawal are
manifest through the increased muscular movements.
COMMON FINDINGS
After the visual inspection, the nurse begins palpation of the
musculoskeletal system. Starting with the shoulders, the examination
progresses downward toward the lower extremities. The muscles
and joints are assessed for symmetry, and gentle passive range of
motion is used to evaluate joint rotation, as full range of motion
should be present at birth. Rotation of the neck is the first and most
important rotation assessed. Passive range of motion should confirm
the infant’s ability to accomplish full rotation of the neck. Failure to
achieve full rotation may be related to torticollis or to the congenital
absence of portions of the cervical vertebrae. Normal growth and
development in infants are reflected by their ability to turn the head
toward the location of sound and then follow the auditory cue with
their eyes. Thus, normal neck rotation plays an important role in the
refinement of hearing and in the development of sight. To assess
head lag, the nurse carefully pulls the infant up while watching the
head gently fall back (Fig. 9-42). This maneuver also provides an
opportunity to inspect the neck for bulging of the thyroid gland and
for assessing the muscle tone of the upper body along with shoulder
and arm strength.
The nurse’s attention is next directed toward assessment of the
hip joint, the second most important joint evaluation in the newborn.
Developmental dysplasia of the hip (DDH) is a congenital condition
that, if left untreated, can affect the infant’s future ability to walk and
maintain balance. It occurs when the acetabulum is flat rather than
round and cuplike in shape. DDH most often results when the
developing fetus assumed a dominant breech position with upwardly
extended legs during the period of bone growth. The assessment
begins with inspection of the skin folds on the infant’s thighs in both
the supine positions and gluteal folds in the prone position. An
uneven number of skin and gluteal folds and one leg shorter than the
other indicate DDH (Fig. 9-43).
FIGURE 9-42 To assess head lag, the infant is gently pulled up as

the nurse observes their head fall back.
FIGURE 9-43 Inspecting gluteal skin folds.
Asymmetry of the skin folds may signal the presence of hip

dysplasia. The nurse also assesses the leg length and knee height
for unevenness. Next, the nurse slowly moves the infant’s lower
extremities in a kicking motion while observing for signs of pain or
distress. The nurse’s hands are placed on the infant’s thigh with the
fingertips around the femur head while the thumb and index finger
stabilize the knee joint. While maintaining this position, the nurse
performs the Barlow test by exerting a downward pressure on the
head of the femur in an attempt to dislodge the femur head from the
acetabulum. The Ortolani maneuver involves a circular rotation of
the femoral head or an inward-outward action that attempts to
reposition the femur head that was displaced by the Barlow test. In
the normal newborn, the hip joints should move easily; a palpable
click or sound known as “hip click” can indicate subluxation and
require further assessment for hip dysplasia. Often an ultrasound or
x-ray will be performed to determine the diagnosis and it is important
to keep assessing if unsure of the result (Scannell, 2020). Another
test for DDH is the Galeazzi test, also known at the Allis test. This is
done with the newborn in the supine position. Both knees are bent
with the feet flat on the surface. In the normal infant the knees
should be parallel to each other. A discrepancy with one knee higher
than the other is considered a positive result for DDH (Fig. 9-44).
It is not unusual to detect hip dysplasia in infants who maintained
a breech position in utero or who were delivered vaginally in a
breech position. Hip dysplasia can be confirmed by a noticeable
difficulty when moving the leg in the hip joint and also by feeling the
head of the femur pop out of the hip socket, sometimes referred to
as a “hip clunk.” Often, infants who were in a breech position in utero
have hyperextended knee joints that can give the appearance of hip
dysplasia. However, subsequent examination confirms that the head
of the femur remains firmly secured in the acetabulum. Parents can
be assured that, over time, the infant’s legs will return to the normal
flexed position. The nurse may also detect a “looseness” in the
infant’s hip joint despite a normal evaluation that shows no evidence
of hip dysplasia. This finding is related to the maternal hormones that
create joint flexibility not only in mothers but in their infants as well.
DDH, once confirmed by ultrasound or computed tomography, is
managed by the placement of a special splint to keep the infant’s
legs in a position of abduction. The Pavlik harness, the most widely
used device, does not rigidly immobilize the hip but acts to prevent
hip extension or abduction. The harness is worn continuously for
approximately 3 to 6 months until new bone growth has formed
around the head of the femur and a normal cup-shaped hip joint has
been created (International Hip Dysplasia Institute, 2018).
FIGURE 9-44 Galeazzi’s maneuver.
To assess the remaining joints, the nurse performs passive range

of motion and also continues to observe the infant’s spontaneous
movements in the crib. It is not uncommon to identify unusual
positions of the foot, and these findings are most often related to the
infant’s position in utero. Pronation, or inward turning, of both feet is
common, and the nurse can demonstrate to the parents how gentle
stroking of the infant’s insoles prompts a ready return to a normal
position. When the foot is severely pronated, spontaneous normal
alignment may be unattainable. In this instance, an evaluation of the
posterior alignment of the infant’s heel and knee is conducted. Club
foot, suspected when there is a medial displacement of the heel from
the posterior knee alignment, can be confirmed by x-ray
examination. Soon after a diagnosis of clubfoot, a cast is placed on
the affected extremity to restore proper alignment. The nurse should
demonstrate how to safely stabilize the cast when holding the infant
and teach the parents how to care for the cast.
Not surprisingly, many infants seek comfort and security by
resuming their dominant in-utero position following birth. The normal
newborn baby assumes a position of flexion of the upper and lower
extremities. Flexed arms enable infants to use their hands to touch
their faces, suck their fingers, and explore their world (Fig. 9-45).
The legs may be extended, arranged in the position assumed at
the time of birth, or flexed. Most often, the infants’ body positioning is
symmetrical. Nurses should recognize that asymmetrical positioning
at the time of the assessment might indicate injury from birth trauma.
An infant’s failure to move one or more extremities also signals that
further investigation is warranted (see Chapter 10).
Before performing the musculoskeletal assessment, the nurse first
must determine that there are no broken bones. In the newborn, the
clavicle is the bone most commonly fractured. The injury occurs
during birth when the infant’s shoulders do not readily rotate during
the birth process. Signs and symptoms of a clavicle fractures include
swelling at the fracture site, bruising, discoloration of the affected
area, expression of discomfort by the infant when moved, or
decrease in arm movement on the affected side. The nurse should
palpate the clavicles bilaterally for symmetry and they should feel
even and smooth. They should be assessed for any separations,
irregularities, unevenness, cracks or breaks anywhere between the
bone ends or for the presence of crepitus, which can indicate a
fracture and requires x-ray for confirmation (Scannell, 2020).
FIGURE 9-45 The full-term infant assumes a flexed position.
PROCEDURE ■ Performing the Barlow Test

(Steps 2 and 3) and the Ortolani Maneuver (Step
4)
PURPOSE
To assess for developmental dysplasia of the hips
EQUIPMENT
None
STEPS
1. Place the infant supine on a flat surface.
2. Place your thumbs on the infant’s inner thighs and your fingers on the
outside of the greater trochanters of the hips.
3. Flex the infant’s knees and move the legs inward until your fingers touch.
4. Using gentle but firm pressure, rotate the hips outward so that the knees
touch the flat surface. No clicking or crepitus should be detected.
RATIONALE: The presence of clicking or crepitus indicates joint instability.
Other common sites for neonatal fractures are the ribs, humerus,
and skull. An x-ray is used to confirm the diagnosis. Clavicular
fractures heal over time without intervention, and the nurse can
teach the parents to position the infant on the side opposite the injury
and how to hold and support the infant’s head and shoulders until
healing is complete. Casts are usually applied to humeral fractures,
while rib fractures are generally wrapped. Infants with skull fractures
are most often cared for in the intensive care unit, where they can be
continuously monitored.
Sometimes, infants are born with extra digits (fingers) and toes
(polydactyly) or with what appears to be webbing of the skin between
the digits and toes (syndactyly). On the hand, the extra digits often
are located below the fourth finger and are attached to the palm by a
thin line of skin. They may resemble the fourth finger and may even
contain a fingernail. The nurse should palpate all extra digits for the
presence of bone, which must be surgically removed. If no bone is
present, the digit may be tied off with suture silk to occlude the
capillary to cause necrosis and loss of the digit. Polydactyly is often
a family characteristic, and parents may recall other family members
who were born with extra digits or toes. Webbing of the toes does
not interfere with balance or walking, and parents may not wish to
have their infant’s toes surgically released from one another.
Webbing of the fingers is often surgically corrected to facilitate
dexterity and for cosmetic reasons.
The nurse inspects the palms of the hands for the presence of
palmar creases. The hands of a normal newborn usually contain
three or four curved palmar creases. A simian crease is a single,
straight crease that appears in the middle of the palm on one or both
hands (Fig. 9-46). When unaccompanied by other findings, the
simian crease is insignificant. However, when detected along with
other symptoms, a simian crease may be associated with other
syndromes, such as Down syndrome.
Assessment of the Neurological System

The physical assessment of the newborn concludes with the nervous
system and reflexes. During this assessment, the nurse focuses on
the reflexes and other movements that provide an indication of the
infant’s level of neurological function. It is helpful to divide the
reflexes into two broad categories: major reflexes (reflective of
normal neurological function) and minor reflexes (finger grasp, toe
grasp, rooting, sucking, head righting, stepping, and tonic neck). The
major reflexes include the gag, Babinski, Moro, and Galant reflexes.
Table 9-5 displays methods for assessing the various reflexes.
FIGURE 9-46 A, Normal palmar crease. B, Simian crease.
The finger or palmar grasp reflex is assessed by observing the

infant curl the fingers around an object (often the nurse’s finger) that
has been placed in the palm. The toe or plantar grasp is assessed in
the same manner by placing an object across the sole of the foot.
The nurse observes the rooting and sucking reflexes by stroking the
infant’s cheek and watching them turn toward the finger, open the
mouth, and suck on an object placed in the mouth. The head righting
reflex is elicited by lifting the newborn in the prone position and then
gently stroking the back in the midline, along the spinal cord. With
this action, the normal infant attempts to raise the head and arch the
back at the same time. To assess the stepping reflex, the nurse
holds the infant in an upright position with the legs flexed. The soles
of the feet are lightly brushed against a flat surface. In response to
the stimulation, the infant lifts their feet and then places them back
down in a stepwise pattern that imitates walking. The tonic neck or
“fencing” reflex is observed with the infant in a supine position. The
nurse observes the infant extend the arm and leg on the side to
which the head and jaw are turned while flexing the arm and leg on
the opposite side.
TABLE 9-5
Newborn Reflexes
Palmar Grasp The infant curls their fingers around an object.
Toe or Plantar Grasp The infant curls their toes around an object that
has been placed at the sole of the foot.
Rooting and Sucking Reflexes Stroke the infant’s cheek and watch them turn
toward the finger, open their mouth, and suck on
an object placed in their mouth.
Extrusion Reflex Touch the tip of the infant’s tongue and the
tongue will protrude outward.
Stepping Reflex Hold the infant in an upright position with the

legs flexed. The soles of the feet are lightly
brushed against a flat surface. In response to the
stimulation, the infant lifts their feet and then
places them back down in a stepwise pattern
that imitates walking.
Tonic Neck or Fencing Reflex Observe the infant, in a supine position, extend
their arm and leg on the side to which their head
and jaw is turned while flexing the arm and leg
on the opposite side.
Glabellar Reflex Tap on infant’s forehead and observe them blink

for the first few taps.
Babinski Reflex Lightly stroke the plantar surface of the foot from
the heel toward the toes. The infant responds to
this stimulation by first incurving the toes, then
uncurling and stretching them out.
Moro Reflex Observe the infant’s head as it is lifted while the

nurse mimics a release and watches for
extension of both arms along with flexion of the
legs.
Magnet Reflex With the infant in a supine position, flex the leg
and apply pressure to the soles of the feet.
Observe the infant extend their legs against the
pressure.
Galant Reflex or Trunk Observe the infant while supported in a prone

Incurvation Reflex position. Stroke one side of the vertebral column.
The infant responds to this stimulus by moving
their buttocks in a curving motion toward the side
that is being stroked.
Crawling Reflex Place infant on their abdomen; observe them

attempt to crawl.
Crossed Extension With the infant in a supine position, stimulate

one foot; observe flexion, adduction, and then
extension of the opposite leg.
To assess the major reflexes, the nurse progresses methodically,
taking care to document and record each finding. For the infant to
successfully eat and move fluid away from the back of the throat
without choking, the gag reflex must be intact. The Babinski reflex is
demonstrated by lightly stroking the plantar surface of the foot from
the heel toward the toes. The infant responds to this stimulation by
first incurving the toes, then uncurling and stretching them out. The
nurse can assess the Moro reflex at the same time as the head
righting reflex is elicited. As the infant’s head is lifted, the nurse
mimics a release and watches for extension of both arms along with
flexion of the legs, movements that confirm the Moro reflex. In the
past, the examiner often assessed the Moro reflex by creating a loud
clapping sound near the infant in an attempt to startle them. This
method of assessment is not reliable. The infant’s response to the
clapping stimulus may not be consistent with the Moro movements
because the infant could be reacting to the movement of air across
the body as the examiner makes the clapping sound or to the sound
of the clap itself. The Galant reflex, also called the trunk incurvation
reflex, is elicited as the infant is held or supported in a prone
position. One side of the vertebral column is then stroked. The infant
responds to this stimulus by moving the buttocks in a curving motion
toward the side that is being stroked.
The most frequently seen neurological injuries in the newborn
involve the brachial plexus and are related to difficulties with
shoulder rotation at the time of birth. The nurse must differentiate
these injuries from shoulder dystocia, which is identified by a
temporary decrease in the movement and muscle tone of a shoulder
and upper arm. Injury related to shoulder dystocia rapidly improves
after the birth.
Erb’s palsy is one form of brachial plexus injury that is readily
identified from the positioning of the infant’s arm while in the supine
position. When Erb’s palsy is present, one or both arms and hands
are extended and do not move into a flexed position. On palpation,
the nurse notes a decrease in muscle tone, a decreased grasp
reflex, and an absence of arm recoil on the affected side. Sometimes
called the “waiter’s position,” the position is reminiscent of a waiter
who keeps one arm by the side while the other is held out for a tip.
Most injuries involving the brachial plexus resolve in approximately
2 weeks without treatment. The infant should be positioned with the
arm in a gently flexed position and, when held, care should be taken
to support the arm on the affected side. The nurse should teach
parents how to use gentle exercise to facilitate the healing process.
Simple arm strengthening exercises that passively flex and extend
the infant’s arm can be practiced during each parent-infant
interaction.
Infants with major neurological problems that occurred during
embryonic or fetal development or resulted from events during the
birthing process are further assessed in the neonatal intensive care
unit. Severe damage that affects the brain or muscle movement may
be associated with periods of anoxia (lack of oxygen) that occurred
during fetal growth or during the birth process. Cerebral palsy is one
condition that results from oxygen deprivation. Infants with cerebral
palsy often demonstrate a number of motor difficulties, such as
difficulty swallowing, breathing, or moving. The length of the anoxic
period corresponds with the severity of brain damage. When caring
for infants with cerebral palsy, the nurse may deal with a spectrum of
difficulties that ranges from minimal limitation to a total loss of
reflexes and controlled body movements.
In-utero development of the brain and spinal cord is initiated
during the embryonic period. During the first 30 days of gestation,
the primitive neural tube closes. A failure of the tube to close at the
posterior end results in an open area that may be filled with fluid or
with a section of the spinal cord. This condition, called spina bifida, is
usually detected during routine maternal-fetal antenatal testing.
When the infant is born, the lesion of spina bifida resembles a skin-
covered sac between the fifth lumbar and first sacral vertebrae. This
is called the meningocele and may contain the dura mater and spinal
fluid. This condition usually does not cause any loss of motor
function, or paralysis, below the waist. Treatment of spina bifida is
related to the location and extent of the lesion. Most often, the sac is
surgically closed to prevent infection. Spina bifida occulta is a mild
variation of spina bifida involving a small defect in the spinal
vertebrae. All motor activity remains intact.
A more serious lesion is the myelomeningocele. When present, a
myelomeningocele is a sac that contains dura mater, spinal fluid, and
a portion of the spinal cord. Individuals with a myelomeningocele
have no bladder or bowel control and lose motor function below the
waist. Treatment of spina bifida is related to the location and extent
of the lesion. Most often, the sac is surgically closed to prevent
infection.
An incomplete closure of the anterior portion of the neural tube
causes a condition known as anencephaly. Lack of closure in this
location causes missing portions of the brain, forehead, skull, and
occiput. Infants born with anencephaly are usually placed on
respirators and monitored to assess viability. When caring for the
mother and her family, the nurse must be extremely sensitive to the
emotional effect associated with this condition and offer the parents
privacy and support.
An active virus known as Zika can be passed from an infected
pregnant woman to her growing fetus. Zika exposure can cause
serious brain anomalies, including microcephaly. Due to this
devastating consequence, women who are pregnant are advised to
avoid areas in which the Zika virus is prevalent and to avoid sexual
contact with partners who are positive for the Zika virus (Centers for
Disease Control and Prevention, 2019c).
CARE OF THE NEWBORN

The newborn’s adaptation to extrauterine life is an amazing and
complex process. In the early days of adjustment as well as through
infancy, newborns need significant physical and emotional care.
Mothers and other caregivers must learn the essential aspects of
newborn care to promote optimal infant growth and development.
Critical aspects of physical care include feeding, clothing, diapering,
and bathing the infant (Fig. 9-47). It is also important that parents’
discharge instructions provide easy-to-understand information about
the proper care of the infant’s nails, umbilical cord, and, when
appropriate, the circumcision. Bonding with the newborn is essential
for emotional care, and the beginnings for spiritual development are
established by building trust through relationships with the primary
caregiver. Parents must be educated about the importance of timely
metabolic screening for the newborn because many life-threatening
problems can be detected early enough for effective intervention.
Temperature Assessment
To prevent dangerous heat loss in the infant, nurses, mothers, and
other caregivers need to understand how to protect the infant from
extreme temperature fluctuations during bath time. In the hospital, to
ensure thermoregulatory stability the newborn’s temperature is taken
before the bath and after to assess for significant changes.
Temperature may be assessed by several methods. The axillary
skin method, which is reflective of the infant’s core temperature and
the body’s compensatory response to the environment, is the
preferred noninvasive method that provides a close estimation of the
rectal temperature (Fig. 9-48). Although rectal temperature
represents the closest approximation of core temperature, this route
is not recommended due to the possibility of transmission of stool-
borne pathogens, irritation, and perforation of the rectal mucosa. The
infant’s temperature may also be assessed with a continuous skin
probe (especially useful with small newborns or infants placed in
incubators or under radiant warmers) or via tympanic thermometer, a
portable sensor probe that is placed in the ear canal. This method
employs infrared technology to measure the temperature of the
internal carotid artery blood flow. As long as the body temperature is
maintained between 97.7°F and 99.3°F (36.5°C–37.4°C), the bath
can be given. At home, it is not necessary to take the temperature
before bath time.
FIGURE 9-47 A new father feeds his infant.
FIGURE 9-48 Proper technique for taking the axillary temperature.
Clothing
Understanding the concepts of thermoregulation is important when
clothing the newborn. In the hospital or birthing center, the infant
often wears a T-shirt, diaper, and booties. Frequently, two or three
blankets and a hat are required to help the newborn maintain body
temperature within a normal range.
If the newborn’s body temperature drops below normal parameters
(97.7°F-99.3°F [36.5°C-37.4°C]), the nurse must immediately initiate
temperature stabilization measures such as skin-to-skin contact by
placing the infant directly on the mother’s unclothed arms, chest, or
abdomen, or move the infant to a radiant warmer. When the
newborn’s body temperature reaches a normal level, they can safely
be dressed in a T-shirt and hat and covered with one blanket, hat,
and diaper.
At home, the type and amount of clothing for the newborn is
dependent on the local climate and temperature. The infant can be
dressed like other family members are dressed; that is, appropriate
for the temperature and season. Special attention should be given
when the newborn is outdoors. A cap or bonnet decreases body heat
loss and protects the newborn from dangerous sun rays and wind
drafts to the ears. During warm weather, babies should be covered in
lightweight clothing and placed in the shade when outdoors.
Protecting the Infant From the Sun

While specially formulated sunscreens especially made for infants are available,
it is important to advise parents to check with their child’s pediatrician about use
of these products. Many health-care providers do not recommend use of
sunscreens until the infant is at least 6 months of age.
Bathing the Newborn

The bath should take place in a warm area free from drafts. The
newborn can be given a sponge bath using only warm water for the
first few days of life. After the cord stump has dried completely and
fallen off in approximately 2 weeks, the infant can be immersed in a
small nonskid infant tub filled with about 4 to 5 inches of water.
Newborns do not require a daily bath; bathing them three times a
week is adequate. However, the face and hands can be wiped off
daily. The infant’s bottom and genital area should be cleaned several
times during the day. The newborn’s skin may be sensitive, therefore
a mild, unscented soap is recommended for the bath. The procedure
for the bath after birth and at home is fairly simple. The bath should
proceed from head to toe. Parents must understand that good
hygiene, including clean clothes, hair, nails, and teeth, is important in
promoting proper growth and development for their infant. Parents
will also have to be educated on proper holding of the newborn for
the bath and supporting the head.
Infants should have their head/hair washed with mild shampoo to
clean away any maternal bodily fluids and also helps prevent cradle
cap. Infants who are immersed in water while bathing tend to be
calmer, quieter, and experience less heat loss than infants who are
sponge bathed. Immersing the infant’s body facilitates thorough
distribution of the water, even temperature, and decreased
evaporative heat loss. Benefits of immersion include a soothing
feeling, hydration to the skin, and tactile stimulation. After bathing,
infants should be dried and dressed in clothes to prevent heat loss
and cold stress.
If dry skin is a problem, baths may be given less frequently, and a
moisturizing lotion can be applied after the infant is dried. Bath time
is an ideal time for the nurse to assess the newborn’s physical
condition, muscular activity, behavior, and state of arousal and
alertness, and the act of showing parents how to properly bathe their
infant provides a perfect opportunity to observe and encourage
maternal and family bonding.
Nail Care
Newborn nails are rarely trimmed in the hospital or birthing center in
the initial days of life due to the increased potential for injury to
surrounding tissue that may result in infection. After about a week,
the nails more readily separate from the skin and often break off
naturally. In the early days, to prevent the infant’s nails from
scratching the face, filing the nails with a fine emery-textured board
or covering the infant’s hands with a cuffed T-shirt or mittens is
effective. In the home, parents may continue to file their newborn’s
nails, or they may be taught how to carefully trim them, often while
the infant sleeps.
Umbilical Cord Care

The umbilical cord appears as a gelatinous white stump with two
arteries and one vein. Immediately after birth, the cord is cut with a
sterile scissors and clamped. Goals of cord care center on the
prevention and early detection of hemorrhage or infection. Cord care
includes cleaning the stump with water and gauze only and avoiding
soaps, lotions, or creams (United States National Library of
Medicine, 2019). The cord begins to dry out in approximately 1 to 2
hours after birth. The cord clamp must remain in place for 24 hours
when it can be removed with a special cord clamp remover. By the
third day, the cord appears to be discolored and shrunken. By 10 to
14 days, the cord has usually detached completely, and parents
often find the remnants in the infant’s diaper or on the bedding.
Patient Education
Umbilical Cord Care
Information regarding umbilical cord care should be included as a component
of discharge teaching. Parents are taught about the cord’s normal appearance
and shown how to fold and position the diaper below the cord stump (Fig. 9-
49). Infants should have a sponge bath until the cord has fallen off. Remind
parents to keep the area free from urine and wetness during bathing and when
to expect complete cord detachment. It is also helpful to alert them to potential
danger signs such as bleeding or an infection such as redness, drainage foul
odor from the cord, lethargy, and fever.
Diapering
Many families prefer the convenience of disposal diapers, which vary
in style, size, functionality, and cost. It is important to remember that
the infant’s sensitive skin may react adversely to the perfume in the
diaper. If diaper rash or dermatitis occurs, parents can be advised to
try another brand of diaper but should contact their child’s health-
care provider if the problem persists. Other parents prefer cloth
diapers, which may be provided by a commercial diapering service
or personally purchased and laundered. Parents need to be taught
that cloth diapers must be laundered separately from other clothing
articles, using 1/4 cup of detergent. Presoaking is often necessary to
remove stains. When teaching parents about the advantages of
breastfeeding, remember to include information that a breastfed
baby’s stools do not have an odor or cause diaper stains.
FIGURE 9-49 The diaper is positioned below the cord stump.
Patient Education
Diapering Practices
While diapering practices vary widely according to personal preference,
custom, and culture, tips to prevent diaper rash are universal:
• Keep the baby’s diaper area clean and dry.
• Change the baby’s diaper often.
• Carefully clean the baby’s bottom between diaper changes, using a mild soap
and plain warm water.
• Cleaning of the genitals should be done from front to back to prevent
contamination of stool into the vagina.
• During a wet or soiled diaper change, allow the baby’s skin to dry completely
before putting on another diaper.
• Allow the baby to go without a diaper whenever possible to let the air dry the
skin.
• If diaper rash persists, contact the health-care provider.
Circumcision
Circumcision is a surgical procedure that involves removal of the
foreskin on the glans penis. Although commonly done to promote
hygiene and easier cleaning, circumcision may primarily be
requested because of family tradition or social and cultural factors.
Historically based on a religious rite of passage from the Jewish and
Muslim traditions, circumcision has gained widespread acceptance
in the United States. Benefits of circumcision includes reducing risks
for urinary tract infections, penile cancer, and sexually transmitted
infections, including HIV (World Health Organization, 2018). While
the health benefits are not great enough to recommend routine
circumcision for all male newborns, it is important that parents be
knowledgeable about this surgical procedure and all the risk and
benefits.
Parents must have the opportunity to examine all the facts
surrounding circumcision, ask questions, and weigh medical
information in the context of their own religious, ethical, and cultural
beliefs and practices. While the surgical removal of the foreskin is a
fairly simple procedure that can take place in either the hospital,
outpatient, or community setting, it must be performed using a sterile
technique. The infant is restrained on a board or chair and warmed
blankets may be placed on the upper body to enhance comfort and
prevent heat loss. Hospitalization is necessary if the infant is older
than 1 month.
The newborn must be stable, and a physical examination by a
physician or other health-care provider, along with a signed permit,
should be completed before the circumcision. The procedure
involves removing the prepuce, which is the epithelial layer of skin
on the penis. This small piece of skin is separated and removed from
the glans penis. Newborn circumcision is frequently performed with
the use of a surgical device such as the Gomco (Yellen) clamp or a
Mogen clamp. Once the procedure is completed, a petrolatum gauze
dressing or a generous amount of petrolatum is applied to the penis
for 1 to 2 days to prevent the diaper from adhering to the surgical
site. Another method involves use of the PlastiBell device, which is
fitted over the glans. A suture is tied around the bell’s rim, the excess
prepuce is cut away and the plastic rim remains in place until it falls
off in approximately 5 to 7 days (Fig. 9-50). No petrolatum gauze
dressing is used after circumcision with a PlastiBell device (Zderic &
Lambert, 2011).
FIGURE 9-50 Removal of the prepuce during a circumcision. A,
Yellen clamp procedure. B, PlastiBell procedure.
Nursing care for the circumcised newborn focuses on alleviating

pain and preventing infection. The circumcision site should be
assessed every 30 minutes for at least 2 hours following the
procedure, and it is important to observe for the first voiding and
bleeding after a circumcision to evaluate for urinary obstruction
related to penile injury or edema. Parent/caregiver education is also
an important component of care. Parents should be taught to apply a
petroleum ointment as directed by the physician, report bleeding or
signs and symptoms of infection (e.g., increased swelling, pus, or
cessation of urination), and take care during diapering to ensure that
the diaper is neither too loose (causes rubbing with movement) nor
too tight (causes pain). Therapeutic touch is a beneficial comfort
measure for all infants and is especially useful following painful
procedures.
Optimizing Outcomes
Pain Management During Circumcision

Adequate pain management for infants undergoing circumcision is essential.
Nurses and other health-care professionals must provide optimal pain
management throughout the circumcision process, and parents must be
prepared for the procedure and educated about infant pain assessment and
pharmacological and integrative pain management therapies. Nerve block,
which is a subcutaneous penile ring block, is commonly used and considered
the most effective method. With this method, buffered lidocaine is
subcutaneously injected on each side of the penile shaft. Alternatively, a dorsal
penile nerve block (DPNB) (buffered lidocaine is subcutaneously injected at the
2 o’clock and 10 o’clock positions at the base of the penis) may be
administered, or the DPNB and the ring block may be used together. In other
settings, a topical anesthetic such as prilocaine-lidocaine cream (i.e., eutectic
mixture of local anesthetic [EMLA]) is applied to the base of the penis 1 hour
before the procedure. Topical therapies can provide adequate relief; however,
rashes and other skin reactions may occur. Although these techniques reduce
surgical pain, the subcutaneous anesthetics are more effective than the EMLA
cream. Nonpharmacological interventions such as nonnutritive sucking,
swaddling, and containment, along with oral acetaminophen and a concentrated
oral glucose solution, were previously used as a primary source of pain
management. This is no longer the recommendation. Today,
nonpharmacological measures serve as adjuvants after the procedure is
performed to provide additional pain management and comfort.
Evidence has shown that infants perceive and remember painful procedures
such as immunizations, venipunctures, and heel sticks. Breastfeeding is natural,
safe, cost-effective, and recommended as the first pain relief modality to use for
procedural pain intervention (Reece-Stremtan, Gray, & Academy of
Breastfeeding Medicine, 2016). Nurses can educate mothers about the
beneficial use of breastfeeding to decrease painful stimuli.
Eye Care
Soon after birth, the newborn receives a prophylactic ophthalmic
agent to prevent ophthalmia neonatorum, an eye inflammation from
gonorrheal infection that can be contracted during passage through
the birth canal if the mother is infected. Medications used include
either erythromycin ointment or erythromycin drops. This is common
practice especially in places with high prevalence rates of gonorrhea
in the general population. Some states require this agent to be
administered to all newborns, because it is a safe, inexpensive
medication and the benefits outweigh the risks.
Optimizing Outcomes
Eye Prophylaxis to Prevent Ophthalmia Neonatorum

In some birth facilities, neonatal eye prophylaxis is delayed up to an hour to
allow eye contact to facilitate parent–infant bonding. However, the Centers for
Disease Control and Prevention (CDC) recommends that the medication be
administered as soon as possible after birth (Fig. 9-51). If installation is delayed,
the facility should have a monitoring system in place to ensure that all infants
receive the prophylaxis (Workowski & Bolan, 2015).
FIGURE 9-51 Newborn just received eye prophylaxis.
MEDICATION: Erythromycin (Ilotycin) (eh-rith-

roe-mye-sin)
Pregnancy Category: B
Indications:
Infants: Prophylaxis of ophthalmia neonatorum
Actions: Suppresses protein synthesis at the level of the 50S ribosome
Therapeutic Effects: Bacteriostatic action against susceptible bacteria
spectrum: Streptococci, staphylococci, gram-positive bacilli
Pharmacokinetics:
ABSORPTION: Minimal absorption may follow topical or ophthalmic use.
CONTRAINDICATED IN: Hypersensitivity
Adverse Reactions and Side Effects: Irritation
Route and Dosage: Apply a thin strip to each eye as a single dose.
1. Inform parents of medication administration.
2. Prepare to administer the eye ointment to the infant I hour after birth.
3. Apply a thin strip to each eye as a single dose.
4. Start at the inner canthus and move to the outer canthus.
5. Dab excess medication off gently; do not wash away the medicine.
Hepatitis B Vaccination
Hepatitis B vaccination is an essential measure to prevent hepatitis
B. The CDC recommends administration of the hepatitis vaccine (0.5
mL intramuscularly) to newborns born with mothers who are HBsAg-
negative and within 24 hours of birth for all medically stable infants
who weigh greater than or equal to 2,000 grams (4.4 pounds), and
within 12 hours when mothers have unknown HBsAG status
(Centers for Disease Control and Prevention, 2019b). Nurses must
remember to give parents the Vaccine Information Sheet, which is
required by federal law, and to document the date, time, and location
of the injections as well as providing the parent with a vaccine
booklet that they can take with them to follow-up visits to receive the
additional doses (Centers for Disease Control and Prevention,
2019b).
Nurses need to be aware that some parents will choose not to
vaccinate their child due to their own beliefs. In these cases, parents
should be aware of the risk and benefits of choosing not to
vaccinate. In addition, parents should be aware of other state
regulations that may prohibit a newborn or child into daycare if they
have not had certain vaccines. After the parent has been educated
and still decides against vaccination, the nurse must respect the
parent’s decision and document accordingly in the patient record
regarding the discussion.
Fostering Attachment
Attachment describes a mutually reciprocal relationship between the
parents and their infant that begins moments after birth. Attachment
is critical to the child’s ongoing optimal growth and development.
One of the nurse’s most important roles is observing for healthy
attachment behaviors and helping the family establish a good
relationship with their infant. By observing parental behaviors and
engaging in meaningful dialogue with the mother and father/partner,
the nurse may uncover important cues that could have an effect on
the infant’s growth and development. Remember that after 9 months
of pregnancy and perhaps a difficult labor and birth, parents often
feel tired and overwhelmed with the realization that their newborn is
totally dependent on them. They may be too embarrassed to ask
questions or clarify information previously given to them. The nurse
must create a nonthreatening and nonjudgmental environment in
which parents can openly express ideas and ask questions. An
important concept for the nurse, mother, and other caregivers to
understand is that healthy bonding is essential for adequate
physical, emotional, and spiritual growth. Early infancy is an ideal
time to establish a trusting relationship between the newborn and the
primary caregiver.
What to Say
Questions to Assess Attachment
On the first day after giving birth, a mother states that she doesn’t want to hold
her baby. The nurse may respond by asking:
• Can you tell me more? Are you in pain? Are you feeling sleepy? Are you
afraid?
• Does your baby have a name yet?
• Do you have any concerns about basic care for your baby such as holding,
feeding, diapering, or bathing?
• How will you respond when your baby fusses or cries?
Minutes after the infant’s birth, most parents are given an

opportunity to spend quality bonding time with their newborn. To
accurately assess this first expression of parent-infant attachment, it
is important for the nurse to watch for and understand the behaviors
commonly observed. Mothers and fathers usually begin with an
exploration of their infant’s physical characteristics. Often, they begin
by examining each tiny fingertip. Next, they carefully explore their
baby’s extremities. Finally, they view and softly stroke the full length
of the infant’s trunk. During this entire process, the parents assume
the en face position where they establish and maintain direct visual
contact with their infant (Fig. 9-52). This initial exploration of gentle
touch, coupled with reciprocal eye contact, helps to lay the
foundation for a loving bond between the parents and their infant.
Patient Education
Promoting Family Attachment
Nurses can promote family attachment by:
• Providing time in the first few hours after birth for privacy and time for the new
family to get to know one another.
• Delaying any unnecessary procedures immediately after birth, such as
measurements and other admission procedures. Instead, allow the family
adequate time alone after birth to spend time getting to know one another.
• Encouraging early breastfeeding by providing proper education and support.
• Teaching parents about infant behavioral cues for feeding (rooting, sucking on
fingers or fist, increasing motor activity, or crying) and how to respond to their
infant.
• Helping parents understand that crying is the infant’s way of communicating,
and all newborns have distinguishable cries for hunger, pain, tiredness,
fussiness, or getting attention.
• Teaching parents that newborns have a built-in capacity to console
themselves and do so by sucking, motion, and distraction.
• Helping parents to recognize the joys and frustrations that go along with
ongoing parenting.
• Assuring parents that it takes time to feel comfortable meeting their newborn’s
unique needs.
• Introducing the concept of anticipatory guidance to help prepare parents for
important developmental milestones that will occur.
• Providing consistent nurses during the hospital or birthing center stay.
Ensuring Optimal Nutrition
Most parents begin to consider feeding options for their baby during
the prenatal period. How to feed a newborn after birth is an important
decision with implications for the entire family. The most common
feeding choices for newborns are breastfeeding or bottle feeding
with a commercially prepared milk formula. It is paramount that the
infant’s diet sufficiently meets their rapidly changing physical and
psychosocial needs and adheres to the current recommended
dietary allowances. The diet must include essential nutrients such as
protein to support rapid cellular growth; carbohydrates to provide
energy; and fat to supply the needed calories, regulate fluid and
electrolyte balance, and sustain development of the brain and
neurological system. Water intake, essential for tissue hydration,
should amount to 140 to 160 mL/kg per day. The bioavailability of
iron in breast milk is much greater than in formula preparations; full-
term infants who are breastfed do not need supplemental iron until
they reach 6 months of age. At that time, breastfed babies require
iron-fortified formula or cereals in combination with the breast milk.
Infants who are bottle-fed should be given a commercial formula
fortified with iron from the beginning. Adequate calories are also
necessary, and daily requirements of 105 to 108 kcal/kg per day
have been established. Due to the side effect of constipation with
iron supplement, infants should be observed for signs of constipation
that include crying, very fussy or appearing uncomfortable when
passing stool, stool is hard, decrease in frequency of bowel
movements, or straining with bowel movements.
DISCHARGE PLANNING FOR THE INFANT AND

FAMILY
The new family is discharged from the hospital or birthing center as
soon as 24 hours after birth, so early initiation of the discharge
planning process is crucial. If this is the couple’s first child, discharge
planning becomes even more important. The nurse must use every
opportunity, beginning during the prenatal period, to teach the family
about newborn care. Part of discharge education should include
education to ensure safety.
FIGURE 9-52 The en face position allows parents and their newborn
eye-to-eye contact.
Car Seat Safety

Discharge from the hospital or birthing center is an ideal time to
discuss and implement car seat safety measures. Infants and older
children must always be transported in a safe seating device.
According to the American Academy of Pediatrics, all infants and
toddlers should ride in a rear-facing car safety seat (CSS) until they
are 2 years of age or until they reach the highest weight or height
allowed by the manufacturer of their CSS. Infants must not be placed
in the front seat because inflating front seat air bags may cause
suffocation. Information about specific child passenger safety laws
for each state has been published by the Governors Highway Safety
Association and is available at https://www.ghsa.org/state-
laws/issues/child%20passenger%20safety
The nurse can assist the new family by providing information and
guidance to resources on car seat safety:
■ When purchasing a car seat, parents should be aware that the
seat must meet certain federal guidelines. A label on the seat tag
or packaging box states whether the product has met these
guidelines. The AAP website (www.AAP.org) also lists the
guidelines. It is important to emphasize that the car seat
instructions must be followed when installing the car seat.
■ Several community resources are available to the family that will
rent or loan a car seat for the infant’s discharge home. The
hospital or birthing center may have a car seat program. Other
resources include the American Red Cross, the Local Health and
Safety Council, and the State Department of Health.
■ The infant must be dressed so that clothing facilitates ease of
positioning and strap placement. To ensure correct fit, the infant
can wear a single layer of clothing, preferably pants, so that the
strap can fit between the legs. Sack sleepers are not
recommended, and bundling is discouraged because the strap
may not fit snugly. Head support is recommended. Parents can
use a commercially made product or place a rolled-up receiving
blanket around the head and neck area. To protect the infant from
burns and overheating in warm weather, parents should check the
temperature of the car seat by touching the surface.
■ Trained professionals may be available to perform safety checks to
help parents with proper car seat installation and use. The National
Child Passenger Safety Certification program offers a searchable
link to local technicians and inspection sites
(http://cert.safekids.org/).
■ New cars are required to be equipped with tethers and lower
anchors to ensure child safety.
■ Technicians trained to fit safety seats for children with special
health-care needs can be found at the Riley Hospital for Children
Automotive Safety Program Web site:
www.preventinjury.org/specNeeds.asp.
■ Car seats that are expired or have been in a previous accident
should not be used. The expiration date is posted on a sticker on
the side of the safety seat.
FOCUS ON SAFETY
Reducing the Risk for SUID
Sudden unexplained infant death (SUID) is the sudden and unexplained death
of an infant less than 1 year of age. It is often due to sudden infant death,
accidental strangulation, or an unknown cause. In 2017, there were 3,600
cases of SUID (Centers for Disease Control and Prevention, 2020). Many
identified factors increase the risk for SUIDs, including cardiac and/or
respiratory anomalies, central nervous system anomalies, low birth weight,
prone sleeping, and parental smoking or substance use. Using a pacifier and
promoting breastfeeding can help decrease SUID risk (Centers for Disease
Control and Prevention, 2020; Sommers, 2019). Nurses can help meet this
goal by teaching parents and all infant care providers the advantages of
placing the newborn on the back to sleep.
Teaching about infant safe sleep practices should extend beyond the
hospital to include postnatal clinics, child care centers, churches, and
community centers (Lavallee & Scannell, 2017). Other actions to help reduce
SUID-related infant deaths include use of a firm sleep surface (i.e., a firm
mattress covered by a fitted sheet), room-sharing without bed-sharing,
removal of soft objects and loose bedding from the crib (including blankets
and bumpers), breastfeeding, offering a pacifier at nap time and bedtime
(once breastfeeding has been established), and avoidance of overheating
exposure (Lavallee & Scannell, 2017).
SUMMARY POINTS
■ Initiation of the newborn’s first breath is influenced by chemical, sensory,
thermal, and mechanical factors.
■ Successful cardiopulmonary adaptation in the newborn is dependent on five
major changes related to aortic, venous, and pulmonary pressures and
closure of the foramen ovale, ductus arteriosus, and ductus venosus.
■ A number of factors, including body size and gestational age, affect the
newborn’s ability to maintain an NTE.
■ Heat loss may occur through the processes of evaporation, conduction,
convection, and radiation.
■ The newborn’s liver has essential roles in iron storage, carbohydrate
metabolism, bilirubin conjugation, and blood coagulation.
■ The newborn receives immunity through active acquired immunity and
passive acquired immunity.
■ The newborn exhibits two periods of reactivity and two behavioral states that
may be divided into sleep states and alert states.
■ The nurse provides newborn care in an environment that is safe and
protective, enhances the transition to extrauterine life, and fosters parent-
infant bonding.
■ Parents must be given correct and impartial information that includes the risks
and benefits of circumcision, an elective surgical procedure.
■ Neonatal pain must be readily identified, assessed, and appropriately
managed. ■ An essential role for nurses involves teaching and discharge
planning for the new family.
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Davis Advantage
CHAPTER 10
Caring for the Newborn at Risk
CONCEPTS
Pregnancy
Nursing
Assessment
KEY WORDS
gestational age
low birth weight (LBW)
very low birth weight (VLBW)
extremely low birth weight (ELBW)
mean arterial pressure (MAP)
total parenteral nutrition (TPN)
enteral feedings
nonnutritive sucking (NNS)
nosocomial infection
cold stress
polycythemia
transient tachypnea of the newborn (TTN)
crepitus
respiratory distress syndrome (RDS)
bronchopulmonary dysplasia (BPD)
gastroesophageal reflux disease (GERD)
retinopathy of prematurity (ROP)
meconium aspiration syndrome (MAS)
gastroschisis
group B streptococcus (GBS)
LEARNING OBJECTIVES
■ Describe the anatomy and physiology of the high-risk infant.
■ Identify the criteria for classification of high-risk newborns using gestational age and birth weight.
■ Examine conditions related to the small for gestational age and large for gestational age infants.
■ Prioritize developmentally appropriate and holistic nursing care for the high-risk newborn.
■ Explain common complications affecting the premature and post-term newborn.
■ Discuss the high-risk newborn physical assessment.
■ Describe additional conditions that place all newborns at high risk.
■ Develop teaching plans and discharge criteria for parents whose children have various high-risk conditions.
PICO(T) Questions
1. What role might (O) nurses play related to (I) ethical decision making for (P) newborns with uncertain viability?
2. What are the best (I) evidence-based practices for (O) early identification of sepsis in (P) neonates?
3. What are the benefits (O) of olfactory stimulation (I) during gavage feedings for (P) premature neonates?
INTRODUCTION
This chapter provides essential information about newborns at risk. An examination of conditions that
are common for newborns at different weights and gestational ages (GAs) is presented. Teaching plans
and discharge criteria for parents whose children have various conditions are included.
Congenital (conditions present at birth) health-care conditions are also presented in this chapter.
Information about the condition is broken down into signs and symptoms, diagnostic tests, medications
prescribed, appropriate nursing interventions, and information regarding family education. High-risk
newborns are a vulnerable population, and the nursing care provided to these special patients makes all
the difference in their initial health-care outcomes and subsequent life, including any long-term
developmental disabilities.
A & P REVIEW: THE NEWBORN AT RISK

High-risk newborns can have conditions that affect any body system, but the three systems that are
commonly affected because of maturational interruption or insult are the respiratory, circulatory, and
neurological systems.

The High-Risk Newborn
The high-risk newborn is extremely vulnerable because of intrauterine or extrauterine factors and immaturity. They require
tedious nursing care to promote lung, circulatory, and neurological maturity. Care should focus on promoting healthy
growth and development while minimizing debilitating consequences of immaturity. Developmental delays are common in
the high-risk newborn. Frequent assessment of growth and developmental milestones is important. The nurse must
provide an optimal healing environment with special attention to noise, light, and infant handling and positioning.
Minimal handling of the high-risk infant is necessary to reduce stressful events they experience. The high-risk newborn
may have difficulties regulating temperature and blood sugar. The nurse should ensure that temperature and blood sugar
are frequently measured and within normal ranges to decrease stress experienced by the infant. Developmental activities
of daily living for the high-risk newborn include positioning, feeding, and skin care. The nurse should place the infant in a
position that promotes comfort. The high-risk newborn should be repositioned to reduce the risk of skin breakdown. Gel
pads may be appropriate to relieve pressure on the infant’s head. The high-risk newborn has increased metabolic needs.
These increased needs must be met through a variety of nursing interventions including enteral and parenteral feedings
when appropriate. The nurse should monitor the weight of the infant daily to ensure adequate weight gain.
Pain and stress management is essential for high-risk newborns because they are unable to handle
high amounts of stress. Pain management and stress-reducing interventions promote comfort. The
nurse should frequently assess the infant for pain and stress (Figs. 10-1 and 10-2).
Circulatory System
Fetal circulation functions in utero to oxygenate the organs needed for intrauterine growth. Fetal blood is
shunted away from the lungs and liver because the placenta performs the functions of those organs.
Increased blood is circulated to the brain and heart to accommodate rapid growth. The circulatory
system of the fetus also develops strength and resiliency with increasing GA. At birth, the three fetal
shunts (ductus arteriosus, foramen ovale, and ductus venosus) close, and circulation converts to adult
circulation to accommodate oxygen intake by the lungs and filtering of blood by the liver. If the shunts
fail to respond to extrauterine oxygen and pressure levels, there is a structural deformity in the
circulatory system, and the newborn is at risk. The preterm newborn is at increased risk because of a
fragile circulatory system that is overexerted by the stress of the extrauterine environmental pressures
that can easily damage the fragile blood vessels.
Respiratory System
Fetal lung maturity develops in utero progressively until term. Fetal lung maturity is determined by the
L/S ratio (lecithin to sphingomyelin) and PG (phosphatidylglycerol) values, which are essential
phospholipids in promoting oxygenation of the lung alveoli. They act on the pulmonary surface to
decrease surface tension and keep the alveoli open when the newborn exhales. L/S ratio and PG
values are often mature at 35 to 36 weeks’ gestation; before this time newborns are at risk for
respiratory distress syndrome (RDS).
FIGURE 10-1 A commonly used pain assessment in the NICU is the Premature Newborn Pain Profile
(PIPP).
FIGURE 10-2 Many NICUs have protocols that treat a newborn for a PIPP score higher than 6 or 7. A
score of 12 indicates severe pain and needs immediate attention.
Neurological System
The neurological system, including the central and peripheral nervous systems and the parasympathetic
and sympathetic nervous systems, is underdeveloped at birth. Neurologically, newborns are immature
because of limited synaptic and dendritic interconnections in the brain and immature myelination of the
nerve cells. The preterm newborn has an increased risk for neurological immaturity resulting in the
inability to cope with the extrauterine stimuli at birth. Neurological deficits are experienced both short
and long term in newborns at risk as a result of interrupted neuronal development (Fig. 10-3).
THE NEONATAL INTENSIVE CARE UNIT

The neonatal intensive care unit (NICU) can be a frightening place for parents. The first visit to the NICU
is extremely difficult, and the parents must be prepared for what they are about to experience. The rules
of the unit must be outlined and the expectations gently discussed. The newborns are extremely small
and fragile, and the unit has several pieces of highly technical equipment, all with alarms. The nurse can
explain that the NICU keeps the lighting dimmed and voices low to increase rest for the newborn to
promote developmental care. Care is done in clusters, and the nurse tries to schedule all the
procedures needed on the newborn during the assessment period, which is usually every 1 to 3 hours
depending on the acuity of care for the threatened newborn. The nurse can also explain that the NICU
tries to simulate an intrauterine environment as closely as possible. This means decreasing the stimulus
to the newborn to allow normal growth and development.
FIGURE 10-3 A high-risk newborn in the neonatal intensive care unit.
Some of the NICU care concepts create a difficult adjustment for parents. Most parents are back to
work long before their newborn is discharged. Many parents have an overwhelming desire to interact
with their newborn but are not available during the care times. Creating partnership in care between the
NICU staff and family benefits the newborn, and every effort needs to be made to communicate and
collaborate with parents. The family of the NICU newborn is encouraged to bond with their newborn just
as if they were in the newborn nursery. NICU nurses encourage the parents to visit and assist with care
whenever possible.
Parents of NICU newborns actually pass through developmental phases that prepare them to partner
with the staff in their newborn’s care. First, the environment of the NICU is overwhelming, but most
parents are able, after a short time, to focus on the baby and keep the environmental distractions in the
background. Second, the parents begin to develop a relationship with the newborn and take ownership
of their care. This transition is less difficult today with the current philosophy of family-centered care.
Parents are partners in the care of their newborns and become the voice of the newborn. This
arrangement provides the best individual developmental care for the newborn.
Most NICUs practice primary care nursing so the parents can have a consistent contact person to ask
questions and call when they are home. Some NICU staffs make routine phone calls to the family to
give updates.
From the very first visit onward, the parents are encouraged to touch the newborn. Touch is a very
important act for bonding with the newborn. Kangaroo Care is also encouraged as soon as the newborn
is stable enough to be removed from the incubator. Many parents stay at the bedside for extended
periods of time. The NICU nurse must assist the parents in finding a realistic routine that enhances the
newborn’s health-care needs. Fathers are included in the educational and care process of the newborn.
Discharge planning includes education about developmental care and continuity of care that includes
home care that is most important to the high-risk newborn.
Patient Education
Kangaroo Care
TOPIC: The nurse will teach parents about the importance and technique of Kangaroo Care
ESSENTIAL INFORMATION:
• The nurse communicates to parents that Kangaroo Care (KC) is skin-to-skin holding of the baby who is dressed only in
a diaper.
• The newborn is held next to the mother’s, father’s, or partner’s chest, preferably with an ear over the parent’s heart to
allow the baby to hear the familiar heartbeat.
• KC is an effective way of maintaining newborn temperature and is recommended for a growing newborn who is stable
and can tolerate periods of time out of the incubator.
• KC has been found to produce benefits by enhancing interaction and promoting bonding and newborn growth and
development.
Parents and the NICU
Nurses and parents work collaboratively in caring for the newborn. The nurse can facilitate this process with these
measures:
• Orient the parents to the NICU environment, policies, and procedures and the Health Insurance Portability and
Accountability Act regulations.
• Assign one primary care nurse as the main contact for the parents.
• Explain the rationale for policies and procedures.
• Listen to the parents’ expectations of their role in the NICU.
• Explain the integration of caretaking roles between parents and nurse.
• Use a whiteboard at the newborn’s bed to relay messages back and forth.
• Encourage parents to call the NICU and inquire about their newborn 24/7.
• Encourage parents to bring in the newborn’s personal clothing for use when allowed.
• Encourage parents to verbalize dissatisfaction with the newborn’s care.
• Incorporate parent’s suggestions and wishes in the care routine.
Classification of the Neonatal Intensive Care Unit

NICUs are classified according to level of care. Regionalization is a concept in care that arose in the
1980s to conserve health-care dollars, consolidate services, and improve outcomes. Today, hospitals
often compete within the same geographic area to have the largest and most recognized services in
specialty care areas. Level I nursery care is for well newborns and can stabilize high-risk newborns for
transport. Level II nurseries can provide the same care as Level I nurseries plus provide premature care,
give oxygen by hood, and start IV therapy. Level III NICUs are the most sophisticated of the nurseries
because they ventilate newborns.
THE HIGH-RISK NEWBORN

Nursing care of the high-risk newborn has become an extremely technologically enhanced specialty
over the past 50 years and has rapidly evolved into a dynamic field of nursing care. Advances in NICUs
are steadily increasing the survival rate of newborns at risk, but this population still has a significantly
higher mortality and morbidity rate compared with uncomplicated, full-term newborns.
Newborns can be put at risk any time during their intrauterine (in utero), intrapartum (from the
beginning of the first stage of labor to the end of the third stage of labor), or extrauterine development
(once the newborn is born). They can be placed at risk in their prenatal or intrauterine environment by
genetic disorders, congenital anomalies, or maternal factors such as disease states, trauma, and drug
use. They can be placed at risk in the immediate neonatal or extrauterine environment as a result of
conditions such as hypothermia, poor oxygenation, or prematurity. Review Table 10-1 for conditions that
place a newborn at risk.
Classification of High-Risk Newborns

High-risk newborns are classified according to two main criteria: gestational age (GA; length of time in
utero) and birth weight (recorded in grams in the NICU).
Gestational Age (GA)

Term newborns are neonates delivered any time from 37 to 41 completed weeks of gestation. This GA
produces optimal fetal developmental time for adjustment to the extrauterine environment. A neonate
born before the completion of 37 weeks of gestation is considered preterm with different behavior and
nursing care needs than a full-term newborn. A newborn delivered on or after 42 weeks of gestation is
post-term and also has different nursing care needs than a full-term newborn.
TABLE 10-1
Risk Factors That Compromise the Newborn
INTRAUTERINE INTRAPARTUM EXTRAUTERINE
Genetic disorders such as trisomy 13, Asphyxia Hypothermia
18, and 21
Congenital anomalies Birth injuries Poor oxygenation
Maternal disease such as diabetes, Complications of labor Prematurity
thyroid disease, renal disease, epilepsy,
and systemic lupus erythematosus
Trauma Multiple gestation Congenital anomalies
Drugs such as phenytoin (Dilantin) or Poor presentation Metabolic disorders
illicit drugs such as alcohol, cocaine, or
nicotine
Maternal infection such as group B
streptococcal or rubella
Birth Weight
Previously, newborns were classified as high risk solely based on birth weight. Now birth weight is
considered along with GA for a more accurate assessment of risk factors and growth patterns.
Newborns who weigh between the 10th and 90th percentile on the developmental growth chart for their
GA have less mortality and morbidity than those above the 90th percentile or below the 10th percentile.
Table 10-2 shows newborn classification by birth weight compared with GA.
Other classification systems use newborn weight as a criterion for classifying premature newborns but
do not consider the GA in relation to weight. This clinical terminology uses low birth weight (LBW),
very low birth weight (VLBW), or extremely low birth weight (ELBW). Low birth weight refers to a
newborn weighing less than 2,500 grams (5.5 lbs), and very low birth weight refers to a newborn
weighing less than 1,500 grams (3.3 lbs). Extremely low birth weight refers to newborns who weigh less
than 1,000 grams (2.2lbs) (Cutland et al, 2017).
Mortality rates for preterm newborns have also been decreasing with the use and invention of
technological advances. The more premature the newborn, the higher the mortality rate will be. Very
preterm newborns present moral dilemmas regarding resuscitation.
CARE OF THE HIGH-RISK NEWBORN

Providing nursing care for the high-risk newborn is multifaceted and complex. The nurse provides
general care measures, interventions tailored to specific conditions, and holistic and developmental care
as well as ensuring a safe nurturing environment. A thorough physical assessment is completed, and
vital signs are monitored frequently. Vital signs include temperature, pulse, respiration, blood pressure,
pulse oximetry reading, and pain assessment.
Assessment Tools
Blood Pressure
Blood pressure measurements are an indicator of fluid status, cardiovascular, perfusion, endocrine function, and overall
disease severity as in cases of sepsis. In the normal newborn, blood pressures are not routinely done; however, in high-
risk infants, accurate blood pressure measurements and monitoring are essential. In most NICUs, the gold standard for
blood pressure monitoring is through an indwelling intra-arterial catheter (Washington, 2020). Systolic, diastolic, and
mean arterial pressure (MAP) are assessed on the high-risk newborns. MAP is the average pressure during the entire
cardiac cycle, and it is reported on cardiac monitors and differs by birth weight. MAP can also be calculated by internal
blood pressure monitoring through an umbilical vessel. Pulse pressure is the difference between the systolic and diastolic
pressures and is another cardiac indicator. A wide pulse pressure is sometimes indicative of a patent ductus arteriosus
(the average values are 25 to 30 mm Hg in term newborns and 15 to 25 mm Hg in preterm newborns).
Most NICUs use oscillometry methods to take noninvasive blood pressure readings in the newborn. Studies have
shown that noninvasive blood pressure readings by oscillation are consistent with invasive blood pressure readings.
To take a blood pressure reading accurately on a newborn, the equipment needs to be reliable and calibrated correctly
for newborns. The appropriate cuff size needs to be chosen. The correct width cuff size is 0.5 of the circumference of the
extremity. The cuff should be placed on the right arm unless contraindicated; otherwise the calf can be used for the first
few days of life (Dionne et al, 2020).
Blood pressures can be greatly affected by the newborn’s temperature, activity, or posture (newborns who are awake
and sucking average 10 to 20 mm Hg higher). Single- and four-extremity blood pressures can be done (Table 10-3).
Low-birth-weight newborns are prone to hypotension (16% to 52%), which jeopardizes organ blood perfusion.
Hypotension is usually treated with fluid boluses to boost blood volume. Single blood pressure reading is done for all high-
risk newborns on a regular basis. In the NICU, blood pressures are recorded on the C-R monitor along with the other vital
signs of the infant. Four-extremity blood pressures are done if a cardiac murmur is heard to determine whether the MAP
of the upper and lower extremities are similar. Blood pressure is normally slightly greater in the lower extremities. A
difference (15 mm Hg or higher) in the upper extremities may indicate aortic coarctation. The following Procedures feature
illustrates the method for taking a newborn’s blood pressure.
TABLE 10-2
Newborn Classification by Birth Weight and Gestational Age
SGA: Small for Gestational Age Weight below the 10th percentile for gestational age
AGA: Appropriate for Gestational Age Weight between the 10th and 90th percentiles for gestational age
LGA: Large for Gestational Age Weight above the 90th percentile for gestational age
Nutritional Care of the High-Risk Newborn

Intravenous Feedings
Initially, parenteral fluids are provided to the high-risk newborn. Peripheral lines are used for shorter
periods of time, and most preterm newborns are placed on parenteral fluids for the first few days of life.
The goal for the newborn in the first few days of life is to provide sufficient fluid to result in a urine output
of 1 to 3 mL/kg per hour and a urine specific gravity of no greater than 1.012.
TABLE 10-3
Normal Blood Pressures by Newborn Weight
<2,000 g 50/35 mm Hg
2,000–3,000 g 60/35 mm Hg
>3,000 g 51/40 mm Hg
PROCEDURE ■ Taking a Newborn’s Blood Pressure

PURPOSE
Blood pressure indicates a newborn’s state of health. It measures the amount of pressure needed to force the blood as it
is forced through the arteries during a cardiac contraction.
EQUIPMENT
• Appropriate-size cuff
• Blood pressure (B/P) machine
• Method to record results
STEPS
1. Choose the appropriate-size cuff by measuring the midpoint of the limb.
RATIONALE: Cuffs that are either too narrow or too small affect the accuracy of the blood pressure measurement.
Choose a cuff that has a width that is approximately 0.5 of the arm’s circumference. A properly fitting cuff will cover
about two-thirds or the entire upper arm (or other extremity). The blood pressure machine is calibrated frequently.
2. Do not use an extremity that has an IV.
RATIONALE: This prevents trauma or damage to the IV site.
3. Do not apply to broken skin areas.
RATIONALE: This prevents further damage to the skin.
4. Do not extend cuff over a joint.
RATIONALE: This prevents an inaccurate measurement.
5. Inspect the cuff for intactness and decompress it to ensure it is not leaking.
RATIONALE: Properly functioning equipment is essential for accurate blood pressure measurement.
6. If the cuff has an arterial mark, palpate the artery and line up the mark.
7. Wrap cuff snugly.
RATIONALE: A properly fitting cuff is essential for accurate blood pressure measurement.
8. Connect the cuff to the air hose.
9. Start the blood pressure device.
10. Remove the cuff and inspect the skin.
Attempt to take blood pressure while the newborn is sleeping or use a pacifier to quiet the newborn for the procedure.
NOTE
The B/P is usually slightly higher in the legs.
Caution: A wide pulse pressure may indicate atrioventricular malformation, truncus arteriosus, or patent ductus
arteriosus. A narrowed pulse pressure may indicate peripheral vasoconstriction and cardiac failure. A systolic pressure in
the arms that is 20 mm Hg or higher may indicate aortic coarctation.
A central line placed in the umbilical artery or vein is used for longer periods of time and provides the
high-risk newborn with fluids, nutrients, blood components, and medications. Another type of line called
a peripherally inserted central catheter line is also used for long-term parenteral therapy.
Total Parenteral Nutrition (TPN)

Total parenteral nutrition (TPN) is the initial essential type of IV nutritional support for high-risk
newborns who cannot tolerate other forms of nutrition. This therapy is used to establish positive nitrogen
and energy balance to promote growth. TPN also increases protein synthesis and reversal of any
negative nitrogen effects that may take place in the first days of life.
The TPN solution is a calculated combination of glucose, amino acids, and electrolytes. TPN is
usually started by the third or fourth day. After the first days of TPN, IV lipid emulsions are added to the
parenteral therapy as a piggybacked, or secondary, solution in concentrations of 10% to 20% over a
slow continuous infusion. This is done to reverse fatty acid deficiency and provide energy for tissue
healing and growth. TPN, although needed to keep high-risk newborns in positive nitrogen balance, is
associated with complications. Long-term TPN is associated with abnormal blood sugars and
electrolytes levels, liver dysfunction, and catheter infections (U.S. National Library of Medicine, 2020b).
Enteral Feedings
Enteral feedings of prescribed formula or breast milk given through either a nasogastric or orogastric
tube begin as soon as the preterm newborn is stable to prevent gastrointestinal damage (Fig. 10-4).
Enteral feeding is provided by continuous infusion pump method or bolus delivery. As the newborn
grows and becomes more stable, bolus feedings every 3 hours are eventually started because the
newborn can now tolerate this kind of feeding. As the feedings are increasingly tolerated by the preterm
newborn, parenteral therapy can be decreased.
Bottle and Breastfeeding

Once the newborn is stable, bottle and/or breastfeeding is attempted, usually once a day and increased
as tolerated. The feedings start slowly and advance over several days. Breast milk is the gold standard
because it decreases the incidence of necrotizing enterocolitis (NEC) and increases the preterm
newborn’s immunological function. Breastfeeding is encouraged for families who choose this method of
feeding as soon as the newborn is able to spend limited amounts of time out of the incubator.
Preterm newborns can be successfully taught to breastfeed with a planned approach that supports
the family’s decision. Before the newborn can successfully breastfeed, mothers should be taught to
pump their milk at regular intervals to maintain breast milk supply. Pumped breast milk stored for later
can be given via a bottle or syringe. Establishing a milk supply for the mother can be difficult and may
need to pump or hand-express every 2 or 3 hours to establish a mild supply. In such cases the infant is
sometimes fed their own mothers’ milk or donor human milk fortified with multiple nutrients and calories
to optimize growth and development. The NICU infant may not be able to latch in the beginning, and
hand-expressing and spoon-feeding the milk or using a syringe may be helpful (Noble et al, 2018).
FIGURE 10-4 Preterm twins with one requiring enteral nasogastric feedings.
Many different types of formulas are used for newborns. Each type of formula has a different
nutritional goal. Preterm newborn formula has increased protein, calcium, phosphorus, and medium-
chain triglycerides compared with full-term newborn formula. When preparing a formula feeding for high-
risk newborns, the procedure is done on a clean surface with only one formula preparation being done
at a time with proper labeling.
Nonnutritive Sucking (NNS)

Nonnutritive sucking (NNS) is promoted for the preterm and high-risk newborn for physiological and
psychological reasons. Using a pacifier promotes comfort, and NNS may promote breastfeeding in the
high-risk newborn. Pacifiers are made in different sizes to accommodate the size of the newborn.
Intake and Output

High-risk newborns are maintained on strict intake and output (I&O) until they are growing adequately.
The actual intake of a newborn is calculated on total daily amount of calories (kcal/kg per day) and fluid
requirements (mL/kg per day). To maintain adequate growth, preterm newborns will need an oral intake
of minimally 160 mL/kg/day (or growing well on exclusive breastfeeding at the breast). Laboratory
minerals and hemoglobin levels are often checked, and supplements may need to be added to the
newborns intake to prevent any mineral or nutrient deficiencies (Noble et al, 2018).
FOCUS ON SAFETY
Calculating Standard Newborn Formulas
The normal output for a preterm newborn is 1 to 3 mL/kg per hour with a specific gravity of
approximately 1.08 to 1.012. Oliguria is defined as less than 0.5 to 1 mL/kg per hour (Fig. 10-5).
Skin Care
The care of a preterm newborn’s skin is extremely important. Skin breakdown can occur in the NICU
setting in areas where tubes touch the skin, such as the nose and behind the ears. In addition, extended
time in the supine position can cause skin breakdown and even pressure ulcers on the occipital region
of the head. Any skin breakdown increases the risk of nosocomial infection, which is an infection
acquired in the health-care setting. Frequency assessment of the infant’s skin is an essential prevention
method in the NICU. Routine assessment and documentation of pressure ulcer classification is
essential, and worsening changes should prompt an immediate consultation with a physician.
Routine bathing of high-risk newborns is not done every day; it is usually done every third day to
avoid drying out the skin. Plain water is used rather than soap for very preterm newborns. Tape and
adhesive are removed carefully with warm water, and solvents are not used.
FIGURE 10-5 Newborn output is calculated by weighing the diaper on a gram scale.
Developmental Care
Although more preterm newborns are surviving, many still experience negative consequences of
prematurity, including neurobehavioral developmental disabilities, temperature instability, increased
blood pressure, decreased oxygenation, and vision and hearing deficits (Centers of Disease Control and
Prevention, 2019c). Appropriate developmental care in the NICU is key to decreasing long-term
developmental disabilities for the preterm newborn. Increasing evidence in the medical literature shows
that environmental issues, such as excessive noise, chemical exposures, uncontrolled lighting, and
limited social interactions from parents and others, are detrimental to the developing preterm newborn.
The NICU environment must be a smooth transition from the intrauterine environment and limit
excessive stimuli to ensure maximum developmental growth. NICU environments are beginning to
change and try to replicate a natural milieu for the newborn, incorporating therapeutic modalities to
prevent some of the adverse neurobehavioral effects of the NICU.
Preterm newborns do not have the neurological and social development needed to deal with the
sudden stimuli of extrauterine life. Cortical organization in the preterm newborn is immature, and
preterm newborns are poorly equipped to self-modulate their behavior. Overstimulation from
environmental factors can have long-term detrimental developmental effects. Providing an environment
for optimal growth is the primary philosophy of developmental care. Developmental care helps modulate
the preterm newborn’s behavioral states. Some of the environmental issues that can be controlled by
the nurse to promote developmental growth include noise, lighting, handling, and positioning.
Noise
The noise level in the traditional NICU can be disruptive to a premature newborn compared with the
intrauterine environment. Noise in NICUs can easily exceed acceptable limits for optimal growth and
development. Premature birth exposes the newborn to excessive stimuli before the sensitive auditory
system fully develops.
Prevalent neurological and behavioral deficits such as disruptive sleep, poor motor function, attention
deficit, sensorineural hearing loss, and language impairments could result from noises in the NICU
environment. Stress levels will increase for newborns in the NICU, which then leads to elevated blood
pressure, increased cardiac demand, decreased oxygen consumption, and increased caloric need
(Susilaningsih et al, 2019).
Environmental changes can be made to decrease the noise level and offset adverse effects.
Therapeutic noises such as the mother’s voice or entrained breathing and heart sounds can have
positive health benefits. The noise level in the ICU must not exceed 45 decibels, which is largely due to
staff activities; the greatest contributor to noise is the human voice. The nurse can help facilitate an
environment that reduces the negative health effects. All newborns must be screened for hearing loss.
Preterm newborns have a secondary follow-up screening (Susilaningsih et al, 2019).
Sleep
Preterm newborns sleep the majority of the day. Preventing interruption of sleep cycles is very important
for neurodevelopment. Sleep is necessary for brain development, and health-care providers need to
ensure that infants’ sleep cycles are protected as much as possible (Lockridge, 2018). Newborns should
not be awakened; care is done when they are naturally awake. Protected sleep is vital for the high-risk
newborn. Often, the immature newborn is not prepared to live outside the womb. Adequate sleep is
necessary for recovery and growth. The environment should be one of healing. A dark and quiet
environment is best to promote sleep and rest. Care should be delivered in a clustered fashion so as not
to wake an infant who is sleeping.
Lighting
Most NICUs use ambient lighting with recommended Lux of light between 10-600 lux with up to 2,000
lux for special procedures (Susilaningsih et al, 2019). Recent studies show that newborns with sufficient
amount of light in the external environment have better weight gain, better respiratory function, blood
pressure, motoric activity, and achieve faster tolerance of the ventilator (Susilaningsih et al, 2019).
The nurse can provide an environment that promotes a natural sleep-wake cycle for the newborn to
help regulate the newborn’s circadian rhythm. Much more research is needed about proper lighting in
the NICU and the light’s effect on the development of retinopathy of prematurity (ROP).
Handling
Overstimulation of high-risk newborns can be detrimental to the newborn’s development. Health-care
providers may need to handle NICU infants and position them in a quick and efficient manner; however,
to the premature newborn, this can cause detrimental effects such as increased stress along with
disorientation, dizziness, and nausea (Lockridge, 2018). This has prompted most NICUs to organize
nursing care into cluster care. With this concept, all the nursing care for a high-risk newborn is done at
one time, usually at 3-hour intervals. This allows the infant several hours of undisturbed time in between
vital signs, feedings, and treatments. Although overstimulation can be detrimental, gentle newborn touch
can be therapeutic and soothing and can actually decrease oxygen consumption, so a balance between
overstimulation and therapeutic stimulation calls for nursing judgment in a family-centered care
environment (Lockridge, 2018). Organization and collaboration of multidisciplinary care to enhance
minimal disturbance of the high-risk newborn is a goal in the NICU. Therapeutic touch such as
Kangaroo Care and skin-to-skin show health benefits such as better cardiopulmonary stability, better
autonomic regulation, improved sleep, and long-term benefits of stress response and executive
functioning (see Patient Education—Kangaroo Care).
Positioning
Positioning is done with the goal of providing comfort and modulation. Premature newborns have
normally extended extremities compared with flexed full-term newborns. Bed nest is a concept in which
the linen is used to safely contain the newborn in a flexed position. Special bean bag rolls, often called
“frogs,” are used to provide security to body parts and keep them in position. These bean bags weigh
around 1 pound and must not be placed on top of the infant. Proper positioning not only provides
comfort to the newborn but affects ventilation, neurological development, and prevention of occipital
plagiocephaly (flattening of the occiput).
Transporting the High-Risk Newborn

The hospital where the mother gives birth may transfer the newborn to another institution if they need
more technologically advanced care than can be safely provided (Fig. 10-6). Most Level III NICUs have
a specially trained transport team who go to the referring institution, stabilize the newborn, and bring the
high-risk newborn back to the regional Level III center by ambulance or helicopter. The terrain, location,
and weather of each referring NICU determine the safest transport mode. Transport of newborns is
traumatic for the newborn and family and is avoided when at all possible.
The Transport Team

Neonatal transport teams are composed of a physician or nurse practitioner from the Level III nursery
along with nursing and respiratory staff who are educated in stabilizing the newborn. The team follows
specific protocols and contacts the referring neonatologist during transport for any updates and further
information.
FIGURE 10-6 Newborn transport.
The S.T.A.B.L.E. Program is an internationally recognized program designed to assist health-care

professionals in the postresuscitation/retransform phase of neonatal care. It is an acronym for aspects
critical to stabilization of the high-risk newborn (Box 10-1). It is a program promoted by the March of
Dimes and American Academy of Pediatrics as an adjunct to neonatal resuscitation to improve neonatal
outcomes (S.T.A.B.L.E. Program, 2020).
Parents often ask if it is necessary for the newborn to be transported. The nurse can explain the
advantages of treatment offered at the referring hospital and make sure the parents have a direct
number to the unit and the name and number of the admitting neonatologist and nurse.
SMALL FOR GESTATIONAL AGE (SGA) NEWBORNS

SGA newborns are those born at any GA who have a birth weight that falls below the 10th percentile on
the growth charts. Table 10-4 lists some conditions that can produce an intrauterine environment leading
to an SGA newborn.
The SGA condition is a result of intrauterine growth restriction (IUGR) and can be classified into two
categories: asymmetrical and symmetrical. Asymmetrically small newborns have an appropriate-size
head circumference that measures between the 10th and 90th percentile for their GA when plotted on
the head circumference chart, but their weight falls below the 10th percentile. Asymmetrical SGA is
sometimes called “brain-sparing” SGA. Symmetrically small newborns are not only below the 10th
percentile for weight but also have a small head circumference that measures below the 10th percentile
for their GA. Symmetrical SGA is sometimes called “nonbrain-sparing.” To further understand the
difference between symmetrical and asymmetrical newborns, review Box 10-2.
BOX 10-1
Steps Emphasized in the S.T.A.B.L.E. Program

S Sugar
T Temperature
A Airway
B Blood pressure
L Laboratory work
E Emotional support
Source: S.T.A.B.L.E. Program (2020).
TABLE 10-4
Conditions That Can Produce SGA Newborns
Genetic factors Maternal diabetes
Chromosomal factors Maternal systemic lupus erythematosus
Maternal fibroids Intrauterine factors
Maternal asthma Twin to twin transfusion
Maternal hypertension Abnormal uterine anatomy
Drug use TORCH infections
Maternal congenital heart disease
Characteristics of an SGA Newborn

SGA newborns are smaller and often have a characteristic appearance. In asymmetrical SGA
newborns, the head appears large in relation to the body. The characteristics of both types (symmetrical
and asymmetrical) of SGA newborns may include:
■ Wasted muscle tissue
■ Lack of brown fat
■ Abdomen is often scaphoid (sunken in)
■ Eyes appear large with a “wise old man” look
■ Fingernails are often long
■ Meconium-stained thin cord is often present
Conditions Affecting the SGA Newborn

Morbidity and mortality are significantly higher for SGA newborns. Delivery problems include asphyxia
and low Apgar scores. The following discussion highlights common conditions found in SGA newborns
who are nursing concerns. These conditions may also be found in other high-risk infants, and they
include:
■ Cold stress (a consequence of prolonged hypothermia)
■ Temperature instability
■ Pain
■ Hypoglycemia
■ Polycythemia
Cold Stress
Cold stress is more likely in SGA and preterm newborns because these infants have less brown fat, are
less flexed, and have thinner skin. In very low birth weight (VLBW) newborns, water loss can be 8 to 10
times greater than in an adult and heat loss 5 to 6 times greater. Cold stress increases metabolic needs
and places the newborn at further risk for respiratory distress and metabolic acidosis. Keeping SGA and
preterm newborns warm and reducing evaporative heat loss is a nursing priority.
SIGNS AND SYMPTOMS
Cold stress occurs when the baby becomes cold and loses heat at a faster rate than the body can
create heat, and it is reflected in the following signs and symptoms:
■ Hypothermia or a body temperature less than 96.6°F (35.8°C)
■ Cold, pale, or bluish skin
■ Poor feeding
■ Lethargy
■ Respiratory distress
■ Bradycardia
BOX 10-2
Symmetrical and Asymmetrical SGA Newborns
SGA newborns are small because they have suffered a nutritional or oxygenation deficit in utero as a result of maternal
causes, fetal causes, or a placental or cord malfunction. If the fetus experienced the deficit in the first trimester, the
newborn is usually symmetrically SGA, but if the deficit started after the 20th week of gestation, the result is more likely to
be asymmetrically SGA. Interestingly, in developed countries, such as the United States, one of the most common factors
related to intrauterine fetal growth restriction is maternal smoking. In developing countries, the leading causes are
maternal nutritional deficits and infections such as malaria.
PREVENTION
Provide a neutral thermal environment (NTE), an environment that provides minimal heat loss or
expenditure at all times. Hypothermia is assessed in at-risk newborns and is continuously monitored
while using radiant warmers for extremely low birth weight babies in incubators (Figs. 10-7 and 10-8).
COLLABORATIVE CARE
Nursing Care
Use an artificial heat source such as a radiant warmer or incubator. Radiant warmers used in the
normal newborn nursery consist of an overhead heater that accommodates an open crib underneath.
The nurse can assess and bathe a normal newborn under the warmer and then remove the crib from
the warmer once the newborn’s body temperature is stable. The radiant warmers used primarily in the
NICU have a flat table-like mattress with low sides that can be taken down for easy accessibility to the
newborn. During warming, the newborn’s temperature is monitored continuously with a skin probe.
Review Box 10-3 for normal temperature readings.
FIGURE 10-7 Radiant warmer.

FIGURE 10-8 Incubator used in the NICU.
Assessment Tools
Skin Probes
The skin probe is attached to the newborn with a reflective insulated adhesive to help the heat source record the
temperature of the skin. The probe is positioned on the newborn’s body so the adhesive piece is exposed to the heat
source above. Skin probes are placed on the abdomen, avoiding bone and the liver border for an accurate reading.
Incubators are used to provide longer periods of artificial heat. These double-walled containers have portholes that are
covered in plastic to allow caregiver access. They can also be set on two different modes: skin (servo) or air (ambient).
The skin mode works by the same mechanism as the radiant warmer servo mode, which uses a skin probe on the
newborn. The air mode maintains a set temperature within the incubator, and the newborn regulates their body
temperature in the warmer environment. The newest models of incubators and radiant warmers open from the top to
maintain some of the heat. Incubators are often covered with a baby blanket or coverlet to protect the newborn from
excessive light. At times a plastic covering is placed over an open warmer.
FOCUS ON SAFETY
Artificial Heat Sources
Any use of an artificial heat source requires frequent nurse monitoring to prevent overheating and infant burns.
EDUCATION/DISCHARGE INSTRUCTIONS
Parents are taught that by the time their newborn is discharged, they will be able to independently
regulate body temperature. Overdressing is not necessary, and hyperthermia can be detrimental
because it increases metabolism and increases the need for oxygen.
Pain
Pain prevention is an important nursing consideration in the NICU. Pain is considered the fifth vital sign
and is assessed per protocol or with nursing care. Nurses must consistently use a pain scale to detect
increases in neonatal pain level and treat pain before it becomes intense. When using pain assessment
tools, nurses should consider the most appropriate tool and have the necessary training in choosing the
appropriate tool for the specific patient population (Maxwell et al, 2019).
BOX 10-3
Normal Temperature Readings in Children

Normal skin temperature: 97°F–98°F (36.2°C–36.8°C)
Normal axillary temperature: 97.7°F–99.5°F (36.5°C–37.5°C)
Normal rectal temperature: 97.9°F–100.4°F (36.6°C–38°C)
High-risk newborns undergo life-saving interventions, many of which can produce pain. Pain is
assessed during both procedural and routine care. An appropriate assessment tool is used to assess
newborn pain. Because newborns cannot verbalize their pain, the assessment tool will measure
physiological symptoms such as heart rate, respirations, movement, and facial expression. Pain has
detrimental physiological short- and long-term effects on the newborn’s cardiovascular, respiratory,
endocrine, metabolic, immunological, and coagulation systems.
A pain assessment is based on nursing assessment using a neonatal pain scale. Many different pain
scales are available for assessing newborn pain. Most assess behavioral components: facial
expression, cry, state of arousal, and body activity as well as physiological components such as blood
pressure, heart rate, respiration, and breathing patterns. The nurse should consider GA when assessing
pain (Maxwell, Fraga, & Malavolta, 2019). Some pain assessment scales are for the term newborn,
whereas others are specific to the preterm newborn, and some focus specifically on procedural or
postoperative pain.
Pain responses in newborns may include:
■ Tachycardia
■ Tachypnea
■ Elevated blood pressure
■ Crying
■ Body movements
■ Painful facial expression
■ State of arousal
■ Crying
■ Desaturations and/or cyanosis
■ Pallor
■ Flushing
■ Muscle tremors
■ Hypertonic
■ Hypotonic
■ Sleep/wake cycles changes
■ More wakeful or lethargic
■ Fussy, irritable, listlessness
■ Feeding difficulties
(Lockridge, 2018; Maxwell et al, 2019)
COLLABORATIVE CARE
Many NICUs have protocols to treat a newborn once the pain assessment scale reaches a specific
score on the scale. Medical care of pain includes treating the newborns with analgesia using oral
sucrose solutions. Interventions to reduce pain during procedures should be implemented, including
skin-to-skin contact, nonnutritive suckling, breastfeeding, and use of sucrose. Sucrose is a sugar
substance that is applied to the tip of the newborn tongue followed by immediate pacifier insertion. The
nurse can administer sucrose 2 minutes before, during, and sometimes 1 to 2 minutes after a minor
procedure such as heel stick, venipuncture, and subcutaneous injection for the purpose of preventing
pain (Lockridge, 2018).
Depending on the condition, procedure, or surgery, other categories of medications used for neonatal
pain include nonsteroidal anti-inflammatory drugs, opiates, sedatives, and local anesthetics. Appropriate
pain medication is determined by the level of pain experienced. Postsurgical pain will commonly be
treated with opiates. Common opiates include fentanyl (Sublimaze), which has a peak effect in 3 to 4
minutes, and morphine (Astramorph), which has a peak effect in 45 minutes. All opiates depress
respiration so care must be taken to closely monitor the medication level and the newborn’s response.
For pain that is less severe, acetaminophen (children’s Tylenol) or ibuprofen (children’s Advil) can be
safely administered.
Hypoglycemia (Low Blood Glucose)

Hypoglycemia occurs rapidly in newborns. Many high-risk newborns can easily develop hypoglycemia
such as SGA, LGA, and those whose mother had gestational diabetes during the pregnancy. In utero,
glucose is provided by continuous placental transfer from maternal circulation. In utero, fetal glucose
levels are maintained at 60% to 70% of the maternal level. After the umbilical cord is cut and the
glucose supply is halted, the newborn has to use liver glycogen and adipose tissue stores to supply
glucose. Gluconeogenesis and ketogenesis are underdeveloped, and glucose levels can fall rapidly
after birth. Glucose is the main source of energy for the newborn’s brain, and levels lower than 30 mg/dL
result in shunting of increased blood volumes to the brain to compensate. Hypoglycemic symptoms in
the newborn may be asymptomatic or manifest by the following: lethargy, jitteriness, poor feeding,
cyanosis, apnea, tachypnea, high pitch or weak cry, seizures, and long-term neurological damage.
Blood glucose levels are obtained by heel sticks. Each nursery has its own policy on what value
constitutes hypoglycemia. Often there are different values for preterm and term newborns because
preterm newborns cannot tolerate glucose levels as low as term newborns because of their lack of fat
stores. It is not abnormal for healthy newborn glucose to be as low as 30 mg/dL within 1 to 2 hours after
birth but then stabilize above 40 to 60 mg/dL within 12 hours after birth (Van Leeuwen & Bladh, 2021).
Often, preterm newborns or high-risk newborns are considered hypoglycemic when blood glucose levels
fall below 50 to 60 mg/dL.
PREVENTION
The most effective way to help a newborn maintain normoglycemic blood values is maternal
regulation of glucose levels in utero. A high maternal glucose level while the fetus is in utero stimulates
the fetal pancreas to produce insulin. After birth, the maternal glucose is no longer available to the
newborn, yet the pancreas is still secreting insulin to produce a hyperinsulinemia and hypoglycemic
state in the newborn. Recognizing newborns who are at risk for hypoglycemia and feeding the newborn
as soon as possible after delivery will assist them to maintain normal glucose blood levels.
COLLABORATIVE CARE
Glucose levels are monitored carefully in all high-risk newborns. Glucose testing is done by heel stick
(capillary blood sampling). A heel stick is done by pricking the heel and scooping the dripping blood into
the appropriate neonatal laboratory tubes that require approximately 1 mL of blood for testing (Fig. 10-
9).
Follow the established nursery protocol, which requires blood glucose levels at specific intervals for
high- and low-risk newborns. Many nurseries have protocols that continue to check newborn glucose
levels at birth and 1, 2, 4, and 8 hours of age. Some NICUs even repeat glucose levels at 12 and 24
hours of age to ensure that glucose levels are being maintained.
For newborns on IV therapy, because a basic component of the parenteral fluid is glucose, nurseries
maintain routine blood glucose checks. IV therapy to treat hypoglycemia consists of providing glucose at
a prescribed rate according to the health-care provider.
If a stable newborn is found to be hypoglycemic on routine blood glucose check, enteral feedings are
started immediately. After the feeding, the glucose level is rechecked at 30 minutes.
Medical care of a newborn whose blood glucose level is not responding to oral feedings will be started
on IV glucose concentrate. The glucose level and IV will be carefully monitored to maintain the
newborn’s glucose within normal limits. Once the newborn is beginning to regulate blood glucose, the IV
glucose solution will be weaned until the newborn is normoglycemic without the parenteral therapy.
FIGURE 10-9 A heel stick is done by pricking the heel and scooping the dripping heel blood into the
appropriate neonatal laboratory tubes that require approximately 1 mL of blood for testing.
FOCUS ON SAFETY
Hypoglycemia of the Newborn
Hypoglycemia of the newborn is a common condition and can be asymptomatic; therefore, nursing care must include
accurate documentation of a newborn’s I&O. A deficit in a newborn’s intake may indicate a risk for hypoglycemia and the
need for a more focused assessment.
Parents are taught the signs and symptoms of hypoglycemia and education to provide frequent
feedings based on the cues of the newborn. Frequent feedings can prevent any future occurrences of
hypoglycemia.
Polycythemia
Polycythemia is a condition consisting of too many circulating red blood cells (RBCs) in the newborn
and has several possible causes. Diagnosis of polycythemia is made by obtaining a complete blood
count, which reveals a venous hematocrit of 65% or greater (Van Leeuwen & Bladh, 2021). Newborns
who experience oxygen deprivation in utero produce additional RBCs to increase the circulation of
oxygen. Polycythemia may also occur when a newborn is exposed to an intrapartum environment that
allows the blood in the cord and placenta to enter their circulation by gravity or “milking the cord” at
delivery. Other causes can occur in twins who develop twin-to-twin transfusion, dehydration, or maternal
factors such as diabetes, smoking, exposure to carbon monoxide, high altitude, and lung disease (Van
Leeuwen & Bladh, 2021).
Polycythemia greatly increases the viscosity of the circulating volume of blood, which can produce
multiple organ damage. Complications of polycythemia are:
■ Necrotizing enterocolitis (NEC)
■ Pulmonary hypertension
■ Thrombocytopenia
■ Jaundice
■ Neurological sequelae including central nervous system lethargy, irritability, seizures, and cerebral
infarction
SIGNS AND SYMPTOMS
Polycythemia may be asymptomatic, but clinical signs can include:
■ (Ruddy) plethoric skin
■ Delayed capillary refilling
■ Hematuria
■ Proteinuria
■ Thrombosis
PREVENTION
Polycythemia is prevented by good prenatal care of mothers to decrease intrauterine stressors for the
fetus because this has been linked to the development of polycythemia. This condition can also be
prevented by maintaining the newborn parallel to the maternal perineum until the umbilical cord is
clamped so the blood flow through the cord is similar to that in utero.
COLLABORATIVE CARE
Nursing Care
Nursing care includes obtaining laboratory work-up. Hemoglobin, hematocrit, and bilirubin levels can
be assessed by peripheral blood drawing or heel stick. Initiating oral feedings or parenteral therapy may
decrease the blood viscosity.
Medical Care
Severe polycythemia (hematocrit greater than 70%) is usually treated with a partial exchange
transfusion (PET). PET refers to manually removing a 5 mL/kg blood sample from the infant and
replacing it with an equal volume of 0.9% saline. This allows for a hemodilution to occur and overall
reduction in RBCs (Merck Sharp & Dohme Corp, 2019).
FOCUS ON SAFETY
Monitoring Bilirubin Levels
Close monitoring of bilirubin levels is needed because of the anticipated breakdown of the excessive RBCs, which will
overload the newborn’s system with heme, the precursor of bilirubin leading to jaundice.
Parents are taught about their newborn’s condition so they can participate in the care by offering
frequent feedings and comforting the newborn during procedures.
Optimizing Outcomes
Preventing Hemolysis of the Blood Specimen

To prevent hemolysis of the blood specimen, avoiding excessive squeezing with capillary heel sticks and transporting the
blood specimen to the laboratory as soon as possible promote the best outcome. Hemolysis has been known to falsely
decrease the bilirubin levels.
LARGE FOR GESTATIONAL AGE (LGA) NEWBORNS

Newborns who are large for gestational age (LGA) are over the 90th percentile on the growth chart
(e.g., a newborn who weighs approximately 3,750 grams [8 lb 4 oz] at 40 weeks’ GA). A macrosomic
newborn who weighs more than 4,050 grams (8 lb 14.85 oz) is always LGA. LGA newborns have a
higher morbidity rate than appropriate for gestational age (AGA) newborns.
There are two reasons why newborns may grow to a larger than average size in utero. They can be
genetically large or, more commonly, they are exposed to an imbalance of nutrients in utero. The most
common energy and growth source in utero is glucose. It is easily transported by diffusion across the
placental barrier. If the maternal circulation contains excessive glucose levels, the fetus’s circulation will
have a higher than normal glucose level also. Box 10-4 lists the intrauterine conditions that place a
newborn at risk for LGA. Box 10-5 lists delivery complications of an LGA newborn.
BOX 10-4
Maternal Risk Factors Contributing to LGA Newborns

• Increased parity
• Increased maternal age
• Increased maternal height
• History of other LGA newborns
• Prolonged pregnancy
• Maternal obesity
• Maternal glucose intolerance
• Large pregnancy weight gain
BOX 10-5
Complications Associated With LGA or Macrosomic Newborns

• Shoulder dystocia at delivery
• Brachial nerve plexus injury
• Asphyxia
• Hyperinsulinemia and hypoglycemia
• Hypocalcemia
Newborns with a diabetic mother are often LGA and are at risk after delivery for:
■ Transient tachypnea because of delayed lung development
■ Hypoglycemia because of insulin overproduction
■ Hypocalcemia from decreased parathyroid production
■ Hypomagnesemia because of metabolic abnormalities
Conditions common to LGA conditions can also occur in other high-risk newborns.
Conditions Affecting the LGA Newborn

Newborns With a Diabetic Mother
HYPERGLYCEMIA
When a mother has diabetes, newborns may experience a chronic hyperglycemic state in utero
because of elevated maternal glucose levels. The effects of the maternal glucose levels on the newborn
depend on several factors, including the maternal glucose control, the onset of the diabetic state, and
the length of gestation. Glucose readily passes through the placenta, but insulin, because of its
molecular size, does not. Therefore, the fetus produces larger than normal amounts of insulin
(hyperinsulinemia) to keep up with the extra glucose. This makes the glucose accessible to the cells,
producing a large newborn. When the cord is cut at delivery, the glucose supply is abruptly stopped, but
the newborn’s pancreas is still hyperstimulated and producing insulin. This results in a severe
hypoglycemic state, as detailed in the previous section on hypoglycemia. Hypoglycemia can occur
rapidly in newborns with a diabetic mother, often within 15 to 20 minutes; therefore, early frequent
glucose monitoring is necessary.
Hyperglycemia is rarer than hypoglycemia but is still significant. Hyperglycemia often occurs when
glucose is administered parenterally because enteral feedings are delayed. A blood glucose level above
150 mg/dL is considered hyperglycemia and can cause dehydration and weight loss. Severe
hyperglycemia may also cause cerebral hemorrhage and be a factor in accelerating ROP as well as a
risk for NEC, sepsis, and long-term neurodevelopmental impairment (Beardsall, 2019).
TRANSIENT TACHYPNEA OF THE NEWBORN

Respiratory distress syndrome type II, or transient tachypnea of the newborn (TTN) , is common in
newborns who have a diabetic mother. TTN is a delayed clearance of fetal lung fluid (which differs from
amniotic fluid). There is fetal lung fluid in the alveoli, and air is trapped in the alveoli resulting in hypoxia
because of poor lung ventilation. The onset of labor appears to be the mechanism by which the lungs
reabsorb fluid, which puts newborns who have not experienced labor (cesarean births) at even greater
risk for TTN. Newborns at risk for TTN include:
■ LGA newborns
■ Newborns with a diabetic mother who are delivered by cesarean birth or a precipitous delivery
■ Late preterm infants—between 34 and 36 completed gestational weeks
Signs and Symptoms
Clinical signs and symptoms of TTN include:
■ A high respiratory rate of 60 to 120 breaths/minute
■ Grunting
■ Retractions
■ Cyanosis may be present
■ Nasal flaring
(Moresco et al, 2020) (Fig. 10-10)
Diagnosis
Blood gases usually show respiratory acidosis (Table 10-5).
Diagnostic Tools
Acid-Base Calculators
Acid-base calculators can be found online and are another assessment tool that nurses can use to support a plan of care
(http://www.medcalc.com/acidbase.html). X-rays of the chest show bilateral streakiness caused by the interstitial and
alveolar fluid.
MEDICATION: Metabolic Acidosis

Metabolic acidosis increases pulmonary resistance. Bicarbonate therapy as a treatment is now used less often because
oxygenation treatments of newborns have improved. Bicarbonate is given IV push 1 to 2 mEq/kg in a maximum
concentration of 0.5 mL. If the newborn weighs 1,000 g, administer 1 to 2 mEq bicarbonate.
Collaborative Care
Perform accurate assessment of the respiratory system immediately after birth and during the
transitional period (within 1–2 hours). Respiratory assessment should include careful observation of the
rise and fall of the chest and abdomen together (one breath cycle) in the newborn for 1 full minute.
Normal findings include the newborn’s respiratory rate below 60 breaths per minute, which may be
irregular in depth, rate, and rhythm with short pauses between 5 to 10 seconds and a peripheral
oximeter reading of greater than 92% (Thompson & Brophy, 2018).
FIGURE 10-10 The Silverman and Andersen Index Evaluation of Respiratory Status.
TABLE 10-5
The Relationship Between pH and Concentration of Arterial Blood Gases
pH PCO2 PaO2 PHCO3
Measures blood acidity Partial pressure of Partial pressure of Partial pressure of
carbon dioxide in blood oxygen in blood bicarbonate (alkaline or
base) in blood
Normal Neonatal Values pH = 7.25–7.45 PCO2 = 35–40 mm Hg PaO2 = 50–80 mm Hg PHCO3– = 20–22 mEq/L
Respiratory Acidosis ↓ pH ↑ PCO2 WNL WNL
(caused by poor
ventilation)
Metabolic Acidosis ↓ pH WNL WNL ↓ PHCO3-
(anaerobic metabolism
from hypoxia, diarrhea,
or kidney disease)
Respiratory Alkalosis ↓ pH ↑ PCO2 ↑ PaO2 WNL
(hyperventilation)
Metabolic Alkalosis ↓ pH WNL WNL ↑ PHCO3–
(vomiting, diarrhea, or
hypocalcemia)
WNL = within normal limits.

Source: Adapted from Noerr, B. (2000). A continuing education service of Penn State’s College of Medicine at the Milton S.
Hershey Medical Center. Hershey, PA.
Abnormal findings include respiratory rate above 60 breaths per minute, grunting, nasal flaring,
retractions, and seesaw respirations. Retractions in newborns are a result of increased chest
compliance and respiratory pressure. Also, the chest muscles of the newborn are immature, so
increasing retraction depth means that the respiratory disease is worsening. Seesaw or paradoxical
respiration appear as the chest wall retracts as the abdomen rises and indicates respiratory distress. If
any of these clinical signs appear immediately after birth or persist into the transitional period, immediate
attention and supplemental oxygen are warranted (Thompson & Brophy, 2018). Nursing care of a
newborn with TTN also includes holding oral feeding for respirations over 60 to decrease the risk of
aspiration. Maintain an NTE to decrease the expenditure of energy and maintain peripheral oxygen
levels within normal limits.
The treatment is often continuous positive airway pressure at 40% oxygen for 24 to 48 hours.
Complete resolution of TTN takes 2 to 3 days. TTN is self-limiting with no reported long-term
complications.
HYPOCALCEMIA
Calcium levels should be greater than 7.5 mg/dL in preterm newborns and 8 mg/dL in term newborns.
The diagnosis of hypocalcemia is made by laboratory study, wherein the calcium level is below 7.5
mg/dL in preterm newborns and 8 mg/dL in term newborns. Low calcium level can produce seizures in
the newborn and may be present along with hypoglycemia. Reasons for hypocalcemia in the newborn
are trauma, hemolytic disease, asphyxia, and maternal hypocalcemia. Lack of oxygen stimulates
calcitonin release, which inhibits calcium release from the bone. Newborns at risk for hypocalcemia are:
■ Newborns with a diabetic mother
■ Preterm newborns
■ Newborns with perinatal asphyxia
Signs and Symptoms
Signs and symptoms of hypocalcemia can range from asymptomatic to manifestations that include:
■ Jitteriness
■ Tremors
■ Hyperalertness
■ Increased tone
■ Poor feeding
■ High-pitched cry
■ Seizures
Prevention
Decreasing intrauterine and intrapartum stress to the fetus and newborn, maintaining normal maternal
glucose and calcium levels, and decreasing birth trauma are the preventive measures.
Collaborative Care
Nursing can help to achieve normal calcium levels after birth by encouraging feeding after birth. Care
includes physiological correction of maternal hypoparathyroidism, administration of calcium
supplements, and in severe cases, the administration of 10% calcium gluconate.
HYPOMAGNESEMIA
Magnesium is necessary for proper parathyroid function. Hypomagnesemia frequently coexists with
hypocalcemia.
Signs and Symptoms
The decreased magnesium in the blood is usually accompanied by:
■ Increased neuromuscular irritability or hypotonia
■ Poor feeding
Diagnosis
Hypomagnesemia is present when the magnesium levels are below 1.5 mg/dL (normal newborn
range is 1.5–2.8 mg/dL). It can be caused by low maternal magnesium levels, SGA or LGA growth
patterns, and hypoparathyroidism.
Collaborative Care
Nursing care consists of neuromuscular assessment (active and passive muscle tone), maintaining
normoglycemic blood levels, and when indicated, monitoring calcium and magnesium levels every 24
hours until stable.
Repeated laboratory work is used to monitor hypomagnesemia. Replacement therapy of magnesium
sulfate may be necessary, administered orally in the form of citrate, gluconate, and chloride.
BIRTH INJURIES
A thorough physical assessment is warranted for the LGA newborn to assess for birth injuries related to
difficult deliveries. Birth injuries or traumas are usually one of two types: neurological injuries (e.g.,
brachial plexus injury [BPI]) or bone fractures (e.g., clavicle fracture). Diagnosis of birth injuries is made
by a thorough nursing assessment, x-ray examination, or appropriate laboratory studies.
Brachial Plexus Injuries (BPI)

The brachial plexus is a complex nerve supply that is responsible for the movement of the shoulders,
chest, and arms. During the birth process, injury can result from stretching of these nerves. The nerve
innervation starts at C5 to T1 nerve roots, and BPI or palsy occurs when these nerves are stretched and
leave the arm without function. Nerve injury to C5 to C7 results in Duchenne-Erb’s paralysis while injury
to C8 to T1 results in Klumpke’s paralysis (Box 10-6). An infant with BPI will have a lack of movement of
an arm, elbow, wrist, or hand or lack of Moro reflex on the affected side. Diagnosis of BPI is made
through a complete neurological assessment to determine the exact damage including the type and
degree as well as the extent of nerve impairment. Diagnostic tests such as myelography, computed
tomography myelography, and magnetic resonance imaging are used to confirm the diagnosis (National
Institute of Neurological Disorders and Stroke, 2019).
Nursing Care
Nursing of BPI care focuses on assessing the injury, resolving the trauma, and preventing further joint
damage. The nurse can assess the Moro, biceps, and radial reflexes. Initially, the arm is rested to allow
swelling to decrease. After 5 to 10 days, passive range-of-motion (ROM) exercises are done multiple
times a day with consultation of a physical therapist. Many cases of BPI will resolve in 3 to 4 months,
and in other cases, surgery may be required (National Institute of Neurological Disorders and Stroke,
2019).
BOX 10-6
The Pathophysiology of Brachial Plexus Injuries (BPI)

Brachial plexus injuries (BPI) are classified by type and degree. A first-degree injury consists of stretching of the nerve
fibers called neurapraxia, and recovery is usually complete within a few days. Second-degree BPI is called axonotmesis,
and the nerve is compressed and becomes edematous. Recovery of second-degree BPI takes longer but is often
complete. In third-degree injuries, axonotmesis, the sheath is damaged, and full recovery is never achieved. Fourth-
degree injury is caused by formation of a neuroma that prevents full nerve regeneration, and fifth-degree injury is a
disruption of the nerve at the spinal cord that results in complete loss of nerve function.
Clavicle Fractures
Clavicle fractures can occur as a common birth injury, especially when there was a difficult delivery, LGA
infant, shoulder dystocia, or a delivery using instruments such as forceps. Broken clavicles are the most
common birth fractures (American College of Obstetrics and Gynecologists, 2017). Fractured clavicles
can occur alone, with BPI, or with a fractured humerus.
SIGNS AND SYMPTOMS
Symptoms of a broken clavicle include:
■ Asymmetrical arm movement
■ Asymmetrical Moro reflex
■ Swelling
■ Pain
■ Crepitus detected on palpation of the bone if the bone is displaced
Crepitus describes the assessment of bone rubbing against bone, which can be felt and sometimes
even heard on examination. This is often described as feeling like rice cereal under the skin.
NURSING CARE
Pain management is needed if the newborn appears uncomfortable. Keep the newborn off the injured
side to decrease pain and promote alignment. Most clavicle fractures heal spontaneously without
medical intervention (Scannell, 2020b). Pain management must be addressed to decrease the pain the
newborn experiences, especially with handling. Surgical treatment with open reduction and internal
fixation is done only in severe cases that threaten the newborn’s full ROM of the affected extremity.
THE PRETERM NEWBORN

Preterm birth is the birth of an infant before 37 weeks of age. In the United States, 1 in 10 infants are
born preterm and have an elevated rate of death and disability, accounting for 17% of infant fatalities in
2017 (Centers for Disease Control and Prevention, 2019c). When infants are born preterm, many of the
bodily organs and functions have not developed properly, leading to serious health consequences. The
most common health consequences of preterm are:
■ Breathing problems
■ Cerebral palsy
■ Developmental delay
■ Vision problems
■ Hearing problems
■ Respiratory distress syndrome (RDS)
■ Apnea of prematurity
■ Bronchopulmonary dysplasia (BPD)
■ Jaundice
■ Anemia of prematurity
■ Necrotizing enterocolitis (NEC)
■ Gastroesophageal reflux disease (GERD)
■ Retinopathy of prematurity (ROP)
■ Intraventricular/periventricular hemorrhage (IVH/PVH)
Key health interventions are to identify those that are at risk and implement early treatments to either
prevent preterm birth or to minimize adverse health outcomes. The primary risk factor for preterm birth is
having a previous preterm birth. Other risk factors are presented in Box 10-7.
The preterm newborn is not only smaller than a term newborn but also has specific characteristics
because of the abbreviated development in utero (Table 10-6).
Respiratory Distress Syndrome (RDS)

Fetal lung maturity develops in utero progressively until term. Fetal lung maturity is determined by the
lecithin-to-sphingomyelin (L/S) ratio and phosphatidylglycerol (PG) values, which are essential
phospholipids in promoting oxygenation of the lung alveoli. They act on the pulmonary surface to
decrease surface tension and are needed to keep the alveoli open when the newborn exhales. L/S ratio
and PG values are often mature at 35 to 36 weeks’ gestation; before this time newborns are at risk for
respiratory distress syndrome (RDS).
RDS is a developmental respiratory disorder affecting preterm newborns because of lack of lung
surfactant and underdeveloped alveolar saccules. RDS causes diffuse atelectasis (parts of the lung are
not expanded), with congestion and edema in the lung spaces. L/S ratio and PG levels are low and
inadequate to keep the immature alveoli of the lungs open. Lung compliance is diminished and
significantly adds to the infant’s work of breathing. The x-ray findings of RDS reveal a reticulogranular
pattern that looks like “ground glass”; possible atelectasis, which looks like “whiteout”; and obscure heart
borders.
Preterm infants are at risk for RDS, due to the immature development of the lungs and lack of
surfactant. The smaller and more preterm the newborn is, the higher the risk for RDS with almost all
infants who are born before 28 weeks’ GA developing RDS (National Heart, Lung, and Blood Institute,
2019).
Signs and Symptoms

The clinical signs and symptoms of RDS begin shortly after birth and include:
■ Expiratory grunting
■ Use of accessory muscles such as retractions and nasal flaring
■ Cyanosis in room air Rapid breathing (tachypnea)
■ Labored breathing with retractions
■ Decreased breath sounds, often with rales
■ Respiratory or mixed acidosis
■ Periods of apnea
BOX 10-7
Risk Factors for Preterm Birth

Maternal smoking
Maternal age: older than 35 years or younger than 20 years at delivery
Maternal drug abuse
Intimate partner violence
Multiple gestations
Maternal uterine abnormalities
Fetal anomalies
Maternal infection (especially chlamydia, gonorrhea, and bacterial vaginosis)
Maternal cervical anomalies
History of previous preterm birth (carries twice the risk)
African American descent
Genetic susceptibility
TABLE 10-6
Assessment of the Preterm Newborn
SKIN HEAD CHEST CARDIAC ABDOMEN MUSCULOSKELETAL GENITALIA NEUROL
Skin tags Irregular-shaped Funnel or Apical heart Cord does not No flexion of Male scrotum Marked he
head, molding pigeon chest rate is have two extremities, resulting in has no rugae positions
after delivery, assessed for arteries and increased susceptibility and the
caput a full minute one vein to heat loss and skin testes are
succedaneum, and is in the breakdown often
cephalhematoma fourth undescended
intercostal
space slightly
left of the
midclavicular
line.
Translucent Large anterior Supernumerary The heart Palpate for Assess for fractures or Female Consisten
and posterior nipples or rate may masses developmental hip clitoris is the cues a
fontanelles nipples are flat normally be dysplasia or fractured often changes
present. Fused on the chest above 160 clavicle prominent
sutures. Bulging wall bpm but not and not
or depressed above 180 covered by
fontanelles. bpm the labia
minora; the
labia majora
are also
small
Lanugo Ear pinnae are Ribs are visible Heart Auscultate Inguinal Sucking a
covering the flat and readily auscultation bowel sounds hernias are are often a
shoulders, fold on is done in the common weeks’ ge
back, thighs, themselves second and
forehead, and fourth right
ears and left
intercostal
spaces as
well as the
apex and
axillae area
Little Eyes are fused Grunting, nasal Auscultation Abdominal Female Moro refle
subcutaneous before 24 weeks’ flaring, or of heart circumference absence of weak
fat gestation retractions sounds are is done to vaginal
(subcostal, done assess for opening or
sternal, or routinely to distention that male urethral
suprasternal) detect may indicate opening
are signs of murmurs, necrotizing covered by
respiratory which may or enterocolitis prepuce
distress may not be (NEC)
innocent
Fragile and Nose flattened or Auscultate Blood Meconium Any signs
easily injured bruised. Nasal anterior, pressures on found in the increased
patency. Low posterior, and all four vaginal pressure i
placement of at the sides of extremities opening insults
ears. the chest are done to
determine
any wide
variations
that are
indicative of a
ductal defect
Mottled Facial anomalies Auscultate Persistent Enlarged liver Ambiguous Hypotonia
related to respiratory rate central or spleen genitalia
poor for a full minute cyanosis
peripheral
perfusion
Prominent Respiratory Displacement Bladder Twitches o
veins rate is between of apex exstrophy jerks
60 and 80
respirations per
minute
Covered in Respiratory Cardiomegaly Eyelids ed
vernix rate above 80 present, m
respirations per light, cong
minute are not absence o
within normal to follow o
limits
Pale (pallor) Asymmetrical Eyes have
related to chest strabismu
anemia from movement may capillaries
blood loss suggest
respiratory
conditions such
as
pneumothorax
or
diaphragmatic
hernia
Congenital Excessive
strawberry secretions will
hemangiomas affect the
oxygen intake
Diaper rash is common related to the increase in irritation of the stool when the newborn is on antibiotics and because of the fr
Soles of the feet are smooth
Collaborative Care
NURSING CARE
Airway maintenance and oxygenation are the priority interventions for the newborn with RDS. Types
of oxygen therapy include:
■ Humidified oxygen
■ Continuous positive airway pressure
■ Conventional mechanical ventilation
■ Bilevel ventilators
■ High-frequency oscillating ventilation
■ High-frequency jet ventilation
■ Nitric oxide (for patients with subsequent persistent pulmonary hypertension [PPHN])
■ Extracorporeal membrane oxygenation (ECMO; in the worst cases)
MEDICAL CARE
The first action to promote the neonate’s stability has historically been to promote oxygenation with
mechanical ventilation via endotracheal intubation. More health-care providers now use continuous
positive airway pressure (CPAP) initially because it is less damaging to lung tissue. If CPAP is not
adequate to oxygenate the newborn, then mechanical ventilation with positive end-expiratory pressure
is needed.
To mechanically ventilate a newborn, an endotracheal tube is placed by a clinician certified in
intubations and neonatal resuscitation. Endotracheal intubation is done by inserting an endotracheal
tube orally to create an open secure airway to which the ventilator can be attached.
Newborns are generally weaned from mechanical ventilation or CPAP as soon as possible to avoid
complications of oxygen such as bronchopulmonary dysplasia (BPD) and ROP.
An oxygen hood is often used to keep a baby in an oxygen-rich environment for a short period of time.
Oxygen hoods are easy to use and provide easy access to the newborn for procedures and assessment
(Fig. 10-11). The newborn with RDS requires blood gas monitoring to determine whether adequate
oxygenation is occurring as well as blood analysis for electrolytes, calcium, and glucose levels.
Newborns who are working harder to oxygenate often have issues maintaining appropriate electrolyte,
calcium, and glucose levels.
FIGURE 10-11 Oxygen hood.
Another mode of delivering oxygen is via nasal cannula, which is continuous flow of low-level oxygen
(1–2 L/min) to supplement the newborn’s own intake. Oxygen by mask is an unreliable method for a
newborn.
After an airway has been established, the administration of synthetic surfactant within 15 to 30
minutes of birth is required. The synthetic surfactant is administered through a catheter in the
endotracheal tube. For newborns less than 1,000 g, it is given to coat the alveoli to keep them open so
that they can perfuse with oxygen. Newborns greater than 1,000 g benefit from surfactant therapy at any
time during the first 2 to 6 hours of life. Continued mechanical ventilation after administration helps the
medication to be spread throughout the lung tissue.
Optimizing Outcomes
Pulse Oximeter
The best outcome to ensure adequate oxygenation (above 92%) is to keep the newborn on a pulse oximeter whenever
oxygen is being used.
MEDICATION: Beractant (Survanta) (be-rak-tant)

Classification(s): Sterile nonpyrogenic pulmonary surfactant.
ACTION: Lowers surface tension at alveoli level. STORAGE: Refrigerate and protect from light.
Pharmacokinetics:
ABSORPTION: Absorbed only in lungs. DISTRIBUTION: Is not absorbed systemically.
Contraindications and Precautions: Monitor heart rate and respiration.
Adverse Reactions and Side Effects: Transient bradycardia, hypotension, oxygen desaturation, endotracheal tube
blockage, pulmonary hemorrhage, and possible increased nosocomial infections.
Route and Dosage: Intratracheal 4 mL/kg q6h x 4 (maximum of four doses in first 48 hours)
1. Give within 15 minutes of birth to premature newborns.
2. Naso-oral suction before administration.
3. Warm vial 20 minutes to room temperature.
4. Do not suction for 1 hour after administration.
5. Discard vial after use—do not refrigerate again once it is warmed (Vallerand, 2021).
Apnea of Prematurity (AOP)

Apnea, a spontaneous pause in breathing, is a common occurrence in preterm newborns and is
commonly seen in the NICU (Eichenwald, 2016). Apnea is diagnosed with absence of respiration that
lasts more than 20 seconds or clinical signs of cyanosis accompanied by absence of respirations that
can be shorter than 20 seconds.
Apnea of prematurity must be differentiated from periodic breathing, which is normal in the newborn.
Periodic breathing is classified as short pauses in the breathing of the newborn that only last
approximately 3 seconds. The incidence of apnea increases as the GA of the newborn decreases. Many
times, the apneic spells are accompanied by a bradycardic episode, which has led to the clinical term
“A&B spell.”
Signs and Symptoms

Apneic spells or episodes are significant if they last more than 20 seconds and many times are
accompanied by:
■ Abrupt pallor
■ Hypotonia
■ Cyanosis
■ Bradycardia
■ Oxygen desaturation
Collaborative Care
NURSING CARE
Most preterm newborns are on a cardiorespiratory (C-R) monitor (Fig. 10-12). The C-R monitor is
attached to the newborn by three electrodes. Two electrodes are placed on either side of the chest and
the third on the abdomen. The electrodes are changed often based on the NICU protocol. Every time
the electrodes are changed, they are applied to a new area of skin to prevent breakdown from the
adhesive. The C-R monitor is set to alarm if the newborn fails to breathe spontaneously for 20 seconds,
the respiratory rate falls below a certain rate (usually 20 respirations/min), or the heart rate drops below
a certain rate (usually 80 to 100 beats per minute). An alarm notifies the nurse of an impending apnea
or bradycardic spell or combined A&B episode.
FIGURE 10-12 Most preterm newborns are on a cardiorespiratory monitor.
Diagnostic Tools
Pulse Oximeter
The pulse oximeter used in conjunction with the C-R monitor is a small, plastic, light-emitting probe that is noninvasive
and can be secured to the newborn’s extremity. The newborn is maintained on continuous pulse oximetry to guard against
desaturation episodes. Oxygen saturation is calculated from the hemoglobin flowing under the light, and then the
percentage is displayed on the monitor. It is easy to use, and the saturation measurements are fairly reliable compared
with arterial samples of blood. The pulse oximeter is also set to alarm during a low peripheral O2 saturation (usually below
88%). If the newborn desaturates without a corresponding A&B spell, it is called a desaturation episode.
An apneic, bradycardic, or desaturation episode requires immediate attention. There are different
severities of A&B spells. Some newborns take a deep breath and regulate themselves back into a
normal cardiorespiratory pattern without intervention, which is often called a self-limiting episode. Some
newborns continue the apnea, bradycardia, and/or desaturation spell and need mild stimulation to
induce them to take a deep breath and regain a normal cardiorespiratory pattern. Stimulation is done by
rubbing their backs or flicking their feet. Periodically, newborns need aggressive stimulation to regain
cardiorespiratory control, which includes increasing existing oxygen flow or using positive pressure
through bag and mask ventilation (Fig. 10-13).
MEDICAL CARE
Initially theophylline (Aerolate) or aminophylline (Phyllocontin) is used to stimulate respirations, but
caffeine (Cafcit) is the most widely used medication for long-term treatment.
FIGURE 10-13 Some newborns need aggressive stimulation to regain cardiorespiratory control that
includes increasing existing oxygen flow or using positive pressure through bag and mask ventilation.
MEDICATION: Caffeine Citrate (Cafcit)

Caffeine citrate (Cafcit) loading dose is 20 mg/kg IV or orally, and the maintenance dose is 5 mg/kg/day. The therapeutic
caffeine level, which is drawn approximately once a week, is in the range of 5 to 20 mcg/mL. Caffeine is never withdrawn
abruptly from the newborn. Once the newborn does not require therapeutic levels to control AOP, the newborn is allowed
to grow out of the dosage and withdrawal takes place slowly.
Parents are taught to give caffeine citrate (Cafcit) to their newborn if it is going to be maintained after
discharge. AOP usually resolves at 37 to 38 weeks postconceptual age but may last longer. Many
preterm newborns are sent home on home C-R monitoring systems that alarm if respirations stop longer
than 20 seconds or the heart rate drops below the set parameters. If newborns are discharged without
monitors, they usually need to be A&B spell-free in the hospital for at least 5 to 7 days before discharge.
Bronchopulmonary Dysplasia (BPD)

Bronchopulmonary dysplasia (BPD), or chronic lung disease, is a condition in which the newborn
becomes oxygen dependent past 36 weeks’ gestation. BPD is a complication produced by long-term
oxygen use, especially with mechanical ventilation therapy. Although oxygen is needed by the preterm
infant to maintain proper tissue perfusion until the maturing lungs can resume that function,
supplemental oxygen can also damage lung tissue by suppressing compliance. Chest x-ray in BPD can
show changes consistent with cyst formation, increased density, and progressive hyperinflation. When
oxygen is administered, the lungs fail to develop the normal compliance needed to force adequate
levels of air in and out. Sometimes the preterm newborn ends up with noncompliant lungs with fibrosis
and are not able to wean off oxygen for an extended period of time, sometimes up to a few years, to
properly oxygenate their growing bodies. Newborns with BPD are often sent home on O2 after the
parents have been educated in oxygen administration. When treating preterm newborns with oxygen,
use the lowest amount possible to maintain acceptable oxygen saturations levels.
Collaborative Care
NURSING CARE
Wean newborns from oxygen as soon as possible. High levels of oxygen and long-term ventilation
have both been linked with the development of BPD, it is critical that nurses prevent erratic oxygen
levels during delivery, maintaining at a constant level of oxygen delivery.
MEDICAL CARE
Management often includes medications to treat the symptoms of BPD. Bronchodilators, such as
beta-2-agonists, anticholinergics, and theophyllines and inhaled and systemic steroids to decrease
inflammation, have been used to try to increase lung compliance. Other medical management includes
the use of oxygen therapy, diuretics, and nutritional therapy.
Newborns discharged on oxygen therapy need a home care nurse to evaluate the home for oxygen
safety and teach parents how to care for the child receiving oxygen therapy. The parents and other
primary caregivers will also need training on the use of a pulse oximeter and CPR training before
discharge. Parents are taught to care for the oxygen-dependent newborn and how to secure an oxygen
supply for the home. Parents are taught newborn positioning and care of the oxygen prongs and
equipment and receive C-R monitor training.
FOCUS ON SAFETY
Infant Car Seat Challenge
Newborns who are born at or before 37 weeks’ GA need an Infant Car Seat Challenge (ICSC). ICSC is done to identify
infants who may have cardiorespiratory difficulty when in a semireclined position. The test is done by placing the
newborn in the car seat that will be used to transport them home for 80 to 120 minutes (or longer if the distance to their
home will take more than 120 minutes). During this period the infant is assessed for apnea, bradycardia, and oxygen
desaturation. The test is failed if there is apnea longer than 20 seconds, bradycardia less than 80 beats per minute, or
desaturation recorded on the pulse oximeter of less than 93%. Newborns who fail the ICSC on multiple occasions may
require a car bed rather than a car seat for transportation.
Physiological and Pathological Jaundice

There are two types of jaundice: physiological and pathological. Neonatal jaundice that occurs during
the first week of life is most often the result of pathological jaundice and is due to an underlying medical
cause. It is also present at birth or occurs during the first 24 hours of life. Physiological jaundice does
not occur until after the first 24 hours of life.
Development of Physiological (Neonatal) Jaundice

Physiological jaundice occurs in more than 60% of full-term newborns and in up to 80% of preterm
newborns (Centers for Disease Control and Prevention, 2019a). Physiological jaundice is the transient
form of jaundice that typically occurs after the first 24 to 48 hours of life and becomes visible when the
total serum bilirubin level is greater than 5 to 7 mg/dL. In the presence of physiological jaundice, peak
bilirubin levels are reached between the third and fifth days in the term infant and between the fifth and
seventh days in the preterm infant. The interaction of the following physiological and pathological factors
can lead to the development of physiological jaundice:
■ An increased amount of unconjugated bilirubin that needs to be presented to the liver. This is related
to an increase in blood volume (following a delay in cord clamping) and accelerated fetal RBC
destruction because of their shortened life span. Newborns produce and break down two to three
times more bilirubin than adults do.
■ Trauma-related causes such as bruising (e.g., cephalhematoma), which leads to an increase in RBC
and HGB that break down, causing an increase the amount of bilirubin transferred to the liver.
■ The hepatic uptake of bilirubin from the plasma is impaired in neonates.
■ Inadequate hepatic circulation from neonatal hypoxia or congenital heart disease is associated with
increased bilirubin levels.
■ Decrease in GI function, leading to a lack of intestinal bacteria and motility, which in turn leads to
increased amounts of unconjugated bilirubin reabsorbed.
■ Defective bilirubin conjugation related to a decrease in glucuronyl transferase activity, coupled with
inadequate caloric intake, may cause saturation of the intracellular-binding proteins and result in
increased blood levels of unconjugated bilirubin.
■ Fatty acids present in breast milk are believed to compete with bilirubin for albumin-binding sites and
interfere with bilirubin metabolism.
■ A defect in bilirubin excretion may result from a congenital infection.
Several nursing interventions can help to decrease the probability of elevated bilirubin levels in the
neonate. For example, the nurse should ensure that the infant’s skin temperature is maintained at
97.8°F (36.5°C) or greater because cold stress causes acidosis. Acidosis decreases the available
serum albumin-binding sites, diminishes albumin-binding powers, and causes elevated unconjugated
bilirubin levels. Because bilirubin is eliminated in the feces, it is important to monitor the infant’s stool for
amount and characteristics. Inadequate stooling can prompt the recycling and reabsorption of bilirubin.
Mothers should be encouraged to initiate early breastfeeding because colostrum exerts a laxative effect
that increases meconium excretion. For all healthy infants, early feedings promote intestinal elimination
and bacterial colonization and provide calories essential for the formation of hepatic-binding proteins
(Fig. 10-14).
Development of Nonphysiological or Pathological Jaundice

Pathological jaundice occurs within the first 24 hours of life. The infant may exhibit a total serum bilirubin
(TSB) that increases by 0.5 mg/dL per hour or 5 mg/dL per day. The diagnosis is usually made when
TSB concentrations climb greater than 12.9 mg/dL in a term infant and greater than 15 mg/dL in a
preterm infant. Pathological jaundice results from disorders that cause excessive hemolysis of RBCs,
leading to an increased production of bilirubin. Excessive blood cell breakdown may result from
polycythemia or increased bruising after a traumatic delivery. Infections, metabolic disorders, and
incompatibilities between the mother’s and newborn’s blood (Rh incompatibility) may also cause
pathological jaundice.
FIGURE 10-14 Laboratory evaluation of the jaundiced newborn of 35 or more weeks’ gestation.
Breastfeeding-Associated Jaundice (Early Onset Jaundice)

Breastfeeding-associated jaundice occurs with a decreased intake of breast milk and a decreased
passage of meconium. Breastfeeding jaundice generally occurs in the first week of life most often
between the second and fourth days of life. Breastfeeding jaundice is believed to be associated with
poor or inadequate breastfeeding practices and delayed passage of stools and is not related to the
composition of the breast milk. Key interventions for breastfeeding jaundice include:
■ Initiating breastfeeding as soon as possible
■ Encourage frequent and exclusive breastfeeding (10–12 times per day)
■ Implement strategies to increase milk supply (hand-expression while feeding, staying hydrated)
■ Support skin-to-skin, which allows for better breastfeeding
■ Assess infant latch and suck
■ Educate of feeding cue
■ Early referral to lactation consultants (Centers for Disease Control and Prevention, 2019a; Flaherman
et al, 2017)
Breast Milk Jaundice (Late-Onset Jaundice)

Breast milk jaundice typically occurs in the full-term infant with an incidence of approximately 2% to 4%.
This condition has a later onset than breastfeeding jaundice, usually appears after the first week of life,
and peaks around day 10. Unlike physiological jaundice, a condition characterized by declining bilirubin
levels within the first week, bilirubin levels associated with breast milk jaundice continue to rise and peak
at 2 to 3 weeks of life. Meanwhile, infants typically are thriving, stooling appropriately, and gaining
weight without any evidence of hemolysis.
There is growing support for universal screening for hyperbilirubinemia, identified as a key
intervention in the prevention of acute bilirubin encephalopathy and kernicterus. Best practices should
include documentation through an hour-specific bilirubin nomogram, which plots the age of the newborn
in hours against total serum bilirubin before infant discharge to assess risk of severe hyperbilirubinemia.
Transcutaneous measurements (TcB) uses a light meter that can detect the level of bilirubin in a
noninvasive method (Centers for Disease Control and Prevention, 2019a).
VITAMIN K
Another important function of the liver involves the production of coagulation factors to enable the
newborn to effectively clot blood after birth. The coagulation factors are activated by vitamin K
(AquaMEPHYTON). Vitamin K is a product of bacteria in the gut; newborns lack vitamin K, as their gut
has not been exposed to bacteria. It is recommended that all newborns are given vitamin K within 1
hour following birth. An IM injection of vitamin K given prophylactically within this first hour of life
prevents hemorrhagic diseases of the newborn. Coagulation factors synthesized in the liver include
prothrombin and factors II, VII, IX, and X. Circulating levels of the coagulation factors vary according to
the GA of the infant.
NURSING CARE
Treatment of jaundice in the newborn is based on the underlying cause. Newborns who are plotted in
the high-risk zone on the bilirubin risk chart undergo phototherapy (bilirubin lights). Phototherapy uses
daylight, cool white, blue, or “special blue” fluorescent light tubes. Fluorescent lights, the most effective
form of phototherapy, are placed around and above the newborn. The level of bilirubin in the blood
determines whether the newborn is placed under single, double, or triple phototherapy. Fiber-optic
systems (biliblanket) can also deliver phototherapy in a blanket form placed under or around the
newborn.
The nurse must remember that when a newborn is under phototherapy, their eyes must be shielded
by an opaque mask. The nurse assesses the newborn’s eyes often to assess for discharge or corneal
irritation. It is important to remove the mask during feedings so the newborn can receive visual
stimulation. The newborn’s genital area must also be covered (Fig. 10-15).
During phototherapy or use of the biliblanket, the newborn is kept warm. The newborn is susceptible
to hypothermia because of skin exposure, and the temperature needs to be monitored closely. In
addition, it is important that the newborn receive proper nutrition to ensure the clearance of the bilirubin.
The breast- or formula-feeding mother can be encouraged to feed the child as often as every 2 hours.
Anemia of Prematurity (AOP)

Newborn RBCs have a life span of only 60 to 70 days compared with 100 to 120 days for adult RBCs.
Premature newborns are often anemic for several compounding reasons. For example, the newborn
undergoes many blood serum evaluations. Even though small amounts of blood are taken for each
study, doing multiple studies reduces circulatory volume. A second reason for anemia is the rapid
growth of a preterm newborn in a short period of time. A third reason has to do with erythropoietin
release. Erythropoietin is not released until 34 to 36 weeks of gestation and then responds when
hematocrit levels are low. Diagnosis is made when there is a decrease in hemoglobin below 35%, which
is the definitive sign of anemia. Infants with AOP will exhibit clinical signs and symptoms such as
fatigue, respiratory distress, and pallor.
FIGURE 10-15 The eyes and genitalia of the newborn are always covered to prevent tissue and retinal
damage.
The nurse assesses skin color, cardiopulmonary status as apnea and bradycardia increase with
anemia, and the hematocrit levels per hospital policy. The nurse may also administer prescribed blood
transfusions to decrease symptoms even though they actually delay the erythropoietin mechanisms.
Laboratory tests should be limited as much as possible, and the least amount of blood is drawn for the
blood analysis. Frequent blood draws have been associated with AOP.
Medications
Anemia of prematurity is treated with recombinant human erythropoietin subcutaneous to stimulate
erythropoiesis. Epoetin (Epogen or EPO) or erythropoietin is given until 34 to 35 weeks of gestation.
Epoetin stimulates erythropoiesis, elevating RBCs. Blood work should be monitored to assess
effectiveness and detect side effects such as elevated white blood cells (WBC) and elevated platelets
(Vallerand, 2021).
Necrotizing Enterocolitis (NEC)

NEC is a serious condition in which bowel inflammation results in bowel damage including ischemia,
caused by limited blood and oxygen flow to the area. Once ischemia occurs, the bowel can become
necrotic, causing food and gas buildup that can result in perforation. This can easily lead to septicemia
in the preterm newborn. Full-term newborns who experience severe asphyxia can also develop NEC.
Necrotizing enterocolitis is diagnosed via x-ray when a sausage-shaped dilation of the intestine is
present. A dangerous sign is free air in the abdomen that may indicate perforation of the bowel.
Laboratory findings show leukopenia, metabolic acidosis, anemia, electrolyte imbalance, and
leukocytosis.
Signs and Symptoms

Necrotizing enterocolitis is suspected if the infant displays:
■ Lack of bowel movements or blood in stool
■ Emesis or prefeeding aspirates
■ Signs of infection, such as temperature instability, cyanosis, bradycardia
■ Abdominal distention, increase of 1 to 2 cm in abdominal circumference from the last feed
■ Irritability
■ Lethargy
■ Observable loops of bowel (late symptom)
PREVENTION
When providing care to a newborn suspected with NEC, enteral feedings are stopped immediately,
and the physician or neonatal nurse practitioner is notified. When caring for a child recovering from
NEC, the nurse must measure and record abdominal circumferences, auscultate bowel sounds before
every feeding, and observe for abdominal distention (observable loops or shiny skin indicating
distention). Before any gastric tube feeding, the nurse must check aspirates for undigested formula or
breast milk. If excessive (20%) undigested breast milk or formula is found, the nurse must follow the
hospital’s protocol, which may suggest that the next feeding be held and the physician or neonatal nurse
practitioner notified. All bowel movements are recorded: amount, consistency, and frequency.
Hematesting stools detects occult (nonvisible) fecal blood. The nurse needs to keep oxygen saturation
levels at acceptable values and decrease excessive environmental stress. Hypoxemia and
environmental stress cause blood to be shunted away from the bowel and to the heart and brain.
Treatment for NEC most often includes bowel rest in which the newborns remain NPO status for 3 to
14 days. A nasogastric tube is placed for decompression of the abdomen, and the newborn is started on
broad-spectrum antibiotics to prevent or treat septicemia. IV fluids are provided, including TPN and
lipids. In severe cases surgery may be warranted and a surgical bowel resection may be necessary.
This can sometimes lead to an ostomy (or ostomies) that may or may not be permanent.
Patient Education
Parents are taught about the condition and all the interventions being completed to avoid complications
(e.g., gavage feedings and special formulas such as Pregestimil) and promote long-term health for the
infant. Specifically, parents must be taught about caring for the ostomy.
Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (GERD) is a frequent and sometimes normal occurrence in high-
risk newborns. It is treated as a disease when excessive amounts of formula or breast milk are being
regurgitated or it causes complications such as failure to gain weight. Residual formula from prior
feedings is common in preterm newborns because of their small stomach capacity and immature
gastrointestinal mobility.
Signs and Symptoms

■ Frequent spitting up or vomiting or regurgitating
■ Eating problems, such as irritability when feeding, refusing to eat, or only eating small amounts
■ Arching the back while feeding
■ Frequent hiccups or cough
■ Frequent waking during sleep
■ Respiratory problems, wheezing, or pneumonia from aspiration
■ Poor weight and growth patterns or weight loss
Treatment for GERD often starts with a change in feedings, including the type of feeding and feeding
position. Measures that can help reduce GERD symptoms include holding the newborn in an upright
position when bottle feeding and for 30 minutes after feeding to decrease reflux; placing the infant at a
30-degree angle while sleeping; smaller, more frequent feedings; adding rice cereal to formula or
pumped breast milk; diet modifications for mothers who breastfeed; and frequent burping to minimize
gastric pressure. The nurse assesses aspirates from nasogastric or orogastric tubes for the amount and
color before each feeding. Use thickened formula or breast milk as prescribed. Place the newborn with
the head of the bed at a 30-degree angle for sleeping. Observe the infant often for signs of aspiration
(e.g., respiratory changes, leakage of food or saliva from mouth or tracheostomy, excess secretions,
shortness of breath, or choking).
Medications such as a proton-pump inhibitor (PPI) or H2 blockers are used to neutralize stomach
acidity, or prokinetic agents are used to increase gastric emptying. PPIs include omeprazole (Prilosec),
lansoprazole (Prevacid), pantoprazole (Protonix), or rabeprazole (Aciphex). Prokinetic agents include
metoclopramide (Reglan) and cisapride (Propulsid). H2 blockers include cimetidine (Tagament HB),
famotidient (Pepcid), nizatidine (Axid, AR), and ranitidine (Zantac).
Patient Education
During the newborn’s hospital stay, the family-centered care includes teaching parents about upright
feedings and sleep positions. Education should be tailored to meet the specific needs of the newborn
and may include information on prescribed medications and special formulas.
Retinopathy of Prematurity (ROP)

The retinal vessels of the preterm newborn are frail and immature. Retinopathy of prematurity (ROP)
is a result of immature retinal vasculature followed by hypoxia. The concentration and duration of
supplemental oxygen are thought to play a role in the development of ROP. In the mid-20th century, a
common practice in the NICU was the high concentration of oxygen in incubators, which was the leading
cause of blindness in children during this period (National Eye Institute, 2019). Retinopathy of
prematurity is inversely related to GA. Therefore, the earlier the GA, the greater the likelihood of
developing this condition. Risk factors for ROP include:
■ High concentrations of oxygen in incubators
■ GA of less than 32 weeks
■ Birth weight of less than 1,500 g
■ Respiratory distress syndrome
■ Patent ductus arteriosus that needs surgery
■ Hypothermia
■ Sepsis and meningitis
■ High-intensity lighting
The extent of retinal damage in the preterm newborn is dependent on three criteria: (1) the GA of the
newborn, (2) the length of exposure to oxygen, and (3) arterial pressure. Damage is classified according
to stages (Box 10-8).
Signs and symptoms of ROP are limited to those that can be assessed by expert examination of the
retina by ophthalmological procedures. During the neonatal period, a newborn who has visual
impairment might not react to a human face.
Preventing retinopathy of prematurity can be accomplished by preventing premature birth. Preventing
other complications of prematurity (such as neonatal RDS) may also help prevent ROP. The more
premature a newborn is, the more likely the development of ROP. If premature birth cannot be avoided,
monitoring the amount of oxygen the premature infant is exposed to decreases the risk of developing
ROP (National Eye Institute, 2019).
BOX 10-8
Stages of Retinopathy of Prematurity (ROP)

Stage I—abnormal blood vessel growth is mild
Stage II—abnormal blood vessel growth is moderate
Stage III—abnormal blood vessel growth is severe
Stage IV—the retina is partially detached
Stage V—completely detached retina; this is the end stage of the disease
Collaborative Care
NURSING CARE
During oxygen administration, fluctuations in arterial concentrations of oxygen must be prevented.
The Pao2 is not set greater than 80 mm Hg, and the preterm newborn is weaned off oxygen as soon as
possible. In addition, the nurse can decrease the constant bright lights in the newborn’s environment. A
blanket to provide shading can be placed over the incubator during the day. Nap time can be designated
in the NICU during which the lights are lowered and other environmental stimuli are decreased.
Treatment and follow-up care are imperative to the newborn’s maintenance of sight, and the nurse is the
coordinator of care.
MEDICAL CARE
The preterm newborn is checked routinely for signs of ROP by an ophthalmologist. Examinations are
started at 4 to 6 weeks of age and continue until vascularization of the retina is complete to reduce the
risk of visual impairment (usually myopia) and blindness. Most babies who develop retinopathy of
prematurity have stages I or II. If ROP is left untreated, it will destroy the newborn’s vision. Cryotherapy
is often the first-line treatment used to treat ROP. Other surgical options include laser surgery, and for
detached or partially detached retinas, scleral buckling surgery and/or vitrectomy may be necessary
(National Eye Institute, 2019).
FOCUS ON SAFETY
Retinopathy of Prematurity
Retinopathy of prematurity (ROP) may occur as a complication of oxygen therapy. The nurse must maintain the lowest
level of oxygen possible for a pulse oximeter reading above 92%.
Acute Intracranial Hemorrhage (ICH)

Intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL) are hemorrhages that cause
bleeding into the epidural, subdural, or subarachnoid areas of the brain. Most bleeds occur within the
first 72 hours of life. IVH is attributed to rapid birth and birth trauma in preterm newborns. An IVH can be
minimal or extensive and present clinically from asymptomatic to seizure activity, depending on the
stage of involvement (Box 10-9). Neurological sequelae related to IVH and PVL are associated with the
severity of the bleed. Severe bleeds can lead to seizures, mental deficiencies, and cerebral palsy. Head
ultrasounds are done routinely in the NICU, usually every week to evaluate the presence of IVH and
PVL in the preterm population. If the bleed causes obstruction of cerebrospinal fluid, a shunt is needed
to prevent hydrocephalus.
Symptoms of intracranial hemorrhages can be asymptomatic to profound neurological impairment
such as decreased tone or change in activity level, seizures, as well as sudden drop in hematocrit and a
full anterior fontanelle. Treatment of RDS and resuscitation by a neonatal team proficient in caring for
low birth weight newborns decreases the incidence of intracranial hemorrhages. Also, gentle nursing
care of the low birth weight newborn and providing an NTE may decrease the risk of low birth weight
newborns developing IVH. Care of the preterm at risk may include measures to decrease intracranial
pressure, including maintaining the head of the bed at 30 degrees. Avoid lifting the legs higher than the
head when changing diapers as this can increase pressure, pain, and stress (Lockridge, 2018).
BOX 10-9
Classifications of Intraventricular Hemorrhage (IVH) and Periventricular

Leukomalacia (PVL)
• Grade I hemorrhages bleed into the subependyma only.
• Grade II hemorrhages bleed into the subependyma, and the ventricles but do not produce distention of the ventricles.
• Grade III hemorrhages bleed into the ventricles and produce dilation of the ventricles that can lead to hydrocephalus.
• Grade IV hemorrhages produce the same bleeding as in grade III, but the bleeding extends to the parenchyma.
The nurse monitors the newborn’s behavior and assesses head circumference and fontanelles.
Priority nursing care centers on recognition of newborn seizures so treatment can begin immediately.
Optimizing Outcomes
Intraventricular (IVH) and Periventricular Leukomalacia (PVL)
When caring for a newborn with either intraventricular or periventricular hemorrhage, the nurse must observe for
neurological symptoms, including poor oxygenation readings on pulse oximeter, poor feeding (if the newborn is being fed),
and lethargic behavior. Increased apnea, bradycardic spells, and seizures may also occur. Critical nursing actions include
keeping accurate and frequent measurements of head circumference in centimeters, reporting any sudden increase in
head circumference, and monitoring fontanelles to ensure they are soft, flat, and open on palpation.
Medications are given to prevent and treat seizure activity that accompanies IVH. Phenobarbital
(Luminal Sodium is the drug of choice) and phenytoin (Dilantin) are prescribed to prevent seizure activity
and are considered maintenance medications. Lorazepam (Ativan) and diazepam (Valium) are often
given to stop seizure activity and are considered emergency medications.
Nutritional Care of the Preterm Newborn

Preterm newborn nutrition is a challenge because these infants are born without the full development of
the gastrointestinal enzymes needed for digestion. The goal of preterm nutrition is to optimize
neurodevelopment and simulate a growth pattern in the NICU similar to what would have been if the
newborn was still in utero. Studies have shown that poor or inadequate nutrition has serious detrimental
consequences including neurological impairment and increase in morbidity and mortality (Hay, 2018).
Feeding readiness in preterm newborns is determined by each individual newborn’s behavioral states.
Alert states around feeding time are assessed to determine newborn feeding readiness. Preterm
newborns spend less time in wake states than full-term newborns. It is recommended that preterm
newborns should begin enteral feedings as soon as possible after birth with the mother’s colostrum and
milk. Maternal breast milk has positive health benefits and reduces the risk of developing NEC. Most
often, the preterm infant will require a specialized feeding plan and often includes both enteral feeding
with supplemental parental IV and TPN or PPN nutrition, which is often started within 24 hours of life
(Hay, 2018). The nutritional needs of the preterm newborn are complicated for several reasons:
1. They have not had the time in utero to build up nutritional stores.
2. They have lost 10% of their body weight after birth.
3. They are often unstable with other medical complications such as RDS, which increases their
metabolic expenditure.
4. They need to gain weight daily at rates double those of a full-term newborn. In addition, the preterm
newborn may not be able to feed because of regurgitating the feeding, losing weight, or cold stress.
If a newborn is not ready to feed by mouth, the nurse uses alternative ways to ensure proper
nutrition such as IV or enteral feeding. Nutritional therapy for preterm infants has lifelong effects on
their physical and neurological development.
THE POST-TERM NEWBORN

Post-term newborns, delivered on or after 42 weeks of gestation, are also considered high-risk.
Although fewer pregnancies are carried to post-term today because of elective inductions, there are still
incidences where a newborn is born after 42 weeks of gestation. Post-term newborns may or may not
be LGA. The newborn may have actually lost weight in utero because of declining placental ability to
transport nutrients and oxygen. Post-term newborns are at risk for passing meconium stool in utero,
which increases their chances of meconium aspiration syndrome (MAS) and PPHN.
Signs and Symptoms

Clinical signs displayed by many post-term newborns include:
■ Meconium-stained cord
■ Desquamation or peeling of the skin
■ Parchment-like skin that is often cracked on the abdomen and extremities
■ Fingers appear long and are often peeling
■ General muscle wasting may be evident
Conditions Affecting the Post-Term Newborn
Meconium Aspiration Syndrome (MAS)
Meconium aspiration syndrome (MAS) is a respiratory condition that occurs when the newborn
aspirated meconium into the respiratory system, often occurring when a newborn is delivered through
meconium-stained amniotic fluid (MSAF). The degree of severity of MAS ranges from mild to severe and
life-threatening and is the leading cause of infant mortality and morbidity (Vain & Batton, 2017).
Diagnosis is confirmed through a chest x-ray examination that shows bilateral diffuse opacities with
areas of atelectasis and hyperinflation from trapped air.
Meconium in the lungs causes obstruction in the small airways and hyperinflation with areas of
atelectasis (collapse of a portion or the entire lung because of blockage of air passage) leading to
hypoxia (Vain & Batton, 2017).
SIGNS AND SYMPTOMS
Signs and symptoms of MAS include:
■ Meconium-stained skin, nails, and umbilical cord
■ Initial respiratory distress, cyanosis, and bradycardia
■ Barrel-shaped chest from overinflated lungs
■ Rales and rhonchi are heard on auscultation
The respiratory symptoms get progressively worse over the first 12 to 24 hours. MAS is often
complicated by pneumothorax (collection of gas in the space surrounding the lungs) and
pneumomediastinum (condition in which air is present in the space in the chest between the two lungs).
Pneumothorax is an emergency and requires chest tubes. Chest tubes require frequent monitoring to
ensure tube patency and prevent air leaks.
Nursing care of newborns with MAS consists of chest physiotherapy (PT) and oxygen administration.
Chest PT can be done by percussion with a small cup, base of a feeding nipple, specifically made
neonatal chest PT device, or by vibration by a battery-operated vibrator. Chest PT is done every 3 to 4
hours to help maintain a clear airway. Postural drainage with percussion or vibration is followed by
suctioning the nasopharynx.
Continuous positive airway pressure is frequently used to provide oxygen. Oxygen by noninvasive
means such as hood or cannula is often not sufficient. Oxygen hoods require a flow meter and blender
to deliver the amount of oxygen concentration prescribed. If the newborn cannot maintain a Pao2 of 50
mm Hg or higher in 100% oxygen, then mechanical ventilation is used.
MEDICATIONS
Newborns with MAS are post-term and neurologically more mature than ventilated preterm newborns.
Neuromuscular medications such as pancuronium (Pavulon) or vecuronium (Norcuron) are used to
increase the effectiveness of ventilation efforts. Analgesic and sedative medications are also used (e.g.,
fentanyl [Sublimaze] or lorazepam [Ativan]). In severe cases with significant respiratory distress, the
newborn will require intubation with mechanical ventilation. Newborns with significant respiratory
distress are treated with surfactant replacement of 100-150 mg/kg up to 4 doses. This is to aid in the
displaced surfactant that occurs when meconium covers the alveolar surfaces and helps to prevent
atelectasis.
Persistent Pulmonary Hypertension of the Newborn (PPHN)

PPHN was once termed persistent fetal circulation because there is right-to-left shunting of blood across
the foramen ovale and through the ductus arteriosus. PPHN is vascular resistance in the pulmonary
system that can be caused by sepsis or pneumonia, but the most common cause of newborn PPHN is
meconium aspiration pneumonia. This occurs when pulmonary vascular resistance does not decrease
after birth so the transition to normal adult-type circulation to the pulmonary system is resisted, forcing
fetal circulation to persist. PPHN produces a right ventricular overload and poor left ventricular filling.
Diagnosis of PPHN is confirmed from the clinical signs and symptoms and chest x-ray examination.
Serum blood tests show hypoglycemia and hypocalcemia. Arterial blood gases show oxygen
desaturation. Ultrasonography of the heart is done to rule out cardiac anomalies and to visualize any
right-to-left shunting. Other causes of PPHN can be due to abnormalities in the newborn’s pulmonary
circulation, surfactant deficiency, or abnormal lung development, such as the case in diaphragmatic
hernias. Figure 10-16 shows the critical cycle of PPHN.
SIGNS AND SYMPTOMS
PPHN usually affects term or post-term newborns because they frequently are born through MSAF.
The newborn usually demonstrates brief respiratory distress at birth and then responds normally. By 12
hours after birth, the signs and symptoms of PPHN are displayed and include:
■ Central cyanosis and tachypnea
■ Grunting and retractions
■ Possible audible murmur because of tricuspid insufficiency
■ Blood pressure usually remains normal
COLLABORATIVE CARE
Newborns with PPHN are oxygenated with nitric oxide because it dilates the pulmonary vessels. If
inhaled nitric oxide (iNO) treatment (which is a potent vasodilator) is not successful (30% of newborns
with PPHN), then ECMO is used. ECMO is a high-risk procedure for circulating blood, removing carbon
dioxide from it, and adding oxygen to it. The blood is warmed to an appropriate temperature and
recirculated to the patient (Venes, 2021).
ECMO has only an 80% success rate, and it is used as a last resort for respiratory support. Delivering
ECMO is a complicated heart and lung bypass procedure used mainly for newborns with meconium
aspiration pneumonia, neonatal pneumonia, and congenital diaphragmatic hernias (CDH) (Venes,
2021). Newborns less than 34 weeks’ gestation or 2,000 g are usually not candidates because of the
need for heparinization of the blood, which can cause a cerebral hemorrhage in small or preterm
newborns. ECMO is accomplished by inserting a catheter into the right internal jugular vein that extends
into the right atrium and another catheter inserted into the right carotid artery into the aortic arch. The
system drains venous blood and replaces arterial blood with oxygenated packed RBCs, platelets, and
fresh frozen plasma. The procedure is expensive, work intensive, and carries a multitude of
complications including infection. It is available only at select Level III neonatal centers (Fig. 10-17).
FIGURE 10-16 Persistent pulmonary hypertension of the newborn.

ADDITIONAL CONSIDERATIONS FOR THE HIGH-RISK NEWBORN
Many conditions of the high-risk newborn are now diagnosed prenatally with an ultrasound. High-risk
newborns may have several conditions that affect their health. Any compromising condition can be
devastating for the family and may require prompt treatment after birth. Some significant conditions
include metabolic, neurological, and gastrointestinal anomalies; infections; and conditions that cause
developmental delays. Examples of common conditions in the aforementioned systems are discussed in
the next section. These conditions can be present at any GA and are not dependent on newborn weight
classifications.
FIGURE 10-17 Extracorporeal membrane oxygenation (ECMO) is used for newborns who are not
responding to conventional or high-frequency ventilation.
Newborn Screening
Every year, 4 million babies are screened for inborn disorders that can lead to permanent disability or
death if left untreated. Screening is used for three groups of disorders, and they include metabolic
disorders (such as phenylketonuria [PKU]), genetic disorders (such as sickle cell disease), and
endocrinopathies (such as hypothyroidism) (Centers for Disease Control and Prevention, 2019b).
Providers can screen for more than 30 disorders with the dried-blood patch method using tandem
mass spectrometry, which can fragment blood elements, checking for any number of deficiencies. All
newborn screening tests as well as any supplemental tests for that particular state are done from this
one dried blood spot test.
A heel stick blood testing method must be done after the newborn is 24 hours old for enough formula
or breast milk intake to have occurred. If the infant was on nothing by mouth status for any reason, the
test may need to be redone at a later date. Blood is collected by heel stick and is soaked into a special
absorbent paper that is left to dry and then mailed to a state-approved laboratory. In the future, newborn
screening may be done by DNA sampling. Further information about newborn screening can be found in
Box 10-10.
BOX 10-10
Newborn Screening
All 50 states (and Puerto Rico) screen for phenylketonuria (PKU) and hypothyroidism; 46 states screen for galactosemia
and 45 for hemoglobinopathy. Maple syrup urine disease is included in the screening for 25 states. Other disorders are
screened for in various states such as homocystinuria, biotinidase deficiency, congenital adrenal hyperplasia, cystic
fibrosis, and toxoplasmosis. Screening for these conditions can promote early intervention, thereby decreasing
devastating complications. States vary greatly among the different screening tests, and new tests that can be included in
regular screening are being discovered on a regular basis. Nurses working with newborns need to know the tests that are
done within their state of employment. More information can be located on the CDC Web site,
https://www.cdc.gov/newbornscreening/ (Centers for Disease Control and Prevention, 2019b).
Nursing care for prevention and education of various inborn conditions is discussed next. Genetic
counseling for parents with a known inborn disorder is imperative. Parents can find information about
these inborn conditions and associated diets at the Centers for Disease Control and Prevention website:
https://www.cdc.gov/newbornscreening/. Additionally, parents can be referred to specialists for genetic
testing and nutritional counseling. Table 10-7 list the common types of inborn metabolic disease.
Congenital Hypothyroidism (CH)

CH is an endocrine disorder that produces a lack of thyroid hormone and, if left untreated, can cause
intellectual disabilities and slow growth. It affects 1 in 2,000 to 4,000 newborns, with more than twice as
many females affected than males, and is screened for in most states (United States National Library of
Medicine, 2020a).
Signs and Symptoms

Clinical signs and symptoms of CH include:
■ Lethargy
■ Poor feeding
■ Constipation
■ Prolonged jaundice
■ Hoarse cry
■ Hypotonia
■ Slow reflexes
■ Delayed linear growth and neurodevelopment
Diagnosis
Laboratory values reveal low thyroxine (T4) and triiodiothyronine (T3) levels (Watson, 2012). The thyroid
hormone levels must remain in a determined range (Tables 10-8 and 10-9) to promote normal brain
development and growth of the child. Thyroid-stimulating hormone assists in the diagnosis of congenital
hypothyroidism (Table 10-10) (Van Leeuwen & Bladh, 2021).
Collaborative Care
A thorough newborn assessment may alert health-care providers to subtle signs, but the manifestations
increase as the child grows. Medical management includes lifelong thyroid hormone replacement
therapy. Levothyroxine (Synthroid) tablets starting at a dose of 10 to 15 mcg/kg/day is the treatment of
choice.
TABLE 10-7
Metabolic Errors
METABOLIC DISORDERS
METABOLIC DESCRIPTION INCIDENCE SIGNS AND TREATMENT SCREENING
DISORDERS SYMPTOMS INFORMATION
Phenylketonuria PKU disorder is the 1 in 10,000 to 1 in There are no signs PKU is controlled by It was the first
(PKU) inability to convert 15,000 or symptoms of PKU a phenylalanine-free metabolic disease
an essential amino at birth; over time, diet with the that prompted
acid, phenylalanine, phenylalanine and elimination of universal
to tyrosine because the by-products proteins (including screening for
of the lack of an accumulate in the breast milk and metabolic
enzyme. It is a nervous system and formula). The diet is diseases, and it is
disease transmitted results in significant started as soon as currently
by an autosomal irreversible possible after birth screened for in all
recessive gene. neurological delays, and continued for U.S. states and
intellectual the child’s entire life. territories.
disabilities, and
seizures.
Galactosemia It is an inherited 1 in 30,000 to Significant difficulty Infants diagnosed Newborn
auto recessive 60,000 of newborns eating, with with galactosemia screening in 46
metabolic disorder vomiting, anorexia, are placed on a U.S. states and
in which there is an and diarrhea leading galactose-free diet territories.
inability to to lethargy and that needs to be
metabolize and failure to thrive and maintained for life.
convert galactose death. Other
into glucose. symptoms include
hepatomegaly, liver
disease and
abnormal bleeding,
seizures, intellectual
disabilities, and
cataracts
Maple Syrup Urine It is an autosomal 1 in 185,000 Signs and Newborns with Newborn
Disease (Branched- recessive disorder in newborn, and a high symptoms develop MSUD will start a screening in 25
Chain Ketoaciduria) which there is an incidence in the Old soon after birth such low-protein diet, and U.S. states and
inability to process Order Mennonite as poor feeding, thiamine territories
certain amino acids. population with 1 in vomiting, poor motor supplements are
380 newborns tone, lethargy, given. The dietary
irritability, and treatment must
hyper-reflexes and begin as soon as
intellectual possible and
disabilities. There continued
are high levels of throughout life.
ketoacids, which
results in urine with
a “maple syrup
odor.” The cerum
and sweat will also
take on a sweet
maple syrup odor.
Homocystinuria There is a deficiency 1 in 200,000 to Skeletal Diet therapy Newborn
in cystathionine 335,000 abnormalities, includes high doses screening in 22
beta-synthase, displacement of the of vitamin B6 and U.S. states and
which causes high eye lens, increase methionine and territories
levels of serum risk for blood clots cystine restriction.
methionine. and intellectual
disability and
developmental
delays.
Biotinidase Is an autosomal 1 in 60,000 Signs and Newborn must Newborn
Deficiency recessive metabolic newborns symptoms start to receive certain screening in 21
disorder that leads show at 7 weeks to types of vitamin B U.S. states and
to carboxylase 3 years and include pantothenic acid or territories
deficiency because developmental biotin. These
of faulty body delay, hypotonia, vitamins must be
recycling the vitamin uncoordinated replaced every day
biotin. movement, because they are
alopecia, rash, essential to growth
fungal infections, and help the body
hearing loss, optic break down and use
nerve atrophy, food. Pantothenic
seizures, intellectual acid and biotin are
disabilities, and also found in foods
metabolic acidosis, such as eggs, fish,
which can lead to milk and milk
death. products, whole
grain cereals, lean
beef, legumes, and
broccoli.
Sources: American College of Obstetricians and Gynecologists. (2017b). National Institute of Health. (2021). Venes (2021)
TABLE 10-8
Thyroxine, Total (T4)
AGE IN DAYS, WEEKS, MONTHS, AND YEARS THYROXINE, TOTAL (T4)
1–3 days 11.8–22.6 mcg/dL
1–2 weeks 9.8–16.6 mcg/dL
1–4 months 7.2–14.4 mcg/dL
Source: Van Leeuwen, A. M., & Bladh, M. L. (2021).
TABLE 10-9
Triiodothyronine, Free (T3)
AGE TRIIODOTHYRONINE, FREE (T3)
Children and adults 260–480 pg/dL
TABLE 10-10
Thyroid-Stimulating Hormone
AGE IN MONTHS AND YEARS THYROID-STIMULATING HORMONE (TSH)
Neonates to 3 days Less than 20 microinternational units/mL
Parents are taught to administer the medication and instructed about the importance of lifelong therapy.
Neurological Conditions
Several neurological conditions can affect newborns of any GA and weight classification. These defects
are multifaceted and prevention may not be possible, but mothers can follow guidelines for thorough
preconceptual and prenatal care and have adequate folic acid intake. Education and discharge
instructions will depend on the prognosis, but families need follow-up by a nurse liaison and referrals to
the appropriate support groups.
Spina bifida is the overriding term for neural tube defects. These defects include anencephaly,
encephalocele, microcephaly, and holoprosencephaly.
Anencephaly
Anencephaly is a condition in which the skull and cerebrum is malformed, but the anterior lobe of the
pituitary is intact. Anencephaly has a higher incidence in girls than boys. The defect is visually disturbing
because most of the skull is not present. Anencephaly is not compatible with life, and these infants may
be born alive and pass away shortly after birth or within a day or due to temperature instability and/or
respiratory compromise.
The overt sign and symptom of anencephaly is the malformed cerebrum or absence of the skull and
brain. Other signs include facial feature abnormalities and heart defects.
Diagnosis of anencephaly is made by visualization and assessment of the defect. Other tests that
may be helpful in the diagnosis include amniocentesis (assessing for increased levels of alpha-
fetoprotein because increased levels suggest a neural tube defect) and urine estriol levels.
Prevention of this condition includes adequate amount of prepregnancy serum folic acid levels. Folic
acid supplements (400 mcg/day) are recommended for all women of childbearing age.
Nurses provide palliative and spiritual care with no effort at resuscitation. The ethical consideration for
these newborns is to Allow a Natural Death (AND). The nurse should ensure comfort measures during
this time including private room with limited interruptions and offering spiritual or religious services.
Encephalocele
Encephalocele is a neural tube defect that is noticeable at birth because there is protrusion of the brain
through the skull. It usually occurs in the occipital area, but it can also occur in the parietal, frontal, or
nasal regions. The mortality rate is estimated at 30%, and many of the survivors have neurological
deficits. Encephalocele requires care that is directed at the defect, including the neurological and
developmental effects.
SIGNS AND SYMPTOMS
Signs and symptoms of encephalocele are noted when the infant’s brain comes through an opening in
the skull. Sometimes, part of the membrane that covers the brain and spinal cord also come through an
opening in the skull. Other areas where the brain can protrude include:
■ From the top of the skull around to the back of the
skull
■ The base of the skull
■ In the area around the nose, sinuses, and forehead
DIAGNOSIS
Diagnosis of encephalocele is made by visualization and assessment of the defect.
COLLABORATIVE CARE
Nursing care will depend on the extent of the defect and the prognosis. The nurse should immediately
cover the defect with warm sterile gauze to decrease the chance of infection. This defect often
accompanies other congenital anomalies, and surgical repair is attempted to close the defect and
prevent infection.
Microcephaly
Microcephaly may be caused by an autosomal recessive disorder, toxic stimulus during prenatal
development, or a chromosomal abnormality. The Zika virus can cause microcephaly if contracted by
the mother during early pregnancy (Centers for Disease Control and Prevention, 2019d). Microcephaly
means the newborn has a smaller than normal head circumference. Microcephalic newborns may have
other congenital malformations but often do not show a recognizable syndrome. There is no treatment
for microcephaly.
SIGNS AND SYMPTOMS
Microcephaly is defined as head circumference 2 standard deviations below the mean for GA and is
identified by progressive head circumference measurements. Microcephaly is also associated with
severe intellectual disabilities. Microcephaly is diagnosed at birth or during routine well-baby
examinations when the infant’s height, weight, and head circumference are measured.
NURSING CARE
Nursing care for microcephaly is supportive and ongoing. Educational efforts should also focus on
prevention efforts. Pregnant women should be counseled to avoid traveling to countries with high
prevalence of Zika and to avoid having intercourse with someone with Zika virus, which can be sexually
transmitted (Centers for Disease Control and Prevention, 2019d; Scannell, 2020a).
NURSING INSIGHT
Holoprosencephaly
Holoprosencephaly is a condition in which the cerebral matter fails to form as two distinct hemispheres. There is no
fissure between the brain’s hemispheres, and often the ventricular system of the brain is malformed. These newborns
often have facial deformities from the midline. These defects can be as severe as having one eye or nostril. These
newborns are often stillborn or die shortly after birth. Nursing care includes the perinatal bereavement nurse who is
sensitive to the grieving needs of the family.

Cleft lip (CL), cleft palate (CP), or both is a multifactorial congenital defect that has genetic and
environmental predispositions. It is the fourth most common congenital birth defect and occurs in 1:500
to 1:10,000 births. During intrauterine fetal life, the primary palate does not fully fuse, and any one of
several degrees of clefts can occur. The different degrees can consist of complete or incomplete CL or
CP as well. They can be unilateral or occur bilaterally. They can occur with or without a cleft of the hard
and/or soft palate and the uvula can also contain a cleft.
CL is sometimes detected prenatally on ultrasound. The focus of nursing care for CL or CP (or both)
is on maintaining adequate nutrition. The nurse understands that newborns with CL and CP can be
successfully breastfed. Breastfeeding may be interrupted based on the need for surgical repair. Bottle
feeding is initiated with a special nipple that is longer than a regular nipple to help prevent aspiration.
Another type of nipple is the Haberman feeder (Fig. 10-18), which is longer and has a reservoir to
regulate the flow of formula. Newborns with clefts are fed in an upright position to decrease the
incidence of regurgitation and aspiration. Often there is a need for lactation consultant early on to help
with the feeding difficulties. Surgical repair of CL is typically done at 3 months of age, and CPs are
usually repaired before 18 months. Some clefts require more than one surgical procedure to
reconstruct.
Parents must be supported by having all the treatments, feeding methods, and care measures
explained. Emotional support is needed to assist in the grieving process of dealing with the reality of the
“nonperfect” child with possible ongoing surgical needs and feeding problems. Later in life the infant
may experience psychosocial problems because of facial deformity and may need ongoing need for
speech therapy, hearing assessment, nutrition, lactation consulting, and orthodontics referrals.
FIGURE 10-18 Haberman feeder.
Congenital Diaphragmatic Hernia (CDH)

CDH is a condition in which the diaphragm is not developmentally complete, and abdominal organs
displace into the thoracic cavity taking up the room needed for proper lung development. It occurs in
approximately 1 in 2,200 newborns. Survival rate is 50%. In CDH, a chest x-ray shows bowel loops in
the thoracic cavity and displaced heart (Fig. 10-19).
FIGURE 10-19 X-ray of infant with congenital diaphragmatic hernia (CDH); note bowel loops in the left
side of the chest and the displaced heart.
Signs and symptoms of CDH include respiratory distress at birth with diminished breath sounds and
difficulty in ventilating the newborn. Additional signs and symptoms include:
■ Bowel sounds in the thoracic cavity
■ Cyanosis
■ Bradycardia
■ Barrel chest
■ Scaphoid abdomen
There is no prevention for CDH, and early detection of CDH in utero can assist the family to deliver at
a Level III NICU center that is capable of ECMO and other emergency care measures needed for the
infant’s survival.
The priority nursing intervention is to maintain the newborn’s airway and oxygenation. It is also
important to ensure a nasogastric tube is in place to decrease bowel distention. Respiratory support and
possibly ECMO is needed to stabilize the newborn for impending surgery. The newborn’s diaphragm is
surgically closed once the bowel is returned to the abdomen.
Abdominal Wall Defects

Gastroschisis is a congenital anomaly that is usually diagnosed during a prenatal ultrasound. In
gastroschisis, the stomach and intestine herniate through the abdominal wall
(Fig. 10-20).
Omphalocele (exomphalos) is a congenital condition in which the intestines protrude into the umbilical
cord region of the abdominal wall. It is often associated with trisomy 13 and 18 and urinary tract
anomalies.
Signs and Symptoms

With gastroschisis, the abdominal wall fails to close, usually on the right side of the umbilicus, and the
intestines are exposed.
With omphalocele, the intestines are covered only by a thin layer of tissue and can be easily seen (the
abdominal wall defect is greater than 4 cm). Note: if the defect is less than 4 cm it is usually considered
an umbilical hernia and does not usually require repair. Diagnosis of either defect is made by
visualization and assessment of the defect.
Prevention
Although gastroschisis and omphalocele cannot be prevented, early detection in utero can occur with
good prenatal care. Good prenatal nutrition has been linked with better outcomes for newborns who
experience these conditions.
FIGURE 10-20 The newborn with gastroschisis.
Collaborative Care
NURSING CARE
For a newborn with gastroschisis, the nurse keeps the abdominal contents sterile by covering them
with moist gauze and wrapped in plastic. The intestines are positioned above the level of the defect to
maintain a sterile environment. Often the bowel is placed in a silo and reduced back into the abdomen
over a few days. Extreme care is taken to position the newborn supine and prevent the mesenteric
vessels from kinking so adequate blood supply continues to flow to the bowel. Both conditions
(gastroschisis and omphalocele) may require either a nasogastric or orogastric tube placement to
eliminate air in the bowel.
MEDICAL CARE
Fluids are replaced IV at 1.5 times the normal maintenance volume because of insensible water loss
from the exposed bowel in gastroschisis. Antibiotics are started preoperatively to prevent against
infection. For larger bowel exposure, a silo device is used to cover the abdominal contents, and they are
pushed back into the abdominal cavity gradually over 7 to 10 days. Then repair is accomplished.
SURGICAL CARE
Surgery is performed as soon as possible to prevent intestinal atresia, which could result in
obstruction. Many times, surgical repair is done within 2 to 4 hours of birth if the repair can be
accomplished in one stage. The amount of displacement determines the course of treatment of an
omphalocele. Postoperative care for either condition focuses on fluid and electrolyte balance, nutritional
support with TPN through a central line, infection protection, and pain management.
Parents must be kept informed about the newborn’s condition and treatment regimens while the
newborn is hospitalized and then taught how to care for the infant at home.
Infections in the Newborn

Herpes Simplex
Genital herpes simplex virus (HSV-2) is one of the fastest growing sexually transmitted infections in the
United States. Mothers who contract a primary infection in the third trimester are more likely to transmit
the infection to the newborn than those who had primary cases preconceptually. Most infections are
transferred during vaginal delivery. A small percentage of newborns can acquire an HSV-2 infection
transplacentally in utero or through reoccurring genital infections. Newborns can acquire HSV type 1
infections from people in the environment with herpes lesions of the mouth. Disseminated infections
(involving multiple organs) carry a high mortality rate and chance for neurological sequelae. HSV-2 can
be disseminated or localized involving brain, skin, eyes, or mouth.
SIGNS AND SYMPTOMS
Genital herpes simplex virus has signs and symptoms that include vesicular rash over the infant’s
presenting part at delivery. HSV-2 can be cultured from the stool, urine, cerebrospinal fluid,
conjunctivae, nasopharynx, and skin.
PREVENTION
Mothers with active genital herpes should have a cesarean birth to decrease the likelihood the
newborn will come in contact with a genital lesion. There is no guarantee that newborns born by
cesarean birth will not develop herpes virus.
NURSING CARE
Nursing care for the newborn involves the administration of acyclovir (Avirax) for a minimum of 14
days after birth. For newborns who develop lesions, it is important to keep them clean and dry to prevent
a secondary bacterial infection. Pain management for newborns who develop lesions is also essential.
The emphasis of teaching is to decrease the newborn’s contact with any active herpes lesions.
Parents should be taught to avoid newborn contact with individuals with active lesions on the face or
lips.
Neonatal Sepsis
Newborn sepsis is a systemic infection and can result from any number of causes, most commonly
preterm delivery, prolonged labor, rupture of membranes greater than 18 hours, maternal fever,
amnionitis, or maternal group B streptococcal (GBS) infection. Sepsis is classified according to the time
of onset. Early onset occurs within the first 5 to 7 days of life and can progress rapidly. Late-onset sepsis
is most common after a week of life, and it often results in meningitis. Nosocomial sepsis occurs in high-
risk newborns who have extended periods of stay in the NICU. Table 10-11 lists the most common
causes of neonatal sepsis according to onset of symptoms.
Sepsis in the newborn may be asymptomatic, so risk factors and maternal history need to be
evaluated carefully. When symptoms do appear, the first indications of sepsis may include:
■ Behavioral changes, which is a good reason to have consistent nursing care in the nursery and NICU.
A nurse who “knows the newborn” may pick up subtle changes earlier than someone who has not
previously cared for the newborn.
■ Hypothermia
■ Lethargy
■ Hypoglycemia
■ Poor feeding
■ Apnea
■ Bradycardia
TABLE 10-11
Most Common Causes of Neonatal Sepsis Broken Down into Onset of Symptoms
EARLY ONSET AND LATE ONSET NOSOCOMIAL ONSET
Group B streptococci (GBS) Staphylococci epidermidis
Listeria monocytogenes Pseudomonas
Staphylococcus Klebsiella
Streptococci Serratia
Haemophilus influenzae Proteus
The diagnostic work-up includes a complete blood count with differential, C-reactive protein level,
platelet count, and blood culture. Some septic work-ups may also include a spinal tap and urinalysis. No
one test is sensitive, so an evaluation of all the data is important. Neutropenia (low neutrophils in the
blood) is a significant sign because neutrophils battle bacterial infections and are depleted if the
newborn has an infection. Many nurseries use a formula that analyzes the ratio of immature to total
neutrophils (I/T ratio) in the WBC count. Most neutrophils should be segmented (SEGS) or mature cells.
When 20% to 25% of the neutrophils are immature or there are bands (sometimes called juveniles or
stabs) or unsegmented neutrophils, it is suspicious of an infection. If a shift of 0.3 or greater is detected,
the newborn is treated for sepsis.
Treatment consists of intravenous antibiotics for a minimum of 48 hours at which time the reports on
the cultured specimens are known. A broad-spectrum antibiotic or a combination of antibiotics is started
as soon as possible. While the infant is being treated the newborn will need close monitoring of vital
signs, maintaining accurate I&O, and allowing the newborn to rest to reduce energy expenditure.
NURSING INSIGHT
Group B Streptococcus (GBS) Infection in the Newborn
Group B streptococcus (GBS) is the leading cause of neonatal sepsis in the United States. One in three women has
colonized GBS in the vagina, and it can be spread to the newborn during the labor process, which is called vertical
transmission. Before the recognition of GBS as a cause of newborn sepsis in the 1970s, the mortality rate was 55%.
Today, mortality rate is less than 5% of those newborns contracting GBS because of protocols in place to treat women in
labor or to treat the newborn if the woman was not adequately treated in labor. All women should be screened for GBS at
35 to 37 weeks of gestation. For newborns delivered in which the maternal GBS status is unknown because of premature
delivery or inadequate prenatal care, the newborns are carefully observed for signs of sepsis including vital signs, poor
feeding, inability to maintain body temperature, inability to maintain blood glucose level over 60 mg/dL, lethargy, and
seizure activity.
Labs
Differential White Blood Cell Count
The formula for an I/T ratio is bands divided by segs + bands or
Example:
This is less than 0.3 shift and is not indicative of an infection.
Developmental Delays
Neonatal Abstinence Syndrome (NAS)
An infant of a drug-abusing mother (IDAM) is a newborn who has been exposed to drugs in the
intrauterine environment, which can cause withdrawal symptoms in the extrauterine environment (Table
10-12). Drugs that are abused have low molecular weight and transfer easily across the placenta. These
drugs have a long half-life in the fetus and bind to central nervous system receptors, causing fetal cell
damage. Some drugs such as cocaine are vasoconstrictors and affect blood flow to the fetus. Newborns
exposed to heroin usually display symptoms about 48 hours after delivery, and newborns exposed to
alcohol begin symptoms 12 hours after delivery. Newborns who require sedation and long-term narcotic
pain management may also experience NAS once the narcotics are withdrawn from care.
SIGNS AND SYMPTOMS

Table 10-13 lists the signs and symptoms of withdrawal or NAS to determine whether a newborn is an
IDAM. Laboratory tests are often done to reveal if the drugs are in the newborn’s system. Urine tests are
most frequently done but reflect only the last few days of intrauterine environmental exposure. The
newborn’s meconium stool and hair specimens are being used more and more to test for drugs in the
newborn’s system. These specimens can be obtained up to 3 days and reflect a longer period of time of
intrauterine exposure than urine testing.
Newborns with NAS are a nursing challenge because they sleep very little and are very irritable.
Using nonpharmacological nursing interventions will aid in comforting a newborn with NAS. Providing a
quiet and dark environment with minimal stimuli helps the infant sleep. Swaddling and gently rocking
and holding the infant provide comfort and security. Other key aspects are to use pacifiers and to feed
the newborn early when they are showing signs of readiness of feeding. Some infants prefer not to be
held. Newborns who have tested positive for drugs or display signs and symptoms of NAS are assessed
using a neonatal abstinence scoring tool approximately every 3 hours. Vitals should be taken at least
every 8 hours or more if indicated.
TABLE 10-12
Drugs That Can Cause Withdrawal Symptoms
OPIATES BARBITURATES OTHERS
Codeine Butalbital Alcohol
Heroin Phenobarbital Amphetamine
Meperidine Secobarbital Chlordiazepoxide
Methadone Clomipramine
Morphine Cocaine
Pentazocine Desmethylimipramine
Propoxyphene Diazepam
Diphenhydramine
Ethchlorvynol
Fluphenazine
Glutethimide
Hydroxyzine
Imipramine
Meprobamate
Phencyclidine
TABLE 10-13
Signs of Neonatal Abstinence Syndrome
Irritability Hypertonia
Tremors Seizures
Wakefulness Exaggerated rooting reflex
Uncoordinated feeding pattern Regurgitation and vomiting
Loose stools Tachypnea or apnea
Yawning or hiccups Sneezing and stuffy nose
Poor weight gain Lacrimation and profuse sweating
Mothers are encouraged to breastfeed unless contraindicated for other reasons, as doing so can
offset withdrawal symptoms in the newborns. A lactation consultant may be necessary in the beginning
to avoid any complications or alleviate concerns early. Other referrals may be necessary such as a
social worker, which may require reporting to the department of families and children depending on the
situation and state regulations.
Naloxone (Narcan) use may increase the severity of drug withdrawal in an IDAM. If the mother is a
suspected drug abuser, it should not be used. If an IDAM is in respiratory distress at the time of delivery,
use positive pressure oxygen to resuscitate the newborn.
MEDICATIONS
Table 10-14 lists the medications used to treat an IDAM.
DISCHARGE PLANNING
Discharge planning must be started as soon as the newborn is admitted to the NICU. Most NICUs use
standards for discharge such as respiratory stability, consistent weight gain, and successful oral
feedings as discharge criteria. Nursing follow-up and phone calls decrease parental anxiety and
increase follow-up. Parents have to assimilate large amounts of information including selecting a
pediatrician and preparing the home for the infant. Not all parents report feeling ready and having
confidence in their child’s health and maturity and their readiness for their newborn’s needs. Discharge
instructions for NICU newborns are extensive and include parental education on:
■ Cardiopulmonary resuscitation
■ Environmental and sleep safety
■ Car seat training
■ Monitor training
■ Recognition of danger signs and illness
■ Medication administration
■ Oxygen therapy
■ Skin care
■ Formula preparation or breastfeeding instructions
■ Vitamin administration
TABLE 10-14
Medications Used to Treat an Infant of a Drug-Abusing Mother
Paregoric (Camphorated tincture of opium) Chlorpromazine (Thorazine)
Phenobarbital (Luminal) Diazepam (Valium)
Clonidine (Catapres) Methadone (Dolophine)
The newborn at risk may have immediate and long-term disabilities. Newborns are extremely resilient,
but the lack of neurological development associated with interrupted intrauterine growth affects them not
only physically but socially and developmentally. NICU “graduates” often need intensive follow-up care.
They are sometimes referred to specialists for sight and hearing follow-up. Ophthalmologist
appointments are made before the family is discharged because ROP is a time-sensitive condition, and
poor scheduling has resulted in newborn blindness.
Other follow-up appointments may include:
■ Ophthalmologist
■ Physical therapy
■ Occupational therapy
■ Developmental specialist
■ Neurologist
■ Registered dietitian
■ Speech pathologist
SUMMARY POINTS
■ Newborns can be put at risk any time during their intrauterine or extrauterine development by genetic disorders,
congenital anomalies, maternal factors, asphyxia, or birth injuries resulting from conditions such as hypothermia, poor
oxygenation, prematurity, or congenital anomalies.
■ SGA newborns can be born at any GA and have a birth weight that falls below the 10th percentile on the growth chart
and have suffered a nutritional or oxygenation deficit in utero because of maternal causes, fetal causes, or a placenta or
cord malfunction.
■ Newborns who are LGA are over the 90th percentile on the growth chart because of genetics or, more commonly, have
been exposed to an imbalance of nutrients in utero.
■ Newborns with a diabetic mother are often LGA. LGA newborns are also at risk for transient tachypnea, hypoglycemia,
hypocalcemia, hypomagnesemia, birth injuries, BPI, and fractures.
■ Post-term newborns are at high risk for complications such as meconium aspiration pneumonia and PPHN.
■ Premature newborns are at risk for RDS, AOP, jaundice, ROP, AOP, and sudden infant death syndrome.
■ Appropriate developmental care in the NICU is key to decreasing long-term developmental disabilities for the preterm
newborn.
■ Discharge planning includes respiratory stability, consistent weight gain, and successful oral feedings. Discharge
planning must be started as soon as the newborn is admitted to the NICU.
■ Newborns with metabolic disorders are screened after they are 24 hours old and if diagnosed are placed on therapeutic
diets for life.
■ Surgical emergencies occur in the newborn, and when organs are outside the body, nursing priority is to cover them with
warm, sterile, wet dressings.
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To explore learning resources for this chapter, go to Davis Advantage

CHAPTER 11
Caring for the Postpartal Woman and

Her Family
CONCEPTS
Postpartum
Family
Breastfeeding
KEY WORDS
puerperium
afterpains
BUBBLE-HE
involution
lochia
lochia rubra
lochia serosa
lochia alba
sitz bath
parturition
paresthesias
let-down reflex
latch-on
engorgement
attachment
CenteringParenting
LEARNING OBJECTIVES

■ Assess the physiological and psychosocial status of the postpartal woman.
■ Plan holistic nursing care for the postpartal woman and her family that includes
strategies for home follow-up.
■ Implement nursing interventions to promote positive breast and formula
feeding outcomes for the mother and her infant.
■ Plan holistic postpartal nursing care with interventions to assess and foster
maternal/infant/family bonding.
PICO(T) Questions
chapter.
1. Do (I) breastfeeding benefits (P) for babies (O) change after the first 12
months of life?
2. What (I) nursing strategies are (O) most effective to assist (P) fathers in
bonding with their newborn child?
INTRODUCTION
Postpartum care, also known as the puerperium, begins
immediately after childbirth and lasts for about 6 weeks. This time
period is filled with almost constant changes that require careful
nursing assessments for the mother, the newborn, and the family.
The nurse’s knowledge and care provided during this “fourth
trimester” of pregnancy can have a lifelong effect in shaping the
future plans and choices for the new family.
Early newborn discharge began as a consumer-initiated movement
and as an alternative to home births in the 1980s. In the 1990s, third-
party payers began to refuse reimbursement for hospital stays that
extended beyond 24 hours, particularly after uncomplicated vaginal
birth. Congress responded to the growing concern over the safety of
this practice by signing into law the Newborns’ and Mothers’ Health
Protection Act of 1996. This legislation prohibits third-party payers
from restricting benefits for hospital stays of less than 48 hours after
a vaginal birth or less than 96 hours after a cesarean birth. Forty-
eight hours is an incredibly short amount of time to assess, assist,
and educate new mothers about matters concerning personal,
newborn, and family health. Information provided by the postpartum
nurse can protect the newborn and their family from unnecessary
morbidity and mortality.
Providing care during this period requires knowledge of the
physiological and psychosocial aspects of the puerperium. The
transitions that occur as the changes of pregnancy are reversed are
considered normal; however, complications can arise and
understanding normal versus abnormal process is key. This chapter
will discuss the normal physiological and psychosocial adaptations
that occur during the postpartum period and the nursing assessments
and interventions required to promote positive, healthy outcomes.
ENSURING SAFETY FOR THE MOTHER AND

INFANT
One of the biggest fears a parent has after the birth of their baby is
the child’s safety. Infant abductions have long been a common
concern among hospital staff and families. These concerns have
created the need for the electronic tracking of infants or heightened
level of identification (O’Neill et al, 2020). Research from the National
Center for Missing and Exploited Children shows that most
abductions occur in the mother’s room, followed by the nursery,
pediatric units, and the hospital grounds. The growing need for fail-
proof mechanisms to ensure infant safety has prompted the
development of a variety of systems designed to foil infant abduction
attempts.
In response to increased litigation and pressure from The Joint
Commission, it has become mandatory for hospitals to offer state-of-
the-art security protection for their patients, mother/baby units, and
visitors. The National Center for Missing & Exploited Children
(NCMEC) has developed guidelines for health-care professionals to
meet The Joint Commission’s mandatory infant safety requirements,
and hospitals have instituted policies and procedures that nurses and
mothers must follow to ensure newborn safety.
Another significant and genuine concern in postpartum units is the
misidentification of newborns while in the hospital (O’Neill et al,
2020). Misidentification of newborns has resulted in infants getting
the wrong procedures done, labs drawn, and given incorrect
medications, formula, and even breast milk. Other grave errors
include newborns being discharged home to the wrong mother/family
(O’Neill et al, 2020).
FOCUS ON SAFETY
Check Identification Bracelets
The safety and security of the infant must constantly be maintained during
hospitalization. This process involves the placement of identification bands:
One band each on the mother and her partner and two bands on the infant
immediately after birth in the delivery room or operating room before the child
is separated from the mother. These plastic locking wristbands indicate the
mother’s medical record number, infant’s last name, sex, and date of delivery.
Any time the infant is separated from and then returned to the mother, the
nurse must verify that the bracelets match. At discharge, hospital policy may
require the nurse to retain both the infant’s and parent’s identification bracelets
as part of the permanent record. This safety measure serves a twofold
purpose: to prevent the unauthorized removal of the infant from the hospital
unit and to prevent the inadvertent mix-up or switching of newborns.
Protecting the Infant From Abduction

Personnel, parents, and significant others must be educated
regarding the various measures implemented to protect the infant
from abduction, an extremely important consideration during
hospitalization. Any time the infant is transported from the nursery to
the mother’s room, it is essential for staff to follow the hospital’s
protocol. In most facilities, infants may be transported only in a
bassinet, and parents are prohibited from carrying the infant in the
halls. When identification bracelets are used, they are matched
before giving the infant to the mother. Mothers should be instructed to
release the infant only to properly identified hospital personnel. Some
facilities use an umbilical cord clamp equipped with an embedded
infant security alarm (Fig. 11-1). The clamp, which remains in place
until discharge, activates an alarm if the infant is removed from the
hospital unit or if the clamp is cut or disengaged. Another system
involves use of an infant electronic radio transmitter tag; a matching
maternal tag is also available to ensure that the mother is correctly
matched with her infant. When two or more infants have a similar or
same last name, it is common practice for the infants’ cribs and
charts to indicate the mother’s first name and bear a label that
designates a “NAME ALERT.” When there are multiple births, the
infants’ cribs may be labeled with the infant’s name followed by a
letter of the alphabet (e.g., A, B, C, or D) or bands may be color-
coded (O’Neill, 2020).
Hospital personnel are typically required to wear visible photo
identification when working in the maternal-child unit. All employee
photo badges should be similar in appearance to facilitate the ready
identification of individuals posing as hospital employees. Visitors
may be required to wear identification badges while on the unit or
even have their pictures taken for security purposes. Key hospital
security measures include hospital unit-based and hospital-based
drills in how to respond to an infant abduction (NCMEC, 2014).
Hospitals are also advised to develop code words such as code
“pink” to enact a hospital-wide security and employee response to an
infant abduction when broadcast in overhead announcements and
hospital-based e-mail and text alerts (NCMEC, 2014). Hospital staff
should be empowered to question any suspicious activity. Be aware
of individuals on the maternal child unit who look or act suspiciously,
such as asking repeated questions about infant feeding times and
emergency exits or carrying large bags that look out of place.
FIGURE 11-1 Umbilical cord clamp equipped with an infant security
alarm.
EARLY MATERNAL ASSESSMENT

Vital Signs
During the postpartum period, vital signs reflect the body’s attempts
to return to a prepregnant state. Vital signs can alert the nurse to the
presence of hemorrhage or infection and should be monitored
according to hospital policy. After a vaginal birth, vital signs are
typically monitored every 15 minutes for 2 hours after childbirth, then
every 4 hours for the first 8 hours, and then every 8 hours until
discharge (Suplee and Janke, 2020). A different protocol is followed
for vital sign assessment after a cesarean birth (e.g., every 30 min 4
hours; then every hour 3; then every 4 to 8 hours). The nurse may
wish to use a postpartum guide such as the rapid assessment tool
presented in Table 11-1 to record vital signs and other critical
information during the early postpartal period.
TABLE 11-1
Postpartum Rapid Assessment Tool: First 24 Hours After Birth
CRITICAL NORMAL FINDINGS ALTERATIONS/POSSIBLE
INDICATORS CAUSES
Temperature (Oral) Within normal range: 98.6°F– >101.0°F (38.3°C) (Infection)
100.4°F (37°C–38°C)
Pulse Within normal range: 50–90 Tachycardia (Difficult
beats/min; bradycardia (50– labor/birth; hemorrhage)
70 beats/min) may be
present
Respirations Within normal range: (12–20 Marked tachypnea (Pulmonary
respirations/min) disease)
Note: Decreased respiratory
rate may occur after an
extremely high spinal block or
epidural narcotic after a
cesarean birth
Blood pressure (BP) Consistent with baseline BP Elevated (Anxiety, pre-
during the first Trimester eclampsia, essential
hypertension, renal disease)
Low (Hemorrhage)
Note: This is a late sign; assess
for increased pulse rate; cool,
clammy skin for acute signs of
hemorrhage
Fundus Immediately after birth: Boggy (Full bladder, uterine
midline, firmly contracted, bleeding)
and palpable through the
abdominal wall midway
between the umbilicus and
the symphysis pubis.
One hour after birth:
approximately at the level of
the umbilicus 24 hours
Lochia Normal progression: lochia Large amounts, clots
rubra (1- to 2-inch stain on (Hemorrhage)
pad, may contain small Foul-smelling (Infection)
clots), consistent with a Abnormal drainage yellow or
heavy menstrual period for greenish
the first 2 hours, then should
steadily decrease, fleshy
odor
Episiotomy or No redness, edema, Redness, edema, ecchymosis,
incision ecchymosis, or discharge; discharge, nonapproximated
edges well approximated edges (Infection)
Hemorrhoids None, or if present, small Tender, enlarged and tense
(Inflamed hemorrhoids)
Bladder Able to spontaneously empty Unable to empty bladder
bladder within 6 to 8 hours, (Urinary retention)
urine output at least 150 Presence of urgency,
mL/hour; bladder not frequency, dysuria (Urinary
palpable after voiding tract infection)
Lower extremities No pain with palpation; no Positive findings: Unilateral
Homans’ sign warmth, tenderness; no pain swelling in one leg not the
with flexion of the foot other, pain and redness behind
(negative Homan’s sign), a calf, and pain on flexion of
swelling that is bilateral and the foot (positive Homan’s sign)
trace to +1 bilateral. (Thrombophlebitis)
Mood Range of emotions; passive Extremely quiet and passive
or talkative; may need to (Fatigue, disappointment about
converse about her birth her birth experience)
experience
Bonding/Attachment Taking-in; maternal-infant en Apprehensive; refuses to care
face position, cuddles infant for infant, no demonstration of
bonding behaviors (Attachment
difficulty)
Temperature
Within the first 2 hours of birth, the woman can develop postpartal
chills with uncontrollable shaking. This is a normal physiological
response, and the nurse should provide the woman with warm
blankets. According to the Association of Women’s Health,
Obstetrical and Neonatal Nursing (AWHONN), during the first 24
hours postpartum, some women experience an increase in body
temperature up to 100.4°F (38°C) (Suplee & Janke, 2020). The
exertion and dehydration that accompany labor are the primary
causes for the temperature elevation, and increased fluids usually
return the temperature to a normal range. Increased breast
vascularity may also cause a transient increase in temperature. After
the first 24 postpartal hours have passed, however, the patient
should be afebrile. A temperature above 100.4°F (38°C) at this time
is indicative of infection requiring prompt evaluation and treatment
(Suplee & Janke, 2020).
Pulse
Heart rates of 50 to 70 beats per minute (bradycardia) commonly
occur during the first 6 to 10 days of the postpartum period. During
pregnancy, the weight of the gravid uterus causes a decreased flow
of venous blood to the heart. After childbirth, there is an increase in
intravascular volume. The elevated stroke volume leads to a
decreased heart rate. Postpartal tachycardia may result from a
complication, prolonged labor, blood loss, temperature elevation,
hemorrhage, or infection.
Blood Pressure
Postpartal blood pressure values should be compared with blood
pressure values obtained during the first trimester. Decreased blood
pressure may result from the physiological changes associated with
the decrease in intrapelvic pressure or indicate uterine hemorrhage.
Women who have had an uncomplicated pregnancy can develop pre-
eclampsia postpartum. An increase in the systolic blood pressure of
30 mm Hg or 15 mm Hg in the diastolic blood pressure, or a reading
of 140/80 or greater, especially when associated with edema,
headaches, or visual changes, may indicate pre-eclampsia. Further
assessment is indicated.
In the puerperium, plasma renin and angiotensin II levels return to
normal, nonpregnant levels. These physiological changes produce a
decrease in vascular resistance. Orthostatic hypotension may occur
when the patient moves from a supine to a sitting position.
Otherwise, maternal blood pressure should remain stable.
Respirations
The respiratory rate should remain within the normal range of 12 to
20 respirations per minute. A slower rate may indicate an opioid
effect and require further monitoring. However, slightly elevated
respirations may occur because of pain, fear, excitement, exertion, or
excessive blood loss. Careful nursing assessment for causes of an
elevated respiratory rate is indicated, along with appropriate
interventions. A sudden onset of tachypnea, abnormal lung sounds,
shortness of breath, chest pain, anxiety, or restlessness are abnormal
findings that must be reported immediately. These signs and
symptoms may be indicative of pulmonary edema or emboli.
Pain
Pain, sometimes considered the “fifth vital sign,” must be recognized
as an important assessment focus immediately and throughout the
postpartum period. Nurses play an important role in assessing,
planning, and implementing interventions to manage maternal pain
effectively. Afterpains are intermittent uterine contractions that occur
during the process of involution. Patients often describe the
sensation as discomfort similar to menstrual cramps. The
primiparous woman typically has mild afterpains, if she notices them
at all, because her uterus is able to maintain a contracted state.
Multiparas and patients with uterine overdistention (e.g., large baby,
multifetal gestation, or hydramnios) are more likely to experience
afterpains because of the continuous pattern of uterine relaxation and
vigorous contractions. When the uterus maintains constant
contraction, the afterpains cease. Breastfeeding and the
administration of exogenous oxytocin usually produce pronounced
afterpains because both cause powerful uterine contractions.
Afterbirth pain is often severe for 2 to 3 days after childbirth.
Nursing interventions for discomfort include assisting the patient
into a prone position with a small pillow placed under her abdomen,
initiating sitz baths (for warmth), encouraging ambulation, and
administrating mild analgesics. The failure to manage pain effectively
has been associated with numerous complications, including
prolonged recovery, increased length of hospital stay, depression,
anxiety, poor coping, and altered sleep patterns.
Medications
Analgesics such as ibuprofen (Advil and Motrin) or naproxen (Aleve
and Anaprox) are frequently administered to lessen the discomforts
of afterpains. Breastfeeding women should take pain medication
approximately 30 minutes before nursing the baby to achieve
maximum pain relief.
Labs
Tests in the Postpartum Period
For the most part, necessary laboratory blood work is completed in the
prenatal period or upon arrival to the labor unit. However, in some cases,
laboratory work is done in the postpartum period to determine whether the
woman requires additional vaccines or interventions such as RhoGAM. Tests in
the postpartum period include:
• Blood type with Rh status (if not done previously) to assess for the need for
RhoGAM
• Hematocrit to assess for anemia
• Rubella status (if not done previously) to assess for the need for
immunization
• Kleihauer-Betke to assess for the presence of fetal red blood cells in maternal
circulation
CONCISE POSTPARTUM ASSESSMENT GUIDE

TO FACILITATE NURSING CARE
BUBBLE-HE Mnemonic
Use of a systematic assessment process helps the nurse ensure that
the special needs of postpartum patients are met. As with all nursing
care, a complete head-to-toe assessment must be completed for the
postpartum patient who has unique needs not found in any other
nursing environment. To assist with the postpartum assessment, the
mnemonic BUBBLE-HE is commonly used to guide nursing practice.
BUBBLE-HE reminds the nurse to assess the breasts, uterus,
bladder, bowel, lochia, and episiotomy (perineum), Homan’s
sign/deep venous thrombosis (DVTs) and emotions (Table 11-2).
Medications commonly prescribed during the puerperium are
Breasts
A number of physiological changes occur during pregnancy to
prepare the breasts for lactation. The mammary glands, which
produce milk, are unlike any other organ system. Throughout the
woman’s growth and development, no other human organ undergoes
the dramatic changes in size, shape, and function that takes place in
the breasts. Breast size has no bearing on the woman’s ability or
capacity to nourish her infant. Instead, the infant’s appetite and
frequent emptying of the breasts dictate the quantity of milk
produced.
TABLE 11-2
BUBBLE-HE(B): Components of a Postpartum Assessment
LETTER ASSESS ASSESSMENT INCLUDES
B Breasts Inspection of nipples: everted, flat, inverted,
intact or cracked? Breast tissue: soft, filling,
firm? Temperature and color: warm, pink, cool,
red streaked?
U Uterus Location (midline or deviated to right or left
side), finger breaths from the umbilicus, and
tone (firm, firm with massage, boggy).
B Bladder Last time the patient emptied her bladder
(spontaneously or via catheter)? Palpable or
nonpalpable? Color, odor, and amount of urine?
B Bowels Date/time of last BM; cesarean patients, bowel
sounds or flatus?
L Lochia Color, amount, presence of clots, odor, any free
flow?
E Episiotomy (Perineum Type as well as other tissue trauma (lacerations,
and hemorrhoids) etc.); assess using REEDA
L/H Legs (Homans’ sign) Pain, varicosities, warmth, swelling, or
discoloration in calves; presence of pedal
pulses; sensation, pain, and movement (after
cesarean birth)
E Emotions Affect, patient-family interaction, effects of
exhaustion, baby blues
(B) Bonding Interaction with infant—”taking-in” phase—
presence of finger tipping, gazing, enfolding,
calling infant by name, identifying unique
characteristics
TABLE 11-3
Commonly Used Medications in the Postpartum Period
CLASSIFICATION MEDICATION DOSE SAFETY OF INDICATION FOR
USE IN USE IN
BREASTFEEDING POSTPARTUM
PERIOD
Stool softener docusate sodium 50 mg to 500 mg by Used in the
(Colace) mouth daily until treatment of
bowel movements constipation
are normal.
Not contraindicated
in breastfeeding
mother.
Stimulant laxative bisacodyl (Dulcolax) 10 mg to 30 mg by Used in the
mouth until bowel treatment of
movements are constipation
normal.
Not contraindicated
in breastfeeding
mother.
Topical anesthetic lidocaine spray Spray to perineal Used on the skin to
area after sitz bath relieve pain and
or perineum care. itching
Not contraindicated
in breastfeeding
mother.
Hemorrhoid care witch hazel (Tucks) Apply to perineal Used on the skin to
area after sitz bath relieve the itching,
or perineum care. burning, and
Not contraindicated irritation associated
in breastfeeding with hemorrhoids
mother.
Nonsteroidal anti- ibuprofen (Motrin) 400–600 mg by Used for the
inflammatory drugs mouth every 4–6 treatment of mild to
hours as needed for moderate pain
pain.
Not contraindicated
in breastfeeding
mother.
Opioid analgesics Percocet Take one to two Used for the
(oxycodone and tablets every 4–6 treatment of
acetaminophen) moderate to severe
hours as needed for pain, should be
pain. used sparingly due
Not contraindicated to opioid crisis
in breastfeeding
mother.

The breast is composed of glandular, connective, and fatty tissue.
The lactating breast contains lobes that house the milk production
cells called alveoli (singular: alveolus), fatty tissue, and a series of
small and main ducts. The ducts converge into 9 to 10 duct openings
in the nipple (Fig. 11-2). According to most published literature, each
breast contains 15 to 20 lobes, although ultrasound studies have
demonstrated variations that range from 4 to 18 lobes per breast.
Each lobe has a small duct that unites with others to form a main
duct. The lobes are connected by areolar tissue and blood vessels.
The ducts function to collect milk from the alveolus and transport it
toward the nipple. The Cooper’s ligaments, along with the fatty
adipose tissue, give shape to the breasts and provide support to the
ductal system (Fig. 11-3).
The areola, a 15- to 16-mm circular pigmented structure, darkens
and enlarges with pregnancy. The Montgomery tubercles are small
sebaceous glands in the areola that enlarge during pregnancy. They
secrete a waxy substance that acts as a lubricant and contains anti-
infective properties that protect the nipples. The nipple, a mass of
conical erectile tissue, is located in the center of the areola and
projects a few millimeters from the center of the breast. Circular
smooth muscles surround the areola and cause the nipple to become
erect with stimulation. The main ducts converge and open into the
nipple.
FIGURE 11-2 Cross section of a lactating breast.
FIGURE 11-3 The ductal system of the breast.
During the days following birth, significant changes in the breasts

require careful assessment. The process of lactation is established in
all postpartum women regardless of their intention to breast or
formula feed. It is important to ensure that milk is filling the breasts
and identify potential problems developing with the nipples and
breasts. During the first 2 postpartal days, the breast tissue should
feel soft to the touch. By the third day, milk is starting to fill the
breasts and they should begin to feel firm and warm. On the fourth
and fifth days postpartum, breastfeeding mothers’ breasts should feel
firm before infant feeding, then soft once the baby is satiated. Tense,
painful breasts in a breastfeeding mother indicate poor transfer of
milk to the infant. This finding should prompt a breastfeeding
assessment and, when appropriate, referral to an international board-
certified lactation consultant (IBCLC; see discussion later in this
chapter).
Occasionally, small, firm nodules can be palpated in the filling
breasts. The nodules result from incomplete emptying of the breasts
during the previous feeding. Usually, a nodule arises from a blocked
milk duct or from milk contained in a gland that is not flowing forward
to the nipple. Although the nodules typically disappear after a
satisfactory feeding, their location should be noted and monitored.
Persistence of any breast mass may be indicative of fibrocystic
disease or malignant growths unrelated to the pregnancy.
Uterus
Involution describes the process by which the uterus returns to the
nonpregnant state (Table 11-4). The uterus undergoes a dramatic
reduction in size, although it will remain slightly larger than its size
before the first pregnancy. The uterus is predominantly composed of
a muscle layer, the myometrium, which is covered by serosa and
lined by the decidua basalis. The process of uterine involution results
from a decrease in the size of the myometrial cells rather than from a
decrease in the number of myometrial cells. The decrease in cell size
results in myometrial thickening and ischemia from reduced blood
flow to the contracted uterus. After birth, placental expulsion
spontaneously occurs within 20 minutes in approximately 90% of
women. To prevent hemorrhage, rapid uterine contractions seal off
the placental site, effectively pinching off the massive network of
maternal blood vessels that were attached to the placenta.
TABLE 11-4
Assessment and Documentation of Uterine Involution
TIME LOCATION OF FUNDUS DOCUMENTATION
Immediately Midline, midway between
after birth umbilicus and symphysis pubis
1–2 hours At the level of the umbilicus at U (umbilicus)
12 hours 1 cm above umbilicus (one U+1
fingerbreadth)
24 hours 1 cm below umbilicus U–1
2 days 2 cm below umbilicus (two U–2
fingerbreadths)
3 days 3 cm below umbilicus (three U–3
fingerbreadths)
7 days Palpable at the symphysis pubis
10 days Not palpable
The original site of placental implantation covers a surface area of

the uterus and will completely heal in approximately 6 to 7 weeks by
a process called exfoliation, the scaling off of dead tissue. New
endometrial tissue is generated at the site from the glands and tissue
that remain in the lower layer of the decidua after separation of the
placenta. This physiological process results in a uterine lining that
contains scar tissue, which could impede implantation in future
pregnancies. Regeneration of the endometrium is complete by the
16th postpartum day, except at the placental site, where regeneration
is usually not complete until approximately 6 weeks after childbirth.
Within a few minutes after birth, the firmly contracted uterine
fundus should be palpable through the abdominal wall halfway
between the umbilicus and the symphysis pubis. Approximately 1
hour later, the fundus should have risen to the level of the umbilicus,
where it remains for the following 24 hours. The fundus then
descends one fingerbreadth (1 cm) per day in size. The fundus,
lochia (puerperal discharge of blood, mucus, and tissue), and
perineum need to be assessed every 15 minutes during the
immediate postpartum period.
To perform the uterine assessment, the nurse assists the patient to
a supine position so that the height of the uterus is not influenced by
an elevated position. The patient’s abdomen is observed for contour
to detect distention and the presence of striae.
The uterine fundus is palpated by placing one hand immediately
above the symphysis pubis to stabilize the uterus and the other hand
at the level of the umbilicus. The nurse presses inward and
downward with the hand positioned on the umbilicus until the fundus
is located. It should feel like a firm, globular mass located at or
slightly above the umbilicus during the first hour after birth. The
uterine fundus should always be midline, although an overdistended
bladder may push the uterus to the right. Within an hour, the uterus
settles in the midline at the level of the umbilicus (Fig. 11-4). Over the
course of days, the uterus descends into the pelvis at a rate of about
1 cm/day (one fingerbreadth) (Fig. 11-5). After 10 days, the uterus
has descended into the pelvis and is no longer palpable.
The fundus is assessed for consistency (firm, soft, or boggy),
location (should be midline), and height (measured in
fingerbreadths). A noncontracted uterus will feel boggy and the
mother is at a large risk for increased bleeding. The nurse documents
the location of the fundus according to fingerbreadths above or below
the umbilicus.
Optimizing Outcomes
Uterine Assessment Crucial During the First Hour Postpartum

Because the first postpartal hour represents the most dangerous time for the
patient, it is essential that the nurse conduct frequent uterine assessments
during this time. Relaxation of the uterus (atony) results in rapid, life-threatening
blood loss because no permanent thrombi have yet formed at the placental site.
FIGURE 11-4 The fundus is palpated in the midline, at the level of the
umbilicus.
FIGURE 11-5 Fundal heights postpartum.

Bladder
After childbirth, spontaneous voiding should occur within 6 to 8 hours,
and the first few voiding amounts should be monitored. Urinary
output of at least 150 mL/hr is necessary to avoid urinary retention, or
stasis. Generalized edema is often present in the early puerperium
related to the fluid accumulation that normally occurs during
pregnancy and the intravenous fluids frequently administered during
labor and birth. Maternal diuresis occurs almost immediately after
birth, and urinary output reaches up to 3,000 mL each day by the
second to fifth postpartum days.
Decreased bladder tone is normal during pregnancy, resulting from
the effects of progesterone on the smooth muscle, edema from
pressure of the presenting part, and mucosal hyperemia from the
increase in blood vessel size. Prolonged labor, the use of forceps,
analgesia, and anesthesia may intensify the changes in the
immediate postpartum period. Pressure caused by the fetal head
pressing on the bladder during labor can result in trauma and a
transient loss of bladder sensation during the first few postpartal days
or weeks. These changes can result in incomplete bladder emptying
and overdistention.
Bladder and urethral trauma are not uncommon during the
intrapartal period and may be associated with a decreased flow of
urine immediately after a vaginal birth. An increase in the voided
volume, the total flow time (how long it takes to empty the bladder),
and the time to peak urine flow (the maximum urinary flow rate)
begins to occur during the first postpartum day. Urine volume and
flow time should return to prepregnant levels by 2 to 3 days after
childbirth. Epidural anesthesia, catheterization before birth, and
instrument-facilitated birth are associated with increased risk of
postpartum urinary retention. Urethral and bladder trauma and
lacerations may accompany vaginal or cesarean birth.
Urinary retention can also result from bladder hypotonia after
childbirth because the weight of the gravid uterus no longer limits
bladder capacity. Assessment of the maternal bladder is an extremely
important component of the nursing evaluation (Table 11-5). An
overdistended bladder, which displaces the uterus above and to the
right of the umbilicus, can cause uterine atony and lead to
hemorrhage.
Other assessment findings may include presence of the bladder
palpated as a hard or firm area just above the symphysis pubis and a
urinary output that is disproportionate to the fluid intake. Bladder
percussion enhances the assessment. To percuss the bladder, the
nurse places one finger flat on the patient’s abdomen over the
bladder and taps it with the finger of the other hand. A full bladder
produces a resonant sound. An empty bladder has a dull, thudding
sound. Patients may express an urge to void but be unable to void.
Fortunately, spontaneous voiding typically returns within 6 to 8 hours
after childbirth. Until this time, the nurse should support and enhance
the woman’s attempts to void. Nursing interventions may include
assisting the patient to the toilet, providing privacy and an unhurried
environment, turning on the lavatory faucet, and assisting the patient
into a sitz bath.
TABLE 11-5
Nursing Assessment and Interventions for the Urinary System
PATIENT’S SIGNS AND SYMPTOMS NURSING INTERVENTIONS
• Location of fundus above baseline level • Promote hydration
• Fundus displaced from midline • Promote ambulation
• Excessive lochia • Administer an analgesic before voiding,
as prescribed
• Bladder discomfort • Place ice on perineum to reduce
swelling and pain
• Bulge of bladder above symphysis • Encourage the use of a sitz bath
pubis
• Frequent voiding of less than 150 mL of • Provide privacy
urine; urinary output disproportionate • Turn on the bathroom faucet
to fluid intake
Bowel
The gastrointestinal system becomes more active soon after
childbirth. The patient often feels hungry and thirsty after the food
and fluid restrictions that usually accompany the intrapartal
experience. The peptide hormone relaxin, which reaches high
circulating levels during pregnancy, depresses bowel motility
(Cunningham et al, 2014). The relaxed condition of the intestinal and
abdominal muscles, combined with the continued effects of
progesterone on the smooth muscles, diminishes bowel motility.
These factors commonly result in constipation during the early
puerperium. After childbirth, bowel movements are typically delayed
until the second or third puerperal day, and hemorrhoids (distended
rectal veins), perineal trauma, and the presence of an episiotomy
may be associated with painful defecation. Early ambulation,
abundant fluids, and a high-fiber diet are a few strategies to help
prevent constipation (Box 11-1).
Lochia
Separation of the placenta and membranes occurs in the spongy or
outer layer of the decidua basalis. The uterine decidua basalis
reorganizes into the basal and superficial layers. The inner basal
layer becomes the foundation from which new layers of endometrium
will form. The superficial layer sloughs off in the uterine discharge,
called lochia. Lochia is composed of erythrocytes; epithelial cells;
blood; and fragments of decidua, mucus, and bacteria. The
characteristics of the lochia are indicative of the woman’s status in
the process of involution.
During the first 1 to 3 days postpartum, the lochia consists mostly
of blood, which gives it a characteristic red color known as lochia
rubra. Lochia rubra also contains elements of amnion, chorion,
decidua, vernix, lanugo, and meconium if the fetus had passed any
stool in utero. These components cause the fleshy odor associated
with lochia rubra.
Around day 4, the lochia becomes the pinkish-brownish lochia
serosa. Lochia serosa contains blood, wound exudates,
erythrocytes, leukocytes, and cervical mucosa. After approximately
10 to 14 days, the uterine discharge has a reduced fluid content and
is largely composed of leukocytes. This combination produces a
white or yellow-white thick discharge known as lochia alba. Lochia
alba also contains decidual cells, mucus, bacteria, and epithelial
cells. It is present until about the third week after childbirth but may
persist for 8 weeks.
BOX 11-1
Nursing Interventions to Facilitate Normal Bowel

Function During the Puerperium
To facilitate the return of normal bowel function in the puerperium, the nurse
should:
• Encourage the patient to drink at least six to eight 8-ounce glasses of water
every day to help keep the stool soft.
• Encourage the patient to eat a high-fiber diet that includes an abundance of
fruits and vegetables, oat and bran cereal, whole-grain bread, and brown rice.
• Encourage the patient to avoid ignoring the urge to defecate.
• Encourage the patient to avoid straining to have a bowel movement.
• Encourage the patient to initiate early ambulation.
• Administer stool softeners and/or laxatives as ordered.
• Explain that, after hospital discharge, over-the-counter medications may be
helpful for hemorrhoidal symptoms of pain, itching, or swelling, but encourage
the patient to consult with her caregiver before using such medications.
The pattern of lochia flow, from lochia rubra to serosa to alba,

should not reverse. A return of lochia rubra after it has turned pink or
white may indicate retained placental fragments or decreased uterine
contractions and new bleeding. Lochia should contain no large clots,
which may indicate the presence of retained placental fragments that
are preventing closure of maternal uterine blood sinuses. The odor of
lochia is similar to that of menstrual blood. An offensive odor is
indicative of infection.
After assessment of the lochia, the nurse may find it difficult to
document the findings correctly. Lochia is typically documented in
amounts described as scant, light, moderate, or heavy. The amount
of vaginal discharge is not a true indicator of the lochia flow unless
the time factor is also considered. For example, a perineal pad
(peripad) that accumulates less than 1 cm of lochia in 1 hour is
associated with scant flow (Fig. 11-6). Nurses must also be certain to
account for the specific type of peripad used because some are more
absorbent than others. At times, visually assessing the amount of
lochia flow can be difficult and inaccurate. Methods should be
employed to more accurately quantify blood loss such as weighing
linens and pads and, when possible, scooping blood and clots into
measuring jugs (Scannell & Lavalee, 2018).
Episiotomy (Perineal Assessment)

The perineal assessment should include an assessment of the
vagina, perineum, and rectum. Upon inspection, the vagina and labia
minora and labia majora should be assessed for swelling, bruising,
and healing of injuries or episiotomy that may have been sustained in
the delivery. Swelling and bruising during the early postpartum period
can indicate worsening condition such hemorrhage or infection. All
lacerations should be assessed for signs of healing and
complications that require interventions. If lacerations were
sustained, they often require suturing, which should be assessed to
determine whether they have remained intact in the postpartum
period. Typically, the episiotomy edges have become fused (the
edges have sealed) by the first 24 hours after birth. Although the
patient’s perineal folds may interfere with full visualization of a midline
episiotomy, it is important for the nurse to carefully assess the
episiotomy and any vaginal/perineal tears for redness, edema,
ecchymosis, discharge, and approximation (REEDA) and then
document all findings.
FIGURE 11-6 Assessment of lochia flow in 1 hour.
Assessment Tools
Perineal Assessment
Protecting the patient’s privacy and ensuring adequate lighting are essential
components of the perineal assessment. To facilitate the perineal assessment,
the nurse assists the patient into a Sims’ (side-lying) position with her back
facing the nurse. Although some edema of the vulva and perineum is a common
finding during the first few postpartum days, excessive swelling, discoloration,
incisional separation, or discharge other than lochia should be reported, along
with the patient’s complaints of pain or discomfort.
With adequate lighting in place, the nurse gently lifts the buttock cheeks to
visualize the perineum. Use of the acronym REEDA guides the nurse to assess
for Redness, Edema, Ecchymosis, Drainage or discharge, and Approximation of
the episiotomy if present (Table 11-6). The episiotomy and/or laceration repairs
should appear intact with the tissue edges closely approximated.
Hematoma After Episiotomy

Severe hemorrhage after an episiotomy is possible. Maternal complaints of
excessive perineal pain should alert the nurse to the possibility of a perineal,
vulvar, vaginal, or ischiorectal hematoma (blood-filled swelling that occurs from
damage to a blood vessel).
To assess for perineal hematoma, the nurse should:
1. Look for discoloration of the perineum.
2. Listen for the patient’s complaints or expression of severe perineal pain.
3. Observe for edema of the area.
4. Listen for the patient’s expression of a need to defecate (the hematoma may
cause rectal pressure).
5. Don sterile gloves, gently palpate the area, and observe for the patient’s
degree of sensitivity to the area by touch.
6. Call the physician or nurse-midwife to report the findings immediately. The
bleeding that has produced the hematoma must be promptly identified and
halted.
TABLE 11-6
The REEDA Acronym to Guide the Perineal Assessment
POINTS REDNESS EDEMA ECCHYMOSIS DISCHARGE APPROXIMATION
0 None None None None Closed
1 Within Less 1–2 cm from Serum Skin separation 3
0.25 cm of than 1 incision mm or less
incision cm from
bilaterally incision
2 Within 0.5 1–2 cm 0.25–1 cm Serosanguineous Skin and
cm of from bilaterally or subcutaneous fat
incision incision 0.5–2 cm separated
bilaterally unilaterally
3 Beyond Greater Greater that 1 Bloody, purulent Skin,
0.5 cm of than 2 cm bilaterally subcutaneous fat
incision cm from or 2 cm and fascial
bilaterally incision unilaterally separation
Optimizing Outcomes
Early Episiotomy Care

The nurse should apply an ice pack to the perineum during the first 24 to 48
hours after childbirth. Application of cold provides local anesthesia and promotes
vasoconstriction while reducing edema and the incidence of peripheral bleeding.
Later (after 24–48 hours), the nurse encourages the use of moist heat (sitz bath)
between 100°F and 105°F (37.8°C-40.5°C) for 20 minutes three to four times per
day.
HEMORRHOIDS
When assessing the perineum, the nurse should also assess the
rectum for hemorrhoids. Hemorrhoids present before pregnancy or
that develop during pregnancy can become enlarged because of
pressure on the lower bowel during the second stage of labor. The
application of ice packs and/or pharmaceutical preparations such as
topical anesthetic ointments or witch hazel pads helps to relieve
discomfort. Other actions to minimize hemorrhoidal discomfort
include assisting the patient to a side-lying position in bed and
teaching her to sit on flat, hard surfaces and tighten her buttocks
before sitting. Soft surfaces and pillows such as donut rings should
be avoided because they separate the buttocks and decrease
venous flow, intensifying the pain. If the hemorrhoids are severe, the
patient can be taught how to manually reposition the hemorrhoids
back into the rectum. Hemorrhoids that developed during pregnancy
generally disappear within a few weeks after childbirth.
Homan’s Sign
Homan’s sign was a common screening tool in the assessment for
DVT in the leg. Homan’s signs have been noted to have limited
accuracy in assessing for a DVT, and current recommendations is to
use this as an adjunct to in the assessment of a DVT. A positive
Homan’s’ sign is indicative of DVT in approximately 50% of patients,
as there may be other conditions that may cause calf pain upon
dorsiflexion, such as strained muscles and contusions. To assess for
Homans’ sign, the patient’s legs should be extended and relaxed with
the knees flexed. The examiner grasps the foot and sharply
dorsiflexes it. A positive sign is present when there is resistance or
discomfort in the calf or popliteal region. The pain occurs from
inflammation of the blood vessel and may be associated with the
presence of a thrombosis.
Thus, a negative Homan’s sign does not rule out DVT. A diagnosis
based solely on the evaluation of clinical signs that include pain in the
calf, erythema, warmth greater in one calf than the other, and
unequal calf circumference has proven unreliable. Instead, specific
diagnostic procedures (e.g., venography and real-time and color
Doppler ultrasound) should be performed when DVT is suspected.
(See Chapter 12 for further discussion.)
In some facilities, Homan’s sign is no longer a component of the
nursing assessment because of its limited diagnostic reliability and
fear that performance of the maneuver could lead to emboli if the clot
is dislodged during the assessment. However, there are no published
reports of emboli resulting from performance of a Homan’s sign.
What to Say
Suggestions to Help Prevent Postpartum Thrombophlebitis
During postpartum care, the nurse can offer the following strategies to improve
peripheral circulation and decrease the risk for thrombophlebitis:
• Early ambulation is important—but ask for assistance the first few times you
walk.
• If ambulation is not possible, perform active and passive leg exercises and do
not place pillows under your knees (sharp flexion at the knees and pressure
on the popliteal space cause pooling of blood in the lower extremities).
• Avoid sitting in one position or standing for a prolonged period of time.
• When you sit, elevate your legs and do not cross them.
• Drink plenty of fluids (10–12 8-ounce glasses) to prevent dehydration.
Assessment of Pain
Discomfort and pain may occur from several sources. Muscular
aches and cramps related to the physical exertion expended during
labor and birth may be relieved with back rubs and massage. When
necessary, acetaminophen (e.g., Tylenol) may be used to alleviate
the discomfort. Pain occurring in the calf of the leg must be carefully
evaluated for thromboembolic disease. Episiotomy pain and
discomfort may be associated with sitting, walking, bending,
urinating, and defecating. It may interfere with the woman’s ability to
comfortably hold and feed her infant. Pain is often an indicator of an
infection, and all complaints of pain should be assessed for signs of
infections. Interventions to decrease discomfort from the episiotomy
include the application of cold (first 24 hours) and heat, and the use
of topical anesthetic creams, sprays, and sitz baths.
PROCEDURE ■ Enhancing Comfort and

Healing With a Sitz Bath
A sitz bath is a warm-water bath taken in the sitting position that covers only the
perineum and buttocks. Sitz baths are used to relieve pain, itching, or muscle
spasms. It can be placed in the toilet, with the seat raised. Other mechanisms
for taking a sitz bath include sitting in a tub filled with 4 to 6 inches of warm
water or the use of a nonportable sitz bath unit (similar to a toilet that fills up
with warm water). When filled with warm water, the swirling action of the fluid
soothes the tissue, reduces inflammation by promoting vasodilation to the area,
and provides comfort. The nurse prepares and assists the patient to the sitz
bath, which should be used for 20 minutes three to four times a day.
Preparing a Sitz Bath
PURPOSE
To facilitate healing through the application of moist heat.
EQUIPMENT
• Sitz bath tub/toilet insert with water receptacle
• Towels for drying the perineal area after the treatment
• Clean perineal pad to be applied after the treatment
STEPS
1. Wash your hands, identify the patient, and explain the procedure.
RATIONALE: Hand washing helps to prevent infection. Providing an
explanation educates the patient and helps to alleviate anxiety.
2. Assess the patient to confirm that she is able to ambulate to the bathroom.
RATIONALE: A sitz bath can cause dizziness and increase the potential for
injury. It is important to ascertain that the patient can safely ambulate to the
bathroom before initiating the procedure.
3. Assemble equipment and ensure that all equipment is clean.
4. Raise the toilet seat in the patient’s bathroom.
5. Insert the sitz bath apparatus into the toilet. The overflow opening should be
directed toward the back of the toilet.
6. Fill the collecting bag with water or saline, as directed, at the appropriate
temperature (105°F [41°C]).
7. Test the water temperature. It should feel comfortably warm on the wrist.
RATIONALE: Ensuring a correct water temperature reduces the chance of
thermal injury. The flow of warm water to the perineum promotes healing by
increasing circulation and reducing inflammation.
8. Hang the bag overhead to allow a steady stream of water to flow from the
bag, through the tubing, and into the reservoir.
9. Assist the ambulating patient to the bathroom. Help with removal of the
perineal pad from front to back. Assist the patient to sit in the basin.
RATIONALE: Assistance with ambulation reduces the chance for patient
injury. Removal of the pad from front to back decreases the risk for infection
transmission. Proper placement on the seat ensures comfort and
effectiveness of the treatment.
10. Instruct the patient to use the tubing clamp to regulate the flow of water.
Ensure that the patient is adequately covered with a robe or blankets to
prevent chilling.
RATIONALE: The swirling warm water helps to reduce edema and promote
comfort. Clothing and extra blankets for warmth prevent chilling and
enhance patient comfort.
11. Verify that the call bell is within reach and provide for privacy.
RATIONALE: Easy access to the call bell reassures the patient that prompt
assistance is readily available when needed.
12. Encourage the patient to remain in the sitz bath for approximately 20
minutes.
RATIONALE: After 20 minutes, vasoconstriction occurs and heat is no longer
therapeutic.
13. Provide assistance with drying the perineal area and applying a clean
perineal pad by grasping the pad by the ends or bottom side.
RATIONALE: Holding the pad correctly decreases the risk for contamination
and subsequent infection.
14. Assist the patient back to the room.
RATIONALE: After the procedure, the patient may be fatigued or light-headed
from the warm water; assistance minimizes the risk of injury.
15. Assess the patient’s response to the procedure. Reinforce teaching about
continued perineal care at home.
RATIONALE: Assessment helps to determine the effectiveness of the
procedure; teaching enhances understanding and promotes continuity of
care after discharge.
16. Record completion of the procedure, the condition of the perineum, and the
patient’s tolerance.
RATIONALE: Documentation provides evidence of the intervention and an
additional opportunity for evaluation of care and the patient’s tolerance of the
procedure.
Clinical Judgment Alert The warm environment associated with a sitz bath
may cause the patient to feel light-headed or dizzy. It is important to monitor the
patient frequently throughout the intervention to ensure safety and tolerance.
TEACH THE PATIENT

1. The benefits of using the sitz bath, which include enhanced hygiene,
comfort, and improved circulation
2. To use the sitz bath as often as recommended—usually three to four times
per day or as needed for discomfort
3. To contact the nursing staff immediately if she becomes light-headed or dizzy
4. To check the temperature of the solution before use; applying water or
solution that is too warm may result in local trauma or burns to the area
NOTE
A specific sitz bath device is more effective for local treatment than a regular
bathtub because the application of heat to the extremities causes vasodilation
and draws blood away from the perineal area. However, if the patient prefers to
prepare a sitz bath in the bathtub at home, she should be instructed not to use
the same water for bathing. Instead, fresh water should be drawn for washing to
diminish the potential for infection.
The nurse assesses and documents the patient’s pain behavior

regarding the:
■ Onset of pain
■ Location of pain
■ Type of pain: stabbing, burning, throbbing, or aching
■ Duration of pain: intermittent or continuous
■ Any alleviating factors or factors that make the pain worse
Nursing interventions include the administration of analgesics and
patient education about other measures to promote comfort. Suggest
nonpharmacological methods for pain relief such as imagery,
therapeutic touch, relaxation, distraction, and interaction with the
infant. Provide pain relief by administering prescribed medications.
Over-the-counter medications and alternative therapies such as
acetaminophen or ibuprofen may be equally as effective as narcotic
analgesics.
Reassure the patient that the pain and discomfort should not
persist beyond 5 to 7 days.
MATERNAL PHYSIOLOGICAL ADAPTATIONS

AND CONTINUED ASSESSMENT OF THE
PATIENT
Hematological and Metabolic Systems
During the immediate postpartum period, a decrease in blood volume
correlates with the blood loss experienced during delivery. During the
next few days after childbirth, the maternal plasma volume decreases
even further as a result of diuresis. The 500-mL blood loss that
typically accompanies a vaginal birth (1,000 mL for a cesarean birth)
usually results in a 1-gram (2 grams for a cesarean birth) drop in
hemoglobin. It is important for the nurse to remember that, as the
body’s excess fluid is excreted, the hematocrit may rise because of
hemoconcentration. However, the hematocrit should return to
prepregnancy levels by 4 to 6 weeks postpartum.
The white blood cell (WBC) count, which increases during labor
and in the immediate postpartum period, returns to normal values
within 6 days. Levels of plasma fibrinogen tend to remain elevated
during the first few postpartal weeks. Although this alteration exerts a
protective effect against hemorrhage, it increases the patient’s risk of
thrombus formation. Overall, the hematological system has usually
returned to a nonpregnant status by the third to fourth postpartal
week.
Circulating levels of estrogen and progesterone decrease
dramatically after delivery of the placenta. The decline in these two
hormones signals the anterior pituitary gland to produce prolactin in
readiness for lactation. In nonlactating (formula feeding) women,
prolactin levels return to normal by the third to fourth postpartal week.
After childbirth and expulsion of the placenta, circulating levels of
other hormones, including human placental lactogen, cortisol, growth
hormone, and insulinase, also fall. During the early postpartum
period, the decline in the serum levels of these substances reduces
the anti-insulin effects that occur during pregnancy. Hence, insulin
requirements are reduced for insulin-dependent women during this
time, sometimes termed a “honeymoon phase.” For many insulin-
dependent diabetics, glucose levels remain in a normal range
(without intervention) during the first few days after childbirth.
Neurological System
Fatigue and discomfort are common complaints after childbirth. The
demands of the newborn frequently create altered sleep patterns that
contribute to increased maternal fatigue. Anesthesia and analgesia
received during labor and birth may cause transient maternal
neurological changes such as numbness in the legs or dizziness.
When these changes are present, the nursing priority is to safeguard
the patient and her infant and prevent injury from falls.
Complaints of headaches require further nursing assessment.
Patients who received epidural or spinal anesthesia may experience
headaches, especially when they assume an upright position. After
spinal or epidural anesthesia, headaches may result from the
leakage of cerebrospinal fluid into the extradural space. Labor-
induced stress or gestational hypertension may also cause
headaches. It is essential that the nurse assess the quality and
location of the headache and carefully monitor maternal vital signs.
Headaches that are accompanied by double or blurred vision,
photophobia, epigastric or abdominal pain, and proteinuria may be
signs of a developing or worsening pre-eclampsia. Report these
findings immediately to the primary health-care provider. Implement
environmental interventions such as reducing the room lighting and
noise levels and limiting visitors. The physiological edema of
pregnancy is dramatically reversed during postpartum diuresis.
Patients who experienced medial nerve compression and carpal
tunnel syndrome during pregnancy often experience symptom relief.
Renal System, Fluid, and Electrolytes

The renal plasma flow, glomerular filtration rate, plasma creatinine,
and blood urea nitrogen return to prepregnant levels by the second or
third month after childbirth. Urinary glucose excretion increases in
pregnancy by 100-fold over nonpregnant values. These values return
to nonpregnant levels after the first postpartal week. Pregnancy-
associated proteinuria is common during pregnancy and generally
returns to prepregnancy values by 6 weeks postpartum (Cunningham
et al, 2014).
During the postpartum period, rapid, sustained natriuresis
(excessively large amount of sodium in the urine) and diuresis occur
as the sodium and water retention of pregnancy is reversed. The
physiological reversal is particularly pronounced during the second to
fifth puerperal days. In most women, the body’s fluid and electrolyte
balance has been restored to a nonpregnant homeostatic state by
the third postpartal week.
After childbirth, a decrease in levels of oxytocin and estrogen
naturally occurs and contributes to diuresis. As the serum levels
decline, the diuresis becomes more pronounced. Nurses often note a
maternal urinary output that reaches 3,000 mL excreted in a 24-hour
period. For the postpartum patient, a single voiding may contain 500
to 1,000 mL of urine.
Respiratory System
Respiratory alkalosis and compensated metabolic acidosis occur
during labor and may persist into the postpartum period. In most
situations, however, after delivery of the placenta and the decline in
levels of progesterone, the respiratory system quickly returns to a
prepregnant state. In addition, the immediate decrease in intra-
abdominal pressure associated with the birth of the baby allows for
increased expansion of the diaphragm and relief from the dyspnea
usually associated with pregnancy. By the third postpartal week, the
respiratory system has returned to a prepregnant state.
Changes in the skin during pregnancy and in the postpartum period
are related to the major alterations in hormones. Women may
experience alterations in pigmentation, connective and cutaneous
tissue, hair, nails, secretory glands, and pruritus. Most pregnancy-
related skin changes disappear completely during the postpartum
period, although some, such as striae gravidarum (stretch marks),
fade but may remain permanently.
Although abdominal stretch marks (striae gravidarum) appear more
pronounced immediately after childbirth, they tend to fade over the
following 6 months. In light-skinned women, striae generally appear
pinkish; in dark-skinned women, they appear lighter than the
surrounding skin.
During pregnancy, the heart is displaced slightly upward and to the
left. As involution of the uterus occurs, the heart returns to its normal
position. Dramatic changes in the maternal hemodynamic system
result from the birth of the baby, expulsion of the placenta, and loss of
the amniotic fluid. These abrupt alterations can create cardiovascular
instability during the immediate postpartum period. Despite the usual
blood loss (500 mL with a vaginal birth; 1,000 mL with a cesarean
birth), the maternal cardiac output is significantly elevated above
prelabor levels for 1 to 2 hours postpartum and remains high for 48
hours postpartum. The cardiac output returns to prepregnant levels
within 2 to 4 weeks after childbirth.
On average, a 3-kg weight loss occurs during the first postpartal
week. Diuresis takes place between the second and fifth day. A major
fluid shift involves the movement of extracellular fluid back into the
venous system for excretion through urine and perspiration. If the
physiological diuresis does not occur, the risk of pulmonary edema
increases. The cardiac output and stroke volume remain elevated for
at least 48 hours after childbirth. Within 2 weeks, the cardiac output
has decreased by 30% and then reaches prepregnant values by 6 to
12 weeks postpartum in most women (Cunningham et al, 2014).
Immune System
The WBC count is slightly increased during labor and birth and
remains elevated during the early postpartum period, gradually
returning to normal values within 4 to 7 days after childbirth. During
pregnancy and the early postpartum period, women are
immunocompromised and at risk for acquired infections. If a mother
acquires an infection, she can pass it to her newborn, who is also
immunocompromised. Before discharge it is critical to determine
whether the mother is up-to-date with all recommended vaccines,
and if not she should receive them so that she doesn’t become
infected and pass the infections on to her newborn (Centers for
Disease Control and Prevention, 2019b).
Rubella Vaccine
Before discharge, the patient needs to be assessed for rubella
immunity. If nonimmune (rubella titer less than 1:8, or antibody-
negative on the enzyme-linked immunosorbent assay [ELISA]), the
MMR vaccine should be administered. The nurse should counsel the
patient about the need to avoid pregnancy for 1 month after receiving
the vaccine because of the teratogenic effects associated with
congenital rubella syndrome and advise her that she may briefly
experience rubella-type symptoms such as lymphadenopathy, muscle
aches, and a low-grade fever. The vaccine may be safely given to
breastfeeding mothers. A signed consent form must be obtained
before administration of the vaccine (Centers for Disease Control and
Prevention, 2019).
Rho(D) Immune Globulin

Nonsensitized women who are Rh(D)-negative and have given birth
to an Rh(D)-positive infant should receive 300 mcg of Rho(D)
immune globulin (RhoGAM) within 72 hours after giving birth.
RhoGAM should be given whether or not the mother received
RhoGAM during the antepartum period. In some situations,
depending on the extent of hemorrhage and exchange of maternal-
fetal blood, a larger dose of RhoGAM may be indicated.
Ovulation
During the postpartum phase, the return of ovulation and
menstruation varies according to the individual. Menstruation usually
resumes within 6 to 8 weeks after childbirth in women who are not
breastfeeding. Seventy-five percent menstruate by the 12th
postpartal week. The first cycle is often anovulatory. The return of
ovulation and menstruation is typically prolonged in lactating women.
Those who exclusively breastfeed may not ovulate or menstruate for
3 or more months. It is important to educate patients that, because
ovulation can precede menstruation, breastfeeding is not a reliable
method of contraception.
Because of hormonal effects, gastric motility is decreased during
pregnancy. It is further decreased during labor and in the first few
postpartal days because of decreased abdominal wall tone.
Abdominal discomfort results from gaseous distention related to
decreased motility and abdominal muscle relaxation. Constipation, a
common nursing diagnosis for the postpartal patient, is associated
with abdominal discomfort and decreased hunger. Straining to pass
hard stool can cause hemorrhoids and tear episiotomy sutures.
Although spontaneous bowel movements usually resume by the
second or third day after childbirth, it is important to educate the
patient about strategies to prevent constipation. Stool softeners may
be necessary. Additional nursing diagnoses for the postpartal patient
focus on a variety of other problems such as pain, fatigue, sleep
disturbances, infant feeding difficulties, and knowledge deficit.
During pregnancy, the pelvic joints and ligaments have increased
laxity. The hormones relaxin and progesterone are believed to
contribute to the relaxation of the soft tissues (muscles, ligaments,
and connective tissue) in the maternal pelvis to create room for the
birthing process. In some women, the loosening of the pelvic joints
causes pain and functional limitations.
During the first few days after childbirth, the woman may
experience muscle fatigue and general body aches from the exertion
of labor and delivery of the baby. Muscle fatigue can be exacerbated
by the extended lack of nutrition and fluids throughout the course of
labor. The maternal expenditure of glucose during parturition (the
act of giving birth) can also add to muscle fatigue and may interfere
with the patient’s ability to ambulate and initiate postpartum
exercises. The nurse needs to assure the patient that the muscular
discomforts are temporary and not indicative of a serious medical
problem.
During pregnancy, the abdominal walls are stretched to
accommodate the growing fetus. The progressive stretching causes
a decrease in the muscle tone of the rectus muscles of the abdomen
and results in the soft, flabby, and weak muscles experienced after
birth. Diastasis recti abdominis (abdominal separation) is a
conventional term used to define the separation between the two
rectus abdominis muscles that can occur from pregnancy (Fig. 11-7).
Women should be aware that, during the early postpartal period, the
abdominal wall may not be sufficiently protected to withstand
additional stress from increased activities. Nurses should teach them
to maintain correct posture when performing activities such as lifting,
carrying, and bathing the baby for at least 12 weeks after birth.
Performing modified sit-ups during this time is beneficial in helping to
strengthen the abdominal muscles.
DEVELOPING CULTURAL SENSITIVITY

Culturally competent care involves knowledge of the various
dimensions of care, including moving beyond the biomedical needs
of the patient. Rather, a holistic approach is one that expands
knowledge, changes attitudes, and enhances clinical skills. To
provide optimal care in a variety of clinical settings, it is important for
health-care providers to conduct cultural assessments and expand
their knowledge and understanding of culturally influenced beliefs,
common health-care practices, customs, and rituals. In preparation
for the cultural assessment, health-care providers should:
■ Assess their own cultural beliefs, identifying personal biases,
stereotypes, and prejudices.
■ Make a conscious commitment to respect and value the beliefs of
others.
■ Learn the customs and rituals of common cultural groups within the
community.
■ Seek input from patients regarding health-related traditions and
practices.
■ Evaluate if what is about to be taught is really better than what the
patient is already doing for herself.
■ Adapt care to meet the special needs of the patient and her family,
as long as standards of health and safety are not compromised.
■ Include cultural assessment as a routine part of perinatal health
care.
FIGURE 11-7 Diastasis recti abdominis A, Normal location of the

rectus muscles of the abdomen. B, Diastasis recti—there is
separation of the rectus muscles.
Clinical Implications of Culturally Appropriate Care

To provide sensitive, appropriate care, nurses need to adopt a
flexible approach when caring for women who embrace differing
health beliefs and practices. Inquiring about cultural beliefs and
incorporating the beliefs into the plan of care when possible are
important strategies to help achieve this goal. For example, to
demonstrate sensitivity to beliefs a client expresses about
temperature, the nurse may offer a warm sponge bath instead of a
shower, adjust the thermostat in the room and provide extra blankets
for warmth, offer warm drinks instead of cold beverages, and allow
female family members as much access to the mother as possible.
The nurse should help facilitate cultural practices for their patients
unless the practice poses a risk for the health and safety of the
mother or newborn (Suplee & Janke, 2020)
PROMOTING RECOVERY AND SELF-CARE IN

THE PUERPERIUM
Activity and Rest
In the postpartum period, it is important for the new mother to begin
ambulating as soon as her condition permits. Despite recent
advances in diagnosis and treatment, blood clots such as DVT and
pulmonary embolisms after birth remain a leading cause of maternal
mortality (Devis & Knuttinen, 2017). Venous stasis and
hypercoagulation, conditions that exist in pregnancy, continue into the
postpartum period. Early postpartum ambulation is key in preventing
maternal thromboembolic events, especially among women who had
a cesarean section and are at an increased risk for a blood clot.
The type of birth and overall health status determine how soon the
patient is allowed to resume exercise. The nurse should recommend
exercises depending on the patient’s previous exercise level. The
woman should be taught to begin with mild exercises, such as Kegel
exercises, to strengthen the pelvic floor muscles. Nonambulating
patients may begin with leg exercises. All exercise methods should
be increased gradually. Exercises that involve the abdominal muscles
should be held off until after 6 weeks and with approval from the
health-care provider, as the rectus diastasis may still be separated
and injury can result if exercises such as sit-ups are resumed too
early. Women should also be instructed of warning signs they may be
exercising too much, such as an increase or change in the color of
lochia (Suplee & Janke, 2020).
Sleep deprivation is a serious concern for many women in the
postpartum period. Many women enter labor fatigued from the
discomforts of pregnancy and lack of satisfying sleep associated with
the third trimester. The length of labor and demands of the new
mothering role further increase the feelings of exhaustion and the
need to feed the newborn during the night all can contribute to sleep
deprivation. During the hospital stay and later at home, all patients
should be encouraged to obtain adequate sleep and frequent rest
periods to help facilitate an optimal recovery. A woman should inform
her health-care provider about ongoing sleep disturbance, as this can
also be a sign of postpartum depression.
Nourishment
A weight loss of approximately 10 to 12 lb (4.5 to 5.5 kg) occurs
immediately after childbirth, and this amount is directly related to the
collective weights of the baby, placenta, and amniotic fluid. An
additional 5 lb (2.3 kg) is lost over the following week as a result of
puerperal diuresis and uterine involution. How quickly the woman
returns to her prepregnancy weight depends on her physical activity
level, eating habits, and lifestyle. In general, women whose weight
increase is within the recommended limit of 25 to 30 lb (11.4 to 13.6
kg) during pregnancy can anticipate a return to the prepregnancy
weight by 6 to 8 weeks postpartum. Factors associated with weight
changes during the postpartum period include gestational weight
gain, frequency of exercise, dietary intake, and breastfeeding for
longer than 1 year.
Because of the restriction of food during labor, most patients
demonstrate a hearty appetite after childbirth. All parturient women
should be encouraged to eat a balanced, nutritious diet with
multivitamin supplements. Iron is recommended only if the patient’s
hemoglobin is low.
Elimination
Voiding should occur within 4 hours of childbirth. Patients should be
encouraged to empty the bladder every 4 to 6 hours and should
expect to excrete large volumes of urine. In addition to the extra- to
intravascular fluid shift that follows childbirth, there is a decrease in
the production of the adrenal hormone aldosterone. Declining levels
of aldosterone are associated with a decrease in sodium retention
and an increase in urinary output.
An intake and output record should be maintained to monitor the
volume of urine passed during the first 24 hours. The woman who
has recently given birth is prone to urinary stasis and retention.
Incomplete bladder emptying or urinary retention may result from
trauma to urethral tissue sustained during the “pushing phase” of a
vaginal birth. Also, patients who were catheterized or received
regional anesthesia during childbirth sometimes experience an
absence of the sensation to void. Bladder hypotonia during labor may
also lead to postpartal urinary retention or stasis, factors that
increase the risk of infection.
Incomplete emptying of the bladder is suspected when the patient
experiences urinary frequency and passes 100 to 150 mL of urine
with each voiding. The nurse’s assessment includes careful palpation
of the lower abdomen to identify a distended or displaced uterus. The
uterine fundus is felt above the symphysis pubis with a lateral
displacement of the uterus. The nurse also notes an increase in the
amount of lochia because the uterus is unable to contract effectively.
The bladder is displaced, bulges above the symphysis pubis, and
feels “boggy” on palpation. Patients experiencing urinary retention
because of absence of the urge to void can be helped by assisted
early ambulation to the toilet and other measures such as running the
water from the lavatory faucet. If ambulation is not possible, the
nurse can pour warm water over the vulva and perineal area to help
relax the urethral sphincter. Because of the risk of urinary infection
associated with urinary stasis, catheterization may be necessary if
the patient is unable to void.
Constipation commonly occurs because of slowed peristalsis
associated with pregnancy hormones and childbirth anesthesia. In
addition, perineal discomfort, fear of suture separation at the
episiotomy site, and incision pain after a cesarean birth may
contribute to decreased frequency in bowel movements. To prevent
constipation, nurses should encourage patients to consume foods
high in fiber and roughage. Adequate fluid intake that includes
drinking at least six to eight glasses of water or juice daily is another
important strategy to prevent constipation. Early ambulation is also
encouraged to improve peristalsis and relieve abdominal gas pain. If
these measures are not effective, the primary care provider may
prescribe a stool softener, suppository, or enema to alleviate the
symptoms.
Perineal Care
The perineum is susceptible to infection because of impaired tissue
integrity resulting from bruising, laceration, or an episiotomy. The
proximity of the perineum to the anus increases the risk of the
incision becoming contaminated with fecal material; continuous
drainage of blood creates a favorable medium for the proliferation of
bacteria. To minimize infection, patients should be taught about
perineal hygiene. A teaching approach that incorporates a return
demonstration, encouragement, and positive reinforcement is most
likely to be successful. Instructions should be given about properly
cleansing the perineal area and the value of sitz baths, which not
only cleanse but also provide relief from discomfort during the first 24
to 48 hours postpartum.
Patients should be educated about the importance of cleansing the
perineum after each voiding and bowel movement. Hand washing
before and after perineal care (“pericare”) is essential for the
prevention of infection. The nurse instructs the patient to gently rinse
her perineum with fresh warm water after use of the toilet and before
a new perineal pad is applied. The patient is taught to fill the
peribottle (handheld squirt bottle) with warm tap water and gently
squirt the water toward the front of the perineum and allow the water
to flow from front to back. Consistent use of the peribottle is soothing,
cleansing, and helps to relieve discomfort. Peripads should be
changed often and secured in the underwear to allow for free
drainage of the lochia. Tampons are contraindicated because of the
risk of infection.
The nurse provides pericare for patients recovering from cesarean
births until they are ambulatory and able to perform personal self-
care. To provide pericare for the bed-bound patient, a plastic-covered
pad is placed under the patient’s buttocks to protect the bed during
the procedure. With the woman in a supine position, the nurse
carefully removes the perineal pad in a front-to-back direction. This
prevents the portion of the pad that touched the rectal area from
sliding forward and contaminating the vagina. Next, a bedpan is
positioned under the buttocks. The movement associated with lifting
the buttocks helps to expel clots and/or pooled blood in the vaginal
canal. This also serves as a good time to assess the fundus for tone.
Uterine palpation may be beneficial in helping the patient expel
additional blood or clots. The nurse uses a peribottle filled with warm
water (or other solution used according to hospital policy) and gently
squirts the perineum from front to back while allowing the water to
collect in the bedpan. The labia are not separated because they
prevent the solution from entering the vagina. The perineal area is
then gently dried and a clean peripad is applied from front to back.
Patient Education
Teaching About Perineal Care
To enhance the patient’s understanding about proper perineal care, the nurse
provides the following instructions:
1. First perform hand hygiene and wash your hands.
2. Fill the squeeze/peribottle with tap water. The water should feel comfortably
warm on your wrist.
3. Sit on the toilet with the bottle positioned between your legs so that water can
be squirted directly on the perineum. Aim the bottle opening at your perineum
and spray so that the water moves from front to back. Do not separate the
labia and do not spray the water into your vagina. Empty the entire bottle
over the perineum—this should take approximately 2 minutes.
4. Gently pat the area dry with toilet paper or cotton wipes. Move from front to
back, use each wipe once, then drop it in the toilet.
5. Remove the old perineal pad and note the amount and color of lochia and
discard.
6. Grasping the bottom side or ends of a clean perineal pad, apply it from front
to back.
7. Stand before flushing the toilet to prevent the water from the toilet from
spraying onto your perineum.
To reduce perineal swelling and pain that result from bruising, ice
packs may be applied every 2 to 4 hours. Application of cold is
beneficial because of its vasoconstriction and numbing effects. The
ice pack should always be covered and applied from front to back. It
should be left in place for no longer than 20 minutes to minimize the
complications associated with prolonged vasoconstriction. Patients
obtain the most relief when ice packs are applied within the first 24 to
48 hours after childbirth.
CARE OF THE POSTPARTAL SURGICAL PATIENT
Permanent Sterilization (Tubal Ligation)
A postpartum tubal ligation is a procedure that blocks the fallopian
tubes to prevent the woman from becoming pregnant. When
requested, the procedure, called a minilaparotomy, is performed after
childbirth while the mother is still hospitalized. The size and position
of the uterus during the early puerperium facilitates the surgical
procedure. When a cesarean birth has been performed, the tubal
ligation may be done at the same time. Patients need to be informed
that, while it is typically considered to be a permanent form of fertility
control, there is a small chance that a future pregnancy may occur.
Patients scheduled for a tubal ligation receive nothing by mouth
(NPO) before the surgical procedure. If epidural anesthesia was used
for childbirth, the catheter is often left in place so that the patient can
be reanesthetized easily. When no epidural was previously placed,
general anesthesia will most likely be used during surgery.
Care of the Patient After Cesarean Birth

Nursing care of the postoperative postpartum patient is similar to the
care provided to all postoperative patients. The nurse must complete
the breasts, uterus, bladder, bowel, lochia, and episiotomy (BUBBLE-
HE) assessment previously discussed. Because the woman is
confined to bed until full sensation has returned to the lower
extremities, interventions for the prevention of DVT must be
implemented. Preventive strategies include leg exercises (flexion and
extension of the knee) and the application of graduated compression
stockings or use of an intermittent pneumatic compression device as
ordered by the physician.
How the patient reacts to her surgery is often tied to the
circumstances surrounding the birth—that is, whether the cesarean
section was a planned procedure or an emergency event. Women
who experience an emergency or unplanned cesarean birth may feel
extreme disappointment, inadequacy, guilt, and personal failure. They
may also harbor hostilities directed toward the medical and nursing
staff.
For women with unplanned or emergent cesarean deliveries, the
experience of cesarean birth may be associated with more negative
perceptions of the birthing experience. In efforts to promote mother-
infant bonding, efforts should be made to provide reunification as
soon as possible after the birth, including skin-to-skin with the mother
or partner if the mother is unable.
The benefits of maternal-child interaction during the early
postpartal hours are well documented. The first few hours after
childbirth are a critical time for the initiation of a healthy maternal-
infant interaction. For most mothers, a successful vaginal birth is
psychologically better tolerated and prevents the need for additional
recovery time that is necessary after a cesarean birth. In addition,
early breastfeeding for those who wish to breastfeed is more easily
implemented after a vaginal birth.
Additional challenges faced by patients during recovery from a
cesarean birth include recovery from the anesthesia, a need to cope
with incisional and gas pain, and slow ambulation. Mother-infant
bonding may be delayed, and patients are at an increased risk for
hemorrhage, surgical wound infection, urinary tract infections (UTIs),
and DVT. (See Chapter 12 for additional information.)
Recovery From Anesthesia

Recovery from anesthesia will depend on the type of anesthesia
used. For a spinal or epidural anesthesia, common side effects
include paresthesias (sensation of pins and needles in the legs) and
headache. Sensation to the legs will resume when the anesthesia
wears off, and it is critical that the patient doesn’t get out of bed until
full sensation is resumed. The nurse can assist this by asking the
patient while in bed to bend both knees and have the bottom of the
feet rest on the bed, and while in this position the patient is asked to
lift her buttocks off the bed (Suplee & Janke, 2020). If she can
complete this task and feels full sensation, it is safe to attempt to get
out of bed. Assistance is required when the patient gets out of bed for
the first time with the nurse standing by the patient’s side to support
her. Nurses should administer pain medication 30 minutes before the
patient attempts ambulation. To minimize dizziness from orthostatic
hypotension, the nurse should instruct the patient to sit on the side of
her bed for several minutes before moving into a standing position.
Early ambulation is encouraged and the nurse should work with the
patient to ambulate as soon as she is ready.
Abdominal Distention
Abdominal distention and gas pains are common after abdominal
surgery and result from delayed peristalsis. Breakdown of digested
food in the colon produces a buildup of gas that results in distention
and discomfort. Anesthesia also causes a delay in the return of
peristalsis, and it usually takes several days for the intestinal function
to return.
Until bowel sounds are present, the nurse should offer the patient
ice chips and small sips of water only. The diet is slowly advanced as
tolerated. To minimize gas pains and stimulate the return of
peristalsis, frequent ambulation is encouraged.
Urinary System
An indwelling Foley catheter connected to a closed drainage system
remains in place for approximately 24 hours after a cesarean birth.
While the catheter is in place, the nurse must assess for urine output
of at least 150 mL/hr and maintain appropriate perineal care to
reduce the risk of UTI. Once the catheter has been removed, the
patient is at risk for urinary retention, and her output must be closely
monitored. The nurse can help facilitate the return of normal voiding
patterns by encouraging early ambulation to the toilet, ensuring
privacy, allowing water to run in the lavatory, and pouring warm water
on the perineum. If the patient is unable to void within 6 hours, a
diagnosis of urinary retention should be considered and
catheterization may be necessary.
Care of the Incision Wound

The surgical incision requires ongoing nursing assessment after a
cesarean birth. A sterile dressing is applied to the incision in the
operating room and left on for 24 hours, and usually the surgeon or a
member of the surgical team removes the first dressing. All
subsequent dressings are then changed by the nurse. During the first
24 hours, the nurse is assessing the dressing to be intact and noting
if there is a seepage or leaking of blood or bodily fluids. If seepage or
leaking of blood or bodily fluids is observed, the nurse will need to
closely monitor this by outlining the perimeter of the area with the
time and date and notifying the physician. When the nurse does
change the dressing, they should assess for redness, edema,
ecchymosis, drainage, the intactness of stables or sutures, and any
warmth, edema, and unusual tenderness.
EDUCATING PARENTS TO MAKE INFORMED

INFANT NOURISHMENT CHOICES
Holistic care during the puerperium includes educating women and
their partners about infant nutrition and providing support to facilitate
success with the feeding method chosen. By the time they enter the
postpartum phase of childbearing, most women have already
decided about infant feeding. Providing current, evidence-based
information; offering clinical guidance; and identifying appropriate
resources when needed empowers patients to achieve success in
nourishing and nurturing their newborn. The World Health
Organization recommends exclusive breastfeeding with no
supplements for the first 6 months of life (World Health Organization,
2018).
Breastfeeding, a vital preventive health practice, has long been
established as the optimal method of infant feeding, and current
trends are reflective of the public’s awareness of its value. Today,
more women in the United States are breastfeeding their babies than
at any time in modern history. While the rate of breastfeeding has
increased in all demographic groups, certain populations of women
are less likely to breastfeed. These include women between ages 20
and 29; non-Hispanic black women; and women who participate in
the Special Supplemental Nutrition Program for Women, Infants, and
Children (WIC) (Centers for Disease Control and Prevention, 2019a).
Human breast milk is the ideal infant food choice. It is
bacteriologically safe, fresh, readily available, and balanced to meet
the infant’s needs. When discussing infant feeding options with
parents, nurses can share factual information about the physiological
and psychological benefits of breastfeeding (Box 11-2).
There are economic benefits as well. Breastfeeding reduces the
cost of feeding and preparation time. Providing such information may
reinforce the mother’s decision to breastfeed or help women and their
partners in the decision-making process. The partner’s level of
support with the infant feeding method is an important factor in the
woman’s decision and success. Breastfeeding is contraindicated only
in a few situations:
■ Infants with galactosemia (because of an inability to digest the
lactose in the milk)
■ Mothers with active tuberculosis
■ Mothers with HIV, unless the risk of not breastfeeding and infant
malnutrition outweigh the risk of HIV transmission
■ Mothers with Hepatitis B or Hepatitis C
■ Mothers who use illicit drugs such as cocaine or amphetamines
■ Mothers with active herpes lesions on the nipples
■ Mothers with suspected or confirmed Ebola
■ Mothers who are receiving certain medications, such as lithium or
methotrexate
■ Mothers who are exposed to radioactive isotopes (e.g., during
diagnostic testing)
■ Infant is diagnosed with galactosemia
BOX 11-2
Selected Breastfeeding Benefits

FOR MOTHERS
• Decreased risk of breast, ovarian, and uterine cancer
• Decreased risk of type 2 diabetes mellitus
• Enhanced involution (caused by uterine contractions triggered by the release
of oxytocin) and decreased risk of postpartum hemorrhage
• Enhanced postpartum weight loss
• Enhanced bonding with infant
• Less expensive than formula feeding
FOR INFANTS
• Enhanced immunity through the transfer of maternal antibodies; decreased
incidence of infections including otitis media, respiratory infections,
pneumonia, urinary tract infections, gastrointestinal infections, and necrotizing
enterocolitis, bacteremia, and bacterial meningitis
• Enhanced maturation of the gastrointestinal tract
• Decreased risk of sudden infant death syndrome (SIDS)
• Decreased likelihood of developing insulin-dependent (type 1) diabetes
• Decreased risk of asthma
• Decreased risk of childhood obesity
• Decreased pain during procedures such as injection
Source: AWHONN (2015); Centers for Disease Control and Prevention (2019);
Lavallee & Scannell (2017).
Despite knowledge of the benefits of breastfeeding, some women
choose to formula feed. Concerns about convenience, opportunity to
involve the father in the baby’s care, modesty embarrassment,
previous negative experiences with breastfeeding, and cultural
factors can influence the mother’s decision. Some women anticipate
that breastfeeding will interfere with plans to return to work. Whatever
the reasons, the nurse must provide information and support in a
caring, nonjudgmental manner. Postpartal women who planned to
bottle-feed may still benefit from education about the benefits of
breast milk over formula. The nurse’s offer of breastfeeding support
and assistance may encourage some women to change their chosen
feeding method. The importance of the nurse’s role in the promotion
of breastfeeding has been underscored in an Association of Women’s
Health, Obstetric and Neonatal Nurses 2015 clinical position
statement.
The Physiology of Lactation

Lactogenesis, the process by which the breasts secrete milk,
depends on the release of the hormones prolactin and oxytocin. The
process of milk synthesis begins after the delivery of the placenta.
This event results in a dramatic decrease in plasma progesterone
and estrogen and an increase in the secretion of prolactin from the
anterior lobe of the pituitary gland. Prolactin stimulates the alveoli, or
milk-producing cells, to secrete milk. Stimulation from infant suckling
or pumping the breasts triggers the release of oxytocin from the
posterior lobe of the pituitary gland. Oxytocin prompts contraction of
the smooth muscle myoepithelial cells surrounding the alveoli to eject
milk from the alveoli into the lactiferous (main) ducts (Fig. 11-8).
Movement of milk into the large lactiferous ducts for removal is
called the milk ejection reflex or the let-down reflex. Lactating
mothers describe let-down as a tingling or pins and needles
sensation that occurs immediately before or during breastfeeding.
Not all women will experience the let-down effect, especially those in
pain or who have high levels of stress. Some women will need to
implement additional strategies such as frequent stimulation of the
breast, increased frequency of feedings, applying warmth to the
breast, and listening to relaxation music to increase the release of
oxytocin (Suplee & Janke, 2020).
The initiation of milk production occurs in three stages. Stage 1
occurs in late pregnancy and is characterized by the maturation of
the alveoli, the proliferation of the secretory alveoli ductal system,
and the increase in size and weight of the breast. Stage 2 begins
during the postpartum period. The transition from colostrum (a sticky
white-yellow fluid secreted by the breasts before the breast milk
comes in) to mature milk occurs approximately 30 to 40 hours after
birth, which allows time for secretory immunoglobulin (IgA) and other
protective proteins present in the colostrum to coat the neonate’s
gastrointestinal and respiratory tracts. Reduced plasma progesterone
levels lead to an increase in prolactin levels that cause a copious milk
production by the fourth to fifth postpartal day. Stage 3, the
establishment and maintenance of the milk supply, is governed by a
principle of “supply and demand” and continues until breastfeeding
ceases. The “weaning” stage, sometimes referred to as “Stage 4,”
begins when breast stimulation ceases. This stage is characterized
by a significant reduction in milk volume (Stuebe, 2014).
FIGURE 11-8 Mechanism for milk production.
A lack of breastfeeding in breastfeeding or nonbreast-feeding

mothers or a failure to empty the breasts by pumping results in an
accumulation of inhibiting peptides, or hormones released from the
hypothalamus. Inhibiting peptides act on the breast secretory cells,
causing a gradual decrease in milk volume and the eventual death of
the epithelial cells.
Strategies for Breastfeeding Success

Providing assistance to a mother soon after the birth of the newborn
is essential in successful breastfeeding. The WHO recommends
counseling during pregnancy and postpartum with at least six
counseling sessions with a health-care provider who is
knowledgeable in breastfeeding, which has been shown to improve
breastfeeding success (WHO, 2018). When the baby is feeding at the
breast, the woman should experience a strong tugging sensation and
occasional mild discomfort. However, pain associated with
breastfeeding is not a normal finding. The nurse should refer women
who experience breastfeeding pain or other difficulties to an IBCLC
for help and assistance.
Although the pediatrician is responsible for the health care of the
infant, the IBCLC is a lactation expert who offers the most current,
up-to-date, accurate information on breastfeeding using a “hands-on”
approach. Mothers should be encouraged to consult with an IBCLC
when they have any questions, are having difficulty with the latch-on
process, or express concerns about their milk production. Ideally, all
breastfeeding mothers should be discharged with an appointment to
an IBCLC.
Partnering With an IBCLC and Other Community Resources
IBCLCs are certified by the International Board of Lactation Consultant
Examiners Inc. under the direction of the U.S. National Commission for
Certifying Agencies. These professionals work in a variety of health-care
settings including hospitals, pediatric offices, public health clinics, and private
practice. The IBCLC credential is primarily an add-on qualification that brings
together health professionals from different disciplines who share a common
knowledge base in human lactation. Among those who become IBCLCs are
certified nurse-midwives, nurses, nurse practitioners, family practitioners,
pediatricians, obstetricians, educators, dietitians, and occupational, speech, and
physical therapists. Most of these professionals have spent at least 4 years
acquiring the experience and education required for certification.
Many government-sponsored health programs such as WIC provide
breastfeeding support services that are staffed by breastfeeding peer
counselors. A mother who indicates that she is breastfeeding and is part of the
WIC program will be provided with a special food package for herself and her
newborn. The La Leche League, an international support organization for
breastfeeding mothers, is another resource that may be available in the
community.
Patient Education
Care of the Breasts During Lactation
The nurse should teach breastfeeding mothers to wash the nipples with warm
water. Soap, which can have a drying effect and cause cracked nipples, should
be avoided. Breast creams are also to be avoided. They may block the natural
oil secreted by the Montgomery tubercles on the areolae; others contain
alcohol, a drying agent. Creams or oils that contain vitamin E should also be
avoided because the infant may absorb toxic amounts of the fat-soluble vitamin.
The optimal time to breastfeed is within the first hour of birth if the
infant is stable and when the baby is in a quiet alert state (World
Health Organization, 2015). Crying is usually a late sign of hunger
and achieving satisfactory latch-on at this time is difficult. Latch-on is
proper attachment of the infant to the breast for feeding. The neonate
is most alert during the first 1 to 2 hours after an unmedicated birth,
and this is the ideal time to put the infant to the breast. The smell of
the amniotic fluid on the infant matches the smells of the mother and
serves as a “homing device” for the baby. The WHO recommends
skin-to-skin contact (Kangaroo care), which helps with breastfeeding
and provides a more stable temperature environment for the infant
(World Health Organization, 2015). Cesarean deliveries and
medicated births, including those with epidural anesthesia, may
require an immediate assessment of the infant as well as more time
with mother-infant skin-to-skin contact before a successful latch-on
occurs.
Optimizing Outcomes
Benefits of the Breast Crawl
The breast crawl (TBC) is the instinctive motions of the infant when placed skin-
to-skin on the mother immediately after birth and “crawl” their way to the breast
without assistance (Rogers, 2016). The primary benefit of TBC is the initiation
and establishment of effective breastfeeding. When the newborn is allowed to
breastfeed right after birth, feeding is more effective than if TBC is interrupted
before the first feeding takes place. When facilitated immediately after delivery,
TBC promotes the physical stabilization (i.e., temperature regulation, heart and
respiratory rates, and blood glucose) of the healthy newborn.
To assist the breastfeeding mother, the nurse must understand that

a baby latched-on to the breast is not necessarily transferring milk. A
baby that breastfeeds effectively cues (shows readiness) for
feedings, is in a good feeding position, latches-on (attaches) deeply
at the breast, and moves milk forward from the breast and into the
mouth. When the infant is properly latched-on to the breast, the tip of
their nose, cheeks, and chin should all be touching the breast (Fig.
11-9).
To feed effectively, the infant must awaken and let the mother know
that they want to eat. When possible, mother-baby rooming-in
creates an optimal situation for breastfeeding. When the infant is in
the mother’s room, she is able to observe cues that signal the infant’s
readiness to feed (Box 11-3).
FIGURE 11-9 Infant latch-on. A. Nipple is aligned with the baby’s
nose. B, C. As the baby latches-on to the nipple, the baby’s mouth is
placed 1 to 2 inches beyond the base of the nipple. D. To remove the
baby from the breast, the mother inserts her finger into the corner of
the baby’s mouth to break the seal.
BOX 11-3
Infant Feeding-Readiness Cues

The infant demonstrates readiness for feeding when they:
• Begin to stir.
• Bob the head against the mattress or mother’s neck/shoulder.
• Make hand-to-mouth or hand-to-hand movements.
• Exhibit sucking, licking, or smacking lips.
• Exhibit rooting.
• Demonstrate increased activity; arms and legs flexed; hands in a fist.
What to Say
To Assist the Mother Whose Infant Will Not Awaken to Breastfeed
During hospitalization, nurses provide much information and coaching regarding
breastfeeding. One new mother expresses her concern that her infant is too
sleepy to breastfeed. The nurse may ask:
• Have you tried to unwrap the baby’s swaddling? Doing this will increase skin-
to-skin contact and help to awaken the infant and promote feeding.
• Have you tried to rest with the baby by your breast? Doing this may allow the
infant to feel and/or smell the breast, which may promote feeding.
• Are you familiar with feeding cues? Watching for feeding cues may help you to
recognize when your baby is ready to breastfeed. Examples of infant feeding
cues are vocalizations, movements of the mouth, and moving the hand toward
the mouth. Hunger-related crying is a late sign of hunger and should not be
used as the cue for feeding.
An optimal breastfeeding experience begins with the mother’s

prompt response to her infant’s feeding readiness cues. The mother
should hold the baby so that their nose is aligned with the nipple and
watch for an open mouth gape. At the height of the gape, when the
mouth is open widest, the mother should aim the bottom lip as far
away as possible from the base of the nipple. With this action, the
infant’s chin and the lower jaw meet the breast first and the nipple is
pointed to the roof of the mouth. To facilitate a proper latch, the nipple
should align with the baby’s nose. This position allows the baby to tilt
their head upward slightly so that the chin and lower jaw drops,
creating the wide-open gape desired. Next, the infant’s mouth should
be placed 1 to 2 inches beyond the base of the nipple. Depending on
the areola size, most of the areola should be visible from the infant’s
top lip but not from the bottom lip. The top and bottom lips should be
flanged outward.
When properly positioned, there should be no slurping or clicking
sounds or dimpling of the cheeks. Also, the mother should report a
tugging sensation but no pain or pinching. If any of these are present,
the infant should be removed from the breast by instructing the
mother to insert her finger into the corner of the baby’s mouth to
break the seal. As an alternative, the mother can gently lift up and
push back on the baby’s upper lip.
NURSING INSIGHT
Assessing for Milk Let-down
The nurse assesses for cues that indicate that the milk let-down reflex has
occurred:
• The mother reports a tingling sensation in the nipples (not always present).
• The infant’s quick, shallow sucking pattern transitions to a slower, more
drawing pattern.
• The infant exhibits audible swallowing.
• The mother reports uterine cramping; increased lochia may be present.
• The mother states she feels extremely relaxed during the feeding.
• The opposite breast may leak milk.
Once the baby is latched-on correctly, they must suckle and

transfer milk. There should be a 2:1 or 1:1 suck/swallow ratio with
audible swallowing to indicate that milk transfer is occurring. A 5:1 or
higher suck/swallow ratio is indicative of nonnutritive suckling.
Nonnutritive suckling can result in poor milk supply and lead to poor
infant weight gain. Feedings that last less than 10 minutes or
continue for longer than 40 minutes are not satisfactory and require
consultation and assessment by a lactation consultant.
Optimal feeding results in the infant coming off the breast without
assistance. Once the feeding has ended, the infant should be in a
relaxed state with hands open; they may or may not be asleep. After
a successful breastfeeding experience, the infant should appear
satiated and sleepy. The nipple should be everted and round, never
flat or pinched on any side. The mother should report no pain, and
the infant should appear satiated.
Facilitating Breastfeeding in the Mother With a Physical Disability
Mothers with physical disabilities, especially those that affect the upper
extremities, may need special assistance and strategies for infant care and
breastfeeding. There are many challenges women with disabilities face, such as
being able to hold the infant for a certain length of time, finding the right position
for breastfeeding, need for early use of a breast pump, needing assistance from
others, issues with infant latching, and adequate milk supply (Powell et al,
2018). Interventions to facilitate breastfeeding include early contact with skilled
lactation consultants, occupational therapy consultants with relevant
experience, support systems, adaptive equipment such as the use of a
wheelchair lap tray for positioning the infant near the breast, and networking
with breastfeeding role models who also have disabilities (Powell et al, 2018).
Evaluation of Nourishment: Infant Weight Gain

All newborns are expected to lose weight during the early days of life.
A newborn who is feeding frequently and effectively in general may
lose an average of 5% of their birth weight. Infants who lose more
than 7% to 10% of the birth weight should be carefully evaluated to
make sure that they are being fed frequently enough and that the
feeding technique is effective in transferring milk from the mother’s
breast. An infant weight loss of greater than 7% to 10% is not an
“automatic” reason to supplement breastfeeding with formula. The
administration of formula may interfere with the baby’s interest in
feeding at the breast and their ability to learn appropriate
breastfeeding techniques. Nurses must evaluate the infant’s latch,
suck, and feeding frequency to determine whether there is adequate
feeding.
Because the infant is very efficient in removing milk from the
breast, frequent feeding (at least every 2 to 3 hours) is advised to
minimize the stasis of milk. The infant should feed at each breast at
least 15 to 20 minutes until at least one breast softens after the
feeding. To help reduce the swelling and enhance milk flow, the nurse
should instruct the mother to use warm compresses and perform
hand expression before nursing. This action softens the areola,
initiates the let-down reflex, and allows the infant to more easily
grasp the areola. Massaging the breasts during feedings is also
beneficial. Other methods to enhance milk flow and help facilitate
infant latch-on include taking a warm shower or leaning over a bowl
of warm water and hand-expressing some milk before nursing.
Because breast swelling is related to increased blood flow, cold ice
packs may be used after breastfeeding or pumping to constrict blood
flow and reduce the edema.
Once the mother’s milk production increases and the volume of
milk consumed increases, most infants begin to gain weight. The rate
of gain continues and is consistent for the first several months of life.
Loss of excessive weight or failure to begin a steady pattern of
weight gain indicates that the mother is not producing adequate milk,
the infant is not ingesting adequate milk, or, much less commonly, the
infant has other organic problems. In most instances, correcting
latch-on difficulties and proper positioning improve milk transfer from
the breast to the baby. As long as the baby continues to feed well and
is gaining weight, the mother can be reassured not to worry.
Positions for Breastfeeding

Common positions for nursing a baby include cradle hold, cross-
cradle hold, football, and side-lying (Fig. 11-10). In the cradle hold
position, the infant is cradled in the arm, close to the maternal breast.
The infant’s abdomen is placed against the mother’s abdomen with
the mother’s other hand supporting the breast. The cross-cradle hold
is similar to the cradle hold, although in this hold, the infant is laying
in the opposite direction. In the football hold, the infant’s back and
shoulders are held in the palm of the mother’s hand. The infant is
tucked up under the mother’s arm, keeping the infant’s hip, shoulder,
and ear in alignment. The mother supports the breast to touch the
infant’s lips. Once the infant’s mouth is open, the mother pulls the
infant toward the breast. In the side-lying position, both the mother
and the infant lay on their sides. Facing one another, the mother
should place a pillow behind the infant’s back for support. The nipple
should be placed within easy reach for the infant with the mother
guiding the nipple into the infant’s mouth.
FOCUS ON SAFETY
Safety During Breastfeeding
Because of reports of apparent accidental infant suffocation during side-lying
breastfeeding, frequent mother-baby checks during breastfeeding and skin-to-
skin interventions constitute important nursing actions. Also, the nurse should
ensure that a newborn is not left with a fatigued mother in a side-lying position
for prolonged periods.
FIGURE 11-10 Common positions for breastfeeding. A, Cradle hold
position. B, Football hold position. C, Side-lying position.
Optimizing Outcomes
Breast Shells for Flat, Inverted, or Sore Nipples

Breast shells, which are plastic nipple cups or inserts that fit into the bra, are
sometimes recommended for women with flat or inverted nipples because they
may help the nipples to become more protuberant. They may also be used to
prevent sore nipples from making contact with the woman’s clothing.
Breast engorgement, excessive swelling and overfilling of the

breast and areola, is a physiological response to an increase in blood
flow and milk production. Engorgement, which may occur from
infrequent feeding or ineffective emptying of the breasts, results in
congestion and overdistention of the collecting ductal system and
obstruction of lymphatic drainage. It typically lasts about 24 hours.
Symptoms of engorgement usually occur between the third and fifth
day after childbirth (when the milk “comes in”) and vary from
minimally engorged (patients complain of breast fullness and
discomfort) to severe engorgement, characterized by symptoms of
pain, tenderness, hardness, and warm to the touch. With severe
engorgement, swelling of the breasts is profuse and extends from the
clavicle to the tail of Spence (an extension of the tissue of the breast
that extends into the axilla) and the lower rib cage. The breasts may
have a shiny, taut appearance. The areolae become very firm, and
the nipples may flatten, making it difficult for the infant to latch on.
Back pressure exerted on full milk glands inhibits milk production.
Thus, if milk is not removed from the breasts, the milk supply may
decrease. Treatment involves relieving the patient’s discomfort by
removal of the milk (via breastfeeding or pumping) to decrease
stasis, which reduces the swelling and discomfort.
A nonprescription anti-inflammatory medication such as ibuprofen
(e.g., Motrin or Advil) may be taken for the pain and swelling related
to engorgement. It may be particularly helpful for the mother to take
the medication before breastfeeding in anticipation of postfeeding
discomfort. Because of the significant increase in breast size during
lactation, patients should be advised to wear well-fitting supportive
bras with no underwire for comfort. Bras that are too small may
compress the ducts and obstruct milk flow. If the infant is unable to
breastfeed, warm soaks, breast massage, and the use of a manual or
electric pump for milk expression help reduce milk stasis and
swelling.
Difficulty Feeding
Sometimes the infant may have difficulty feeding, especially in the
first 4 weeks when breastfeeding practices are being established.
The nurse should encourage the mother to continue breastfeeding
and provide additional strategies as needed. Some parents may
choose to supplement breastfeeding with bottle feeding. However,
studies have associated this practice with increased difficulty in
establishing good breastfeeding practices. Alternative methods can
include feeding a newborn with a cup, spoon, or even finger,
especially in the early days when there is colostrum, which can be
placed on the tip of the finger and inserted into the newborn’s mouth
(Suplee & Janke, 2020).
Collecting and Storing Breast Milk

Collecting and storing breast milk is a necessity for mothers who are
separated from their infants because of problems such as prematurity
or illness. Women who elect to return to school or work may wish to
have breast milk available for feeding by another individual. Freshly
pumped breast milk can be safely stored at room temperature 77°F
(25°C) for 4 hours or refrigerated at 40°F (4°C) for 4 days after
collection. Milk kept in a deep freezer at 0°F (–18°C) can be stored
for 6 to 12 months (CDC, 2020) (Table 11-7).
The oldest milk should be used first unless the pediatrician
recommends the use of recently expressed milk. Women should be
taught to thaw breast milk by placing the collection container in the
refrigerator. The thawing process may be accelerated by holding the
collection container under warm running water or by placing it in a
cup, pot, bowl, or basin of warm water. Breast milk should not be
allowed to thaw at room temperature, in very hot water, or in the
microwave oven. Microwaving the breast milk container can create
“hot spots” and use of the microwave oven or heating the container in
very hot water may decrease the milk’s anti-infective properties.
Breast milk separates during storage. The cream rises to the top
because breast milk is not homogenized. To mix the milk after
storage, the collection container should be gently swirled or rotated;
vigorous shaking should be avoided. After the feeding, any milk that
remains in the feeding container should be discarded and not saved
for a later feeding. Thawed milk should never be refrozen.
TABLE 11-7
Safe Breast Milk Storage
STORAGE LOCATION AND TEMPERATURES
Type of Breast Milk Countertop Refrigerator 40°F Freezer
77°F (25°C) or (4°C) 0°F (–18°C) or
colder colder
(room temperature)
Freshly Expressed Up to 4 Hours Up to 4 Days Within 6 months is
or Pumped best
Up to 12 months is
acceptable
Thawed, Previously 1–2 Hours Up to 1 Day (24 NEVER refreeze
Frozen Use within 2 hours hours) the baby is human milk after it
Leftover from a after finished feeding has been thawed
Feeding (baby did
not finish the bottle)
Source: Centers for Disease Control and Prevention (2020).

A variety of manual and electric breast pumps are available, and,
for most women, the choice is made according to needs,
preferences, and financial resources. Hospital-grade electric breast
pumps are designed for complete mother-baby separation. In these
situations, the infant will not be able to breastfeed for an
indeterminate period of time because of problems such as
prematurity, surgery, or illness. Hospital-grade electric pumps are
typically considered multiple-user rental equipment. Retail or
“personal use” electric breast pumps are excellent alternatives to the
rented hospital-grade pump (Fig. 11-11). These single-user electric
breast pumps usually work well for the working mother or in
situations in which consistent pumping is needed. Occasional-use,
battery-powered, or manual breast pumps are designed for the
mother who needs to have extra milk only once in a while.
Electric Expression of Breast Milk

Women should be encouraged (if able) to avoid pumping the breasts
until the infant is breastfeeding comfortably. Although the mother can
help her baby learn to take a bottle once breastfeeding has been
well-established, it is best to wait for 3 to 4 weeks before introducing
bottle feeding.
The nurse teaches the woman to use hot, soapy water to wash her
hands, all components of the breast pump that will touch her breasts,
and all collecting bottles before proceeding. Most equipment may
also be safely cleaned in an automatic dishwasher. If soap and water
are not available, many “quick clean” products may be safely used
instead. Collecting bottles should be allowed to air dry on a clean
towel.
The woman is encouraged to carefully read the instruction manual
and practice pumping when she is rested, relaxed, and her breasts
feel full. The nurse can teach employed mothers to begin to pump
and store breast milk 2 to 3 weeks before returning to work. The
breasts should be pumped once a day, every day. The first morning
pumping usually produces the largest quantity of milk. If possible, the
woman should nurse the baby on one breast while pumping the other
breast. The breast milk may be stored in the refrigerator or freezer.
The 7-day-a-week pumping schedule should continue even after the
woman has returned to work.
Many employed mothers use the fresh breast milk they pump while
at work for infant feedings the following day. For example, the breast
milk pumped at work on Monday should be refrigerated and used on
Tuesday. Mothers should be counseled to breastfeed the infant
before leaving for work and then adhere to a set schedule of pumping
and feeding each day. Breast milk collected (by pumping) on Friday
and Saturday can be frozen for future use. Ideally, mothers should
pump the breasts for each missed feeding, but two pumpings per
workday during an 8-hour work shift is realistic for most women. The
breasts should be pumped for 15 to 20 minutes or until the milk flow
stops. Breastfeeding should be resumed during the evening and
throughout weekends.
FIGURE 11-11 Personal use electric breast pump.
Optimizing Outcomes
Donor Breast Milk

Women who do not produce enough milk, are unable to breastfeed, or have
adopted an infant may choose to use pasteurized donor milk instead of formula.
Donor milk processed through a Human Milk Banking Association of North
America maintains many of the benefits of breastfeeding and is safer than
formula for preterm and low-birth-weight infants (Centers for Disease Control
and Prevention, 2019). Before donation, potential donors undergo serological
screening (e.g., HIV, Hepatitis B and C, syphilis, and human T-cell lymphotropic
virus) and complete an interview and lifestyle questionnaire to evaluate their
suitability. Although milk can be bought from the Internet, this is not
recommended as there is no guarantee that the milk has been screened, tested,
or processed according to national standards (Centers for Disease Control and
Prevention, 2019)
Infant Weaning
When a mother decides to wean the baby from the breast, she
should begin by eliminating one feeding at a time (Centers for
Disease Control and Prevention, 2019). If the infant is older than 12
months, he or she can be weaned to fortified cow’s milk. Infants
younger than 12 months must be weaned to formula (CDC, 2019).
After a few days, an alternate feeding time (not the one immediately
before or after the one already discontinued) may be eliminated.
Mothers should be advised to carefully observe the baby for signs of
emotional or physical reactions (e.g., cow’s milk allergy if formula is
introduced). Infants sometimes choose to stop nursing, although this
does not usually occur with infants younger than 12 months.
What to Say
Tobacco, Alcohol, and Breastfeeding
When asked about caffeine, alcohol, and breastfeeding, the nurse can offer the
following information (CDC, 2019). The CDC recommends that all women who
use tobacco products should quit and for women not to consume alcohol while
drinking. However, if women do use tobacco products or consume alcohol, the
following talking points can assist the nurse in having conversations about these
substances.
• Nicotine will be transferred into breast milk, and the mother can reduce or limit
infant exposure by reducing the amount of tobacco used, reducing exposure
to secondhand smoke, and not smoking around the infant.
• Alcohol does pass through you to your breast milk and reaches its highest
level 30 to 60 minutes after consumption.
• Alcohol does not improve the quality or the quantity of your breast milk.
• Neither you nor your baby receives any sleep benefits when you drink alcohol.
• The amount of alcohol you drink may be more than you realize because the
alcohol content of drinks may vary dramatically.
• If you wish to go out and drink alcohol, you may pump and store your breast
milk beforehand so that it will be available when you return home.
• Women should wait 2 hours after drinking before breastfeeding an infant.
Assisting the Mother Who Chooses to Formula-Feed

Information regarding formula choices should be offered to mothers
who choose not to breastfeed. Formula preparations come in ready-
to-feed cans that can be poured directly into a bottle, liquid
concentrates that require dilution before feeding, and powder
formulas that are mixed with water. When counseling parents about
formula preparation, stress that all water used must come from a safe
and tested source. Water obtained from rural wells may be
contaminated with nitrates (from fertilizer) or bacteria that can cause
significant infant morbidity. Also, boiling well water does not ensure
its safety; boiling causes the nitrates (if present) to become more
concentrated.
Optimizing Outcomes
Reducing the Likelihood of Formula-Related Fluorosis

Community water fluoridation is widely used to prevent and control tooth decay.
According to the CDC (2013), fluoride intake from water and other fluoridated
substances (e.g., toothpaste and mouth rinses) during tooth development (from
birth through age 8) can result in changes in the appearance of the tooth’s
surface, a condition known as “dental fluorosis.” In the United States, most
dental fluorosis is mild and appears as faint white lines or spots on the
permanent teeth. Recent evidence suggests that regularly mixing powdered or
liquid infant formula concentrate with fluoridated water may increase the chance
of mild enamel fluorosis. To reduce the likelihood of dental fluorosis, nurses can
teach parents to use low-fluoride bottled water (labeled as “deionized,” “purified,”
“demineralized,” or “distilled”) some of the time to mix the infant formula.
A variety of bottles and nipples are also available, and selection is

usually based on the parent’s preference. For example, the mother
may choose from glass bottles or plastic bottles with angled or
straight nipples or convenience bottles with disposable liners. Nurses
can assist parents in making informed decisions about a bottle/nipple
system by suggesting that they gather enough information to
consider the evidence critically and realize that no one product is
best. The nurse should remind the parents to periodically check the
nipple integrity to ensure that the formula flows freely one drop at a
time. If the formula flows too quickly, the nipple should be discarded
because it poses a risk for infant choking and aspiration.
Parents should also be advised to read and follow the
manufacturer’s instructions explicitly when preparing the formula. For
example, no water should be added to the ready-to-feed
preparations, and care should be taken to correctly dilute the
concentrate and powder preparations. Poorly prepared formula that
is too concentrated from adding an incorrect amount of water may
result in infant hypernatremia and dehydration. Formula that is too
dilute may cause the infant to demonstrate symptoms of
undernourishment and water intoxication.
Bottles and nipples must be thoroughly washed in hot, soapy water
with dishwashing detergent and then rinsed in hot, clean water. They
may also be cleaned in an automatic dishwasher. Some parents
prefer to sterilize their equipment, and a variety of commercial
sterilizers that can be placed in a microwave oven are available for
purchase at most baby stores. If boiling is the preferred cleaning
method, parents should be instructed to wash the bottles, nipples,
rings, discs, and all other equipment used to prepare the formula in
hot soapy water. The items are then well rinsed in hot, clean water;
placed in a pot filled with enough water to cover the equipment; and
boiled for 5 to 10 minutes.
Although formula can be fed to the baby at room temperature, if
warmed formula is preferred, the parents are instructed to place the
prepared bottle of formula in a bowl of hot (not boiling) water for a
few minutes. Alternatively, the prepared bottle of formula can be
warmed in an electric bottle warmer available at most baby stores. It
is important to emphasize to parents the need for testing the
temperature of warmed formula before feeding. Parents are
instructed to shake a few drops of formula on the inside of the wrist.
The liquid should feel warm but not hot.
When feeding the baby, parents should choose a comfortable chair
and hold the baby in their arms close to them with the baby’s head
higher than the rest of the body to prevent aspiration and minimize
ear infection (Fig. 11-12). Holding the baby skin-to-skin and
maintaining full eye contact throughout the feeding helps facilitate the
bonding process. To prevent the baby from swallowing too much air,
the bottle should be kept in an angled position with the nipple
continuously filled with formula. Burping is usually performed midway
and at the end of the feeding to remove excess air from the infant’s
stomach. To burp the baby properly, parents are taught to either hold
the baby over their shoulder or on their lap with the baby’s head
supported. The baby’s back is gently rubbed until air is expelled (Fig.
11-13).
Parents should be advised that babies usually spit up during
burping and that this is normal regardless of whether the infant is
breastfed or bottle-fed. However, the pediatrician must be consulted if
the baby vomits a large amount of formula with burping or after
feeding. Because babies eat more efficiently and take in the desired
amount of formula when they are hungry, a “baby-driven” demand
feeding schedule rather than a regimented feeding schedule is
desirable. The pediatrician can provide guidelines regarding the
volume of formula the baby needs.
FIGURE 11-12 When formula feeding, parents should choose a
comfortable chair and hold the baby close with the head higher than
the rest of the body to prevent aspiration.
FIGURE 11-13 One infant burping technique.
PROMOTING FAMILY AND INFANT BONDING

Bonding is described by Klaus (1982) as the promotion of a unique
and powerful relationship between the parent and the infant.
Attachment refers to the tie that exists between the parent and infant
and is recognized as a feeling that binds one person to another.
Bonding begins at the moment the pregnancy is confirmed and
continues through the birth experience, during the postpartal period,
and throughout the early years of the child’s life. Bonding is critical for
the infant’s survival and development. Providing parents with a model
of caring during labor, birth, and in the early postpartum period
enhances the bonding process and helps to lay the foundation for the
nurturing care that the child will later receive.
Facilitating the Transition to Parenthood

The transition to parenthood can be an especially difficult and
challenging time for primiparous mothers with limited experience in
infant care and for new parents who are experiencing social isolation
from family or friends. Feelings of anxiety and inadequacy regarding
parenting skills, lack of knowledge and confidence about providing
baby care, emotional concerns, depression, and detachment toward
the infant are all symptoms not infrequently expressed by first-time
mothers. This information underscores the importance patients place
on nurses and other health-care professionals to provide emotional
support and accurate information about self-care and baby care.
An essential goal of nursing care at this time is to create a
supportive teaching environment that increases the parents’
knowledge and confidence in caring for themselves and their infants.
Using the principles of family-centered care as a guide, nurses can
help parents cope with the emotional and physical changes that
accompany the childbearing years. To create a supportive teaching
environment, the nurse can:
■ Perform a needs assessment to identify the parents’
knowledge/skill deficits.
■ Use good communication and listening skills to provide support.
■ Empower the parents by assisting them in recognizing their own
strengths.
■ Facilitate parents’ actions to participate in the decision-making
process.
■ Provide learning opportunities that move the parents from
dependence to independence and self-reliance.
The nurse can also teach the parents about bonding behaviors.
“En face” (face-to-face) is a position in which the mother’s face and
the infant’s face are approximately 8 inches apart and on the same
plane. Research shows that mothers seek eye-to-eye contact and
that they instinctively move the baby to an en face position (Fig. 11-
14). New fathers exhibit signs of intense interest and absorption in
their newborn. These behaviors have been identified as
“engrossment.” Engrossment has been defined as an absorption,
preoccupation, and interest in the newborn, and new fathers can be
observed gazing at their infants for prolonged periods of time, as if
they are in a hypnotic trance (Greenberg & Morris, 1974) (Fig. 11-15).
Assumption of the Maternal Role

Rubin (1975) described three distinct phases that are associated with
the woman’s assuming the mothering role. She labeled these phases
“Taking-in,” “Taking-hold,” and “Letting-go” (Table 11-8). At the time of
Rubin’s work, women were traditionally hospitalized for 5 to 7 days
after childbirth, and nurses could readily observe their patients’
transitions through each phase. Today, however, with shortened
hospital stays, women seem to move through the transitions much
more rapidly, and phases often overlap.
FIGURE 11-14 Mother and son engaged in en face position.

FIGURE 11-15 By gazing intently at his new son, a father exhibits a
sign of engrossment.
In the first day or two after birth, the mother is exhausted and
should be encouraged to rest. During this time she is reflecting on
and clarifying, or “taking-in,” her birth experience. Many mothers want
to talk about their labor, discuss with family members the detailed
events of the labor, seek clarification if unexpected events occurred,
and share joys or disappointments associated with the birth. Mothers
who hold specific expectations for their birth experience and are
unable to follow a birth plan or who are required to transfer from a
birth center to a hospital setting may experience feelings of loss and
mourn for the hoped-for birth experience.
As the mother’s physical condition improves, she begins to take
charge and enters the taking-hold phase where she assumes care for
herself and her infant. At this time, the mother eagerly wants
information about infant care and shows signs of bonding with her
infant. During this phase, the nurse should closely observe mother-
infant interactions for signs of poor bonding and implement actions to
facilitate attachment where needed.
Touch is recognized as an important communication tool between
humans. Touch is an essential element in the creation of a loving
relationship and lasting attachment between the parents and their
child. Nurses can be instrumental in enhancing the bonding process
by minimizing the time that the infant is separated from the mother.
Fostering a positive mother–child relationship begins in the
delivery/birthing room when the infant is placed directly on the
mother’s chest and is held skin-to-skin. The nurse should encourage
the mother to initiate breastfeeding and early eye contact during the
first 30 minutes after childbirth when both the mother and her baby
are alert. This special quiet time provides an opportunity for
connecting and communicating with one another. Early initiation of
breastfeeding for mothers who wish to breastfeed and utilizing a
rooming-in protocol are important nursing interventions that
contribute to a positive maternal-child relationship (WHO, 2018).
Assessment Tools
Assessing for Maternal–Infant Attachment
When observing the mother with her newborn, the nurse should look for clues
that indicate successful bonding. The nurse should assess for the following
indicators:
• Does the mother seem eager to care for her infant?
• Is the mother touching her baby, making skin-to-skin contact?
• What is her response when the baby cries?
• Does she make eye contact when holding and feeding her baby?
• Does the mother show warning signs of appearing dazed or detached?
In the letting-go phase, seen later in the mother’s recovery, the woman begins
to see the infant as an individual separate from herself. At this point, she can
leave the baby with a sitter, set aside more time for herself, become more
involved with her partner, and begin adapting to the realities of parenthood.
Maladjustment during this phase may occur with an overprotective mother who
has difficulty accepting help with infant care from others and who excludes the
partner from her affections.
TABLE 11-8
Phases Associated With the Mothering Role
PHASE 1: TAKING-IN PHASE 2: TAKING-HOLD PHASE 3: LETTING-GO
FIRST I-2 DAYS SECOND AND/OR THIRD FIRST 2–6 WEEKS
DAY POSTPARTUM
The mother is recovering The mother starts to This is the time during
from the immediate initiate action and to begin which the mother redefines
exhaustion of labor. some of the tasks of her new role.
motherhood. She may: She:
She is relatively 1. Ask for help with self- 1. Moves beyond the
dependent on others to care mother-infant symbiosis of
meet her physical needs. 2. Begin caring for the pregnancy and early
Characteristics of her baby postpartum and begins to
behavior include 3. Be anxious about her see her infant as an
mothering abilities emerging individual
1. Physical exhaustion 2. Starts to focus on issues
2. Elation, excitement, larger than those
and/or anxiety and associated directly with
confusion herself and her newborn
3. Reliving, verbally and (She begins to focus on her
mentally, the events of her partner, other children, and
labor and birth family issues.)
Source: Adapted from Rubin R. (1975). Maternal tasks in pregnancy. MCN: The
American Journal of Maternal-Child Nursing, 4(3), 143-153.
Optimizing Outcomes
Mother-Baby Care
Mother-baby care is defined as care of the postpartum mother and her newborn
by the same nurse. This model of care centers on treatment of the mother and
baby as an inseparable unit; mother and baby should remain unseparated
except in extreme circumstances.
Assumption of the Paternal Role

Changes in societal gender roles, couples’ participation in childbirth
preparation classes, allowing fathers in the delivery room, and
encouraging early contact with the infant have all been instrumental
in promoting and fostering early paternal-infant bonding. Researchers
(Ramchandani et al, 2012) have documented the benefits of early
and ongoing contact between fathers and infants. When the primary
caregiver is able to touch, hold, and attach with the newborn infant,
this special interaction helps to build the foundation for a nurturing
and protective relationship. Fathers should be encouraged to assume
an active role in infant bonding by participating in the caregiving
activities. For example, fathers can change diapers, engage in skin-
to-skin holding and infant massage, and feed the bottle-fed infant.
Factors That May Interrupt the Bonding Process

Stress associated with insufficient finances to purchase infant
supplies, a chaotic home life, concerns about child care if the mother
must return to work, lack of family support, and substance abuse may
negatively interfere with the bonding process. An essential nursing
role involves identifying obstacles to optimal bonding and
coordinating with appropriate community resources such as social
services to explore the mother’s eligibility for Medicaid, the WIC
program, and Healthy Start. Other resources may include counseling
and support services, financial aid, and pastoral care.
An interruption in the bonding process may occur when infants
must be separated from their parents for medical or surgical
interventions. To promote optimal bonding in these special
circumstances, it is important to allow the parents early and frequent
access to the infant. The staff in the neonatal intensive care unit can
enhance parental attachment and bonding by encouraging the
parents to touch, speak to, and hold their neonate skin-to-skin as
soon as is medically safe. If the mother is unable to visit,
photographs of the infant should be sent to her as soon as possible
and frequent telephone calls made to keep her advised of the infant’s
status. The mother must be reassured that the bonding process is
ongoing and that lack of early contact will not interfere with the
development of a positive relationship with her infant.
Adjustment of Siblings to the Newborn

The arrival of a new baby into the family results in many emotional
changes for the siblings. Feelings of hurt and jealousy, sibling rivalry,
and behavioral regression are all common among younger siblings.
For example, a toilet-trained toddler may once again require diapers
or a 2-year-old who has been weaned may now wish to breastfeed.
Parents should be prepared for these common emotional
upheavals and formulate strategies that will help sibling(s) adjust to
and accept the baby. Many hospitals offer sibling classes for young
(ages 2 to 8) children that introduce the concept of having a new
addition to the family and provide parents with specific information
about how to make the transition easier (Fig. 11-16).
Patient Education
Helping Older Siblings Adjust to the New Baby
Nurses can be instrumental in arming parents with strategies to help their
children accept and adjust to a new infant. The following tips may be useful:
• Talk with the child(ren) about their feelings regarding the new baby. Listen and
validate their feelings.
• Teach the older sibling how to play with the new baby; encourage gentleness.
• Help develop the child’s self-esteem by giving him or her special jobs, for
example, bringing the diaper when you are changing the baby. Praise each
contribution.
• Praise age-appropriate behaviors and do not criticize regressive behaviors.
• Set aside a special time each day for you to be alone with the older child;
remind the child that they are loved very much.
Adjustment of Grandparents to the Newborn

Grandparents can provide much support to the new family. Often, the
grandparents are intimately involved in the fabric of family dynamics
and frequently exert a strong influence on child-rearing practices (Fig.
11-17). Grandparents’ classes, offered by most hospitals and family
centers, usually focus on defining grandparent roles such as helping
with sibling care during the mother’s hospitalization and with
household activities like cooking and shopping during the first few
postpartal weeks. Other class themes include current
recommendations concerning infant positioning, feeding, and
clothing; responding to behavior cues; and positive strategies for
assuming a supportive, rather than a parenting role.
EMOTIONAL AND PHYSIOLOGICAL

ADJUSTMENTS DURING THE PUERPERIUM
Emotional Events
Many mothers experience a rollercoaster of emotions after childbirth.
These feelings stem from a number of influences and are often linked
to perceptions concerning the fulfillment of expectations surrounding
the childbirth experience. A complicated birth, a premature birth or a
sick infant, and the woman’s parity, age, marital status, and stability
of family finances are some of the many factors known to shape
emotions experienced during the postpartum period.
The first 3 months after birth are recognized as the most vulnerable
emotional period for mothers. Insecurity about infant care, the
constant demands associated with caring for the baby, sleep
deprivation, and minimal social support create the potential for
frequent and dramatic mood changes. Rapid hormonal changes
during the first few postpartal days and weeks may give rise to mood
disorders. The most common of these is often termed “the blues.”
Other less common puerperal mood disorders include postpartum
depression and postpartum psychosis.
FIGURE 11-16 Providing an opportunity for the sibling to spend time
with the newest family member facilitates sibling adjustment.
FIGURE 11-17 Grandmother spending time with new twin babies.
Maternity Blues/Baby Blues/Postpartum Blues

The “maternity blues” are considered to be a normal reaction to the
dramatic changes that occur after childbirth including abrupt
withdrawal of the hormones estrogen, progesterone, and cortisol.
Women experience a range of symptoms that include tearfulness,
mood swings, insomnia, fatigue, anxiety, difficulty concentrating,
irritability, and poor appetite. The symptoms usually begin during the
first few postpartal days, peak on the fifth day, and then subside over
the next several days. Blues do not affect the woman’s ability to care
for herself or her newborn and family.
The “blues” are treated with support and reassurance. Proactive
education to prepare the woman and her family for the possibility of
postpartum blues is important. The nurse needs to explore what
resources the new mother will have available when she goes home.
The discussion should focus on whether the patient has adequate
food, clothing, shelter, and transportation and whether relational
concerns need to be addressed before discharge. Incorporating
community resources such as the woman’s church, a Mother’s Day
Out group, a hobby club, or La Leche League can help the new
mother realize she is not alone in the experience of nurturing a
newborn, while also caring for herself and her family. Referral to a
health-care provider is appropriate for women whose symptoms
persist for more than 10 days because this pattern is suggestive of
postpartum depression.
Postpartum depression, which affects 10% to 13% of women, usually
appears around 2 weeks after childbirth. The symptoms associated
with this condition are often insidious and include sleep disturbances,
guilt, fatigue, and feelings of hopelessness and worthlessness. In
severe instances, suicidal ideation may occur. Patients who
demonstrate symptoms of postpartum depression must be promptly
referred for evaluation and intervention.
Postpartum psychosis develops in approximately one or two women
in every 1,000 births and is unlikely to manifest during the early
postpartum period. Symptoms include delusions, hallucinations,
agitation, inability to sleep, and bizarre, irrational behavior. Before
hospital discharge, patients with a history of mood disorders or
depression should be referred to appropriate resources for
community support and follow-up.
Physiological Responses to Emotional Events

Tiredness and Fatigue
Postpartum tiredness and fatigue have long been considered a
natural physiological and psychological response to the stresses of
labor and childbirth coupled with the additional responsibilities of
motherhood. Although new mothers are often confident that tiredness
will improve upon returning home, this phenomenon is not supported
by the nursing literature. Rather, the multiplicity of demands
associated with motherhood augments the experience of physical
and mental exhaustion. While changes in societal trends in the care
of children suggest that fathers and partners are taking a more active
role, mothers continue to hold the main responsibility for care. Thus,
it is essential for the nurse to encourage new mothers to enlist the
support and assistance of family and friends in an effort to promote
time for rest and recovery.
POSTPARTAL DISCHARGE PLANNING AND

TEACHING
Promoting Maternal Self-Care
Because of early postnatal discharge, all postpartal women must be
taught strategies for self-care. A self-assessment sheet completed
before discharge helps identify areas of deficit. When possible,
parents are encouraged to attend a discharge teaching class. Topics
reviewed usually include infant feeding and bathing, breastfeeding,
perineal hygiene, physical activity, rest, and expected emotional
changes. This information is useful because it empowers the family
to identify normal events and promptly recognize complications that
should be reported to the health-care provider. Many institutions also
distribute home care booklets that provide written information about
maternal and newborn care and available community resources.
Often, home visitation by a community health nurse is arranged
before the patient’s discharge. The community health nurse visit
typically includes an examination of the mother and infant, an
opportunity for discussion about problems or concerns, and
breastfeeding or formula feeding support. Additional areas of focus
during the postpartal visit include education regarding basic maternal
and infant care, plans for follow-up visits, mental health assessment,
and contraception counseling (Fig. 11-18).
Optimizing Outcomes
Planning Early Postpartum Discharge

Early postpartum discharge occurs within 48 hours of the birth (Jones, Taylor,
MacArthur, Pritchett, & Cummins, 2016). Women and their families may have the
option of early discharge with postpartum home care if they meet the specific
hospital/birth center criteria such as uncomplicated perinatal course, vaginal
delivery, no evidence of premature rupture of membranes, no difficulties with
voiding or ambulation, normal vital signs, hemoglobin greater than 10 g, and no
significant vaginal bleeding. The infant must also meet certain criteria (e.g., full
term, normal vital signs and physical examination, feeding, urinating, stooling,
and laboratory/screening tests completed). Early follow-up visits are essential for
both mother and newborn as a component of safe care so that any issues or
concerns can be addressed in a timely manner.
Patient Education
Locating the Fundus
The woman is taught how to locate and palpate the fundus and how to
determine the progression of the fundal height as it involutes into the pelvis.
After months of abdominal enlargement, many women are delighted to be able
to rest in a prone position. Nurses can explain that lying on the abdomen is
beneficial because this position supports the abdominal muscles and aids
involution because the uterus is tipped into its natural forward position.
FIGURE 11-18 The postpartum home visit usually involves an
examination of the mother and baby. It provides an opportunity for
teaching and promotes continuity of care.
Lochia
Patients should be educated on assessment of lochia so that they
can report any concerning findings to the health-care provider.
Educational aspects include:
■ Washing hands before and after going to the bathroom and
changing the peripad
■ Promptly reporting the following to the health-care provider:
■ Heavy, bright bleeding that saturates the peripad every 1 to 2 hours
■ Numerous clots or clots that are large
■ Foul-smelling, green, or purulent vaginal discharge
■ Lochia serosa that extends beyond 7 to 10 days
Hygiene
The patient is advised to continue to use her perineal squeeze bottle
until the bleeding stops and to use the prescribed medications and/or
sitz bath for episiotomy discomfort. She is reminded to carefully wipe
from front to back after each visit to the toilet and thoroughly wash
her hands before and after changing the peripads.
Abdominal Incision
Nurses should instruct the postoperative patient to shower as normal
and carefully pat the incision dry. If staples were applied at the
incision site, the obstetrician will inform her when to come into the
office for removal. Steristrips used for incision closure should remain
undisturbed until they eventually fall off. The woman is advised to
avoid the application of cream or powder to the incision site and to
notify her obstetrician if she experiences fever or develops signs of
incisional infection such as redness, offensive odor, or discharge.
Body Temperature
Some women experience a transient increase in body temperature
along with breast heaviness on the third to fourth postpartum day
when the milk supply is established. They should be reminded that
temperatures above 100.4°F (38.0°C) and flu-like symptoms (e.g.,
chills, body aches, or severe pain) may indicate infection and should
be promptly reported to the health-care provider.
Urination
Before discharge, all patients should be able to pass urine without
difficulty. Women should be taught the signs and symptoms of a UTI.
Specifically, burning on urination (dysuria), frequent voiding with only
a small amount of urine passed, the presence of a “fishy” odor to the
urine, and lower abdominal or flank pain are symptoms that must be
reported to the health-care provider. To reduce the likelihood of a
UTI, patients are advised to drink at least eight 8-oz glasses of water
each day, avoid delays in emptying the bladder, wipe the perineum
from front-to-back after each use of the toilet, change peripads after
toileting, and wash their hands frequently.
Bowel Function
The nurse teaches about the importance of maintaining good
hydration and consuming a healthy diet abundant in fiber and
roughage. An exploration of the woman’s dietary preferences
facilitates discussion about specific types of foods (e.g., fruits,
vegetables, and whole-grain cereals) that promote bowel regularity.
The patient should consult with her obstetrician or certified nurse-
midwife if laxatives or other medications become necessary. Stool
softeners are usually prescribed for women with third- or fourth-
degree episiotomies or vaginal lacerations.
Nutrition
Many women are concerned about weight increase during the
pregnancy and how quickly they can expect to return to their
prepregnancy weight. A well-balanced diet that includes high-energy
foods is essential to recovery in the puerperium. Patients should be
counseled about the need for adequate protein to promote tissue
repair and healing, as well as encouraged to select a healthy, low-fat
diet that contains protein along with carbohydrates, fruits, and
vegetables.
Fatigue
Patients should be reminded that, because the first 6 postpartal
weeks are devoted to infant care and recovery from childbirth, energy
depletion, usually manifested as extreme tiredness and fatigue, often
occurs. They should be encouraged to limit visitors and to rest when
the baby sleeps whenever possible. Patients may wish to cook easily
prepared meals in advance and freeze foods for later use. When
possible, the new mother should solicit help from her partner, family
members, and friends to assist with the household chores, shopping,
and child care.
Weight Loss
Weight loss at the time of childbirth is precipitous. Within minutes
after birth, the parturient woman loses half of the weight gained
during the previous 9 months. On average, the weight loss amounts
to 10 to 12 lb (4.5 to 5.5 kg). This loss comes from the infant, the
placenta, amniotic fluid, and blood. Rapid diuresis and diaphoresis
occur during the second to fifth postpartum days and result in an
additional weight loss of about 5 lb (2.3 kg). By the sixth to eighth
postpartal week, many women will have returned to their prepregnant
weight. The amount of weight lost during the puerperium is primarily
related to the amount of weight gained during pregnancy and the
woman’s level of physical activity.
Exercise
The patient is advised to resume activities gradually, beginning with
Kegel exercises to strengthen the pelvic-floor muscles. After a
vaginal birth, patients may begin modified sit-ups to strengthen the
abdominal muscles and perform knee and leg roll exercises to firm
the waist. Modified sit-ups are especially beneficial for women with
diastasis recti.
Optimizing Outcomes
Postnatal Exercises to Promote Physical Fitness
Teaching patients about exercises to help return the body to its prepregnant
state is an important component of postpartal care. Exercises to strengthen the
back, abdominal muscles, thighs, and shoulders are particularly beneficial.
Supple Spine
Begin on all fours. Inhale. Lift your head, keeping your back
straight or arching slightly (avoid strain). Then exhale, round your
back, tighten abdominals, tuck in tail and head. Repeat the
sequence eight times. This exercise strengthens the back and
abdominals.
Stronger Back
Sit upright, knees bent, feet flat on the floor, back straight, arms
forward at shoulder level. Inhale, then exhale and lean back
halfway. Inhale again and sit up slowly. Repeat five times. This
exercise strengthens the back and abdominals.
Flexible Body
Stand upright with arms raised, elbows slightly relaxed. Inhale,
then exhale and bend forward, keeping back straight and swinging
your arms down and back. Then relax your head and stretch your
arms up behind you. Inhale as you swing your arms and straighten
your body up again, returning to your original position. Repeat
eight times. Go carefully and do not strain. This exercise is good
for thighs, hips, back, arms, shoulders, and neck.
Pain Management
Medications for pain relief (nonsteroidal anti-inflammatory
medications or analgesics) may be prescribed, especially for
postoperative patients. The nurse should ensure that medications
prescribed for breastfeeding patients are not contraindicated.
Information regarding therapeutic modalities such as ice packs, sitz
baths, or topical anesthetics may be helpful for the relief of perineal
discomfort from hemorrhoids or the episiotomy incision. Patients are
instructed to notify their health-care provider if pain persists or
increases in intensity, and the nurse also reviews other danger signs
and symptoms that must be promptly reported (Box 11-4).
Optimizing Outcomes
Postpartum Education About Perinatal Pre-eclampsia
Pre-eclampsia is associated with major maternal and perinatal morbidity and
mortality. Because the condition abates following delivery of the placenta, most
obstetric units tend to discontinue seizure prophylaxis within 48 hours
postpartum. However, preeclampsia can develop during the postpartum period
and lead to eclamptic seizures beyond 48 hours and as late as 6 weeks after
childbirth. Before discharge, an important nursing intervention centers on
teaching patients about prodromal symptoms that may herald pre-eclampsia-
eclampsia: headache, shortness of breath, blurry vision, nausea, vomiting,
edema, seizure, other neurological deficits, and epigastric pain.
Sexual Activity and Contraception

To maximize healing and prevent infection, patients are discouraged
from resuming sexual activity until after the 6-week postpartum
checkup with the obstetrician or midwife. It is important for the nurse
to inform the woman and her partner that, because ovulation may
resume as early as 2 weeks after childbirth, pregnancy can occur if
no contraceptive is used.
BOX 11-4
Postpartum Discharge Teaching: Danger Signs

to Report
An important component of discharge teaching focuses on alerting patients to
signs and symptoms that must be reported to the health-care provider. The
nurse should ensure that the patient is given written information and knows how
to reach her care provider. The patient should immediately report:
• Temperature greater than 100.4°F (38.0°C), chills, or flu-like symptoms
• Signs of pre-eclampsia, headache, vision changes, swelling
• Swelling or masses in the breasts, red streaks, shooting pain in the breasts, or
cracked, bleeding nipples
• Abdominal incision that is red, tender to touch, or painful, or if edges of the
incision have separated
• Difficulty initiating urination, urinary frequency, or painful urination
• Increased vaginal bleeding with or without clots, or foul-smelling vaginal
discharge
• Persistent pain or marked swelling at the site of a perineal laceration or
episiotomy
• Swelling, warmth, tenderness, or painful areas in the legs
• Overwhelming feelings of sadness or an inability to care for self or the baby
Although advised to abstain from sexual intercourse until the

postpartum examination, many couples wish to resume intimate
relations before this time. Coitus is safe once the woman’s lochia has
transitioned to alba and the episiotomy (if present) has healed. This
usually occurs after the first week after childbirth. The patient should
be warned that she may experience vaginal discomfort because the
cells lining the vagina may not be as thick as before because of a
hormone imbalance. Breastfeeding may alter sexual function as a
result of vaginal dryness produced by the high levels of prolactin and
lowered estrogen levels. A contraceptive foam or lubricating jelly may
be used to enhance comfort.
Exploring previously used methods of contraception may be helpful
in identifying a starting place for the discussion. The couple’s religion
and cultural background often dictate their contraceptive choice.
Discussing contraception options with the patient and her partner (if
present) before discharge allows the couple time to make informed
decisions before resuming sexual intercourse. The breastfeeding
mother should be warned that she can become pregnant during
lactation and that breastfeeding is not a substitute for birth control. If
the breastfeeding patient wishes to use an oral contraceptive, the
nurse must inform the health-care provider so that a progesterone-
only pill can be started immediately postpartum (Curtis et al, 2016).
Postpartum women should not use combined hormonal oral
contraceptives during the first 3 weeks after childbirth because of a
high risk for venous thromboembolism, and women with additional
risk factors for venous thromboembolism should not use oral
contraceptives during the first 6 weeks postpartum (Curtis et al,
2016).
Planning for the Follow-Up Examination

Women who have had uncomplicated cesarean section will have a
scheduled follow-up appointment at 2 weeks postpartum and then
again within 4 to 6 weeks postpartum. All women will also have a
follow-up postpartum visit within 4 to 6 weeks to assess the various
physical, social, and psychological changes that occur postpartum
(McKinney, Keyser, Clinton, & Pagliano, 2018; World Health
Organization, 2015). Aspects of the postpartum assessment include:
■ Maternal well-being and mental health for postpartum depression
■ Sleep pattern
■ Screening for substance use: alcohol, tobacco, marijuana, and
other illicit substances
■ Pain
■ Breast: breastfeeding
■ Uterus: involution, fundal height, position, and tenderness
■ Lochia
■ Vaginal examination with Pap
■ Urination and urinary incontinence
■ Gastrointestinal: constipation, hemorrhoids, and fecal incontinence
■ Wound healing: tears, episiotomy, or surgical incisions
■ Sexual activity
■ Contraception and birth spacing
■ Chronic disease management
■ Domestic violence
■ Support systems
PATIENTS WITH SPECIAL NEEDS DURING THE

PUERPERIUM
Care of the Adolescent
The period of adolescence is a time to form important relationships
with peers; these close connections help to facilitate self-growth and
development. Adolescents who are thrust into an untimely
motherhood role must also deal with their own personal and social
development. Adjusting to pregnancy and impending motherhood
can be emotionally and physically challenging for a mature woman;
the adolescent requires special assistance from the nurse.
Many adolescents enter motherhood with unrealistic expectations
and without mothering and child-care skills. Fatigue and sleep
deprivation, common in all new mothers, coupled with the
responsibility of caring for an infant who requires constant attention,
often result in limited time for social activities and subsequent social
isolation from peers.
Nurses who care for the adolescent mother must be cognizant of
personal prejudices or feelings of disapproval and avoid expressing
negative feelings toward the teen mother. It is important for the nurse
to provide emotional support for the postpartum adolescent that will
help her adjust to role changes, foster feelings of positive self-
esteem, and assist her in developing a new identity and sense of self.
Often the young mother will need linkage to support systems and
early follow-up visits within the week to assess the adaptation into
motherhood.
A supportive family environment is the single most important
element in facilitating the adolescent mother’s successful transition to
motherhood. When appropriate, referrals should be made for social
services and other community resources such as home health
nursing care, pastoral care, teen parent support groups, and
economic assistance. Guidance and support provided by these
professionals help to reinforce infant care skills and identify additional
resources to enable the young mother to complete her education.
Professional and family support has proven effective in helping
adolescents delay a subsequent pregnancy, stay enrolled in school,
find work, and complete the developmental tasks of adolescence.
What to Say
Planning the Adolescent Mother’s Hospital Discharge
The adolescent mother has unique needs for discharge planning. The nurse can
best explore the young patient’s immediate plans for herself and the baby by
initiating dialog in a supportive, nonthreatening environment. Examples of
appropriate questions that the nurse may ask include the following:
“Do you have someone available to offer you help and/or support?”
“Do you feel a sense of closeness or attachment to your baby?”
“After you leave the hospital, will anyone be helping you to care for your
baby?”
“Will anyone be taking care of the baby so that you can go back to school?”
“Where will you take the baby for follow-up care?”
These questions can help to facilitate conversation that will enable the nurse
to determine the need for specific resources and community supports.
The Woman Placing Her Infant for Adoption

The relinquishment of an infant triggers a host of emotions for the
woman and her family. Nurses must be sensitive to the psychological
stressors and social stigmas associated with placing a child for
adoption. Depending on hospital policy, the patient may be admitted
to the postpartum unit where she can be attended to by nurses who
are experienced in perinatal care. The nurse should offer support, a
“listening ear,” and a compassionate environment where the patient
feels safe expressing her feelings. The woman will likely experience
a range of emotions such as grief, loneliness, and guilt. After birth,
the patient should have access to her newborn if she so desires. The
opportunity to see, hold, and feed the infant may help her to accept
the reality that she has given birth to a healthy child. This affirmation
may foster feelings of self-esteem and provide a foundation for
emotional healing. Postpartum care may continue well beyond
hospital discharge for women who choose to give up the infant.
The Older Woman

Today, it is not uncommon for women over age 35 to experience
pregnancy, and when pregnancy occurs among this population, it is
deemed “advanced maternal age.”
The older patient may have pre-existing medical conditions (e.g.,
hypertension or diabetes) and experience greater health risks and
pregnancy complications such as gestational diabetes and pre-
eclampsia. In these situations, pregnancy and puerperal care involve
a collaborative approach that includes a physician with special
training in high-risk obstetrics (perinatologist) and medical specialists
(e.g., endocrinologist, rheumatologist, and cardiologist).
Women experience pregnancy after the age of 35 for a number of
reasons. Some postpone pregnancy to make advancements in
careers; others have struggled with infertility and become pregnant
following advanced reproductive techniques; while others report
contraceptive failure. A wide range of attitudes and emotions
accompany parenthood during midlife. Some women believe that
delaying motherhood enhances the adaptation to the parental role.
They cite qualities such as maturity, patience, understanding, and
greater life experiences as positive influences for assuming the
parental role. For others, parenthood at an older age can be
disruptive to intimate relationships, interfere with career goals, and
create a perception of loss of control. Reassurance, support, and
referral, when appropriate, help to facilitate transitions during the
puerperium for the older couple.
COMMUNITY RESOURCES FOR THE NEW

FAMILY
Support Groups
The birth of a newborn is a major life transition. For the new parent,
attending a support group can provide a venue for sharing
experiences and challenges with other new parents. Information
about essential parenting topics, such as infant feeding and nutrition,
behavior, sleeping patterns, and strategies for fostering family
relationships, is readily available during the meetings. Specific
support groups may also be available for unique populations, such as
single parents, working mothers, and parents of infants with special
needs. Parents who participated in childbirth education classes
together often reunite to form a support group after childbirth.
Home Visits
Some facilities routinely schedule home visits for maternal and baby
assessment. This visit provides the nurse with an opportunity to
assess bonding, conduct patient teaching, answer questions, correct
learning deficits, reinforce hospital discharge instructions, and make
appropriate community referrals.
CenteringParenting is an innovative model of centering health
care in which five to six mother-infant dyads continue group care
throughout the baby’s first year of life. The model incorporates 10
postpartum and well-baby examinations and provides an avenue of
continued support for the woman’s transition to motherhood. In
keeping with the centering model of care, mothers are actively
engaged with tasks such as weighing the baby, plotting the baby’s
growth on an appropriate chart, and assisting with developmental
screens. Educational themes focus on health, safety, growth and
development, and mother-baby attachment.
Telephone Follow-Up
Facilities that offer home follow-up services usually call parents
approximately 2 to 3 days after discharge. Making personal contact
with the family provides early support and reassurance and allows for
questions to be answered and discharge instructions to be reviewed
and clarified.
Outpatient Clinics
Outpatient clinics provide another option for facilities that do not offer
home visitation. The clinics are often nurse-managed and allow the
mother and her baby to receive further information about maternal-
infant care. The patient’s additional questions or concerns can also
be dealt with at this time.
SUMMARY POINTS
■ During the postpartum period, the nurse assumes the responsibility of

facilitating the integration of the newborn into the family unit. ▪ The postpartum
patient has unique assessment needs that include physical and psychosocial
considerations.
■ The new mother should be given the opportunity to discuss her birth
experience.
■ The postpartum woman who has experienced a cesarean birth is also
considered to be a surgical patient who has special needs for additional
nursing care.
■ Effective pain management should be an integral component of the postpartal
nursing assessment.
■ The breastfeeding mother should be provided with sufficient support to
facilitate success. The nurse should provide anticipatory guidance that
includes family members whenever possible.
REFERENCES
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(2015). Clinical position statement. Breastfeeding. Journal of Obstetric,
Gynecologic, and Neonatal Nursing, 44(1), 145–150.
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fluorosis. Retrieved from https://www.cdc.gov/fluoridation/faqs/infant-
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D. J., & Whiteman, M. K. (2016). US selected practice recommendations for
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Breastfeeding Practices: Geneval. Vol. Licence: CC BY-NC-SA 3.0.

Davis Advantage
CHAPTER 12
Caring for the Woman Experiencing Complications

During the Postpartal Period
CONCEPTS
Pregnancy
Nursing
KEY WORDS
postpartum hemorrhage (PPH)

uterine atony
thrombin
disseminated intravascular coagulation (DIC)
hematoma
superficial venous
thrombosis
deep venous
thrombosis
pulmonary embolism
puerperal infection
Methicillin-resistant
Staphylococcus aureus (MRSA)
LEARNING OBJECTIVES
■ Describe the causes and collaborative management of postpartum hemorrhage.
■ Discuss the signs and symptoms of postpartum hematoma; describe nursing care for a patient experiencing
a postpartum hematoma.
■ Discuss the collaborative management of venous thromboembolic conditions in postpartum women.
■ Describe the collaborative management for infections during the puerperium.
■ Summarize important interventions in meeting psychosocial needs of postpartum women and their families.
■ Describe current community and governmental services that are available to vulnerable postpartum women
and their families.
PICO(T) Questions
1. Is late (I) postpartum hemorrhage (O) more prevalent in (P) Caucasian women (C) than in African American
women?
2. What (I) strategies best assist (P) family members to (O) help and support women with postpartum
depression?
INTRODUCTION
Most childbearing women have healthy babies and recover from the physiological and
psychological adaptations to pregnancy without difficulty. However, more than 810 women
worldwide die each day from pregnancy-related causes, and more than half of these deaths
occur during the postpartum period (Suplee & Janke, 2020; World Health Organization, 2020).
Physiological and psychosocial complications are significant concerns leading to an increase
in maternal morbidity and mortality. This chapter describes postpartum physiological and
psychosocial complications and concerns from a nursing process perspective. The nurse’s role
in the collaborative treatment of patients and their families who experience these complications
is multifaceted and cannot be overly emphasized. More than any other health-care team
member, the nurse uses vigilance to apply nursing knowledge and implement informed nursing
actions instrumental in helping women achieve optimal health outcomes.
POSTPARTUM HEMORRHAGE
Incidence and Definition
Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality in the
United States and around the world (Centers for Disease Control and Prevention, 2020) (Table
12-1). Postpartum hemorrhage is a blood loss greater than 500 mL after a vaginal birth and
1,000 mL or more after a cesarean birth. Hematocrit levels that decrease 10% from pre- to
postbirth measurements are also included in the definition (Sommers, 2019), along with a
need for a red blood cell transfusion because of anemia or hemodynamic instability.
TABLE 12-1
PPH Terminology
Readiness Emergency equipment available (hemorrhage cart with equipment), ongoing
training and education of health-care professionals, designated response
team, standard emergency treatment protocol such as massive blood
transfusion protocol.
Recognition Routine assessment of patient, prenatal, on admission, in labor and
postpartum for early identification. Identify at-risk populations. Monitoring of
acute changes (blood loss, vital signs). Accurate quantitative measurement of
blood loss.
Response Unit-based standard response with checklist, support programs for staff,
patients, and families.
Reporting Establish culture of huddle’s, monitor outcomes and process matrix, establish
quality assurance initiatives.
Source: California Maternal Quality Care Collaborative. (n.d.).
FOCUS ON SAFETY
Recognizing Additional Indicators of Hemorrhage
To recognize obstetric hemorrhage in a timely manner, nurses should begin to quantify blood loss
immediately after birth and remain alert to indicators that may point to ongoing obstetric hemorrhage; one of
the first signs is a maternal heart rate greater than 110 beats per minute, 15% drop in blood pressure (often a
late sign), or oxygen saturation less than 95%.
After a vaginal birth, the health-care provider visually assesses and estimates the amount of blood loss.
This method is frequently inaccurate and may lead to an underestimation of actual blood loss, missing many
cases of acute PPH. Accuracy in determining true blood loss is possible if a member of the health-care team
carefully weighs the placenta basin and all bloody items such as pads, linens, and clothing with a gram scale
(1 mL = 1 gram in fluid volume). Calibrated drapes manufactured specifically for the obstetric setting are
readily available, and newer technology including artificial intelligence has been developed to calculate blood
loss based on algorithms and images (American College of Obstetricians and Gynecologists, 2019).
Early vs. Late Postpartum Hemorrhage

An early (primary) PPH occurs within the first 24 hours after childbirth. A late (secondary) PPH
occurs from 24 hours to 12 weeks after childbirth. The greatest likelihood for occurrence of an
early hemorrhage is within the first 4 postpartum hours. During this time, the blood flow to the
uterus is between 500 and 800 mL/minute, and the placental site contains multiple exposed
venous areas and low resistance. In clinical practice, the four “Ts” serve as a reminder of
factors associated with PPH: tone, trauma, tissue, and thrombin. A lack of uterine tone (atony)
and genital tract trauma are the most common conditions that cause PPH (Scannell &
Lavallee, 2018).
Late PPH occurs in only 1% to 2% of all childbearing women, usually within the first 2 weeks
after birth. Retained placental fragments are the most common cause of late PPH. Other
causes include subinvolution (failure of the uterus to return to its prepregnant size), uterine
infection, and less commonly, inherited coagulation defects such as von Willebrand (vW)
disease.
Uterine Atony
Uterine atony, the leading cause of early PPH, is a failure of the uterine myometrium to
contract and retract following birth. Normally, the uterine muscle fibers contract firmly around
the blood vessels during placental separation. A lack of contraction and retraction results in
noncompression of the uterine arteries and veins at the placental implantation site, preventing
hemostasis. The hallmark of uterine atony is a soft, boggy uterus filled with clots and blood.
Multiple factors place the childbearing woman at risk for hemorrhage from uterine atony. An
understanding of the factors that increase the risk of uterine atony allows the nurse to
anticipate hemorrhage and intervene to prevent excessive blood loss (Box 12-1).
Trauma
During the second stage of labor, soft tissue trauma from a number of causes (e.g., rapid
labor, operative delivery, and episiotomy) can result in genital tract lacerations (Box 12-2).
While PPH from uterine atony is evident from a soft, blood-filled uterus, if the source of
hemorrhage is genital tract lacerations, the uterus remains firm and midline. Because one
large or several small lacerations can adversely affect hemodynamic stability, it is essential to
frequently monitor vital signs. Perineal inspection may reveal either a steady stream or a small
trickle of bright red blood.
BOX 12-1
Risk Factors for Uterine Atony

• Uterine overdistention (associated with multifetal gestation, hydramnios, large infant, and macrosomia)
• Dysfunctional, prolonged labor or precipitous labor (indicator that the uterus is not contracting normally)
• Previous history of uterine atony/PPH
• Trauma during birth (e.g., forceps-assisted birth, vacuum-assisted birth, and cesarean birth)
• Labor induction/augmentation with oxytocin
• Chorioamnionitis
• High parity (stretched uterine musculature has decreased contractility)
• Retained placental fragments
• Manual removal of placenta
• Use of anesthesia/analgesia, especially halogenated anesthetic agents or other drugs (e.g., magnesium
sulfate and nifedipine) that promote uterine relaxation
• Prolonged/mismanaged third stage of labor
BOX 12-2
Risk Factors for Postpartum Hemorrhage From Tissue Trauma

• Rapid second stage labor
• Rapid/precipitous labor (less than 3 hours from onset to delivery)
• Operative vaginal deliveries (forceps- or vacuum-assisted)
• Fetal manipulation (extrauterine or intrauterine version, corkscrew maneuver for shoulder dystocia
[corkscrew maneuver: a progressive 180-degree manual rotation of the baby’s posterior shoulder to release
the impacted anterior shoulder])
• Large episiotomies, including extensions
• Fetal macrosomia
• Cesarean birth
• Uterine rupture (increased incidence with previous uterine surgery, tetanic contractions, labor stimulation,
versions, and placental attachment abnormalities—placenta accreta, placenta increta, and placenta
percreta)
Lacerations are usually internal and not visible when the nurse examines the perineum.
Identifying either a vaginal wall or cervical laceration usually requires that the physician or
midwife examine the patient while she is in the lithotomy position. Not infrequently, the
physician locates and repairs a laceration before the patient’s transfer to the postpartum unit.
Tissue
Careful examination of the placenta after delivery is a component of standard care. Hence,
retained placental tissue is an uncommon cause of early PPH and more often a cause of late
PPH. If the pregnancy included problems with placental implantation (e.g., placenta previa or
placenta accreta), the primary care provider is aware of these risks before the birth takes place
and is alerted that retained tissue can occur due to the abnormal placental adherence. Should
the practitioner note that lobes of the placenta are missing during the placental examination,
the physician or certified nurse-midwife explores the patient’s uterus to remove them.
Thrombin
Thrombin refers to problems with maternal coagulation. Disorders of the coagulation system
and platelets do not usually result in excessive bleeding during the immediate postpartum
period. Pre-existent maternal factors such as low fibrinogen levels and idiopathic
thrombocytopenia (ITP) and acquired pathology such as HELLP syndrome (condition
characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count), disseminated
intravascular coagulation (DIC), sepsis, and abruptio placentae require vigilant care and
anticipation of possible hemorrhage after birth.
Congenital Clotting Disorders

Von Willebrand (vW) disease is a thrombin disorder that places a patient at high risk for PPH
(Govorov et al, 2016). Von Willebrand disease is caused by a deficiency of vW factor, a protein
required for platelet adhesion. Although vW disease is rare, it is the most common of all
hereditary bleeding disorders. Von Willebrand disease results from a factor VIII deficiency and
is transmitted as an incomplete autosomal dominant trait to both sexes. Symptoms include a
familial bleeding tendency, reports of previous bleeding episodes, prolonged bleeding time,
factor VIII deficiency, and bleeding from the mucous membranes. Although pregnancy is
associated with an increase in factor VIII, the patient with vW disease remains at risk for PPH
as the levels of vW factor begin to decrease; the risk for bleeding may persist for up to 4
weeks postpartum. Treatment usually involves the administration (orally, nasally, or IV) of
desmopressin, which promotes the release of vW factor and factor VIII; other treatment
modalities include the transfusion of plasma products treated for viruses that contain factor VIII
and vW factor; the IV administration of antihemophiliac factor-vW factor complex; or IV
Tranexamic acid (TXA) every hour while in labor and postpartum (Govorov et al, 2016).
Another congenital clotting disorder is idiopathic thrombocytopenic purpura (ITP). ITP is an
autoimmune disorder in which the life span of platelets is decreased by the body’s own IgG
antiplatelet antibodies, occurring in about 3% to 4% of pregnancies (Akhtar, 2019; Venes,
2021). This can result in severe hemorrhage following a cesarean birth or lacerations. During
pregnancy, postpartum platelet count is monitored closely. In addition to vaginal bleeding,
women should be monitored for additional signs of low platelets that can indicate high risk for
bleeding such as easily bruised, petechia, and bleeding gums (Akhtar, 2019).
NURSING INSIGHT
Characteristics of Postpartal Bleeding
The color and character of the blood and consistency of the uterus can often identify the source of postpartal
bleeding. When bleeding is associated with uterine atony or retained placental fragments, the blood is dark red
with clots and the uterus is soft and boggy. When bleeding is associated with lacerations from the perineum,
cervix, or vagina, the blood is bright red, often without clots, and the uterus remains firmly contracted.
Blood Loss and Vital Signs

Normal physiological adaptations in pregnancy mean that a large loss of blood can occur before changes in
vital signs (decreased blood pressure and increased pulse) are evident. The lack of objective signs and
symptoms may lead to a delay in treatment.
The nurse, physician, or midwife may not see the usual signs of shock—restlessness;
anxiety; pallor; cool, clammy skin; increased pulse; tachypnea; shaking; and decreased blood
pressure—until 30% to 40% of the patient’s total circulating blood volume has been lost.
Collaborative Management of PPH

After birth, standard care requires frequent measurement of vital signs and fundal massage to
check the location and condition of the uterine fundus. Most hospitals and birthing centers
require that the registered nurse perform these checks at least every 15 minutes for the first
postpartal hour. Thereafter, the frequency of assessment varies from one institution to another.
As the primary caregiver and the one completing these assessments, the registered nurse
may be the first person to identify excessive blood loss. When identified, immediate actions
are necessary. While another member of the team calls the physician or nurse-midwife, the
nurse can obtain some important assessment data. The nurse must be cognizant of risk
factors in the patient’s history.
After locating the uterine fundus and initiating fundal massage, the nurse can also begin
frequent vital sign measurements with an automatic device. The nurse should also palpate the
bladder for distention. The length of time it takes for blood loss to saturate a perineal pad is an
important parameter to record, as is a measurement of total intake and output up to that point.
Keeping in mind that the pulse and blood pressure may remain unchanged until a large
volume of blood has been lost, the nurse must pay particular attention to the mean arterial
pressure (MAP). A decrease in this measurement may be the first indicator of hypovolemia. Of
importance, also, is to note the patient’s behavior, in particular her level of consciousness, the
presence of restlessness, vague complaints, and her pain level.
Once the physician, midwife, or nurse identifies a PPH, interventions quickly follow. The
California Maternal Quality Care Collaborative has established a PPH toolkit that has been
implemented into hospitals to improve outcomes of PPH (California Maternal Quality Care
Collaborative, n.d.). If the cause of the hemorrhage is uterine atony, continual vigorous fundal
massage with lower uterine segment support is mandatory. While one member of the team
massages the fundus, another health-care provider or nurse establishes IV access with a
large-bore needle (usually an 18-gauge or larger) and administers oxytocic drugs, with
oxytocin as the first-line treatment if available.
MEDICATION: Methylergonovine (Methergine)

(meth-ill-er-goe-noe-veen)
Pregnancy Category: C
Indications: Prevention and treatment of postpartum and postabortion hemorrhage caused by uterine atony
or subinvolution
Actions: Directly stimulates uterine and vascular smooth muscle
Therapeutic Effects: Uterine contraction
Pharmacokinetics:
ABSORPTION: Well absorbed after oral or IM administration ONSET OF ACTION: Oral: 5 to 10 minutes; IM: 2
to 5 minutes; IV: Immediately
DISTRIBUTION: Oral: 3 hours; IM: 3 hours; IV: 45 minutes. Enters breast milk in small quantities.
METABOLISM AND EXCRETION: Probably metabolized by the liver
HALF-LIFE: 30 to 120 minutes
CONTRAINDICATED IN: Hypersensitivity. Should not be used to induce labor.
USE CAUTIOUSLY IN: Hypertensive or eclamptic patients (more susceptible to hypertensive and
arrhythmogenic side effects); severe hepatic or renal disease; sepsis
EXERCISE EXTREME CAUTION IN: Third stage of labor
Central nervous system: Dizziness, headache
Eyes, ears, nose, throat: Tinnitus
Respiratory: Dyspnea
Cardiovascular: Hypotension, arrhythmias, chest pain, hypertension, palpitations
Gastrointestinal: Nausea, vomiting
Genitourinary: Cramps
Dermatological: Diaphoresis
Route and Dosage:
PO: 200 to 400 mcg (0.4–0.6 mg) q6 to 12h for 2 to 7 days
IM, IV: 200 mcg (0.2 mg) after delivery of fetal anterior shoulder, after delivery of the placenta, or during the
puerperium; may be repeated as required at intervals of 2 to 4 hours up to five doses.
1. Physical assessment: Monitor blood pressure, heart rate, and uterine response frequently during medication
administration. Notify the primary health-care provider if uterine relaxation becomes prolonged or if
character of vaginal bleeding changes.
2. Assess for signs of ergotism (cold, numb fingers and toes; chest pain; nausea; vomiting; headache; muscle
pain; and weakness).
Source: Data from Vallerand, A. H., & Sanoski, C. (2021). Davis’s drug guide for nurses (17th ed.)
Philadelphia, PA: F.A. Davis.
In Situ Drills to Enhance Emergency Response
In situ drills (simulation that occurs in the patient care area) involving the multidisciplinary health-care team
serve as a key adjunct to evidence-based protocols and established educational programs. Held every few
months, the drills are instrumental in reinforcing important educational concepts concerning high-risk events
such as maternal hemorrhage, allowing the team to develop skills to improve performance, and identifying
areas that warrant further work and collaboration.
If the patient has a distended bladder, an indwelling urinary catheter needs to be inserted
and all intake and output carefully recorded. The nurse also needs to weigh pads, linens, and
other bloody items on a gram scale to obtain an accurate picture of blood loss. It may be
necessary to administer oxygen at 10 to 12 L/min to treat compromised tissue perfusion
(Scannell & Lavallee, 2018).
PROCEDURE ■ Performing Fundal Massage

PURPOSE
Fundal massage is used as an emergency measure to contract the uterus that is soft and boggy because of
atony. It is performed to promote uterine tone and consistency and minimize the risk of hemorrhage. Uterine
atony may result from prolonged labor, rapid or precipitous labor and birth, high parity, medications during
labor (e.g., oxytocin, magnesium sulfate, or inhalation anesthesia), intra-amniotic infection, operative delivery
and uterine overdistention from multiple gestation, hydramnios, or macrosomia.
EQUIPMENT
• Clean examination gloves
• Disposable cleansing wipes
• Two clean peripads
PRE-EXAMINATION PREPARATION
1. Wash and dry hands, explain the procedure and its purpose to the patient; ensure privacy.
RATIONALE: Hand washing helps to prevent the spread of microorganisms. Explanations help to decrease
anxiety; providing privacy helps to promote the patient’s comfort and self-esteem.
2. Assemble necessary equipment, including clean examination gloves, disposable cleansing wipes, and
clean peripads.
3. Ask the patient to void, unless fundal massage must be performed immediately because of excessive
bleeding.
RATIONALE: An empty bladder prevents uterine displacement and facilitates an accurate assessment of
uterine tone.
4. Assist the woman to a supine position with the knees flexed and the feet placed together.
RATIONALE: Proper positioning facilitates easy visualization and enhances the effectiveness of the
procedure.
STEPS
1. Don gloves, remove the peripad, and inspect the perineum. Observe the character and amount of drainage
on the pad and the presence of clots. Apply a clean peripad.
RATIONALE: Gloves serve as a barrier against possible infection from the vaginal drainage. Obtaining a
baseline assessment provides information for future assessments; it also provides a means for evaluating
the effectiveness of the procedure.
2. Place one hand on the abdomen, just above the symphysis pubis.
RATIONALE: This location provides support for the lower uterine segment.
3. Place the other hand around the top of the fundus.
RATIONALE: This location helps to locate and assess the fundus and the fundal height.
4. With the lower hand maintained in a stable position, rotate the upper hand and massage the uterus until it
is firm. Avoid over-massaging the uterus.
RATIONALE: The uterus should be massaged only when it is not firm. Massaging a firm uterus may result
in muscle fatigue and uterine relaxation. Overly aggressive fundal massage may result in uterine prolapse.
5. Once the uterus has become firm, gently press the fundus between the hands. Apply a slight downward
pressure against the lower hand.
RATIONALE: Gentle squeezing with downward pressure assists in the expulsion of blood or clots that have
collected in the uterine cavity.
6. Observe the perineum for the passage of clots and the amount of bleeding.
RATIONALE: This action helps to assess the presence of clots and the degree of bleeding.
7. Once the uterus remains firm, cleanse the perineum and apply a clean peripad. Dispose of the soiled
gloves and pads according to institutional policy.
RATIONALE: This action promotes maternal comfort and hygiene and reduces the risk for infection.
8. Document the findings. Continue to assess the fundus and vaginal drainage according to institutional
protocol.
RATIONALE: Documentation serves as a means for evaluation. Continued assessment allows for the early
identification of problems and facilitates timely intervention with additional measures such as medications
(e.g., oxytocin) to prevent hemorrhage.
WHAT IF?
What if the fundus does not remain contracted, or heavy bleeding persists despite a contracted uterus?
After ensuring that the bladder is empty (ask the patient to void; palpate for bladder fullness), alert the
physician or nurse-midwife, ensure IV access, continue to provide ongoing maternal surveillance, and prepare
for an intervention (e.g., examination, medication, or bimanual compression).
Medical management of PPH begins with administration of uterotonics starting with oxytocin (Pitocin).
Guidelines recommend 10–40 units of oxytocin IV or 10 units IM as one acceptable uterotonic for active
management of the third stage of labor (American College of Obstetrician and Gynecologists, 2019). Other
medications that may be used include misoprostol (Cytotec), methylergonovine (Methergine), ergonovine
(Ergotrate), carboprost (Hemabate), or dinoprostone (Prostin E2). Tranexamic acid (TXA) is another line of
medication used when there has been significant loss of blood up to 1,500 mL or two or more other
medications are being used and there is a need for additional medication (American College of Obstetrician
and Gynecologists, 2019). Table 12-2 displays further information and nursing implications concerning these
medications.
TABLE 12-2
Medications and Nursing Considerations for Postpartum Hemorrhage
NAME CLASSIFICATION/ACTION DOSAGE/ROUTE CONTRAINDICATIONS NURSING
CONSIDERATIONS
oxytocin (Pitocin) Oxytocic 10 units IM if no IV Hypersensitivity First-line treatment
Stimulates uterine smooth access; 10–40 for PPH due to
muscle and produces units IV in 500– uterine atony.
contractions similar to those 1,000 cc Monitor uterine
that occur during crystalloid IV fluid response. DO NOT
spontaneous labor (lactated Ringer’s administer a bolus
solution or normal of undiluted
saline) oxytocin, because it
can cause
hypotension and
cardiac arrhythmias.
Consider
administration of
pain medication for
uterine cramping.
Can cause water
intoxication, which
can lead to
drowsiness and
lightheadedness.
methylergonovine Ergot alkaloid 0.1–0.2 mg IM Hypersensitivity Keep refrigerated.
maleate Causes uterine contractions q2–4h; followed History of hypertension DO NOT add it to IV
(Methergine) by stimulating uterine and by 0.2 mg PO q4– or current elevation of solutions or mix in a
vascular smooth muscles 6h × 24 hours (for blood pressure syringe with other
6 doses) medications.
carboprost Prostaglandin analogue 0.25 mg (250 Asthma, hepatic, renal, Do not administer if
tromethamine Stimulates contractions of mcg) IM or directly and cardiac disease patient
(Hemabate) the myometrium into the uterus (by demonstrates shock
MD or CNM) q because it will not
15–90 min; 8 be well absorbed.
doses maximum Keep refrigerated.
This medication is
VERY expensive.
misoprostol Prostaglandin analogue; 800–1,000 mcg Hypersensitivity to Stable at room
(Cytotec) stimulates powerful rectally or 600 mg prostaglandins temperature.
contractions of the Orally or 800 mg Rectal absorption is
myometrium sublingually likely slower than IV
medication.
dinoprostone Prostaglandin analogue; 20 mg suppository Hypersensitivity to Monitor uterine
(Prostin E2) stimulates powerful vaginally or prostaglandins response.
contractions of the rectally q2h Avoid in severe If vaginal bleeding is
myometrium hypotension brisk, the use of
vaginal
suppositories is not
likely to be effective.
Fever is common.
Stored frozen, it
must be thawed to
room temperature.
Sources: ACOG (2019); Scannell & Lavallee (2018); Sommers (2019); Vallerand, A. H., Sanoski (2021).
Labs
Blood Work in PPH Cases
These patients should receive:
• Blood type with cross and match for transfusion
• Hematocrit and hemoglobin: May need serial levels drawn to determine extent of blood loss and monitor for
further blood loss
• Coagulation studies consisting of prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, and
fibrin degradation products
• DIC panel in cases of suspected DIC
DIC is a serious concern in anyone with a PPH. This diffuse clotting pathology involves the consumption of
large amounts of clotting factors including platelets, fibrinogen, prothrombin, and factors V and VII. The
pathological process may cause both internal and external bleeding. Vascular occlusion of small vessels
occurs as small clots form in the microcirculation. Although DIC may occur during the postpartum period, it is
most likely to be associated with abruptio placentae, severe pre-eclampsia, amniotic fluid embolism,
septicemia, cardiopulmonary arrest, hemorrhage, and dead fetus syndrome (a complication that may occur
when the fetus has died and is retained in the uterus for 6 or more weeks). Diagnosis is made according to
clinical findings and laboratory results.
The physician or midwife may also perform bimanual compression in an effort to empty the
uterus of clots and restore its tone. To perform this procedure, the physician inserts one hand
in the vagina while pushing against the fundus through the abdominal wall with the other hand
(Fig. 12-1). If these conservative measures fail to stabilize the patient by restoring tone to the
uterus and decreasing the blood loss, surgical intervention is indicated. Invasive procedures
include the placement of uterine packing (used less often today because of concerns of
concealed hemorrhage); uterine balloon tamponade known as Bakri balloon; ligation of the
uterine arteries, which provide approximately 90% of the uterine blood flow; hypogastric artery
ligation (rarely used in contemporary practice); uterine suture techniques; radiographic-guided
pelvic arterial embolization; and hysterectomy, a last resort to life-threatening hemorrhage
(American College of Obstetrician and Gynecologists, 2019).
FIGURE 12-1 Bimanual compression.
The nurse provides physiological care in a timely manner, serves as an advocate for the
patient, and reassures the patient and her family by explaining interventions as they occur.
These actions help facilitate open communication with the family and may help reduce anxiety.
If the nurse or health-care provider is not able to reassure the family in the acute period, a
social worker should be called to help support the family, as PPH is an emergency. Not all
outcomes will be positive, and the family will need support.
Collaborative interventions for hemorrhage from genital tract lacerations are essentially the
same. Patients who are experiencing hemorrhage from genital tract lacerations need one or
two large-bore IV sites, frequent recording of vital signs, accurate measurements of intake and
output from all sources (including blood), laboratory work, an indwelling urinary catheter,
oxygen, and pain medication. In addition, the physician or nurse-midwife examines the
perineum, vagina, and cervix to locate the source of bleeding. The postpartum nurse needs to
help the patient assume a lithotomy position, obtain bright lighting and examination
instruments, and prepare suction equipment. The nurse continually provides support and
reassurance to the patient and her family.
AWHONN’s Postpartum Hemorrhage Project

The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) launched the Postpartum
Hemorrhage Project to achieve the following goals: increase clinician recognition of women at greatest risk of
obstetric hemorrhage, increase early recognition of which women are bleeding too much, increase the
readiness of clinical team preparedness to successfully respond to obstetric hemorrhage, and track clinician
response to obstetric hemorrhage for improving future performance. Additional practice improvements include
the identification of barriers to treating obstetric hemorrhage and methods for effectively implementing similar
improvements in all hospitals in the United States. At https://www.awhonn.org, they provide additional
resources for health-care providers, including a video on quantifying blood loss (AWHONN, n.d.).
HEMATOMAS
A hematoma is a localized collection of blood in connective or soft tissue under the skin that
follows injury of or laceration to a blood vessel without injury to the overlying tissue. At the time
of injury, pressure necrosis and inadequate hemostasis occurs. This complication can result in
a large amount of blood loss and patient discomfort if not recognized rapidly. Risk factors for
hematoma formation include genital tract lacerations, episiotomies, operative vaginal
deliveries, difficult or prolonged second stage of labor, and nulliparity. Hematomas occur most
frequently in the vulva, but they can also occur in the vagina and in the retroperitoneal area
(Figs. 12-2 and 12-3).
Signs and Symptoms

The most common sign or symptom of a hematoma is unremitting pain and pressure. The pain
and pressure worsen if active bleeding continues; the uterus remains firm. When located in the
vaginal area, the patient often complains of a sensation of “heaviness” in the vagina and/or
rectal pressure. On examination of the perineal or vulvar areas, the nurse may notice a bluish
discoloration and bulging of the tissue at the hematoma site. If touched, the patient complains
of severe tenderness, and the clinician generally describes the tissue as “full.” If the hematoma
is large, signs of shock (e.g., tachycardia and hypotension) may be evident, and the patient
may exhibit an absence of lochia and an inability to void.
FIGURE 12-2 Vulvar hematoma.

FIGURE 12-3 Vaginal wall hematoma.
Assessment for the presence of a hematoma involves listening to the patient’s subjective
complaints, measuring vital signs, and examining the perineal and vulvar areas to identify a
bulging mass. To examine the perineal and vulvar gently have the patient lift the upper buttock,
and asks her to bear down. The nurse also needs to watch for behavioral signs and symptoms
of shock (previously described) and assess the patient’s and family’s understanding of what is
occurring.
If findings from the assessment are strongly suggestive of a hematoma, the nurse needs to
immediately notify the physician or nurse-midwife and implement pain relief measures. If the
hematoma is less than 3 to 5 cm in diameter, the physician usually orders palliative treatments
such as ice to the area for the first 12 hours along with pain medication and close observation
of the area for extension of the hematoma. After 12 hours, sitz baths are prescribed to replace
the application of ice in providing comfort and in facilitating reabsorption of the clot. A
hematoma larger than 5 cm may require incision and drainage with the possible placement of
a drain. This invasive procedure is performed in the operating room while the patient is
sedated with an anesthetic.
The health-care team must be particularly sensitive to the fact that large hematomas can
lead to shock. In this case, the physician orders aggressive treatment that includes IV fluids,
oxygen, frequent measurement of vital signs, urinary catheter placement, and strict intake and
output measurements to stabilize the patient before taking her to the operating room.
In the midst of the important interventions implemented to deal with the hematoma, the
nurse needs to remember that the family is watching and responding to events as they unfold.
Neither the patient nor the family may understand what they are seeing or experiencing. As the
various treatments and medications are administered, the nurse should explain each action,
along with the rationale for it. If the patient and her family can be involved, it is important to
allow them to make choices, so that they do not feel as powerless. The nurse can assist the
family by encouraging them to care for and bond with the infant as much as possible.
CASE STUDY
Patient Experiencing a Vulvar Hematoma

Francisca is a 20-year-old Mexican American gravida 1, para 1 who gave birth to a term, healthy baby boy,
weighing 9 lb 1 oz (4.1 kg) at 23:32 hours. She received an epidural for labor pain control, pushed for 3 hours,
and required a vacuum-assisted delivery. Her perineum required repair of a third-degree laceration. After birth,
the nurse discontinued the continuous epidural pump, placed ice on the perineum, completed the required 15-
minute checks (× 5), helped Francisca breastfeed, and assisted Francisca’s boyfriend in holding the baby and
taking pictures. On arrival to the mother-baby unit, Francisca requests pain medication and states that the ice
is helping some but that she wants to “stay on top of it.” She rates the pain as a 5 on a 10-point scale. The
admission vital signs and fundal location are within normal limits. An examination of Francisca’s perineum
reveals mild swelling and a normal amount of vaginal bleeding. Francisca is tired and asks that she be allowed
to sleep. Her boyfriend goes home to sleep, and the baby is taken to the nursery.
Two hours later, Francisca calls for her nurse and complains of intense burning, pain, and pressure “where I
had my stitches.” You examine her perineum and note an 8-cm bulging mass on her left vulva. When you touch
it with a gloved hand, Francisca says, “Oh, that is so tender! That hurts!”
1. What factors during birth placed Francisca at risk for development of a hematoma?
2. Name two appropriate nursing diagnoses for Francisca.
3. What are the expected outcomes for Francisca?
4. List four nursing interventions along with rationales.
THROMBOPHLEBITIS AND THROMBOSIS

Thrombophlebitis and thrombosis are terms that describe an inflammation of the venous
circulation and blood clot formation that typically occur in the lower extremities. The depth of
the inflammation and the location of the involved veins determine the severity of this
complication. Veins located above the fascia, such as the saphenous vein system, are
superficial, and distend easily, while veins below the fascia, such as the popliteal system, are
deep and less elastic.
During pregnancy and the puerperium, three thromboembolic conditions are of concern.
Superficial venous thrombosis involves the superficial saphenous venous system. Deep
venous thrombosis (DVT) may extend from the foot to the ileofemoral region. Pulmonary
embolism, a complication of DVT, occurs when part of a blood clot dislodges and travels to
the pulmonary artery, where it causes vessel occlusion and obstruction of blood flow to the
lungs.
Although incidence of postpartal thrombophlebitis and DVT is low and varies from
approximately 0.5 to 3 per 1,000 women, it is one of the leading causes of maternal mortality
(Centers for Disease Control and Prevention, 2020). The decline in incidence over the past 2
decades is largely attributable to early postpartum ambulation, which has become the standard
of care.
During the postpartum period, women are at a risk for venous thrombosis due to normal
physiological changes such as venous statis, hypercoagulation, and increased fibrinogen
levels, and in the second half of pregnancy, there is an increase in clotting factors VII, VIII, IX,
and X in preparation for minimizing normal blood loss during birth. Lower extremity venous
stasis results from the weight of the gravid uterus on the maternal inferior vena cava and pelvic
veins. Additional factors can drastically increase the risk, such as smoking, obesity, age
greater than 35 years, immobile or sedentary lifestyle, or a grand multigravida. Chronic health
problems such as inflammatory bowel disease, sickle cell disease, lupus erythematosus,
antiphospholipid syndrome, varicose veins, and pregnancy-related conditions such as pre-
eclampsia, operative vaginal delivery, cesarean birth, hemorrhage, and sepsis are all possible
precursors to the development of DVT. A woman with a positive history of DVT is also at
greater risk than one with no DVT history, and the risk of venous thromboembolism is higher
during the puerperium than it is during pregnancy (Rybstein & DeSancho, 2019).
Signs and Symptoms

Superficial venous thrombosis involves the superficial saphenous venous system. The most
common form of postpartum thrombophlebitis, superficial venous thrombosis, is characterized
by pain and tenderness in the lower extremity. Deep venous thrombosis is more common
during pregnancy and may extend from the foot to the iliofemoral region. It is associated with
unilateral leg pain, calf tenderness, and swelling. However, up to 50% of all individuals with a
DVT are asymptomatic. Signs and symptoms depend on the size, location, degree of vessel
occlusion, and development of collateral circulation around the clot. The classic presentation of
DVT involves pain, tenderness, edema, redness, and localized heat. The presence of a
palpable cord, changes in skin color (“milk” or “blue leg”), a decreased peripheral pulse, and a
circumference that is 2 cm larger (or more) in the affected extremity assists in the DVT
diagnosis (Fig. 12-4). Dorsiflexing the woman’s foot while her knee is extended may elicit a
positive Homans’ sign (resistance or discomfort in the calf or popliteal region) in the presence
of thrombophlebitis and thrombosis. However, there are other causes of calf pain upon
dorsiflexion such as strained muscles and contusions, and a positive Homans’ sign is
indicative of DVT in only around 50% of patients. Thus, a negative Homans’ sign does not rule
out DVT.
NURSING INSIGHT
Recognizing Signs and Symptoms of DVT
Additional signs and symptoms that may be associated with DVT include elevated temperature, cough,
tachycardia, hemoptysis, pleuritic chest pain, and increasing apprehension. The presence of dyspnea and
tachypnea may signal pulmonary embolism. Pulmonary embolism is a complication of DVT that occurs when
part of a blood clot breaks away and travels to the pulmonary artery, where it occludes the vessel and
obstructs blood flow to the lungs. Iliofemoral venous thrombosis is manifested by coolness of the entire
extremity, associated with edema and pain.
FIGURE 12-4 Deep venous thrombophlebitis.
Diagnostic Tools
The clinical signs and symptoms of a possible thrombophlebitis and DVT should alert the health-care provider
for the additional need for diagnostic testing so that an accurate diagnosis can be made and treatment started
promptly. Diagnostic methods such as compression duplex ultrasonography (real-time imaging and Doppler
flow studies) can be conducted to establish the diagnosis of DVT. If the results of these tests are equivocal,
magnetic resonance imaging (MRI) (a diagnostic test that uses electromagnetic energy to provide images of
the heart, large blood vessels, brain, and soft tissues) may be ordered to determine the extent of any pelvic
vein involvement. Additionally, a negative ultrasonography with high clinical suspicion for thrombosis may
warrant serial ultrasonography over the next few days, due to the low specificity of the test (Rybstein &
DeSancho, 2019). Other diagnostic tests include the ventilation-perfusion scan, spiral computed tomography
scan, and pulmonary arteriogram.
Labs
Venous Thrombosis
Labs for venous thrombosis include:
• D-dimer: A product of the degradation of fibrin by the circulating enzyme plasmin. A negative indicates low
risk for DVT, while a positive D-dimer is inconclusive and warrants further testing; it can indicate additional
disease processes or health conditions.
• Basic chemistry test: Assesses kidney function to determine the need for advanced spiral computed
tomography scan and pulmonary arteriogram (in cases of PE) with possible contrast dye that requires
normal kidney function to process.
• PT and aPTT: Coagulation studies are done to establish baseline, in case diagnostic testing is positive for a
blood clot. In this case, the woman will need to start anticoagulation therapy.
Due to the strong association of risk factors and the development of DVT, many institutions
implement prophylaxis treatment for high-risk populations. This includes patients who had
greater than a 3-day stay in the hospital (includes antepartum, birth, and postpartum), patients
on anticoagulant therapy antepartum, PPH >1,000 cc or required a blood transfusion,
postpartum infection, pre-eclampsia, multiple gestation, or history of prothrombotic medical
comorbidities such as lupus (Simon & Delaney, 2019).
Routine interventions for superficial venous thrombosis include the administration of
analgesics (nonsteroidal anti-inflammatory agents); rest with elevation of the affected
extremity; graduated compression stockings or intermittent pneumatic compression devices
along with increased fluid intake; and the local application of moist, warm packs. The nurse
should ensure that the weight of the warmed pack does not rest on the leg, causing
obstruction of blood flow.
FOCUS ON SAFETY
Avoiding Extremity Massage When DVT Is Suspected
If DVT is present or suspected, it is essential to refrain from massaging the affected area. This action could
loosen the clot and result in a pulmonary or cerebral embolism.
Treatment of DVT is use of low molecular weight heparin (LMWH) for at least 3 months
postpartum. The dose of LMWH is calculated by weight with enoxaparin given at 1 mg/kg
subcutaneously twice daily or 1.5 mg/kg once daily, and dalteparin at 100 U/kg twice daily or
200 U/kg once daily. Women must be educated on how to self-administer these injections, and
follow-up is necessary to monitor platelet levels and anti-Xa levels. Unfractionated heparin
(UFH) is another treatment for DVT but requires IV administration and hospitalization. Dose of
UFN includes a bolus of 5,000 U intravenously and 10,000 U or more subcutaneously or an
intravenous dose with adjustment to dose based on target therapy of the activated partial
thromboplastin time (aPTT) measuring 1.5–2.5 X control (Rybstein & DeSancho, 2019).
During hospitalization, the nurse should monitor the patient for signs of unusual bleeding
and make certain that the antidote for heparin (protamine sulfate) is readily available. Vital
signs should be measured at least every 4 to 6 hours, analgesics administered as needed, and
circulation to the affected extremity checked during every nursing shift. The circumference of
the affected extremity should be measured and recorded daily. Depending on the type of
treatment, additional laboratory testing of Pt and PTT and platelets counts will be done
frequently, requiring the nurse to be aware of blood draws and laboratory results that may
indicate worsening condition or the need to adjust medication treatment.
Warfarin sodium (Coumadin), an oral anticoagulant, is introduced before the patient’s
discharge, and during this time, the heparin therapy is tapered. The oral anticoagulant therapy
(warfarin sodium) is continued for a minimum of 3 months after birth and is safe for lactating
mothers. Use of this long-term therapy regimen mandates specific patient–family education
and support from the team of health-care providers. An important component of the discharge
teaching conducted by the nurse, dietitian, or pharmacist includes a discussion about all
medications, side effects, and potential interactions.
Patient Education
Teaching Patients About Aspirin and Anticoagulants
The nurse, pharmacist, or dietitian can initiate patient and family education about food and drug interactions.
Nurses do not always feel comfortable providing education on dietary topics, and the dietitian has the
knowledge to discuss this information with the patient and her family. Likewise, the pharmacist has greater
knowledge than the nurse about drug effects and side effects. A team approach works well with topics such as
these. Be sure to obtain an interpreter if needed and have written information available that the patient and her
family can take home.
During discharge teaching, the patient should be counseled on anticoagulant therapy to avoid medications
that contain aspirin (acetylsalicylic acid) and nonsteroidal agents such as naproxen and ibuprofen. Aspirin,
which acts as an antiplatelet agent and prevents blood clotting, can lead to a prolonged clotting time and can
significantly cause an increased risk of bleeding in a patient also taking an anticoagulant. Cranberry products
and herbal supplements such as anise, arnica, chamomile, clove, dong quai, fenugreek, feverfew, garlic,
ginger, ginkgo, Panax ginseng, and licorice may increase the risk of bleeding; Saint John’s wort decreases the
effect of the medication. If a patient is on coumadin, they need to be counseled on the interactions with vitamin
K. Ingestion of large quantities of foods high in vitamin K (e.g., green leafy vegetables, liver, and green tea)
may antagonize the anticoagulant effect of warfarin, making it ineffective.
The nurse should emphasize the importance of follow-up care for laboratory tests and
medication dosage adjustments. Avoiding trauma that may result in extensive bruising, using
safe-care practices to avoid bleeding, and instructing the patient and her family to be alert for
signs that indicate the anticoagulation therapy is excessive are also important topics for
instruction. Short-term referral to a home health nurse should be considered; the hospital
nurse may need to mention the need for this referral to the physician.
MEDICATION: Warfarin sodium (Coumadin)

(war-fa-rin)
Pregnancy Category: X
Indications: Prophylaxis and treatment of venous thrombosis, pulmonary embolism, and atrial fibrillation with
embolization
Action: Interferes with hepatic synthesis of vitamin K-dependent clotting factors (II, VII, IX, and X)
Therapeutic Effects: Prevention of thromboembolic events
Pharmacokinetics: Well absorbed from the GI tract after oral administration. Crosses the placenta but does
not enter breast milk. Protein binding: 99% binds to plasma proteins, thereby delaying the effects of warfarin.
Route and Dosage: Orally; dosage adjusted on the basis of international normalized ratio (INR) results (range
is 2.5 to 10 mg daily)
Contraindications and Precautions: Drug-drug interactions occur with NSAIDs, diuretics, antidepressants,
steroids, some antibiotics and antifungals, vaccines, vitamin K, and aspirin, which may increase the response
to warfarin and increase the risk of bleeding. Chronic alcohol ingestion may decrease the action of warfarin;
acute alcohol ingestion may increase the action of warfarin.
Even after the drug is discontinued, its effects may continue for up to 10 days. Warfarin dosage must be
individualized on the basis of prothrombin time results. The INR is now used for dosage adjustments. A normal
INR is 2.0 to 3.5.
Adverse Reactions and Effects: Overdosage leads to excessive blood loss that may appear via
gastrointestinal bleeding, bleeding from the gums, nosebleeds, petechiae, excessive bruising, excessive
menstrual flow, hematuria, etc. The patient begins with heparin therapy for anticoagulation and transitions to
warfarin. Because normal clotting factors circulate in the patient’s bloodstream routinely, several days of both
heparin and warfarin therapy may be required for the anticoagulant effect.
1. The patient and family must receive detailed information regarding follow-up care and drug-drug, drug-herb,
and food-drug interactions.
2. Instruct the patient to notify the doctor of excessive bruising, take warfarin at the same time each day, and
to avoid activities that could result in a bleeding injury.
3. Be sure the patient receives instructions on foods to minimize or avoid. (Involve the dietitian.)
4. Instruct the patient to carry identification describing medication regimen at all times and to inform all health-
care personnel caring for the patient before laboratory tests, treatment, or surgery.
5. Emphasize the importance of frequent laboratory tests to monitor coagulation factors.
Source: Data from Vallerand, A. H., & Sanoski, C. (2021). Davis’s drug guide for nurses (17th ed.).
Philadelphia, PA F.A. Davis.
Pulmonary Embolus
The abrupt onset of chest pain, dyspnea, shock, diaphoresis, syncope, and anxiety in a patient
with DVT signals a major complication, pulmonary embolus (PE). PE is a life-threatening
emergency that results from the breakup of the clot with migration of pieces through the heart
to the lungs. Emergency treatment for this potentially fatal complication involves the “ABC”
response used for any cardiorespiratory event. The nurse should immediately call for
assistance, administer oxygen, obtain the crash cart, and begin cardiopulmonary resuscitation
if necessary. Both the physician and respiratory therapist are important responders. Assuming
chest compressions are not needed, the nurse should elevate the head of the bed and apply
an automatic blood pressure machine, cardiorespiratory monitor, and pulse oximeter. If not
already in place, a large-bore IV line must be started immediately, so that fluids, heparin, and
pain medication (usually morphine) can be readily administered. Once stabilized, patients with
a PE are routinely transferred to a critical care unit for further care.
If the PE occurs while the patient is still recovering from childbirth, ensuring care for the
newborn and support for the patient’s family are paramount. Until the patient’s condition
improves, limitations are placed on visitors. This arrangement usually means that the family
can remain with the infant. In this situation, the postpartum nurse can debrief and provide
explanations to the family about events and possible future care requirements. If the patient
survives, both she and her family will need detailed instructions concerning the prevention of
thrombus reoccurrence. They also need to understand that the patient is at a much greater risk
for the subsequent development of a DVT, even in the absence of another pregnancy.
PUERPERAL (POSTPARTUM) INFECTIONS

Puerperal infection refers to a bacterial infection that occurs within 28 days after miscarriage,
induced abortion, or childbirth. Puerperal infections are one of the leading causes of maternal
morbidity and mortality worldwide with approximately 750,000 women dying annually as
estimated by the World Health Organization. Infections during the puerperium most commonly
involve the endometrium (endometritis), operative wound (cesarean incision; episiotomy),
urinary tract, and breasts (mastitis). Septic pelvic thrombophlebitis may also occur. Certain
factors place a woman at risk for developing any of these infections, including:
■ Poor hygiene
■ Low socioeconomic status
■ Smoking
■ Malnutrition
■ Obesity
■ Comorbidities: diabetes, hypertension, immunocompromised
■ Infections in pregnancy: sexually transmitted infections, GBS, UTIs, MRSA
Endometritis (Metritis)
During the immediate postpartum period, the most common site of infection is the
endometrium, or lining of the uterus (Fig. 12-5). Endometritis is an inflammation of the uterine
lining that usually starts at the placental site and spreads to the entire endometrium. It can
extend to the fallopian tubes, ovaries, pelvic perineum, pelvic veins, or pelvic connective tissue
(Venes, 2021).
FIGURE 12-5 Postpartum endometritis.
This infection presents with a temperature elevation over 101°F (38.4°C), often within the
first 24 to 48 hours after childbirth, followed by tachycardia, uterine tenderness, suprapubic
pain, subinvolution, and malaise. Heavy, foul-smelling lochia (a later sign that occurs when the
entire endometrium is involved) is noted when anaerobic organisms are present; scant,
odorless lochia is noted when beta-hemolytic Streptococcus is present. Endometritis often
develops after the woman has been discharged, and follow-up in the home or clinic by a nurse
or primary care provider may offer the first opportunity to identify infectious processes.
Wound Infections
Wound infections in the postpartum period can result from birth trauma, a procedure such as
an episiotomy, or a surgical site infection from a cesarean section. The rate of perineal wound
infection is up to 10% and surgical site infection up to 5%. Perineal infection is often due to
trauma with the highest risk from a third-degree or fourth-degree laceration. Symptoms include
fever, pain at the site, purulent drainage, nonapproximation of sutures, and repair breakdown.
One concerning complication is the development of a fistula that develops between the vagina
and the rectum.
Cesarean births are a genuine concern for surgical site infection (SSI) in the postpartum
period. Reducing the occurrence of an SSI is a major priority with several leading health-care
organizations developing a consensus bundle on preventing SSI (Pellegrini et al, 2017). SSI
can result in an increase in maternal morbidity, extended hospitalizations requiring antibiotics,
increased medical costs, and hospital readmissions. Developing an SSI can lead to abdominal
cellulitis, abscess, wound dehiscence, and in extreme cases necrotizing fasciitis.
Mastitis
Mastitis is an infection and inflammation of the mammary glands seen in about 10% of
lactating women (Sommers, 2019). The infection is usually unilateral and develops after the
flow of milk has been established. The most common causative organism is the hemolytic
Staphylococcus aureus, introduced from the infant’s mouth through a fissure, crack, or
abrasion in the nipple. Other, less common causes include Haemophilus parainfluenzae,
Haemophilus influenzae, Escherichia coli, Streptococcus, and Methicillin-resistant
Staphylococcus aureus. The infection involves the ductal system, causing inflammatory
edema, enlarged axillary lymph nodes, and breast engorgement with obstruction of milk flow
(Fig. 12-6). Symptoms include:
■ Fevers or chills
■ Pain or tenderness in the affected breast
■ Reddish or pink area on the affected breast
■ Tenderness to touch
■ Warmth at the infection site
■ Generalized aches, fatigue, and malaise
■ Nipples with cracks, fissures, or sores
■ Axillary adenopathy of the affected side
■ Purulent drainage from the nipple or with expressing milk
Diagnosis is often based on clinical signs and symptoms. In some cases, culture of the
breast milk can help determine the appropriate antibiotic to treat especially in cases of
resistant bacteria (Sommers, 2019).
FIGURE 12-6 Mastitis usually occurs several weeks after childbirth. The axillary lymph nodes
are enlarged, and there is a warm, tender, hardened area on the affected breast.
Treatment centers on antibiotic therapy (e.g., cephalosporins and vancomycin). Many

antibiotics are safe to give to the mother who is breastfeeding, and the choice of antibiotics
often allows the mother to continue breastfeeding. All mothers who start on antibiotics need to
complete the course of therapy even if they feel better to prevent recurrence and reduce the
chance of developing antibiotic-resistant bacteria. Additional management includes the
application of heat or cold to the breasts for comfort, hydration, and analgesics. Part of
treatment is to ensure breastfeeding is maintained and the infant has a good latch and suck.
Proper hand hygiene should be maintained with hand washing before and after feedings.
Frequent feeding should occur to maintain lactation, and the woman may empty the breasts
every 2 to 4 hours by breastfeeding, manual expression, or breast pump. When feeding, the
mother should always start with the affected breast and change positions of the infant when
feeding so that they are drawing milk from all the milk ducts and lobes equally and emptying
the breasts completely. If breastfeeding is too painful, then manual expression or pumping
should occur every 2 to 3 hours. After feeding, the breast should be dried, and if the breast
pad or clothing worn such as a bra is wet then it should be replaced with a clean, dry one.
Mastitis usually occurs after hospital discharge, and an important component of nursing care
includes teaching the breastfeeding mother about signs of mastitis. Women should be
instructed to avoid breast creams, which may block the natural oil secreted by the Montgomery
tubercles on the areolae (the darkened area around the nipple). Prevention remains
paramount, and mothers should be informed of strategies to prevent cracked nipples and signs
to report immediately to the health-care provider (Sommers, 2019).
MRSA
Methicillin-resistant Staphylococcus aureus (MRSA) infections have become increasingly
more common in the United States. MRSA colonization is a frequent finding with pregnant
women and is associated with cesarean and episiotomy incision infections and mastitis.
Postpartum mastitis associated with MRSA is more likely to produce abscess and requires
longer recovery times, possibly because of the virulence of MRSA. Women who do not
respond to first-line antibiotic therapy (e.g., trimethoprim-sulfamethoxazole, clindamycin, and
rifampin) may require incision and drainage of the breast abscess, along with breast milk
culture. Breastfeeding should continue on the affected breast as MRSA is not transmitted
through human milk. However, MRSA is transmitted through direct contact with an open lesion
or purulent drainage, and this area should be avoided to prevent MRSA transmission. Most
often, mothers can be treated during the postpartum period with an antibiotic that is compatible
with breastfeeding. Antibiotic treatment should be initiated in infants who test positive for
MRSA. NICU infants who have increased risk of morbidity and mortality may have additional
precautions to minimize any risk, such as mothers wearing gown and gloves when coming in
contact with their infant, and in some cases, breast milk may be cultured to determine the
presence of MRSA (Centers for Disease Control and Prevention, 2019).
Nursing Assessment
The presence of fever often indicates puerperal infection. According to the U.S. Joint
Commission on Maternal Welfare, postpartum febrile morbidity is defined as an oral
temperature of greater than or equal to 100.4°F (38°C) on any two of the first 10 days
postpartum or 101.6°F (38.7°C) or higher during the first 24 hours, taken by a standard
technique at least four times a day. A fever of 102.2°F (39°C) or greater within the first 24
hours is often associated with severe pelvic sepsis, usually resulting from Group A or B
Streptococcus (Dashe et al, 2018) (Table 12-3).
Assessment is central to the delivery of safe, effective postpartal nursing care. The nurse
must pay ongoing, careful attention to the patient’s mental status and to her vital signs,
breasts, fundus, lochia, incisions, and urinary status. Temperature elevation may be the first
indication of an infection. If an elevated temperature is combined with any of the following
signs and symptoms, the nurse must notify the primary care provider immediately: tachycardia,
uterine or fundal tenderness or pain, foul-smelling lochia, an absence or decrease in lochia,
chills, decreased appetite, malaise, elevated white blood cell count (WBC), back pain
(costovertebral angle tenderness [CVAT]), generalized aching, headache, dysuria, urinary
frequency or retention, wound drainage, erythema, and edema. Early, ongoing collaborative
treatment can then be initiated.
Labs
Puerperal Infection
To detect sources of puerperal infection, the nurse can anticipate that the following samples are likely to be
obtained:
• Complete blood count (CBC) with differential
• Blood cultures if sepsis is suspected
• Urinalysis with culture and sensitivity
• Cervical, uterine, or wound culture as needed
All bacterial puerperal infections require treatment with antibiotics. The nurse can encourage
rest and increased fluid intake and instruct the patient about the importance of increasing
protein and vitamin C in her diet. In many hospitals, a nurse can refer a patient to a dietitian for
instruction without a physician’s order.
TABLE 12-3
Postpartum Infections
TYPE OF INFECTION RISK FACTOR ONSET SIGNS AND SYMPTOMS
Mastitis Milk stasis, plugged milk 2 to 4 weeks postpartum General malaise and
duct, infrequent fatigue, fevers, chills;
breastfeeding, fatigue, tender, hardened, warmth,
nipple trauma, primiparity or reddened area on breast
(usually only one); a
triangular flush underneath
the affected breast is an
early sign, nipples with
cracks or fissures, enlarged
axillary lymph nodes on the
affected side
Endometritis Cesarean birth, prolonged 2–4 days postpartum Prolonged fever >100.4°F
labor, prolonged rupture of (38°C), heavy, dark, or foul-
the membranes, PPH, smelling lochia (later sign;
multiple vaginal signals anaerobic
examinations, manual organisms) or scant,
placental removal, retained odorless lochia (signals
placental fragments, beta-hemolytic
internal electronic FHR Streptococcus), uterine or
monitoring, low abdominal tenderness or
socioeconomic status, poor cramping, low back pain,
nutrition, young age, chills, poor appetite,
diabetes, prior genital malaise, tachycardia,
infection, lapse in aseptic cramping pain, increased
technique, anemia, white blood cell count
smoking, nulliparity, (WBC) (above 20,000–
operative vaginal delivery, 30,000 mm3)
poor postpartum perineal
care
Wound infection Poor hygiene, poor nutrition Early: 48 hours Late: 6–8 Pain, foul-smelling
status, fecal contamination, days discharge, edema, low-
hematoma, obesity, grade fever, sudden chills,
diabetes, hypertension, high fever, abdominal
immunosuppression, tenderness, erythema,
malnutrition, anemia, edema, warmth of incision,
hemorrhage, prolonged drainage from the incision
labor, chorioamnionitis,
prolonged rupture of the
membranes, hematoma,
perioperative hair removal,
appropriate prophylactic
antibiotics, long
complicated surgery
Urinary infection Catheterization, multiple Any time during pregnancy Dysuria, frequency, burning
vaginal examinations, poor or after childbirth on urination, difficulty
postpartum hygiene, genital voiding and/or urinary
tract trauma, epidural retention, costovertebral
anesthesia, cesarean birth, angle tenderness back or
premature rupture of the suprapubic pain,
membranes, poor hematuria; fever, fatigue,
nutritional status, history of nausea, vomiting
UTIs during pregnancy,
diabetes, decreased
bladder sensation following
birth
Septic pelvic thrombosis Cesarean birth, prolonged 48 hours to 4–6 weeks Fever >102.2°F (39°C) with
labor with potential pelvic postpartum; ovarian vein spikes after initiation of
vein endothelial damage, thrombophlebitis onset antibiotic therapy,
lower extremity trauma, usually within 1 week abdominal and/or back
genital tract lacerations, pain, chills, increased pulse
history of varicosities, (resting tachycardia), few
immobility, operative or absent bowel sounds
vaginal delivery, obesity,
multiple vaginal
examinations, advanced
age, infection/septicemia,
inherited or acquired
hypercoagulation condition
Sources: Pellegrini et al. (2017); Sommers (2019), World Health Organization (2015), Venes (2021).
Comfort measures are as important in facilitating the patient’s full recovery as the
administration of antibiotics. Cool showers, sitz baths, warm compresses applied to the
breasts, therapeutic touch and massage, soothing music, relaxation techniques, pain
medications, and antipyretics are all strategies to promote patient well-being. Because of their
anti-inflammatory effect, many physicians order a nonsteroidal anti-inflammatory medication to
serve as an antipyretic and analgesic. Throughout the course of treatment, health-care team
members also need to provide education to the patient and her family regarding diagnosis and
prognosis, treatment plan, measures to promote good hygiene, and follow-up care.
Although the infection may be easily treated and short-lived, any postpartum complication
can psychosocially affect a patient and her family. Prolonged treatment or hospitalization may
create financial hardships, negatively affect family relationships and attachment with the infant,
or result in psychoemotional or spiritual crises. Referrals to the social worker, hospital chaplain
or pastor, financial counselor, lactation consultant, community health nurse, or counselor are
an essential component of holistic care. As the health-care team member who is most
consistently present, the nurse has a responsibility to help the patient and her family identify
when such referrals would be beneficial and to serve as an advocate to ensure that the patient
receives these services.
Patient Education
Risk Factors for Puerperal Infection
The prevailing practice of shorter hospital stays after birth makes the nurse’s role in educating the new mother
and her family about signs and symptoms of postpartum infection vitally important. The nurse should alert the
patient about antepartum or intrapartum events that are risk factors for the development of a postpartum
infection and make certain the family understands the importance of promptly notifying their care provider if
any symptoms occur.
• Wash your hands before and after going to the bathroom, when changing pads, changing the baby’s diaper,
etc. Hand washing with friction removes infection-causing microorganisms.
• Use a squeeze bottle with warm water to cleanse the perineum, pat the perineum dry, and remove and
replace peripads from front to back. Front to back patting and peripad removal/application prevents bringing
rectal organisms forward to the perineum and vagina.
• Change your peripad at least every 3 to 4 hours. A soiled peripad can encourage the growth of bacteria that
can enter the urethra or vagina.
• Drink extra fluids (eight 8-ounce glasses of water) to increase urine production. The increased blood flow and
urine production will decrease the stagnation of microorganisms in the urinary tract and help prevent urinary
tract infection.
• Wash incisions with soap and water. Be sure to dry the incision completely. A dry incision is less likely than a
wet one to promote bacterial growth.
• If breastfeeding, wash hands before each feed, feed the infant every 2 to 3 hours, and alternate feeding
positions. Be sure the baby gets as much of the nipple and areola in their mouth as possible. These actions
reduce the likelihood of injury to the nipple.
• For the diabetic mother, maintain glycemic control.
• Encourage lifestyle changes, smoking cessation, and proper nutrition.
Essential Information
• Notify your health-care provider if you develop pain, redness, or swelling at the site of any incision.
• Notify your health-care provider if you develop a fever of 100.4°F (38°C). (If you are breastfeeding, a
temperature elevation to 100.4°F [38°C] may occur when your milk production begins.)
Mitigating Risk for Infection
If the postpartum patient is at risk for a postpartum infection, the nurse needs to communicate this information
to health-care providers and family members who may be involved in helping her after she goes home. Some
hospitals routinely follow new mothers into the home with a postpartum and newborn visit by a registered
nurse. The lactation consultant or breastfeeding support group, newborn’s physician, or public health nurse
should also be notified of events during labor, birth, or postpartum that they should address the first time they
see the new mother following discharge.
POSTPARTUM PSYCHOSOCIAL COMPLICATIONS

The focus on physiological recovery and health in the childbearing woman and her infant can
easily result in an inaccurate assumption that all is well with the new family. Beyond the
physical needs of the new mother lies a gamut of emotional, spiritual, relational, and
socioeconomic concerns to which the nurse must be sensitive. Because most people consider
childbearing a joyful time in life, the new mother who experiences negative emotions or who
cannot cope with new demands on her time, energy, or priorities may struggle to recognize her
need for help. Moreover, even if she recognizes her limitations and knows she needs help, the
new mother may be reluctant to ask for help. Whether working in the hospital, in home care, in
a clinic, or in a physician’s office, the nurse can be a lifeline for the woman who experiences
postpartum psychosocial complications. These complications include postpartum blues,
depression, psychosis, panic disorder, and the long-term sequelae from abusive relationships,
homelessness, and access to care.
Postpartum Blues
Postpartum blues are a common emotional response of periods of happiness followed by
periods of tearfulness. Fifty to eighty percent of all postpartum women will experience some
degree of postpartum blues within the first 2 weeks after childbirth. Blues are usually self-
limiting and resolve by 10 days postpartum (Venes, 2021). Signs and symptoms include
tearfulness, mood swings, anxiety, fatigue, sadness, insomnia, forgetfulness, and confusion.
Often, extra rest, reassurance, and therapeutic listening help alleviate many of these issues.
Incidence, Definition, and Risk Factors
Fortunately, most postpartum women recover from the blues and are able to enjoy their
newborns and families. However, 10% to 20% of postpartal women progress beyond the baby
blues into postpartum depression (PPD), which occurs within 6 months postpartum (Venes,
2021). PPD has a significant health effect on the woman, infant, and other family members.
Mothers with a history of PPD are more likely to experience mental health disorders, retain
pregnancy weight, be unable to return to work at the expected time, become homeless, and
report a lower quality of life (Slomian et al, 2019). Infants with mothers with PPD display more
infections, sleep interruptions, colic, higher pain response, and an overall increased risk in
morbidity and mortality (Slomian et al, 2019). Children of depressed mothers have a greater
likelihood of delayed psychological and cognitive development and are at higher risk of
avoidance and distressed behavior. Infants of depressed mothers who exhibit withdrawn,
unresponsive, or negative behavior are more likely to be fussier, vocalize less, and make fewer
positive facial expressions than infants of mothers who are not depressed.
Signs and Symptoms

Symptoms of PPD include depressed mood or decreased interest/pleasure in previously
enjoyable activities, insomnia or hypersomnia, lack of appetite or weight loss, restlessness,
anxiety, inability to cope, and feelings of hopelessness (Box 12-3). The woman may have a
decreased interest in the baby or may be overly concerned that “something bad” is going to
happen to the baby. These fears may be expressed in a panic attack with hyperactivity and an
inability to make decisions or prioritize. Male partners of women suffering from PPD report
feelings of being anxious, depressed, overwhelmed, inadequate, fearful, isolated, stigmatized,
and extremely frustrated. Recognized risk factors for PPD include an undesired/unplanned
pregnancy, a history of depression or other mental health disorder, a history of PPD in
previous pregnancies, recent major life changes such as the death of a family member or
moving to a new community, an infant with a disability or chronic condition, lack of family or
social support, financial stress, marital discord, adolescent age, low self-esteem, history of
substance abuse, and homelessness.
Assessment
Screening for the presence of PPD risk factors should begin with the first prenatal visit. The
office or clinic nurse may be the first health-care provider to obtain basic information, such as
educational level, living conditions, financial stressors, whether the pregnancy was planned or
unplanned, support systems available for the pregnant woman, and family involvement and
attitudes of its members toward the pregnancy. If the nurse, physician, social worker, or other
health-care team member identifies risk factors, these should be noted in detail on the prenatal
record. If prenatal support groups are available, the woman should be referred to one of them
to minimize the risk for PPD.
BOX 12-3
Signs and Symptoms of Postpartum Depression

Anorexia or weight loss Excessive fears about the infant’s
health/safety
Insomnia/fragmented sleep Feelings of worthlessness or excessive guilt
Fatigue or loss of energy Negativity, irritability
Inability to concentrate Intense mood swings
Anhedonia Flat affect
Withdrawal Feelings of hopelessness
Decreased self-esteem Decreased interest and functioning in both
self and infant care
Suicidal thoughts Depressed mood almost every day for at least
2 weeks
Infant neglect or abuse Recurrent thoughts of death
The postpartum nurse needs to be aware of previously identified risk factors. A personal
history of a mood disorder or a family history of a mood disorder, mood or anxiety symptoms
during the prenatal period, and postpartum blues are factors that increase the risk for PPD.
Moreover, as the nurse carefully assesses the new mother and her interaction with the baby,
other risk factors may be noted. Some of these may include unmet pregnancy or labor and
birth expectations resulting in feelings of failure, a delay in a prolonged sleep and rest period,
and a demanding newborn without the presence of family members to help. A new mother’s
continued dependency on caregivers despite adequate sleep and apparent control of
postpartum discomforts may constitute another signal that requires close observation. If the
new mother does not respond to her infant’s needs or demonstrate bonding or attachment
behaviors, these actions require follow-up. The hospital nurse’s primary responsibility is to
detect comments or behaviors that need to be referred to the social worker, home health
nurse, physician, chaplain, lactation consultant, and community agencies.
If a home health nurse does not visit the newborn and mother within the first week, the well-
baby checkup that follows 1 to 2 weeks after the hospital discharge may offer the first
opportunity to assess the mother-baby dyad. In this setting, the nurse needs to be alert for
subtle cues from the new mother, such as making negative comments about the baby or
herself, ignoring the baby’s or other children’s needs, and the mother’s physical appearance.
Does she look unkempt or exhausted? Is the baby clean and dry? Does the new mother say
something about needing more help at home? Did she come to the office or clinic with the
baby (and other children) or by herself?
What to Say
Exploring the New Mother’s Feelings
In a private area, the nurse should take time to explore the new mother’s feelings. A nonthreatening way to
open the dialogue might be to say: “Tell me how the first few days at home have gone.” This statement
provides the new mother with an opportunity to share both positive and negative impressions. Do not “fill the
silence” if the new mother does not respond immediately. She may need to process her thoughts before
speaking. Be aware, too, of nonverbal cues and body language, such as affect, eye contact, and open or
closed posture.
Assessment Tools
Assessing for PPD

If the nurse believes that the new mother is demonstrating signs and symptoms of PPD, several depression
screening tools are available. These include the Edinburgh Postnatal Depression Scale, the Postpartum
Depression Screening Scale, the Patient Health Questionnaire, and Beck Depression Inventory II (Arnold et al,
2020; Beck et al, 2006). Because they are highly predictive, these scales are valuable tools that can be
combined with the informal interview during a routine postbirth checkup.
Cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) have been shown
to be beneficial in treating perinatal depression. CBT is an action-oriented approach that treats
maladaptive thinking as the cause of pathological behavior and “negative” emotions. IPT is a
treatment in which the woman is educated about depression and its symptoms and her relation
to the environment, especially social functioning. If the depressive symptoms are moderate to
severe and do not respond to nonpharmacological treatment, the health-care provider often
prescribes a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine
reuptake inhibitor (SNRI) antidepressant. If the woman is experiencing sleep disturbances,
tricyclic antidepressants may be useful. (Table 12-4).
Therapies for Postpartum Depression

The nurse may be asked about various complementary therapies that may help new mothers
and their families deal with PPD. Hypnosis enhances relaxation and an ability to focus on daily
tasks. Exercise has been shown to increase levels of neurotransmitters that communicate with
brain cells to increase feelings of euphoria. Saint John’s wort (Hypericum perforatum) is an
herb that has been approved in Germany for the treatment of anxiety and depression, skin
inflammation, blunt injuries, wounds, and burns. It is believed to bind with neuroreceptors in
the brain to prevent a response to the “depression” neurotransmitters. Saint John’s wort
cannot be used in combination with SSRI antidepressants. Biofeedback promotes relaxation
and decreases anxiety; meditation helps the woman to focus on “being rather than doing,”
thereby relieving stress and tension; and humor has been shown to decrease anxiety, fear,
tension, anger, and frustration and stimulate the immune system. Acupuncture, aromatherapy,
bright light therapy, massage, and dietary calcium are other complementary therapies that may
be beneficial for women with mild depressive illness according to the National Center for
Complementary and Alternative Medicine.
TABLE 12-4
Medications Used to Treat Postpartum Depression
CLASS DRUG INDICATIONS MATERNAL SIDE INFANT
EFFECTS BREASTFEEDING
EXPOSURE
EFFECTS
SSRIs Citalopram, Anxiety disorders and Abdominal pain, All SSRIs have been
Escitalopram, depression diarrhea, dry mouth, detected in human
Fluoxetin, Fluvoxam anorexia, decrease milk. S/E in infant
Paroxetin, Sertraline libido, drowsiness adverse events
reported include
uneasy sleep, colic,
irritability, poor
feeding, and
drowsiness. The FDA
indicated that
fluoxetine should not
be use by nursing
mothers.
SNRIs Venlafaxine, Anxiety disorders, Abdominal pain, Venlafaxine can be
Duloxetine, depression diarrhea, dry mouth, found in the plasma
Desvenlafaxine anorexia, sexual of most breastfed
Doxepin dysfunction, abnormal infants, but no proven
dreams, insomnia, drug-related side
nervousness, effects.
weakness Monitor infant
sedation and weight
gain.
TCAs/heterocyclics Amitriptyline, Anxiety disorder, Lethargy, sedation, Limited data;
Amoxapine, depression hypotension, urinary nortriptyline
Clomipramine, retention, sexual undetectable in infant
Desipramine, dysfunction, dry eyes, serum, no proven
Doxepin, Maprotiline, vision changes, adverse effects
Nortriptyline, constipation
Imipramine
Other antidepressants Bupropion, Depression Headache, nausea, Very limited data,
Mirtazapine vomiting, dry mouth, ranging from
constipation, weight asymptomatic with
gain undetectable infant
serum levels to
concerns with
irritability and
seizures
Antipsychotic Quetiapine Bipolar, schizophrenia Dizziness, weight Sedation
gain, sedation
Mood stabilizer Lithium Postpartum psychosis Fatigue, headache, Elevated TSH
impaired memory,
ECG changes,
abdominal pain,
anorexia, diarrhea,
vomiting
Natural/herbal St. John’s wort, Depression Poorly excreted into
Omega 3 fatty acids human milk,
drowsiness, lethargy
Source: Sriraman et al (2015); Vallerand and Sanoski (2021).

Definition, Incidence, and Onset
Postpartum psychosis is a rare but severe form of mental illness that seriously affects not only
the new mother but also the entire family. The incidence is low, occurring in .25 to .6 per 1,000
live births (Bergink, Rasgon, & Wisner, 2016). Its onset may be dramatic, occurring within the
first 6 months and most often between the third and sixth day postpartum (Venes, 2021).
Women with pre-existing psychosis, especially bipolar disorder, are at the greatest risk for
postpartum psychosis, and health-care providers need to be aware of risk factors and the need
for early follow-up and identifications.
Postpartum psychosis may present with symptoms of PPD. However, the distinguishing
signs of psychosis are hallucinations, delusions, agitation, confusion, disorientation, sleep
disturbances, suicidal and homicidal thoughts, and a loss of touch with reality. This condition
may also resemble a sudden manic attack. Mothers who are in a manic state require constant
supervision when caring for their infant; they are frequently too preoccupied to tend to their
infant’s needs.
Recognizing Behavioral Cues That Signal Postpartum Psychosis
When providing hospital and community care for postpartum women, the nurse and other health-care
providers should be alert to behavioral cues that may signal psychosis. Tell the doctor if a patient:
• Demonstrates manic behavior, hyperactivity, and agitation
• Reports auditory hallucinations to inflict harm to the infant
• Voices delusions that the infant is dead, defective, or the birth did not occur
• Voices excessive complaints
• Exhibits obsessive concerns about the baby’s health and welfare
• Feelings of suspicion and fear
• Restlessness
• Feeling very confused or loss of reality
• Signs of depression, low mood, isolation, withdrawn, or lacking energy
Infanticide (the killing of an infant) is as high as 4% in women with postpartum psychosis.
Because of this danger and the loss of touch with reality, postpartum psychosis is a true
emergency. The woman must be hospitalized, and mental health experts must become
involved in her care as quickly as possible. Immediate treatment usually includes
antidepressant medications, mood stabilizer medications (e.g., lithium and valproic acid),
antipsychotic medications (e.g., chloropromazine, thioridazine, and trifluroperazine), and
antianxiety medications (benzodiazepines—alprazolam, chlordiazepoxide, diazepam).
Treatment may include long-term cognitive behavioral and psychotherapy therapy with a
trained therapist. In other cases, electroconvulsive therapy may be required, which can result
in rapid results of improvement (National Health Service, 2017).
Childbirth-Induced Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a psychological reaction occurring after experiencing
a highly stressful event (e.g., wartime combat, physical violence, or natural disaster) that may
be characterized by depression, anxiety, flashbacks, recurrent nightmares, and avoidance of
reminders of the event. For some women, a traumatic birthing process causes the
development of PTSD. Women at risk include those with a prior history of life trauma, those
who experienced a negative delivery, low coping ability, fear of delivery, lack of control during
the delivery, history of mental health disorders, low social supports, low income, young age,
primiparity, and multiparity (Dekel, Stuebe, & Dishy, 2017). Routinely screening all childbearing
women for a past history of trauma can aid in the early identification of those who may be at
increased risk of PTSD after childbirth and facilitate the initiation of early treatment.
Summarizing Postpartum Psychosocial Nursing Care

Perinatal nursing offers an opportunity to develop a therapeutic relationship with a woman and
her family during one of the most vulnerable times in their lives. Most pregnancies are both
planned and desired, but physiological and psychosocial adaptations to the pregnancy, birth,
and expanded family present challenges that require maturity and flexibility. The nurse can
become involved with the childbearing family during the first prenatal visit. As the pregnancy
progresses, the nurse becomes increasingly familiar with the woman and her family’s lifestyle,
stressors, successes, disappointments, and challenges. The postpartum nurse is at a distinct
disadvantage because of the limited time a woman remains hospitalized after birth. However,
any nurse, regardless of care setting or time constraints, can develop an attentive ear and
sensitivity. By doing so, the nurse is then able to promote health and well-being for the new
mother, her newborn, and the family.
During the postpartum period, the nurse can provide information that stresses the
importance of asking for help if the patient feels overwhelmed. Promoting care and activities
that allow the new mother and her family to attach to the infant is vitally important. Examples of
bonding-oriented nursing care include rooming-in, decreasing sensory stimuli so that the family
can focus on one another, and limiting visitors (if the patient desires). The postpartum nurse
should note negative comments the patient makes about herself, her family, or the newborn
and encourage the patient to talk about her expectations for both herself and the family. If the
pregnancy and birth were difficult, the patient may be disappointed in herself and “blame” the
baby for the difficulties.
Moreover, if the patient is exhausted and requires extra rest, the nurse can help inform her
friends and family about this need. The nurse should give the patient permission to send her
newborn to the nursery without feeling guilty, so that when she awakens, she can enjoy the
newborn rather than becoming frustrated by his demands. It is paramount for the nurse to
remain sensitive to patients who are not coping well in the hospital and advocate for follow-up
by a home health nurse or social worker.
After discharge, the nurse in the office or clinic can use waiting time for conversation and
make note of any physical characteristics that may indicate the need for some respite time
from the demands and responsibilities of parenthood. The nurse should become familiar with
available community support services such as a Mother’s Day Out to which the mother can be
referred. It is also important to involve the collaborative team—the physician, lactation
consultant, social worker, and spiritual advisor—in the patient’s care.
SUMMARY POINTS
■ Postpartum hemorrhage may occur early (within the first 24 hours after birth) or late (after the first 24 hours
but within 12 weeks after childbirth). Thrombophlebitis is an inflammation of the venous circulation and blood
clot formation that typically occurs in the lower extremities. Treatment involves analgesia, bedrest with
elevation of the affected extremity, compression stockings or devices, application of moist heat, and
anticoagulant therapy. If thromboembolic disease is suspected, the affected area should never be massaged
because this action may cause dislodgement of the clot and the potential for a pulmonary embolism.
■ Puerperal infections may involve the uterus, urinary system, incisions, and breasts. Each type of infection
has common and unique risk factors, onset, signs and symptoms, causative organisms, and complications.
■ Postpartum “blues” are common and usually self-limiting. Postpartum depression is a multifactorial problem
that requires prompt assessment and intervention.
■ Vulnerable populations include homeless, minority, and undocumented immigrant women, as well as those
who are victims of abuse. Providing holistic, quality postpartal nursing care for vulnerable populations
requires self-examination, sensitivity, and compassion.
REFERENCES
Akhtar, R. (2019). A case report: Idiopathic thrombocytopenic purpura (ITP) and pregnancy. KJMS, 12(3), 506.
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Guidelines for perinatal care. (7th ed.) Washington, DC: Author.
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https://www.acog.org/About-ACOG/ACOG-Districts/District-II/SMI-OB-Hemorrhage
Arnold, S. R. C., Uljarevic, M., Hwang, Y. I., Richdale, A. L., Trollor, J. N., & Lawson, L. P. (2020). Brief report:
Psychometric properties of the Patient Health Questionaire-9 (PHQ-9) in autistic adults. Journal of Autism and
Developmental Disorders, 50(6), 2217–2225.
Association of Women’s Health, Obstetric and Neonatal Nurses. (n.d.). Postpartum Hemorrhage. Retrieved from
https://www.awhonn.org/postpartum-hemorrhage-pph/
Beck, C. T., Records, K., & Rice, M. (2006). Further development of the Postpartum Depression Predictors
Inventory—Revised. Journal of Obstetric, Gynecologic & Neonatal Nursing, 35(6), 735–745.
Bergink, V., Rasgon, N., & Wisner, K. L. (2016). Postpartum psychosis: Madness, mania, and melancholia in
motherhood. American Journal of Psychiatry, 173(12), 1179–1188.
Bloom, K. C., Bednarzyk, M. S., Devitt, D. L., Renault, R. A., Teaman, V., & Van Loock, D. M. (2004). Barriers to
prenatal care for homeless pregnant women. Journal of Obstetric, Gynecologic and Neonatal Nursing, 33(4),
428–435.
Bulechek, G. M., Butcher, H. K., & Dochterman, J. M., & Wagner, C. (2013). Nursing interventions classification
(NIC) (6th ed.). St. Louis, MO: Elsevier Mosby.
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from https://www.cmqcc.org/content/obstetric-hemorrhage-0
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Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C., & Dashe, J. (2014). Williams obstetrics (24th ed.).
New York: McGraw-Hill Professional.
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Dekel, S., Stuebe, C., & Dishy, G. (2017). Childbirth induced posttraumatic stress syndrome: A systematic review
of prevalence and risk factors. Frontiers in Psychology, 8, 560.
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women with Von Willebrand Disease — A retrospective observational study. PloS One, 11(10), e0164683.
National Health Service. (2017). Postpartum psychosis. Retrieved from https://www.nhs.uk/conditions/post-
partum-psychosis/
Pellegrini, J. E., Toledo, P., Soper, D. E., Bradford, W. C., Cruz, D. A., Levy, B. S., & Lemieux, L. A. (2017).
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85(1), 1.
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Use of antidepressants in breastfeeding mothers. Breastfeeding Medicine: The Official Journal of the
Academy of Breastfeeding Medicine, 10(6), 290–299.
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in pregnant and postpartum women. Obstetrics & Gynecology, 117(4), 961–977.
doi:10.1097/AOG.0b013e3182118a7

UNIT 6
Foundations in Nursing Care of

Children
CHAPTER 13
Caring for the Developing Child
CONCEPTS
Child Growth and Development
KEY WORDS
theories of child development

sequential pattern
anticipatory guidance
growth
development
cephalocaudal
proximodistally
gross motor skills
fine motor skills
attachment
self-efficacy
temperament
informed consent
LEARNING OBJECTIVES

■ Describe the principles inherent in the developmental process.
■ Identify and explain the theories of growth and development.
■ Discuss the components for each developmental stage.
■ Address anticipatory guidance for each developmental stage.
■ Develop a developmental care plan for the child and family.
PICO(T) Questions
To better support patients and families, pediatric hospitals work to

improve the child’s overall experience during hospital admission. This
PICO(T) question examines how to better manage nonpharmacological
pain control during acute painful pediatric procedures.
Population: Pediatric patients undergoing acute painful procedures.

Intervention: Nonpharmacological pain management such as cold and
vibration.
Comparison: Procedures performed with no pain intervention.
Outcome: Decreased acute procedure related pain and stress.
Question: How does the utilization of nonpharmacologic pain management
techniques affect pain outcomes in pediatric patients during acute
procedures?
INTRODUCTION
This chapter presents the concepts of growth and development,
reviews major theories of child development, and covers important
growth and developmental milestones of childhood. It is important for
the pediatric nurse to have a thorough understanding of growth and
development to tailor care to the specific needs of the child and help
the family understand normal limits.
The following are acceptable referenced ages: Newborn refers to
the stage immediately after birth until 1 month. Infancy is the period
from 1 to 12 months of age. The toddler stage is from 1 year to 3
years of age. The next developmental stage, ages 3 to 6 years, is
interchangeably referred to as preschool age. School-age children
are 6 to 12 years old, and adolescence is the time period between 13
and 18 years of age.
Age and developmental stages are critical for the pediatric nurse
to understand as they must incorporate this knowledge when
assessing whether the patient is at the expected level of growth and
development and modifying the nursing care plan to be
developmentally appropriate for the specific pediatric patient. These
assessments include the physical, cognitive, and psychosocial
stages of growth and development.
INFLUENCES ON GROWTH AND DEVELOPMENT

The debate over nature versus nurture is longstanding. Which is the
more powerful influence in forming a person’s essence? Nature
describes the traits inherent in the infant at birth: biologically imposed
idiosyncratic factors that create what and how each person “is.”
Nurture, on the other hand, refers to the influence of external events
such as parenting received, culture, or the times in which a child
lives. It appears that both are intrinsically influential. Overall, genes
are responsible for the basic wiring plan—for forming all of the cells
(neurons) and general connections between different brain regions—
while experience is responsible for fine-tuning those connections,
helping each child adapt to the particular environment to which they
belong.
Child development has been described with various theories,
stages, principles, and models. In each of these frameworks, child
development is typically an organized sequence of advancing
milestones. Nursing care promoting normal growth and development
must be individualized to each child and incorporated into the
nursing plan of care; therefore, the nurse must assess the
developmental age and stage of the child to anticipate normal growth
and development expectations.
While each child grows and gains skills at their own pace, overall,
children move through milestones in a predictable manner. These
concepts of growth and development happen in an expected and
sequential pattern. The role of the nurse is to monitor the major
growth and developmental milestones in the areas of physical growth
and cognitive, emotional, social, and motor development. If a child is
missing milestones, or has regressed or lost milestones, these are
red flags for further evaluation and possible referral to a specialist.
This chapter will review the important concepts of growth and
development. This should include measurement of height, weight,
head circumference, and body mass index. By plotting
measurements on a standardized growth chart, the nurse can track
and identify alterations in normal growth and development.
In addition to measuring and plotting growth parameters to assess
physical growth, the nurse should also assess for achieved
developmental milestones and identify any red flags or specific
needs of each child based on their stage of development. The nurse
can assist the family to understand developmental needs of the child
and provide direction if there are any concerns for developmental
delays or deficits.
In addition, the nurse should also understand that growth and
development is an individualized and unique process for each child
and that variability in ages of achievement of milestones may exist
from child to child. The nurse should provide appropriate education
including anticipatory guidance to the parents about the normal
trajectory of growth and development. Once the nurse and family
members have identified developmental goals for the child, age-
appropriate toys, stimulation, play, nutrition, and sleep should be
provided to facilitate normal growth and development.
PRINCIPLES OF CHILDHOOD GROWTH AND

DEVELOPMENT
It is inherently pleasurable to watch a baby grow and develop. Each
child does so at their own pace. One child may move quickly through
physical tasks, only to be slower with words. Another child may be
emotionally tuned into the needs of others while peers are still very
self-focused. Despite these differences, development occurs in an
orderly sequence, and each child should progress through the
predictable stages within a certain time frame.
Growth refers to the continuous adjustment in the size of the child,
internally and externally. Development refers to the ongoing process
of adapting throughout the life span. Growth and development is a
continuous process from conception to death. For the child, growth
“spurts” tend to be followed by periods of relative “rest” because it
takes plenty of energy to continue the growth process. The periods
of rest allow the child to incorporate the new growth or the newly
developed skill into their personal repertoire more completely before
attempting the next level.
Three primary considerations are related to growth and
development. First, development proceeds in a cephalocaudal
direction. Cephalocaudal is a progression from head to toe—top to
bottom. For example, the baby’s brain develops quickly; therefore,
the head grows first in comparison to the rest of the body. The child
gains head and neck control before learning to grasp or sit up.
Second, development proceeds proximodistally. This means
children develop from near to far and midline to periphery. For
example, the torso develops before the arms and legs, and
development proceeds to the hands and feet and then to the fingers
and toes. The third consideration is that development proceeds from
gross motor skills to fine motor skills, or differentiation. Gross
motor skills such as running, jumping, or riding a bike provide the
foundation for fine motor developments such as eating, coloring, or
buttoning a shirt (Box 13-1).
Optimizing Outcomes
Understanding Growth and Development
To achieve the best outcome, the nurse can use the multidimensional
developmental framework of Drs. Brazelton and Sparrow (2002) to anticipate
developmental transition points to help both families and caregivers deal with
the difficulties that may arise during these times. T. Barry Brazelton, a renowned
pediatrician, developed the Touchpoints model of child development. Brazelton
described Touchpoints as periods of intense child development that disrupt the
family system during the first 3 years of the baby’s life (Brazelton, 2006, p. xvii).
An early Touchpoint is noted in the 4-month-old infant who becomes
increasingly aware of surroundings. This interest in the environment will disrupt
meals as the infant searches out the sounds that are heard. Sleep may also be
disrupted because of this new awareness, and the infant may awaken at night.
Brazelton mapped the psychological development of children, focusing on the
periods of regression that occur just before periods of growth; “the cost of each
new achievement can temporarily disrupt the child’s and even the whole family’s
progress” (Brazelton, 2006, p. xvii) (Box 13-2). Brazelton also tracked the
variations in these Touchpoints and offered anticipatory guidance for parents
and professionals who are moving with the child through the stages of
development.
BOX 13-1
A Paradigm Shift
FROM TO
• Deficit model • Positive model
• Linear development • Multidimensional development
• Prescriptive • Collaborative
• Objective involvement • Empathic involvement
• Strict discipline boundaries • Flexible discipline boundaries
Source: From Touchpoints The Essential Reference by T. B Brazelton, copyright

1992. Reprinted by permission of DaCapo Lifelong Books, an imprint of Hachette
Book Group, Inc.
BOX 13-2
Touchpoint Examples: Birth to 3 Years

PREGNANCY TO 7 MONTHS
Parents are concerned with who the child will be. Choice time to develop a
rapport with the parents before the child is born.
NEWBORN
Soon after birth, the newborn is assessed for the ability to habituate or remain
calm in a chaotic environment.
3 WEEKS
Infant starts to learn to self-calm. Parents debate use of pacifier versus thumb.
6 TO 8 WEEKS
Infant reacts differently to each parent through facial expression and physical
movements.
4 MONTHS
Infant cycles through light and deep sleep several times a night as they learn to
sleep through the night. This is important to avoid sleep problems.
7 MONTHS
Naps and bedtime are interrupted by the constant practice of new physical
skills, such as sitting and crawling.
9 MONTHS
Increasing independence (e.g., crawling and cruising) makes the infant more
dependent as separation anxiety takes hold.
12 MONTHS
All foods become finger foods. Parents must often give up on the idea of a
“rounded diet” because the child now controls what is eaten and when.
15 MONTHS
The word “no” becomes prevalent. Toddlers demonstrate frustration at not
being able to talk.
18 MONTHS
The child tests the limits of parents and caregivers and learns appropriate
behavior through consistent limit-setting and consequences.
2 YEARS
The child has now developed gender identity and behaves accordingly.
3 YEARS
Learning to handle anger and aggression is paramount. Children may regress
and exhibit temper tantrums as they process these emotions.
Source: Brazelton, T. B. (2006). Touchpoints: Birth to three: Your child’s emotional

and behavioral development. Cambridge, MA: Perseus.
Diagnostic Tools
Using Touchpoints
Brazelton and Sparrow (2002) went on to develop specific aspects about the
Touchpoints that related to temperament, learning, moral development,
relationships, independence, and separation issues for each of the years from
ages 3 to 6. Responding to these Touchpoints gives parents the tools to help
the child develop in a healthy manner.
Touchpoints represents a positive and well-integrated way of conceptualizing
developmental progress. Its perspective assumes, among other things, that
parents know their child better than anyone else (Brazelton and Sparrow,
2002). With that in mind, the nurse works with the family at the various
Touchpoints to help them anticipate and move through the periods of
disequilibrium.
GROWTH AND DEVELOPMENT THEORIES

Growth and development can be discussed in terms of theoretical
approaches or developmental domains. A theoretical approach
explains, describes, and predicts the various aspects of growth and
development. A developmental domain refers to a way of
understanding the total child in relation to the mind, body, and spirit.
Understanding both the theoretical and developmental aspects is
important because each contributes to a broader understanding
about the child. A variety of theories are discussed as well as the
following developmental domains: physical, psychosocial (emotional,
psychological, and social), cognitive (including language and
intelligence), moral/spiritual, and family development. Some of the
theories are stage-related, meaning that the theorist identified
specific stages and ages through which a child progresses.
Each child develops at an individualized pace, and the stages are
not rigid. It is also important to note that there is developmental
variability within each child. For example, a child may be ahead or
behind physically and within normal cognitive and emotional limits, or
any combination of these patterns. Growth and development take
energy. How each child expends that energy is a result of individual,
family, and social variables. In contrast to the stage theories that are
described, the nonstage theories are less concerned with specific
ages or time frames but are focused on the process or trajectory of
developing maturity.
Psychosocial Development Theories

The psychosocial domain refers to the psychological and emotional
progression of the child and the relationships with others who are
involved in the child’s life. Although there are many psychosocial
theorists, this chapter describes the well-known theories of Sigmund
Freud and Erik Erikson.
Sigmund Freud, Psychosexual

Sigmund Freud (1856–1939) believed that development was most
influenced by biological instincts. Freud observed that these instincts
were psychosexual in nature, meaning that a child progresses
through developmental stages based on resolution of conflicts
surrounding urges and rules (Box 13-3). Through observation, Freud
developed a framework that is widely known today and that set the
stage for modern psychoanalysis.
Freud also described the development of three essential aspects
of the human personality: the id, the ego, and the superego. The
initial aspect, the id, is the emotional part of the personality. The id is
present at birth and is predominantly unregulated. For example, the
infant responds to all stimuli emotionally. The infant cries, laughs, or
coos automatically and without thought. The id is the part of the
personality that relies solely on instinct.
BOX 13-3
Freud’s Stages of Psychosexual Development

ORAL STAGE (BIRTH–1 YEAR)
The infant is fixated on oral curiosity (whatever can be put in the mouth). The
infant derives pleasure from, and relieves anxiety through, oral sensations (e.g.,
the infant sucks on the mother’s breast or bottle and is fed and pleasured). The
infant puts their fist in the mouth or uses a teething ring. Children at this stage
often use pacifiers or thumbs to decrease anxiety and increase comfort.
ANAL STAGE (1–3 YEARS)
By the time the child reaches this stage, they are ready to control elimination.
Some children readily use the “big kid” potty; others resist. This is a time of
increasing control in other areas of the child’s life. The child recognizes that this
newfound control can run a collision course with the world, hence the term “the
terrible twos.” For example, the child explores, asserts, and learns boundaries
about where to play safely. The child may struggle against these boundaries by
escaping the backyard and running down the street.
PHALLIC STAGE (3–6 YEARS)
By early childhood, sexual difference is discovered. The child begins to
compare both the male and female bodies simply out of curiosity. For example,
the child notices that girls are physically different from boys. During this time, a
girl child wants to push mommy aside and marry daddy, or vice versa.
LATENCY STAGE (6–12 YEARS)
Freud believed that the child “takes a break” psychosexually during this period
of development. This allows the child to focus more intently on other aspects of
growth and learning. For example, the child spends time with their same-gender
friends, excelling in sports or video games. At this age, the child presumably
has little interest in issues of sexuality.
GENITAL STAGE (12–18 YEARS)
By the time the child reaches puberty, sexuality and relationships are the focus.
For example, this is a time for exploring relationships and developing a sense of
romanticism.
During the baby’s first year, the ego begins to develop to provide
balance between the competing id and reality. The ego provides a
sense of identity separate from others and promotes the ability of the
child to function individually. During infancy, the ego helps the baby
begin to learn that the mother is not simply an extension of his body.
Between the ages of 3 and 6, a superego, which serves to help
regulate behavior, is developed. In this stage, the child develops
cognitively and learns about rules and the needs of others. The
superego functions as not only a center for conscience but as a
sense of what and how the child perceives self. An example of the
superego is the young child obeying the parents’ rules by picking up
toys even though the child would rather continue playing. The child is
learning that there is a difference between right and wrong and that
the child is not the “center of the universe” as previously believed.
The child knows that a “good” person obeys their parents.
During adolescence, the ego again provides a balance, this time
between the id and the superego. When the adolescent refuses to
drink alcohol with friends because it is against their conscience and
the law, the ego has prevailed.
Erik Erikson
Erik Erikson (1902–1994) was a contemporary of Freud. Unlike
Freud, who attributed personality formation only to the interplay
within a person’s family of origin, Erikson focused on the influence of
social interaction. Erikson identified seven stages of development.
Mastery of each stage requires that the individual achieve a balance
between two tasks (conflicting variables). Each stage represents a
crisis that must be resolved to move on to the next stage in a healthy
manner. Erikson’s stages (listed and explained in the following
sections) are well known and are used often in tracking the
development of children.
TRUST VS. MISTRUST
This stage, which occurs between birth and 1 year, requires infants
to develop trust when the parental figure cares for them and meets
needs such as diaper changing and feeding. The infant develops a
sense of mistrust if basic needs are not met; for example, they may
be left in the crib, wear a dirty diaper, or go hungry. Through trust,
the infant gains confidence in personal worth and well-being along
with connectedness to others. Failure to master this stage leaves a
sense of hopelessness and disconnectedness. Examples of this
disconnect can be seen in infants with failure to thrive or attachment
disorders. Even adults who have problems maintaining significant
relationships may be unable to trust others.
AUTONOMY VS. SHAME AND DOUBT
This stage occurs between 1 and 3 years of age as the child
learns to balance independence and self-sufficiency against the
predictable sense of uncertainty and misgiving when placed in life’s
situations. It is the time for the child to establish willpower,
determination, and a can-do attitude. An example of this stage
happens when the toddler wants to choose clothing and dress
independently. The struggle happens when the parents allow the
child to make personal choices yet expect the choices to be socially
acceptable. At this age, the child can do many new things and wants
to explore everything. This newfound independence is accompanied
by new rules that may cause internal conflict. The child must develop
personal abilities while struggling with both fears and wishes. The
child has self-doubt later in life if this stage is not successfully met.
INITIATIVE VS. GUILT
Initiative versus guilt occurs between 3 and 6 years of age. The
child’s task during this stage is to develop the resourcefulness to
achieve and learn new things without receiving self-reproach. It is
difficult for a young child to resolve the conflict between wanting to
be independent and needing to stay attached to parents. The child’s
learning of new songs, games, or jokes are good examples of
initiative. The child feels confident to try new ideas. It is important
that parents and teachers encourage this initiative to help the child
develop a sense of purpose. If initiative is discouraged or ignored,
the child may feel guilt and lack of resourcefulness.
INDUSTRY VS. INFERIORITY
Industry versus inferiority occurs between the ages of 6 and 12. In
this stage, the child develops a sense of confidence through mastery
of tasks. This sense of accomplishment can be counterbalanced by a
sense of inadequacy or inferiority that comes from failing. The
realization that the child is competent is one of the important building
blocks in the development of self-esteem. Industry is evident when
the child can do homework independently and regulate social
behavior. Performing the prescribed tasks at school or home also
shows industry. If the child cannot accomplish realistic expected
tasks, the feeling of inferiority may result.
IDENTITY VS. ROLE CONFUSION
Identity versus role confusion occurs between the ages of 12 and
18. This is a time of forging ahead and acquiring a clear sense of self
as an individual in the face of new and at times conflicting demands
or desires. During this stage, the adolescent wants to define “what to
be when I grow up.” The adolescent concentrates on goals and life
plans separate from those of peers and family. At this point, the
adolescent child can think about self as well as others and proceeds
accordingly. An adolescent who is unable to make decisions about
possible career choices, a personal belief and value system, and
sexual orientation, for example, may develop a weak sense of self
and be incapable of committing to an identity. This indecision leads
to role confusion.
What to Say
When Parents Ask About Their Child’s Development
When parents ask the nurse about a delay in their child’s development, the
nurse can respond by saying “It is important to note that your child may not
have reached the appropriate developmental stage based on chronological age
alone. Other events or variables such as illness may delay your child’s attempts
to move forward.”
Attachment Theories
Attachment refers to the bond or emotional and physical connection
that develops between an infant and caregiver and tends to endure
(Ainsworth, 1978). Early theorists associated attachment with the
mother who met the infant’s innate drive to be fed and nurtured.
Other examples of attachment behaviors are dressing, bathing,
diapering, cuddling, loving, playing, and comforting.
John Bowlby and Mary Ainsworth

In 1978, psychologists John Bowlby (1907–1990) and Mary
Ainsworth (1913–1999) wanted to expand on early attachment
theories by focusing on the attainment of and subsequent quality of
the bonding relationship between the infant and caregiver. Both the
infant and the caregiver rely on the quality of the interaction between
them. In other words, a healthy mother-infant relationship is
contingent on the characteristic value of their communication. Most
researchers generally concentrated on the birth mother as the
primary attachment figure in the infant’s world, but Bowlby (1978)
also referred to attachment with a “mother-substitute” (p. xxvii).
Bowlby viewed attachment as a biological and evolutionary
adaptation. The infant develops an attachment to the mother or
mother-substitute to survive the vulnerability of infancy rather than as
a simple response to having biological needs met. As the infant
begins to explore the world and the other people in it, the mother or
mother-substitute is perceived as “home base.” When the infant
becomes frightened or threatened, home base is found. If the infant
feels secure in the knowledge that the home base is reliable, the
infant can move on to develop additional relationships and
attachments.
Bowlby was not only fascinated with the attachment of mother and
child but also with the influence that separation had on their ability to
bond with their caregivers. Bowlby became particularly interested in
the effect of separation of young children from their mothers, and he
identified three phases of response to that separation: protest (in
response to the anxiety produced by separation), despair (related to
the grief and mourning caused by prolonged separation), and
detachment (a defense against the feelings associated with despair).
TYPES OF ATTACHMENT
Ainsworth added to Bowlby’s work with studies about infants in
unfamiliar situations. Through the use of the “strange situation” room,
the researcher introduced infants and toddlers, ages 10 to 24 months
old, to a series of situations that tested the strength of their
attachment to their mothers. The situations demonstrated three
patterns:
■ Secure attachment: Baby cries when the mother leaves and is
happy when the mother returns.
■ Avoidant attachment: Baby rarely cries when the mother leaves
and avoids the mother upon return.
■ Ambivalent attachment: Baby becomes anxious before the mother
leaving, is very upset when the mother leaves, and seeks contact
with her while pushing her away on return.
Ainsworth’s research in Uganda and later in Baltimore was the first
truly empirical research related to Bowlby’s original attachment
theory (Table 13-1).
Social Learning Theories

Beginning with Ivan Pavlov’s work in 1890 about “classical
conditioning,” learning theorists began to understand development
as a cognitive or learning process. There were two main types of
learning theorists: behavioral and social learning scientists.
Behavioral scientists saw the learner as passive, while social
learning scientists emphasized the interplay of the individual within
the specific environment.
Albert Bandura
Albert Bandura’s (1925-present) theory of development does not rely
on predetermined stages. Bandura proposed that learning occurs
within a social context through observation and modeling. The child
pays attention to a new concept or task, retains that image, and then
reproduces the action physically. Each successful approximation
(reproduction) of the action increases the child’s perception of
personal effectiveness, which contributes to the development of new
social skills. For example, a newborn has no sense of self as
separate from others. As the infant develops new skills, inadvertently
at first, they become motivated to continue learning. Bandura also
describes self-efficacy (sense of self) and refers to several
foundations for developing self-efficacy: mastery (being successful),
modeling by others (imitation), social persuasion (pairing situations in
which success is likely to occur after positive feedback), and ability to
decrease the perception of stress and threat (a conscious willingness
to use the senses for learning rather than simply for surviving).
TABLE 13-1
Phases of Attachment
PHASE BOWLBY (1978) AINSWORTH MANIFESTATION
(1978)
Phase I (birth-2 Orientation and The initial The infant responds
months) signals without preattachment to everyone in their
discrimination of phase environment
figure without
discrimination.
Phase II (8–12 Orientation and Attachment-in-the- The infant responds
weeks) signals directed making phase most to those
toward one or more significant
discriminated caretakers in their
figures life.
Phase III (6–7 Maintenance of Clear-cut The baby attaches
months) proximity to a attachment to their caretaker by
discriminated figure crawling toward the
by locomotion and caregiver, reaching
signals for, or cooing at the
caregiver.
Phase IV (around Implications of the Goal-corrected The preschool child
age 3) partnership for the partnership begins to develop
organization of an understanding of
attachment the caregiver’s
behavior during the goals. The child
preschool years knows that a
tantrum might get
the mother to fulfill
demands.
Source: Ainsworth, M. (1978). Patterns of attachment: A psychological study of the

strange situation. Hillsdale, NJ: Lawrence Erlbaum Associates.
As the infant acquires this sense of self and begins to differentiate
self from others, the infant develops new skills and, hopefully,
resilience in the face of life’s difficulties, along with adaptations to
surviving developmental transitions. Conversely, children who have
not had adequate positive modeling, or who have not had access to
success-inducing experiences, may suffer negative consequences
and lack good self-efficacy.
Urie Bronfenbrenner
Urie Bronfenbrenner (1917–2005) studied the effects that social
environment has on a child’s development (1979). Within this
ecological approach, Bronfenbrenner defined three systems in each
child’s life. The microsystem refers to the systems in which the child
is actively involved. Typically, in a child’s life, the microsystem would
be family, school, and peer group. Mesosystem refers to the
interaction between two microsystems, such as the interplay
between a child’s home and school. The exosystem refers to those
systems that may have an effect on the child but with which the child
is not intimately involved—for example, the parent’s work. The
parent’s work affects the child’s life, yet the child is not directly
involved in it.
Cognitive Theories
Cognitive theory focuses on how an individual thinks and how
thinking influences worldview. The capacity to think develops over
time and with experience. Jean Piaget (1896–1980), a Swiss
psychologist, studied the development of cognition in children. In
Piaget and Inhelder’s book, The Psychology of the Child (1969),
information was presented about how children think and learn.
Thinking and learning for children take place through four distinct
stages. The initial period, the sensorimotor stage, takes place from
birth to age 2. During this time, the primary means of cognition is
through the senses. The child takes in and processes information
strictly on a physiological or emotional level.
At the age of 2, the child begins to use cognitive processes to
respond to the world physically. The preoperational stage (ages 2–7
years) considers the development of motor skills and is divided into
two substages: preconceptual and intuitive. The child is still not
capable of logical thinking, but because of an increased ability to use
words and actions together, the child is increasingly able to connect
cognitively with the world.
The third stage is the concrete operational stage. At this stage, the
7- to 11-year-old child can organize thoughts in a logical order. The
child can categorize and label objects. It is also possible at this stage
for the child to solve concrete problems.
Piaget’s final stage of cognitive development is the formal
operational stage during which the 11- to 15-year-old child uses
abstract reasoning to handle difficult concepts and can analyze both
sides of an issue.
Intelligence Theories
Intelligence is the capacity for learning, abstract thought, problem-
solving, and self-awareness (Venes, 2021). It is measured by
objective criteria such as tests. Intelligence has been studied
primarily in terms of how it is measured. As in all other
developmental dimensions, intelligence does not exist in a vacuum.
The ability to bring in and retain new information and skills relies on
the interconnectedness of cognitive, emotional, and environmental
factors. Traditional standardized measures of intelligence have relied
on assessing cognitive abilities, most specifically math and verbal.
Many of these measures are criticized for not accounting for varying
cultural and socioeconomic factors. Standardized IQ tests have also
been criticized for not measuring varying learning styles and
experiences.
In the early 1980s, psychologist Howard Gardner argued that
intelligence cannot be measured by a single number from an IQ test.
In his book, Frames of Mind (2011), he describes eight forms of
intelligence: bodily kinesthetic, interpersonal, intrapersonal, linguistic,
logical-mathematical, musical, naturalistic, and spatial. Every child
possesses the ability to use all eight of these intelligences. However,
over time, children develop one or more to a greater degree than the
others. While the particular forms of intelligence possessed by a
child may vary, Gardner believes that the multiple intelligences are
all equally important. Thomas Armstrong (2009) applied Gardner’s
work to the classroom to describe how a child learns depending on
the form(s) of intelligence for which the child demonstrates a
tendency (Table 13-2).
Nurses are responsible for teaching children and their families as
part of the implementation phase of the nursing process. The nurse
uses information from learning and intelligence theories to assess a
child’s ability to learn. Assessment includes questioning the child’s
hobbies and interests, which provides the nurse information about
how the child learns.
The nurse uses this information to plan appropriate teaching
interventions and assist the family in understanding how the child
learns best. The nurse advises the family about opportunities that will
stimulate learning at home. Empowering the family with information
about the child’s favored methods of learning also allows the parents
to advocate for the child within the school system.
Moral Development Theories

Study of moral development deals with a child’s perception about
right and wrong. Jean Piaget and Lawrence Kohlberg are the most
well-known theorists in this area. Of these, Kohlberg is the writer
most often cited for his understanding of moral development in
children.
Piaget studied the progression of moral thinking in children based
on the ability to reason and understand the environment. Piaget
identified two stages of moral judgment. The first stage describes the
way in which children younger than 11 years old experience right and
wrong as concrete, black-and-white concepts. Simply put, the child
understands that an act is good or bad, right or wrong. The second
stage coincides with Piaget’s formal operational stage of cognitive
development during which the child is better able to think abstractly.
Rules are important but are not always absolute or “carved in stone.”
Lawrence Kohlberg
Lawrence Kohlberg (1927–1987) based the theory of moral
development (1984) on the thinking processes involved when
making moral decisions. Kohlberg identified three levels of moral
development: preconventional, conventional, and postconventional.
Each level of moral development represents a major modification in
the child’s thinking and is further separated into stages (Table 13-3).
Within Level I, the Preconventional Level, the child’s thinking is
concrete and egocentric. Obedience and punishment are
unquestioned and understood as either good or bad. The child’s
behavior is based on which actions are rewarded or punished.
Individualism and exchange occur when the child begins to define
right and wrong and develops an individual sense of fairness and
personal justification. As the child matures and is confronted with
opposing views, they begin to recognize that not everything is black
and white. The child’s sense of morality is still concrete, but the child
begins to take into account personal reasoning. If the child can justify
an action, then, in their mind, it is acceptable to bend or break rules.
TABLE 13-2
Eight Ways of Learning
CHILDREN WHO THINK … LOVE … NEED …
ARE HIGHLY …
Linguistic in words reading, writing, books, tapes,
telling stories, writing tools, paper,
playing word games diaries, dialogue,
discussion, debate,
stories
Logical- by reasoning experimenting, materials to
Mathematical questioning, experiment with,
figuring out logical science materials,
puzzles, calculating manipulatives, trips
to planetariums and
science museums
Spatial in images designing, drawing, art, Legos™,
visualizing, videos, movies,
doodling slides, imagination
games, mazes,
puzzles, illustrated
books, trips to art
museums
Bodily kinesthetic and pictures dancing, running, role-play, drama,
jumping, building, movement, building
touching, gesturing things, sports and
physical games,
tactile experiences,
hands-on learning
Musical through somatic singing, whistling, sing-along time,
sensations humming, tapping trips to concerts,
feet and hands, playing music at
listening home and school,
musical instruments
Interpersonal via rhythms and leading, organizing, group activities,
melodies relating, social events,
manipulating, sports
mediating, partying
Intrapersonal by bouncing ideas setting goals, secret places, time
off other people meditating, alone, self-paced
dreaming, planning, projects, choices
reflecting
Naturalist in relation to their playing with pets, access to nature,
needs, feelings, gardening, opportunities for
and goals investigating interacting with
nature, raising animals, tools for
animals, caring for investigating nature
planet Earth (e.g., magnifying
glasses, binoculars)
through nature and
natural forms
Source: Reprinted with permission from the Association of Supervision and

Curriculum Development.
TABLE 13-3
Lawrence Kohlberg’s States of Moral Development

Level I. Preconventional Morality Stage 1: Obedience and Punishment—The child
will obey to avoid being punished.
Morality is determined by Stage 2: Individualism and Exchange—The child
external sources—rules, laws, thinks that it may be okay to do something wrong
possibility of punishment. if good comes from it (in other words, the end
justifies the means).
Level II. Conventional Morality Stage 3: Good interpersonal relationships—The
Morality is determined by being child’s moral decisions are based on the
a “good person.” The intent is to “goodness” of motivation and on what others
please others and to do the expect.
“right thing.” Stage 4: Maintaining the social order—The
child’s good moral decisions are those that
preserve the needs of society.
Level III. Postconventional Stage 5: Social contract and individual rights—
Morality The individual’s thinking is characterized by a
deeper questioning of social order versus an
individual’s personal rights. A person in this
stage works tirelessly to change unjust laws.
Stage 6: Universal principles—An individual
incorporates a deep awareness of justice. An
example would be breaking an unjust law to
save the lives of innocent people.
Transition to Level II, the Conventional Level for the child, is

marked by the child’s incorporation of social and interpersonal
relationships. The interpersonal and relationships stage is where the
child’s actions are justified by personal motivation to “do good” for
family members or other individuals. The child understands that
maintaining the social order means that society as a whole may
benefit by their actions.
Level III, Postconventional Morality, is divided into social contract
and individual rights and universal principles, both of which require
significant degrees of personal deliberation and maturity. These
stages are sequential and require a level of cognitive development;
they are not necessarily age-related. In fact, because progression
through the levels is influenced by a variety of factors, such as
experience, health, socioeconomic status, family structure, and
culture, an adult may have reached only the preconventional level of
moral development and not the postconventional level of moral
development.
Family Development Theories

Many theories describe family interaction. Duvall’s (1977) eight-stage
theory, based on Erikson’s individual stages of psychosocial
development, is the most well known. This theory is based on the
oldest child as the marker for transition into the next stage. The
family development stages are:
■ Marriage. The task of couples in this stage is to establish
themselves as a pair and prepare for parenting. This is also a time
for realigning with both families of origin from the position of a new
family.
■ Family With Infants. During this stage, a child is born and the
family adjusts to its new structure while the couple begins to adjust
to their new role as parents. Grandparents and others in the child’s
life adjust to their new roles, too.
■ Family With Preschool Children. As the oldest child enters the
stage of early childhood, the family functions to socialize the
children, helping them to cope with separation involved in starting
school.
■ Family With School Children. As the children develop friendships
and launch socially outside the family, the system must adjust.
■ Family With Adolescent. The oldest child turns toward launching
and independence. At this point, the parents begin to refocus on
their marriage.
■ Family Launching Young Adult. This stage begins when the oldest
child leaves home. If there are other children, it ends when the
youngest leaves home. Family tasks during this stage center on
the development of individual and independent identities of both
the children and the parents. The marriage continues to be a major
area of energy.
■ Middle-Age Family. The family continues to focus on reinvesting in
the couple’s relationship. Relationships with extended family are
realigned.
■ Aging Family. During this stage, the family copes with the process
of, and losses involved in, retirement and aging.
The Health-care Team
Various members of the health-care team oversee growth and development
across care settings throughout the life of a child. Nurses and physicians
assess a newborn while in the hospital, and a lactation consultant may be
involved if the newborn is breastfed. Well-child visits to the primary health-care
provider at regular intervals help track a child’s growth and development and
intervene if problems arise. Public health nurses may also assess the child,
particularly for immunizations. Complementary and alternative health-care
providers such as chiropractors, massage therapists, and naturopaths may also
play a role in caring for a child.
When providing nursing care to a child and her family, the nurse must be
cognizant that none of these theories stand alone but are interconnected. It is
essential that the nurse and all health-care providers base their care on the
knowledge of growth and development based on the theories presented thus
far (Table 13-4).
TABLE 13-4
Summary of Theorists
THEORIST(S) KEY POINTS
PYSCHOSOCIAL DOMAIN
Sigmund Freud Psychosexual stages
• Oral (birth–1 year)
• Anal (1–3 years)
• Phallic (3–6 years)
• Latency (6–12 years)
• Genital (12–18 years)
Erik Erikson Psychosocial stages
• Trust Versus Mistrust (birth–1 year)
• Autonomy Versus Shame and Doubt
(1–3 years)
• Initiative Versus Guilt (3–6 years)
• Industry Versus Inferiority (6–12 years)
• Identity Versus Role Confusion (12–18
years)
LEARNING DOMAIN
Urie Bronfenbrenner Ecological definition of development
• Microsystem
• Mesosystem
• Exosystem
COGNITIVE DOMAIN
Jean Piaget Stages of cognitive development
• Sensorimotor (birth–2 years)
• Use of reflexes
• Primary circular reactions
• Secondary circular reactions
• Coordination of secondary schemes
• Tertiary circular reactions
• Mental combinations
• Preoperational (2–7 years)
• Preconceptual (2–4 years)
• Intuitive (4–7 years)
• Concrete Operational (7–11 years)
• Formal Operational (11–15 years)
MORAL DOMAIN
Lawrence Kohlberg Moral development
• Preconventional Morality
• Obedience and punishment
• Individualism and exchange
• Conventional Morality
• Good interpersonal relationships
• Maintaining the social order
• Postconventional Morality
• Social contract and individual rights
• Universal principles
CHILD TEMPERAMENT
Children come in all shapes and sizes and represent all
temperaments and personality styles. Children are not simply
miniature adults. They require professional assessment and attention
across care settings based on their level of development.
Temperament refers to those characteristics present at birth that
govern the way in which an infant responds to their surroundings.
There is a strong biological and environmental basis for
temperament. Likewise, the baby’s temperament generally has a
profound influence on their interactions with caretakers and the
environment.
Understanding an infant’s temperament is essential in the care of
the child to help both the parent and child adapt to these
experiences. Based on the work by Thomas, Chess, and Birch
(1968), the following descriptors are used to help recognize the
infant’s unique personality.
■ Regularity: The child needs regularity in sleeping, eating, and
bowel habits. A child who is “easy” is one who
can adapt to relatively flexible schedules. A child who is “difficult” has
difficulty when the schedule has been disrupted.
■ Reaction to new people and situations: The “easy” child responds
easily to new people in their environment. Another child may stand
back or withdraw when something or someone new is present.
■ Adaptability to change: This trait refers to a child’s willingness to
change routine. An “easy” child makes transitions with little or no
discomfort. A slow-to-adapt child will become distressed with even
the smallest changes, for example, taking a different route home
from school.
■ Sensory sensitivity: An “easy” child with lower sensitivity will
appear much less meticulous or disturbed by her senses. A
“difficult” child with high sensitivity may react strongly when
exposed to sensory stimuli. The child may become irritated with
certain textures, tastes, smells, or sounds.
■ Emotional intensity: An “easy” child shows little or no response to a
situation. An intense child reacts dramatically and profoundly,
whether that reaction is loud or withdrawn.
■ Level of persistence: This trait refers to the child’s willingness to
stay engaged regardless of setbacks. A persistent child has
difficulty giving up until the goal is reached. A less persistent child
is more flexible and may give up more easily.
■ Activity level: An “easy” child will generally be less frenetic with
activity. A “difficult” child has difficulty with inactivity, preferring to
always be on the move.
■ Distractibility: The distractible child has difficulty concentrating on
tasks in which they are not immersed—this is not the same as the
entity known as attention deficit disorder (ADD). A less distractible
child stays with a task longer.
■ Mood: An “easy” child tends to see the world in a more positive
way. A “difficult” child tends to react in a more negative manner.
The ability to recognize these traits is helpful for determining the
strength of the fit between the caregiver, family members, and the
child, along with helping families strategize to improve the fit. Each
person in the child’s life also has a unique temperamental style,
which complements, becomes enmeshed with, or antagonizes that of
the child.
GROWTH AND DEVELOPMENT MILESTONES

An understanding of normal growth and development helps the
nurse assess whether the child is meeting expected milestones for
each stage of development. Early detection of alterations in growth
and development is important in the life of the child and family. The
following is a discussion of the predictable growth and development
at each age division.
Newborn and Infant

The entire infant period of development encompasses the time
between birth and 12 months of life. More growth and development
occur in the first year of life than at any other time in the life span.
There is rapid change in all aspects of development. It is important
for the nurse to remember that while each infant moves at their own
pace through the developmental stages, stages still occur in a
somewhat sequential fashion that can be anticipated (Table 13-5).
Reflexes and Neurological Development

Primitive reflexes are the adaptive and innate mechanisms that
protect the developing infant while the brain is maturing. This is the
first sign of an intact neurological system. However, failure of these
reflexes to disappear can signify altered or delayed neurological
development. The reflexes are controlled by the lower brain centers.
Several reflexes present at birth or shortly after help determine
normal or altered neurological development. The reflexes present at
birth naturally disappear by 9 months.
As the nurse performs an assessment, it is imperative to note
important infant reflexes:
■ Rooting: Infant’s head turns and they begin to suck when the
cheek or lower lip is stroked.
■ Sucking: Sucking motion of lips, mouth, and tongue allows the
infant to take in sustenance.
■ Moro: Startle response with sudden jarring causes extension of the
head. The arms abduct and move upward. The hands form a “C.”
■ Grasping: This is noted when the palms of the hands or soles of
the feet are stroked, causing fingers or toes to curl inward.
■ Babinski: This is the turning in of the foot and fanning out of the
toes when the sole of the foot is stroked.
At birth, the lower portions of the nervous system, the spinal cord,
and the brainstem are already developed. These structures are
necessary for the infant to sustain basic body functions and primitive
reflexes. As the infant matures, the higher sections of the nervous
system become more developed. For example, the limbic system
and the cerebral cortex are responsible for ongoing learning that
occurs during the life span.
TABLE 13-5
Developmental Milestones of the Infant (0–12 Months)
PHYSICAL GROSS FINE MOTOR COGNITIVE, PSYCHOSOCIAL
GROWTH MOTOR SKILLS SENSORY, AND PLAY
SKILLS AND
LANGUAGE
NEWBORN: BIRTH–1 MONTH
Height: Reflexes Hands Uses all five Psychosocial:
19–21 inches present predominately senses to Learns to relieve
Weight: 7.5 Absence of closed explore the anxiety through
pounds head control, Strong palmar world oral sensations
Head but can and plantar Touch: First (breastfeeding,
circumference: momentarily grasp reflexes sense to sucking on fist);
13–14 inches hold the head develop begins to learn to
Chest in midline Smell: trust caregivers
circumference: Head lag when Recognizes Play: Interaction
12–13 inches the newborn is mother and with parents and
pulled from a has a taste caregivers;
lying to a sitting preference for mobiles
position sweets
Assumes Hearing well
flexed position developed:
When supine Becomes quiet
assumes tonic when hears a
neck flex familiar voice
position Limited visual
Kicks legs and acuity 20/100,
waves arms fascinated with
Rounded back faces, follows
when sitting moving
Rolls over objects,
accidentally contrasting
colors (black
and white)
Language:
Cries to
express unmet
needs
Smiles during
sleep
INFANT: 1–2 MONTHS
Weight: Less head lag Holds hands When supine Psychosocial:
Increases 1.5 when pulled to open follows Same as previous
pounds per sitting position Grasp reflex dangling toys entry; learns to
month When prone absent Visually calm self
Height: can slightly lift Can pull at searches for Play: Solitary play
Increases 1 head off floor clothes and sounds stimulates
inch per month Improved head blanket, bats at When crying, sensorimotor
Head control, turns object can be development with
circumference: and lifts head consoled simple imitative
Increases 0.5 from side to easily by being games
inches per side when held or spoken Interaction with
month prone, some to parents and
head control Turns head to caregivers
when upright sound through games
Language: such as:
Coos, has • Patty-cake
social smile • Peek-a-boo
Weight: Double Can hold head Plays with toes Follows object Psychosocial:
the birth weight more erect Clutches own 180° Same as previous
by 6 months when sitting, hands, Develops entry
Height: still some inspects and binocular Play: Solitary play
Increases by 1 bobbing, by 6 plays with vision stimulates
inch per month months sturdy hands Locates sound sensorimotor
head control Pulls blanket by turning development with
Only slight over face head simple imitative
head lag, by 6 Rakes objects Beginning eye games
months no Grasps objects —hand Interaction with
head lag with both coordination parents and
Raises head to hands (palmar Pursues caregivers
45°–90° off grasp) dropped object through games
floor Shakes rattle visually such as:
In sitting and holds Sees small • Patty-cake
position (tripod) bottle objects • Peek-a-boo
back is straight Eventually able Responds to • Songs
and balances to put objects name
head well, sits in container Recognizes
alone by 8 and bang them parent’s voice
months together and touch; by
When held in a Carries objects 6 months
standing to mouth differentiates
position can Transfers between
bear some objects from parents
weight, by 8 hand to hand Language:
months readily Reaches and Coos, babbles,
bears weight bangs toys on laughs
Rolls from back table By 6 months
to side and Likes mirror may say
then abdomen images “dada” and
to back “baba”
When supine Begins to
puts feet to distinguish
mouth emotion based
Begins to on tone of
creep on hands voice
and knees
Weight: Triple Creeps on Uses pincer Increasing Psychosocial:
the birth weight hands and grasp depth Completes
Height: knees Hand perception Erikson’s stage of
Increases 1 Pulls self to dominance Moves toward trust versus
inch per month standing now evident sound mistrust; able to
Head and position Releases and Thoroughly calm self
chest Stands while rescues an explores and Play: Solitary play
circumference holding on to object experiences stimulates
are the same furniture and When sitting, objects sensorimotor
at 1 year of begins to purposely Points to development with
age cruise reaches simple objects simple imitative
Stands alone around back to Language: games;
Changes from retrieve object Says “mama,” interaction with
prone to sitting Can randomly “dada,” and parents and
position turn pages in a “uh-oh” caregivers
Can reach book Understands a through games
backward while Can make a few words such as:
sitting simple mark on Responds to • Patty-cake
Can sit down paper own name • Peek-a-boo
from standing Waves bye- Exhibits • Songs
position alone bye and plays stranger • Finger painting
Begins to walk patty-cake anxiety • Ball rolling
holding hand Begins to feed Begins to
• High chair
and then self finger distinguish
fishing
independently, foods colors
takes first step Increasing
ability to see
things in the
distance
Sensory Development
Touch is an extremely important sense and is the first sense to
develop (Fig. 13-1). The ability to feel objects, textures, and other
people opens the newborn’s world of learning. It is important for the
infant to experience soft, comforting textures. The ability to
experience pain is also an extremely important element, particularly
as a protective device. If the infant experiences pain, they react to
pain with the whole body by quickly extending and then retracting the
extremities. Along with this reaction, the infant cries.
Smell and taste begin developing in utero and are intrinsically
connected. Infants respond to smells within the first few days and
have an innate preference for sweet tastes. The nurse is aware that
infants can recognize their mother’s smell long before they achieve
visual recognition.
FIGURE 13-1 An example of sensory play with an infant and toddler.
Hearing is well developed at birth. A newborn can immediately

recognize the difference between male and female voices and will
generally turn toward the female voice. By the second week, the
newborn can recognize the sound of the mother’s voice. A newborn’s
ability to discriminate sounds develops quickly, contributing to
language development. By the time the infant is 3 months old, the
infant jabbers and begins to imitate sounds. During the next few
months, the infant becomes more adept at responding to and
imitating familiar sounds by smiling and cooing.
Vision is the least developed of the senses at birth. Newborns are
fascinated with faces and with designs or objects that resemble
faces. A newborn is able to remember an object but only in the exact
form originally seen (e.g., if the child sees a sister in pigtails, the
child does not recognize the sister with her hair down). Infants are
most attracted to bright colors and to black and white because of the
limited nature of their vision. The newborn generally has poor
peripheral vision until 10 weeks of age. Within the first 3 months, the
infant will watch faces intently, follow moving objects, and recognize
familiar objects and people at a distance. There will also be the
beginnings of eye–hand coordination. Binocular vision (ability to use
both eyes to see) develops at about 4 or 5 months of age. The
capacity to distinguish colors and to see things in the distance
develops throughout the first 7 to 12 months.
Physical Development
Growth is rapid. Infants gain 1.5 pounds (680 g)/month, double their
weight by 6 months, and triple it by 1 year. Height increases by 1
inch (2.5 cm)/month for the first 6 months and slows during the
second 6 months. A newborn’s head is proportionally larger than the
rest of the body, which is in keeping with the cephalocaudal course
of development. The newborn’s head grows rapidly during the first
month as the brain grows. By the time the infant reaches 1 year of
age, the head and chest circumferences are about the same.
For the infant to move or to perform actions (motor skills), the
infant must have adequate muscle development. At birth, the
newborn’s movement is involuntary. It takes the infant time to mature
physically to be able to demonstrate motor skills. Gross motor skills
(the ability to use large muscles for movement) are the first to
develop in the newborn and infant. Generally, by the end of the first 3
months of life, the infant can raise the head and chest while lying on
the belly, stretch the legs out and kick from a prone position, and roll
from side to side (Fig. 13-2). The infant can turn over completely at
about 6 or 7 months of age. By 8 to 9 months of age, the infant
begins to crawl and then, by using high objects, the infant can begin
pulling up. Once the infant has mastered an upright position, they
may begin to cruise (walking while holding on to furniture) or even
attempt to walk unaided. It is important to remember that every child
develops at their own pace. One child may be walking before their
first birthday, while another does not walk until months later.
Fine motor skills (the use of muscles to accomplish minute tasks
like pinching or picking up food) build upon the gross motor skills
(Fig. 13-3). Those fine motor skills that develop between 6 and 12
months include the ability to stack large objects, scribble, bang on
pots and pans, and transfer objects from one hand to another and
back again.
Cognitive Development
Infancy corresponds to Piaget’s sensorimotor stage of development.
The infant uses the five senses to explore and to learn about the
world. For example, the infant learns that lip smacking when hungry
leads to a full stomach. When the infant’s belly is full, physical needs
are met, and they can begin to explore the environment. Ultimately,
the infant learns that they can have an effect within that environment.
The infant must achieve three major tasks during this phase of
development:
FIGURE 13-2 At 3 months of age, an infant can lift their head and
chest while on their belly (top) and roll on their side (bottom).
FIGURE 13-3 One of the first fine motor skills to develop is the ability
to pinch to pick up small objects like food.
■ Separation. The infant recognizes that there is no merging with or

attachment to familiar people (family members).
■ Object Permanence. The infant knows that an object or person still
exists even if covered up or removed from sight; this is why infants
respond so strongly to peek-a-boo.
■ Mental Representation. The infant has the ability to use symbols to
communicate.
Piaget also identified six substages within the sensorimotor stage
that describe mental representation. It is important to note that four
of these substages occur during the first year of life. The first
substage, use of reflexes, is present at birth. The majority of the
reflexes are necessary for survival and disappear during the first 9
months. The second substage, primary circular reactions (1–4
months), takes place when the infant responds to things that give
pleasure. The infant’s response encourages caregivers to continue
providing pleasurable experiences. The third substage, secondary
circular reactions, begins when the infant recognizes cause and
effect. For example, the actions that the infant can perform
independently begin to capture their attention (e.g., shaking a rattle).
The fourth substage begins around 8 to 12 months when the infant
becomes deliberate with their actions. During substage 4,
coordination of secondary schemes, the infant intentionally seeks out
objects. The infant now knows that pushing a button starts the music
on a toy. During this substage, the infant also develops object
permanence. The remaining substages, tertiary circular reactions
(making interesting things last such as hitting a drum with a stick and
making the rat-a-tat-tat sound) and mental combinations (problem-
solving such as putting a toy down to open a drawer), take place
during the toddler stage of development.
Language Development
Infants initially communicate through the universal language of crying
to indicate physical discomfort or loneliness. As a mother or father
responds to the cries, the infant learns to communicate more
deliberately. The nurse must recognize that an infant’s early speech
is characterized by crying, babbling, and imitation. Influences on
language development include maturation of the brain and the
degree and quality of social interaction. If families respond favorably
to the infant’s sounds, like “ba” for bottle or “da” for daddy, the infant
is more likely to repeat these sounds, thus bringing the infant closer
to the native language.
Psychosocial Development
In infants, the first displays of emotions, crying and smiling, are
related to physiological needs rather than to psychological stimuli.
For example, the newborn wails loudly when physically
uncomfortable and smiles involuntarily during sleep. However, by the
time the baby is 2 weeks of age, the smiles begin to signify
contentment and elicit a positive family response. The infant’s smile
then becomes social, and interaction with the environment occurs.
Corresponding with Erikson’s psychosocial stage of trust versus
mistrust, the nurse recognizes that this is a critical time for the
newborn to absorb the whole environment along with its related
experiences. The caretaker’s task is to respond to the infant in such
ways as to engender a sense of security and well-being. Essentially,
the infant’s mission is to develop a sense that their caretakers are
reliable and present.
Ainsworth described four stages of attachment. During the first
stage (birth to 2 months), the newborn and infant randomly respond
to anyone. By the second stage (8–12 weeks), the infant begins to
respond more to the mother than to anyone else, but the infant
continues to respond indiscriminately to others. It is not until the third
stage (6 or 7 months) that the infant demonstrates a strong
connection to the mother and possibly develops a fear of strangers.
Not all infants develop stranger anxiety. Throughout the first year, the
infant develops attachments to all the important people in the family.
Achieving the necessary milestones is essential for the infant to
move on to the next stage of psychosocial development. An example
of psychosocial development is the infant becoming more aware of
others by responding with a social smile and tracking their parents’
or others’ faces (Fig. 13-4).
Discipline
Discipline plays an important role in the psychosocial development of
the infant because it helps correct misbehavior and mold moral
character. Infants learn about safe boundaries and trusting
relationships through effective discipline. The nurse helps parents
determine how they plan to discipline their child now and later as the
child grows and develops. The American Academy of Pediatrics
(2020; Lipkin & Macias, 2020) indicates that early forms of discipline
take place when the caregiver molds and structures the infant’s daily
routines and responds to the infant’s needs. Limit-setting acclimates
the infant to the world and keeps them out of harm’s way. It is
important to note that parents often learn how to discipline from their
own experiences as children. It is essential that parents be taught
appropriate strategies for teaching and limit-setting.
FIGURE 13-4 An example of psychosocial development is when an

infant becomes more aware of others by responding with a social
smile and tracking their parents’ or others’ faces.
Anticipatory Guidance
Infancy is a period of tremendous growth and development. As
infants acquire new skills at a rapid rate, parents must know what to
expect at each stage. In the first year, infants see a health-care
provider at regular intervals for physical assessment and
immunizations. Nurses are in a unique position to provide
anticipatory guidance during each of these visits. It is important to
provide teaching regarding nutrition, health promotion, safety, sleep-
wake patterns, growth and development, and discipline (Box 13-4).
Health promotion and safety are priority topics to approach with
parents. They need to know the signs and symptoms of illness, when
to call the health-care provider, and procedures to follow in an
emergency. Infants require a safe environment, from cribs and car
seats to a childproofed home.
BOX 13-4
Anticipatory Guidance for Infants

Nutrition: Review breast- and bottle feeding guidelines; introduction of solid
foods (6 months); encourage self-feeding when appropriate; finger foods;
weaning to cup (9–12 months); family meal time; change to whole milk at 12
months
Health Promotion: Signs and symptoms of illness: vomiting, diarrhea, fever,
dehydration, and jaundice; immunizations (see immunization schedules at
http://www.cdc.gov/vaccines/schedules/); recommend CPR training; review
emergency procedures; oral health—brushing with nonfluoride toothpaste
after eruption of first tooth, schedule first dentist appointment
Focus on Safety: Safety guidelines for crib; place car seat in back of car in a
rear-facing position; position on back for sleeping to decrease risk of sudden
infant death syndrome, do not leave infant unattended, install smoke
detectors; lower crib mattress and childproof environment as child becomes
more mobile; close supervision; discourage use of baby walkers
Sleep-Wake Patterns: Expected patterns at each month of age; expectations
for sleeping through the night, naps; establishment of nighttime rituals (see
Family Teaching Guidelines: Sleep/Rest)
Cognitive and Emotional Development: Age-appropriate toys and interactive
games; talk and sing to infant; read stories; respond to infant cries; face-to-
face time
Motor Development: Support head and neck; supervised “tummy time” to
increase neck, arm, and torso strength; provide safe space for child to move
about; provide opportunities for sitting, crawling, and walking
Discipline: Discuss discipline versus punishment; limit-setting; apply rules
consistently
Patient Education
Infant Discipline
It is important that the nurse teach parents that infants do not misbehave on
purpose. Exploration and crying are normal behaviors for infants. The purpose
of discipline at this age is to keep the child safe. Parents can use a firm tone of
voice or facial expression while telling the child “no” or “stop” as they reach for
the stove; this helps the infant know that there are limits to their actions. The
infant can then be redirected to a similar experience, such as reaching instead
for a toy off a countertop.
Toddler (1–3 Years)

By the time the infant reaches 1 year of age, physical growth has
slowed. For each year between the ages of 1 and 3, the typical
toddler gains 3 to 5 pounds (1.3–2.6 kg) and grows 3 inches (7.6 cm)
taller. Most of the toddler’s energy during this period is directed to
other realms of development. As the physical growth rate slows, the
toddler develops physical, cognitive, and emotional skills that help
them become more independent. As the toddler develops mobility,
they explore how things work and senses become more refined. The
toddler uses newly acquired gross motor skills to run, jump, and
move up and down stairs with increasing ease. Around age 3, the
toddler may learn to ride a tricycle or slide down the slide in the park
without help. This newfound freedom and movement create many
opportunities for danger as the toddler moves quickly from one new
experience to another.
Fine motor skills continue to develop rapidly in this age group. The
toddler can hold a spoon or a large crayon appropriately and
continues to make artwork that is more representative of the object
they are trying to depict. The toddler is increasingly able to
manipulate smaller toys (Table 13-6).
Early toddlerhood corresponds with Piaget’s fifth substage of
cognitive development, tertiary circular reactions, during which time
the toddler experiments and learns new behaviors. The toddler then
transitions into Piaget’s sixth substage, mental combinations, when
they begin to understand cause and effect and are able to imitate
others and solve problems.
The toddler loves to imitate the people in their life. Much of the
toddler’s behavior is replication of what is heard and seen in the
environment. The toddler also learns through repetition. For
example, they may want the same book at bedtime night after night,
staying engrossed in the story every time.
A toddler also likes order and often responds with difficulty to
disruption in routine. The level of response is related to the
temperament of the child. Some toddlers may revolt with temper
tantrums, and others will calmly transition into an experience.
Regardless of temperament, most children at this stage respond
favorably to predictable routines.
With increasing cognitive development, toddlers can listen to and
understand short explanations. This is a time when the child
develops a more understandable language system. Language is
about fulfilling needs: “I do” or “want drink.” The toddler moves from
using single words to short phrases. Some parents worry when their
child does not fall exactly within what are considered normal
language parameters. The nurse can reassure parents that it is
important to assess what the child understands and what the child is
able to communicate, with or without words, rather than exact
correctness in pronunciation.
Toddlers typically exemplify characteristics of Freud’s anal stage.
The child begins to develop a sense of self as separate from the
mother. The toddler’s task is to move away from the primary
caregiver while maintaining enough connection to feel secure. This
process, called rapprochement, is healthy and expected.
Toddlerhood also corresponds with Erikson’s stage of autonomy
versus shame and doubt. It is a time when the child makes every
effort to “do it myself.” Mastery is an extremely important task of this
stage of development. Because the toddler’s abilities begin to
surpass cognitive judgment, it is also a time of potential hazard for
the developing child. Caregivers must walk the fine line between
allowing exploratory independence and “mastery” on one hand and
vigilance on the other. It is often a time of bumps and “booboos.”
TABLE 13-6
Developmental Milestones of the Toddler (1–3 years)
SKILLS AND
LANGUAGE
Weight: 3–5 Stands without Holds a pencil or Experiments Psychosocial:
pounds per support a large crayon and learns Increases control
year Walks Makes artwork new behaviors of self and
Height: 3 independently that is more Begins to environment;
inches per Walks representative of learn cause explores; learns
year backward the object and effect about safety and
Creeps up Copies a circle Imitates boundaries, but
stairs and cross by age behaviors of may test those
Pulls toys 3 years parents and boundaries;
while walking Knows colors caretakers shows affection
Runs with Feeds self with a Well- Play: Parallel play
wide stance spoon and drinks developed (play alongside
Jumps in place from a cup vision another child)
with both feet Constantly Can identify helps children
Climbs throws objects on geometric make the
Throws a ball; floor objects transition from
eventually Builds tower of 3 Intense solitary play to
kicks the ball to 4 cubes, interest in associative play
Rides a eventually picture books by stimulating
tricycle by 3 building tower of and listens to sensorimotor and
years of age 7 to 8 cubes stories psychosocial
Begins to Screws/unscrews Distinguishes development;
stand on one Turns pages in a food activities include:
foot book one page at preferences • Matching games
momentarily; a time based on • Simple puzzles
may be able to Turns knobs senses • Blowing bubbles
hop on one Removes shoes Language: • Bean bag toss
foot and socks, learns Single words • Catching fireflies
Can walk up to undress self and simple
• Ring around the
and down Begins toilet phrases, “I do”
rosy
stairs with training around 3 or “Want
alternate feet years of age drink”; by 15 • London Bridge
Blows kisses months knows • Duck-duck-
15 words; 20 goose
words by 2 • Hide and seek
years • Coloring
• Drawing
Follows simple
instructions
Often dubbed as the “terrible twos,” this entire stage can be a

tumultuous time for both caregivers and toddlers. The child must
begin to internalize behavioral standards at a time when establishing
independence is important. The nurse can help parents understand
that the toddler does not set out to make life miserable. The toddler
simply has few internal mechanisms in place to accomplish what
needs to be done safely. It is frustrating to the toddler when
confronted with blocks to budding mastery. The word “no” begins to
signify the toddler’s simple response to frustrated emotions
encountered.
Moral Development
Cognitively, the toddler is still a very concrete thinker and knows that
something is “good” or “bad” but does not know why. At this stage,
the toddler identifies good and bad and right and wrong by virtue of
whether it is rewarded or punished. This corresponds to Kohlberg’s
preconventional level of moral development.
Discipline
The purpose of discipline is to teach the child socialization and
safety. It is the responsibility of the parent to provide a firm structure
so the toddler can explore the world while offering safe limits (Box
13-5). Many children repeatedly test rules while also unconsciously
learning to rely on the security those limits provide. Having a
structured environment for the child does not necessarily mean it is
rigid or inflexible. Parents must learn to structure the toddler’s
surroundings to allow enough flexibility to test limits.
A child at this stage needs guidance to determine how to act
appropriately. The toddler thinks concretely and must rely on others
to help give realistic parameters. Some parameters may create a
great deal of conflict when what the toddler is allowed to do does not
match what the toddler wants to do, which may result in a temper
tantrum. Praise becomes an excellent component of discipline
because most children want to please the parent.
Temper Tantrums
Because this is a time of intense exploration and discovery and the
toddler is establishing a sense of self as a competent doer, there will
be bumps in the road (Fig. 13-5). A tantrum is a normal way of
working things out internally for the toddler. Parents and caregivers
need to know that tantrums are normal for the toddler. It may be
possible for parents to anticipate when tantrums are most apt to
occur (e.g., when the toddler is tired, hungry, or overwhelmed by new
situations, reserves are low, and therefore, the toddler may be more
likely to explode or “melt down”).
BOX 13-5
Discipline Strategies
Distraction: Provide a toy to divert the child’s attention. Time-Out: Move the
child to a “cooling-off” place where the child can calm down.
Removal of Privileges: Withhold a favorite toy until the child’s behavior is
appropriate.
Verbal Reprimands: Give spoken warnings or disapprovals without berating
the child or judging the child as “bad.” Corporal Punishment (e.g., spanking,
swatting, and grabbing): Not recommended.
FIGURE 13-5 Toddlers enjoy doing things for themselves.
Tantrums may be avoided or minimized if anticipated. Get a tired

child to rest or feed a hungry child to decrease their frustration level.
The nurse can teach the parents coping strategies to use when
tantrums do occur. When the child is wailing and thrashing but not
doing any harm, ignore them. Often this is not possible, and it may
be necessary for the parent to intervene quickly and decisively to
remove the child to a quieter or safer place. Touching and
distractions may help soothe a tantrum for one child. Another child
may need to continue the tantrum under the watchful eye of the
parent. The latter requires that the parent be present but not
engaged in direct communication with the child. The goal is for the
child to feel (and be) safe without being negatively or positively
reinforced for having a tantrum.
What to Say
Tips for Effective Discipline
During effective discipline, allow for negotiation and flexibility, which can help
build the child’s social skills. Also, allow the child to experience the
consequences of behavior.
• Speak to the child as you would want to be spoken to if someone were
reprimanding you.
• Never resort to name-calling, yelling, or disrespect.
• Be clear about what you mean.
• Be firm and specific.
Whenever possible, the consequences must be delivered immediately, relate
to the rule broken, be short in duration, and emphasize the positives. In
addition, the consequences must be fair and appropriate to the situation and
the child’s age.
The increasingly mobile toddler challenges parents and caregivers to
keep them safe at all times. Constant supervision is required. As the
toddler actively explores the environment, they do so with little
understanding of the consequences of their actions. Cabinet doors
must have child-safe locks, mini-blind cords must be secured above
the reach of the toddler to prevent asphyxiation, and windows and
doors must be locked. As the older toddler learns to ride a tricycle,
teach the importance of wearing a helmet.
The toddler is beginning to learn about rules and consequences.
Consistency in how those rules and consequences are applied is
very important. Discipline must be appropriate to the rule broken.
Providing a toddler with a brief time-out is a very effective disciplinary
tool. It is important to choose a safe place for the time-out, such as a
chair in a visible area of a room. A general rule of thumb for time-
outs with toddlers is 1 minute per year of age. Box 13-6 discusses
additional anticipatory guidance guidelines for the toddler.
Early Childhood (Preschooler) (3–6 Years)

Children at this age come in various sizes, shapes, and body types.
As a rule, the preschooler begins to grow taller and thinner. The
abdomen will flatten as the child grows. The abdominal muscles
strengthen and the pelvis straightens. The physical growth rate for
this stage of development is slow but steady. The average weight
gain of the preschooler is about 5 pounds (2 kg), and growth is 2.5 to
3 inches (6.3–7.6 cm) per year. By age 4, the child’s posture
straightens and the child is able to move around in a more balanced
fashion. As muscles become more developed, the preschooler
becomes stronger. The face narrows, the nose enlarges, and the
skin becomes more adult-like.
BOX 13-6
Anticipatory Guidance for Toddlers

Nutrition: Family meals; allow toddler to self-feed and use a cup at meal times;
allow child to make food choices; provide finger foods; provide two to three
healthy snacks per day; do not force eating
and dehydration; immunizations (see immunization schedules at
http://www.cdc.gov/vaccines/schedules/); recommend oral health: brushing,
routine cleanings
Focus on Safety: Lower crib mattress; transition to toddler bed by age 3;
toddler car seat; lock windows and secure curtains and mini-blind cords to
prevent asphyxiation; secure doors; update childproofing of home; use bike
helmet; water safety; check smoke detectors; supervise play; sunscreen
Sleep-Wake Patterns: Continue nighttime rituals; consistent bedtime; expect
nightmares and develop strategies to deal with them (see Family Teaching
Guidelines: Sleep/Rest)
Cognitive and Emotional Development: Read short stories daily; provide
simple explanations; respond to child’s verbalizations; praise
accomplishments; schedule play dates; teach child how to express feelings;
expect child to test limits; encourage self-expression and self-care; limit TV to
1 to 2 hours/day
Motor Development: Promote fine motor skills: crayons, blocks; provide
outdoor play with balls, push and pull toys; play with toddler
Discipline: Apply rules and consequences consistently; provide brief time-outs
The preschooler is much more agile. At age 4, the preschooler can

ride a tricycle and climb up and down the stairs comfortably using
alternating feet. The preschooler can also skip and hop and is much
more coordinated on the balance beam.
Fine motor skills rely on the use of the forefinger and the thumb.
As the brain becomes more developed, they are better able to pick
things up with the fingers. Hand dominance begins to develop
around the age of 3 when the preschooler may show a preference in
using one hand over the other. By the age of 4, that preference is
established (Table 13-7).
This period of development corresponds with Piaget’s preoperational
stage (2–4 years). During this time, the preschooler increases the
ability to verbalize. The preschooler can symbolically use language
to represent concepts that need to be conveyed. The young child is
still egocentric (focused only on their own sense of things) and
therefore is limited socially. This is in large part because of concrete
thinking processes and the inability to abstractly shift focus from self
to others. The preschooler is also not able to transfer attention from
one aspect of an object to another (e.g., a child at this stage can
identify a dog’s collar but is not able to describe its texture) (Fig. 13-
6).
The preschooler has increased ability to verbalize; vocabulary
increases from 1,500 to 2,000 words between the ages 3 and 5. The
preschooler uses sentences and is much more able to convey an
intended message. When the young child is able to use words,
tantrums generally begin to subside. The preschooler loves silly
words and rhymes and asks many questions, generally those that
begin with “why?” To meet the needs of the preschooler, keep
answers simple and avoid giving too much information. Bombarding
the preschooler with overwhelming answers can be disconcerting for
the child. The nurse can tell the parent that a preschooler may stutter
as they try to get out all of the words faster than they are able to
speak them. Stuttering generally resolves quickly.
Assessment Tools
Developmental Surveillance and Screening
Monitoring for any developmental concerns/problems is a vital role within
pediatric nursing.
Many children with developmental delays or behavior concerns are not
identified as early as possible. Understanding that early identification leads to
early intervention and better outcomes, it is therefore important to screen for
developmental delays early and often. In the United States, about one in six
children aged 3 to 17 years have one or more developmental or behavioral
disabilities, such as autism, attention deficit-hyperactivity disorder, or other
developmental/behavioral delays such as language (Lipkin et al, 2020).
However, many children are not identified until they are in school, by which time
significant delays might have occurred and opportunities for treatment might
have been missed.
SERVICES FOR CHILDREN WITH DEVELOPMENTAL DISABILITIES
• Early intervention services help children from birth through 3 years of age (36
months) learn important skills.
• For children age 3 and older with an identified developmental delay or
disability, special education services may be needed.
Early identification of developmental delays also helps identify associated
medical conditions or other needs of the child and family. For these reasons, it
is important for the nurse to be familiar with developmental surveillance and
screening.
Various screening tools in primary care identify children at risk of
developmental delays, but the Denver Developmental Screening tool (DDST) is
widely used for examining children 0–6 years of age (Frankenburg, 1967). The
key take-away with developmental screening is that if a delay is identified,
further evaluation should be pursued.
Other important components of developmental surveillance/screening include
asking about and addressing parental concerns about their child’s
development, observing the child’s development during the examination,
closely documenting developmental history, and identifying any risk or
protective factors for development. In addition, if a red flag is uncovered or
observed during the history or physical examination, the nurse should
document and follow up on this concern.
An estimate of developmental risk should be assessed early in a child’s
development, and a child at risk for developmental delays should be referred
for evaluation to Early Intervention (0–3 years of age). For children older than
3, an evaluation can be completed by their local public school system.
CASE STUDY
Early Childhood Development

Mrs. James brings Steven, her 3-year-old son, into the clinic for a well-child visit.
She states she is concerned because Steven does not talk as well as his peers.
She describes how, at play group, the other 3-year-olds talk more than Steven,
and she states that Steven barely says a word. When asked how Steven
communicates what he wants, Mrs. James states that he points to things and
sometimes says single words such as “more” or “juice.” Mrs. James added that
Steven often gets frustrated when his parents do not understand what he wants.
A review of his medical history reveals that Steven was born at 39 weeks,
weighed 8 lb 1 oz (3.7 kg), and had an unremarkable birth. He has had no
difficulties with feeding or sleep. He began babbling at 6 months but did not
speak his first word until 14 months. By 19 months he could say “mama,”
“dada,” and “juice.” Presently, Mrs. James states he uses approximately 10
words but does not combine them.
1. What further assessments would you complete for Steven?

2. What would you say to Mrs. James about Steven?
3. What nursing interventions would be appropriate at this time?
TABLE 13-7
Developmental Milestones of Early Childhood (Preschooler) (3–6 years)
SKILLS AND
LANGUAGE
Weight: Dresses self Moves around Focus is on self Psychosocial:
Increases 5 Throws and in a more Uses language Begins to regulate
pounds per catches ball balanced to convey own behavior;
year Pedals tricycle fashion concepts learns about
Height: Kicks ball Builds tower of Concrete rules; increases
Increases 2.5– forward 9 to 10 cubes thinking confidence to try
3 inches per Stands on one Draws stick Well-developed new things;
year foot for 5 to 10 figure with six senses recognizes
seconds Skips parts Preferences differences
and hops on Uses scissors based on the between boys and
one foot to cut outline of use of senses girls
Walks down picture Learns address Play: Associative
steps with Copies and and phone play helps
alternate feet traces number children learn how
Jumps from geometric Language: to share, play in
bottom step patterns Recognizes small groups, and
Balances on Ties shoelaces most letters; learn simple
alternate feet Uses fork, vocabulary has games with rules,
with eyes spoon, and increased from concepts of
closed knife with 1,500 to 2,000 language, and
supervision words, social rules;
Colors, prints eventually activities include:
letters speaks in • Memory
Mostly complete • Chutes and
independent sentences with Ladders
toileting and increasing • Candyland
dressing fluency • Hokey Pokey
Sings songs • Hot Letters
Enjoys silly
• Alphabet games
words and
rhymes • Color games
Asks many • Checkers
“Why” • Make-believe
questions play
FIGURE 13-6 Preschooler discovers what it means to be kind.
Early childhood is a wonderful time marked by the exploration of new
skills and the ability to finally figure out how to get and do things for
oneself. As the preschooler develops, they are presented with many
situations to truly excel. The preschooler has learned many new
skills and is becoming a “big kid.” The preschooler enjoys positive
feedback for accomplishments. The fact that the preschooler can do
many new things creates a dilemma, and the preschooler must
decide which things are most important. Parents may not approve of
the decisions made by the preschooler, and the child may become
conflicted when limits are set. Often the preschooler ponders about
doing “the right thing” or doing “the wrong thing” and risking the
parent’s dismay. Conscience develops and begins to guide the child
through the maze of “wants” versus “cans.”
The preschool child displays a good deal of magical thinking. For
example, if they imagine something bad happening and that event
actually occurs, the preschooler will believe that their thinking caused
the outcome.
Freud described this period as the phallic or oedipal period. The
child is becoming more aware of gender differences. The female
preschooler may want to marry dad or the boy in preschool rather
than relate to her best female friend.
Family is very important to the preschooler. However, the
preschooler is now discovering the joys of friendships. The young
child looks to their peers for new ideas and information and begins to
develop an understanding of what it means to be kind. The
preschooler is more social and is often more willing to share toys
with others than when they were a toddler.
Moral Development
Early childhood typically corresponds with Kohlberg’s
preconventional morality stage when the major impetus for moral
judgment is to avoid punishment. It is common for the child in this
age group to tell lies to avoid consequences. A child at this age may
judge an action to be wrong only if caught. The young child is only
guilty if the parent has seen the actions.
Discipline
Because the preschooler is beginning to understand that actions
have consequences, caregivers can take advantage of this
understanding. The preschooler knows that there are rules and that
not obeying those rules leads to consequences. It is best if rules are
explained before infractions occur. At the very least, rules must be
explained before disciplining the child. This helps the preschool child
learn more clearly how to behave. Consequences can, as much as
possible, follow naturally and fit the behavior being punished (e.g.,
having the child clean up their own mess or miss a favorite television
show if they dawdle).
As with toddlers, a typical discipline strategy instituted with
preschoolers is providing the child with a time-out. A rule of thumb is
a minute time-out per year of age. Whether that time-out is in a
specified chair or section of the room, it is important to help the child
know that the purpose of the time-out is to calm themself and to shift
gears and act appropriately.
Many parents begin using behavioral charts at this age to praise
positive behavior and to help the preschooler understand what is
expected and to be rewarded when “good” behavior is shown. For
many preschoolers, simply getting a star or sticker on the chart is
reward enough to encourage good behavior. For others, a more
sophisticated measure of rewards is needed, such as allowing
additional television time or a favorite activity. The goal of discipline
and limit-setting at this stage of development is to begin teaching the
preschooler to regulate their own behavior.
The preschooler has much to learn in these years. Parents can
assist in language development and comprehension by reading and
singing to the preschooler each day. It is important to praise the
child’s accomplishments to build confidence and a sense of
achievement. Parents can expect the preschooler to test limits. It
becomes increasingly important for parents to set and maintain
consistent limits on behavior and provide appropriate discipline (Box
13-7).
Many parents ask how they will know their preschooler is ready to
begin kindergarten. Mastery of skills before and including the
preschool years prepares the child to start school. Preschools and
child care programs provide opportunities for the preschooler to
interact with other children, learn cooperative play, and enhance
cognitive, language, social, and physical skills. Working closely with
the teachers in these early childhood programs gives parents the
information they need to assess when their child is ready to begin
school.
School-Age Child (6–12 Years)

Early in this stage, boys and girls follow similar growth trajectories.
Both begin to grow taller and further lose their baby fat. Children at
this age gain about 4 to 6 pounds (1.8–2.7 kg) and grow 2 inches (5
cm) per year. As abdominal muscles strengthen, posture straightens.
Facial features become more refined. Still, there are many variations
in size and shape of children in this period. These variations are
influenced not only by familial and cultural genetics but also by
environmental factors (e.g., diet and exercise).
BOX 13-7
Anticipatory Guidance for Early Childhood

(Preschooler)
Nutrition: Family meal times should be pleasant; provide three meals and two
nutritious snacks per day; allow child to make nutritious choices
dehydration; immunizations (see immunization schedules at
http://www.cdc.gov/vaccines/schedules/); recommend CPR training; oral health:
brushing, routine cleanings
Focus on Safety: Car seat (see guidelines at safercar.gov:
http://www.safercar.gov/parents/CarSeats.htm); update home childproofing
(secure matches, guns, outlets, medications, poisons); sunscreen; bike helmet;
water and playground safety; teach about stranger safety; continue close
supervision
Sleep-Wake Patterns: Dreams and nightmares are evident now; develop
strategies to handle them; naps start to disappear; maintain consistent
bedtime routine (see Patient Education: Sleep/Rest)
Cognitive and Emotional Development: Offer praise; show affection; expect
fantasy play as child tries new roles; address fears as they occur; read, sing,
and talk to child to develop language skills; creative toys; expose child to
various places within the community; encourage assertiveness, not
aggression; teach how to solve conflicts; encourage self-expression; expect
sexual exploration and answer questions; assign simple chores; encourage
self-care: toileting, dressing
Motor Development: Encourage peer play and physical activities; may want to
join an organized sport; bike safety; water safety
Discipline: Continue with consistent rules; teach right from wrong; teach
respect for authority; continue with time-outs
Patient Education
Sleep/Rest
Sleep and rest are the body’s way of replenishing energy and supporting a
feeling of well-being. Sleep provides not only physical renewal but also mental
renewal. It is also a time for essential brain development in young children,
facilitating growth, healing, and learning. If a person is deprived of sleep,
problems can occur with concentration and emotional functioning. Sleep and
rest affect many body cycles, including temperature regulation and heart, lung,
kidney, and digestive functions. The sleep-awake cycle of persons varies with
age.
HOW TO PROMOTE AGE-APPROPRIATE SLEEP
• Establish a household schedule that provides the appropriate amount of sleep
for the child.
• Determine signs of sleepiness or fatigue, such as yawning, increased activity,
temper tantrums, rubbing eyes, fussiness, and/or crying.
• Decide on a bedtime agreed on by both parents.
• Establish a prenight or nap-time ritual, such as bathing, bottle- or
breastfeeding, toileting, and/or story time.
• Encourage quiet play activities before bedtime.
• Avoid excess stimuli such as excessive screen time (AAP, 2020). Consider
quieting behaviors, such as rocking, walking, and/or use of a pacifier/feeding.
• Provide a consistent nighttime room environment appropriate for the child’s
age, which may include the child’s own bed/crib, quiet environment,
comfortable room temperature, use of a night-light, and/or restful music.
• Avoid exposing children to environmental smoke and avoid overheating of
infants.
• Ensure that the mattress used in a crib is firm and that the crib is free of soft
or loose bedding or toys.
ESSENTIAL INFORMATION
Because children use a lot of energy growing and learning, it is important that
they receive adequate rest. Newborns sleep an average of 17 to 20 hours in a
24-hour period. A 6-month-old child needs approximately 12 to 16 hours of
sleep in a 24-hour period. The average 2-year-old needs approximately 12 to
14 hours of sleep in a 24-hour period, and the average preschool-aged child
needs about 10 to 12 hours of sleep in a 24-hour period. Sleep problems are
not unusual during the preschool years. Children of this age (3–6 years old)
may have nightmares and trouble falling asleep because of their imaginations
and immaturity. Because of the immaturity and imagination, children of this age
frequently have a difficult time distinguishing between fantasy and reality and
believe that monsters and creatures lurk in their rooms after the lights are
turned out. A familiar environment, comfort with a hug, and verbal reassurance
are provided and repeated to reassure the child.
Most school-age children begin to develop axillary sweating. In

girls, hips begin to broaden and the pelvis widens in preparation for
childbearing. Breasts begin to enlarge and become tender. The
vaginal pH changes from alkaline to acidic, and the vagina develops
a thick mucoid lining. Pubic hair begins to develop between the ages
of 8 and 14. While menarche can begin as early as 8 to 10 years of
age, the average age in the United States is 12 years of age.
Boys also begin sexual development at these ages. Their bodies
become more muscular. Between 10 to 12 years of age, the testes
become more sensitive to pressure, the skin of the scrotum darkens,
and pubic hair begins to develop. Boys often experience
gynecomastia, a temporary enlargement of breasts as a result of
hormonal shifts. This can be embarrassing, and the child and family
need reassurance of its transient nature.
Both males and females are assessed at well-child visits using the
Tanner staging of development of secondary sex characteristics.
Tanner staging is done to document evidence of normal pubertal
development for the age of the child, and it is an important
assessment to detect signs of sexual abuse and precocious puberty
(Table 13-8).
TABLE 13-8
Developmental Milestones of the School-Age Child (6–12 years)
SKILLS AND
LANGUAGE
Weight: Gradual Good eye– Increased Psychosocial:
Increases 4–6 increase in hand logical thinking Increases peer
pounds per dexterity and coordination leads child to group
year becomes Balance be able to solve involvement as
Height: limber improves problems peers influence
Increases 2 Improves Can sew, draw, Wants to know values and
inches per coordination, make arts and “how” things beliefs; same-sex
year strength, crafts, build work friends; masters
balance, and models, play Understands skills; increases
rhythm video games that actions confidence and
Climbs, bikes, Handwriting have self-esteem
skips, jumps improves consequences Play: Cooperative
rope, and Prints and Aware of own play teaches
swings writes thinking and children how to
Learns to Likes activities how bargain,
swim, dance, that promote conclusions cooperate, and
do dexterity such were reached compromise to
somersaults, as playing a 20/20 Visual develop logical
and skate musical acuity reasoning, which
instrument and Color increases social
building discrimination skills; activities
models fully developed include:
Mature sense • Baseball
of smell • Soccer
Hearing deficits • Gymnastics
may be • Swimming
discovered as • Dodge ball
language
• Board games
develops
Language: • Simple card
Accelerated, games
vocabulary • Computer
expands to games
8,000 to 15,000 • Video games
words; as • Puzzles
comprehension • Crosswords
expands
children • Word search
engage in long puzzles
conversations
on a variety of
topics; enjoy
jokes; may
experiment with
profanity
At this age, it is important to guard the child’s privacy. As a nurse,

be aware of self-conscious behavior related to physical changes
occurring in the body. Along with privacy, the nurse must be aware of
other issues affecting the child and family related to menstruation,
secondary sexual characteristics, hormone imbalances, mood
swings, and social needs, as well as other specific areas identified
by the child and family.
The school-age child is better able than the younger child to use
logical thinking. This logic in thinking corresponds with Piaget’s
Concrete Operations stage of cognitive development. While the
child’s thinking is still quite concrete, they can begin to solve
problems. During this childhood stage, they begin to replace the
ever-present “why?” question with “how?” Mastery is focused on
figuring out how things work. The school-age child builds on
experience and begins to recognize consequences of actions. In
school, they work on tasks requiring awareness of space (where
things are in relation to other things), causality (logical
consequences), categories (how things fit together), conservation
(physical quantity can remain constant even when state is altered),
and numbers. They are also capable of metacognition, the ability to
think about thinking. At this age, the child is aware of their own
thinking and can assess how he came to conclusions, a process that
eventually leads to critical thinking.
Memory deepens as the child grows. They become more adept at
processing and working through information. Memory improves
because the brain retains more information. A child in this age group
is also better able to determine what is important to remember and
what is not. This helps them filter out irrelevant data, leaving memory
space available.
Language improves considerably. The child uses words more
accurately, particularly verbs, metaphors, and similes. The child can
elaborate on concepts that they want to express.
There is vast emotional growth during the middle child years. Erikson
described this stage as one of industry versus inferiority. Unlike the
younger child who believes they can do almost anything, the 6- to
10-year-old child begins to assess what they can and cannot
accomplish. School-age children need and seek praise. They have a
more definite sense of self-esteem or competence based on the
ability or lack of ability to perform.
Early in the middle childhood period (ages 6–9), the child is still
self-focused. The school-age child continues to exhibit magical
thinking, in that they still may feel responsible for bad things that
happen. Later in this stage (ages 9–12), the child is increasingly
independent, although they want approval and validation.
Throughout this stage, sorting, collecting, and board games are
common activities. Competing and winning become important in the
growing sense of self-competence. Friendships are exceptionally
important at this stage. The school-age child looks more to friends
than family, but family is still important. Best friends tend to be of the
same gender, although mixed gender groups of school-age children
become common as they reach the preteen and early teen years
(Fig. 13-7).
Moral Development
For the first several years, the school-age child is still operating
within preconventional morality. The younger child sees things as
black and white and as self-referenced, rather than connected with
more generalized rules and concepts. By the age of 10, the child
enters Kohlberg’s conventional morality stage. During this time, the
child has internalized rules and is intently gaining approval. The older
child operates within a morality of cooperation that implies
recognition of the interaction between the self and a “bigger”
worldview. Most children at this age are motivated to adhere to laws
as a way to keep order.
FIGURE 13-7 Establishing strong friendships is very important to

school-age children.
Discipline
Because the child in this stage of development is beginning to
internalize rules, it is important to allow the child more independence
and thus more awareness of the natural consequences of behavior.
An effective parental technique is to refrain from “rescuing” the child
from the consequences of their behavior (e.g., rushing home to
retrieve a forgotten piece of homework whenever the child calls
rather than allowing them to learn a valuable lesson).
While many school-age children respond appropriately to natural
consequences, some do not yet understand responsibility. In fact,
most children opt at some time to ignore natural consequences.
Parents may need to impose the previously discussed time-out
strategy (e.g., grounded for a period of time or privileges restricted).
The school-aged child experiences many physical changes that can
be confusing and frightening. Many parents are uncomfortable
discussing, or unsure how to discuss, pubertal changes and need
information to help them explain these changes to their child.
Educating the parents and child about these changes before they
occur is important. Many elementary and middle schools invite
parents to view the materials taught in health classes regarding
puberty and physical changes. Nurses can encourage parents to
review those materials and give permission for their child to receive
that information in class and then reinforce it at home (Box 13-8).
Adolescence (12–19 Years)

Adolescence technically begins with the onset of puberty when the
pituitary gland relays messages to sex glands to manufacture
hormones necessary for reproduction. It is a period of great growth,
second only to infancy. While the growth rate is not as dramatic as
that of the earlier stage, it is still significant. It is not unusual for girls
to gain 15 to 55 pounds (6.8–25 kg) and grow 2 to 8 inches (5–20
cm) and boys to gain 15 to 66 pounds (6.8–30 kg) and grow 4 to 12
inches (10–30 cm) before they reach maturity. Girls develop earlier
than boys and tend to have a smaller overall physical structure. Both
boys and girls develop primary and secondary sex characteristics at
this stage. The timing of development is variable (Table 13-9).
BOX 13-8
Anticipatory Guidance for School-Age Children

Nutrition: Family meals; provide three healthy meals and two to three
nutritious snacks per day; teach child how to make nutritious choices; avoid
high-fat, processed, and “fast” foods; manage weight through exercise and
healthy nutrition
Health Promotion: Immunizations (see immunization schedules at
http://www.cdc.gov/vaccines/schedules/); oral health: brushing, routine
cleanings; be alert to mood changes, stress; discuss smoking and substance
abuse avoidance; discuss sexual feelings and how to say “no” to sex
Focus on Safety: Seat belt and car safety (use seat belt safety information
based on the state of residence; see general guidelines at safercar.gov:
http://www.safercar.gov/parents/index.htm); sunscreen; safe home
environment: secure matches, guns; bike helmet; water, sports, and
playground safety; check smoke detectors; protective equipment for sports;
review rules for being home alone
Sleep-Wake Patterns: Require 8 to 12 hours of sleep a night; night terrors may
occur
Physical Development: Discuss physical changes related to secondary sex
characteristics in later childhood; body odor; some girls may start
menstruation in late childhood
Cognitive and Emotional Development: Stimulate thinking; praise academic
achievement; provide regular time and space for homework; teach
organizational skills; teach and encourage problem-solving skills; implement
goal-setting through calendars or charts; assign regular chores; provide for
family centered activities and trips; assist child to recognize and handle new
emotions; teach social skills; demonstrate acceptance, love, concern for the
child; support participation in hobbies, clubs, and extracurricular activities;
discuss ways to handle peer pressure; encourage taking on new
responsibilities: volunteering in the community
Motor Development: Daily regular exercise; support participation in organized
sports
Discipline: Clearly defined limits; restriction of privileges
Labs
Patient Screening Tests
Screening tests are laboratory tests that help to identify people with increased
risk for a condition or disease before they have symptoms so that preventive
measures can be taken. They are an important part of preventive health care.
Screening tests help detect disease in its earliest and most treatable stages.
They should be sensitive—that is, able to correctly identify those individuals
who have a given disease. Many routine tests performed at regular pediatric
well-child examinations are screening tests. For example, newborns are
screened at birth for a variety of conditions including metabolic disorders and
cystic fibrosis. A positive screening test often requires further testing with a
more specific test. This is important to correctly exclude those individuals who
do not have the given disease or to confirm a diagnosis.
Labs
Lead Exposure
Lead is a metal that was once a common additive to household paint and
leaded gasoline, in water pipes, and as a solder in canned foods. Although
these uses have been limited in the U.S., the interiors of many houses built
before 1978 contain peeling lead paint chips and dust and lead-contaminated
water (CDC, 2020). Children who live, play, or spend time in these
environments are at risk of exposure to this metal and can bring lead into their
bodies by inhaling or ingesting contaminated dust, water, paint chips, or lead-
contaminated items. Lead can deposit in all organs, and in children can
irreversibly affect the growing and developing brain. In fact, lead poisoning can
be an organic cause of attention and learning difficulties in children and cause
behavioral problems and developmental delays. Physical symptoms and
impaired cognitive development may not be noticed until the child enters
school.
The American Academy of Pediatrics (AAP) recommends that a risk
assessment be performed for lead exposure at well-child visits at 6 months, 9
months, 12 months, 18 months, 24 months, and at 3, 4, 5, and 6 years of age
(CDC, 2020). According to the AAP and the U.S. Centers for Disease Control
and Prevention (CDC), universal screening or blood lead level tests are no
longer recommended except for children in high-risk areas with increased risk
factors.
Any child who has an elevated blood lead level needs to have their home or
other environment evaluated. Other people at the residence should be tested
as well.
Prevention of Unintentional Injuries
Many studies have been done to examine the reasons that more
than 3 million children between the ages of 1 and 7 years are seen
annually in emergency rooms and clinics for unintentional injuries
(UI). Many legislative and educational initiatives have attempted to
reduce the number of UI with varying degrees of success.
It has been hypothesized that ED visits may be a more effective
place for pediatric injury prevention education to occur. However, no
difference has been found in studies comparing injury prevention
interventions on parents of injured children versus parents visiting for
other reasons (Ishikawa et al, 2018).
TABLE 13-9
Developmental Milestones of the Adolescent (12–18 years)
SKILLS AND
LANGUAGE
Variable Girls: Begins to Manipulates Abstract Psychosocial:
Weight: develop complicated thought well Peer group
Increases 15– endurance objects developed primary social
55 pounds Increases High skill level Uses logic to environment;
Height: speed, playing video solve problems desires parent
Increases 2–8 accuracy, and games and Projects involvement yet
inches coordination using thoughts over pushes parent
Boys: Develops the computer long term to away at same
Weight: necessary Good finger develop future time; begins to
Increases 15– skills for an dexterity for plans explore romantic
66 pounds identified writing and Increased relationships;
Height: interest other intricate concentration concentrates on
Increases 4–12 (sports, tasks so can follow goals and life
inches hobbies) Precise eye— complicated plans
Both genders hand instructions Play: Cooperative
develop coordination Senses tied play continues
secondary sex into body within peer group,
characteristics image team sports,
Develops adult school or
preferences community
based on activities, and
senses dating; enjoys
Language: solitary time
Continues to
develop and
refine with
increased
vocabulary up
to 50,000
words
Improved
communication
skills;
converses with
increasing
abstract
thought and
analysis
As such, nurses and primary care providers are well-positioned to

identify strategies to educate parents and families on how to best
prevent UI.
Strategies identified to improve child safety include the following:
■ Provide age-appropriate anticipatory guidance on child safety and
UI.
■ Ask parents or caregivers about UI to other children in their
families to personalize the potential for injury.
■ Identify dangerous behaviors exhibited by the child in the
examination room that could result in injury.
Adolescence corresponds with Piaget’s formal operational stage.
The adolescent can think abstractly and use logic to solve problems
and to test out hypotheses. In addition, they use deductive reasoning
and can think about thinking. An individual in this age group begins
to be concerned with such things as philosophy, morality, and social
issues. The adolescent can project thoughts over the long term, thus
making plans and setting life goals. They often compare beliefs with
those of peers.
By adolescence, the child has highly developed and sophisticated
language skills. They have the ability to speak and write correctly.
The adolescent is also able to communicate and debate alternative
points of view.
According to Erikson, the adolescent crisis is concerned with identity
versus role confusion. The adolescent must begin to identify who she
is and who she will be in life. One of the major sources of influence
over an adolescent is the peer group (Fig. 13-8). Members of the
peer group offer differing viewpoints, allow for the establishment of
strong relationships, and provide the opportunity for the adolescent
to practice adult behaviors by becoming active within a social group
and increasingly self-sufficient. Three major issues must be
confronted by the adolescent: selecting an occupation, establishing
and subscribing to a set of values, and developing a satisfactory
sexual identity. As the adolescent makes these important decisions,
they become more confident in their abilities and gradually develops
a sense of self.
FIGURE 13-8 Development of strong peer relationships provides

adolescents the opportunity to practice adult behaviors.
Moral Development
At this stage, conflicts emerge between what the adolescent has
believed to be right or wrong and what others may believe. This is a
time of great questioning and consternation as the adolescent learns
that it is possible for several views of morality to exist. Kohlberg
defined this stage as postconventional morality.
What to Say
Helping the Adolescent Make Good Decisions
The nurse can be influential in helping the adolescent make healthy decisions.
This can be accomplished by employing these techniques:
• Listen: Pay close attention not only to what the adolescent is saying but also
to the nonverbal cues. Try to understand their view of the world and stay
open-minded.
• Discuss without judging: The nurse can share a personal understanding of the
issues and various perspectives while respecting those of the adolescent.
• Encourage critical thought: Allow the adolescent to explore and further
develop their options.
Discipline
The adolescent is at the stage where they begin to internalize
responsibility for behavior. Parental input and guidance are still
needed in terms of rules (e.g., curfew, homework, chores, etc.) and
possible consequences for infractions, but adolescents are much
more able than children in any previous stage to monitor and
regulate actions based on critical thinking. It is important in this
stage, as in all others, that the parent focus on the positives of the
adolescent’s behavior. Natural consequences are powerful
motivators, but by this time, the adolescent may have learned that
they can avoid consequences by being crafty. Removing privileges
may be an effective consequence for the adolescent’s poor decision-
making.
The adolescent is deeply influenced by the peer group. They spend
a great deal of time with their peers, often foregoing family activities
in favor of time with friends. Depending on the peer group, teens
may experience peer pressure to drink alcohol, smoke, experiment
with illicit drugs, or engage in sexual activity. Parents must keep the
lines of communication with their adolescent open and talk about
how to resist peer pressure. It is important for the adolescent to
identify a trusted adult with whom they can talk about sensitive
issues and get advice (Box 13-9).
PROCEDURE ■ Include the Adolescent in
the Informed Consent Process
An informed consent is a way to elicit freely given permission that protects a
person’s right to autonomy and self-determination. Informed consent is given
when the person understands the usual procedures, their rationales, and
associated risks. A parent or legal guardian customarily gives informed consent
on behalf of the child. As children gain critical thinking skills, they can become
more active in the consent process. Depending on state law, children younger
than 18 can give legal informed consent under these circumstances: when they
are minor parents of the child patient; when they are seeking birth control,
counseling, or help for substance abuse; or when they are self-supporting
(emancipated). In many states, a pregnant teen is considered emancipated and
can provide informed consent. The physician is ultimately responsible for
explaining the procedure and related risks, and the nurse’s role is to serve as a
witness to the signature of a parent for the minor child or an emancipated
adolescent. The nurse is responsible for notifying the physician if the parent (or
legal guardian) does not understand the procedure or related risks.
BOX 13-9
Anticipatory Guidance for Adolescents

Nutrition: Provide three healthy meals and two to three healthy snacks per
day; avoid high-fat, processed, and “fast” foods; manage weight through
exercise and healthy nutrition
Health Promotion: Immunizations (see immunization schedules at
http://www.cdc.gov/vaccines/schedules/); oral health; discuss sex, sexual
feelings, protection against sexually transmitted infections; abstinence as the
best way to prevent pregnancy and sexually transmitted infections; if having
sex, discuss birth control and safe sex practices; discuss smoking and
substance abuse avoidance; symptoms of stress and how to deal with it
Focus on Safety: Seat belts; driving safety; sports and water safety;
sunscreen; avoid tanning salons
Sleep-Wake Patterns: Require 8 to 10 hours of sleep per night
Physical Development: Explain development of secondary sex
characteristics; females: explain menstruation and masturbation; males:
explain masturbation and nocturnal emissions
Cognitive and Emotional Development: Praise academic success; monitor
for academic struggles; encourage new challenges; model respect for
differing opinions and needs of others; model conflict resolution strategies;
expect increasing independence from family; peer groups and activities with
peers are increasingly important; provide for some privacy at home;
development of intimate relationships; teach to balance school, work, and
peer group participation; begin planning for the future
Motor Development: Daily regular exercise; support participation in organized
sports
Discipline: Increase levels of responsibility at home to foster movement to
adulthood; restriction of privileges
SUMMARY POINTS
■ Prominent theories of development allow the nurse and family to have a
deeper understanding of the “why” behind developmental tasks and stages.
■ Each child possesses their own way of learning about the world around them.
■ Information about growth and development, newborn through adolescence, is
important for the nurse and family.
■ Principles of growth and development can assist the nurse when teaching the
family about their child.
■ It is important for the nurse to recognize cultural influences on growth and
development.
■ Even though all children grow and develop in their own manner, each child
typically follows a designated pattern or trajectory.
■ Identifying the specific characteristics that define the temperament of a child
can help the nurse and family understand the uniqueness of the child.
■ Families must adjust to new skills and tasks at each stage of development.
■ Understanding growth and development provides the nurse with tools to
develop a plan of care for the family across care settings. ▪ Anticipatory
guidance is an important aspect of the teaching provided to parents by
nurses.
REFERENCES
Ainsworth, M. (1978). Patterns of attachment: A psychological study of the strange
situation. Hillsdale, NJ: Lawrence Erlbaum Associates.
American Academy of Pediatrics (AAP) Policy Statement. (2020). Discipline.
Armstrong, Thomas. (2009). Multiple intelligences in the classroom (3rd ed.)
Alexandria, VA: Association for Supervision & Curriculum Development.
Bowlby, J. (1978). Attachment and loss. Harmondsworth, UK: Penguin Education.
Brazelton, T. B. (2006). Touchpoints: Birth to three: Your child’s emotional and
behavioral development. Cambridge, MA: Perseus.
Brazelton, T. B., & Sparrow, J. (2002). Touchpoints: Three to six: Your child’s
emotional and behavioral development. Cambridge, MA: Perseus.
Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA:
Harvard University Press.
Centers for Disease Control and Prevention (CDC) (2020). Child Developmental
Milestones. Retrieved from:
https://www.cdc.gov/ncbddd/childdevelopment/facts.html
Gardner, H. (2011). Frames of mind: The theory of multiple intelligences. New
York: Basic Books.
Ishikawa, T., Mâsse, L. C., & Brussoni, M. (2018). Changes in parents’ perceived
injury risk after a medically-attended injury to their child. Preventive Medicine
Reports, 13, 146–152. doi:10.1016/j.pmedr.2018.12.008
Johnston, RB. (2019). Poor education predicts poor health—a challenge unmet by
American medicine. NAM Perspectives. Available at:
https://doi.org/10.31478/201904a
Kohlberg, L. (1984). Essays on moral development. San Francisco: Harper & Row.
Lipkin, P. H., Macias, M. M., Council on Children with Disabilities, Section on
Developmental and Behavioral Pediatrics (2020). Promoting optimal
development: Identifying infants and young children with developmental
disorders through developmental surveillance and screening. Pediatrics,
145(1), e20193449.
Piaget, J., & Inhelder, B. (1969). The psychology of the child. New York: Basic
Books.
Ruggiero, K., & Ruggiero, M. (2020). Fast facts handbook for pediatric primary
care. Springer Publishing Co.
Thomas, A., & Chess, S. (1977). Temperament and development. New York, NY:
Brunner/Mazel.
F.A. Davis Company.
Zuckerman, B., & Needlman, R. (2020). Thirty years of reach out and read, Need
for a developmental perspective. Pediatrics, June, 145(6) e20191958; doi:
https://doi.org/10.1542/peds.2019-1958

Davis Advantage
CHAPTER 14
Developmentaly Appropriate Nursing

Care Across Care
CONCEPTS
Development
Nursing
KEY WORDS
family-centered care
chief complaint
medical history
ethnocultural beliefs
review of systems
menarche
anthropometric
measurements
stadiometer
craniosynostosis
deformational posterior
plagiocephaly
micrognathia
allergic shiners
philtrum
chalazions
cerumen
pectus carinatum
pectus excavatum
retractions
hyperpnea
hypopnea
piloerection
informed consent
gavage
health surveillance
LEARNING OBJECTIVES
■ Discuss a developmental approach to gathering the history of and physically
assessing the child.
■ Identify assessment and management issues related to the child in pain.
■ Explore the health-care needs of the family and child living with a disability.
■ Prioritize developmentally appropriate and holistic nursing care for the child and
family across care settings.
■ Examine ways to care for the family across care settings.
PICO(T) Questions
1. What is the (O) best method for screening for (I) caregiver fatigue in (P) parents
of children with disabilities?
2. Are (I) guided imagery techniques helpful in (O) reducing pain in (P) hospitalized
school-age children?
INTRODUCTION
The standards of nursing practice describe a competent level of care for
the nursing profession. Several fundamental themes of these standards
include providing age-appropriate and culturally sensitive care,
maintaining a safe environment, educating patients about healthy
practices, and ensuring continuity of care (ANA, 2020). For a pediatric
nurse, these themes are fundamental to a holistic and caring practice.
This chapter provides the basis of that core in several areas by
presenting a complete assessment of the child and family. Age-
appropriate and culturally sensitive topics in relation to history-taking
and the physical assessment of the child are also reviewed in this
chapter.
This chapter will also cover the nursing assessment and
management of pain in children. A sound understanding of how children
perceive and respond to pain can help the nurse account for the child’s
developmental level, type and severity of pain, and psychological
considerations. Pain assessment tools and common pain management
strategies are described.
The child with a disability presents additional challenges for the
pediatric nurse. The child living with a disabling condition often requires
the involvement of several medical specialties. The pediatric nurse is in
a unique position to assist the family in learning about complex medical
issues and providing support when needed.
Pediatric nurses in all settings must have a thorough understanding
of normal growth and development to assess for disturbances in
progress, including regression or loss of previously attained milestones
because of hospitalization. The nurse becomes acquainted with the
norms of pediatric nursing practice in the context of caring for the child
across care settings and understands that the nurse’s practice must be
individualized for the child’s unique needs.
Finally, the chapter presents the fundamentals of general care
measures the nurse provides in the hospital, clinic, and community
settings. Maintaining a safe environment is an essential component for
some general care practices, including the use of restraints and
infection control measures. Explaining procedures gives nurses the
opportunity to educate the patient about healthy practices to relieve
anxiety and promote well-being.
REASONS FOR ACCESSING MEDICAL CARE

Each year, millions of children visit emergency departments (EDs) for
everything from primary care to severe, life-threatening injuries and
illnesses. Head and neck injuries resulting from bicycle and motor
vehicle accidents; concussions from contact sports; and strains,
sprains, and fractures explain a large percentage of those visits. In
adolescents aged 15 to 19, violent incidents such as motor vehicle
accidents, sports, and assault account for over half of all ED visits for
injuries (Table 14-1).
Illnesses that include fever, cough, vomiting, and diarrhea are leading
causes of visits to the ED. Additional reasons include upper respiratory
infections, abdominal pain, and asthma. Many of these children are
triaged to the urgent care or “treat and release” area of the ED and
rarely need admission to the hospital. Of the approximately half a
million pediatric ED visits per year warranting admission, the most
frequent reasons are infections of the respiratory system, urinary tract,
and skin. The examples included in this chapter are epistaxis
(nosebleed), poisoning caused by ingestion of medicine, and lead
poisoning.
TABLE 14-1
Injuries by Age Group
AGE GROUP MOST MOST COMMON NONFATAL INJURIES BY AGE
COMMON GROUP
FATAL INJURY
BY AGE
GROUP
Infancy Suffocation Head injury, fractures, and sprains resulting from
falls
Motor vehicle accidents because of improperly
installed car seats
Burns caused by sunburn, stoves, cigarettes,
bathwater, electrical outlets
Choking on food or foreign bodies
Suffocation caused by cords and strings
Toddler Drowning Head injury, fractures, and sprains resulting from
falls
Motor vehicle accidents
Drowning
Poisoning
Preschool Drowning Head injury, fractures, and sprains resulting from
falls Motor vehicle accidents
Poisonings
Firearms
School-age Motor vehicle Ages 5–9 years:
accident Head injury, fractures, and sprains resulting from
falls Being struck by or against another person or
object Animal bites Insect bites Ages 10–12 years:
Head injury, fractures, and sprains resulting from
falls
Being struck by or against another person or object
(sports injuries)
Overexertion
Adolescents Motor vehicle Being struck by or against another person or object
accident (sports injuries)
Overexertion
Motor vehicle accidents
Source: Centers for Disease Control and Prevention, National Center for Injury
Prevention and Control, CDC Childhood Injury Report. Reviewed February 6, 2019
http://www.cdc.gov/safechild/Child_Injury_Data.html
ATRAUMATIC CARE OF THE PEDIATRIC PATIENT

As Ruggiero and colleagues (2018) point out, parents are the utilizers
of their child’s health care, and therefore obtaining parental buy-in is
important in pediatric nursing to garner parental understanding.
Embracing the concepts of family-centered care or patient- and family-
centered care is essential for the pediatric nurse. Family-centered
care supports the around-the-clock presence and participation of
parents in the care for hospitalized children. This approach provides
many benefits, such as increasing the satisfaction of family and
patients, improving effective communication between health workers
and families, a better understanding of diseases, better coordination in
care and the planning of follow-up visits, improving patient safety, and
increasing work satisfaction among health workers (Ruggiero et al,
2018).
Parents’ perceptions of the application of atraumatic care for the
hospitalization of children has been widely studied (Handayani &
Daulima, 2020). Hospitalization is often a traumatic experience for a
child. Hospitalization requires children to adapt to various difficult
conditions, such as treatment, health personnel, and separation from
their family, especially parents (Handayani & Daulima, 2020).
Separation from parents often causes significant emotional changes in
children in terms of coping with the anxiety they feel due to the fear of
being hospitalized. Hospitalization trauma leads to various reactions in
children, such as crying, panic attack, refusal to eat, hyperactivity, and
self-alienation, which make it difficult for the health worker to approach
them. Parental presence has been shown to help the child cope with
hospitalization (Handayani & Daulima, 2020).

Promoting Development Through Play in Care Settings
Pediatric care can occur in a variety of settings including the hospital, clinic,
school, or rehabilitation center. Regardless of location of service, measurement
and assessment of pediatric growth and developmental milestones should be
included in routine health screening and physical assessment. Growth and
development occur across varying settings and can be influenced by the
environment. The nurse must have a sound understanding and knowledge about
the concepts of growth and development as this can better support the child and
family moving through the various growth and development stages.
Children primarily learn through stimulation and play. Play helps children develop
fine and gross motor skills, hand-eye coordination, communication skills, social
skills, problem-solving skills, and memory development. Nursing care should focus
on providing age-appropriate interventions as needed depending on the needs of
the child and family. For example, toys and stimulation that are appropriate for
school may not be acceptable in the hospital. The nurse can encourage the family
members to bring the child’s favorite things from home to minimize stress and
create a sense of safety for the child as they receive care in different settings.
When hospitalization is required, health restoration is a priority, but consideration
of growth and development must be included in the nursing plan of care.
Other members of the health-care team can collaborate to support the needs of
the child during stressful times, such as before procedures. One example is a child
life specialist (CLS), a master’s-prepared specialist who works with the patient,
family, and health-care team to provide age-appropriate interventions and can be
helpful to identify appropriate resources for the child, regardless of location of
service.
GATHERING THE CHILD’S HEALTH HISTORY

Establishing a Relationship With the Patient and the Family
Assessing a child’s health history can be a daunting task. Children vary
in language skills, clarity of speech, cognitive abilities, and social skills.
Some children can verbalize where they hurt while others may only
react by crying. Each child must be approached with these differences
in mind. Any differences that fall out of the realm of what is considered
normal growth and development should be noted by the nurse and
other members of the health-care team.
For an infant or a nonverbal child, the nurse begins the health history
with an interview of the parents, grandparents, foster parents,
stepparents, nannies, older siblings, and adult guardians who
accompany the child to the health-care setting. After introductions are
made, it is important to clarify the identity of the person who has
brought the child in for care.
Young children need to feel secure before engaging in conversation
with the nurse. Once the child feels comfortable with the nurse present,
the child may be more apt to contribute to the interview process. They
may be able to add important pieces of information needed for optimum
care.
The school-age child may elect to be interviewed without the parent
in the room. This allows them to speak freely of health concerns and to
ask questions. The nurse should speak with the parent separately to
determine whether the parent has specific concerns or issues that may
need to be addressed during the visit.
With the adolescent, the nurse may ask the parent to leave the room
during discussion of issues related to social and sexual content. The
adolescent needs to know that this conversation can take place without
the parent’s knowledge. This allows the nurse to provide appropriate
medical and nursing care that will ensure the adolescent’s health and
safety. Exceptions to maintaining confidentiality involve instances
concerning abuse or a life-threatening situation, which should be
discussed with the adolescent before the health-care encounter.
NURSING INSIGHT
Family Dynamics
Family dynamics are assessed by observing the behaviors between the child and
parent. Questions to consider:
• During a health-care visit, does the parent or caregiver seem appropriately
concerned about the problem?
• Does the parent or caregiver have the information/knowledge or is there a gap
identified by the nurse that can be addressed through education of the parents
regarding their child’s condition? Is the parent or caregiver a reliable historian?
• Is the parent or caregiver providing comfort to the child if the child is frightened?
• Does the parent or caregiver appear angry about being in the office?
• Is the parent or caregiver aware of the needs of the child?
• Does the child look well cared for?
Asking Questions
The interview process is the most widely used method of
communicating with parents on a professional basis. Whether caring for
children in an acute, ambulatory, or other care setting, it is most
important to have an organized approach to the interview. The nurse’s
interaction with the child is frequently mediated by the parents, and
research shows that parents’ perception of their child’s health often
mediates their child’s health outcomes (Ruggiero et al, 2018). As such,
it is important for the nurse to establish a good rapport with the parent
by asking open-ended questions. Conduct the interview in a
comfortable room with available seating for the parent and with eye-
level interaction with both the parent and the child. An unhurried
environment encourages the parent to ask questions appropriate to the
health of the child. The nurse projects a genuine interest in and desire
to help the child and family. They acquire information through this
interview process by observing the interactions between the child and
parent, and from the nurse’s own assessment of the child. This lays the
foundation for a positive therapeutic relationship.
Beginning with open-ended questions allows the nurse to explore
concerns as they invite the child or parent to tell their story by asking,
“How can I help you today?” or, for a problem-oriented visit, “What
made you come in today?” This type of question allows the parent to
recount the history of the present condition, also known as the chief
complaint. A focused or problem-oriented health history is then
obtained.
Assessment Tools
Pediatric History
When clarifying the child’s history, the nurse may use the mnemonic OLD CAT
(Hogan-Quigley et al, 2011) to ask the appropriate questions. For example, a child
complaining of pain would be asked these questions:
Onset: “When did the pain start?”
Location: “Where is the pain?”
Duration: “How long does the pain last?”
Character: “Can you tell me on a scale of 1 to 10 how bad it is?” For a younger
child, ask the parent, “How much pain do you think the child is experiencing?”
or use a pain scale that is appropriate for the child’s level of development.
Aggravating/Alleviating: “What has made the pain better or worse?”
Timing: “When does the pain start/stop?”
After the chief complaint is determined, the child’s past medical

history is reviewed. This includes past acute illnesses and history of
chronic illnesses, immunization history, hospitalizations, emergency
room visits, serious injuries, operations, and current medication usage.
Inquiries are made as to the use of any over-the-counter medications,
herbal preparations, or folk remedies, and any history of allergic
reactions to food, medications, and environmental allergens should also
be reviewed.
Use of Culturally Appropriate Care

A culturally competent nurse becomes familiar with the health practices
and beliefs of the diverse cultures in the community in which they
practice. The nurse understands that culture is a dynamic set of shared
components that develop through environmental acquisition,
socialization, and language. Examples of cultural considerations include
common health conditions, health beliefs, health practices, occupation,
education level, religion, environmental conditions, and other
characteristics that could influence a person’s mental or physical health.
The nurse must value and respect cultural practices and adapt the
intake history to determine communication and decision-making
practices within the family and account for stated ethnocultural
(relating to a particular ethnic group) beliefs about health and illness.
Comprehensive Health History

When a child is seen for a well-child visit, a comprehensive health
history is necessary. Components of a child’s health history include
family medical and social history, immunizations, past medical history,
developmental milestones achieved, patterns of daily activities, and a
review of systems.
Family Medical and Social History

The family medical and social history includes documenting the current
household makeup and the age and health of each family member.
Document the following:
■ Ages and cause of death of any deceased parents, grandparents,
and siblings
■ Chronic illnesses experienced by family members
■ Inherited diseases
■ Parents’ professions, religious affiliations or spiritual beliefs, and
family activities
■ For the older child interviewed without the presence of the parent, the
social history must also include information regarding grade level,
friendships, drug or alcohol use, smoking, sexual activity, and safe
sex practices
Past Medical History

A thorough birth history can provide valuable information about the
health status of a younger child. The history of the pregnancy, labor and
delivery, and the health of the baby at birth are documented, including
the birth weight and APGAR scores if available. In addition, any
difficulties with feeding, breathing, jaundice, or other medical problems
in the early neonatal period must be documented.
The past medical history in children includes documentation of all
acute illnesses. Chronic illnesses and the medications that have been
prescribed are listed, as are the use of any herbal products and home
remedies. If the child’s chart is available, all encounter forms are
reviewed to determine the reason for the visits, resultant medical
diagnoses, and outcomes of previous treatments.
Immunizations
Immunizations received are documented and the chart is reviewed
before the interview to determine whether the immunizations are
current. Maintaining current immunization status protects the child and
family against preventable communicable diseases. The Centers for
Disease Control and Prevention (CDC) reviews and updates the
immunization schedule regularly, so it is important for the nurse to be
aware of and follow the most current guidelines (CDC, 2020).
Developmental Milestones
The developmental assessment is essential to determine whether a
child’s development is within the normal range, delayed, or the child is
at risk. The newborn has newborn reflexes (such as the grasp reflex,
Babinski reflex, and rooting reflex). These reflexes show that the
neurological system is grossly intact. As the child grows and develops,
most of these reflexes disappear (around 4–6 months) as the child
progresses in their development. Developmental milestones can be
assessed using the Denver II Screening Test in children from birth to 6
years of age. The Denver II assesses personal-social, fine motor-
adaptive, gross motor, and language skills (Frankenburg et al, 1992).
The nurse also documents the child’s behaviors during administration
of the test, including compliance, interest in surroundings, fearfulness,
and a subjective measure of the child’s attention span. After the test
has been administered, the parents may be asked if the child’s
performance was characteristic of their normal behaviors. Referral is
needed when the child’s results show two or more delays, if there is no
improvement in areas of concern 3 months after the initial screen, or if
the child is determined to be “untestable” at two consecutive
screenings.
Patterns of Daily Activities

The effect of the current illness is evaluated by inquiring about the
child’s daily activities, using the mnemonic SODA to ask the appropriate
questions:
Sleep: “How has your child been sleeping?”
Output: “How many times per day do you___________ ?” (Use an expression the
family has adopted to convey urine/stool output.) Or, for the younger child ask,
“How many wet diapers have they had today?”
Diet: “How much fluid has your child taken in today?” “Has the illness affected the
child’s appetite or diet?” Activity: “Has the child’s activity level changed since they
have been ill?”
Interviews are commonly concluded by asking if the parents have any

other concerns or problems they would like to discuss.
SLEEP
The nurse must determine both the number of hours and the quality
of sleep the child receives each night. Sleep requirements change as
the child grows, and each child’s sleep requirements are different.
Newborns sleep about 16 or 17 hours a day, typically in stretches of 2
to 3 hours at a time. Babies are typically able to sleep through the night
by 6 months. Children also differ in their ability to sleep. Some can
sleep anywhere under any conditions while others suffer sleepless
nights with even the slightest change in normal routine. Naps may be a
part of a child’s life up to the preschool years. Some children
experience nightmares or night terrors that can disrupt sleep.
Nightmares may reflect the struggles children experience during the
day or the fears they have about separation, impulses, or conflicts.
Night terrors occur during the first few hours of sleep. A child can
recount their nightmares and may be frightened but will have no
recollection of night terrors. In addition, the American Academy of Sleep
Medicine has recommended that children aged 6 to 12 years should
regularly sleep 9 to 12 hours per 24 hours and teenagers aged 13 to 18
years should sleep 8 to 10 hours per 24 hours. Children who get
enough sleep may have fewer attention and behavior problems (AAP,
2018).
NUTRITION
The questions a nurse asks regarding nutrition are based on the
child’s age. If the infant is breastfed, information is gathered about
frequency and length of feeding as well as how many wet diapers are
changed in 1 day. With sufficient breast milk intake, the infant will have
six or more wet diapers and gain weight.
For the infant who is receiving formula, gather information about the
type of formula, the amount taken at each feeding, and the number of
feedings per day. For both breastfed and formula-fed babies, it is also
important to note if and when juices or solid foods have been started
and whether supplements or vitamins have been prescribed.
When assessing children and adolescents, a 24-hour recall elicits the
food items eaten in a typical day and reflects sociocultural trends. In
addition, the nurse must document food allergies for all children. Foods
and caloric intake should be appropriate for age and developmental
level (Table 14-2). Analysis of the child’s food intake is compared with
the foods suggested on MyPlate.gov for children older than 2. The
servings for children are based on age, gender, and activity. For those
who participate in more than 30 minutes of physical activity per day, the
number of servings may need to increase, provided they do not exceed
the recommended daily caloric intake. The nurse must be familiar with
proper nutritional guidelines for educating children and families.
Daily caloric intake must have a balance of the macronutrients—
protein, carbohydrates, and fat. Together, these macronutrients provide
for a healthy diet.
TABLE 14-2
Average Daily Caloric Requirements for Children
AGE DAILY CALORIC REQUIREMENTS
0–1 month 100–110 kcal/kg per day
2–4 months 90–100 kcal/kg per day
5–60 months 70–90 kcal/kg per day
>5 years 1,500 kcal for first 20 kg + 25 kcal for each
additional kg
Source: Hay, W. W. Jr., Levin, M., Sondheimer, J., & Deterding, R. (2020). Current
diagnosis & treatment: Pediatrics (24th ed.). New York, NY: Lange Medical
Books/McGraw-Hill.
Protein
From 10% to 35% of daily caloric intake must come from protein
sources such as dairy products, eggs, lean meat, seafood, poultry,
beans and peas (e.g., pinto, lentils, lima, split pea, and white beans),
soy products (e.g., soybeans, tofu, and veggie burgers), and nuts and
seeds (e.g., almonds, peanuts, and sesame seeds). Protein intake each
week should include 8 ounces of seafood because this is a good source
of lean protein and omega-3 fatty acids. After age 2, whole milk should
be switched to low-fat or skim milk.
Carbohydrates
Carbohydrates should account for 45% to 65% of the daily caloric
intake. Carbohydrate sources include grains, fruits, and vegetables.
Half of all grain servings per day should be whole grains like quinoa,
oatmeal, and brown rice or pasta.
Fat
Contrary to popular belief, not all fat is bad fat. In fact, 20% to 35% of
daily caloric intake should be from fat. Keep total fat intake between
30% to 35% of calories for children 2 to 3 years of age and between
25% to 35% of calories for children and adolescents 4 to 18 years of
age, with most fats coming from sources of polyunsaturated and
monounsaturated fatty acids, such as fish, nuts, and vegetable oils.
Unsaturated fats are those that are liquid at room temperature, known
as oils; olive oil, canola oil, and soybean oil provide healthy alternatives
to saturated fats.
PLAY, ACTIVITIES, AND SCHOOL
Patterns of play and children’s activities reflect the interests of the
child, the family financial circumstances, work schedules of the parents,
environmental safety, and the availability of after-school activities.
Throughout infancy, learning takes place in the context of sensory
stimulation. The parent can provide insight into whether there is
sufficient stimulation in the immediate environment to help the child
learn. For example, talking and singing adds auditory stimulation.
Holding, cuddling, and consoling the infant provides the tactile sensory
stimulation for developing a sense of trust and facilitates the bonding
process.
As the child matures, continued supervision of the child’s activities is
needed to encourage social competence and healthy habits.
Information is gathered about the daily routine of the child; the contact
the child has with playmates, older siblings, and adults; and whether the
child has an opportunity to develop gross and fine motor skills or has
attended community programs such as Head Start. Head Start
programs promote school readiness of children ages birth to 5 from
low-income families by supporting the development of the whole child.
For school-age children, additional information is gathered regarding
achievement with schoolwork, special education needs, extracurricular
activities, and interaction with peers.
An understanding of the patterns of daily activities allows the nurse to
make suggestions for a healthy lifestyle to the parent or child, alert the
primary care provider of potential problems, and provide anticipatory
guidance as appropriate to the situation.
Review of Systems
The review of systems (a series of questions about each body
system) is best conducted with a head-to-toe approach, starting with a
general question regarding each body system. It can also be conducted
by asking questions during the physical examination. The review of
systems includes the following areas:
■ General: Usual weight, change in weight, weakness, fatigue, fever, or
allergies
■ Skin: Rashes, pruritus, turgor, changes in color, indications of injury,
acne, changes in nails or hair
■ Head, Eyes, Ears, Nose, Throat (HEENT): Injury to head, headaches,
dizziness; eye infections, itching or watering eyes, behaviors
indicating change in visual acuity, use of glasses, date of last eye
examination; ear infections, behaviors indicating change in hearing;
nose bleeds, colds, hay fever, sinus infections; sore throats, tonsils,
dentition, caries
■ Neck: Neck pain, enlarged lymph glands, neck range of motion
■ Chest: Respiratory infections, asthma, chronic cough, wheezing,
shortness of breath, breast changes
■ Cardiovascular: Heart murmur, palpitations, date of last blood work
■ Gastrointestinal: Regurgitation, vomiting, changes in bowel habits,
constipation, diarrhea, food intolerance, abdominal pain, changes in
appetite or eating pattern
■ Genitourinary: General—dysuria, urgency, odor to urine, date of last
urinalysis, signs of puberty, urethral or vaginal discharge, presence of
lesions, sexual habits, contraceptive use, and symptoms or history of
sexually transmitted infections; males—changes in
groin/scrotum/glans, presence of circumcision; females—menarche
(the first menstrual period), date of last menstrual period,
dysmenorrhea, and date of last Pap smear (if appropriate)
■ Musculoskeletal: Injuries, fractures, weakness, clumsiness, gait,
muscle pains
■ Neurological: Seizures, tics, psychiatric diseases, anxiety, depression
■ Endocrine: History or symptoms of thyroid disease or diabetes or
diseases that affect normal growth
HEALTH ASSESSMENT
When examining children, the approach to the physical assessment is
based on the child’s age, cognitive level, and degree of illness. Infants
can be examined from head to toe without difficulty. Some children are
fearful of any examiner and are uncooperative. Others seem to enjoy
the experience as something new. As a guideline, an examination starts
with the least invasive actions and concludes with the most distressful
actions. For example, it is easier to examine the posterior lung fields
with the caregiver holding the child on their lap early in the examination
while leaving the examination of the ears and mouth for the end of the
examination.
Anthropometric Measurements
Before the physical assessment, vital signs and anthropometric
measurements (growth measurements of length, weight, and head
circumference) are taken, recorded, and plotted on appropriate growth
charts. Growth charts use percentile curves to demonstrate the percent
of a child’s body measurements. The CDC recommends that the World
Health Organization growth standards be used to monitor for children 0
to 2 years of age, and the CDC growth charts be used for children older
than 2 (www.cdc.gov/growthcharts).
Length
Length is measured while an infant is lying supine on a measuring tray
or board. If a measuring board is not available, the nurse holds the
head in midline while an assistant holds the hips and knees extended
flat on a paper-covered table. Points are marked at the top of the head
and the heels of the feet, the child is moved, and the distance between
markings is measured. For the older child, a stadiometer (a device
used to measure a standing height) is used to obtain a standing height.
The child removes their shoes and stands with their back to the
stadiometer, with the back of the heels and shoulders touching the wall.
Weight
The weight of an infant is measured using an infant scale lined with a
thin paper cover. After the scale setting is balanced, the infant’s clothing
is removed and the child is weighed in either a supine or sitting position.
The nurse protects the child from an accidental fall by placing a hand
over the infant without direct contact. Older children are weighed on a
standing scale. The same scales should be used to measure height and
weight at each visit.
Once weight and height are assessed, body mass index (BMI) can be
calculated. The BMI is used to assess total body fat and nutritional
status. In children, the BMI is represented as a percentile, allowing a
comparison to other children of the same age and gender. BMI is
assessed at least once a year at the annual well-child appointment.
Diagnostic Tools
Body Mass Index (BMI)
A BMI-for-age plotted below the 5th percentile indicates a child who is
underweight; a BMI-for-age between the 5th and less than the 85th percentile is
considered a healthy weight; children with a BMI-forage between the 85th and less
than the 95th percentile are considered overweight; and those with a BMI-forage
greater than the 95th percentile % are considered obese.
Assessment Tools
Body Mass Index (BMI)
The BMI-for-age is calculated by dividing the weight in kilograms by the meter
height squared. Because most health-care providers obtain height in centimeters,
an alternative calculation is to divide the weight in kilograms by the centimeter
height squared multiplied by 10,000. For example, the BMI for an 8-year-old boy
who weighs 26 kg with a height of 135 cm is calculated as follows: 26 divided by
1352 (18,225) × 10,000 = 14.26. A BMI of 14.26, plotted on the growth chart
between the 10th and 25th percentile, is a healthy weight.
Head Circumference
For children 3 years old and younger, head circumference
measurements are done at routine well-child visits. The head’s largest
circumference is measured by placing the tape over the lower forehead,
above the pinna of the ears, and over the occipital prominence (Fig. 14-
1). This measurement is recorded in centimeters and displayed as a
percentile. As with weight and height, evidence of growth within the
percentiles remains consistent over time, with normal values according
to age and gender reflecting normal development. A deviation either
below or above the percentile from the previous visit may signify a
problem. The nurse informs the primary care provider of these findings.
Vital Signs
Temperature
Vital signs consist of temperature, pulse, respirations, and blood
pressure (Table 14-3). A variety of digital and tympanic thermometers
are available. The route used for assessing temperature depends on
the age and developmental level of the child. Newborn temperature is
assessed via the axillary route. The tip of a digital thermometer is
placed in the axilla with the arm held against the side of the body until
the temperature registers. Rectal temperatures are not routinely
measured. If a rectal temperature is desired, caution is taken not to
insert the thermometer more than ½ inch. In older children, tympanic
membrane or temporal temperatures are obtained (Fig. 14-2). Because
temperatures register within seconds, this route is a convenient one in
pediatrics. The route used is charted when recording the child’s
temperature.
FIGURE 14-1 Measuring head circumference.

TABLE 14-3
Average Range for Pediatric Vital Signs
AGE GROUP HR RR BP SYSTOLIC BP DIASTOLIC
Infant 80–150 25–55 65–100 45–65
Toddler 70–110 20–30 90–105 55–70
Preschooler 65–110 20–25 95–110 60–75
School-age 60–95 14–22 100–120 60–75
Adolescent 55–85 12–18 110–125 65–85
FIGURE 14-2 Taking tympanic temperature.
Pulse
Assessing the pulse in newborns and children requires concentration.
The heart rate is variable and changes with illness. The apical pulse is
counted for a full minute while the infant or child is quiet. With an
uncooperative infant, the femoral arteries are palpated in the inguinal
area, or the brachial arteries in the antecubital fossa.
Respirations
Respirations are to be counted for 1 full minute and can be assessed
accurately only when the infant or child is not crying. A good time to
count them is when a child is sleeping or resting quietly in a parent’s
arms. If possible, it is wise to start the vital sign assessment with
respirations. There is a great deal of variability in the respiratory rate in
children. Infants and young children are diaphragmatic breathers. The
nurse can visually count the number of respirations by observing the
abdomen as the child breathes.
Blood Pressure
Blood pressure is measured during well-child visits or routine physicals
beginning at age 3. Readings are especially important for children with
cardiac, pulmonary, or kidney disease; dehydration; or complaints of
dizziness, regardless of age. For accurate radial blood pressures,
selection of the cuff size is important. Appropriate cuff size is one in
which the width of the bladder is approximately 40% and the length is
approximately 80% of the circumference of the arm (AAP, 2019).
Electronic blood pressure devices with varying cuff sizes are also
available.
Physical Assessment
General Impression
As the nurse meets the child and the parents and engages in
conversation with them, an impression begins to form. This subjective
feeling about the child encompasses many areas of assessment. As the
nurse conducts the health history and performs the physical
assessment, additional notions regarding the child and family develop.
Not only is the uniqueness of the child portrayed, but a reflection of the
child’s family life becomes evident.
Take note of the behaviors of the child as they interact with their
parents. How does the child react to questions? What is the child’s
speech like? Is the child quiet, pleasant, talkative, uninterested, or
angry? For the younger child, does the child listen to parents, interact in
a meaningful way, or engage in age-appropriate behavior?
Hygiene and nutritional status are also examined. Is the child clean
and appropriately dressed for the season? Body size, skin color, eyes,
and the condition of the hair are observed for evidence of a good
overall nutritional state.
Skin Assessment
The skin is assessed for color, turgor, and lesions. Skin color reflects
ethnicity, diet, disease, and injury. Variations in tone are a result of
genetic composition. Carotenemia, a benign yellowing of the skin
caused by excessive carotene in the blood, may be present in the child
with a diet high in yellow and orange vegetables, or yellowing of the
skin and sclerae may indicate a dysfunction of the liver. Pallor may
indicate anemia. Cyanosis may indicate a compromised
cardiorespiratory state. Petechial lesions may indicate an infectious
process or a blood disorder. Ecchymotic lesions may also indicate a
blood disorder or signify past accidental or nonaccidental injuries.
The nurse can assess the child’s skin turgor for evidence of
dehydration by grasping a small area of skin and pulling up. Once
released, the skin should quickly return to its normal position. Skin that
remains in the “tenting” position for several seconds indicates absence
of skin turgor or presence of skin turgor with inadequate hydration.
If a rash is present or if jaundice is suspected, the nurse determines
whether the skin blanches or turns pale by applying pressure to the skin
with the thumbs about 1 to 2 inches apart. This presses the normal pink
and darker colors out. In the presence of jaundice, there is a yellowish
underlying color. Petechial lesions do not blanch, which may indicate a
serious bacterial infection in an ill child. The primary healthcare provider
should be notified immediately.
The skin examination concludes with the inspection and
documentation of the texture of the hair and the condition of the scalp,
palms, and nails. Cradle cap is common in newborns and infants and is
identified by thick, crusty scales over the scalp. The older child is
monitored for lice or ticks.
Normal nails are pink and convex, with white edges extending over
the end of the fingers. In children with cardiac disease, nails are
examined for evidence of clubbing. Nail biting is a nervous habit
evidenced by very short nails without the normal white edges.
The palms are examined for the normal flexion creases. While most
people have three creases, in a small section of the population the two
horizontal creases fuse to form a single horizontal palmar crease. This
is a common finding in many genetic disorders, particularly Down’s
syndrome. If this palmar crease is evident on only one hand, the child
may have no genetic disorders.
Head Assessment
The head is observed for symmetry and shape. Beyond the newborn
period, head shape abnormalities in the infant may be caused by
craniosynostosis, a premature fusing of one or more of the cranial
sutures, or from gravitational influences caused by the infant’s head
being kept in the same position for an extended period of time. An odd
head shape can develop because of the malleability of the skull bones.
The supine sleep position has greatly reduced the incidence of sudden
infant death syndrome. However, infants who are placed in the
recommended supine position for sleep are at increased risk for
deformational posterior plagiocephaly, or flattening, of the occiput.
The skull is palpated to evaluate fontanelles, sutures, contusions, or
other swellings. Fontanelles are fibrous membrane-covered areas
where two or more skull bones converge. Although there are six
fontanelles, the two most commonly evaluated are the posterior and
anterior fontanelles. The posterior fontanelle closes within 1 to 3
months after birth, while the diamond-shaped anterior fontanelle (AF)
remains open until 12 to 18 months of age.
The AF is the most significant fontanelle for evaluation (Fig. 14-3).
Assess the fontanelles when the infant is held in a sitting position.
Depression of the AF may indicate dehydration; fullness of the AF is a
potential sign of increased intracranial pressure.
The face is examined for general appearance and the comparison of
features to those of the parents. Unusual features are noted, such as a
micrognathia (shortened chin), low-set ears, flattened nasal bridge,
enlarged or protruding tongue, allergic shiners (dark, undereye rings),
or a wide and flattened philtrum (the vertical groove from the bottom of
the nose to the upper lip).
Neck Assessment
Lymph nodes of the head and neck are palpated systematically, starting
at the preauricular area, proceeding to the postauricular area, and then
to the occipital nodes (Fig. 14-4). Next, the tonsillar nodes at the angle
of the mandible are examined, followed by the submandibular and
submental nodes under the chin, the cervical chain of lymph nodes, and
the supraclavicular area. Size, shape, mobility, and tenderness are
documented. It is common for young children to have palpable,
painless, movable nodes up to 1 cm in diameter. Pain upon palpation
may be indicative of an upper airway infection. The trachea is palpated
for midline placement and masses. A lateral deviation of the trachea
may be caused by a mass or a collapsed lung. The thyroid gland is
examined for enlargement, nodules, and goiters.
FIGURE 14-3 Anterior and posterior fontanelles.
FIGURE 14-4 Lymph nodes of the head and neck.
Eye Assessment
Observation of the eyes includes assessment of symmetry, shape, and
placement in relation to the nose. In addition, the nurse can assess for
symmetry and size of the pupils and their response to light. The
conjunctiva and lids are observed for conjunctivitis, styes, or
chalazions (small discrete swellings of the upper lid that develop when
a meibomian oil gland becomes blocked). The sclerae are inspected for
color. The nurse notes erythema, swelling, or discharge from the eye.
Documentation of the presence of discharge includes type (e.g., watery
or purulent), color, amount, and associated symptoms. Treatment
depends on the cause, which may be bacterial, viral, or allergic.
VISUAL ACUITY
To ensure optimal eye health in children, testing for ocular alignment
and visual acuity should be examined yearly. Assessment of visual
acuity depends on the age of the child. Infants begin to use a steady
gaze to regard faces or objects with interesting patterns. The nurse
observes for and documents this finding during the physical
examination. Any difference in visual acuity between one eye and the
other is abnormal and requires a referral to a specialist. In addition,
children are referred for further evaluation if they have a visual acuity
reading of less than 20/50 or after failing a second screening.
Assessment Tools
Screening for Visual Acuity
Visual screening for children can begin at the age of 2.5 years. Various charts
assist in the assessment of visual acuity. Visual acuity for each eye is assessed by
occluding the contralateral eye with a plastic paddle. With all charts the objects,
letters, and numbers decrease in size. The Allen chart requires the child to identify
common objects; the “tumbling E” requires the child to identify the direction to
which each E is facing; and the Snellen charts require the child to identify letters or
numbers.
OCULAR ALIGNMENT
A common method for assessing ocular alignment is the Hirschberg
corneal light reflex test, in which a light is shone directly into the child’s
eyes and the position of the corneal light reflection in both eyes is
noted. The reflection should fall in the same location on the cornea of
each eye. Displacement of the corneal light reflection in one eye is
indicative of strabismus.
The second screening test is the cover-uncover test, in which the
child is asked to focus on a distant object across the room. The nurse
covers the first eye while watching the second eye for movement. The
cover is then removed from the first eye, which is observed for any
movement. If no movement is detected, ocular alignment is intact. The
examination is repeated on the opposite eye.
The red reflex is tested by viewing the pupil through an
ophthalmoscope from a distance of 10 inches. If the pupil appears red,
the finding is normal. A white retinal reflex may indicate cataracts,
retinoblastoma, or chorioretinitis.
Ear Assessment
The external ears are examined for size, shape, placement, pain, and
presence of drainage from the ear canal. The pinna of the ear should
be above the imaginary horizontal line drawn from the medial and
lateral canthi toward the occiput. Various congenital anomalies are
associated with low-set ears; for example, a congenital anomaly such
as Down’s syndrome is associated with low-set and/or misshapen ears.
In another example, because ears and the kidneys are developed
during the same time in utero, ear anomalies are also associated with
renal abnormalities.
To assess for pain, and potential otitis externa (infection of the outer
ear), the nurse moves the pinna of the ear up and down. If the child
complains of pain when pressure is applied to the tragus, the canal is
examined for evidence of otitis externa. Cerumen (ear wax) may be
seen on the external ear or in the external canal with an otoscope.
Purulent drainage may indicate a foreign body in the external ear canal
or a ruptured tympanic membrane. Any clear drainage noted from the
ear, particularly after head trauma or with cranial infections, should be
reported to the health-care provider immediately because this fluid may
indicate a cerebrospinal fluid leak.
FOCUS ON SAFETY
Use of an Otoscope
When an otoscope is used, the canal should be positioned for the optimal viewing
of the tympanic membrane and canal. As a general rule, the pinna is pulled down
and back for children younger than 3 years and up and back for older children.
The child is positioned to prevent injury or discomfort. With the parent’s help to
gently restrain the child from moving, the otoscopic examination can take place
with the child either sitting on the parent’s lap or in the supine position. The
tympanic membrane is examined for the presence of normal anatomical
landmarks (Fig. 14-5).
Visual loss of these landmarks may occur because of erythema,
fullness behind the tympanic membrane, inflammation, purulent
exudate, or fluid. Because of the anatomical structure of their ears,
infants and young children are prone to developing otitis media. The
eustachian tubes are shorter and more horizontally positioned than
those of adults, enabling viruses and bacteria to travel to the middle
ear. Infants who are breastfed, do not attend day care, and are fed in an
upright position have decreased rates of otitis media.
Early detection of hearing loss is important to prevent delayed
hearing, speech, and language development. Hearing loss may affect
both the academic success and psychosocial development of the child.
Because hearing loss in childhood is associated with middle ear
disease, it is recommended that children with positive results from office
screening examinations be referred to an audiologist for further
evaluation and treatment.
Nose/Sinus Assessment
The nasal mucosa is inspected for color and inflammation. Pale, boggy
mucosa is a typical finding in a child with allergic rhinitis. The nasal
mucosa appears erythematous with upper respiratory infections. Note
any bleeding of the mucosal lining because this can indicate injury.
Purulent discharge from the nose may indicate a viral or bacterial
condition. Purulent discharge occurring in one nostril suggests a foreign
object in the other nostril. The septum is inspected for the midline
position. Maxillary sinuses are detected via x-ray examination by age 4,
with other sinuses radiologically evident by age 6. These areas are
palpated for tenderness, using the thumbs of both hands and holding
the child’s head.
FIGURE 14-5 Tympanic membrane landmarks.
Throat/Mouth Assessment
The examination of the throat and mouth is saved for last in younger,
less cooperative children. The nurse may ask the child to see “all of the
tongue.” Eliciting the sound “eeehh” flattens the tongue better than
“aaahh,” and visualization of the posterior pharynx is possible without
the use of the tongue blade. The palate, uvula, tonsils, and mucous
membranes are observed and assessed for color, exudate, and odor.
The lips are observed for shape, symmetry, color, dryness, fissures at
the corners of the mouth indicative of vitamin B2 (riboflavin) deficiency,
and clefts.
The teeth are inspected for number present, condition, color,
alignment, and caries. Tooth eruptions occur at varying rates. Generally,
when counting teeth on visual examination, the nurse can expect one
tooth per month after 6 months of age until all 20 deciduous teeth are in
place. The gingival tissue is inspected for color and condition. The
gingival tissue is the same color as the surrounding mucous
membranes and should not be hypertrophied or show evidence of
bleeding.
Chest Assessment
The nurse inspects the chest for size, shape, symmetry, respiratory
effort, and breast development. In infants, the anteroposterior diameter
is fairly equal to the lateral diameter. By age 2, the lateral diameter is
greater than the anteroposterior diameter. Equal anteroposterior and
lateral diameter after the age 2 may indicate chronic lung disease. A
chest that is larger on the left than on the right may indicate an enlarged
heart or a collapsed right lung. Pectus carinatum (protrusion of the
chest) and pectus excavatum (abnormal depression of the lower
portion of the sternum) are abnormal chest shapes caused by sternal
deviations.
With any increased work of breathing, retractions are observed.
When the trachea or the smaller airways of the lungs experience air
flow restriction, the pressure within the chest is reduced. As a result, the
intercostal muscles are drawn inward in an attempt to assist in
breathing. This drawing inward is visible as intercostal retractions.
Retractions may also be seen in the substernal, subcostal, and
suprasternal notch regions.
Normal breast development begins in girls between 10 and 14 years
of age. Boys also undergo breast changes, and many show evidence of
breast development. For the female, breast development is
documented using the Tanner Staging of Development of Secondary
Sex Characteristics (Table 14-4). Breast assessment is important at
every well-child visit for early detection of precocious puberty. Girls
must be taught breast self-examination when breast tissue begins to
develop.
Lung Assessment
Lung sounds are best auscultated with the child in a sitting position.
The nurse instructs the child to take slow deep breaths through an open
mouth. Using a stethoscope with an appropriately sized pediatric
diaphragm, the nurse systematically auscultates the five lobes of the
lungs, anteriorly and posteriorly, beginning with the apices and then
moving side to side to compare bilateral lung sounds. In an infant,
auscultation of lung sounds is best done early in the examination, while
the child is quiet.
Direct observation of a child’s breathing can help determine
inadequate oxygenation status. For example, a child with tachypnea (a
rapid respiratory rate is 80 to 120 breaths/minute), shallow breathing,
and use of accessory muscles means respiratory distress. Conversely,
the child with slow breathing means the child does not have the energy
for adequate oxygenation. Quiet breath sounds with an increased work
of breathing means that air is not entering the lung fields. An alteration
in depth, hyperpnea (too deep), is associated with fever, and
hypopnea (too shallow) is associated with central nervous system
depression.
TABLE 14-4
Tanner Staging of Development of Secondary Sex Characteristics
SEX SCORING
CHARACTERISTICS 1 2 3 4 5
Breast Slight to no Breast buds Entire Enlargement Mature
Development in elevation of appear; breast of the entire breast with
Females papilla areolar enlarged breast with protrusion
widening with no formation of of nipple
with slight protrusion secondary only; no
elevation of the mound of protrusion
papilla or areola and of the
nipple papilla papilla
Pubic Hair None Sparse, Darker Coarse, Adult
Development in lightly and thicker, female
Females pigmented, increasing curly; triangle
straight amount on increasing with
along labia and amount, less extension
border of pubis; than adult of hair
labia distribution onto
in typical medial
female thighs
inverted
triangle
Pubic Hair and No pubic hair. Scant, long, Pubic hair Pubic hair is Adult
Genital Development Preadolescent slightly darker, coarse, distribution
in Males genitalia. pigmented starting to curly, less of pubic
pubic hair. curl and quantity hair with
Slight extends than adult. extension
enlargement across Scrotum is to medial
of scrotum pubis. darker; thighs;
and testes; Scrotum penis genitalia
scrotum and testes increases in adult in
reddens and continue length and size and
becomes to enlarge. breadth. shape
more Penis Glans is
textured. becomes broader.
longer and
slightly
wider.
Adapted from Tanner, J. M. (1962). Growth at adolescence (2nd ed.). Oxford:

Blackwell Scientific.
The child’s posture can also indicate adequate or inadequate
oxygenation. The child in respiratory distress sits in a tripod position
sitting upright, leaning forward on outstretched arms with the jaw thrust
forward. This position helps maximize opening of the airway and use of
accessory muscles of respiration. Because a child with respiratory
difficulties is often anxious, it is important to allow them to assume the
position of comfort, which is usually the position that is easiest for the
child to breathe.
BREATH SOUNDS
Normal breath sounds can be classified as bronchial,
bronchovesicular, or vesicular. Adventitious sounds of these three
classifications are described as crackles, wheezes, and rhonchi,
respectively. Bronchial breath sounds are loud, high-pitched, and heard
only over the trachea. The inspiratory and expiratory sounds are equal
in length. Bronchovesicular breath sounds are of intermediate intensity
and pitch, with equal inspiratory and expiratory phases. These sounds
are best heard between the scapulae and over the mainstem bronchi. If
bronchial or bronchovesicular sounds are heard elsewhere, it is
indicative of an area of consolidation. Vesicular breath sounds are
heard throughout the lung fields. These soft and low-pitched sounds
have a longer inspiratory phase than an expiratory one. Decreased or
absent breath sounds indicate a serious condition such as asthma,
atelectasis, emphysema, pneumothorax, or acute respiratory distress
syndrome (ARDS).
NURSING INSIGHT
Lung Assessment and Breath Sounds
The nurse will more accurately assess the lungs by creating a quiet environment,
placing the child in the best position for auscultation, warming the diaphragm of the
stethoscope before auscultation, placing the stethoscope on the child’s bare skin,
and comparing bilateral breath sounds.
THE CHILD IN PAIN

What one person experiences as mild pain, another may experience as
severe pain. With the use of pediatric pain scales, most children can
communicate their level of pain very clearly. The important thing is for
the nurse to listen to the child rather than prejudge what the child
should feel. If a child expresses pain, they are experiencing pain.
Whether hospitalized, in a clinic, or in the home, a child may
experience pain related to an acute injury, medical or surgical condition,
or disability. A child’s pain may be either acute or chronic. All pain is not
the same for all people. The skill of the nurse lies in helping the child to
convey the kind and intensity of the pain he is experiencing and then
determining the best pharmacological and/or nonpharmacological way
to manage pain.
Understanding Pain in Children From a Developmental

Perspective
How children perceive and express pain is a dynamic process. Nurses
must consider multiple factors when assessing a child in pain, including
age, developmental level, temperament, the type and severity of the
pain, and environmental and psychological factors. Probably one of the
most significant influences is the cognitive level of the child. For this
reason, it is very important for the nurse to have a sound understanding
of the cognitive development of children and situations in which
cognitive development may be delayed, altering how the nurse will
assess for pain. Infants and children up to age 2 are in Piaget’s
sensorimotor stage of cognitive development. Although they certainly
experience pain, they do not understand it. Older infants and younger
toddlers learn to anticipate painful events, both from repeated exposure
to it (as in chronic illness) or from parental anxiety. As a toddler
becomes verbal, they will use words such as “boo-boo” or “owie” to
express pain. However, the toddler will not be able to describe the pain
in detail.
Children ages 2 to 7 years progress through preoperational cognitive
development. Children ages 2 to 4 years are in the substage of
preconceptual development. Ages 4 to 7 years progress through the
substage of intuitive development. As a group, these children often
believe they are experiencing pain as a form of punishment. They
recognize the presence of pain but may not report it because they
believe that the adults around them already know it exists. Children in
this age range, especially those in the toddler and preschool years, can
point to the area of pain but will be unable to describe it.
Piaget’s stage of concrete operational development encompasses
ages 7 to 11 years. In this stage, children begin to understand that
injury and illness may be accompanied by pain, but they do not
understand the cause. The older school-age child develops a greater
understanding of the relationship between pain and illness, injury, and
diagnostic procedures. These children also understand and use much
more descriptive words to express their pain, such as pain that “comes
and goes” or is cramping, burning, dull, or sharp. School-age children
are beginning to differentiate between physical and psychological or
emotional pain.
Formal operational thought, the final stage of Piaget’s cognitive
development theory, occurs between ages 11 and 18 years of age but
may continue into early adulthood. The ability to think abstractly and
use logic allows this age group to develop an advanced understanding
of pain and its causes and to describe that pain in more detail.
However, the need for control and the independence of adolescents is
significantly affected by the presence of pain. They may not admit to
experiencing pain if they think they should “grin and bear it” like they
perceive an adult might or if they believe the nurse thinks the pain
should be tolerated.
Pain Assessment and Management

Ongoing assessment is essential for the child experiencing pain. Proper
pain assessment requires identification of the type of pain (source and
location) the child is experiencing, the origins of either physiological or
psychological pain, the severity of the pain, and the behavioral patterns
associated with the pain.
Pain assessment tools are invaluable for obtaining a child’s
perception and for the younger or disabled child as well as the parent’s
view of pain levels. There are several statistically reliable pain scales
available for use with children of different ages and stages of cognitive
development.
The most commonly used pain scales are the numeric scale, the
Wong Faces Scale, the FLACC, and CHEOPS pain scales (Fig. 14-6
and Table 14-5). Accurate pain assessment also requires an
understanding of multiple factors, not the least of which is cognitive
development, education of the child and family regarding the pain
assessment tool being used, and consistency in application of the
chosen tool.
Assessment of the severity of pediatric pain is based upon the child’s
cognitive ability. Self-reporting is the “gold standard” and is used in
children who are able to understand and report their pain severity along
a continuum, such as a visual analog scale.
To ascertain if a child can cognitively understand the numeric scale,
the nurse can ask a child which of two numbers is larger. If the child is
able to understand the question and answer correctly, the visual analog
scale is appropriate. For most children, this occurs around age 7. The
Wong-Baker FACES scale is often used for children ages 4 to 7 who
can distinguish between a happy and sad face.
In infants and children who cannot self-report, the nurse can use
behavioral observational scales such as the FLACC tool (Face, Legs,
Activity, Cry, Consolability). Pain assessment in nonverbal children with
neurological impairment is challenging because they are unable to self-
report. For this population, the FLACC has been approved as an
appropriate tool.
FIGURE 14-6 Pain scales. A, Numeric pain scale (about 12 years or

older). B, Wong-Baker FACES pain scale (preschool through school-
age).
The nurse should familiarize the child and family with an appropriate
pain scale during hospitalization or a clinic visit, when the child is
injured or ill, or for a medical procedure or surgery. The nurse
understands that it is important to use the same pain scale according to
age, developmental stage, and cognitive function level. In addition to
the pain scales, the nurse asks about intensity, duration, and location of
the pain; the effects of movement on the severity of pain; any
aggravating and alleviating factors; and, if appropriate, previous
interventions that alleviated the pain. It is useful to know what
experiences the child has had with pain, including previous surgeries,
illnesses, or congenital conditions. A child’s ability to manage pain is
sometimes related to the child’s position in the family or their
experience of illnesses in other close family members. Pain has many
descriptors: mild, moderate, severe, chronic, stabbing, burning,
pricking, aching, throbbing, or dull. Pain is also expressed nonverbally
with facial expressions, guarding, and muscle tension.
Mild pain is a slight discomfort. Its management may include minor
analgesics along with comfort measures or distraction. However,
engaging in a distraction does not mean that the child has no pain. It is
simply a coping mechanism that diverts a child’s attention from the pain
for a finite period of time. Pharmacological intervention for mild pain
starts with analgesics such as children’s acetaminophen (Tylenol) or
children’s ibuprofen (Advil or Motrin) and is administered on a
scheduled or as-needed basis.
Although moderate pain may also be relieved by using distraction,
the child experiences much stronger unpleasant sensations. Using a
child’s vivid imagination is very effective in pain management, as long
as it is used in conjunction with regularly timed analgesic
administration, including milder opioids such as codeine in varying
combinations of acetaminophen (Children’s Tylenol).
Severe pain causes pallor, sweating, piloerection (elevation of the
hair above the skin), dilated pupils, increased respiration and blood
pressure, and muscle tension. However, if pain has been prolonged, the
child’s body may have become accustomed to it, in which case marked
increases in vital signs may not be noted. Again, that does not mean
that the child is not experiencing pain. When brief, intense pain
subsides, the child’s body may respond with a lower blood pressure or
pulse rate.
Management of severe pain, often associated with surgical
interventions, usually calls for strong analgesics like morphine sulfate
(Astramorph). The maximum allowable dosage according to the child’s
weight in kilograms may be started in the recovery room and followed
by regular dosing, within the allowable limit for the specific child, to
ensure adequate pain coverage.
TABLE 14-5
FLACC Pain Scale
SCORING
CATEGORIES 0 1 2
Face No particular Occasional grimace or Frequent to constant
expression or smile; frown; withdrawn frown, clenched jaw,
disinterested quivering chin
Legs Normal position or Uneasy, restless, Kicking, or legs drawn
relaxed tense up
Activity Lying quietly, normal Squirming, shifting Arched, rigid, or
position, moves easily back and forth, tense jerking
Cry No cry (awake or Moans or whimpers, Crying steadily,
asleep) occasional complaint screams or sobs,
frequent complaints
Consolability Content, relaxed Reassured by Difficult to console or
occasional touching, comfort
hugging, or talking to;
distractible
Each of the 5 categories—(F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability—
is scored from 0 to 2, which results in a total score between 0 and 10.
Acute pain occurs 24 to 48 hours after trauma or surgery. It is initially
experienced as severe pain and gradually subsides over time. With
orthopedic trauma, a short period of autoanesthesia can occur that
belies the extent of the injury. Because narcotics do not relieve all the
pain following surgery, they can be accompanied with some success by
comfort measures, such as holding a hand or encouraging the child “to
send their pain to you by squeezing your hand tightly.”
Chronic pain in children is any pain lasting more than 3 months. It
can result in fear of reinjury, anorexia, weight loss, changes in sleep
patterns, guarded movements, a rigid facial expression, and an overall
diminishment of the child’s joy of living. Management of chronic pain
involves careful observation of which pain relief measures work best for
a particular child. Decreasing pain to acceptable levels allows the child
to carry on with as many age-appropriate activities as possible given
the circumstances of their illness or condition. Table 14-6 shows a
comparison of acute and chronic pain.
FOCUS ON SAFETY
Naloxone (Narcan)
When giving morphine sulfate (Astramorph), be sure to have the opioid antagonist
naloxone (Narcan) available if respiratory depression occurs. Narcan completely
blocks the effects of opioids including central nervous system effects and
respiratory depression. The dose for children is 5 to 10 mcg/kg (0.01 mg/kg).
Data from Vallerand, A. H. & Sanoski, C.A (2021). Davis’s drug guide for nurses
(17th ed). Philadelphia, PA: F.A. Davis.
THE CHILD WHO HAS A DISABILITY

Disabilities may be congenital or genetically based or develop from
illness, injury, or disease progression (Table 14-7). Regardless of the
cause, families of children with disabilities are beset with emotional
upset and confusion about the reality of not having the child they
expected (i.e., one without a disability). In addition, the family is often
distressed about the child’s pain and their experiences with surgery,
treatments, procedures, and repeated clinic appointments. The child is
apt to have ongoing physical, occupational, or speech therapy, and
parents often need to perform physically painful procedures at home to
promote their child’s development. Other ongoing treatments and
procedures include respiratory therapy, gavage feedings, medication
administration, using assistive devices, planning special diets, taking
care of elimination needs, and implementing special techniques to
maintain the musculoskeletal system. Understanding the child with a
disability includes knowing about emotional, developmental, and
physical concerns as well as comprehending caregiver fatigue and the
concept of resiliency.
Understanding the Child With a Disability

Emotional Concerns
Raising a child with a disability is distressing because of the disruption
of the normal routine, the conveyance of continuous “bad news” or
prognostics, the reconfirmation of future emotional and physical
concerns, and the awareness of financial implications of diagnosis and
treatment. These financial concerns include medical care that is not
covered by insurance or government-sponsored healthcare programs
as well as expenses incurred for child care or respite care. Often, a
parent is required to stop working and become a full-time caregiver,
resulting in further economic distress. The nurse can help the family
access community resources that can provide ongoing emotional
support.
Developmental Concerns
Many congenital problems are repaired surgically either shortly after
birth or once the child is physically developed and strong enough to
withstand the rigors of surgery. Parents and the child need constant
support from health-care personnel to sustain a loving environment for
the child with a disability who may be undergoing the same growth and
development changes as any other child of the same age. However,
because of constant medical and surgical interventions, the child may
demonstrate signs of regression.
TABLE 14-6
Characteristics of Acute and Chronic Pain
ACUTE PAIN CHRONIC PAIN CHRONIC CANCER PAIN
Identifiable cause Cause hard to find Usually identifiable cause
Short duration Lasts longer than 3 months Duration varies
Sudden onset Begins gradually and persists Onset varies
Well defined May or may not be well May or may not be well
defined defined
Limited Unlimited Unlimited
Decreases with healing Persists beyond healing time May persist beyond healing
Reversible Exhausting and useless Exhausting and useless
Signs and symptoms Signs and symptoms absent Signs and symptoms absent
present
Anxiety Depression and fatigue Depression, fatigue, and
anxiety
TABLE 14-7
Common Genetic Disorders
GENETIC COMMON ASSESSMENT FINDINGS
DISORDER/INCIDENCE
Cystic fibrosis/l:2,500 Caucasians Infancy: Failure to thrive, frequent pneumonias
Childhood: Chronic pulmonary disease,
malnutrition
Down’s syndrome/1:800–1,000. Flattened nasal bridge resulting in wide-set eyes;
1:1,250 if mother is under age 25 low set ears, Simian crease, developmental
years; 1:100 if mother is >40 delays. Comorbidities: diabetes, celiac disease,
years of age. congenital heart defects.
Sickle cell disease/1:500 African Anemia, pain, frequent infections
Americans
Klinefelter syndrome/1:600 males Speech delay, possible learning disabilities,
gynecomastia during puberty, smaller genitalia
after puberty, infertility
Thalassemia/1:25,000 Anemia, pallor, facial deformity, hepatomegaly,
Mediterranean/Asian/African splenomegaly, cardiomegaly, brittle bones
American descent
Neural tube defects/1:1,000 Learning disabilities, bowel and bladder
dysfunction, paralysis of the lower extremities,
latex allergy
Fragile X syndrome/1:1,500 Mild to severe mental retardation; speech and
males; 1:2,500 females language difficulties
Physical Concerns
Caring for a child with a disability can pose various physical concerns.
For example, children with severe congenital heart problems face a
lifetime of corrective procedures to augment initial surgeries or
pharmacological therapies that consume time, energy, and finances. In
addition, both parent and child need to learn physical self-care
techniques, such as diabetes or anticoagulation monitoring. Often,
abnormalities affect several body systems so visits must be made to
several different medical specialists who may require multiple
pharmacotherapeutic regimens. Throughout all this, families must learn
to care for the physical needs of the child.
Caregiver Fatigue
Caring for a child with a significant disability takes its toll on the entire
family. Respite care agencies were developed in response to the needs
of parents of extremely disabled children to give short-term relief from
the 24-hour surveillance and care often required in cases of severe
disability. As medical advancements have increased the life expectancy
of disabled children, so too have the number of disabled children or
premature births resulted in larger numbers of children and families
requiring long-term medical care and social systems to support their
needs.
Patient Education
Caring for the Child With a Disability
When caring for a child who has a disability:
• Maintain a respectful attitude toward the parent and the child.
• Assess the child’s communication strategies and incorporate them in the nursing
plan of care.
• Listen carefully to the parent’s concerns, realizing that parents often “know their
child best.”
• Evaluate how social and health-care agencies can assist parents and the child to
manage the disability—financial, medical, and community services.
• Assess the child’s skills for coping with pain or fatigue.
• Evaluate the need for respite care and reliable community resource providers.
ACROSS CARE SETTINGS

Pediatric nursing care is based on normal growth and development,
emphasizing the optimization of preventive health. Pediatric nurses
provide health care for children from birth through college. These
nurses provide expert care to the child while working with the family to
address their concerns, fears, problems, and options.
Pediatric nurses work in a variety of settings including but not limited
to:
■ Doctor’s offices
■ Clinics
■ Hospitals
■ Surgical centers
Their skills bring comfort to children being treated in acute care
departments, such as the neonatal unit, pediatric critical care unit, and
pediatric oncology settings.
Hospital-Based Care
When a child enters the hospital, it may be an unfamiliar medical
experience for both the child and family. The hospital may be a
specialty children’s hospital located in a separate building or part of a
general care hospital. Hospitals provide many health-care services,
such as emergency care, specialized inpatient care, surgery, critical
care, diagnostic tests and treatments, therapies, patient education, and
other specialized services.
A children’s hospital is a specialty pediatric hospital designed and
managed for children’s health care, providing services such as
emergency care, specialized inpatient care, surgery, critical care,
diagnostic tests and treatments, patient education, and other
specialized services. Some children receive care at a day hospital, a
specialized facility that provides medical treatments such as blood
transfusions, chemotherapy, steroid pulse therapy, IV hydration, IV
antibiotic therapy, immunoglobulin therapy, or Remicade (infliximab)
infusions.
Areas for Care in the Hospital

AMBULATORY SURGERY CENTER
Some hospitals have a surgical center where children receive minor
surgical treatment, recover from the procedure, and are discharged
soon after the surgery.
Children are more vulnerable to the stress of hospitalization because
they do not have a full range of coping mechanisms such as highly
developed problem-solving skills. The child and family are also
introduced to an entirely new group of people and exposed to
uncomfortable or painful treatments and procedures and many other
new and difficult stressors. The pediatric nurse must provide skilled,
safe, and competent care and be supportive in the patient and family
adaptation to this unfamiliar and potentially frightening environment.
Patient Education
Caring for the Child at Home After Minor Surgery
Nurses teach parents how to care for their child at home after minor surgery. Care
includes:
• Knowing how to take the child’s axillary temperature
• Knowing how to assess the child’s level of consciousness
• Knowing when to offer liquids based on type of surgery, prescribed diet, and age
• Knowing when to offer solid food based on type of surgery, prescribed diet, and
age
• Knowing what type of activity is expected or should be encouraged
• Knowing what are the actions and side effects of medications
• Knowing what are the signs and symptoms of infection
• Knowing what are signs of poor airway exchange
• Knowing how to use assistive devices and medical equipment and perform home
treatments
• Knowing how to contact a nurse, pharmacist, healthcare professional, or
community agency
• Knowing when to call the doctor
FAST-TRACK CARE
Children who have a minor illness such as an ear infection often go to
an acute care facility, sometimes called urgent care. This may be a
standalone facility or a facility housed in a public business such as a
grocery store, retail pharmacy, or shopping mall. In a hospital or
community setting, a “fast-track” system quickly assesses, treats, and
discharges pediatric patients with minor medical issues. Sometimes,
after the child receives an initial assessment and treatment, they are
admitted to a hospital depending on the diagnosis and subsequent
treatment.
EMERGENCY DEPARTMENT
Emergency care occurs in a hospital or health-care facility where
doctors provide time-sensitive treatment for children who have become
suddenly ill or experienced a severe injury. Emergency departments
(ED) are open 24 hours per day, 7 days a week. Children who arrive in
the ED first receive a rapid screening or triage assessment to establish
the nature and severity of their presenting illness. If the illness or injury
is severe, the child is treated in an urgent manner, and all necessary
procedures, treatments, and tests are performed immediately. The ED
may have several areas of treatment, including a general and minor
care area, a resuscitation room, and specialty areas for specific
populations such as children, women, or persons requiring mental
health care.
CRITICAL CARE UNIT

When critical care is required, the child is admitted to the critical care
unit, usually through the ED or the operating room. A child who
becomes very ill on a medical–surgical floor is transferred into a
pediatric critical care unit. After delivery, a newborn who requires
intensive care is transferred to a neonatal intensive care unit. Other
types of critical care units where children might receive care include
cardiac, surgical, or psychiatric critical care units. In any of these units,
the child is extremely ill and receives specialized care, medication, IV
fluid, and respiratory or ventilator support (Fig. 14-7).
DECREASING THE STRESS OF HOSPITALIZATION

Hospitalization of a child places stress on both the child and family.
Family visitation and the family-centered care have dramatically helped
children and families cope with the stress of a hospitalization. Despite
the availability of parental rooming-in, the parent may also be coping
with other children at home or the need to work, which could lead to
separation from the child even though family visitation is encouraged. It
is important to remember that the ill child depends on their parents as
the primary source of coping and comfort. To help a child of any age
adapt to the stress of hospitalization, the pediatric nurse can suggest
rooming-in to the parents, where they stay in the room both during the
day and through the night (Table 14-8).
The nurse can also use creativity in helping the child to gain control
over the environment by encouraging them to bring items from home to
familiarize the room and make it personal. They might also encourage
the child to draw a picture or design that can be hung up in the hospital
room or ask them to watch a movie or select a game that they would
like to play.
FIGURE 14-7 Child in critical care unit.
TABLE 14-8
Erikson’s Developmental Tasks and What May Happen During Hospitalization
AGE DEVELOPMENTAL WHAT MAY THE NURSE CAN
TASK HAPPEN DURING
HOSPITALIZATION
Infant Trust vs. mistrust Separation anxiety Encourage consistency among
Stranger anxiety caregivers. Encourage the
Disruption in normal parents to stay with the infant.
routine Encourage bonding.
Allow the infant’s home routine
whenever possible.
Comfort the infant; rock, hold,
cuddle, swaddle.
Encourage parents to bring
familiar toys/blanket from
home.
Communicate with parents.
Toddler Autonomy vs. Regression Encourage consistency among
shame and doubt Separation anxiety caregivers.
Negative behavior Encourage the parents to stay
Increase in tantrums with the toddler.
Fearfulness Allow the child’s home routine
whenever possible.
Encourage parents to bring
familiar toys/blanket from
home.
Allow the child to participate in
care whenever possible.
Use therapeutic play. Offer
praise.
Ensure a safe environment.
Preschool Initiative vs. guilt Play restrictions Encourage consistency among
Fearfulness caregivers. Encourage the
Thinks that parents to stay with the
hospitalization is a preschool child. Allow the
punishment child’s home routine whenever
possible. Encourage parents to
bring familiar toys from home.
care whenever possible. Use
therapeutic play. Offer praise.
Encourage use of the playroom
and interaction with other
children.
Explain a procedure,
treatment, and/or surgery in
simple terms. Allow the child to
ask questions.
Encourage realistic choices
whenever possible.
<School Industry vs. Play restrictions Encourage the parents to stay
Age inferiority Questions identity with the school-age child.
Increased need for Allow the child’s home routine
attention whenever possible.
Regression Encourage parents to bring
Fear of bodily familiar toys from home.
mutilation Communicate with parents.
care whenever possible.
Use therapeutic play. Offer
praise.
Encourage use of the playroom
and interaction with other
children.
Explain a procedure,
treatment, and/or surgery in
simple terms. Allow the child to
ask questions.
whenever possible.
Encourage the child to
verbalize feelings.
Alleviate fears about changes
in body image.
Respect the child’s privacy.
Adolescent Identity vs. role Concerns about Encourage visits or contact
confusion body image from peers.
Separation from Explain a procedure,
peers Loss of treatment, and/or surgery in
independence understandable terms.
Decrease in Be honest.
socialization Allow the teen to ask
questions.
whenever possible.
Encourage the teen to
verbalize feelings.
Alleviate fears about changes
in body image.
Respect the teen’s privacy.
Encourage parent’s
involvement in care.
Recognize the teen’s tendency
to reject authority.
Therapeutic Play
Therapeutic play, otherwise known as play therapy or medical play, is
used with children who have had or will have a stressful medical
experience. Therapeutic play has been shown to help to ease the
stress of hospitalization and decrease the child’s fear and anxiety. It
may provide children with a means for dealing with their concerns and
feelings.
Some facilities have a child life therapist to assist with therapeutic
play and offer age-appropriate toys or distraction such as music or
games. Therapeutic play also may help the child to cope with, and
master, stressful experiences (Fig. 14-8). Pediatric nurses are
encouraged to incorporate therapeutic play in their everyday care of the
child. By using play techniques and activities in all settings, including
the emergency and outpatient departments, children benefit even from
watching other children at play.
Therapeutic play can be used to prepare a child who requires an
injection. The nurse or child life therapist encourages the child to play
with equipment such as a needleless syringe filled with water, a doll,
and an alcohol prep pad. After the injection, the nurse can then provide
a bandage and a sticker for a reward. Another example is an older child
simulating the medical procedure (administering IV antibiotics), a
therapeutic play technique that the nurse uses to discuss the process
with the child, clarifying what is going to happen and allowing them to
release anxiety and decrease fears of the imminent situation.
FIGURE 14-8 Child life specialist playing with child.
Guided Imagery
Another way to help a child cope with the stress of hospitalization is the
use of guided imagery. This relaxation technique, which can be used by
people of all ages, aims to ease stress and promote a sense of peace
and harmony during a difficult time. With this technique, the mind helps
the body maintain a relaxed state with the help of all five senses.
Role Modeling
Role modeling can help decrease fears and anxieties as well as teach
coping skills. During this process, the child learns certain behaviors by
observing the behavior of others. Role models can be the people who
are involved in the child’s life, such as parents, grandparents, siblings,
or teachers as well as peers and entertainment and sports figures. Role
models who are similar in age, sex, race, and attitudes and who have a
caring demeanor are more likely to be imitated. For example, a child
might view a video about another child and their experience preparing
for hospitalization and surgery. Seeing another child going through a
similar experience may help them cope with the anxiety and stress of
the impending procedure.
PARENTS WITH A HOSPITALIZED CHILD
Parents with a hospitalized child often need to debrief and tell their
story about the events that led to their child’s hospitalization. Nursing
assessment of parental needs, knowledge, concerns, expectations, and
coping abilities is imperative to direct nursing actions that ease parental
role stress. Parental stressors include sights and sounds of the hospital,
changes in the child’s behavior or appearance, changes in the parental
role, unknown outcome, financial concerns, guilt or anger over the
situation, and frustration about the function of the entire family (Fig. 14-
9).
FIGURE 14-9 Parents at the bedside of a child in the hospital.
Seeking parental advice about the best way to approach their child,
acknowledging parental need for involvement, and anticipating stressful
events are integral to appropriately caring for the child in a family-
centered manner. The communication between the pediatric nurse and
family members must be genuine, and the plan of care must include
resources available in the hospital as well as the community.
The nurse must recognize the parent’s concerns, including possible
guilt, fear, or other anxieties about the child’s hospitalization. The
pediatric nurse plans care ensuring the promotion of trust by the child
and parents through prompt attention to the child’s needs. The nurse
provides opportunities for the child and family to participate in care and
by including parental preferences and home schedules so that care is
provided in a familiar and consistent manner. The nurse can also
provide positive reinforcement for the parents that may help alleviate
some stress. Finally, the nurse ensures an ongoing evaluation of the
plan of care is necessary to make needed adaptations and
modifications.
Effects of a Hospitalized Child on Parents

Parenting an ill child can be stressful and demanding on both the child
and the parent. During the period of illness, the child can begin to
recover, become gradually sicker, or suddenly begin to exhibit
behaviors that give the parents cause for great concern. Symptoms
such as withdrawal, lack of activity, or irritability in performing basic
functions may be a signal that the child’s condition is worsening.
During these times, parenting of a hospitalized child has many
dimensions, such as interpreting the child’s behaviors, teaching the
child new skills or how to perform basic functions again, helping a child
understand the words and language of health-care providers, and
offering support during frightening experiences. Hospitalization has
been demonstrated to be equally stressful for the parent as for the
child. Parents may describe themselves as feeling incapable because
of their loss of control over the situation and their inability to be able to
protect their child. Some observed behaviors of parents include anxiety,
denial and withdrawal, guilt, and fear (including concerns by the parents
that they may have had a causal effect on their child’s illness).
The pediatric nurse has a critical role in helping parents adapt to the
child’s hospitalization. The plan of care for the hospitalized child begins
with the admission process when the pediatric nurse includes the
parents in a conversation to gather important information about the
child while at the same time offering support. The planning stage, with
parental involvement, includes setting goals and objectives that are
used to evaluate overall care. The plan of care also includes home
routines, preferences, developmental needs, and identification of
special needs.
HOLISTIC NURSING CARE FOR THE CHILD
The child who requires general care in the health-care setting may be
admitted for testing or treatment of an illness or disease. Holistic care
measures include bathing, feeding, rest and safety measures,
medication administration, infection control, and fever-reducing
measures. Parents may wish to provide much of the care their child
needs in regard to bathing and feeding. These measures are comforting
to the child and parent and reduce anxiety in both. The nurse is
responsible for these activities in addition to the child’s safety. The
nurse also provides emotional and spiritual support as needed.
Bathing
Family home practices and preferences for bathing are assessed on
admission of the child. Bathing of infants can be accomplished at the
bedside using a portable tub. For infants younger than 6 months or for
those who have head lag, the nurse supports the head and neck with
one hand while using the other hand to wash. If a tub bath is
contraindicated, a bed bath can be given. Precautions are taken to
control the water temperature so that it does not exceed 100°F (37.8°C)
and to quickly cover areas of the body after washing. The parent may
welcome the respite from caring for the child or may wish to continue
bathing the child in the hospital. Toddlers and preschoolers may enjoy a
bath in a larger tub. Although they can wash some body areas without
supervision, most children need reminders or prompting to wash. Never
leave a child alone while tub bathing. Older children may be able to
shower and groom themselves with little assistance. Privacy is valued
by the older child. A child who is feeling ill or who has tubes, drains, or
dressings may be unable to ambulate to the bathroom for washing or to
immerse herself in water. A sponge bath is appropriate in this case.
Shampooing hair during the bath may be part of daily care for
children. Again, the nurse can assess family preferences and practices.
Shampoo basins can be used at the bedside to wash hair. Parents
should be asked for instructions in hair care.
The nurse can use bath time to observe parent–child interaction and
to assess the child. Language skills and social skills can also be
assessed during the bath. The skin is assessed for lesions, rashes,
turgor, color, and circulatory integrity. Muscle tone is easily assessed
along with adequate respiratory status. This can also be a time for the
child to become acquainted with the nurse as a caring, supportive
person.
NURSING INSIGHT
Key Actions in Caring for the Child Confined to Bed
The child confined to bed is at risk for skin breakdown. The nurse should do the
following:
• Keep the skin clean and dry.
• Assess nutritional status for adequate protein.
• Use the draw sheet for position changes.
• Assess skin for irritated areas.
• Assess for pressure ulcers by looking for the “red flush” (the first sign of tissue
compromise and ischemia).
Feeding
Basic knowledge of nutritional requirements is essential when working
with children. Formula-fed infants require no more than 24 to 32 ounces
of iron-fortified formula daily. For infants who have a gastrointestinal
disturbance, pulmonary failure, or are in congestive heart failure, it may
be difficult to ingest the required amount of calories without tiring, and
gavage (nasogastric or gastric) feedings may be necessary.
For the older child, assess preferences by taking a diet history and
asking about routines at mealtimes. Children are often prescribed an
“as tolerated” diet, and they are able to select foods that appeal to
them. It is best to gently encourage the intake of wholesome and
nutritious foods and snacks. Foods ingested are also important for their
fluid content (e.g., gelatin and ice pops). Parents can be encouraged to
bring in favorite foods from home. Cultural preferences may make a
difference in whether a child eats while hospitalized.
Rest
Hospitalization disrupts a child’s normal daily routine as well as their
sleep pattern. The pediatric nurse can assess normal sleep patterns,
including both nighttime hours of sleep and daytime naps. Most
pediatric units allow parents to stay overnight with the child. This
provides both the parent and child with comfort and creates an
environment with decreased levels of unfamiliarity and anxiety. The
nurse understands that children up to the age of 5 may take an
afternoon nap. If the child’s condition allows, uninterrupted naptimes
should be included in the plan of care.
Safety Measures
Safety measures instituted on a pediatric unit are based on the
developmental level of each child to protect them from harm. Safety
measures include keeping toxic materials out of reach, identifying
children with name bands, and knowing the whereabouts of children on
the unit. The nurse must also provide a safe environment in the hospital
room and in the transport of children from their room to other
departments in the hospital.
The nurse verifies the child’s identity by checking the name band
before any treatment or medication is administered. Name bands can
be removed by the child easily, or they may inadvertently fall off, leaving
the nurse with no means to verify a child’s identity. If a child is found
without a name band, the child’s name must be verified and a new
name band applied to an extremity. The nurse cannot depend on all
children to correctly identify themselves. Younger children may answer
to any name or may not answer at all. When a name band is not on a
child’s extremity, medications or treatments are administered only after
a parent or nurse has identified the child and the name band has been
replaced.
Many pediatric units have alarms and restricted access at stairways,
elevators, and the entrance to the unit. The nurse can review with the
older child the places they are allowed to go and the activities they can
engage in while a patient on the unit. Limits must be set and enforced.
To prevent child abduction, pediatric personnel must be vigilant about
visitors.
In the child’s room, safety features are used on high chairs and
strollers, and beds are kept in the locked position with the height of the
bed in the lowest position. Crib side rails are elevated when the child is
in the bed. Bubble tops may be needed to prevent a child from climbing
over the rails. Check the room for any small articles that may be left
behind in a bed, such as syringe covers and alcohol wipes. All items
must be removed from the bed because they present a choking hazard.
Safety concerns regarding the transport of children are based on
developmental level. Infants can be carried short distances in the room
or on the unit. For longer transports to other areas of the hospital,
bassinets, cribs, strollers, wheelchairs, or special vehicles are used
(e.g., wagon with raised sides). The wagon can be painted in bright
colors, and some have plastic bubble tops in the shape of small
automobiles. Children enjoy this type of transport. It is important to
check that restraint devices like a seat belt in a stroller are securely
fastened and that the child is not left unattended during transport.
Medication Administration
When administering medications to a child, the pediatric nurse needs to
consider the child’s developmental level. Each age group responds
differently to the medication administration process. Administering
medications to an infant may require additional assistance to minimize
movement, particularly with injections. The infant needs immediate
cuddling and comfort after medication administration. A toddler may
consider medications to be a punishment. Often a child will close the
mouth tightly and refuse to take the medication. To minimize this, it
might be useful to let the toddler administer medications to a doll or play
with a needleless syringe if receiving oral liquid medications. To
increase compliance of the toddler, it may be necessary for the nurse to
allow a parent to administer the oral medications. Offer immediate
praise after medication administration.
The preschooler will want to take charge of the medication and, in
some instances, this may be appropriate. Oral medications in a cup or
syringe can be self-administered by the preschooler under direct and
close supervision. The preschooler will benefit from some therapeutic
play before medication administration. Offer simple explanations about
the medications and why the child is receiving them. The school-age
child is far more cooperative but still fears a loss of control and pain and
will negotiate with almost every intervention. It is best to allow a school-
age child as much control and choice as possible and offer praise and
rewards after medication administration.
The school-age child will want to know what the medications are for
and how they work. Offer age-appropriate explanations and allow time
for questions. The adolescent is far more advanced in their thought
processes, will be able to understand more detailed explanations, and
will want a greater role in health-care decisions. The nurse must be
patient and allow time for more complex questions from the adolescent.
Ask the parent how the child prefers to take the medications (e.g.,
whole with juice, crushed in applesauce, one at a time, etc.). If the child
does not normally take medications at home but will be going home
with routine medication, the nurse may need to help the parent
determine the best technique for medication administration.
Educating the child and parent about the medications being
administered is important. Explanations about the purpose of the
medication, why the child is taking it, dosing, frequency, and common
side effects must be discussed at the fifth-grade level for parents and at
an age-appropriate level for the child. It is prudent to provide written
information on all medications and may be necessary to create a chart
of the daily medications, doses, and the times they are to be
administered. Additional information to give the child and parents
includes drug-drug interactions, duration of the medication therapy,
what to do if a dose is missed or vomited, and how to store the
medications. Assess the level of understanding of the parents and child
before discharge. For any medication that requires psychomotor skills
to administer, such as eye drops, gastrostomy tube (GT) administration,
or subcutaneous injections, provide ample time for demonstration and
return demonstration by the parents and child, if appropriate. Provide
time for the parents to ask questions and express concerns they may
have about the medication.
The Role of the Pediatric Nurse in Medication Administration

Nurses must ensure safe medication administration of medications.
This includes:
■ Engaging in safe medication practices and contributing to a culture of
safety
■ Knowing the limits of one’s own knowledge, skill, and judgment, and
seeking help when needed
■ Assessing the appropriateness of the medication practice by
considering the patient, the medication, and the environment
■ Adhering to institution’s policies when administering medications
FOCUS ON SAFETY
The Eight Rights of Medication Administration
Competent medication administration is a continual process and goes beyond the
task of simply giving a medication to a patient. The nurse giving a patient
medication is responsible for:
• Preparing the medication correctly
• Ensuring the following eight rights:
- Right PATIENT (If the DOB is used, the nurse should state “when is your
birthday?” In addition to this, the nurse should check the patient’s MRN
[medical record number], which should match their armband and the electronic
medical record/computer.)
- Right MEDICATION
- Right REASON
- Right DOSE for the patient’s weight
- Right ROUTE
- Right FREQUENCY
- Right TIME
- Right SITE
• Monitoring the patient and appropriately intervening as necessary
• Providing the right education and information about the medication
• Evaluating the outcome of the medication on the patient’s health status
• Documenting the process
THE NURSE MUST ENSURE THAT THE RIGHT MEDICATION IS
ADMINISTERED TO THE CORRECT PATIENT BY:
• Verifying patient using two unique identifiers, such as patient name and medical
record number
• Using barcoding technology as per hospital policies
WHEN PREPARING AND ADMINISTERING MEDICATIONS, THE NURSE
SHOULD:
• Administer medications within 30 minutes of the scheduled time.
• Promptly document the medication administration in the electronic health record.
• Consult the provider if a child vomits medication to determine whether the dose
should be repeated.
In addition to assessing the eight rights of medication administration, before
administering medications, nurses must also assess:
• Patient drug allergies
• The expected actions, dose range, side effects of the medication, and
precautions to be taken
• The developmental stage of the infant/child/adolescent patient
• Alterations in the patient’s condition or functional status that interfere with their
physical capacity to take medications (for example, not being able to swallow
oral medications)
• The child and family’s level of understanding and knowledge of each medication
Despite the education of health-care professionals in the rights of

safe administration of medications, medication errors in the health-care
setting continue to be a leading cause of adverse medical events. With
advancing technology, electronic systems have been developed to help
decrease the number of medication errors. Barcode medication
administration (BCMA) technology allows for the scanning of a barcode
on each medication and IV fluid. The scan verifies that the medication
scanned is the medication that was ordered. The nurse must attend to
all eight rights regardless of the presence of the BCMA system.
Infection Control Measures

Each year, heath-care-associated infections affect 2 million people and
account for 80,000 deaths from those infections. The majority of these
infections are because of poor hand hygiene practices of health-care
professionals. According to the Institute for Healthcare Improvement
(IHI) (2020), compliance by health-care workers with mandated hand
hygiene guidelines is less than 50%. To improve compliance and
decrease health-care-associated infections, the IHI has published a
“How-to” guide for health-care facilities with implementation and
compliance guidelines for improving hand hygiene practices. The IHI
publications “How-to Guide: Improving Hand Hygiene” and the “Hand
Hygiene Monitoring Tool” can be found at
http://www.ihi.org/resources/Pages/Tools/HandHygieneMonitoringTool.a
spx. Best practices for hand hygiene are (IHI, 2020):
■ Use of waterless, alcohol-based hand rubs is the preferred method
for hand hygiene. These rubs are highly bactericidal and rapidly kill
many of the viruses and fungi that cause health-care-associated
infections. Rubs used in sufficient amounts to cover the hands and
fingers are rubbed into the skin for a minimum of 15 seconds and until
the hands are dry.
■ Hand washing with water and soap in sufficient amounts to cover all
surfaces of the hands and fingers with 15 seconds of rubbing that
causes friction should be done when hands are visibly soiled, after
using the restroom, before eating, and after caring for patients with
diarrhea. Single-use towels are used to dry the hands and turn off the
faucet to avoid recontamination.
■ Gloves should be used properly in direct-care situations with a high
risk of exposure to bodily fluids. Gloves must be changed when
moving from a contaminated area to a clean site on the same patient
or after touching something else in the room, such as a doorknob or
computer. Once gloves are removed, the health-care worker must
perform hand hygiene immediately.
Transmission of infection requires three essential elements: an
offending microorganism, a susceptible host, and a method of
transmission to infect the host. The offending microorganism can be
brought into the hospital setting with the ill child or can be part of the
new environment. Main routes of transmission include contact, droplet,
airborne, common vehicle, and vector-borne. Fundamental isolation
precautions include hand washing and gloving, the appropriate
placement of a patient in isolation appropriate for disease process, and
the use of barrier gear to protect the caregiver and prevent further
transmission of infection.
When caring for children in a hospitalized setting, the specific
guidelines from the CDC should be followed for procedures related to
the type of precautions implemented for the patient.
The experience of isolation for a child can be perceived in negative
ways. In the preschool years, when magical thinking is the predominant
manner of processing information, the child may perceive the situation
as a punishment for some previous thought or action. Once the
precautions are in place and the child and family are coping with the
restrictions, the child may need diversional activities. Child life
specialists (CLS) can assist in the selection of age-appropriate games
and toys. Once a toy is brought into a precaution room, it must be
cleaned before other children can play with the toy. Visitors need not be
restricted from the room, but they do need specific instructions on how
to protect themselves and the patient. Isolation guidelines are placed on
the door with step-by-step instructions on what is required before
entering the room. Hand washing before and after leaving the room is
essential.
Fever-Reducing Measures
Fever (a temperature greater than 100.4°F [38.0°C]) accompanies
many childhood illnesses. A fever is a natural and beneficial response
to the invasion of an offending organism and can help kill the virus or
bacteria. If a child with a fever is very uncomfortable and irritable, their
fever may be treated with antipyretics (e.g., acetaminophen and
nonsteroidal anti-inflammatory drugs [NSAIDs]) or by using
environmental measures. Antipyretics work to lower the set point at the
thermoregulatory center in the hypothalamus.
FOCUS ON SAFETY
Aspirin (Salicylates)
Aspirin (salicylates) is not given because of the correlation between the use of
aspirin and the development of Reye’s syndrome in children with viral infections.
Acetaminophen (Children’s Tylenol) is available in suppository, liquid,

and capsule form. It can be given every 4 to 6 hours with no more than
five doses in a 24-hour period; there is little risk of hepatic toxicity.
Ibuprofen (Children’s Advil), a common NSAID, is given to children as a
fever-reducing measure. This drug is given every 6 hours and may be
an advantage when rest is crucial or when administering medications to
the child is a challenging task. Dyspepsia and nausea are common side
effects of ibuprofen. The medication, taken as a chewable tablet, caplet,
or liquid, can be given with food or after meals if gastrointestinal (GI)
upset occurs. The child should be monitored for GI bleeding. Dosing for
ibuprofen is dependent on the temperature of the child. A fever less
than 102.6°F (39.2°C) warrants a dose of 5 mg/kg of body weight. If a
child’s temperature is greater than 102.6°F (39.2°C), the dose is
increased to 10 mg/kg of body weight. The efficacy of antipyretic
medication is assessed by retaking the child’s temperature 1 hour after
administration.
MEDICATION Dosage Recommendations for

Acetaminophen (Children’s Tylenol)
Acetaminophen (a-seet-a-min-oh-fen)
Age Dosage
Neonates (0–4 weeks) 10–15 mg/kg/dose every
6–8 hours
Infants (1–12 months) 10–15 mg/kg/dose every
4–6 hours, as needed,
not to exceed five doses
in 24 hours
Children (1–12 years) 10–15 mg/kg/dose every
not to exceed five doses
in 24 hours
Children (>12 years) 325–650 mg every
not to exceed 4 grams
in 24 hours
Source: Vallerand, A. H. & Sanoski, C.A (2021). Davis’s drug guide for nurses (17th
ed.). Philadelphia, PA: F.A. Davis.
Environmental measures are effective in reducing fevers in children.

Cooling measures, such as reducing room temperature, applying cool
compresses to the skin, and wearing a light layer of clothing, are
effective alone or after the antipyretic is given.
A cooling blanket, which has coils through which a refrigerated
solution circulates, may be necessary to control hyperthermia. The
cooling blanket is placed on the bed, covered with a sheet, connected,
and set to a temperature of 98.6°F (37°C). The temperature is
decreased according to the child’s response to cooling. Rectal
temperature must be monitored every 15 minutes while the child is on
the blanket, and the child must be assessed for shivering. Cooling
blankets are only used in circumstances warranting an immediate drop
of a very high fever.
Emotional and Spiritual Support

Parents may need emotional and spiritual support when a child is
hospitalized. It is important for the nurse to be “in the moment” with
parents and other family members. Conveying a caring attitude and
listening closely to what the parent is really saying is important in
making a connection with them. The relationship that the nurse creates
with parents and family members is basic to healing and is an
expression of spirituality.
The nurse helps family members by listening to their concerns,
clarifying any misconceptions, and helping the family develop coping
strategies to decrease stress and optimize functioning. Coping
resources include using both the strength from within and the support
from resources in the community.
Spiritual Care
The parents and child may find comfort in talking with a priest, monk, chaplain,
deacon, rabbi, imam, or other trusted person with religious ties. Spiritual care may
come from a particular faith community that has shared beliefs and values. At
times when parents ask, “why is this happening to my child?” it may be beneficial
for the nurse to arrange a meeting with people from their faith community to
discuss the parents’ concerns and issues.
PREPARING CHILDREN FOR PROCEDURES

Explaining Procedures
As a child grows and develops cognitively, their understanding of
experiences and response to the events naturally changes. To an
adolescent, a venipuncture may be an annoyance, but to a toddler, it
may be a frightening experience that is stressful to both the child and
parent. Developmental characteristics dictate how to approach the child
and what to say to the child. What the nurse conveys to the patient and
the parents can diminish the anxiety and fearfulness associated with
common procedures.
What to Say
Using Developmentally Appropriate Words
For children with beginning language skills, use simple terms that are familiar to
the child, such as “go potty,” “owie,” and “boo-boo.” For the concrete thinker who
takes what is said literally, do not use words that may frighten the child (e.g., “dye
in your vein,” “shot in the arm,” “cut out the tonsils,” and “take your temperature”).
Instead, use “special medicine in your vein,” “special medicine in your arm,”
“make your tonsils better,” “check to see if your temperature is working.” For all
children, be honest and they will learn to trust you.
Preparing an Infant for a Procedure

■ Describe the procedure to the parents, explaining what will happen
and how long it will take. Encourage the parent to stop you at any
point if they have a question.
■ Remind parents that infants often cry for reasons other than
discomfort but be honest about any discomfort the infant may
experience with the procedure.
■ Identify what restraints may be used and give an explanation as to
why they are needed.
■ Allow parents to decide whether they would like to be present for the
procedure. Parents may prefer to leave the room and return
immediately following the procedure to comfort their child.
Preparing a Toddler for a Procedure

■ Describe the procedure to the parents, explaining what will happen
and how long it will take.
■ Use play to demonstrate the procedure to the toddler; encourage
them to demonstrate or practice with a doll or teddy bear.
■ Use simple, concrete language to describe the procedure and how it
might feel to the toddler. Limit preparation to 5 to 10 minutes because
of the child’s short attention span.
■ Identify what restraints may be used and explain why they are
needed.
immediately after the procedure to comfort their child. Allow the
parents to stroke their child or speak soothingly to their child if they
remain in the room.
Preparing a Preschooler for a Procedure

■ Explain the procedure in terminology the child can understand.
■ Begin preparation immediately before the procedure so the child will
not worry for hours or days.
■ Use play to demonstrate the procedure to the child; encourage them
to demonstrate or practice with a doll or teddy bear.
■ Set limits for the child so they are aware of expectations. For
example, tell them they can yell and scream as much as they want
but must hold very still.
■ Give legitimate choices to the child whenever possible.
PROCEDURE ■ Before, During, and After a

Procedure
BEFORE:
1. Think through the procedure in advance and anticipate problems.
2. Gather all equipment and check to make sure it functions properly.
3. Establish trust by getting to know the child first.
4. Through play, allow the child to “perform” the procedure on their doll, teddy bear,
or other appropriate surrogate.
5. Offer a coping strategy such as guided imagery or relaxation breathing.
6. Give the child realistic choices.
7. Be sure informed consent is signed.
8. Wash hands.
9. Let the child know that it is OK to cry.
DURING:
1. Whenever possible, schedule all treatments away from the child’s bed or “safe
area.”
2. Expect the child to do well.
3. Talk to the child and ask how he is doing.
4. Keep the child informed as to the progress of the procedure.
5. Use distraction techniques such as pop-up picture books, bubbles, “shutting off
the pain switch,” or other techniques that have been practiced before the
procedure.
6. When appropriate, give the child some control by allowing them to make some
of the decisions.
7. Involve the parent to provide comfort to the child, if the parent is able.
Sometimes a parent’s presence at the procedure may not be beneficial for the
child.
AFTER:
1. Praise the child for completing the procedure.
2. Provide an opportunity for the child to verbalize feelings.
3. If the parents were not involved in the procedure, comment on a positive aspect
involving the child during the procedure. “Jill was able to help out and keep still
when she was asked to do so! She did a great job!”
4. Give a reward (e.g., stickers, small toy, or previously agreed-on reward
negotiated with parents).
5. Document the child’s response to the procedure and outcomes.
Source: Stollery Children’s Hospital, Edmonton, Alberta, Canada
immediately after the procedure to comfort their child.
■ Allow the parents to stroke their child or speak soothingly to their child
if they remain in the room.
■ Use distraction techniques such as deep breathing, singing, or
squeezing a parent’s or nurse’s hand.
Preparing a School-Age Child for a Procedure

■ Explain the procedure in terminology that the child can understand.
Children in this stage of development have a better concept of time
than younger children do, so preparation can begin in advance of the
procedure.
■ For the younger school-age child, use play to demonstrate the
procedure and if possible, have the child demonstrate on and practice
positioning with a doll or teddy bear.
■ Allow the child to touch and explore equipment to be used in the
procedure and involve the child in simple tasks during the procedure
when possible.
■ Set limits for the child so they are aware of expectations. For
example, tell them they can yell and scream as much as they want
but must hold very still.
■ Give legitimate choices to the child whenever possible.
■ Allow parents and the child to decide together whether parents will be
present for the procedure. Some school-age children may be modest
about exposing body parts in front of family members. Allow the
parents to stroke their child or speak soothingly to their child if they
remain in the room.
■ Teach the child techniques such as deep breathing, counting, reciting
a silly rhyme, or anything else that might help distract and relax the
child during the procedure.
Preparing an Adolescent for a Procedure

■ Describe the procedure, explaining exactly what will happen and how
long it will take. Encourage the adolescent to stop you at any point if
they have a question.
■ Be honest. Describe potential risks and pain associated with the
procedure, but don’t dwell on it.
■ Allow the adolescent to take as active a role as possible in the
procedure. Practicing positioning or demonstrating the equipment
before the procedure helps give the adolescent a sense of control.
■ Provide a peer video of the procedure if possible.
■ If possible, allow the adolescent to make decisions such as when the
procedure should take place.
■ Allow the adolescent the option of having a parent present.
■ Offer tips for distraction such as deep breathing, relaxation, counting,
or squeezing an object or parent’s hand.
Informed Consent
Informed consent involves providing the patient with the necessary
knowledge to make a decision regarding health care. Informed consent
implies that the person understands the benefits and risks of treatment
or the refusal of treatment. The person must also be legally able to give
consent by virtue of their age. In most of the United States and
Canadian provinces, the age of legal consent is 18. An exception is
made for the adolescent younger than 18 who is married, a parent, self-
supporting, or a member of the military (Peoples Law Library of
Maryland, 2012). Informed consent can be obtained from these
emancipated minors. In some jurisdictions, the age of consent varies for
girls aged 14 years and older for contraception advice and
gynecological procedures. For most children, the parent or legal
guardian is the person who gives consent for their care.
Written informed consent is required before diagnostic procedures,
medical treatments, or surgical procedures. It is also required before
immunizations or any treatment with inherent risks.
COMMON PROCEDURES
IV Lines
In the hospital, children may require IV therapy for fluid maintenance or
replacement before diagnostic testing, blood product replacement,
medication administration, or a surgical procedure. IV fluids may be
administered through a peripheral line, a central venous access, or a
peripherally inserted central catheter.
Peripheral IV Lines
A peripheral line with a normal saline lock is used to keep the vein open
for the possibility of future IV therapy or for the child who requires
intermittent medication administration. The tubing is capped at the end
with an injection cap that allows for multiple punctures. Once the
medication is disconnected from this tubing and the line flushed, the
child can ambulate unencumbered by the IV pole and tubing. The
hospital’s protocol for flushing the peripheral intermittent infusion device
is followed. The normal saline lock is secured to prevent accidental
dislodgement. For the younger child who has a normal saline lock
inserted in the dorsum of the hand, a cover with cling wrap may be
necessary to prevent the child from manipulating or pulling out the
normal saline lock (Fig. 14-10).
Central Venous Access

Children with a condition necessitating long-term IV access are
candidates for central venous access devices. The IV catheter is
inserted into a large vein such as the vena cava, subclavian, jugular, or
femoral vein. Broviac, Hickman, and Groshong catheters are used for
access. These catheters are multilumen and accommodate more than
one IV therapy. After insertion, a chest x-ray examination is done to
confirm proper positioning of the catheter before use. With a central
venous access device, the child is not subjected to multiple IV “sticks.”
It is easily accessed for medication and fluid administration as well as
blood draws without the pain associated with further needle punctures.
FIGURE 14-10 Normal saline lock.
Peripherally Inserted Central Catheter

The peripherally inserted central catheter line (PICC line) can be left in
place for up to 4 months. It is inserted above the antecubital fossa into
the median, cephalic, or basilic vein and threaded into the superior
vena cava. PICC lines are most often used for long-term antibiotic and
analgesic therapy (Fig. 14-11). These lines may also be threaded just to
the head of the clavicle. This is considered a midline placement and is
often used for antibiotic therapy. The hospital’s protocol for PICC line
flushing and dressing changes over the insertion site is followed.
Vascular Access Port

A vascular access port is another central venous access device that is
implanted under the skin and is used for long-term fluid or medication
administration. The Infuse-A-Port or Port-A-Cath is not visible and no
dressing is required (Fig. 14-12). Although the child may be restricted
from contact sports, they can swim or shower without restrictions. To
access this device, the nurse palpates for placement, cleanses the
area, and uses the Huber needle to puncture the port’s central
diaphragm.
FIGURE 14-11 PICC line.

FIGURE 14-12 Infuse-A-Port.
FOCUS ON SAFETY
Risk of Infection
With any procedure in which the skin barrier is compromised, adhere to sterile
techniques for dressing changes over IV sites and to monitor for signs and
symptoms of infection (change in temperature, erythema, edema, or pain at IV
site and tenderness on palpation).
Measuring Intake and Output

The pediatric nurse carefully assesses the intake and output in children,
especially those with vomiting, diarrhea, fever, nasogastric suctioning,
draining wounds, and burns; presurgical patients; and children with
cardiac, renal, or respiratory illnesses. Table 14-9 describes calculation
of daily maintenance fluid requirements. The nurse measures intake for
the breastfed infant by recording “breastfed” (or by weighing the infant
before and after the feeding and recording the increase in weight as
ounces or milliliters consumed) on the intake sheet. For infants with
congestive failure or a respiratory illness like bronchiolitis, the nurse
also asks about the length of time the feeding took to complete.
Expending too much energy in feeding may be deleterious to the child’s
health. Gavage (feeding a patient via a feeding tube passed through
the nose into the stomach) feedings may be necessary for the child in
congestive heart failure. IV fluids may be required for the child
struggling to breathe with a dyspneic respiratory condition.
For the child who wears diapers, the diaper can be weighed before
and after use to determine urinary output. Diapers are weighed on a
gram scale, and output is determined by subtracting the weight of a dry
diaper from the weight of a wet one. Each gram is equal to about 1
milliliter; therefore, the difference is the amount of urine output in
milliliters. The method used to measure normal urinary output is 1 to 2
mL/kg per hour.
TABLE 14-9
Calculation of Daily Maintenance Fluid Requirements
CHILD’S WEIGHT DAILY MAINTENANCE FLUID REQUIREMENT
0–10 kg 100 mL/kilogram of body weight
11–20 kg 1,000 mL + 50 mL/kilogram for each kg >I0
>20 kg 1,500 mL + 20 mL/kilogram for each kg >20
Example:
A child weighs 48 kg. For the first 20 kg the child needs 1,500 mL. For the next 28 kg,
the child needs 20 mL/kg. So, 1,500 mL + (28 kg x 20 mL) = 1,500 mL + 560 mL =
2,060 mL/day
X-ray Examinations
Children may require x-ray examinations for diagnostic purposes or
when checking for the placement of a chest tube, central line, or a
feeding tube. For the younger child needing an x-ray examination, the
nurse may be asked to help position the child for an optimal view. A
lead apron is worn by the nurse or technician to protect against
unnecessary exposure to radiation. Pregnant women should not assist
because fetal tissue is especially sensitive to damage by x-rays.
Specimen Collection
Urine Sample Collection
To collect a urine sample, children may require either catheterization or
a clean-catch specimen. A catheterized specimen is obtained using
sterile technique. Bladder catheterization can be a traumatic experience
for both the child and the parents. Distraction techniques can be helpful
in decreasing anxiety and fear. A lubricant with 2% lidocaine may be
used to eliminate the discomfort of catheterization. If a clean-catch
specimen is requested, the nurse places a urine collection bag around
the perineal area after cleaning the perineum and surrounding skin (Fig.
14-13). The infant is diapered and the bag monitored for urinary output.
The urine must be removed from the bag and sent to the laboratory
within 30 minutes of voiding.
Stool Sample Collection

Stool samples are frequently obtained for ova and parasites (O&P), to
determine the causative agent for a diarrheal condition, or to check for
the presence of occult blood. If the child is toilet-trained, they can use
the potty chair or the toilet with a collection hat under the seat. In a
nonpotty-trained child, stool from the diaper is collected. Samples are
transferred into a collection cup using tongue blades. O&P samples are
sent to the laboratory as soon as possible. When laboratory services
are not provided 24 hours a day, the sample should be refrigerated as
soon as possible.
Blood Sample Collection

Having blood drawn can be a traumatic event. Preparation and support
during the procedure alleviates some of the fear and pain associated
with venipuncture. Trauma can be alleviated by using distraction
techniques with the child before the venipuncture. Application of EMLA
cream, a topical analgesic containing lidocaine and prilocaine,
anesthetizes the skin before any painful procedure. The cream is
applied to the site, covered with a transparent dressing for 1 hour, and
removed before the venipuncture.
FIGURE 14-13 Urine collection bag.
Throat Culture Collection

A rapid strep test or a throat culture can be used to diagnose group A
streptococci as the cause of sore throat. If the rapid strep test is
positive, an antibiotic is prescribed. If the rapid strep test is negative, a
culture to grow the bacteria is done to confirm the results. A throat
culture is more accurate than the rapid strep test, but it may take
several days to obtain results. Most children do not tolerate throat
cultures very well. For younger children, it may help to place the child
on the parent’s lap facing forward and have the parent place one arm
across the child’s chest and over their arms, and one hand on the
child’s forehead. The child is now sufficiently restrained to obtain a
specimen safely. The nurse uses a tongue blade to push the tongue
downward and swabs the posterior pharynx with two sterile cotton-
tipped applicators (Fig. 14-14).
FOCUS ON SAFETY
Epiglottitis
One caveat exists regarding throat cultures. Throat examinations and cultures
should not be performed on a child who has suddenly developed a high fever; is
drooling; has severe sore throat, hoarseness, or stridor; or sits in a tripod position.
This history indicates the possibility of epiglottitis. Eliciting the gag reflex, as
happens with a throat culture, in this child may cause the inflamed epiglottis to
completely obstruct the airway.
Cerebrospinal Fluid Collection

A lumbar puncture (LP) is a necessary procedure to rule out sepsis or
meningitis. It can also be scheduled as a procedure for children
undergoing treatment for cancer. The nurse prepares the child for an LP
by telling the family and the child the reason for the procedure and
teaching distraction methods to the child. Practicing the position
required for the procedure can be helpful with the older child. An hour
before the LP, EMLA cream can be applied to the skin at the designated
site. This makes the procedure less painful. With the lumbar puncture, a
needle is inserted into the subarachnoid space at the level of L4 or L5
to withdraw cerebrospinal fluid (CSF) for analysis. An infant is seated
upright with the head bent forward. An older child must lie on their side
with the head flexed, hips and knees flexed, and the back arched while
being firmly held to make sure they do not move. CSF samples are sent
for culture, glucose, red blood cells, and protein.
FIGURE 14-14 Throat culture.
After the LP, vital signs are taken. The child is encouraged to lay flat
for 1 hour and drink fluids. The child may complain of a headache or
pain at the site of the LP. Frequent neurological assessment is
performed to note changes in status. Complications such as nerve
trauma, infection, bleeding, or pressure effects are rare.
Labs
Analysis of Cerebrospinal Fluid
Pressure Protein RBCs Glucose WBCs
(mm Hg) (mg/dL) (mg/dL)
Infant <200 20–170 None 34–119 0–30
Child <200 5–40 None 60–80 0–20
RBCs = Red blood cells, WBCs = White blood cells.
Data from Van Leeuwen, A. M., Poelhuis-Leth, D., & Bladh, M. (2021). Davis’s
comprehensive Manual of laboratory and diagnostic tests with nursing implications
(9th ed.). Philadelphia, PA: F.A. Davis.
Enteral Tube Feedings

When a child is unable to take adequate nutrition by mouth, an
alternate feeding method is used to maintain and promote growth in the
child. The type of feeding method selected depends on the child’s
medical condition. Children can be nourished through an oro- or
nasogastric feeding tube or a GT. Feedings may be administered as a
bolus or a continuous infusion. Bolus feedings are given at relatively the
same rate as an oral feeding would normally be taken and are the
preferred method to deliver formula in children who cannot tolerate oral
feedings. Formula given as a continuous infusion is placed on a feeding
pump and regulated to be administered over a predetermined number
of hours. Continuous infusions are often preferred in children with
serious cardiac defects to decrease the workload of the heart while
providing enteral nutrition. To allow underweight infants or children to
gain weight, a continuous feeding may be given during hours of sleep to
boost calorie intake without interfering with a normal daily
feeding/eating schedule.
FOCUS ON SAFETY
Risks With an Oro- or Nasogastric Tube
There are some risks with an oro- or nasogastric tube. The liquid from the feeding
or medication may enter the lungs and possibly cause pneumonia. The feeding
tubes may also cause the child discomfort. The tube can also become plugged,
causing pain, nausea, or vomiting.
TEACH PARENTS
It is important for parents to understand the purpose of the feeding tube. Enteral
tube feedings offer complete nutrition, but children often need additional water
flushes to provide for maintenance fluid requirements. Parents must be able to
recognize signs that the NG tube is not functioning properly or may be displaced.
If the child is discharged home with the NG tube in place, parents need to know
how to check placement, administer feedings, secure the NG tube to the child’s
face, and recognize signs of intolerance to feedings.
DOCUMENTATION
6/18/10 1,300 8F nasogastric tube inserted in left nostril without difficulty.
Placement of the tube confirmed. Nasogastric tube secured.
—Jagger Ruggiero, RN
Orogastric and Nasogastric Feeding Tubes

For newborn infants requiring gavage feedings, the orogastric route is
preferred because newborns are obligate nose breathers. The tube is
inserted and then removed at the end of the bolus feed. If the tube is to
be left in place, the nasogastric route should be considered.
Nasogastric tube feedings are preferred over total parenteral nutrition
because they preserve the stomach’s mucosa, allow the digestive
process to continue, and are cost-effective.
The time taken to administer a gavage feeding can be used in the
same way as in a regular feeding. Place the infant comfortably in the
mother’s arms with the head elevated. Provide the infant with a pacifier
to help simulate an actual feeding. Nonnutritive sucking has been
shown to increase weight gain and decrease crying and to allow for the
normal muscular development of the mouth and tongue.
Once placement of the tube is confirmed and the child is in position,
the nurse administers a bolus feeding of room-temperature formula via
gravity through an appropriately sized syringe attached to the feeding
tube. The formula-filled syringe is held less than 12 inches above the
infant. When the feeding is complete, the tubing is flushed with tap
water to prevent clogging of the lumen, the syringe is removed, and the
feeding port is capped. To decrease the chance of regurgitation, the
infant is burped after the bolus is infused. Follow hospital guidelines for
nasogastric gavage feedings. The nurse must remember that the
amount of water should be only the amount required to successfully
flush the length of tubing; excess water may result in overfeeding.
Gastrostomy Feeding Tubes

When a child requires enteral tube feedings over a longer period of
time, such as with oral feeding aversions or neurological dysfunction, a
GT is an alternative to the nasogastric tube. A GT is inserted through
the abdominal wall into the stomach. The GT is secured internally and
externally with a variety of bumpers depending on the manufacturer of
the GT. Some physicians also secure the GT in place with external
sutures for the first 7 to 10 days postoperatively.
After the initial insertion, the GT is left open to gravity drainage for 12
to 24 hours and the wound site observed for signs of infection. Stoma
care and assessment are important nursing interventions because of
the potential for leakage of gastric secretions onto the periostomal skin.
Guidelines for feeding the child through a GT are similar to nasogastric
tube feedings. Figure 14-15 shows two of the many types of GTs
available.
FIGURE 14-15 Gastrostomy tubes. A, PEG. B, Mic-Key.
PROCEDURE ■ Inserting an Oro- or

Nasogastric Tube
PURPOSE
To maintain optimum nutrition using a feeding tube passed through the mouth or
nares into the stomach
EQUIPMENT
• Oro- or nasogastric tube
• Tap water or water-soluble lubricant
• Syringe
• pH indicator paper
STEPS
1. Wash hands and don gloves.
2. Determine tube length by measuring from the nose to the earlobe, then to the
midway point between the end of the xiphoid process and the umbilicus.
RATIONALE: Proper measurement ensures that the catheter will be inserted
the correct distance.
3. Note the measurement by finding the manufacturer’s black mark on the proximal
end of the tube near the nares.
4. Lubricate the tube with tap water or water-soluble lubricant.
RATIONALE: Lubrication eases catheter insertion.
5. Using your dominant hand, gently direct the tube toward the back of the throat
or toward the occiput for a nasogastric tube.
6. Aspirate stomach contents.
RATIONALE: Indicates proper placement.
7. Check for proper placement using the method following the institution’s policy:
a. Use pH indicator paper for assessment of gastric aspirate.
b. Inject a small amount of air into the tube while auscultating over the stomach;
the nurse should hear a “swoosh” as the air enters the stomach.
c. Obtain an x-ray film to verify placement. This method is not practical for every
feeding, but is often used after initial placement of the oro- or nasogastric
feeding tube when used for continuous feeding.
FOCUS ON SAFETY
Gastrostomy Tubes
A GT may move into the duodenum and cause an obstruction as it occludes the
pyloric sphincter. Mark the tube with indelible ink to make it is easy to observe for
migration. The nurse must report any vomiting, abdominal distention, or evidence
of bile drainage as aspirate.
Ostomies
An ostomy is a surgical opening from either the small or large bowel to
the surface of the abdomen to allow for fecal elimination (Fig. 14-16).
An ostomy may be needed for a variety of reasons, including trauma,
obstruction, disease, and infection. Ostomies may be temporary to
allow the bowel sufficient time to heal or permanently when the child’s
condition does not allow for ostomy reversal.
For infants and toddlers, the parent assumes all responsibility for the
care of the ostomy. The nurse assists the parents by clarifying
misconceptions, addressing concerns about caring for the child with an
ostomy, and providing teaching guidelines regarding ostomy care. The
nurse must feel comfortable discussing difficult issues with the child. If
the child is unable or unwilling to verbalize their feelings, the nurse may
attempt to engage them through the use of play or art by bringing
crayons and paper to the child’s room and giving the child time to
process the current events in their life by drawing. The child may be
able to express himself through art or play more readily than through
words. A CLS may recommend additional ways for the child to
communicate their “stories” about how the ostomy is affecting everyday
life. Nurses must be aware of community resources and refer the
parents and child to appropriate support groups. Through participation
in support groups, the parents and child will be able to talk with others
who face the same issues and have struggled with similar concerns.
FIGURE 14-16 Child with an ostomy.
Older children must be encouraged to become independent in the

care of their ostomy. A school-aged child needs to learn all aspects of
ostomy care, including removal and reapplication of the ostomy
appliance and periostomal skin care. The child must be aware of the
signs and symptoms of potential complications to report to the school
nurse or parents. Nurses and parents must be aware of the special
needs of all adolescents (peer group and self-acceptance, sexuality,
and depression) and how those needs may be further affected in the
presence of an ostomy. When the child is in the school setting, an
arrangement should be made with the school nurse to allow for
adequate time and privacy for maintenance of the ostomy and for
storage of ostomy supplies.
Restraining the Child

Physical Restraint
Restraining a child may be a necessary intervention to ensure a child’s
safety during a procedure or to prevent injury to an operative site.
Parents and the child need to be informed as to why a restraint is
necessary. Once the restraint is applied, the child must be checked and
documentation made as to the condition of the skin and circulation of
the affected extremity. The extremity is checked every 15 minutes for 1
hour after initial application and then every 1 to 2 hours to ensure the
child’s safety.
FOCUS ON SAFETY
Use of Restraints
The Joint Commission has specific information about caring for the patient with
restraint and seclusion. The nurse must assess:
• Signs of injury associated with the application of restraint or seclusion
• Nutrition/hydration
• Circulation and range of motion in the extremities
• Vital signs
• Hygiene and elimination
• Physical and psychological status and comfort
• Readiness for discontinuation of restraint or seclusion
For more information go to http://www.jointcommission.org/
FOCUS ON SAFETY
Care of the Child in Restraints
1. Remove restraints every 2 hours to assess skin and provide range of motion to
the affected extremity.
2. If appropriate, provide supervised time with restraints off to allow the child to
engage in activities of daily living (e.g., toileting, feeding, reading a book,
watching TV, etc.).
3. Encourage games and activities that promote growth and development.
4. Reapply restraints.
5. Document condition of skin, nursing care given with restraints off, and removal
and reapplication of restraints.
6. Teach parents how to remove and reapply restraints.
Common types of restraints used for children are the elbow restraint
and the papoose restraint. The elbow restraint prevents the child from
flexing the elbow, therefore preventing the child’s hands from reaching
the head (Fig. 14-17). They prevent the child from pulling out an IV line
in a scalp vein or other peripheral line. If the child is recovering from
cleft lip repair, the elbow restraint prevents the child from touching the
incision area. Most children tolerate this type of restraint without
problems related to skin integrity or circulatory compromise. Elbow
restraints should be removed one at a time every hour to allow for
exercise of the arm. The child must be supervised when the restraints
are removed.
The papoose restraint is a total body restraint similar to an infant
swaddle. The papoose restraint temporarily immobilizes an infant or
small child for an examination or procedure that involves the head,
neck, or throat (Fig. 14-18). This is ideal to keep the child safe during
venipuncture, throat examination, insertion of a nasogastric tube, or
administration of ophthalmic, otic, or oral medications.
Pharmacological Restraint
In addition to physical restraints, pharmacological restraints can be
used with children during diagnostic and therapeutic procedures.
Sedation of children is administered to allow the safe completion of a
procedure. Chloral hydrate (Aquachloral) is a nonbarbiturate sedative-
hypnotic drug commonly used in children to produce sedation. The drug
decreases anxiety and induces sleep without respiratory depression or
suppression of the cough reflex.
FIGURE 14-17 Elbow restraint.
FIGURE 14-18 Papoose restraint.
MEDICATION Chloral Hydrate (Aquachloral)—

Points to Remember
(klor-al hye-drate)
• As a sedative or antianxiolytic, administer 25 mg/kg per day PO divided every 6
to 8 hours up to 500 mg per single dose.
• As a sedative for dental and medical procedures, administer 50 to 75 mg/kg 30 to
60 minutes prior, may repeat if needed. Do not exceed 1 gram total for an infant
or 2 grams total for a child.
• As a hypnotic, administer 50 mg/kg PO up to 1 g per single dose, max of 2
grams/day.
• Peak time is 1 hour.
• Assess level of consciousness at time of peak effect. Notify health-care provider if
desired sedative effect not reached.
• Duration of action is 4 to 8 hours.
• Dilute chloral hydrate syrup in juice or water to decrease gastric irritation.
• Monitor for dizziness, confusion, excessive sedation, and paradoxical excitation.
Source: Vallerand, A. H. & Sanoski, C.A. (2021). Davis’s drug guide for nurses (17th
ed.). Philadelphia, PA: F.A. Davis.
COMMUNITY SETTINGS
Children have special health-care needs for which families, nurses, and
other health-care providers collaborate to create a family-centered plan
of care. Today, children are apt to receive the majority of their health
care in a community setting. Community settings are on the front line of
prevention and early detection and may be located in neighborhood
clinics, schools, shopping malls, or health-care centers.
Primary Health-Care Provider’s Office or Clinic

When a child becomes ill, pediatric nursing care traditionally takes
place in a primary health-care provider’s office or clinic setting. This
medical facility provides diagnosis and treatment related to a variety of
acute and chronic conditions along with education, dissemination of
information, well childhood checkups, and administration of
immunizations. Caregivers must understand the importance of
accessing a primary health-care provider to receive comprehensive
care for their child’s condition. The pediatric nurse in this setting can
recommend additional community resources for the family (Fig. 14-19).
Patient Education
Teaching Tips for Families
The nurse can tell the family to bring a list of questions or concerns to discuss
when visiting the primary care physician’s office. You can also instruct parents or
guardians to:
• Bring a list of any allergies that the child has along with medications the child is
currently taking.
• Be ready to share information as to how the child is growing and changing. Keep
track of the child’s developmental progress.
• Inquire about resources including community organizations that may provide
assistance.
• Ask about how to receive care after normal business hours or emergency care.
• Request to meet the health team members who will be working with the child (a
nurse, a referral coordinator, or a medical assistant).
FOCUS ON SAFETY
Keeping Children Safe in the Home
In the home, parents must think like a child. Suggest that parents get down on the
floor in their home to see what their child sees (e.g., electrical plugs and outlets,
tablecloths ready to be pulled, and hot coffee mugs on the edge of the table). Be
sure to store all chemicals and medications out of children’s reach in a locked
cabinet. In the hospital, toxic and nontoxic materials should be stored in a locked
utility room, on the top shelf of a cabinet, or in another location where children do
not have ready access. Utility rooms, kitchens, medication carts, treatment rooms,
and supply rooms are locked, denying access to children. Play areas should be
locked unless the child is accompanied by an adult.
FIGURE 14-19 The nurse provides community resources to parents.
Infant Safety
■ The home needs to have a smoke and carbon dioxide detector and
fire extinguisher.
■ The car seat is placed in a backward-facing position in the backseat
of the vehicle.
■ Crib safety: the distance between slats of railings should be less than
2 ⅜ inches to prevent head entrapment or strangulation, no sharp
edges, mattress snug, bumper pads are suggested.
■ Furniture paint should be nontoxic and positioned to avoid cords,
windows, curtains, blinds, outlets, and lamps.
■ Bottles are warmed slowly in hot water, and the microwave is never
used to warm a bottle.
■ Keep hot liquids and foods away from the baby.
■ Never attach a pacifier with clip to infant’s clothes or around neck.
■ Keep one hand on infant when changing the infant’s diaper.
■ Never leave the baby alone on a high surface.
■ Do not let infant sleep in a playpen.
■ Never leave baby unattended in high chair, stroller, or swings.
Walkers are not recommended.
■ Make sure the infant’s toys have no removable small parts that can
present choking hazards.
■ The bath water must be below 120°F. Test the water before the
baby’s bath. Keep one hand on infant at all times in bathtub.
Toddler Safety
■ Prevent burns by keeping items like boiling pots, curling irons, and
other hot items out of the toddler’s reach. Turn pot handles in on
stove.
■ Prevent choking by maintaining an environment that is free of any
small toys or objects that a toddler could swallow.
■ Prevent poisoning by keeping all toxic chemicals locked in drawers or
on the top shelves of cabinets.
■ Prevent drowning by keeping toilet seat lids down and bathtubs
drained completely when not in use. Never leave a child alone in any
depth of water.
Preschool Safety
■ Teach the child about stranger danger.
■ Fire safety includes teaching stop-drop and roll and how to exit the
home in case of a fire.
■ Survey the playground for sharp objects and other unsafe objects.
■ Teach the child to wear a helmet when riding bikes.
■ Teach the parents about safe boundaries.
School-Age Safety
■ Keep car doors locked.
■ Use the buddy system when walking home from school.
■ Teach crossing the street safely. Teach about safe touch.
■ Keep toxic chemicals locked up and out of the child’s reach.
■ Keep the Poison Control Center number handy.
■ Ride in backseat of car, in an age-appropriate booster seat if
necessary.
■ Teach hand washing.
Adolescent Safety
■ Teach behaviors that contribute to unintentional injuries and violence
including:
Tobacco use
Alcohol and illicit drug use
Sexual risk behaviors
Unhealthy dietary behaviors
Physical inactivity
Lack of wearing seat belts
Firearm safety
Medical Home
A medical home provides ongoing, comprehensive primary care
services in a manner that encourages a positive relationship between
the child, family, and health-care team. The child lives in the facility
because of complex care needs. The concept of a medical home has
gained attention, particularly in the care of children who have special
medical needs, are homeless, or who do not have health insurance
(Bachrach, 2011). The care is provided in a manner that is family-
centered, coordinated, culturally sensitive, and accessible (Robert
Wood Johnson Foundation, 2010). Quality of life can be improved for all
children, especially those with special needs, with the collaboration of
families, insurers, employers, government, medical educators, and
other components of the health-care system, through the care provided
in a medical home.
Optimizing Outcomes
Outcomes of Coordinated Care Within a Medical Home
Children with special needs receive coordinated ongoing comprehensive care
within a medical home based on these desired outcomes from the National Center
for Medical Home Initiatives for Children With Special Needs:
• Families of children with special health-care needs will have adequate private
and/or public insurance to pay for the services needed.
• Children will be screened early and continuously for special health-care needs
and will have increased wellness.
• Services for children with special health-care needs will be organized in a manner
that fosters trust, considers the family’s cultural and religious beliefs, and builds
support for the child and family.
• Families of children with special needs will partner in decision making at all levels
and will be satisfied with the services they receive.
• All youth with special needs will receive the services necessary to make
appropriate transitions to adult heath care, work, and independence.
• Families will have increased satisfaction with their health care Benefits of a
medical home include the following:
• A child regularly sees the same primary care physician and staff.
• There is coordination of care for the child.
• There is an open exchange of information in an honest and respectful manner.
• There is support for finding resources and information related to all stages of
growth and development and medical conditions.
• The family is connected to information and family support organizations.
• The medical home partnership promotes health and quality of life as the child
grows and develops.
Other Community Settings

Mobile Health-Care Unit: A portable van that visits neighborhoods,
schools, and other community locations where children can obtain
screening, diagnosis, and treatment related to a variety of medical
conditions, receive immunizations, and receive well childhood checkups
or basic care.
Rehabilitation Service: Services that can be provided in a
community-based center or hospital where children can receive
occupational, physical, audiology, and/or speech therapy.
State Health Program: Each state works with its federal and local
partners to help children remain healthy and safe. The programs and
services help prevent illness and injury, promote healthy places to live
and work, provide education to help people make good health
decisions, and ensure that states are prepared for emergencies or
natural disasters.
The Department of Health and Human Services: The United
States government’s principal agency for protecting the health of all
Americans and providing essential human services, especially for those
who are least able to help themselves.
Specialty Camps: Specialty camps are a recreational, educational,
and supportive resource where children can play, learn how to care for
and cope with their condition, and meet other children who share the
same medical condition (e.g., Asthma Camp, Arthritis Camp, Diabetes
Camp, and Ventilator Assistive Camp). In specialty camps, activities are
planned that help children alleviate stress, interact with their peers,
achieve mastery over planned activities, and provide a diversion from
the challenges of coping with their illness or condition.
Churches, Synagogues, Mosques: Faith community health centers
integrate care of the spirit with care of physical body and mind. Nurses
who practice in a faith-based health center provide spiritual comfort and
counseling in keeping with the religious beliefs of the center. Faith
communities offer a wide variety of health-related services, including
health promotion education, disease prevention, immunizations, and
referrals to appropriate resources.
Faith Community Nursing is recognized as a nursing specialty by the
American Nurses Association (ANA). This specialty is governed by the
individual state Nurse Practice Act, the ANA Scope and Standards for
Registered Nurses, and the ANA Scope and Standards for Faith
Community Nurses.
After a child has received the needed health care, parents may
wonder how to continue to care for their child and their special needs.
Families must be given information about follow-up care especially
related to rehabilitation. Follow-up care can help ensure that the child
returns to normal functioning, learns to adapt to their condition, or
reaches the highest, most realistic level of health.
Care in the School Setting

Care in school settings is provided by nurses who specialize in the
prevention of illness, help children with special health-care needs, and
assist in the early identification of health concerns for children. Schools
offer basic nursing care for various health conditions, disease
management, and teaching about health promotion and disease
prevention, as well as play a role in advocacy, screening, and
counseling services.
The purpose of the National Association of School Nurses. (NASN) is
to advance the delivery of professional school health services to
promote optimal health and learning in students. School nursing is a
specialty whose members help children maintain good health practices
along with academic success. The school nurse’s role is to facilitate
normal development, promote health and safety, and intervene with
actual and potential health problems. The school nurse also provides
case management services and collaborates with other professionals to
maintain the family unit, instill self-management skills, and promote self-
advocacy.
The school health nurse also plays a leadership role in the support of
a coordinated school health initiative. The school nurse may be
involved in eight potential areas:
■ Providing experience and resources in health education including
developing health information and health programs.
■ Providing activities and health information, including increasing the
awareness and education of staff and faculty of the school, and
keeping accurate health records.
■ Assessing the health of students and provide access to health care.
■ Counseling and advising staff in the early identification of
psychological or social issues.
■ Providing health education about nutrition, encouraging healthy
eating and snacking behaviors, and reviewing and improving school
menu offerings.
■ Working with students and physical education teachers to encourage
physical activity, including students who may have special health-care
needs.
■ Reporting and intervening in hazardous situations within the school,
including crisis intervention.
■ Providing leadership and collaborative partnerships with community
agencies to meet the health-care needs of children and their families.
School nurses are the link between health and education and foster
this connection by:
■ Educating on health-related topics such as nutrition.
■ Assisting special needs children with their unique needs.
■ Helping families access health care.
■ Completing important screenings such as vision, hearing, and
scoliosis.
■ Offering counseling, primary health-care services, and emergency
care.
■ Ensuring communicable disease control by tracking immunizations
and tuberculin skin test.
■ Working with teachers to identify children at high health risk.
■ Supplying information for community referral and follow-up.
■ Serving as advocates for children through medical case
management, child abuse recognition, and crisis intervention and
triage.
■ Assisting in the creation of community-wide disaster plans.
■ Using individualized care plans and individualized family service
plans.
Health Screenings
Health screenings test or examine children for the presence of a
disease, illness, chronic condition, developmental delays, or mental
health issue. Health screening plays an important role in the early
diagnosis and management of selected illnesses or conditions and the
initiation of treatment, which can then prolong and improve lives.
Community settings often provide primary care along with health
screening and surveillance. Health surveillance is continuous
observation related to tracking health conditions and risk behaviors.
Nurses, physicians, and other health-care professionals gather ongoing
information about disease incidence, demographics of an illness, and
implementation of policies that may prevent further spread of diseases.
SUMMARY POINTS
■ The nurse becomes acquainted with the norms of pediatric nursing practice in the
context of caring for the child across care settings and understands that their
practice must be individualized for the unique needs of the child.
■ When examining infants, children, and adolescents, the assessment approach
depends on the child’s age, developmental and cognitive level, and the extent of
the illness if applicable.
■ A culturally competent nurse takes the time to become familiar with the health
practices and beliefs of the diverse cultures in the community in which they
practice.
■ Much like the physical examination, the review of systems is best conducted with
a head-to-toe approach, starting with a general question regarding each body
system.
■ Children react to pain and its management in ways that correspond to their
developmental level. Accurate pain assessment depends on the consistent use of
an assessment tool familiar to both the child and parent.
■ Caring for the child with a disability takes a toll on the entire family. The pediatric
nurse must be aware of all available resources within the community to assist the
family in the care of the disabled child.
■ Multiple options exist for the delivery of nursing care, ranging from the traditional
hospital inpatient environment to the broader community setting. Pediatric
nursing care for families is holistic, based on normal growth and development,
and emphasizes the optimization of preventive health and safety measures
yielding positive health outcomes.
■ Nurses can help children and families adapt to the stress of hospitalization in
several ways, including rooming-in with parents and therapeutic play.
■ Holistic care measures include feeding, rest and safety, medication administration
safety, infection control, and fever-reducing measures. The nurse also provides
emotional and spiritual support as needed. The nurse is responsible for these
activities in addition to the child’s safety.
■ Explanations of procedures must be given at a developmentally appropriate level,
avoiding words that may be unintentionally frightening.
■ Community settings are on the front line of prevention and early detection and
may be located in neighborhood clinics, schools, shopping malls, or health-care
centers.
REFERENCES
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ages 9–11, be screened for cholesterol.
American College of Obstetricians and Gynecologists (ACOG). (2019). Your first
gynecologic visit. https://www.acog.org/womens-health/faqs/your-first-gynecologic-
visit
Centers for Disease Control and Prevention (CDC). (2018). Latent tuberculosis
infection: A guide for primary health Care providers. Retrieved from
https://www.cdc.gov/tb/publications/ltbi/default.htm
Centers for Disease Control and Prevention (CDC). (2019). Recommended
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Advantage
CHAPTER 15
Caring for the Child With a

Respiratory Condition
CONCEPTS
Oxygenation
Nursing
KEY WORDS
bronchodilator medication
arterial blood gas (ABG) test
pediatric polysomnography (PSG)
polysomnogram
sleep onset latency
sleep stages
sleep efficiency
hyposmia
tonsillectomy
croup
tripod position
steeple sign
status asthmaticus
LEARNING OBJECTIVES

■ Describe the anatomy and physiology of the respiratory system.
■ Examine common conditions of the respiratory system seen in childhood.
■ Prioritize developmentally appropriate and holistic nursing care measures for
common pediatric conditions of the respiratory system.
■ Explore diagnostic screening, laboratory testing, and medications for common
pediatric conditions of the respiratory system.
■ Develop teaching plans and discharge criteria for parents whose children
have common respiratory conditions.
PICO(T) Questions
The following is an example of a PICO(T) question to consider while
reading this chapter:
Do (I) overweight (P) adolescents with asthma (O) have more

asthma attacks (C) than adolescents of average weight with
asthma?
INTRODUCTION
This chapter provides a review of the anatomy and physiology and
developmental aspects of the respiratory system. The discussion
includes an examination of the various respiratory conditions
including developmentally appropriate and holistic nursing care.
Information is given about diagnostic and laboratory testing and
medications. Teaching plans and discharge criteria for parents
whose children have various respiratory conditions are incorporated.
Respiratory diseases account for about 25% of all pediatric
consultations, and 10% of these are for asthma. The other main
pediatric respiratory diseases, in terms of incidence, are
bronchiolitis, acute bronchitis, and respiratory infections. Respiratory
conditions are common causes of illness among children and can be
acute, severe, or even life-threatening. Children can experience
chronic respiratory illnesses that affect growth and development and
overall lifestyle. Pediatric respiratory disorders are responsible for a
number of acute and chronic health conditions and are a leading
cause of pediatric emergency room visits and hospitalizations
(American Academy of Pediatrics, 2018).
ANATOMY AND PHYSIOLOGY REVIEW OF THE

RESPIRATORY SYSTEM
The respiratory system (Fig. 15-1) consists of the upper respiratory
tract, which comprises the nose, nasal cavity, sinuses, pharynx,
larynx, and trachea, and the lower respiratory tract, which includes
the lungs, bronchi, bronchioles, and alveoli. The anatomy and
physiology of the respiratory system in children differ from that of
adults, most obviously in size.
Ventilation (breathing) involves taking in oxygen through the nose
and mouth and delivering it to the lungs. The nose has cilia (small
hairlike projections) and mucus-producing cells that line the nostrils
to prevent small particles from entering the nasal cavity. The mucus
is a protective mechanism to trap foreign matter that enters the
nasopharyngeal cavities.
FIGURE 15-1 The respiratory system.
Oxygen then passes from the pharynx to the larynx. To prevent

food or liquid from entering the larynx, the epiglottis closes over the
opening of the larynx during swallowing. A cough reflex expels
foreign bodies. From the larynx, air passes through the trachea,
which branches into the left and right bronchi. The bronchi divide into
smaller branches called bronchioles. The bronchioles end in a
cluster of air sacs called the acinus.
Individual air sacs called alveoli exchange oxygen and carbon
dioxide. Oxygen exchange with the bloodstream occurs in the
capillaries. Oxygen attaches to the red blood cells and is transported
to the rest of the body. Carbon dioxide diffuses from the bloodstream
into the alveolus where it is transported out of the body during
exhalation.
DEVELOPMENTAL ASPECTS OF THE
RESPIRATORY SYSTEM
The airway of the newborn is narrow and more easily occluded than
that of an adult. Newborns are obligatory nose breathers; they do not
use their mouths for breathing. The cough of a newborn is usually
nonproductive because young infants produce little respiratory
mucus. Because they lack this cleansing function, they are more
susceptible to respiratory infections. Newborns have a highly
developed sense of smell, and the mucous membranes are highly
vascular. The ethmoid and maxillary sinuses are present at birth,
though the frontal and sphenoidal sinuses are not fully developed
until the child is 6 to 8 years of age. The lymphoid tissues, or tonsils,
are absent at birth and grow more rapidly in the child than any other
tissue. By age 7, the tonsils present at adult size.
Children younger than the age of 6 are abdominal-breathers
instead of thoracic-breathers. The intercostal muscles are too weak
to facilitate respiration, causing the child to rely on the use of the
diaphragm for inspiration. As the diaphragm moves downward,
negative pressure is created, expanding the alveoli and filling the
lungs with air. The downward movement of the diaphragm places
pressure on the abdominal contents. With increased airway
resistance, the weak musculature of the thorax is pulled inward,
causing retractions, as if sucking on a collapsed straw.

Development Considerations for the Child With a Respiratory Condition
The child with a respiratory condition can easily become overwhelmed and
burdened with the disease process and extensive medical therapies. For
example, cystic fibrosis (CF) is a multisystem respiratory disease that requires
extensive medical management to minimize recurrent lung infections.
Treatment for CF requires chest physical therapy, exercise regimens, and
medications. Additionally, alterations in oxygenation and perfusion can affect
the child’s ability to participate in physical activity and play. Because of these
factors, the child with a respiratory condition is vulnerable to alterations in
regular growth and development.
Nursing care of the child with a respiratory condition should maintain a
balance of disease symptom management and promotion of regular growth
and development. This can be accomplished by providing developmentally
appropriate toys that promote oxygenation and the stimulation needed for
growth. For example, bubbles and pinwheels engage children in play, promote
deep breathing and lung expansion, and assist with development of motor skills
and fine motor movement. The nurse should understand the child’s abilities and
limitations and provide growth and developmental activities that are
appropriate. Activity that supports airway maintenance and adequate
oxygenation is essential. The child should be encouraged to participate in
activities and allowed to rest as needed. The child with a respiratory condition
such as CF and asthma require lifelong medical care and often need frequent
hospitalizations. Frequent hospital admissions can result in delays or
regression of developmental milestones based on environmental changes and
social isolation. The nurse should educate the family about strategies to
prevent disease regression and hospital readmission to avoid this.
Retractions are a pulling in of the soft tissue of the chest wall with
inspiration and occur when the accessory muscles are used for
breathing. This is an abnormal finding and requires the nurse to
conduct a more thorough respiratory assessment. In the chest,
common sites for retractions include suprasternal, supraclavicular,
intercostal, subcostal, and substernal areas.
The respiratory system of the toddler expands to hold a greater
volume. This also increases the distances between the structures of
the respiratory tract, decreasing the risk of infections. The tonsils and
adenoids of the toddler are increasing in size. The eustachian tubes
remain short and horizontal during the toddler and preschool-age
years, providing easier access for nasal bacteria to enter the ear.
NURSING INSIGHT
Ear Medicine Administration for Toddlers
To administer ear medicine for children younger than 3, place the wrist of the
hand you will be using to give the medicine on the child’s cheek or head. Place
the dropper/nozzle above the child’s ear canal. Gently pull the outer flap of the
affected ear downward and backward to straighten the ear canal.
The epiglottis is long and flaccid among children ages 8 and

younger, making it more susceptible to swelling that can lead to
airway occlusion. The epiglottis is small and does not close properly,
and the larynx and the glottis are higher in the younger child’s neck,
which makes the child more prone to aspiration. The thyroid, cricoid,
and tracheal cartilages are immature and easily collapse with flexion
of the neck. The child’s neck has fewer functional muscles than that
of the adult. The increased amount of soft tissue makes the younger
child more susceptible to infection and edema.
The trachea in children is shorter and narrower in diameter than in
adults. To compare, the trachea of a newborn is approximately 4 mm
in diameter, about the diameter of a drinking straw. By age 6, the
diameter of the trachea is approximately 12 mm, while an adult’s
trachea is from 18 to 20 mm in diameter. A child’s trachea bifurcates
(separates into two branches) at the third thoracic vertebra, but an
adult’s trachea bifurcates at the sixth thoracic vertebra. In addition to
the higher level of bifurcation, the angle of the right bronchus (one of
the two large branches of the trachea) is much sharper in children.
Because of the narrow lumen of the trachea, excess mucous
production can easily produce a greater degree of swelling that can
lead to an obstruction and severe respiratory distress.
The right bronchus is shorter, wider, and more vertical than the
left; therefore, inhaled foreign bodies more often lodge in the right
bronchus. The bronchioles of the infant are little more than a thin
layer of muscle elastic-lined with ciliated epithelium. Lung tissue is
also immature at birth and continues to develop until about age 12.
Children have less alveolar surface for gas exchange than adults.
The surface area increases ninefold by age 12. The alveoli increase
in number from 25 to 300 million during this time, along with
increasing in size and functionality. The maturity of the alveoli
enhances ventilation and respiration, promoting more effective gas
exchange.
Because of the differences in a child’s airway, the force needed for
ventilation is greater. Increased friction and resistance make it more
difficult to generate ventilation in the presence of airway edema that
may result from hypersensitivity reactions or infectious processes.
The average full-term infant has 20 to 50 million alveoli at birth.
Rapid growth and maturation of alveoli occurs during the toddler and
preschool ages. This expansion improves ventilation; respiratory
rates decrease significantly from those of the newborn. The alveoli
continue to increase in number during the school-age period,
reaching approximately 300 million by 8 years of age. Lung
development is complete by 5 to 6 years of age. The respiratory
structures of the adolescent are of approximately adult size and
capacity.
NURSING INSIGHT
Respiratory Rate
In assessing the respiratory rate of a child, the nurse understands that the rate
and depth of respirations can be affected by crying, physical activity, anxiety,
anemia, acid-base disturbances, fever, central nervous system disturbances,
and salicylate ingestion. The child’s respiratory rate is assessed in correlation
with other overall physical findings. When assessing the respiratory rate of the
pediatric patient, the nurse counts for a full minute (Table 15-1).
TABLE 15-1
Average Respiratory Rates in Children
PRETERM NEWBORN 1 YEAR 3 6 10 14 18
YEARS YEARS YEARS YEARS YEARS
40–70 30–50 20–40 20–30 16–22 16–20 14–20 16–20
Source: Kliegman, R. (2020). Nelson textbook of pediatrics (Edition 21). Chapter

121, Respiratory Track Infections. Philadelphia, PA: Elsevier.
What to Say
Assessing a Child’s Respiratory System
Always adjust your approach to a pediatric physical examination based on the
child’s age, developmental and cognitive abilities, and how well or unwell the
child appears. In addition, try to take advantage of periods of quiet to listen to
lung sounds.
Always introduce yourself to the parents and the child, including your name
and role.
Confirm the child’s name and date of birth. Briefly explain what the
examination will involve using age-appropriate language:
“Hi, my name is Lola, and today I’ll be Emily’s nurse. I’d like to perform a
respiratory examination now, which will involve observing your child’s
breathing, feeling her pulse, and listening to her breathing with my
stethoscope.”
Diagnostic Tools
Pulmonary Tests for Pediatric Lung Disorders
Pulmonary tests are an important aspect of diagnosing lung disorders in
children. Diagnostic tests used in pediatric pulmonary assessments can include
the following:
• Pulmonary function testing (PFT) is a series of breathing tests that measure
lung function. PFTs are used to determine how efficiently the lungs take in
and exhale air and transfer oxygen to the blood. PFT is usually performed to:
- Diagnose respiratory conditions
- Assess lung and airway growth
- Monitor chronic respiratory conditions
- Evaluate medication effectiveness
• A spirometry test is the most common pulmonary function test. During a
spirometry test, the patient breathes into a mouthpiece, usually while sitting in
a special booth called a body plethysmograph. The spirometry test typically
requires at least three long blasts of air and takes just a few minutes. Your
child may be asked to use a bronchodilator medication (Albuterol) after the
test and repeat the spirometry test 15 minutes later to assess lung response
to the bronchodilator. The mouthpiece is connected to a spirometer that
records the amount and rate of air being inhaled and exhaled. Spirometry
testing is used to diagnose certain lung conditions, including:
- Asthma
- Chronic obstructive pulmonary disease (COPD)
- Bronchitis
- Emphysema
- Pulmonary fibrosis
Pulmonary function can often be evaluated through the body’s response to
exercise. Depending on the pulmonary condition being tested, your child may
be recommended for:
• A 6-minute walk test (simple pulmonary stress test), which measures how far
the patient can walk in 6 minutes. At the conclusion of the test, the child rates
shortness of breath from 0–10 on a special scale. A finger probe is used to
evaluate oxygen levels and heart rate. Slowing down or resting is permitted if
necessary.
• Cardiopulmonary exercise test (CPET), a 12- to 15-minute test that measures
breathing variations, as well as blood and oxygen flow to the muscles, during
exercise. Patient walks on a treadmill or pedals a stationary bicycle while
breathing into a mouthpiece. Other monitoring devices measure vital
functions as resistance is increased. Monitoring continues while the child
rests afterward.
• Exercise-induced asthma challenge, which measures functionality of the
lungs before and after exercise. Testing process is similar to CPET but for a
shorter time period and with no resistance. Used to identify exercise-induced
asthma, set exercise limits, or evaluate the effectiveness of current
medications.
• Pulse oximetry, a noninvasive test used for monitoring oxygen saturation in
the blood. A sensor device is placed on the patient’s body, usually the
fingertip, which transmits wavelengths of light that pass through a pulsating
capillary bed to a photodetector. The photodetector measures absorbency of
the wavelengths to determine blood oxygen levels. Often used overnight to
determine whether oxygen levels drop during sleep.
Several radiological imaging studies may be used to diagnose pulmonary
conditions or disorders. Common studies used to assess the respiratory
system can include:
• Thoracic (chest) imaging, instrumental in diagnosing, as well as evaluating
treatment effectiveness in conditions such as asthma, pneumonia, pulmonary
embolism, and CF.
- Chest x-rays (CXR) can help diagnose and monitor certain lung conditions,
such as pneumonia or emphysema.
- Computerized axial tomography (CAT or CT) scan, a combination of special
x-ray equipment and computer technology to produce more detailed
imaging. The horizontal (axial) images provide a cross-sectional view of the
organs. Often used to identify pulmonary embolism.
- Magnetic Resonating Imaging (MRI), which provides three-dimensional
pictures of the organs using a magnetic field and radio wave energy. Can
detect problems not seen on CT scans or x-rays without the use of
radiation.
- Ultrasound, which uses high-frequency sound to produce images of what’s
happening inside of the body in real time. Used to confirm conditions such
as pneumonia, pulmonary edema, and pneumothorax.
Oxygen and carbon dioxide monitoring involves attaching electrode-
containing sensors to the skin to measure oxygen and carbon dioxide levels in
the blood. The electrodes warm the skin, which causes capillary dilation
resulting in an increase in blood flow and oxygen delivery to the skin surface.
The sensors are connected to a monitor where the oxygen and carbon dioxide
levels are displayed.
Oxygen and carbon dioxide levels may also be measured by performing an
arterial blood gas (ABG) test. An ABG test uses the blood taken from an artery
to measure: Partial pressure of oxygen, partial pressure of carbon dioxide,
bicarbonate, pH, oxygen content, and saturation values. ABG testing can
identify how efficiently the lungs remove carbon dioxide from the blood and
move oxygen into the blood.
A sweat test is the most reliable method for diagnosing CF (Wood et al,
2018). Sweat testing involves measuring the amount of chloride and sodium
(salt) present in the patient’s sweat. During the sweat test, small electrodes and
gauze are placed on the forearm or leg while a special machine stimulates
sweating at the area under the electrodes. The gauze absorbs the sweat,
which is then analyzed for chloride content. Stimulation is administered in 5-
minute increments. Sweat testing is not painful and usually takes approximately
30 minutes. Results of the sweat test are generally available the same day.
Diagnostic Tools
Diagnosing Pediatric Sleep Disorders
Pediatric polysomnography (PSG) is a sleep study test used in diagnosing
sleep disorders in children. During polysomnography, information is collected
about brain waves, blood oxygen levels, eye and leg movements, respiratory
effort or events, and heart rhythm. This test is usually performed by closely
monitoring the patient overnight. The information obtained from the
polysomnogram is analyzed by scoring several variants of sleep including:
• Sleep onset latency: Time elapsed from lights out to onset of sleep
• Sleep stages: REM (rapid eye movement) sleep, slow wave sleep, and two
stages of light sleep
• Sleep efficiency: Minutes of sleep divided by minutes in bed, breathing
irregularities, oxygen saturation, and cardiac rhythm abnormalities
PSG is beneficial in diagnosing sleep apnea, hypoventilation syndromes, and
other sleep-related disorders.
CONGENITAL RESPIRATORY CONDITIONS AND

STRUCTURAL ANOMALIES
Children can be affected by various congenital respiratory conditions
and structural anomalies that affect health and function. It is
essential that the nurse has a good understanding of the presenting
signs and symptoms of the diagnosed condition and the prescribed
care.
MEDICATION
Medications Used to Treat Respiratory Conditions
Therapeutic Category Indication(s) Action(s)
Antibiotics (oral, Abscess, bacterial Treats respiratory tract
parenteral, inhalation) pneumonia, cystic bacterial infections.
fibrosis, empyema,
pharyngitis,
sinusitis, tonsillitis,
tuberculosis.
Inhaled antibiotics
are used in cystic
fibrosis.
Antihistamines (oral) Allergic rhinitis, Counteracts the effects
asthma. of histamine on a
receptor site used to
treat allergies,
hypersensitive
reactions, and colds.
Anticholinergics Acute or chronic Produces
(inhalation) wheezing in bronchodilation
asthma or chronic (without systemic
lung disease. effects) and inhibits the
muscles from
tightening around the
bronchi (large
airways).
Antiviral agents (oral, Influenza virus Treats the flu
parenteral) types symptoms. Antiviral
A and B. agents do not destroy
their target pathogen;
instead they inhibit
their development.
B2, Agonists (oral, Asthma, chronic Acts as a smooth
inhalation) obstructive muscle relaxant
lung resulting in
disease. bronchodilation.
Caffeine (oral) Apnea. Stimulates the
respiratory center.
Corticosteroids (oral, Asthma. Acts as a potent anti-
parenteral, inhalation) inflammatory agent.
Cough suppressants Common cold, Treats a cough
(oral) bronchitis, (productive or dry). For
pneumonia, a productive cough
sinusitis. (with phlegm), the
cough syrup contains
an expectorant to help
loosen mucus. For a
dry cough, the cough
syrup contains
suppressants
(antitussives) in an
attempt to suppress
the urge to cough.
Decongestants (oral) Common cold. Reduces swelling and
congestion.
Expectorants (oral) Common cold, Reduces viscosity of
pneumonia. thick mucus
secretions.
Leukotriene receptor Asthma, bronchitis, Inhibits leukotrienes
antagonists (inhalation) constricted airways. that cause
inflammation.
Mast-cell stabilizers Asthma Prevents or controls
(inhalation) (maintenance). certain allergic
disorders.
Recombinant human Cystic fibrosis. Helps delay cystic
deoxyribonuclease I fibrosis progression by
(rhDNase) (inhalation) improving lung function
and reducing the risk
for respiratory tract
infections and thins
and loosens mucus.
Racemic epinephrine Croup, Produces
(inhalation) bronchiolitis. bronchodilation.
RSV vaccine (IM Respiratory Provides infection-
injection) syncytial virus. fighting antibodies to
help protect high-risk
infants’ vulnerable
lungs.
Source: Wood et al (2018).
Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF)

EA is the failure of the esophagus to develop a continuous passage
characterized by the presence of a blind pouch. The proximal and/or
distal portions of the esophagus may or may not be connected to the
trachea by a fistula (TEF). A TEF creates an abnormal
communication between the trachea and the esophagus. The defect
occurs in approximately 1 in 3,000 live births and is commonly
associated with polyhydramnios (the presence of excess amniotic
fluid in the amniotic sac) and cardiac defects (Baird et al, 2019). TEF
is often associated with other anomalies, which may involve the
kidneys, heart, limbs, or spine.
This anomaly occurs during fetal development when the
tracheoesophageal groove fails to close, resulting in incomplete
separation of the trachea and esophagus. The esophagus and
trachea begin forming from the foregut in the 4- to 6-week-old
embryo. During this process of formation, the posterior deviation of
the tracheoesophageal septum leads to failure of closure between
the trachea and esophagus (Fig. 15-2).
Signs and Symptoms

EA and TEF may manifest with:
■ Excessive drooling and secretions
■ Frothing and bubbling at the mouth and nose
■ Cyanosis
■ Choking with attempted feeding
■ Inability to pass orogastric tube into the stomach
Clinical symptoms may intensify with feeding, leading to
regurgitation, choking, and aspiration.
In cases of isolated TEF, symptoms may occur later in life, such as
chronic respiratory problems and abdominal distention because of
air building up in the stomach. Because EA and TEF have been
associated with other congenital anomalies that occur in the
musculoskeletal, GI, cardiac, and genitourinary systems, a thorough
assessment by the nurse is necessary.
Diagnosis
If not diagnosed with prenatal sonogram, most neonates are
diagnosed soon after birth or during infancy because TEF is a life-
threatening condition. TEF is confirmed by observing an early onset
of respiratory distress accompanied by signs and symptoms
described earlier, as well as possibly the inability to pass a
nasogastric or orogastric tube. Confirmatory diagnosis is made
through radiography. Chest films are taken to determine the patency
of the esophagus or the presence and level of the blind pouch.
NURSING INSIGHT
Nursing Assessment
When assessing a child diagnosed with EA or TEF, the nurse watches for
subtle changes in the child’s color, respiration, behavior, heart rate, and general
health. Subtle changes often occur before technology can recognize these
changes. It is essential to have emergency equipment ready at the bedside. It
is also important to remember that the child has an uncanny ability to
compensate. When the child is no longer able to compensate, the child
“crashes” and may have a poor probability of recovery.
FIGURE 15-2 Esophageal atresia and tracheoesophageal fistula.
Surgical Care
After life-sustaining measures are given, surgical corrections may
come in stages as needed for palliative care (e.g., gastrostomy and
drainage of esophageal pouch). The goal of surgery is to close the
fistula and attach the two sections of the esophagus. Artificial
ventilation may be required in the beginning, and the child can be
weaned off the artificial ventilation as the condition improves.
However, endotracheal (ET) intubation is often avoided because it
may worsen abdominal distention because of the connection
between the trachea and esophagus (Fig. 15-3).
Before surgical correction, the neonate is not given oral feedings,
but IV (parenteral) fluids. The nurse positions the neonate at a 30- to
45-degree elevation of the head to protect the trachea from
secretions, and the head is turned to the side to prevent aspiration
and drain secretions. Suctioning is done regularly and at frequent
intervals. A nasogastric or orogastric tube with continuous, low
suctioning is likely to be placed by the health-care provider into the
blind pouch and monitored for patency. The tube should not be
irrigated because this may cause aspiration. Hydration and fluid and
electrolyte balance are monitored. Often, antibiotic therapy is started
because aspiration pneumonia is inevitable.
FIGURE 15-3 Child with an endotracheal tube.
FOCUS ON SAFETY
Preoperative and Postoperative Suctioning
Preoperatively, any nasogastric or orogastric tube placement for suctioning
must be done carefully and gently. Stop progression immediately if any
resistance is met because this can lead to a perforation of esophageal tissue
in an infant with an anomaly. Tube placement is usually done by the primary
care provider. Postoperative oral or nasal suctioning of the infant with EA or
TEF must also be done extremely carefully to avoid disruption of the repairs.
Carefully measure the catheter and do not insert any farther than the distance
from the nares to the ear lobe.
Immediately after the surgical correction, nurses must monitor vital

signs at regular intervals. The site requiring correction is usually in
the thoracic cavity, so the nurse expects the baby to return with a
chest tube and possibly still be intubated with an ET tube. Infants
with chest tubes are carefully handled to avoid dislodging the tube.
Suctioning of the oropharyngeal area is kept to a minimum to avoid
disruption of the surgical repair.
Postoperatively, the nurse performs vigilant assessments on all
body systems to detect any complications or new problems.
Because the child may have low blood counts and a decrease in
fluid volume, the nurse must regulate plasma or blood transfusion
and the IV infusions adequately. To maintain adequate nutrition,
gavage feeding may be initiated by the second or third postoperative
day. Gavage feedings are administered slowly while watching the
child closely for any untoward manifestations, such as aspiration.
The child requires prolonged hospitalization, so the family must be
informed about the lengthy hospital stay and the need for ongoing
treatments. After the child has recovered, he or she may be
discharged to the care of the parents. Emphasize to the family the
need for frequent follow-up visits to ensure that no complications or
problems are present.
Chest Tubes
Removal of air, fluid, or blood from the pleural, pericardial, or
mediastinal spaces may be facilitated by the placement of chest
tubes. The purpose of closed chest suction is to remove air and fluid
from the thoracic cavity and to improve postoperative lung
reexpansion, as well as to treat pneumothorax. The chest tube is
connected to a closed drainage system. The closed drainage
systems consist of an underwater seal, a collection chamber, and
suction chamber in a single unit, which is subsequently connected to
sterile tubing and a suction device. Suction is applied as prescribed
by the primary care provider and typically ordered at –15 to –20 cm
H2O. To function properly, the chest drainage system needs to be
placed a minimum of 1 foot (30 cm) below the level of the lungs.
NURSING CONSIDERATIONS
■ Explain procedure to the child and parents.
■ Note character, consistency, and amount of drainage in the
collection chamber.
■ Note integrity of the tubing and chest tubes every 2 to 4 hours.
■ Carefully coil the tubing and secure to the edge of the bed,
avoiding pressure or kinks in the tubing.
■ Mark drainage level according to the policy of your institution.
■ Never clamp the tube when moving or transporting the child.
■ Encourage coughing and deep breathing according to the policy of
your institution.
■ Check the rate and quality of respirations and auscultate the lungs
according to the policy of your institution.
■ Instruct the child and parents to report any breathing difficulty.
■ Notify the primary care provider of changes in color, decreased
oxygen saturation, rapid or shallow breathing, chest pain, or
excessive bleeding.
■ Check the chest tube dressing according to the policy of your
institution.
■ Do not routinely milk or strip the chest tubes because it can cause
negative pressure, which may damage lung tissue.
■ Document observations, routine care, dressing appearance,
drainage, and functioning of the chest drainage system according
to your institution’s policy.
After corrective surgery, most affected infants lead normal lives. The
potential for postoperative infection can be prevented by instructing
the parents to keep the wound clean and dry. Instruct the parents on
carefully observing the infant during feeding and reporting any
difficulty swallowing. Parents also need to be instructed on proper
feeding and positioning to avoid aspiration. In addition, parents must
be educated on signs of respiratory infection, as well as on the signs
of a stricture, which may be demonstrated by refusal to eat and can
require dilation. If complications do occur, they are challenging,
especially during infancy. Prognosis depends on the presence or
absence of other associated anomalies.
Acute Respiratory Distress Syndrome (ARDS)

ARDS is a life-threatening condition characterized by increased
pulmonary capillary permeability and pulmonary edema, which leads
to hypoxemia, reduced lung compliance, and alveolar infiltrates
(Khemani et al, 2019). An acute underlying illness or injury such as
sepsis, viral pneumonia, smoke inhalation, aspiration of gastric
contents, hydrocarbon ingestion or aspiration, or near-drowning may
progress to ARDS. Infection is the most common cause, often
associated with respiratory syncytial virus (RSV) in children. Indirect
lung injury, such as with pancreatitis, shock, burns, trauma, drug
overdoses, and blood transfusions, may also precipitate ARDS. The
underlying disease or disorder influences the mortality rate. Mortality
in adults can be as high as 90% with underlying liver disease and as
low as 10% in children with RSV. The average mortality rate overall
is 40%. Multisystem organ failure is a frequent complication of
ARDS, has a major effect on the prognosis, and is the leading cause
of death in both adults and children.
As the disease progresses, the alveolar-capillary membrane
becomes more permeable. As exudate enters the alveolar spaces,
the lung becomes less compliant and susceptible to pulmonary
edema. This further leads to decreased surfactant production, which
exacerbates alveolar instability. Swelling leads to atelectasis, and
gas diffusion is impaired (Burns & Dunn, 2020). As a result,
decreased oxygen enters the bloodstream, which may lead to
multisystem organ damage.
Patient Education
Care for the Child With Esophageal Atresia and/or Tracheoesophageal
Fistula
The nurse prepares the parents/caregivers for discharge and home
management. The nurse must teach parents these topics at discharge to home
care for the child who has a diagnosis of EA and/or TEF:
• In the case of tracheotomy, teach parents proper sterile technique of
suctioning and how to handle the equipment appropriately.
• Verify that all emergency numbers are written down in a prominent place so
parents can reach out for emergency care if necessary.
• Ensure parents know how to identify respiratory distress.
• Confirm parents know feeding techniques for gastrostomy tube and how to
handle tube plugging and dislodging.
• Instruct parents in performing CPR before the child goes home.
• Encourage parents to use different toys and games to promote stimulation
during regular care (e.g., encourage mobilization or action play to help the
child reach developmental milestones and divert the child’s mind, which may
help the child cope during the prolonged sickness). Mobilization can be as
simple as holding or rocking, while action play can be games, toy figures, or
crafts.
• Involve other siblings in adapting the young child with EA or TEF. It is
essential that the family help the child with EA or TEF learn socialization and
interaction with others.
• Ensure the family knows how to operate equipment and proper maintenance
of the equipment used at home.
Signs and Symptoms

Respiratory distress results when breathing does not match the
body’s metabolic demand for oxygen due to failure of oxygenation
and/or ventilation. Respiratory distress is typically characterized by
signs of increased work of breathing, such as tachypnea, use of
accessory muscles, and/or retractions. Head bobbing, nasal flaring,
and grunting are additional signs more commonly seen in very young
children. A respiratory rate that is inappropriately slow for the clinical
condition may also be a sign of respiratory distress and may be more
important than impending respiratory arrest. An abnormal pattern of
respiration is a sign of respiratory distress that may offer clues to
etiology.
ARDS is usually diagnosed in a patient who is in the hospital from
a critical illness such as shock, sepsis, or other trauma. Diagnostic
tests may include:
■ Arterial blood gases
■ Chest x-ray
■ Other blood tests that can find an infection that may be causing
ARDS
■ CT scan of the lung
■ Electrocardiogram and echocardiogram to rule out cardiac causes
Prevention
The incidence of ARDS may be decreased through primary
prevention of traumatic injuries by use of child car restraints, bicycle
helmets, and protective sports gear. Some infectious illnesses
primarily affecting the respiratory tract may be prevented through
compliance with recommended immunizations and good hand
washing hygiene. RSV passive immunization with immunoglobulins
can inhibit more serious illness in vulnerable patients.
Collaborative Care
NURSING CARE
Caring for children with ARDS requires advanced training and
technical skills along with vigilant nursing assessment and
monitoring of vital signs. The nurse must accurately record and
report significant changes in vital signs to the physician. Calories and
fluids are provided intravenously; therefore, the nurse monitors exact
intake and output. In addition, the child with ARDS requires
supportive care. The child will be placed in intensive care, and both
the respiratory and cardiovascular status will be monitored closely.
Care includes positioning, pain and anxiety control, maintenance of
nutrition, and infection control practices. Ventilator support may be
required as the disease progresses and requires the nurse to be
sensitive to the psychological support of both the child and family.
Education should include an explanation of procedures and assisting
the family to understand test results and evidence of disease
progress.
MEDICAL CARE
Medical management is directed at improving oxygenation and
ventilation and often includes the use of mechanical ventilation with
attention to positive end-expiratory pressure (PEEP). Monitoring
includes continuous blood pressure measurements, central venous
pressure monitoring, and ABS analysis to assess for adequate
oxygenation, ventilation, fluid volume, and cardiac functioning. Fluids
may be restricted to reduce intravascular volume because of the
potential for pulmonary edema related to increased pulmonary
capillary permeability.
Most people with ARDS will need mechanical ventilator assistance
with a low tidal volume. Use of a high tidal volume can overdistend
the lungs, leading to lung inflammation and ventilator-associated
lung injury. For milder symptoms, oxygen may be delivered using a
properly fitting face mask. PEEP is considered an essential
component of ventilation. Use of PEEP helps expand alveoli and
increases lung volume.
Prone positioning has been demonstrated to improve postural
drainage and ventilation of collapsed portions of the lungs. Use of
inhaled nitric oxide, which causes pulmonary vasodilation increasing
blood flow, has been found to improve oxygenation, though research
has not demonstrated an overall significant improvement in survival
rates. Surfactant therapy has been studied as a potential treatment
for ARDS, though consistent benefits in children have not been
identified. Use of extracorporeal membrane oxygenation (ECMO),
which removes the blood from the body and then returns it, has also
been used in adults, though according to Cheifetz (2011), limited
data addresses its use in children. Though ECMO is a life-saving
therapy, it is also considered invasive with a high risk of bleeding.
Parents need to be instructed about the need for that long-term care
follow-up and monitoring of the pulmonary system. In addition,
parents need to understand the importance of maintaining a smoke-
free environment, providing proper nutrition, avoiding infections, and
ensuring compliance with immunizations.
Cystic Fibrosis
Cystic fibrosis (CF) is an inherited autosomal-recessive disorder of
the exocrine glands that causes the production of thick mucus that
affects several body systems, including respiratory, gastrointestinal
(GI), and reproductive. CF is the most common cause of chronic
respiratory disease in children and is accompanied by multiple,
severe respiratory infections. CF is the most common autosomal
recessive disease in the Caucasian population, occurring in
approximately 1/3,500 births (Wood et al, 2019). The increased
mucus production in the airways causes obstruction and stasis of
fluid, providing a rich habitat for bacterial growth. In addition, the
pancreatic ducts are often blocked by mucus, prohibiting the
secretions of pancreatic enzymes necessary for the metabolism of
food nutrients. In later childhood, the reproductive system is affected
because ovarian ducts and the vas deferens may be occluded,
leading to infertility. An increased loss of sodium causes salt
depletion in children with CF.
Most patients become symptomatic at birth or soon after birth.
Respiratory infections and poor weight gain are the most frequent
presentation. These symptoms coupled with pancreatic insufficiency
usually signify a diagnosis of CF. Other classic disease
manifestations are excessive salt loss via sweat and male infertility.
Respiratory disease is the most severe manifestation and the most
frequent cause of death or lung transplant in early adult life. While
CF is part of the normal newborn screening tests in the U.S., it can
be sometimes missed. If CF is suspected, a sweat chloride test is
performed; a sweat chloride concentration above 60 mmol/L is
diagnostic for CF.
Prevalent CF pathogens leading to chronic lower lung infections
include Staphylococcus aureus and Pseudomonas aeruginosa; while
later in the disease course, some patients become infected with
more unusual and difficult to treat pathogens like Burkholderia
cepacia Achromobacter xylosoxidans, Stenotrophomonas
maltophilia, and mycobacteria (Wood et al, 2019). However,
complications can occur in nearly every organ and increase with
age, including liver disease, CF-related diabetes, nasal polyps, and
intestinal obstructions.
CF is transmitted as an autosomal-recessive trait, which means
that a child can receive a defective gene from either parent. When
both parents carry the defective gene, the child has a 75% chance of
inheriting one CF gene from each parent and manifesting the
disease. There is a 50% chance that the child will inherit one
defective gene and one normal gene from each parent and become
a carrier of the disease. There is a 25% chance that the child will
inherit only normal genes and be free of CF.
The CF genes have been found on chromosome 7, which encodes
CF transmembrane conductor regulator (CFTR) protein. CFTR
normally regulates the chloride channel and facilitates the activity of
other chloride and sodium channels at the cell surface. Abnormal
functions of CFTR cause a disruption of sodium ion transport across
the exocrine and epithelial gland cells and make the cell walls
impermeable to chloride ions. This causes an excess of sodium and
chloride found in the sweat of children affected by CF. In addition,
the loss of sodium and water from the airways increases the
viscosity of the mucus and disrupts the ciliary mechanism (hairlike
process) that is intended to clear the airways, predisposing the child
to recurrent respiratory infections.
A similar transport defect occurs in the pancreatic and bile ducts.
With inadequate excretion of pancreatic enzymes for food
breakdown, children experience varying levels of protein and fat
absorption. Reduced protein and fat absorption leads to weight loss
and failure to thrive, requiring an affected child’s diet to be high in
protein and calories. Fat is excreted in the stool, resulting in
abnormal bowel patterns, including steatorrhea, diarrhea, and
abdominal pain.
The mucus gland produces thin, free-flowing secretions, but in CF
it produces thick mucus that accumulates and obstructs organs. In
newborns, thick secretions may plug the small intestine and lead to
failure in passing meconium (the first feces of a newborn infant,
which is greenish black, odorless, and tarry) (Venes, 2021). In the GI
system, thick secretions impair the digestive system and lead to
malnutrition in childhood.
Signs and Symptoms

CF affects the vital organs of the body, and children with the
condition show a wide range of signs and symptoms. The severity of
the symptoms also varies. Because CF is a multisystem disease
(failure of two or more organ systems), the symptoms are presented
according to the body system affected. Gastrointestinal tract
symptoms include:
■ Meconium ileus
■ Prolonged jaundice
■ Steatorrhea
■ Rectal prolapsed
Respiratory symptoms include:
■ Crackles
■ Wheezes
■ Diminished breath sounds
■ Productive cough
■ Tachypnea, hypoxia, and cyanosis
Integumentary symptoms include:
■ Salty-tasting tears and skin
Secondary consequences include:
■ Dehydration
■ Secondary respiratory infections, namely bacterial pneumonia
■ Malnutrition
■ Intestinal atresia
■ Idiopathic pancreatitis
■ Biliary cirrhosis
■ Cholestasis
■ Emphysema and atelectasis
■ Prolonged hypoxia
■ Hemoptysis
■ Diabetes
■ Anemia
■ Failure to thrive
■ Osteoporosis
Common characteristics include a child who:
■ Is thin and underweight (classified as less than or equal to 10th
percentile for height and weight on a standardized growth chart)
■ Has a barrel chest
■ Has a protuberant abdomen and distention
■ Has wasted buttocks
■ Has thin extremities
■ Is listless and lethargic
■ Has delayed development of secondary sex characteristics and
infertility
■ Has occlusion of the vas deferens in males
■ Has occlusion of the ovarian ducts in females
Diagnosis
The diagnosis of CF is based on the child’s signs and symptoms,
including a positive family history of the disease, absence of
pancreatic enzymes, increase in the electrolyte concentration of
sweat, and chronic pulmonary involvement. Chest x-ray films show
patchy atelectasis and obstructive emphysema. A quantitative sweat
chloride test is performed on sweat obtained by iontophoresis of
pilocarpine. The results of the sweat chloride test are determined
differently depending on the age of the child.
Prevention
CF is currently not preventable. In families with a known history of
CF, identification of carriers may assist the parents in family planning
decisions.
Collaborative Care
NURSING CARE
The goal of treatment is to ensure respiratory function, enhance
nutrition, promote growth and development, and encourage
independence in an individual child and family. The potential for the
complications related to respiratory
infection and malnutrition can be reduced or prevented by
instructing the parents on proper nutrition, medication compliance,
good hand washing, and avoiding contact with persons with
respiratory infections.
MEDICAL CARE
Airway clearance and antibiotic use are the key treatment
modalities for lung disease related to CF. Ensuring respiratory
function in children entails controlling infection and improving
aeration. These care measures are achieved via medicated aerosol
therapy, chest physiotherapy (CPT; percussion and postural
drainage), and antibiotic therapy (Fig. 15-4). Some children with CF
have a central venous access device for frequent antibiotic
administration. Evidence-based medications routinely used in the
treatment of CF include inhaled mucolytic agents, recombinant
human DNAse (Pulmozyme), inhaled hypertonic saline, and
medication for chronic pseudomonas infections, which include
inhaled tobramycin (TOBI) and oral azithromycin (Baird et al, 2019).
Most children with CF have a complete loss of pancreatic function
and inadequate digestion of fats and protein; therefore, replacing
pancreatic enzymes is an important aspect of management. Enzyme
replacement is administered with meals and snacks, so the digestive
enzymes are mixed with food in the duodenum.
Optimizing Outcomes
Nutrition With CF
The best outcome for a child with CF is a well-balanced, high-protein, high-
caloric diet. Pancreatic insufficiency results in malabsorption of fat-soluble
vitamins (vitamins A, D, E, and K). Daily vitamin supplementation is
recommended. The nurse can also work closely with family to prevent infection
as well as optimize nutrition and growth of a child.
FIGURE 15-4 Chest physiotherapy is performed to loosen and

remove lung secretions. Percussion and vibration are used over the
affected areas of the lungs.
It is essential that the nurse teach parents how to care for their child
at home. After the diagnosed and acute phase of illness, the family is
prepared for home management and assists in promoting child
growth and development with limitations.
■ Teach the family about the nature of the disease and prepare them
to manage day-to-day minor complaints.
■ Assist the family in arranging for the portable suction machine and
about the proper suctioning technique at home.
■ Instruct the family to do the respiratory therapy before a meal
because CPT may induce vomiting of thick mucus.
■ Teach the family different techniques used for CPT and postural
drainage and coughing exercises based on the child’s age. The
child needs to be suctioned, followed by CPT and inhalation to
liquefy the thick secretions.
■ Teach the family about preferred meal plans, high-caloric diet, and
mixing pancreatic enzyme with meals.
■ Instruct the family to monitor the child’s weight to ensure proper
growth patterns.
■ Teach the family how to administer medications properly.
■ Inform the family how to access community resources and how to
contact their home health nurse.
1. Wash hands or use approved alcohol-based hand rubs, before
and after providing care. Appropriate hand hygiene helps prevent
infection outbreaks, reduces transmission of antimicrobial-
resistant organisms, and reduces overall infection rates.
2. Monitor temperature every 4 hours. Report a single temperature
greater than 101.3°F (38.5°C) or three temperatures greater than
100°F (38°C) in 24 hours to the care provider. Fever is often the
first indication of infection.
3. Observe for and report additional signs of infection such as
increased mucus production, persistent cough, tachypnea,
difficulty breathing, or cyanosis. Increased mucus production in
the airways causes obstruction and stasis of fluid, providing a rich
habitat for bacterial growth. Early detection of infection allows for
prompt and appropriate intervention.
4. Monitor and report laboratory values as ordered, such as
complete blood count with differential, serum protein, serum
albumin, and cultures. Laboratory values are correlated with the
child’s history and physical examination to provide a global view
of the patient’s immune function and nutritional status.
5. Encourage fluid intake and a high-calorie balanced diet,
emphasizing proteins, fatty acids, and vitamins. Nutrients
benefiting the immune system include essential amino acids,
linoleic acid, vitamin A, folic acid, vitamin B6, vitamin B12, vitamin
C, vitamin E, Zn, Cu, Fe, and Se. Efficient immune function may
be affected by deficiencies in one or more of these nutrients.
6. Instruct the child and parents on principles of medication
management: prophylactic antibiotics, medicated aerosol therapy,
CPT, and deep breathing and cardiovascular exercise. Instruction
empowers the child and family to manage care. Medicated
aerosol therapy, CPT, and deep breathing exercises help reduce
atelectasis and risk for infection and promote healing.
7. Encourage use of community resources, such as the Cystic
Fibrosis Foundation. The use of community resources may help
support the family to find ways to prevent infection and increase
the possibility of a positive adjustment to the condition.
The nurse must help the parents understand that caring for a child
with CF can be challenging. There are sufficient resources and help
lines that can assist parents, and the nurse uses these resources to
provide adequate health education to parents and older children.
UPPER AIRWAY DISORDERS

Rhinosinusitis
Sinuses are hollow air spaces in the human body. In relation to the
respiratory system, each sinus cavity has an opening into the nose
for free exchange of air and mucus and is joined with the nasal
passages by a continuous mucous membrane lining. The maxillary
(behind the cheek) and ethmoid (between the eyes) sinuses are
small but present at birth. The sphenoid sinuses, located behind the
ethmoid sinuses, begin to develop in the first 2 years of life but are
not fully visible on radiograph until about 6 years of age; they reach
their permanent size by about age 12. The frontal sinuses are
located between the lamina of the frontal bone and begin to develop
around 7 years of age. The child’s sinus cavities are not fully
developed until 20 years of age, which makes the child vulnerable to
sinus infection (Burns & Dunn, 2020).
Normally, mucus collects in the sinuses and drains into the nasal
passages. When children have a cold or an allergy attack, the
sinuses become inflamed and drainage is difficult. In addition, air is
trapped within the already blocked sinus along with pus or other
secretions. This inflammation and accumulation of secretions can
lead to congestion and infection. There is usually accompanying
facial pain, headache, and fever. Approximately 5% to 10% of upper
respiratory tract infections become complicated with the
development of acute sinusitis.
Signs and Symptoms

The nurse observes for the following signs and symptoms that
indicate rhinosinusitis:
■ A cold lasting more than 10 to 14 days, sometimes with low-grade
fever
■ Cough that is worse at night because of sinus drainage
■ Fever
■ Facial pain (may or may not be present)
■ Eyelid edema (when the ethmoid sinuses are involved)
■ Thick yellow-green nasal discharge
■ Postnasal drip leading to sore throat, cough, bad breath, nausea,
and vomiting
■ Headaches (usually not before age 6)
■ Maxillary or dental pain
■ Decreased ability to smell (hyposmia)
■ Ear pressure or fullness
■ Irritability and fatigue
■ Poor appetite
Diagnosis
Rhinosinusitis is difficult to diagnose in children because respiratory
infections are more frequent during childhood. When the child comes
to the health-care facility, diagnosis of acute rhinosinusitis is
determined by a physical examination and the presence of purulent
nasal discharge, nasal obstruction, and facial pain, pressure, or
fullness with symptoms from 10 to 30 days (Burns & Dunn, 2020).
Prevention
Prevention of rhinosinusitis includes instructing the parents on
allergy management, measures to relieve nasal airway obstructions,
and attention to persistent nasal discharge.
Collaborative Care
NURSING CARE
The nurse’s primary responsibilities in caring for the child with
rhinosinusitis include assessment, medication administration,
providing comfort measures, and providing instructions to the
parents.
MEDICAL CARE
Medical management for uncomplicated bacterial rhinosinusitis
includes a prescription of antibiotics with Amoxicillin (Amoxil)
generally considered the first line of treatment. Saline irrigation via a
nasal spray or irrigator may thin secretions with acute or chronic
rhinosinusitis. Acetaminophen (Children’s Tylenol) and ibuprofen
(Children’s Advil) may be used for pain relief. A cool-mist humidifier
and oral fluids can relieve dry mucous membranes associated with
mouth breathing.
The nurse teaches the child and parents the importance of
supportive care including the use of saline nasal sprays, adequate
oral fluids, and cool-mist humidifiers to help relieve sinus discomfort.
Parents also need to be instructed on the importance of completing
the full course of antibiotic therapy to treat the cause of the bacterial
infection.
Pharyngitis
Pharyngitis is an inflammation of the mucosa of the pharynx that
frequently results in sore throat. It occurs most commonly in winter
and is spread by close contact. The incidence is high among children
and declines in late adolescence and adulthood. Most sore throats
are viral in nature, most commonly caused by adenovirus. About a
quarter of cases of pharyngitis are caused by group A beta-hemolytic
streptococci (GABHS).
Pharyngitis can either be a short illness with no symptoms or
result in severe, life-threatening illness. In cases of the latter, the
causative agent is group A beta-hemolytic streptococci, which may
lead to acute rheumatic fever, scarlet fever, or acute
glomerulonephritis. Colonization of the pharynx by GABHS may
produce either asymptomatic or acute infection. The M protein is the
major virulence factor of GABHS and facilitates resistance to
phagocytosis by polymorphonuclear neutrophils. Type-specific
immunity develops during infection and provides protective immunity
to subsequent infection with that particular M serotype.
Signs and Symptoms

■ Often an abrupt onset
■ Fever
■ Sore throat
■ Difficulty swallowing
■ Headache
■ Abdominal pain
■ Inflamed, red, and enlarged pharynx and tonsils, often covered
with exudates
■ Anterior cervical lymphadenopathy
■ The presence of petechiae on the palate; a fine, red, sandpaper-
like rash on the trunk or abdomen; and a strawberry tongue are
common findings with a group A streptococcus infection
Viral pharyngitis is usually self-limiting, with symptoms subsiding in
3 to 5 days unless superimposed by sinusitis or parapharyngeal or
peritonsillar abscess.
Diagnosis
Throat culture remains a good way to diagnose streptococcal
pharyngitis (Fig. 15-5). A false-positive culture can occur if other
organisms are misidentified as GABHS, and children who are
streptococcal carriers may have positive cultures. False-negative
cultures are attributed to a variety of causes, including an inadequate
throat swab specimen and a patient’s covert use of antibiotics
(Smith, 2020). Diagnostic test kits with rapid identification of GABHS
are available for use at the office or clinic settings. These rapid tests
have high specificity. Therefore, a positive result generally does not
need a throat culture confirmation. The throat culture does give
information about susceptibility of the organism to specific
antibiotics.
Medical Care?
Viral pharyngitis is generally treated with supportive care as needed,
which includes pain and fever relief with acetaminophen or
ibuprofen. Most untreated cases of streptococcal pharyngitis resolve
in a few days. The objective of antibiotic therapy is to hasten clinical
recovery and prevent acute rheumatic fever. Antibiotics may be
started immediately without culture. Oral penicillin is the prescribed
treatment of choice. Oral penicillin is inexpensive and is given two or
three times a day for 10 days. Oral amoxicillin (Amoxil) is suitable for
children because it is available as chewy tablets or as a suspension.
Oral erythromycin (Erythrocin) is indicated in children allergic to
penicillin.
FIGURE 15-5 Use a long, sterile cotton swab to swab a culture from
the back of the child’s throat.
For children who are cared for at home, it is important that the nurse
instruct the parents to give the full dose of the antibiotic prescribed
even after the child shows signs of improvement. This is a very
important aspect in the management of pharyngitis to prevent
valvular damage of the heart. Instruct parents on methods used to
provide pain and fever relief, such as administering acetaminophen
(Children’s Tylenol) or ibuprofen (Children’s Advil) and use of a cool-
mist humidifier.
Tonsillitis
Inflammation of the tonsils often occurs with pharyngitis, which may
lead to the diagnosis of tonsillitis or tonsillopharyngitis. Tonsillitis is
an inflammation of the tonsils, which are masses of lymphoid tissue
located within the pharynx. Tonsils protect the respiratory and
alimentary tracts from infection by inducing secretory immunity and
regulating the production of secretory immunoglobulin. Tonsils
normally enlarge progressively between 2 and 10 years of age and
reduce progressively during preadolescence, so tonsils of children
larger than those of adults. Nearly all children in the United States
experience at least one episode of tonsillitis. Viruses and group A
beta-hemolytic streptococcus are the most common cause of
infection in tonsillitis.
Surgical Care
Tonsillectomy (surgical removal of the tonsils) is used for recurrent
or chronic tonsillitis. The American Academy of Otolaryngology and
Head and Neck Surgery suggests the occurrence of three or more
treated infections per year as sufficient to necessitate a surgical
intervention. Surgery is performed 6 weeks after an acute infection
has been resolved.
After the surgery, children are kept on their side to facilitate
drainage of secretions. Providing comfort and reducing activities that
may aggravate bleeding are the priorities. Coughing, clearing the
throat, and blowing the nose are to be avoided. Secretions and
vomitus are checked for fresh blood. Because the throat is sore after
surgery, the nurse can apply ice packs and an ice collar to provide
relief. Food and fluids are offered when the child is alert, initially cool
water, crushed ice, and flavored ice pops. However, redor brown-
colored fluids are not given so the nurse is able to distinguish the
drainage, which might be fresh or old blood. As the child begins to
tolerate food, items such as gelatin, cooked fruit, sherbet, soup, and
mashed potatoes are offered. Foods to avoid include milk, ice
cream, and pudding because they coat the mouth and throat and
cause the child to clear the throat, which may cause bleeding.
The nurse should teach the parents to:
■ Keep the child away from highly seasoned food and “sharp” foods
(e.g., nacho chips) for a period of 2 weeks. The scab is most likely
to be dislodged at 8 to 12 days.
■ Have the child avoid gargling and vigorous tooth brushing.
■ Instruct the child that he or she should not cough or clear the
throat.
■ Limit the child’s activities that may result in bleeding.
FOCUS ON SAFETY
Signs of Bleeding After Tonsillectomy
When the nurse is caring for a post-tonsillectomy child, if the child is
continuously swallowing, this indicates bleeding. Additional signs include
restlessness, increased pulse rate, and pallor (late symptom). This is
considered a medical emergency and the nurse should direct the patient to the
ED for management.
Croup
Croup is a generic term encompassing a heterogeneous group of
illnesses affecting the larynx, trachea, and bronchi. The lateral walls
of the trachea below the level of the vocal cords are marked by
swelling and erythema. Croup is described according to the main
anatomical area affected. Epiglottitis, supraglottitis, laryngitis,
laryngotracheobronchitis, and bacterial tracheitis encompass croup
syndrome. Croup commonly affects children between 3 months and
5 years of age, most often around age 2. The incidence is higher in
boys, and it is most frequent during the winter months. The incidence
of epiglottitis has dramatically decreased since the introduction of the
Hib vaccine in the late 1980s.
Viral agents, particularly the parainfluenza viruses (types 1, 2, and
3), and RSV are the most common cause of croup and account for
the majority of cases. Streptococcus pyogenes, S pneumoniae, and
Staphylococcus aureus are the common causes of epiglottitis while
Haemophilus influenzae, S aureus, and Corynebacterium
diphtheriae are involved in bacterial tracheitis.
Signs and Symptoms

The symptoms of croup can be explained in terms of the child’s
anatomical structure. The subglottic region of the larynx is held
within the rigid ring of the cricoid cartilage. Symptoms are related to
the extent of upper airway involvement and the infectious agent
responsible for the croup. Croup can lead to obstruction because
children have a narrow larynx, such that a decrease in airway
diameter causes a decrease in airflow, leading to the symptoms of
croup.
Acute laryngotracheitis is characterized by these signs and
symptoms:
■ Usually viral (parainfluenza, adenovirus, RSV)
■ Peak age is 3 to 36 months
■ Gradual, acute onset during the night
■ URI symptom
■ Seal-bark cough
■ Mild to moderate dyspnea
■ Symptoms worse at night
■ Low-grade fever
■ Respiratory rate less than 50
Spasmodic croup typically has these manifestations:
■ Usually viral
■ Generally no preceding illness, though may have coryza
■ Sudden onset, often at night Fever variable
■ Barky cough
■ Hoarseness
Epiglottitis displays the following characteristics:
■ Peak age is 1 to 5 years
■ Rapid onset
■ Sore throat
■ Dysphagia
■ Anxiety related to inspiratory distress
■ Drooling
■ Muffled speech
■ Toxic appearance
■ Tripod positioning
■ Marked distress
■ High fever ranging from 101.8°F to 104°F (38.8°C to 40°C)
Croup is characterized by these findings:
■ Usually caused by Staphylococcus aureus (Smith, 2020)
■ Acute onset
■ Hoarseness
■ Barky cough
■ Inspiratory stridor
■ Toxic appearance
■ Purulent sputum
■ Marked distress
■ High fever 102.2°F (39°C)
Bacterial tracheitis symptoms include the following:
■ Considered a bacterial complication of a viral disease
■ Can lead to a life-threatening airway obstruction severe enough to
cause respiratory arrest
■ Preceded by upper respiratory tract infection
■ “Croupy” cough
■ Stridor unaffected by position
■ Toxic appearing
■ High fever
■ Stridor
■ Hoarseness
■ Dyspnea
■ Retractions and nasal flaring
■ Thick purulent tracheal secretions
Laryngitis typically has these characteristics:
■ More common in older children
■ Usually caused by a virus
■ Hoarseness
■ May have upper respiratory symptoms including coryza, sore
throat, and nasal congestion
■ Malaise
■ Low-grade fever
■ Headache
■ Myalgia
Medical Management
Corticosteroids are the mainstay of therapy for croup, regardless of
clinical severity. A single dose of dexamethasone (0.15 to 0.60 mg
per kg usually given orally) is recommended in all patients with
croup, including those with mild disease. Nebulized epinephrine is an
accepted treatment in patients with moderate to severe croup (AAFP,
2020). Dexamethasone and inhaled budesonide relieve croup
symptoms as early as 3 hours after treatment. Based on historical
data, nebulized adrenaline in children with severe croup substantially
reduces the number requiring an artificial airway. Adrenaline reduces
respiratory distress within 10 minutes of administration and lasts
longer than 1 hour.
Acute Epiglottitis
Acute epiglottitis or supraglottitis is a medical emergency presenting
as a sudden, potentially lethal condition characterized by high fever,
sore throat, dyspnea, and rapidly progressing respiratory obstruction.
Acute epiglottitis is a serious obstructive inflammatory condition that
requires immediate attention.
NURSING INSIGHT
Indications of Epiglottis
A common scenario is that the child goes to bed asymptomatic and awakens
with complaints of sore throat and pain or swelling accompanied by a febrile
state. The classic sign of acute epiglottitis is when the child sits upright in a
tripod position with the chin thrust out (sniff position). The child’s mouth is
open with drooling, a protruding tongue, and dysphagia. The child is irritable
and restless with a thick and muffled voice and frog-like croaking sound on
inspiration. Suprasternal and substernal retractions may be visible. The nurse
notes that the child breathes slowly, the throat is red and inflamed, and displays
a distinctive large, cherry-red, edematous epiglottis.
FOCUS ON SAFETY
Hospitalization
Symptoms that warrant hospitalization are progressive stridor, severe stridor
at rest, respiratory distress, hypoxia, cyanosis, inability to maintain an
adequate SpO2 oxygenation on room air and depressed mental status
(confusion, altered levels of consciousness, etc.).
Diagnosis
Diagnosis of croup is based on the signs and symptoms along with
history, and treatment takes priority over testing because of the
severity of respiratory distress. Soft tissue imaging of the neck and
chest demonstrates the classic presentation of subglottic narrowing
or the “steeple sign.” When epiglottitis is suspected, blood cultures
are ordered to identify the causative organism. A radiograph of the
lateral neck may present with the “thumb sign,” which describes the
x-ray appearance of the epiglottis. The diagnosis of a bacterial cause
for croup, such as in the case of bacterial tracheitis and
laryngotracheobronchitis (LTB), can be confirmed by an elevated
white blood cell count, which includes leukocytosis with a left shift.
Bacterial tracheitis can be differentiated from epiglottitis by a slower
onset, the absence of the thumb sign, and classic symptoms
presented in epiglottitis.
Prevention
Routine immunization with Hib provides primary prevention of
epiglottitis. Good hand washing, proper tissue disposal, and covering
the nose and mouth when coughing are effective methods of
preventing spread of infection.
FOCUS ON SAFETY
Epiglottitis
If epiglottitis is suspected, DO NOT attempt to visualize the throat with a
tongue blade because this may cause a laryngospasm leading to an
immediate airway occlusion. If the health-care provider plans to do a direct
laryngoscopy, the nurse prepares for tracheal intubation because of the
potential for an airway occlusion. The insertion of an artificial airway may
rapidly improve the child’s respiratory status.
Collaborative Care
NURSING CARE
In mild croup, a child may present with only a croupy cough and
may just require parental guidance and reassurance, given
alertness, baseline minimal respiratory distress, proper oxygenation,
and stable fluid status.
The nursing care measures for croup depend on the various
causative organisms. The most important goal in the treatment of
children with croup is maintaining the airway and providing adequate
respiratory exchange. The nurse stays at the child’s side to reduce
child and parent anxiety, observes for worsening symptoms, and
helps the child maintain a position that supports maximum airway
and respiratory exchange. Key areas of nursing responsibility include
maintaining the airway, providing rest and humidification, monitoring
fluid balance, and administering medications as prescribed. Changes
in condition are based on observations and assessment of the child’s
response to therapy, including careful observation of the child’s
response to their surroundings (changes in level of consciousness).
Urgent care or emergency department treatment of croup depends
on the patient’s degree of respiratory distress:
■ Corticosteroids. Corticosteroids are beneficial due to their anti-
inflammatory action; their use decreases both laryngeal mucosal
edema and the need for salvage nebulized epinephrine;
corticosteroids may be warranted even in those children who
present with mild symptoms.
■ Epinephrine. Patients who receive nebulized racemic epinephrine
in the emergency department should be observed for at least 3
hours after last treatment because of concerns for a return of
bronchospasm, worsening respiratory distress, and/or persistent
tachycardia; patients can be discharged home only if they
demonstrate clinical stability with good air entry, baseline
consciousness, no stridor at rest, and have received a dose of
corticosteroids.
■ Heliox. Heliox is a gas that contains a mixture of helium and
oxygen (with not less than 20% oxygen); delivery to the patient is
via nasal cannula, face mask, or hood; it has low viscosity and low
specific gravity, which allows for greater laminar airflow through the
respiratory tract; helium facilitates the movement of oxygen
through the airways and decreases the mechanical work of
respiratory muscles; this clinical response reduces respiratory
distress.
As previously mentioned, current treatment approaches for
patients with croup are corticosteroids and nebulized epinephrine;
steroids have proven beneficial in severe, moderate, and even mild
croup.
■ Corticosteroids. Steroids are thought to decrease airway edema
via their anti-inflammatory effect; corticosteroids have been shown
to reduce hospitalization rates by 86%, and in mild disease, they
have been proven to reduce the number of children returning to
the ED for further treatment.
■ Epinephrine. Epinephrine stimulates alpha receptors and beta2
receptors; it constricts the precapillary arterioles, thus decreasing
airway edema; because of the potential adverse effects of
tachycardia and hypertension, it is reserved for children with
moderate to severe disease.
MEDICAL CARE
Mild cases of croup are commonly treated with cool mist. A high-
humidity, cool air vaporizer may be used at home in the child’s room.
In the hospital setting, oxygen hoods for infants and oxygen tents for
toddlers are used. Cool mist is thought to moisten airway secretions
to facilitate clearance, soothe inflamed mucosa, and provide comfort
and reassurance to the child, thereby lessening anxiety. Nebulized
racemic epinephrine (Micronefrin or Vaponefrin) (0.25 to 0.5 mL in 3
mL of a normal saline solution) or /-epinephrine (5 mL of 1:1,000
solution) are equally effective to cause mucosal vasoconstriction and
consequently decrease subglottic edema, thus relieving the
symptoms. This treatment is indicated for those with moderate to
severe stridor at rest or when stridor does not respond to cool mist.
Observe the child after nebulization to assess the airway and side
effects of the delivered medication.
Corticosteroids are also given to children to decrease the edema
in the laryngeal mucosa through their anti-inflammatory action. IM
dexamethasone (Decadron) and nebulized budesonide (Pulmicort)
are widely used.
Antibiotic therapy is indicated for epiglottitis and bacterial
tracheitis. Combinations of ampicillin and sulbactam (Unasyn) are
the drugs most often prescribed. Antibiotics are not used in the
management of viral croup.
Parents are instructed on the use of cool-mist humidification, as well
as the use of a steamy bathroom to help modify respiratory
symptoms. If the child has been hospitalized and discharged on
medications, the parents also need information about the importance
of compliance and the proper administration and dosage of
medications. Parents are also instructed on symptoms of potential
side effects of the medications and the symptoms of a worsening
condition (e.g., specifically increased signs of respiratory distress,
restlessness, and confusion).
LOWER AIRWAY DISORDERS

Bronchitis
Bronchitis is a nonspecific bronchial condition in which the bronchial
tubes are inflamed. It is unusual for children to be diagnosed with
bronchitis alone; other associated upper and/or lower respiratory
tract conditions are likely to be involved because of the proximity of
the respiratory tract structures. Tracheobronchitis is a more common
term used when the trachea is prominently involved.
Bronchitis may be acute or chronic. Acute bronchitis is commonly
preceded by a viral upper respiratory tract infection and may last for
1 to 3 weeks. The incidence of acute bronchitis is highest during the
winter months. Children are usually affected in their first 4 years of
life. Chronic bronchitis lasts for months or years and is more
common among adults, particularly smokers. The incidence of
chronic bronchitis in children is also more often associated with
cigarette smoking or the presence of secondhand smoke, as well as
with the presence of another chronic condition such as allergies,
asthma, or CF.
Viruses are usually the causative organism. The tracheobronchial
epithelium is invaded by the infectious agent, and this leads to
activation of inflammatory cells and release of cytokines, giving way
to the occurrence of symptoms. If the tracheobronchial epithelium
becomes significantly damaged or hypersensitized, then a protracted
cough may last for 1 to 3 weeks.
Signs and Symptoms

■ Dry, hacking cough that becomes more productive and purulent
over time and worsens at night
■ Rhinorrhea occurring 3 to 4 days after onset of a cough
■ Signs of nasopharyngeal infection and conjunctivitis
■ Coarse breath sounds, rhonchi, and coarse, changing rales
■ Low-grade or no fever
■ Low substernal discomfort or burning in the chest
■ A productive cough lasting more than 3 months with chronic
bronchitis
Diagnosis
Because a virus is usually the causative organism, bronchitis is
diagnosed based on the child’s symptoms. In children older than 6,
M pneumoniae is a common cause, and bronchitis can be
determined by the identification of this bacterium.
Prevention
Good hand washing, covering the nose and mouth when coughing,
and care in avoiding touching eyes and nose can help prevent the
spread of the organisms that cause bronchitis. Instruct parents on
the avoidance of secondhand smoke, dust exposure, known
allergens, air pollution, crowded places during flu seasons, and
contact with persons known to have bronchitis.
Collaborative Care
NURSING CARE
Nursing care is generally directed toward providing supportive
care and adequate air exchange. To provide oxygenation, the nurse
must ensure that the airway is open and free of obstruction. The
airway can be opened by administering prescribed bronchodilators.
The nurse encourages the child to clear the airway from secretions
by coughing. Use of a cool-mist humidifier at the bedside may help
liquefy secretions, which promotes expectoration when coughing.
Secretions are disposed of in sealed plastic bags.
MEDICAL CARE
For acute bronchitis, care is primarily supportive. Symptom relief
may include use of antipyretics, analgesics, and humidity. Cough
suppressants are administered with caution because they interfere
with clearance of secretions. The condition is self-limiting, and
antibiotics, though often prescribed, do not hasten improvement in
uncomplicated cases. The treatment for chronic bronchitis depends
on the cause or underlying condition.
Home care may include instructing the parents on using a cool-mist
humidifier, providing sufficient fluids and nutrition, and encouraging
the child to expectorate secretions. Parents are instructed to avoid
exposing the child to secondhand smoke, environmental pollutants,
and known allergens.
Bronchiolitis and Respiratory Syncytial Virus (RSV)

Bronchiolitis is an inflammation of the bronchioles and small bronchi.
Bronchiolitis causes lower respiratory tract obstruction because of
inflammation and edema, which may lead to bronchospasms.
Bronchiolitis is usually caused by viral pathogens, such as RSV,
adenovirus, and parainfluenza virus (types 1, 2, and 3), among
others. Respiratory syncytial (sin-SISH-uhl) virus, or RSV, is a
common respiratory virus that usually causes mild, cold-like
symptoms. Most people recover in a week or two, but RSV can be
serious, especially for infants. In fact, RSV is the most common
cause of bronchiolitis (inflammation of the small airways in the lung)
and pneumonia (infection of the lungs) in children younger than 1
year of age in the United States (CDC, 2020). By the age of 2, nearly
every child has been exposed to the virus.
RSV peaks in the winter, generally beginning as early as
September or October and continuing through April or May.
Bronchiolitis is common among children age 2 years and younger.
Nearly 80% of the cases of bronchiolitis occur in children younger
than 1 year of age. Bronchiolitis is highly contagious and spreads by
direct contact with respiratory secretions or from particles on
contaminated objects. Bronchiolitis is easily spread from hand to
eye, nose, and mucous membranes.
The peak period for a child to acquire RSV is December through
March. RSV most often begins as an infection in the nasal epithelial
cells. The RSV virus then replicates in the host cell. The host cell is
destroyed, and virus particles are released to propagate the
infection. The infection results in the destruction of the epithelial cells
of the respiratory tract. Exposure to RSV triggers a humoral immune
response. Primary RSV infection results in only a weak antibody
response with IgM, IgG, and IgA produced. This response is not
enough to destroy the virus completely or to prevent upper
respiratory tract replication of the virus. Consequently, an upper
respiratory tract illness develops. High levels of neutralizing
antibodies are required to prevent the progression of infection from
the upper respiratory tract to the lower respiratory tract.
Signs and Symptoms

■ Upper respiratory infection (URI) symptoms of cough, coryza, and
rhinorrhea lasting 3 to 7 days
■ Respiratory distress marked by noisy, raspy breathing and
cyanosis
■ Audible wheezing
■ Retractions
■ Rales and prolonged expiratory phase of respirations
■ Tachypnea
■ Low to moderate fever up to 102°F (38.9°C)
■ Decreased appetite and poor feeding
■ Pharyngitis
■ Depending on the duration of symptoms and oral intake,
dehydration may be manifested by poor tearing, dry mucous
membranes, and poor skin turgor
■ Thick mucus, exudate, and mucosal edema obstruct the smaller
airways (bronchioles) leading to a reduction in expiration, air
trapping, and hyperinflation of the alveoli
■ The obstruction interferes with gas exchange, possibly leading to
hypoxemia (decreased oxygen) and hypercapnia (increased
carbon dioxide in the blood), which in turn leads to respiratory
acidosis
■ May be accompanied by otitis media and conjunctivitis
■ May result in hospitalization
Diagnosis
Positive identification of RSV is accomplished from nasal secretions
or nasopharyngeal washings. These are tested for the virus or for
the antibodies the virus makes.
Prevention
Proper hand washing, reducing exposures to and transmission of
RSV, and avoiding secondhand smoke are the best means of
prevention. The monoclonal antibody palivizumab (Synagis) is given
IM to high-risk infants and shown to be effective in reducing the
complications of RSV, hospitalization, and associated morbidities as
prophylaxis for high-risk infants.
Collaborative Care
NURSING CARE
RSV is treated symptomatically through maintenance of hydration,
fever control, oxygenation, and keeping the mucous membranes
clear of mucus. Children may be managed at home. Hospitalization
is recommended for children who have some other underlying illness
or are in a debilitated state. In the hospital, nursing care includes
head elevation of 30 to 40 degrees, oxygen saturation monitoring,
and cool-mist therapy combined with oxygen administered by hood
or tent in concentrations sufficient to alleviate dyspnea and hypoxia.
The nurse administers IV fluids until the child shows signs of
improvements.
Strict isolation is required for patients infected with RSV virus
because it is easily spread from hand to eyes or nose and other
mucous membranes. The nurse emphasizes hand washing and that
contact precautions such as the use of gown, gloves, and masks are
required (Fig. 15-6). Parents need to know that the first 24 to 72
hours is the critical time and in most cases children recover
completely.
FIGURE 15-6 When a child has respiratory syncytial virus, contact
precautions, such as the use of gowns, gloves, and masks, are
required.
MEDICAL CARE
The clinical goal is to return the child to a normal respiratory
status. Medical therapy is aimed at relief of respiratory distress,
improvement in oxygenation, and alleviation of airway obstruction.
Educate parents on the importance of watching for signs of
worsening conditions, such as signs of respiratory distress and
dehydration, and on when to seek care. Instruct parents on the use
of cool-mist humidification, providing fluids, and fever control.
Parents can be instructed to manage rhinitis with saline drops and
nasal suctioning.
Pneumonia
Pneumonia is a lower respiratory tract infection of the pulmonary
parenchyma. It is more common in infancy and early childhood and
may occur as a primary infection or secondary to another illness or
infection. Pneumonias are classified as lobar, bronchopneumonia,
and interstitial. Lobar pneumonia involves lobes of the lungs. Viral
pneumonia, a more common form, involves RSV infection in infants
and parainfluenza and adenoviruses in older children, whereas
Streptococcus pneumoniae is the common pathogen causing
bacterial pneumonia. Viral pneumonia accounts for 45% of
pneumonia cases (Redjal, 2020). A viral infection can have a
secondary bacterial infection 6 to 8 days after initial onset because
of viral insult of protective mechanisms.
Aspiration pneumonia may occur as a result of aspiration of
foreign material into the lower respiratory tract.
Collaborative Care
NURSING CARE?
Nursing care is primarily directed toward providing supportive care
and educating the family about the illness and management.
Supportive care includes ensuring adequate hydration, which will
help in thinning secretions. Oxygen administration via nasal cannula
with cool mist, CPT, and postural drainage are initiated for patients
requiring hospitalization. Supplemental oxygen may be necessary
with children experiencing significant respiratory distress and who
would be easily fatigued by activities. IV fluids help prevent
dehydration. Elevating the head of the bed will promote improved air
exchange of the lungs.
Labs
Sputum Culture and Sensitivity
To establish the causative organism and the most effective and appropriate
antibiotic, culture and sensitivity tests of the sputum are performed. Coughed-
out sputum is difficult to obtain from children, especially those who are very
young. A specimen may be obtained via a direct throat swab immediately after
coughing. In some cases, a sterile catheter may be inserted directly into the
trachea through the ET tube or during direct laryngoscopy. During sleep,
children usually swallow their sputum; therefore, an early morning fasting
specimen obtained via gastric aspiration may also be obtained. The gastric
content can be collected before breakfast by inserting the naso-oral tube into
the stomach.
The nurse must place the specimen in the appropriate container and
properly label it with the patient’s name, the nature of the specimen, date and
time collected, and the examination desired. Ideally, the specimen must be
sent immediately to the laboratory. If this is not feasible, the specimen is kept
in a refrigerator until it is taken to the laboratory. Results of the test may be
reported in 2 or more days.
Nursing care measures such as changing the child’s clothes and

linen take place frequently to prevent chills. Positioning the child on
the affected side naturally splints the chest and reduces pleural
rubbing that causes discomfort. Assess the child’s sputum for color,
amount, and consistency. The sputum assessment must be recorded
in the child’s record.
To detect any change in condition, assess vital signs and breath
sounds. Also assist the child and the parents in alleviating anxieties
through continuous emotional support and reassurance.
MEDICAL CARE
Most cases of pneumonia can be treated at home with rest and
fluids and symptomatic management with analgesics and
antipyretics. Antibiotics are given for bacterial pneumonia and not for
viral pneumonia. If antibiotics are given, the drugs may range from
amoxicillin (Amoxil) to the third generation cephalosporins,
depending on the severity of the condition. Bronchodilators also
might be used. Analgesics may reduce the pain associated with
coughing.
Treatment of a child with pneumonia is supportive depending on the
severity of the symptoms. Education includes instructing the parents
on the importance of adhering to the prescribed antibiotic regimen.
Parents of infants may need to be instructed to continue frequent,
small feedings because the child may tire easily. Inform the parents
that complete recovery from pneumonia may occur in about 2
weeks. Even if the child is feeling better after treatment, gradual
return to normal activities like school and play are encouraged.
INFECTIOUS CONDITIONS
Pertussis
The causative organism of pertussis is Bordetella pertussis, a gram-
negative coccobacillus. The disease is spread via droplet infection
and direct contact with discharges from respiratory mucous
membranes of an infected child. Pertussis is highly contagious;
approximately 80% to 90% of susceptible individuals exposed to the
infection develop the disease.
In this condition, B pertussis attaches to and multiplies on the
respiratory epithelium, starting in the nasopharynx and ending
primarily in the bronchi and bronchioles (John & Brady, 2012a). A
tracheal cytotoxin is produced that is responsible for the local
epithelial damage that produces the respiratory symptom.
Signs and Symptoms

Pertussis is divided into three stages: catarrhal, paroxysmal, and
convalescent stages. The classic cough of pertussis lasts from 6 to
10 weeks. Each of the stages lasts for 2 to 4 weeks. The incubation
period ranges from 6 to 21 days.
CATARRHAL STAGE
■ Lasts 1 to 2 weeks
■ URI similar to common cold
■ Mild cough, coryza, and sneezing
■ Low-grade fever less than 101°F (38.3°C)
PAROXYSMAL STAGE
■ Lasts 2 to 4 weeks
■ Fever absent or minimal
■ Persistent staccato, paroxysmal cough ending with an inspiratory
whoop
■ Cyanosis, sweating, prostration, and exhaustion from coughing
■ Coughing may be accompanied by a red face and protruding
tongue
■ Conjunctival hemorrhage and facial petechiae may occur related to
the force of the cough
■ Saliva, mucus, and tears may flow from nose, eyes, and mouth
during cough
■ Vomiting may accompany coughing
CONVALESCENT STAGE
■ Lasts 3 weeks to 6 months
■ Symptoms diminish
■ Coughing becomes less severe and paroxysms and whoops
slowly disappear
■ Cough may persist for months and is aggravated by physical
stress and respiratory irritants
Diagnosis
It is not easy to diagnose pertussis because the initial symptoms are
similar to those of other upper respiratory tract infections. The
diagnosis of pertussis is based on a history of severe coughing, with
or without a whoop, reddening of the face during coughing, and
incomplete or absent pertussis vaccination.
Blood testing will show profound lymphocytosis, usually more than
70% of the total WBC count, which often increases to 20,000 to
40,000 or even 100,000 cells/mm2. Chest radiography may show
focal atelectasis and/or peribronchial cuffing.
The criterion standard for diagnosis of pertussis is isolation of B
pertussis in a culture from a swab taken from nasopharyngeal
secretions. Polymerase chain reaction (PCR) testing to detect DNA
is also common. The CDC recommends both culture and PRC tests
if a child has a cough lasting longer than 3 weeks. Many health-care
professionals now consider serological testing with enzyme linked
immunosorbent assay (ELISA) to be the criterion testing standard.
Prevention
Primary preventive care occurs through vaccination against the
disease with DTaP. The vaccine is a combination of diphtheria,
pertussis, and tetanus toxoids. DTaP is recommended at 2, 4, 6, and
between 15 and 18 months with a booster at 4 to 6 years. A booster
is also recommended for adolescents between 11 and 12 years of
age. The vaccine has an efficacy of 70% to 90% and may not
prevent the illness entirely, but it has been shown to lessen disease
severity and duration (CDC, 2020).
Collaborative Care
NURSING CARE
The goals of nursing care include limiting the number of
paroxysms; observing the severity of cough; and maximizing
nutrition, hydration, rest, and recovery. During hospitalization, the
nurse can implement droplet precaution. This isolation technique that
decreases transmission of organisms when an infected child coughs,
sneezes, or spits (Venes, 2021). Droplet precautions are
recommended for 5 days after the commencement of therapy or 3
weeks after the onset of paroxysmal cough if no antimicrobial
therapy has been given. During hospitalization, the nurse must
vigilantly monitor the child’s vital signs and oxygen saturation.
Nursing care also centers on the child’s hydration and nutritional
status. If the child is unable to drink, an IV infusion is given. The
nurse accurately records coughing, feeding, vomiting, and weight
changes.
MEDICAL CARE
Antibiotic therapy is given to eradicate the infection, reduce
morbidity, and prevent complications. Erythromycin (Erythrocin) is
the drug of choice for pertussis. It is given at 40 to 50 mg/kg per day
(not to exceed 2 g) four times in a day for 14 days. Children allergic
to erythromycin (Erythrocin) are given trimethoprim
sulfamethoxazole (Bactrim) (Smith, 2020). Corticosteroids may be
used to reduce the severity of the illness although they could mask a
superinfection.
The nurse also instructs the parents that no special diet is required
for the child because the child is fed according to what is tolerated.
The same is true for the child’s activities. For as long as the child can
tolerate, he or she can participate in regular activities and play. The
prognosis for recovery is good for children who are well managed. It
is important for the nurse to emphasize the importance of follow-up
checks.
Pulmonary Tuberculosis
Tuberculosis (TB) is a chronic bacterial infection, usually of the
lungs, that is spread through the air. Mycobacterium tuberculosis is
its most common causative agent (Rollet-Cohen, Roux, Le
Bourgeois, et al, 2019). There was a declining rate of TB until the
mid-1980s, when outbreaks drew new attention to this disease. This
outbreak was brought about by the increase in immunosuppressed
individuals, particularly those with HIV, as well as an increase in
drug-resistant strains.
Aside from M tuberculosis, Mycobacterium bovis may also affect
children because the microorganism may be present in
unpasteurized milk or milk products. Latent TB infection occurs after
the inhalation of infective droplet nuclei of M tuberculosis. Conditions
such as lowered body resistance, HIV infection, malnutrition,
untreated upper respiratory tract infection, and other debilitating
conditions increase the chance of acquiring an active infection.
Transmission of TB is person-to-person through airborne droplet
nuclei. It rarely occurs by direct contact with infected discharge or a
contaminated fomite (any substance that adheres to and transmits
infectious material) (Redjal, 2020). Young children with TB rarely
infect other children or adults because the tubercle bacilli are sparse
in the endobronchial secretions of children and cough is often absent
or lacks the force necessary to suspend the infectious particles.
When the organism enters the lungs, a proliferation of epithelial
cells surrounds and encapsulates the multiplying bacilli to ward it off.
This process forms the typical tubercle. The extension of the primary
lesion causes progressive tissue destruction as it spreads within the
lungs. The tubercle bacilli are carried to most tissues of the body
through the blood and lymphatic vessels.
Other forms of TB are abdominal or GI tract TB, which occurs from
swallowing infected material. It may involve associated TB
peritonitis. Urogenital TB involves the kidneys. Once a person
becomes infected with the organism, progression may occur in three
different directions. The infection can heal, which occurs 90% of the
time; the person may experience a primary infection that leads to an
active case of TB; or a primary infection heals and the organism
becomes dormant, which reactivates months to years later, generally
in relation to something that causes stress or major life changes.
This occurs in approximately 10% of individuals. Once infected with
the organism, the person will have a positive tuberculin skin test
regardless of whether an active case occurred.
Signs and Symptoms

Many children with TB may be asymptomatic and do not develop
symptoms early in the infection. When symptomatic, children present
with the same clinical manifestations as adult patients, which
include:
■ Low-grade fever
■ Mild cough
■ Night sweats
■ Flu-like symptoms that resolve within a week may be observed
■ Anorexia and weight loss may follow as the disease progresses
Diagnosis
The diagnosis of TB in children is challenging because they exhibit a
variety of symptoms. Exact diagnosis of TB is based on the child’s
physical signs and symptoms, the history of exposure to TB, x-ray
films that may show evidence of M tuberculosis infection, and
laboratory cultures that may confirm the diagnosis. Early morning
gastric contents from the stomach may be helpful in diagnosing TB.
However, it takes about 4 weeks for the culture test to confirm the
diagnosis because the bacillus grows slowly on a culture medium.
Skin testing for TB is based on delayed hypersensitivity.
The test does not become positive until 3 weeks to 3 months after
the person has inhaled the organism. A positive TB skin test is an
indication for a radiographic evaluation, which may suggest, but not
confirm, the diagnosis. The positive skin test does not indicate an
active case, only that the person has become infected with the
organism. Skin testing is also not always accurate; up to 40% of
children with positive cultures have negative skin tests (Blosser et al,
2012). The accuracy may be affected by the presence of HIV,
malnutrition, viral illnesses, and poor injection technique or
interpretation error. The diagnosis is confirmed by a positive culture
of sputum or other body fluids, such as urine, gastric lavage, or
spinal fluid.
Prevention
Prevention is directed toward avoiding contact with the organism.
This includes screening populations at risk to identify and treat
infected persons, which helps avoid secondary transmission from
close contact. Health-care settings can avoid transmission through
the use of appropriate physical ventilation of air around the infected
case. Healthcare facilities should have adequate ventilation with air
exhausted to the outside via negative-pressure ventilation (Redjal,
2020). In addition, health-care providers should have annual testing.
BCG is the only available vaccine that is not routinely used in the
United States. Studies demonstrate varying degrees of protection,
ranging anywhere from no protective efficacy to 90% protection
(Redjal, 2020). Drinking pasteurized milk helps decrease
transmission of M bovis.
Collaborative Care
NURSING CARE
Nursing care is supportive and directed toward educating the
parents to adhere to the medication regime. Supportive care also
involves ensuring the patient has adequate rest, nutrition, and
hydration, as well as aiding fever reduction and avoiding exposure to
others. Most individuals receive care on an outpatient basis through
clinics, schools, or a public health setting. However, in cases of
serious infection and involvement of other organs, children may need
hospitalization. Children started with drug therapy are not contagious
and require only standard precautions. Children with no cough and
negative sputum smears may be cared for without isolation. Children
with contagious infections must be placed in isolation.
During the child’s hospitalization, the nurse must work closely with
the family and the child to ensure that optimal care is provided. The
nurse can explain the nature of disease and how children are at high
risk of getting the infection. The nurse must emphasize good hand
washing to reduce the chance of transmission from one person to
another.
During hospitalization, the nurse must assist the child in collecting
different specimens for the diagnosis, which includes sputum for
culture. Children are unable to cough properly, so sputum may be
difficult to collect from the young child.
MEDICAL CARE
Children over 2 years of age can be treated for latent TB infection
with once-weekly isoniazid-rifapentine for 12 weeks. Alternative
treatments for latent TB infection in children include 4 months of
daily rifampin or 9 months of daily isoniazid. The regimens are
equally acceptable; however, health-care providers should prescribe
the more convenient shorter regimens, when possible. Patients are
more likely to complete shorter treatment regimens.
TB disease is treated with a regimen of several anti-TB medicines
for 6 to 9 months. It is important to note that if a child stops taking
the drugs before completion, the child can become sick again. If
drugs are not taken correctly, the bacteria that are still alive may
become resistant to those drugs. TB that is resistant to drugs is
harder and more expensive to treat, and treatment lasts much longer
(up to 18 to 24 months).
The family of the child can be informed about the benefits of Direct
Observation Therapy (DOT). Nurses can discuss with the family
about the methods for giving the medicines (e.g., tablets may need
to be crushed well to facilitate its oral intake). The availability of liquid
preparation in syrup form may be explored. The nurse can tell the
family that they need to follow precautionary measures to prevent
latent infection. The nurse emphasizes regular follow-up visits and
regular intake of medications.
Influenza
Influenza, or flu, is a common infection of the respiratory system
caused by viruses. Infants and children are most vulnerable to the
influenza virus. It is estimated that children are 3 times more likely to
become ill with influenza than adults are. The American Lung
Association notes that in the United States influenza and its related
complications result in an estimated 226,000 hospitalizations and
anywhere from around 3,000 to 49,000 deaths annually, particularly
among older individuals and those with chronic medical conditions.
The disease rapidly spreads worldwide in seasonal epidemics.
Influenza is most common during the winter months.
Labs
Tuberculin Skin Test
The TST is an exact indicator whether a child has been infected with the
tubercle bacillus. The TST consists of injecting a measured amount of the
intermediate strength of 5 tuberculin units of tuberculin-purified protein
derivative intradermally to form a small wheal in the forearm. In 48 to 72
hours, a positive reaction is marked by an area of red induration (an area of
hardened tissue). Reactions are classified based on the diameter of the
induration. A reaction greater than or equal to 15 mm is considered positive in
children 4 years of age and older. A reaction of 10 mm in size are considered
positive in children younger than 4 years of age and with high risk factors,
such as underlying kidney disease, diabetes, or known contact with a health-
care worker or other person with active TB. A reaction of 5 mm of induration is
considered positive in immunocompromised patients. A reaction of less than 2
mm, without blistering, is considered a negative TST. The American Academy
of Pediatrics recommends that administration and interpretation of the TST be
performed and read by trained health-care professionals (Fig. 15-7).
Three types of virus cause influenza. Influenza types A and B are

the major influenza pathogens and cause epidemics. These viruses
mutate and create different strains. Influenza type C causes mild
symptoms and does not cause epidemics. Regular H1N1 and H3N2
are categorized under type A influenza and are included in the
seasonal flu vaccine. Type B viruses are generally not found in
humans, although they can cause illness with less severe symptoms.
Type C viruses cause mild illness in humans and are not typically
included in the seasonal flu vaccine. Influenza is spread through
droplets when an infected person coughs, sneezes, or speaks.
Indirectly, articles contaminated by nasopharyngeal secretions may
spread the infection. Infected individuals shed the virus for 1 to 2
days before symptoms appear and may continue to shed the virus in
increasing amounts for as long as 2 weeks. Influenza causes a lytic
(cellular destruction) infection of the respiratory epithelium with loss
of ciliary function, decreased mucus production, and desquamation
of the epithelial layer. These changes may permit secondary
bacterial invasion directly from the epithelium or through the middle
ear space.
Signs and Symptoms

■ Abrupt onset of fever
■ Facial flushing
■ Chills
■ Headache
■ Myalgia
■ Malaise
■ Diarrhea, nausea, and vomiting
■ Cough
■ Coryza
■ Dry or sore throat
■ Photophobia, tearing, burning, and eye pain may occur
■ Complications include severe viral pneumonia, encephalitis, and
secondary bacterial infections such as otitis media, sinusitis, or
pneumonia
■ Flu symptoms in children are similar to that of adults, except that
children have higher degrees of fever of up to 105.1°F (40.6°C)
FIGURE 15-7 Nurse is performing a tuberculin skin test.

Diagnosis
The diagnosis of flu is based on the child’s signs and symptoms and
epidemiological considerations. In the presence of a known
epidemic, a child who has symptoms of fever, malaise, and
respiratory illness may easily be diagnosed. Laboratory tests may
also isolate the virus from the nasopharynx if done early in the
course of illness. Rapid influenza diagnostic tests are available,
although they have varying degrees of sensitivity. Results may be
obtained within 15 minutes, but their routine use should be
considered based on whether the results would change the clinical
care. Nasopharyngeal swabs or aspiration taken within 72 hours of
the onset of the symptoms can isolate and confirm the virus in 2 to 6
days.
Prevention
Prevention includes frequent hand washing, covering the mouth and
nose when sneezing or coughing, properly disposing of used tissues,
and avoiding close contact with persons who may have become
infected. Influenza vaccines are now widely used for prevention.
There are two routes for the vaccines: IM and nasal spray.
Vaccination is recommended annually to populations at risk because
the flu virus is continuously changing. Current guidelines recommend
that all children ages 6 months to 18 years be immunized with 2
doses being administered during the first year of immunization. In
addition, health-care providers should receive a yearly influenza
vaccine to protect themselves and prevent spread to patients and
their families.
Collaborative Care
NURSING CARE
Because influenza is a self-limiting condition, nursing care is
supportive. Depending on the severity of influenza, the child
recovers within 1 to 2 weeks. The nurse must emphasize to the
parents the importance of adequate rest and sleep. When the child
has the flu, more fluids are offered. An electrolyte solution is
recommended. The nurse can reiterate the importance of having an
annual vaccination.
MEDICAL CARE?
In uncomplicated cases, influenza is treated symptomatically
because symptoms usually recede in 48 to 72 hours. Adequate rest
and fluid intake are important components of the regimen. For fever
and pain, acetaminophen (Children’s Tylenol) or ibuprofen
(Children’s Advil) is given. Antiviral drugs such as oseltamivir
(Tamiflu), amantadine (Symmetrel), and rimantadine (Flumadine) are
currently used to manage influenza. These medications are usually
given in the first 48 hours to decrease the severity and duration of
the illness. Antibiotics are given when there is evidence of a
superimposed bacterial infection, like prolonged fever and
deterioration of the condition.
MEDICATION: Oseltamivir (Tamiflu)

(o-sel-tam-i-vir)
Indications: Used for uncomplicated acute illness due to influenza infection in
adults and children greater than
1 year of age that have had symptoms for greater than
2 days
Prevention of influenza in patients greater than 1 year
Unlabeled Use: Treatment or prophylaxis for infection in infants less than 1
year and of patients symptomatic for 2 days with severe illness.
Actions: Inhibits the enzyme neuraminidase, which may alter virus particle
aggregation and release.
THERAPEUTIC EFFECTS: Reduced duration of flu-related symptoms.
CONTRAINDICATED IN: Hypersensitivity and children less than 1 year old.
CNS: Insomnia, vertigo, seizures, abnormal behavior, agitation, confusion,
delirium, hallucinations, nightmares
RESP: Bronchitis
GI: Nausea, vomiting
Route and Dosage:
PO:
Children greater than 88 lb (40 kg): 75 mg twice daily for 5 days
Children 50.6 to 88 lb (23–40 kg): 60 mg twice daily
Children 33 to 50.6 lb (15–23 kg): 45 mg twice daily
Children less than 33 lb (15 kg) and less than 1 year:
30 mg twice daily
1. Monitor influenza symptoms. Additional supportive treatment may be
indicated to treat symptoms. Treatment should be started as soon as
possible from the first sign of flu symptoms. Administer with food or milk to
minimize GI irritation.
2. Drug should be used within 10 days of constitution.
3. Caution patients/parents that Tamiflu should not be shared with anyone even
if they have the same symptoms.
4. Tamiflu is not a substitute for flu shots according to immunization guidelines.
5. Advise patient to consult health-care professional before taking any
medications concurrently with Tamiflu.
6. Advise patients to report behavior changes.
7. Follow dosage as indicated by the health-care provider (Vallerand & Sanoski,
2021).
Parents can be instructed to ensure adequate rest, hydration, and
nutrition as well as provide fever control as necessary. Continued
education includes a reminder of the importance of receiving the
influenza vaccine as well as frequent hand washing, covering the
mouth and nose when sneezing or coughing, properly disposing of
used tissues, and avoiding close contact with persons who may have
become infected.
Patient Education
Salicylates (Aspirin)
The nurse can instruct the parents to avoid giving salicylates (aspirin) because
of the possibility of Reye syndrome. Reye syndrome is an encephalitis-like
illness following a viral infection. Reye syndrome is highly associated with the
intake of salicylates (aspirin) during the course of the viral disease. The
symptoms include nausea, vomiting, lethargy, and indifference; in severe
cases, there may be irrational behavior, delirium, and rapid breathing. Warn
parents to watch out for these symptoms, especially if aspirin has been given to
the patient before consultation.
PULMONARY NONINFECTIOUS IRRITATION

Foreign Body Aspiration
Foreign body (FB) aspiration refers to any solid or liquid substance
that becomes caught in the respiratory tract and blocks air passage.
Young children are at greater risk of aspirating foreign bodies
because of curiosity and the habit of putting things in the mouth.
Foreign body aspiration may occur at any age, but it is most
common among toddlers. A total of 4,100 deaths from unintentional
ingestion or inhalation of food or objects occurred in 2006 (Smith,
2020). The incidence in children from ages 0 to 4 years was
0.5/100,000 population. The most frequently aspirated objects are
organic food items such as peanuts, popcorn, hot dogs, or vegetable
matter and fruit gel snacks. Nonfood objects include balloons, coins,
pen tops, and pins (Burke & Dunn, 2016).
In the child, the aspirated object may stay in the same place of
obstruction or move with air. If the child forcefully coughs, the object
may be spit out. During the presence of the FB, the bronchioles and
bronchi may become larger during inspiration and smaller during
expiration. Small objects may cause little damage, and large objects
may occlude the whole airway passage, causing more severe
symptoms. A sharp object not only blocks the airway but also may
lead to severe trauma, and the child may have complications such
as inflammation and abscess, atelectasis, and emphysema.
Signs and Symptoms

Signs and symptoms of FB aspiration vary with location.
■ Laryngeal FB
■ Rapid onset of hoarseness
■ Chronic, croupy cough
■ Aphonia (inability to speak)
■ Unilateral wheezing
■ Recurrent pneumonia
■ Tracheal FB
■ History of brassy cough
■ Hoarseness
■ Dyspnea
■ Possible cyanosis
■ Homophonic wheeze (musical and having the same sound)
■ “Audible slap and palpable thud sound produced by the
momentary expiratory effect of the FB at the subglottic level”
(Smith, 2020)
■ Bronchial FB
■ Most objects are aspirated into the right mainstem bronchus
because it is at a less acute angle than the left mainstem
bronchus
■ Initial findings similar to those seen in tracheal or laryngeal FB
aspiration
■ Blood-streaked sputum
■ Metallic taste (if metallic object was aspirated)
■ May have few initial symptoms if the object did not cause
obstruction and was nonirritating
■ Homophonic wheeze
■ Emphysema-like changes result in hyporesonance or
hyperresonance
■ Diminished breath sounds
■ Crackles, rhonchi, and wheezes
The child’s condition may worsen with total obstruction, and the
child may become cyanotic or unconscious. Delay in removal of the
FB may be fatal.
Diagnosis
The child’s history and physical signs help in the diagnosis of FB
aspiration. In children, an FB is suspected in the presence of acute
or chronic pulmonary lesions. The nurse can communicate to the
family that an x-ray examination with fluoroscopic examination can
be helpful in locating the site of the aspirated object. Definitive
diagnosis of FB aspiration is through bronchoscopic examination.
Prevention
Prevention of foreign body aspiration includes educating parents and
caregivers. Parents are instructed to avoid giving nuts, uncooked
carrots, or other foods that are broken into pieces to infants and
children before the molars have erupted. In addition, balloons,
marbles, coins, tiny toys, or toys with small pieces (e.g., button eyes
or beads) are not to be given to small children. Instruct parents to
keep toxic substances out of the reach of young children. Force
feeding is also to be avoided.
Collaborative Care
NURSING CARE
In the hospital, the nurse must closely monitor the child’s vital
signs and assess the level of consciousness. The nurse can explain
any procedures to the parents to help allay anxieties. Initially, the
child may be placed on “nothing by mouth” status, and the family is
encouraged to follow the medical regimen. The nurse can provide a
cool-mist vaporizer and administer antibiotic therapy if deemed
appropriate.
The nurse, especially in the community, plays a very important role
in foreign body aspiration because the community nurse is involved
in health care in the home setting where the accidents commonly
occur. In the community setting, the nurse must be skillful in the
Heimlich maneuver and can provide health education to parents
regarding the procedure.
MEDICAL CARE
If a large object has been swallowed, it may be difficult for the
child to remove the FB spontaneously by coughing. In this case, the
child will need instrumental assistance to remove the obstruction.
The nurse understands that delays in the treatment may lead to
swelling in the obstructed site and inflammation may set in,
hampering the removal of the object. The FB may also adhere to the
lumen of the air passage.
Medical management involves the removal of FBs from the
respiratory tract by direct laryngoscopy or bronchoscopy. The child is
hospitalized during and after the procedure for observation of
laryngeal edema and respiratory distress.
Parents can be taught about safety precautions to avoid FB
aspiration. For example, the nurse can communicate to the parents
that toys must not have small detachable parts and food should be
cut into small bits appropriate for the child’s age.
RESPIRATORY CONDITIONS RELATED TO

ALLERGENS
Allergic Rhinitis
Allergic rhinitis is an inflammation of the nasal membranes
predominantly in the child’s nose and eyes. Airborne particles of
dust, dander, or plant pollens in children who are allergic to these
substances cause allergic rhinitis. It appears alone or in combination
with a cold.
Inflammation of the mucous membranes is characterized by a
complex interaction of inflammatory mediators and is triggered by an
immunoglobulin E (IgE)-mediated response to an extrinsic protein.
Mediators are immediately released, including histamine, tryptase,
chymase, kinins, and heparin. The mast cells quickly synthesize
other mediators including leukotrienes and prostaglandin D2. These
mediators create the symptoms of rhinorrhea.
Mucous glands are stimulated, leading to an increase of
secretions produced. Vasodilation then leads to congestion and
pressure. Sensory nerves are also stimulated, leading to sneezing
and itching. This sequence happens in a matter of minutes and is
called the early phase response.
In the next 4 to 8 hours, a complex interplay of neutrophils,
eosinophils, lymphocytes, and macrophages occurs. This interaction
brings about continued inflammation, termed as the late phase
response. The phase may persist for days, and systemic effects
range from fatigue to sleepiness to malaise to generalized
weakness.
Signs and Symptoms

■ Mouth breathing, snoring, and nasal speech
■ Clear, thin, watery rhinorrhea
■ Nasal congestion and inflammation
■ Bogginess of the nasal mucous membranes—may appear pale to
purplish
■ Nasal crease—horizontal crease across the lower third of the nose
■ Itching or rubbing nose referred to as an “allergic salute”
■ Nasal stuffiness and postnasal drip
■ Sneezing
■ Congested cough or night cough
■ Itching palate, pharynx, nose, or eyes
■ Hoarseness and frequent attempts to clear the throat
■ Redness of the conjunctiva, tearing, and edema of the lid and
periorbital area
■ Allergic shiners (dark periorbital swelling)
■ Enlarged tonsils and adenoids
■ Cobblestone appearance of pharynx and/or palpebral conjunctivae
■ Fatigue
■ School performance issues related to lack of sleep
■ Dennie lines, Morgan fold, or atopic pleats—extra groove in lower
eyelid (Venes, 2021)
Diagnosis
A thorough history and physical examination of the child confirm
allergic rhinitis. A nasal smear is done to determine the number of
eosinophils in the nasal secretions. A radioallergosorbent test is
done to determine specific IgE antibodies. Skin testing is often done
to identify the specific allergen.
Prevention
The key to preventing an allergic rhinitis is in learning to avoid known
allergens. Strategies for controlling exposure include the following:
■ Avoiding exposure to tobacco smoke
■ To avoid dust mites, use pillow and mattress covers, wash bed
linens weekly in 130°F (54.4°C) water, remove stuffed animals
from the bedroom, replace bedroom curtains with blinds, remove
carpet from bedroom, and wet mop solid surface floors weekly
■ Remove pets from the home
■ Repair water leaks; reduce indoor humidity to less than 50%
■ Avoid outdoor activity when pollution, mold, and pollen levels are
high
Collaborative Care
NURSING CARE
Nursing care is primarily directed toward providing supportive care
and educating the family about the illness and management.
Supportive care includes ensuring rest, nutrition, and adequate
hydration, which will help in thinning secretions.
MEDICAL CARE
Treatment for allergic rhinitis in the child involves pharmacological
management. Pharmacological management includes short-acting
antihistamines, longer acting histamines, nasal corticosteroid sprays,
decongestants, and leukotriene inhibitors. Evidence recommends
the use of high-dose allergy shots if the allergen cannot be removed
and the child’s symptoms are hard to control. This includes regular
injections of the allergen in increasing doses, which help the body to
adjust to the allergen and prevent the severe reaction.
Education includes giving instruction on environmental control
strategies as noted under prevention. In addition, the nurse reviews
the prescribed medications with the parents and patient, giving
instructions for use in the case of inhalers or internasal sprays, as
well as reviewing dosage, common side effects, and contradictions.
Patient Education
Avoiding Allergic Triggers
Education about environmental control measures involves both the avoidance
of known allergens (substances to which the patient has IgE-mediated
sensitivity) and the avoidance of nonspecific irritants and triggers. In the clinic
setting, the nurse can explore possible allergens of the child with the parents to
obtain important information that might determine the cause of the allergic
rhinitis. Parents must understand the possible complications that allergic rhinitis
may cause. These complications range from otitis media, eustachian tube
dysfunction, and acute sinusitis to chronic sinusitis.
Asthma
Asthma is the most common chronic disease in childhood and is
characterized by the triad symptoms of bronchial smooth muscle
spasm, inflammation and edema of the bronchial mucosa, and
production and retention of thick, tenacious, pulmonary secretions
leading to airway obstruction. Asthma is the most common chronic
condition among children, currently affecting an estimated 6.7 million
children under 18 years, of which 3.5 million suffered from an
asthma attack or episode in 2016 (Szefler et al, 2019). Prevalence
and mortality rates are higher and continue to rise among minority
and inner-city children. Risk factors include environmental factors,
such as air pollutants, allergen exposure, exposure to tobacco
smoke, and strong chemical odors. Other factors include low
socioeconomic status and health-care disparities (Redjal, 2020). An
asthma episode is a series of events that result in narrowed airways.
These include swelling of the airway lining, tightening of the muscle
surrounding the airways, and increased secretion of mucus inside
the airway. The narrowed airway causes difficulty breathing and the
familiar “wheeze.” The term status asthmaticus is used to refer to
persistent and intractable asthma exacerbation in which the child
does not respond to therapy and is a medical emergency.
Genetic, environmental/extrinsic, and intrinsic factors predispose
the child to develop asthma. Although allergens play an important
role in asthma, 20% to 40% of children with asthma have no
evidence of allergic disease. Among the extrinsic factors are
allergens such as dust, pollen, animal hairs, chemical sprays,
perfumes, baby powder, molds, and foods such as nuts, chocolates,
oranges, and chicken. Conditions such as changes in weather,
pollution, and smoke may also trigger an attack. Intrinsic factors
include exercise, anxiety, strong emotions such as fear and laughter,
and infections.
When any of the factors trigger an asthma attack, the response
comes in 10 to 20 minutes. The allergen/antigen binds to the
allergen-specific immunoglobulin E (IgE) surface, causing activation
of resident airway mast cells and macrophages. Proinflammatory
mediators, such as histamine and leukotrienes, are released. They
provoke contraction of the airway’s smooth muscles, increased
mucus secretion, and vasodilation. Consequently, microvascular
leakage and exudation of plasma into the airway walls cause them to
become thickened and edematous with subsequent lumen
constriction (Smith, 2018).
Signs and Symptoms

■ Recurrent wheezing
■ Shortness of breath
■ Nonproductive cough
■ Chest tightness or pain
■ Exercise intolerance
■ Prolonged expiratory phase of respirations
■ Tachypnea
■ Retractions and nasal flaring
■ History of allergies
■ History of atopic dermatitis
■ Nasal polyps
■ History of nighttime cough
■ Family history of atopy (asthma, allergic rhinitis, or atopic
dermatitis)
Diagnosis
The asthma diagnosis for the child is based on clinical symptoms,
history, physical examination, and to a lesser extent, laboratory tests.
Diagnostic studies may include pulse oximetry to measure oxygen
saturation, blood gases to determine carbon dioxide retention and
hypoxemia, complete blood count, pulmonary function tests to assist
in determining the degree of disease, peak expiratory flow rate,
allergy testing, and chest radiography to evaluate hyperinflation and
the potential for coexisting infection (Smith, 2018).
Labs
Blood Gases
Blood gases are used to evaluate respiratory and metabolic functioning
through determining the acid-base balance of the blood by the measurement
of oxygen and carbon dioxide. Blood gases may be obtained through arterial,
venous, capillary, or cord blood. Normal values vary depending on the source.
During normal metabolic processes, oxygen is used and carbon dioxide is
produced. Various disease conditions affect the levels of each gas in different
ways. Blood gas measurements provide information that may help the primary
care provider manage metabolic or respiratory disorders. Arterial blood gases
measure the amount of dissolved oxygen and carbon dioxide present in
arterial blood and reveal the acid-base state and how well the oxygen is being
carried to the body. Common measures obtained from blood gases include
pH, which measures free H+ (hydrogen) ion concentration in the circulating
blood. The pH is regulated and the acid-base ratio maintained through the
work of the lungs and kidneys. The pH is elevated (alkaline) in respiratory or
metabolic alkalosis and decreased (acid) in the case of respiratory or
metabolic acidosis. The amount of carbon dioxide in the blood is determined
by the partial pressure of carbon dioxide (PCO2) measurement. The PCO2 is
primarily controlled by the lungs. As the CO2 level increases, the pH
decreases. The lungs also help compensate for metabolic disturbances.
HCO3– represents the bicarbonate ion. As the HCO3– level increases so also
does the pH. The amount of oxygen dissolved in the blood is measured by the
partial pressure of oxygen (PO2) measurement. The amount of oxygen bound
to hemoglobin is determined by oxygen saturation (O2Sat).
Prevention
Prevention is directed toward day-to-day management of asthma.
This includes educating the parents and child on the importance of
identifying environmental factors that trigger an attack; compliance
with medication; and how to use and clean inhalers, spacer devices,
or aerosol equipment as needed. In addition, parents and children
need to understand how to manage asthma in settings away from
home, how to recognize when there is a need to seek additional
assistance, and the importance of regular follow-up.
Collaborative Care
NURSING CARE
Nursing care for children with asthma involves assisting with relief
of symptoms and providing health education to patients and family.
Asthma attacks are frightening and stressful both for the child and
family; therefore, the nurse has a calm approach in its initial
management. Administering quick-relief medications without delay is
important (Fig. 15-8). Essential nursing interventions include giving
medications on time, liquefying secretions through adequate
hydration, positioning the child properly (head of bed elevated 30
degrees) to provide comfort, and lung expansion. The side-lying and
semiprone positions are also recommended. It is vital that the nurse
reports and records the child’s respiratory assessment and
responses to medications so that appropriate management may be
initiated immediately. The nurse can also ensure that respiratory
treatments happen in a timely manner and that ordering a prn (as
needed) treatment may be necessary.
MEDICAL CARE
Treatment consists of early relief of symptoms through drug
therapy and prevention of further attacks through allergen control,
environmental manipulation, health education, and attainment of
self-management skills. The goal is to enable the child to have as
regular a life as possible by keeping the lung function within normal
limits. The nurse provides adequate health education about the use
of a peak flow meter to help the parents increase their capacity to
care for the child.
Drug therapy depends on the level of severity of the disease.
There are two approaches to this therapy: (1) the quick-relief or
rescue medications and (2) the long-term control medications.
The U.S. Department of Health and Human Services (2017), the
National Asthma Education and Prevention Program, expert panel
give guidelines for the diagnosis and management of asthma via
revised age-related classification schemes for asthma severity (Table
15-2, Table 15-3, and Box 15-1).
FIGURE 15-8 A 3-year-old exhibiting an asthma exacerbation being
treated with an albuterol nebulizer in the Pediatric Emergency
Department.
The guidelines recommend daily anti-inflammatory agents to

control the levels of persistent asthma, with increasing doses of
medication as necessary. The use of low-dose control medications,
such as inhaled steroids, cromolyn sodium (Intal), nedocromil
(Tilade), or an antileukotriene agent such as a montelukast sodium
(Singulair) tablet is recommended for children with mild, persistent
asthma (Fig. 15-9). A higher dose of steroids with the addition of
long-acting beta antagonists may be needed for moderate and
severe persistent asthma. For quick relief of bronchospasm and for
children with asthma, short-acting inhaled beta antagonists are
recommended. For more detailed information of the guidelines visit
http://www.nhlbi.nih.gov/guidelines/asthma/index.htm.
Asthma Action Plan

The Asthma Action Plan (Fig. 15-10) is an educational
communication tool used between the health-care provider and the
patient, along with their family and caregivers, to properly manage
asthma and respond to asthma episodes. The Asthma Action Plan is
completed by the child’s primary care provider. It includes the
symptoms and management for each color zone including peak flow
measurements appropriate for each color zone. Nurses can provide
adequate instructions on how to use, interpret, and complete the
form.
A peak flow meter (Fig. 15-11), which can be purchased over the
counter, is an essential companion for the Asthma Action Plan for
children older than 6 years. The peak flow meter is a portable
handheld device that is used to measure the ability to push air out of
the lungs. To determine the child’s zone for children younger than 6
years, the symptoms alone are used. The “personal best” peak flow
is determined when the child is symptom free. A peak flow meter
package usually contains a form where peak flow readings are
recorded regularly. A personal best normal may be obtained from
measuring the patient’s own peak flow rate. Therefore, it is important
for the patient, parents, and the doctor to discuss what is considered
“normal.”
TABLE 15-2
Criteria for Classification of Asthma Severity in Children 0–4 Years of Age
SEVERITY DAY NIGHT SABA USE* LIMIT TO
SYMPTOMS AWAKENINGS ACTIVITY
Intermittent ≤ 2 days/week None None ≤ 2 times/week
Mild Persistent 3–6 days/week 1–2 >2 days/week Minor
times/month
Mod. Persistent Daily 3–4 Daily Some
times/month
Severe Several > 1 time/week Several Extremely
Persistent times/day times/day
*Short-acting beta 2 agonists (SABA), such as albuterol, does not include

prevention of exercise-induced bronchospasm (EIB).
Source: The U.S. Department of Health and Human Services (2007). National
asthma education and prevention program.
Expert panel report 3: Guidelines for the diagnosis and management of asthma;
Global Initiative for Asthma. Global strategy for asthma management and
prevention, 2020. http://www.ginasthma.org.
TABLE 15-3
Criteria for Classification of Asthma Severity in Children 5–11 Years of Age
SEVERITY DAY NIGHT SABA USE* LIMIT TO
SYMPTOMS AWAKENINGS ACTIVITY
Intermittent ≤ 2 days/week ≤ 2 ≤ 2 days/week None
times/month
Mild Persistent ≥2 days/week 3–4 ≥2 days/week Minor
but not daily times/month but not daily limitations
Mod. Persistent Daily ≥ 1 times/week Daily Some limitation
but not nightly
Severe Throughout the Often nightly Several Extremely
Persistent day times/day limited
*Use of short-acting beta 2 agonists (SABA), such as albuterol, does not include
prevention of exercise-induced bronchospasm (EIB). Source: The U.S.
Department of Health and Human Services (2007). National asthma education and
prevention program. Expert panel report 3: Guidelines for the diagnosis and
management of asthma; Global Initiative for Asthma. Global strategy for asthma
management and prevention, 2020. http://www.ginasthma.org.
BOX 15-1
Asthma Management Guidelines
Asthma management guidelines have been recently updated. The 2019 Global
Initiative for Asthma (GINA) guidelines categorize asthma severity as mild,
moderate, or severe. Severity is assessed retrospectively from the level of
treatment required to control symptoms and exacerbations, as follows:
• Mild asthma: Well-controlled with as-needed reliever medication alone or with
low-intensity controller treatment such as low-dose inhaled corticosteroids
(ICSs), leukotriene receptor antagonists, or chromones.
• Moderate asthma: Well-controlled with low-dose ICS/long-acting beta2-
agonists (LABA).
• Severe asthma: Requires high-dose ICS/LABA to prevent it from becoming
uncontrolled, or asthma that remains uncontrolled despite this treatment
(Morris, 2019).
The 2019 GINA guidelines stress the importance of distinguishing between
severe asthma and uncontrolled asthma, as the latter is a much more common
reason for persistent symptoms and exacerbations, and it may be more easily
improved. The most common problems that need to be excluded before a
diagnosis of severe asthma can be made are the following (Morris, 2019):
• Poor inhaler technique
• Poor medication adherence
• Incorrect diagnosis of asthma, with symptoms due to alternative conditions
such as upper airway dysfunction, cardiac failure, or lack of fitness
• Comorbidities and complicating conditions such as rhinosinusitis,
gastroesophageal reflux, obesity, and obstructive sleep apnea
• Ongoing exposure to sensitizing or irritant agents in the home or work
environment
Sources: Global Initiative for Asthma. Global strategy for asthma management and
prevention, 2020. http://www.ginasthma.org; Morris, M., Updated Asthma
Management Guidelines (2019).
Asthma education is critical and is directed at addressing activities
discussed in the section on prevention. The community nurse can
offer health education to families that emphasizes correctly adhering
to the treatment regimen, preventing infection, and avoiding asthma
triggers. Nurses are in the best position to provide health education
because they are in contact with the patients and the parents most of
the time.
PROCEDURE ■ Using a Peak Flow Meter
The peak flow meter is a portable handheld device that is used to measure the
child’s ability to push air out of the lungs.
PURPOSE
The purpose of a peak flow meter is to keep track of the results and help the
parents and child to learn about asthma. Keeping a daily record may also help
determine whether the child’s asthma is getting worse.
EQUIPMENT
• Peak flow meter
• Peak flow record
FOCUS ON SAFETY
Peak Flow Meter
A peak flow meter package usually contains a peak flow record where the
peak flow readings are recorded regularly.
TEACH PARENTS
Teach parents about the child’s personal best. The “personal best” peak flow is
determined when the child is symptom free. It is important for the child,
parents, and doctor to discuss what is considered “normal.” Remind parents of
the need to discuss the readings with the physician.
DOCUMENTATION
01/31/2013 0900 Peak flow meter used. Green Zone, good control; 80% of
personal best, no symptoms noted. Continues to take usual medication. N.
Kramer, RN—C. Kildare RN
FIGURE 15-9 The respiratory therapist helps the child use a metered
dose inhaler.
SARS-CoV-2 (COVID-19)
While children with COVID-19 (SARS-CoV-2) may have fewer
symptoms than adults, health-care providers caring for children
should be aware of the possibility of infection, particularly for infants
and children with underlying medical conditions. In the U.S. and
globally, fewer children (ages 0–17 years of age) have been affected
with COVID-19 than adults. While children comprise 22% of the U.S.
population, recent data show that 7.3% of all cases of COVID-19 in
the United States reported to CDC were among children (as of
August 3, 2020) (CDC, 2020). Hospitalization rates in children are
significantly lower than hospitalization rates in adults with COVID-19,
suggesting that children may have less severe illness from COVID-
19 compared with adults (CDC, 2020).
Symptoms, Diagnosis, and Severity of COVID-19 in Children

Nonrespiratory symptoms of COVID-19—such as GI symptoms
(e.g., nausea, vomiting, diarrhea), neurological symptoms (e.g.,
anosmia, ageusia, headache), or fatigue or body and muscle aches
—may appear before fever and lower respiratory tract symptoms
(e.g., cough and shortness of breath).
The incubation period of SARS-CoV-2 appears to be about the
same for children as in adults, at 2 to 14 days with an average of 6
days (CDC, 2020). Comparing trends in pediatric infections before
and after the return to in-person school and other activities may
provide additional understanding about infections in children.
Treatment
Treatment of COVID-19 in the pediatric populations is largely
supportive and strives to prevent secondary infections such as
pneumonia. In addition, while initial trials are showing promise for
Remdesivir, currently no specific drugs have been approved by the
U.S. Food and Drug Administration (FDA) for treatment of COVID-19
for children (CDC, 2020). While there is currently no FDA-approved
vaccine, under the FDA Emergency Use Authorization Act children
ages 12 and over can receive the COVID-19 vaccine.
FIGURE 15-10 Asthma Action Plan. Source: Used with permission
from American Lung Association, © 2020.
FIGURE 15-11 Peak flow meter.
SUMMARY POINTS
■ The differences between the adult and child respiratory system affect function
and subsequent respiratory conditions.
■ It is essential that the nurse has a good understanding of congenital
respiratory conditions and structural anomalies in children, along with an
understanding of signs and symptoms and prescribed treatment.
■ Nurses must provide adequate emotional support to parents whose children
have life-threatening respiratory conditions.
■ The diagnosis, signs and symptoms, and nursing care measures are
important in caring for children with respiratory conditions.
■ Nursing care for children with infectious respiratory conditions includes close
monitoring and correct treatment to prevent spread of infection.
■ Nursing care for noninfectious respiratory conditions is aimed at managing the
upper airway to prevent obstruction and further damage.
■ During health teachings, nurses emphasize to parents an awareness of the ill
effects of the different forms of air pollutants, including environmental tobacco.
■ The goal for children with asthma is to enable the child to have as normal of a
life as possible by keeping the lung functioning within normal limits. The nurse
can educate the family about the benefits of the child wearing a medical alert
bracelet.
REFERENCES
American Family Physicians (AFP). (2020). Management of Croup. Retrieved from
https://www.aafp.org/afp/2011/0501/p1067.html#:~:text=A%20single%20dose%
20of%20dexamethasone,with%20moderate%20to%20severe%20croup.
AAP Updates Recommendations for Flu Vaccine. (2020). Retrieved from
https://services.aap.org/en/news-room/news-releases/aap/2020/american-
academy-of-pediatrics-issues-2020-21-recommendations-on-preventing-
influenza
Baird, R., Lal, D. R., Ricca, R. L., et al. (2019). Management of long gap
esophageal atresia: A systematic review and evidence-based guidelines from
the APSA Outcomes and Evidence Based Practice Committee. J Pediatr Surg
54:675.
Burns, C. E., & Dunn, A. M. (2016). Environmental health issues. In C. E. Burns,
A. M. Dunn, M. A. Brady, N. B. Starr, & C. G. Blosser (Eds.), Pediatric primary
care (25th ed., pp. 1010–10729. Philadelphia: Elsevier.
CDC.gov Information for Healthcare Professionals (2020). Retrieved from
https://www.cdc.gov/flu/season/health-care-professionals.htm.
França, U. L., & McManus, M. L. (2020). An approach to consolidating pediatric
hospital beds during the COVID-19 Surge. Pediatrics, 146(2), 1–3. https://doi-
org.treadwell.idm.oclc.org/10.1542/peds.2020-1464.
Khemani, R. G., Smith, L., Lopez-Fernandez, Y. M., Kwok, J., Morzov, R., Klein, M.
J., Yehya, N., Willson, D., Kneyber, M., Lillie, J., Fernandez, A., Newth, C.,
Jouvet, P., Thomas, N. J., Pediatric Acute Respiratory Distress syndrome
Incidence and Epidemiology (PARDIE) Investigators, & Pediatric Acute Lung
Injury and Sepsis Investigators (PALISI) Network (2019). Paediatric acute
respiratory distress syndrome incidence and epidemiology (PARDIE): An
international, observational study. The Lancet. Respiratory Medicine, 7(2), 115–
128. https://doi.org/10.1016/S2213-2600(18)30344-8
Hay Jr., W. W., Levin J. M., Sondeheimer, & R. R. Deterding (Eds.), (2010).
Current diagnosis & treatment (20th ed., pp. 1201–1203). New York: McGraw
Hill.
Morris, M., Updated Asthma Management Guidelines. (2019). Retrieved from
https://emedicine.medscape.com/article/296301-guidelines#g2.
Redjal, N. (2020). Wheezing and asthma. In C. D. Berkowitz (Ed.), Berkowitz’s
pediatrics: A primary care approach (6th ed., pp. 324–331). Elk Grove, IL:
American Academy of Pediatrics.
Rollet-Cohen V., Roux A. L., Le Bourgeois M., et al. (2019) Mycobacterium bolletii
Lung Disease in Cystic Fibrosis. Chest 156:247.
Smith, S. (2018). Pharyngitis. In K. J. Marcdante, R. M. Kliegman, H. B. Jenson, &
R. E. Behrman (Eds.), Nelson essentials of pediatrics (8th ed., pp. 259–280).
Philadelphia: Elsevier.
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Commentary: Treating pediatric asthma according to guidelines. Frontiers in
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etiquette reduce the cough aerosol concentration of pseudomonas aeruginosa
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20;382(8):727-733. doi: 10.1056/NEJMoa2001017.

Davis Advantage
CHAPTER 16

Gastrointestinal Condition
CONCEPTS
Bowel elimination
Digestion
Inflammation
Abdominal pain
KEY WORDS
defecation
glycogenesis
rectal atresia
rectal stenosis
imperforate anus
pyloromyotomy
tenesmus
arthralgias
uveitis
erythema nodosum
rule of 2s
Grey Turner sign
Cullen sign
hematochezia
pica
bilious vomiting
constipation
Nissen fundoplication
biliary atresia
acanthosis nigricans
LEARNING OBJECTIVES

■ Describe the anatomy and physiology and developmental aspects of the
gastrointestinal system.
■ Examine common conditions of the gastrointestinal system.
■ Prioritize developmentally appropriate and holistic nursing care for common
conditions of the gastrointestinal system.
■ Explore diagnostic, laboratory testing, and medications for common conditions
of the gastrointestinal system.
have common gastrointestinal conditions.
PICO(T)Questions
chapter.
1. Does (I) delaying the introduction of gluten in (P) infants’ diet until at least 1
year of age (O) decrease the rate of celiac disease (C) compared with
introducing gluten earlier?
2. Is there a (O) higher incidence of (I) Crohn’s disease in (P) children who were
bottle-fed (C) compared with those who were breastfed?
INTRODUCTION
developmental aspects of the gastrointestinal (GI) system. This
chapter includes an examination of the various GI tract conditions,
diagnostic and laboratory testing included in various GI disorders,
and common therapies. Developmentally appropriate, holistic
nursing care is incorporated into the care of children with GI
disorders.

Nutrition for the Child With a GI Condition
Nursing care for the child with a GI condition should promote balanced nutrition
required for healthy growth and development. The proper treatment of failure to
thrive in childhood consists of identifying and treating the underlying illness
combined with nutritional treatment that addresses the mechanism of the
accompanying failure to thrive. The nurse should collaborate with the
nutritionist to implement an appropriate oral, enteral, or parenteral diet to
optimize caloric intake. The nurse should closely monitor the child’s height,
weight, BMI, and weight-to-length ratio observing for an upward trajectory on
the growth chart. Conditions affecting the GI tract can impair the body’s ability
to digest and absorb nutrients, resulting in failure to thrive. Failure to thrive can
pose detrimental consequences on a child’s physical growth and development.
Failure to thrive impairs the child’s ability to gain weight, grow, and fight against
infection.
GI SYSTEM
The upper portion of the GI system is responsible for nutrient intake
or ingestion: the mouth and esophagus. The tongue senses the taste
and texture of food, which initiates salivation. The salivation that
occurs in the mouth initiates the beginning of the digestive process.
The saliva releases two enzymes: amylase and ptyalin. These
enzymes begin the breakdown of complex starches into
disaccharides. The esophagus transports food to the stomach by the
process of peristalsis. In the stomach, food mixes with gastric fluids
and is then propelled into the small intestine.
The lower portion of the GI system handles the remainder of the
digestion, absorption, and metabolism processes with the assistance
of the liver and pancreas. The small intestine does most of the work
of absorption through a system of villi and folds, which increases the
absorptive surface. The small intestine further converts
disaccharides into monosaccharides. Hindrance of this process can
lead to diarrhea. The small intestine is primarily responsible for
absorption of carbohydrates, fats, proteins, minerals, and vitamins
into the systemic circulation. The duodenum forms the first portion of
the small intestine. Pancreatic and bile ducts empty in the upper
portion of the duodenum. The duodenum is followed by the jejunum,
where the majority of water, protein, carbohydrates, and vitamins are
absorbed. Fat breakdown occurs mainly in the jejunum through the
secretion of lipases by the pancreas. The lymphatic system then
absorbs fats. Proteins are converted to amino acids by the
pancreatic enzyme trypsin and are absorbed via the capillary walls of
the villi and into the systematic circulation. The last and longest
segment of the small intestine is the ileum, which absorbs bile salts,
vitamins C and B12, and chloride.
The large intestine takes care of elimination. The contents of the
small intestine enter the cecum through the ileocecal valve, which is
located in the right lower quadrant of the abdomen and forms the
beginning of the large intestine. The appendix, which is described as
a blind tube containing lymphoid tissue, is attached to the cecum.
The ascending colon rises along the right anterior portion of the
abdomen, followed by the transverse colon, which lies horizontally
across the abdomen, and then forms the descending colon along the
left lateral abdomen. The sigmoid colon follows the descending colon
into the pelvic cavity. The sigmoid colon then connects to the rectum,
where stool is stored until it is expelled through the anal canal and
through the anus. Elimination culminates in the removal of solid
waste products through defecation.
Accessory Structures
The liver, located below the right diaphragm, is the largest and
heaviest organ in the body. The liver is a vascular organ composed
of right and left hepatic lobes. The liver is responsible for
metabolizing carbohydrates, fats, and proteins and breaking down
toxic substances such as drugs. In addition, the liver stores vitamins
and iron and produces antibodies, bile, prothrombin, and fibrinogen
for coagulation.
The gallbladder, which lies within the inferior surface of the liver,
stores bile, which is produced by the liver. The bile is then secreted
into the duodenum through the cystic duct and common bile duct,
where it assists in the digestion of fats.
The pancreas can be found between the spleen and stomach in
the left upper quadrant of the abdominal cavity. The pancreas
produces pancreatic enzymes, which are excreted into the
duodenum by way of the pancreatic duct. The pancreatic enzymes
assist in the metabolism of proteins, fats, and carbohydrates. Insulin
and glucagon are also produced by the pancreas and secreted
directly into the bloodstream.
DEVELOPMENTAL ASPECTS OF THE

GASTROINTESTINAL SYSTEM
The GI system plays an essential role in a child’s growth and
development. Because the GI system is complex, the nurse must
understand the ways in which each developmental stage contributes
to the promotion of the child’s health. The infant has several
physiological mechanisms to ensure the adequate intake of
nutrients. The posterior portion of the tongue that separates the
mouth and throat is raised against the soft palate while the infant
sucks. This allows the infant to suck and breathe at same time. The
infant also has a longer posterior soft palate, which assists in
swallowing milk. In addition, the passage from mouth to pharynx is
smaller, which helps to control the amount of liquid taken in. The
nurse can teach the parents that the infant’s stomach usually
empties in 2.5 to 3 hours, so the child requires frequent feedings.
Digestion takes place in the intestines, so it is important that the
intestines function properly. The infant digestive system is immature
at birth. Enzymes such as amylase (in saliva, digests
carbohydrates), lipase (enhances fat absorption), and trypsin (which
breaks down protein into polypeptides and some amino acids) are
not at normal levels until about 4 months of age. This may be the
reason newborns experience colic. Other important differences in the
GI system of the infant include:
■ Gastric pH below adult values until 20 to 30 months
■ Increased absorption of some drugs, such as beta-lactams and
decreased absorption of others, such as phenobarbital
■ Orally administered drugs are absorbed in the small intestine
■ Proportionately larger small intestinal surface area
■ Unpredictable absorption compared with adults
■ Immature liver and pancreas until 6 months of age; for example,
the process of gluconeogenesis is not well-developed in the
newborn, which increases risk for hypoglycemia during periods of
stress
Because of these differences and immaturity of the GI system in
infants, drugs that are absorbed primarily in the stomach may be
absorbed more completely than anticipated. In the case of drugs
absorbed in the small intestine, therapeutic effect may be delayed.
Peristalsis in the neonate is irregular and may be slow.
The nurse should tell the parents that infants younger than 4
months of age do not require solid foods. Pancreatic lipase is
essential for fat and protein metabolism but is not adequately
secreted until age 1, which limits the body’s ability to absorb fats,
such as those present in cow’s milk. This information reinforces the
need to carefully introduce foods into the infant diet, limiting foods to
those specially prepared for infant digestion.
NURSING INSIGHT
Appetite and Digestion
In the newborn, bowel sounds are audible within the first few hours of life. A
newborn with a scaphoid abdomen or signs of respiratory distress is evaluated
carefully for bowel sounds and/or decreased breath sounds in the chest, which
may be evidence of congenital diaphragmatic hernia. A congenital
diaphragmatic hernia is an opening between the chest and abdominal cavities
through which abdominal organs may herniate into the chest cavity,
compromising respiratory and cardiac structures.
Breastfed infants tend to have watery stools. Formula-fed infants’ stools are
soft and sometimes “seedy.” Infants do not absorb water as rapidly as older
children. During defecation (evacuation of the bowels, feces), the infant may
appear to be straining because of immature muscle coordination (Venes,
2021).
Infants gain approximately ½ to 1 ounce of weight per day, or approximately
1.5 lb (680 g)/month. Other important growth and development milestones
include infants doubling their birth weight by 6 months and tripling it by 1 year.
By 2 years, the child’s birth weight should have quadrupled. In addition, by age
2 the child’s salivary glands reach adult size. The average toddler gains 5 to 6
lb (2.3–2.7 kg) per year. The stomach capacity increases to about 500 mL, and
the liver matures to become more efficient in vitamin storage, glycogenesis (the
formation of glycogen from glucose), and amino acid changes.
The growth of the child’s digestive system slows during the toddler years,
which leads to a reduction in caloric needs. The average toddler needs
approximately 102 kcal/kg (46 kcal/lb) as opposed to 108 kcal/kg (50 kcal/lb)
during infancy. Since the toddler characteristically has a decreased appetite
and reduced metabolic rate, the appetite may be sporadic or appear finicky.
Toddlers may also go on food jags during which they prefer only one item and
refuse other previously enjoyed foods.
The preschool-age child continues to have appetite fluctuations, with periods
of overeating or refusal to eat. Parents should continue to offer healthy food
choices and the nurse should reassure them that the child will eat when they
become hungry enough. The preschool-age child gains about 4 to 5 lb (1.8–2.3
kg) per year. By age 4 to 5, the GI system is mature enough for the child to eat
a full range of food, with stools becoming more like those of adults.
School-age children gain about 4 to 6 pounds (1.8–2.7 kg) per year. When
the child reaches the middle-school years, the GI tract has become relatively
stable. The digestive systems of the middle-school child and adolescent are
adult-size and fully functional. Stools are usually passed once per day and are
well formed. The liver and spleen enlarge during the adolescent growth spurt
but do not change in function.
Patient Education
Dealing With Food Fads or Jags With Young Children
TOPIC: The nurse will promote good nutrition in children
• Reassure the parents that food fads or jags are normal at this age and that
the tendencies will pass.
• Stress that a little patience will keep both parents and child from further GI
upsets.
• Suggest that the parents not force the child to eat foods they are not
interested in but to provide a variety of nutritious foods during meals and for
between-meal snacks in the amount appropriate for the child’s age.
• Inform the family about resources when they need additional help.
• Go to www.nal.usda.gov/fnic/, www.choosemyplate.gov/, and www.aap.org for
more information on this topic.
STRUCTURAL GASTROINTESTINAL DISORDERS

Cleft lip (CL) and cleft palate (CP) are the most common craniofacial
abnormalities in the U.S. A CL is an opening or split in the upper lip,
while a CP is an opening or split in the roof of the mouth (called the
palate). Normally, complete closure of the lip is accomplished by 35
days postconception and is considered incomplete when only the
upper lip is affected and complete when the defect extends to the
nose. With CP, midline fusion of the palatal shelves fails to occur. A
baby can be born with one or both these conditions.
Babies with CP before surgical correction are more at risk for
frequent episodes of acute otitis media (AOMs) due to the opening in
their oropharynx. Babies with either CL or CP may have increased
difficulty with forming a good seal and thus have a poor suck,
increasing the risk for feeding difficulties.
The prevalence of CL with CP is approximately 5.6 per 10,000 live
births. The male-to-female ratio of CL is 2:1, while the male-to-
female ratio of CP is 1:2. Maternal age of older than 35 has been
associated with an increased risk of
CL and CP.
While the prevalence of CP is consistent across ethnic groups, the
prevalence of CL varies. CL occurs most frequently in American
Indian or Alaska Natives (4.2 and 10.1/10,000 live births), least often
in black Americans (2.1 and 3.7/10,000 live births), and at an
intermediate level in other groups (Caucasians, Hispanics, Asians,
Pacific Islanders) (Esherick et al, 2020).
Nursing Care
The initial focus of postdelivery newborn care is assessment of the
infant’s airway and sucking ability. Infants with a CP generally cannot
effectively suck from the bottle or breast and will require adaptive
feeding equipment before the surgery, such as a modified shorter
nipple that expresses liquid into the mouth but not into the posterior
pharynx. By contrast, infants with CL and no palatal abnormality may
require a longer nipple but may be able to feed independently from
the bottle or breast. Consultation with an infant feeding/lactation
specialist with expertise in this area is suggested.
Educate parents that while CL and CP are not always possible to
prevent, certain things can be done during pregnancy to reduce the
risk, such as:
■ Avoiding certain medications, such as medicines used to treat
seizures, and Methotrexate, which is used to treat cancer and
other diseases
■ Avoiding cigarettes and alcohol
■ Taking prenatal multivitamins that contain at least 400 micrograms
of folic acid
■ Telling the health-care provider about all prescription drugs, over-
the-counter medications, and supplements
Primary lip repairs can often occur earlier than CP repairs (as CL
repairs require less anesthesia) and are a less invasive surgery.
They are performed early on to also promote maternal child bonding,
usually at or before 3 months of age. By contrast, palatal repairs can
occur around 6 months but should be performed before the child
begins speaking (as interference in speech can result in a delay in
palatal repairs).
Inguinal Hernia
Inguinal hernia is the most common type of hernia in children,
accounting for approximately 80% of such cases. An inguinal hernia
arises from the failure of the processus vaginalis to atrophy and
close during the eighth month of gestation. This provides a canal that
allows for abdominal fluid or structure (bowel, ovary, or fallopian
tube) to extend up to or through the inguinal ring into the scrotum or
labia.
This type of hernia is 8 to 10 times more common in males, with
an incidence ranging from 7% to 30% (Masoudian et al, 2019). An
inguinal hernia is defined as the protrusion of bowel through the
inguinal canal and is usually evident by a protrusion in the inguinal
area and a bulging of the scrotal sac. In females, the hernia may
involve a protrusion through the round ligament into the labia.
Inguinal hernias in the pediatric population are generally considered
indirect, meaning that the hernia passes through the internal
abdominal ring, traverses the spermatic cord through the inguinal
canal, and emerges at the external inguinal ring.
Signs and Symptoms

Inguinal hernias can have any of the following symptoms:
■ Bulge on either side of pubic bone
■ Burning, gurgling, or aching sensation at the bulge
■ Pain or discomfort that increases while bending, coughing, or lifting
■ Heavy or dragging sensation in groin
■ Weakness or pressure in groin
Diagnosis
An inguinal hernia is identified by swelling in the inguinal area that
extends toward or into the scrotum. Most inguinal hernias are
observed by 6 months of age, with more than 50% diagnosed before
1 year of age.
Prevention
Though this condition may not be prevented, good prenatal care
provides an opportunity to promote optimal fetal development in
utero.
Collaborative Care
NURSING CARE
Most inguinal hernias are managed through surgical correction on
an outpatient basis. The initial nursing care of the child hospitalized
for the hernia repair involves parental education and preoperative
preparation of the child.
SURGICAL CARE
Elective surgical correction is the treatment of choice for the child.
After surgery, the nurse can inform the parents that the child’s vital
signs are monitored frequently and that the child’s position will be
changed often to avoid undue stress on the surgical area.
Traditional postoperative measures such as assessing the child’s
vital signs and bowel sounds as well as maintaining fluid and
electrolyte balance, monitoring pain, and ensuring return to normal
bowel elimination are also done. Postoperative complications can be
prevented by instructing the parents to keep the wound clean and
dry and to change wet or soiled diapers as soon as possible for
children who are not toilet trained.
If the child has an inguinal hernia, the nurse can tell the parents that
the surgery will repair the defect caused by the hernia. Recovery
from an inguinal hernia is usually rapid, and the child will return
home the same day as the surgery. Discharge instructions include
informing the parents on wound care and the importance of keeping
the surgical site clean and dry. The nurse also tells the parents the
child can resume normal activity in 4 to 6 weeks and that they may
be given a prescription for stool softeners to prevent straining during
defecation (Venes, 2021).
Umbilical Hernia
The nurse understands that umbilical hernia is the most common
type of hernia in infants. An umbilical hernia is the protrusion of the
intestine through the abdominal fascia, which is often identifiable
during crying, defecation, or coughing (Fig. 16-1). An umbilical
hernia occurs as a result of failure of the umbilical ring to close,
which normally begins at the end of the first trimester. The incidence
of umbilical hernias is estimated at one out of every six live births.
Umbilical hernias are more common in premature and low-birth-
weight infants and ten times more common in African American
children. Umbilical hernias are also more common in children with
Down’s syndrome and in children with hypothyroidism.
FIGURE 16-1 An umbilical hernia is the protrusion of the intestine

through the abdominal fascia.
Signs and Symptoms

Most umbilical hernias are asymptomatic. Umbilical hernias are more
prominent when the infant is crying.
Diagnosis
Umbilical hernias can be identified as a soft midline swelling in the
umbilical area, which can be reduced with pressure.
Prevention
utero.
Collaborative Care
NURSING CARE
Most umbilical hernias resolve spontaneously by 3 to 5 years of
age, though there is a decreased likelihood of spontaneous closure
for a hernia larger than 1.5 cm in diameter or for one with a large,
proboscis-like defect (elongated or extensible tubular process). The
initial nursing care of the child hospitalized for the repair of an
umbilical hernia involves parental education and preoperative
preparation of the child. The majority of umbilical hernias are
managed on an outpatient basis.
SURGICAL CARE
Surgery is considered for a persistent hernia beyond age 5, an
incarcerated hernia, or a hernia that enlarges dramatically. Vital
signs are done frequently in the postoperative period. Postoperative
care also includes keeping the wound clean and dry as well as
managing the child’s pain. A pressure dressing is generally applied
for 48 hours postoperatively. The child may resume a normal diet
and activity postoperatively. Postoperative complications of umbilical
hernia repair are rare.
Before surgery the nurse instructs the parents about umbilical hernia
and prognosis for the spontaneous resolution of the umbilical hernia.
If surgery is required, parents are instructed to have the child avoid
strenuous activities after surgical correction for 2 to 3 weeks and
resume a normal diet as tolerated. Nursing care is similar to care of
a child with an inguinal hernia.
Anorectal Malformations
Anorectal malformations include imperforate anus and anal atresia.
There is an inner and outer anal sphincter, and an ultrasound is
required to diagnose the depth of the defect. Anal malformations can
range from singular defects to defects associated with other
abnormalities. Up to 70% of anal malformations are associated with
other congenital deformities or syndromes including anomalies of the
GI system and the genitourinary (GU) system and pelvic organs. The
incidence of anorectal malformation is approximately 1 in 4,000 to
5,000 births and is more common in males. As one of the most
common groups of congenital defects, these abnormalities are
caused by abnormal or arrested development of the GI system. The
location of the abnormality and actual organ systems involved is
related to the week of gestation at which the development was
disrupted. The etiology of anorectal malformations is unknown.
Signs and Symptoms

Rectal atresia (closure of the rectal passage) may initially present
as a normal appearing anal opening but is later detected as an
abnormal situation that becomes a complete obstruction that
precludes the passage of stool. Immediate surgical intervention is
mandatory for rectal atresia.
Rectal stenosis (constriction or narrowing of the rectal passage)
includes vomiting, abdominal distention, and difficulty passing stool.
Rectal stenosis may present with a ribbon-like or narrow stool that is
not always readily apparent at birth.
Absence of a rectal opening is referred to as an imperforate
anus. An imperforate anus defect manifests in several forms, which
include a fistula or connection from the distal rectum to the perineum
or GU system. Passage of meconium through the vagina, urethra, or
an opening under the scrotum is early evidence of an imperforate
anus, though the presence of a fistula may not be evident at birth. In
the presence of an imperforate anus, as peristalsis increases,
meconium is forced through the abnormal passage.
More extensive defects may present with evidence of a rectal
connection to the vagina or urethra as the opening through which the
stool passes.
Diagnosis
Diagnosis is made by physical examination and radiological imaging
(x-ray), which indicates the level of the defect and location of fistula
formation (Gaylord & Yetman, 2018). The visualization of gas in the
bladder or urethra during imaging also indicates the presence of a
fistula connection between the bowel and associated structure
(Gaylord & Yetman, 2018). Magnetic resonance imaging of the
lumbosacral spinal cord is required for all children presenting with an
imperforate anus to rule out the presence of a tethered spinal cord,
which is common in children with this malformation. An ultrasound
(outlines the shape of tissues and organs) of the abdomen and
pelvis, an IV pyelogram (provides information about the structure
and function of the kidney, ureter, and bladder), and voiding
cystogram (radiography of the bladder) are performed to evaluate
associated defects of the urinary tract.
Prevention
utero.
Collaborative Care
NURSING CARE
Overall nursing care depends on the type of defect and the extent
of surgical correction. The child is kept NPO (nothing by mouth);
therefore, the care of the infant before surgery includes parent
education and maintenance of IV fluids. In addition to basic needs of
the child undergoing surgery of the GI tract, pain control and the
importance of infection control postsurgery must be stressed related
to the location of the surgical incision and the potential for fecal or
urinary contamination. The nurse also communicates to the family
that, postoperatively for high anorectal malformations, a colostomy is
placed and subsequent colostomy care is required.
SURGICAL CARE
Management of anorectal malformations may require extensive
treatment depending on the extent of the defect and associated
organ involvement, including GI, urinary, and reproductive systems.
Repeated manual dilation can be used to treat anal stenosis. The
creation of a new anal opening may be used to correct anatomically
lower anorectal defects.
A two-stage repair is generally necessary for anatomically higher
anorectal defects. The first stage of anorectal repair involves
resection and the creation of a temporary colostomy. The second
stage involves closing the colostomy and anastomosing the blind
pouch of the rectum to the anus (Blosser et al, 2018).
Common postoperative nursing measures include monitoring vital
signs and intake and output, fluid maintenance, pain control, and
developmentally appropriate play. With the presence of a colostomy,
the nurse stresses the importance of good skin care and infection
control in the postoperative period. Nasogastric decompression is
often required early in the postoperative period. Oral feedings are
generally initiated with the reestablishment of peristalsis and once
stooling has begun.
Discharge instructions include colostomy care, wound care,
prevention of infection, and the procedure for anal dilation, if
appropriate for the defect. The importance of adequate fluids is also
stressed. The parent is instructed on the potential need for dietary
fiber and the possible use of stool softeners or bulking agents. In
addition, the parent is advised about the potential for delayed toilet
training.
OBSTRUCTIVE GASTROINTESTINAL
DISORDERS
Hypertrophic Pyloric Stenosis
Hypertrophic pyloric stenosis occurs in approximately 3 in 1,000 live
births, more commonly in males (4:1 to 6:1), with approximately 30%
of cases occurring in firstborn children (van den Bunder, Hall, van
Heurn, 2020). The etiology of hypertrophic pyloric stenosis is
unknown (Fig. 16-2).
The classic presentation of Idiopathic Hypertrophic Pyloric
Stenosis (IHPS) is the 3- to 6-week-old baby who develops
immediate postprandial, nonbilious, often projectile vomiting with a
palpable “olivelike” mass at the lateral edge of the right upper
quadrant of the abdomen. The infant often wants to be refed after
vomiting. Laboratory evaluation may reveal an infant in metabolic
alkalosis resulting from the loss of large amounts of gastric
hydrochloric acid.
FIGURE 16-2 Hypertrophic pyloric stenosis.
Signs and Symptoms

Projectile vomiting is the classic and most common symptom of
hypertrophic pyloric stenosis.
There is a pattern of normal feedings and new onset of nonbilious
vomiting. The vomiting usually begins with episodes of regurgitation
during the first few weeks of life (van den Bunder, Hall, van Heurn,
2020). Vomiting usually occurs immediately after a feeding and may
become projectile in nature. The infant generally appears hungry
immediately after vomiting and eagerly wants to feed again.
Other symptoms are as follows:
■ Insatiable appetite
■ Weight loss
■ Dehydration
■ Constipation
■ Olive-shaped mass
■ Visible reverse, or left to right, peristalsis may be observable in the
left upper quadrant
Diagnosis
Diagnosis of hypertrophic pyloric stenosis can be made by palpating
the pyloric mass. The mass is olive-shaped, moveable, firm, and
best palpated from the left side and located above and to the right of
the umbilicus in the midepigastrium (the superior central portion of
the abdomen) beneath the liver edge; however, definitive diagnosis
is made by ultrasound. Examination of the pylorus on ultrasound
shows elongation and thickening of the pylorus, which may be
confirmed by a barium upper GI series.
Diagnostic Tools
Ultrasound
A diagnosis is often made after the history and physical examination. If the
diagnosis of hypertrophic pyloric stenosis is inconclusive, an ultrasound can be
used to demonstrate an elongated muscular mass surrounding a long pyloric
canal. Ultrasound confirms the diagnosis of hypertrophic pyloric stenosis.
Prevention
utero.
Collaborative Care
NURSING CARE
Initial care of the child with the diagnosis of pyloric stenosis
includes a careful history and assessment. The nurse needs to be
alert to signs of dehydration, such as changes in skin turgor,
appearance of the mucous membranes, depressed fontanelle,
presence or absence of tears, urine output, and changes in vital
signs as well as weight loss and evidence of discomfort.
Before surgery, the child is given nothing by mouth (NPO), and a
nasogastric tube is inserted to provide gastric decompression.
Surgery may be performed without delay in infants without
dehydration and electrolyte imbalances. If dehydration is present, the
dehydration imbalance is corrected with IV fluids and administration
of appropriate electrolyte therapy.
SURGICAL CARE
Treatment for hypertrophic pyloric stenosis is surgery called a
pyloromyotomy (incision and suture of the pyloric sphincter). It is
performed by laparoscopy (abdominal exploration) with an
endoscope.
Postoperative care includes monitoring vital signs frequently. The
nurse communicates to the family that it is common for the infant to
experience some vomiting in the first 24 to 36 hours after surgery.
Fluid balance is maintained through administration of IV fluids and
oral liquids as tolerated. Whether or not bowel sounds are present,
feeding begins 6 hours after surgery.
Pedialyte 15 mL is given every 2 hours for two consecutive feeds,
if the baby tolerates this with no vomiting, then it is advanced to half-
strength formula 15 mL every 2 hours for two consecutive feeds. If
no vomiting, then advance to 30 mL for two consecutive feeds, then
45 mL for two consecutive feeds, and finally 60 mL for two
consecutive feeds.
If the baby vomits, then the baby stays at that level until two
consecutive feeds are tolerated.
It is important for the nurse to continue to monitor for signs of
dehydration and the infant’s response to oral fluids. After surgery, the
family members can be instructed on the importance of saving wet
diapers that are weighed to measure output. Postoperative care also
includes monitoring the surgical site for signs of infection, keeping
the wound clean and dry, and providing pain relief. The potential for
complication of postoperative infection can be prevented by
instructing the parents to keep the wound clean and dry and to
change wet or soiled diapers as soon as possible for children who
are not toilet trained.
Discharge instructions include care of the incision and observation
for signs of infection. The nurse must instruct the parent to observe
the infant’s response to feedings because some vomiting may still
occur within the first 48 hours postoperatively. Vomiting beyond 48
hours must be reported to the child’s health-care provider.
Intussusception
Intussusception occurs when one portion of the intestine invaginates
or telescopes into another portion, most commonly at the ileocecal
valve (Fig. 16-3). Intussusception is the most common cause of
intestinal obstruction in infants between 6 and 36 months of age.
Patients with intussusception typically have a characteristic
presentation of paroxysmal abdominal pain (pain that comes and
goes), currant-jelly stools, and a sausage-shaped mass palpable in
the right side of the abdomen. Children develop this sudden onset of
intermittent, severe, crampy, progressive abdominal pain
(paroxysmal), accompanied by inconsolable crying and drawing up
of the legs toward the abdomen. The episodes become more
frequent and more severe over time. Vomiting may follow episodes
of abdominal pain. Initially, emesis is nonbilious, but it may become
bilious as the obstruction progresses. In approximately 70% of
cases, stool contains blood, often of a gelatinous appearance and
frequently characterized as “currant-jelly stool” based on the
appearance (Krebs et al, 2020).
FIGURE 16-3 Intussusception.
Intussusception may be preceded by an upper respiratory infection

that occurs a week to 10 days prior. Other predisposing factors
include the presence of polyps, Meckel’s diverticulum, Henoch-
Schonlein purpura, constipation, lymphomas, lipomas, parasites,
rotavirus, adenovirus, and the presence of foreign bodies.
Signs and Symptoms

■ Acute abdominal pain caused by the spasm of the telescoping
bowel
■ Pain frequently mimics the pain experienced by “colicky” infants
■ Infants may pull their legs up toward the abdomen
■ Pain is relieved once the abdomen relaxes
■ Vomiting may or may not be present and it may or may not be
projectile
■ Fever
■ Dehydration
■ Abdominal distention
■ Lethargy
■ Grunting noises because of pain
Assessment Tool
Classic Symptomatic Triad for Intussusception
The classic symptomatic triad for intussusception includes:
• Paroxysmal, episodic abdominal pain with vomiting every 5 to 30 minutes
• Screaming and drawing up legs with periods of calm, sleeping, or lethargy
between episodes
• Stool with blood (currant-jelly stool)
Diagnosis
Diagnosis of intussusception is based on a history of the
characteristic symptoms and the physical findings during
examination. The presence of a “sausage-shaped” mass in the
upper right quadrant (Dance’s sign) during palpation of the abdomen
is indicative of intussusception. Although the upper right quadrant is
the most common site, the mass may be felt in other abdominal
areas too. The abdomen is distended and tender on palpation, and
bowel sounds may be either increased or decreased.
Diagnostic Tools
Intussusception
Barium enema is the diagnostic gold standard for intussusception. It is also
therapeutic in most cases, whereas air enema is strictly therapeutic. At 82.7%,
air enema has a higher success rate and lower perforation risk because it does
not involve risk of peritoneal contamination in case of bowel perforation. An
abdominal ultrasound confirms the diagnosis in most cases (Krebs et al, 2020).
Prevention
utero.
Collaborative Care
NURSING CARE
When the child has been diagnosed with intussusception, the
nurse can provide information about the condition and reassurance
to the parents. The nurse is responsible for monitoring the infant for
signs of perforation, peritonitis (inflammation of the abdominal
cavity), or shock in addition to evidence of increased pain. The nurse
also monitors and records the child’s stools. The spontaneous
passing of a stool may indicate a resolution of the obstruction.
Postoperative care is similar to that of the child surgery for pyloric
stenosis.
The child with perforation has acute pain, beginning at the
perforated area and spreading over the abdomen. The abdomen
may become rigid, and the child may experience nausea and
vomiting, tachycardia, fevers, chills, sweats, confusion, and
decreased urinary output (Venes, 2021). Moderate or mild abdominal
pain that worsens with movement, fever, change in bowel habits, and
malaise are also common. In addition, the child has nausea, loss of
appetite, and fever or hypothermia. During the nursing assessment,
the nurse notes that the abdomen is distended with decreased bowel
sounds.
MEDICAL CARE
A barium or air enema is used to both diagnose and treat
intussusception. In radiological reduction, the barium (contrast
media) or air allows visualization of the telescoped bowel. The
pressure applied by the enema may cause the telescoped bowel to
return to its normal position, thus relieving the obstruction. Reduction
rates are reported as high as 65% to 90% through the instillation of
barium or air (Krebs et al, 2020). If the treatment is managed through
radiological reduction, the nurse should educate the family that the
child will likely be admitted for 24-hour observation as the
intussusception can recur. The nurse also continues to monitor the
child’s vital signs and assess overall condition. If radiological
reduction is ineffective or if peritonitis, perforation, or shock is
evident, prompt surgical correction is required.
SURGICAL CARE
If the child is having surgery, preparation before surgery includes
placing the child NPO, inserting a nasogastric tube, and initiating IV
fluid therapy. The surgical procedure either repairs the bowel or
removes any portion that has been permanently damaged.
Discharge instructions include care of the incision and observation
for signs of infection. Parents can be taught about feeding,
dehydration, and appropriate pain management strategies.
Malrotation and Volvulus

Abnormal rotation of the intestine around the superior mesenteric
artery during fetal development may lead to malrotation of the
intestine. Malrotation may be present in utero, appear during early
infancy, or later in childhood. Malrotation is the most serious type of
intestinal obstruction because it may lead to intestinal necrosis,
peritonitis, perforation, and death related to a complete twisting of
the intestine around itself, or volvulus. The incidence of malrotation
is approximately 1 in 500 live births (Zhang, Sun, Luo, 2017).
Signs and Symptoms

Symptoms of malrotation or volvulus may occur at any age but are
most common in the first month of life. A major symptom is
intermittent bilious or green vomit. Additional symptoms include
abdominal distention, recurrent abdominal pain, lower GI bleeding, a
palpable epigastric mass, dehydration, lethargy, and shock. The
child’s stools may be bloody, which suggests ischemia and possibly
gangrene of the bowel.
Diagnosis
Diagnosis is based on history, physical examination, and
radiographic studies such as barium enema and upper GI series,
which is the definitive procedure to diagnose the condition. This
abnormal condition has a characteristic corkscrew, coiled, or bird’s
beak appearance.
Prevention
utero.
Collaborative Care
NURSING CARE
Preoperative nursing care includes IV hydration to restore fluid
and electrolyte balance, nasogastric suction, and administration of IV
antibiotics.
SURGICAL CARE
Timely repair of this condition is indicated to prevent potential
complications. Surgical treatment for malrotation and volvulus
includes resection of nonviable intestinal segments with anastomosis
(surgical connection). Short bowel syndrome is a potential
postoperative complication because extensive portions of the bowel
are either reconstructed or removed. Postoperative care is
comparable to that of an infant or child undergoing abdominal
surgery.
Postoperative care and discharge instructions are similar to that of
the child surgery for pyloric stenosis.
INFLAMMATORY DISORDERS
Peptic Ulcer Disease
Peptic ulcer disease (PUD) refers to a variety of upper GI tract
disorders that result from gastric acid injury, causing inflammation
and subsequent ulceration (Gaylord & Yetman, 2018). Duodenal
ulcers are more common than gastric ulcers in children. The most
common cause of gastric ulcer is infection with the gram-negative
organism Helicobacter pylori with an estimated 50% of the world
population infected with this organism (Blosser et al, 2018). Risk
factors for acquiring H pylori include low socioeconomic status and
poor sanitation. Transmission of H pylori is person-to-person or by
contaminated water.
Secondary ulcers are more likely to be peptic in origin and may
occur as a result of factors such as stress, medication, or underlying
conditions. Risk factors for PUD in children include:
■ Helicobacter pylori infection
■ Drugs
■ Nonsteroidal anti-inflammatory drugs (NSAIDs)
■ Bisphosphonates
■ Potassium supplements
■ Family history
■ Stress
■ Sepsis
■ Head trauma
■ Hypotension
Signs and Symptoms

Children with PUD may be asymptomatic or present with a wide
range of symptoms:
■ Abdominal pain (epigastric, worsening after meals)
■ Dyspepsia
■ Nausea and vomiting
■ Excessive belching, hiccupping, and regurgitation
■ Nocturnal awakening
■ Anorexia
■ Poor feeding
■ Weight loss
■ Hematemesis
■ Melena
■ Iron-deficiency anemia
Diagnosis
Upper GI endoscopy is considered the most accurate and definitive
test for diagnosis of PUD.
Prevention
The most common cause of PUD, H pylori, is associated with poor
sanitation, contaminated water, and person-to-person contact.
Appropriate prevention is directed at teaching proper hand washing
and avoidance of potential sources of contaminated water. Child and
parent health promotion and maintenance education is directed at
instructing family members in strategies to avoid stress and
instructing them on the complications related to the use of caffeine
and NSAIDs.
Collaborative Care
NURSING CARE
Nursing care for children with PUD centers on stabilization of the
child, decreasing the gastric acid, and determining the cause of the
inflammation that results in the ulceration. The child may be
discharged when the condition stabilizes and oral feeding is
tolerated.
MEDICAL CARE
PUD is treated with antibiotics (in the presence of H pylori),
histamine agonists, and/or proton pump-inhibitors, which may be
administered IV if bleeding is present. A nasogastric tube is placed
for decompression of the stomach in the presence of severe gastric
or esophageal hemorrhage.
Child and parent education must stress the importance of
compliance with medication and dietary management, which
includes avoiding certain foods identified by the child or family such
as caffeinated soda, fatty foods, chocolate, and spicy foods.
Avoiding late-night snacks also helps. Bland diets have not been
proven to promote healing. In addition, stress reduction is necessary
to successfully treat PUD in children. Discharge instructions also
include teaching the child and family about the importance of
avoiding substances that cause pain, such as NSAIDs.
Labs
Urea Breath Test
The urea breath test requires the child to swallow a tablet or drink a solution
containing urea, which is composed of nitrogen and carbon. The carbon
dioxide exhaled is then measured and indicates the presence of H pylori in
the stomach. Urease, which breaks down into ammonia and carbon dioxide, is
an enzyme produced by H pylori.
Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a general term for two major
forms of chronic intestinal inflammatory conditions, Crohn’s disease
and ulcerative colitis, which have common epidemiology and clinical
features. Both Crohn’s disease and ulcerative colitis are
characterized by extraintestinal and systemic features, yet they are
distinct disorders as described in the following sections.
Crohn’s Disease
Crohn’s disease is a chronic inflammatory disease characterized by
periods of exacerbations and remissions. Crohn’s disease can affect
any portion of the GI tract. The bowel may present with a
combination of nonsequential areas of pathology and disease-free
sections of bowel. Crohn’s disease rarely affects the oropharynx,
esophagus, and stomach; the small bowel is affected 25% to 30% of
the time; the colon and anus are affected 25% of the time; the
ileocolonic region is affected up to 40% of the time; and diffuse
disease occurs 5% of the time (Starr et al, 2020). Crohn’s disease is
characterized by skipped lesions or areas of inflammation anywhere
in the upper or lower GI tract. Because of these “skipped” areas, the
appearance is often described as cobblestone. Affected areas are
described as containing varying degrees of edema, erythema,
ulceration, friability, and thickening of the bowel wall and mesentery.
Common features of Crohn’s disease include abscess formation,
fistulas, and perianal disease.
SIGNS AND SYMPTOMS
Children with Crohn’s disease may have an acute or insidious
onset.
■ Abdominal pain
■ Diarrhea
■ Blood and mucus in the stool
■ Urgency and tenesmus
■ Sensation of incomplete emptying after defecation
■ Anorexia
■ Weight loss
Clinical presentation of Crohn’s disease varies extensively
depending on the area of the intestine that is involved and the
severity of the inflammation. For example, if the disease is limited to
the colon, symptoms are similar to those of ulcerative colitis. Upper
GI tract involvement is manifested by vomiting and epigastric pain.
Small bowel involvement is manifested by the following signs and
symptoms:
■ Cramplike pain commonly located in the right lower quadrant
■ Lower right quadrant tenderness and a feeling of fullness
■ Postprandial pain
■ Anemia
■ Lethargy
Perianal abnormalities, such as skin tags and fistulas
■ Partial or complete bowel obstruction
Extraintestinal signs and symptoms may include, but are not
limited to, the following:
■ Fever
■ Growth delay
■ Delayed sexual development
■ Arthralgias (joint pain)
■ Arthritis in the large joints
■ Stomatitis (inflammation of the mouth, lips, tongue, and mucous
membranes)
■ Aphthous ulcers
■ Uveitis (inflammation of the eye)
■ Conjunctivitis
■ Renal stones
■ Erythema nodosum (a tender, red, nodular rash on the shins)
(Venes, 2021).
DIAGNOSIS
Diagnosis is based on client history, physical findings, and
laboratory results. Endoscopy and colonoscopy are the most useful
diagnostic methods and may demonstrate segmented lesions with
thickened circular folds and a cobblestone appearance of the bowel
wall with longitudinal ulcers and transverse fissures as well as a
narrowed lumen, fistulas, and the string sign.
PREVENTION
Though the cause of Crohn’s disease is unknown, the disease is
most likely inherited. Preventive activities are directed toward
physical, social, and psychological health maintenance activities,
which promote growth and development through proper nutrition,
sleep/rest, physical activity, stress reduction, medication compliance,
and lifestyle.
COLLABORATIVE CARE
Nursing Care
Nursing care includes education around medication adherence
and nutritional management. The focus of care during periods of
remission involves monitoring compliance. As symptoms resolve, the
child may resist taking medications. The adolescent with Crohn’s
disease presents unique challenges in the treatment of their disease.
Adolescents have a natural desire to be “normal” and to be like their
peers. This may lead the adolescent to resist taking prescribed
medications that cause obvious side effects, such as those
experienced with prolonged use of steroids.
Medical Care
The goals of treatment include controlling the disease, including
remission, preventing relapses, and maintaining normal nutrition,
growth, and lifestyle (Lee & Marcdante, 2018). Initially the focus is on
reducing inflammation. Drugs known as 5-aminosalicylic acid, or 5-
ASA, are the most commonly used and include sulfasalazine
(Azulfidine), balsalazide (Colazide and Colazal), or mesalamine
(Asacol, Lialda, and Pentasa) products (Petersen-Smith &
McKenzie, 2018).
Corticosteroids are effective for reduction of inflammation in
moderate to severe disease and may be given orally, rectally, or IV
for acute exacerbations.
Immunosuppressive medications are useful with corticosteroid-
resistant disease. Immunomodulators, which change the way the
immune system responds to inflammation, are also used to treat
Crohn’s disease. Immunomodulators that decrease activity of the
immune system are known as thiopurines or immunosuppressants.
Immunosuppressants used to treat Crohn’s disease may include
azathioprine (Imuran and Azasan), 6-mercaptopurine (6MP and
Purinethol), tacrolimus (Prograf), and methotrexate (MTX,
Rheumatrex, and Mexate).
For children with Crohn’s disease who do not respond to other
treatments, a biological drug, infliximab (Remicade), is often
prescribed. Infliximab is an antibody that attaches itself to the
inflammation-promoting protein, tumor-necrosis factor-alpha (TNF-
alpha).
Additional treatment may include (1) antibiotics, such as ampicillin,
sulfonamides, cephalosporins, tetracycline, and metronidazole; (2)
antidiarrheal agents; and (3) fluid replacement and nutritional
supplements. Hospitalization, total parenteral nutrition, and gastric
decompression may be required during severe episodes of the
disease.
Surgical Care
Surgery for a child with Crohn’s disease may be indicated if the
child does not respond to medical treatment or in the case of bowel
strictures, obstruction, perforation, toxic megacolon, intractable
bleeding, or diarrhea. Surgical correction involves removal or
resection of the diseased segment with resection or anastomosis
(connection). The nurse communicates to the family that surgical
repair does not cure Crohn’s disease but removes an affected
portion of the bowel.
Teach the child and family about nutritional management, which
may include the following:
■ Frequent, small meals
■ High-protein and high-carbohydrate diet
■ Vitamin and iron supplement in the presence of lactose intolerance
■ Restriction of irritating and poorly absorbed foods, such as fried
food and carbonated drinks
■ During inflammatory periods, decrease foods that stimulate
peristalsis, such as high-fiber food because they promote water
retention
■ Nutritional supplements may be needed to maintain nutrition and
normal growth
Provide child and family education regarding the disease process
and medication management. Psychosocial referral may be
necessary to assist the child and family in coping with the disease.
The child and family may face issues related to school absences and
tardiness, need for special bathroom privileges at school, issues
related to self-esteem because of small stature caused by steroid
use, or the presence of an ostomy (Burns & Dunn, 2018).
Ulcerative Colitis
Ulcerative colitis is an acute or chronic inflammation of the colon,
which is characterized by recurring bloody diarrhea (Venes, 2021).
Unlike Crohn’s disease, ulcerative colitis involves a continuous
segment of the colon and usually the epithelial lining of the bowel.
The pathology of ulcerative colitis is described as a superficial, acute
inflammation of mucosa with microscopic crypt abscess (Rosen et al,
2018).
The cause of ulcerative colitis is unknown although infectious
agents, autoimmune responses, and environmental factors may play
a role. The probability of a genetically determined and an altered
immunologically mediated response to the intestinal mucosa is likely.
The overall incidence of ulcerative colitis in the United States is 10
to 20 cases per 100,000 (Ruggiero & Ruggiero, 2020). The peak
onset occurs between ages 15 and 25, with approximately 20% of
the cases occurring in children and adolescents younger than 20
years.
SIGNS AND SYMPTOMS
■ Abdominal pain
■ Bloody diarrhea
■ Bowel elimination urgency
■ Tenesmus (a painful spasmodic contraction of the anal sphincter
leading to the sensation of constantly needing to empty the bowel)
■ Left lower quadrant pain with cramping
■ Pain that increases before defecation and passing flatus (Venes,
2021)
■ Weight loss
■ Delays in growth and sexual maturation
Other manifestations, though not present in all cases, may include
the following:
■ Arthritis/arthralgias of the large joints
■ Oral ulcers
■ Erythema nodosum (chronic liver inflammation leading to scarring
of hepatic ducts)
■ Uveitis (inflammation of the uvea) (Venes, 2021)
■ Skin lesions such as those found in pyoderma gangrenosum (a
rare, ulcerating skin disease) and erythema nodosum (a tender,
red, nodular rash)
DIAGNOSIS
Diagnosis of ulcerative colitis in a child is based on history and
physical findings. Radiological and endoscopic examinations are
used to evaluate the characteristics and location of the lesions.
PREVENTION
As with Crohn’s disease, the cause of ulcerative colitis is
unknown, but researchers think the disease is most likely inherited.
Preventive activities are directed toward physical, social, and
psychological health maintenance activities, which promote growth
and development through proper nutrition, sleep and rest, physical
activity, stress reduction, medication compliance, and lifestyle.
COLLABORATIVE CARE
Nursing Care
Similar to Crohn’s disease, nursing care includes medication and
nutritional management, emotional support, and community referrals.
These can be found through the Crohn’s & Colitis Foundation of
America (www.ccfa.org) and other related organizations. There are
also support mechanisms via Facebook and Twitter. However, social
media safety must be stressed. In addition, a referral is made to an
ophthalmologist to rule out ophthalmological manifestations of the
disease. Psychosocial therapy may be indicated because depressive
disorders are common.
Medical Care
Laboratory findings for ulcerative colitis may include elevated
sedimentation rate, microcytic anemia, and an elevated white blood
cell count. Goals of the treatment of ulcerative colitis include disease
control, inducing remission, preventing relapse, and achieving
normal growth and lifestyle. Pharmacological, nutritional, surgical,
and psychosocial management may be included in the plan of care.
IV or oral steroids are used for moderate to severe ulcerative colitis,
with dosages tapered when the child is in remission. As with Crohn’s
disease, biological therapies are used to treat the inflammatory
response. Humira (adalimumab), Remicade (infliximab), and Entyvio
(vedolizumab) are biologics commonly prescribed to treat ulcerative
colitis. These drugs target TNF-alpha that contributes to
inflammation.
Surgical Care
Ulcerative colitis is curable surgically with a total mucosal
proctocolectomy with the ileal pouch–anal anastomosis as the most
common restorative surgery. Failed medical therapy and persistent
hemorrhage are the most common indications for surgical correction.
The nurse can communicate to the family that nutritional
recommendations include use of a diet high in protein and
carbohydrates with normal fat and decreased roughage. Vitamin and
iron supplements are recommended.
Appendicitis
Appendicitis is an inflammation of the appendix, which is a small
saclike structure at the end of the cecum. Appendicitis is one of the
most common conditions requiring abdominal surgery in childhood.
In appendicitis the lumen of the appendix becomes obstructed with
fecal matter, lymphoid tissue, tumor, parasite, foreign body, or
inspissated (thickened) cystic fibrosis secretions, which causes the
organ to become distended and subject to ischemia and necrosis.
The characteristic symptoms are caused by the inflammation around
the infected appendix with approximately a 36-to-72-hour window
from pain onset to rupture.
The incidence of appendicitis increases with age, with the average
age of occurrence at between 6 and 10 years of age. The incidence
is slightly higher in boys than in girls and more common in
Caucasians. The risk of perforation is twice as likely for children
younger than 5. Perforation occurs in approximately one-third of
children before treatment is initiated (Starr et al, 2020).
Signs and Symptoms

The most reliable diagnosis of appendicitis is gained through an
evaluation of the sequencing of the symptoms as follows:
■ One of the earliest symptoms is periumbilical pain (pain around the
umbilicus). This pain often awakens the child, peaking at 4-hour
intervals. The periumbilical pain subsides and then is followed by
the classic sign of right lower quadrant pain.
Additional symptoms include:
■ Vomiting generally follows periumbilical pain, unlike the vomiting
associated with gastroenteritis, which precedes the pain
■ Anorexia
■ Stools described as low in volume and mucuslike; diarrhea is
atypical
■ Constipation
■ High fever may be associated with perforation; otherwise the child
may be afebrile or have a low fever
Perforation is suspected when abdominal pain is suddenly relieved
without intervention. In that case the physician is notified
immediately. The child needs immediate attention and transport to a
nearby health-care facility.
Diagnosis
The child diagnosed with appendicitis experiences a progression of
symptoms with no single test providing overall confirmation of the
diagnosis. Laboratory findings may demonstrate an elevated white
blood cell count. An elevated white blood cell count does not
distinguish simple appendicitis from perforated appendicitis. Children
with appendicitis may also have a normal white blood cell count. An
abdominal radiograph may reveal fecal matter, or some other
obstruction, although this rarely confirms the diagnosis. If there is
uncertainty in young children, ultrasound and CT scan may help
differentiate abdominal pain from other causes, though the
usefulness is variable (Ruggiero & Ruggiero, 2020).
Collaborative Care
NURSING CARE
Nursing care of the child with appendicitis who has undergone an
appendectomy includes monitoring intake and output, wound care,
and pain control. The child will be NPO for 24 hours or until
peristalsis returns. Most children are discharged to home in 2 to 3
days. If the procedure is performed by laparoscope (abdominal
exploration with an endoscope) (Ruggiero & Ruggiero, 2020), the
child may remain in the hospital overnight or be discharged the day
of surgery. If perforation occurred, drains may protrude from the
incision or the wound and remain open to prevent infection and allow
healing. In the case of a perforated appendix, IV antibiotics are
given.
SURGICAL CARE
Treatment for children who have appendicitis is surgical, and an
appendectomy is curative if performed before perforation. The
potential for the complication of postoperative infection can be
prevented by instructing the parents to keep the wound clean and
dry.
Discharge instructions include informing the parents on wound care
and the importance of keeping the surgical site clean and dry and
monitoring the site for signs of infection. The parents are instructed
on pain management and the progression of activity over a 2-week
period, and the resumption of normal nutritional intake as directed by
the health-care provider and as tolerated.
Meckel’s Diverticulum
Meckel’s diverticulum arises from a remnant of fetal development in
the midgut that creates a congenital outpouching or bulge in the
lower part of the small intestine. The bulge is a leftover of the
umbilical cord. If it causes symptoms, Meckel’s diverticulum can be
repaired with surgery. It is the most common congenital malformation
of the GI tract and represents a true diverticulum because it contains
all the layers of the small bowel wall. The diverticulum can
sometimes have ectopic tissue within the walls.
Signs and Symptoms

Symptoms of Meckel’s diverticulum are recognized in childhood, with
65% of affected children younger than 5, with incidence peaking at
age 2 (Kwon et al, 2019). Meckel’s diverticulum is characterized
using a rule of 2s, that is, 2% of the population, located within 2 ft
(60–100 cm) of the ileocecal valve, usually 2 in. (5 cm) long, and
most (well over 50%) present before age 2 years. Manifestations
include the following:
■ Abdominal pain described as periumbilical or lower abdominal and
similar to appendicitis or volvulus
■ Pain may be vague and recurrent
■ Painless rectal bleeding (more often found in the older child)
■ Stools described as bright or dark red with mucus or with a
“currant jelly” appearance
■ Rectal bleeding accompanied by pain in infants
■ Severe anemia and shock can occur in undiagnosed disease
Diagnosis
Diagnosis in the child is based on history, physical examination, and
radiography, specifically a nuclear medicine scan. A radionuclide
scintigraphy or Meckel scan uses injection of radioactive isotopes to
identify the presence of Meckel’s diverticulum and has 90%
accuracy. Diverticulum may be difficult to visualize with plain films,
CT, or barium studies. Abdominal radiographs and barium enema
are not useful for diagnosis. The child is also screened for anemia.
Prevention
utero.
Collaborative Care
NURSING CARE
Nursing care is similar to that of any child undergoing surgery, as
well as monitoring for shock and blood loss and providing rest.
Preoperative antibiotics may be ordered if diverticulitis has occurred.
If obstruction has occurred, fluid and electrolyte imbalances are
corrected before surgery. Postoperative care includes fluid
replacement and gastric decompression and evacuation via
nasogastric tube.
SURGICAL CARE
Treatment for symptomatic Meckel’s diverticulum involves surgical
removal of the diverticulum. Surgical repair is more common in
children younger than 2 years of age, which accounts for 50% of
those requiring surgery.
Discharge instructions include teaching the parents about wound
care and the importance of keeping the surgical site clean and dry,
as well as monitoring for signs of infection. The parents are
instructed on pain management, the progression of activity over a 2-
week period, and the resumption of normal nutritional intake as
directed by the health-care provider and as tolerated.
Pancreatitis
The diagnosis of acute pancreatitis should be suspected in a patient
with acute onset of a persistent, severe, epigastric pain with
tenderness on palpation on physical examination. Diagnosis requires
the presence of two of the following three criteria: acute onset of
persistent, severe, epigastric pain often radiating to the back;
elevation in serum lipase or amylase to three times or greater than
the upper limit of normal; and characteristic findings of acute
pancreatitis on imaging (contrast-enhanced computed tomography
[CT], magnetic resonance imaging [MRI], or transabdominal
ultrasonography). In patients with characteristic abdominal pain and
elevation in serum lipase or amylase to three times or greater than
the upper limit of normal, no imaging is required to establish the
diagnosis of acute pancreatitis (Blosser et al, 2018).
Triggers for pancreatitis in children differ from those of adults and
in most cases are idiopathic. In children, common causes include
drugs, hypertriglyceridemia, biliary microlithiasis, trauma, or viral
infection.
Chronic pancreatitis involves irreversible changes in the structure
and function of the pancreas caused by recurrent or persistent
attacks of pancreatitis and more common in hereditary pancreatitis
and cystic fibrosis. Reoccurring attacks of pancreatitis lead to
scarring of the small and large pancreatic ducts, stone formation,
duct stasis, and inflammation.
Signs and Symptoms

Clinical signs and symptoms of pancreatitis are nonspecific and vary
with age:
■ Abdominal pain (be sure to assess frequency of the pain)
■ Epigastric location: steady, achy, and worse in recumbent
position
■ Back pain
■ Radiation of pain to the back
■ Diffuse pain
■ Guarding pain
■ Nausea and vomiting (the most common presenting symptom in
children younger than 3) (Blosser et al, 2018)
■ Grey Turner sign: a discoloration or bruising and induration of
skin on flank (Venes, 2021)
■ Cullen sign: bluish discoloration of periumbilical region caused by
a hemorrhage (Starr, 2020)
■ Low-grade fever
■ Hunched-over or knee-to-chest position
■ Dehydration or shock
■ Jaundice
■ Symptoms of diabetes mellitus and malabsorption may develop
late in the course of chronic pancreatitis (Blosser et al, 2018)
Diagnosis
Baseline laboratory studies include serum amylase and lipase levels
as well as complete blood count (CBC), C-reactive protein, and
phosphorus levels. Elevated serum amylase or lipase levels, which
occur as a result of pancreatic injury, support the diagnosis of
pancreatitis. As pancreatitis progresses, lipase levels remain
elevated longer than amylase levels, making lipase a better choice
for diagnostic testing. Amylase and lipase are measured at least
daily along with a CBC, C-reactive protein, and phosphorus level. In
addition, infants and toddlers are more likely to be diagnosed
through serum lipase levels because they demonstrate fewer signs
and symptoms.
Prevention
Prevention of pancreatitis includes maintaining a well-balanced, low-
fat diet, controlling triglycerides, and educating the child and parents
on the effects of drug and alcohol abuse on the pancreas.
Collaborative Care
NURSING CARE
Nursing care for pancreatitis is supportive and includes
management of fluid balance, nutritional support, and pain control.
The child is placed on bowel rest (NPO) when pancreatitis is
suspected. A nasogastric tube (NG) is placed to maintain stomach
decompression. Vomiting necessitates the use of IV fluid
replacement. Pre- and postoperative nursing care would be
consistent with that provided for general abdominal surgery.
MEDICAL CARE
Broad-spectrum antibiotics are used if the child is febrile and has
evidence of extensive pancreatic necrosis.
SURGICAL CARE
Surgical management, though rare, may be indicated in patients
whose pancreatitis is caused by severe abdominal trauma or major
ductal abnormalities.
Chronic pancreatitis is rare in children. Care involves educating the
patient and family about signs and symptoms that indicate a
recurrence and complications.
Gallbladder Disease
Though gallbladder disease, or cholelithiasis, is relatively uncommon
in childhood, gallstones may develop at any age and in utero.
Cholelithiasis is the presence of stones in the gallbladder and is
often associated with hyperlipidemia, obesity, pregnancy, use of birth
control pills, infection, bile stasis, congenital anomalies, use of TPN,
and family history. Children with cystic fibrosis, hemolytic disease,
Crohn’s disease, and Wilson’s disease are at greater risk for
gallstone formation. The cause of cholecystitis is an obstruction in
the flow of bile from the gallbladder to the cystic ducts and is often
associated with gallstones. Pancreatitis is the most common
complication of gallstone disease in children.
Signs and Symptoms

■ Right upper quadrant pain, often radiating substernally or to the
right shoulder
■ Pain episodes often occur after eating
■ Pain episodes more common after ingestion of fatty or greasy
foods
■ Pain may be diurnal but is usually worse at night
■ Sudden onset of severe, sharp right upper quadrant pain and
localized tenderness is associated with biliary obstruction
■ Jaundice
■ Fever (with cholecystitis)
■ Pear-shaped palpable mass in the right upper quadrant
Diagnosis
Common diagnostic and laboratory studies are generally normal
unless calculi have lodged in the extrahepatic biliary system. The
following are commonly ordered for gallbladder disease:
■ Liver function tests, bilirubin, and C-reactive protein may be
elevated in the presence of ductal stones.
■ Amylase and lipase may be elevated if pancreatitis is also present.
■ CBC may demonstrate leukocytosis when cholecystitis is present.
■ Plain abdominal x-ray may reveal radiopaque stones.
■ Ultrasound is the best imaging technique and will show stones,
sludge, and anatomic alterations, such as dilation of the duct
system.
■ CT scan provides similar information to an ultrasound but involves
radiation.
Prevention
Prevention of cholelithiasis includes maintaining a well-balanced,
low-fat diet, controlling hyperlipidemia, weight control, and educating
the child and parents on the effect of birth control pills on the
gallbladder.
Collaborative Care
NURSING CARE
Nursing care of the child admitted with symptomatic cholecystitis is
supportive and includes management of fluid balance, nutritional
support, and pain control. The child is placed on NPO status, and
gastric decompression via NG tube is initiated. IV antibiotics may be
ordered if fever is present.
SURGICAL CARE
When cholelithiasis causes symptomatic cholecystitis, surgical
removal of the gallbladder is necessary. Laparoscopic
cholecystectomy is the treatment of choice for symptomatic
cholelithiasis (Blosser et al, 2018). Use of lithotripsy or shock waves
to break up the stones has not been approved for use in children.
Postoperative care for the child undergoing a laparoscopic
cholecystectomy is routine and brief because the length of stay is
generally 1.6 days (Gaylord & Yetman, 2018). Traditional GI
postoperative nursing care measures are employed.
Discharge instructions include informing the parents on wound care
and the importance of keeping the surgical site clean and dry as well
as monitoring the site for signs of infection. The parents are
instructed on pain management and the progression of activity over
a 2-week period and the resumption of normal nutritional intake as
directed by the health-care provider and as tolerated.
FUNCTIONAL GASTROINTESTINAL CONDITIONS

Irritable bowel syndrome (IBS) is a common cause of recurrent
abdominal pain in children. IBS affects males and females equally,
typically arising in school-age children and adolescents. IBS is
characterized by chronic pain and changes in bowel habits and
affects the large intestine. Symptoms are linked to visceral
hypersensitivity and altered motility (Blosser et al, 2018). IBS is
thought to involve a combination of motor, autonomic, and
psychological functions. A diagnosis is generally made by ruling out
organic causes for the symptoms, such as other inflammatory
diseases, lactose intolerance, and parasitic infections.
IBS is sometimes referred to as “nervous stomach” or spastic
colon. IBS is classified as a functional GI disorder because the
symptoms occur when the intestines, or bowels, function improperly.
When the intestines are exposed to certain “triggers,” they respond
with muscle spasms instead of normal peristalsis. These muscle
spasms result in one or more of the symptoms of IBS. Triggers that
can cause the symptoms of IBS to “flare” include eating large
amounts of food at one time; eating spicy, high-fat, or gas-causing
foods; or stress. Most children with IBS have various symptoms
including variable stool patterns, alternating between constipation
and diarrhea.
Signs and Symptoms

Children with IBS have abdominal pain beginning with a change in
stool frequency or consistency. IBS does not cause constant
symptoms, and exacerbations can occur at any time. Other
symptoms include flatus, bloating, constipation, diarrhea, or a
combination of both constipation and diarrhea. Children with frequent
bouts of IBS or those who suffer several symptoms simultaneously
may experience headache, nausea, anorexia, and weight loss.
Assessment Tool
The Rome Criteria III provides a criteria guideline that is commonly used to
diagnose IBS that includes:
• Abdominal discomfort or pain commonly associated with at least two of the
following:
- Improved with defecation
- Onset associated with a change in frequency of the stool
- Onset associated with a change in form of the stool
• No evidence of inflammatory, anatomical, metabolic, or neoplastic disorder
that would explain symptoms
Additional symptoms of IBS may include:
• Pain described as dull or cramping
• Tenesmus
• Fever
• Weight loss
• Abnormal stool frequency (i.e., four or more per day or two or fewer per week)
• Abnormal stool form (i.e., lumpy and hard, loose and watery, or alternating
between diarrhea and constipation)
• Straining, urgency, or feeling of incomplete bowel emptying
• Bloating or feeling distended
• Dyspepsia
• Hematochezia (stools containing red blood rather than tarry stool)
Diagnosis
Since there is no specific test or procedure to diagnose IBS, the
diagnosis is based on clinical signs and symptoms, history, and
physical assessment. The history includes finding a family pattern of
IBS and discovering the triggering events or psychosocial factors. A
diagnosis of IBS is also made by ruling out other GI disorders.
Recommended laboratory studies to verify the diagnosis and rule out
other conditions include CBC, erythrocyte sedimentation rate (ESR),
c. reactive protein, urinalysis and optional serum electrolytes,
thyroid-stimulating hormone, blood glucose/Hb A1c, and renal and
liver function studies.
Prevention
Prevention and control of the symptoms of IBS include maintaining a
well-balanced, low-fat diet; avoiding caffeine, fatty and gas-causing
foods, and cruciferous vegetables; and avoiding large meals.
Collaborative Care
NURSING CARE
Nursing care of the child admitted with symptomatic IBS is
supportive and includes management of fluid balance, nutritional
support, and pain control.
MEDICAL CARE
The goal of management is to modify the symptoms and identify
strategies for dealing with factors that trigger the symptoms.
Treatment for IBS may include a combination of pharmacological
and nonpharmacological therapies (Kwon et al, 2019). Identifying
foods that trigger symptoms is most important. Triggers may include
caffeine, fatty food, large meals, gas-producing foods, lactose, and
cruciferous vegetables (Starr et al, 2020). Food diaries are very
useful in helping determine what foods must be avoided. In addition,
eating more fiber and less fatty foods seems to help prevent
intestinal muscle spasms. Having the child drink plenty of liquids,
including water, can promote regular stool elimination patterns.
Healthy toilet training and toileting patterns can control some
symptoms. Promoting a healthy routine for regular bowel elimination
can decrease the symptoms and the stress related to worry about
bowel movements at school or at other inconvenient times.
Encouraging the child to adapt positive strategies for managing
stress can prevent exacerbations.
Family support and education are the primary goals in nursing care.
The nurse can assist the parent and child in developing strategies
that will decrease symptoms. Nutritional strategies include eating
more slowly, avoiding carbonated drinks, and including fiber in the
diet. The child also needs support and assistance in developing
strategies to reduce environmental stressors.
Acute Diarrhea
Though the term gastroenteritis has been used to describe diarrhea
in the past, the term is now considered by many health-care
providers to be a misnomer because the cause of diarrhea does not
involve the stomach (Starr et al, 2020). One of the most common
side effects of antibiotic use is antibiotic-associated diarrhea.
Infectious agents associated with diarrhea include bacteria
(Campylobacter jejuni, Clostridium difficile, Yersinia enterocolitica,
Salmonella, Shigella, and enterohemorrhagic Escherichia coli) and
viruses (human rotavirus and adenovirus) (Starr et al, 2020).
Signs and Symptoms

■ Increased frequency and fluid content of the stools with or without
associated symptoms
■ Parents are asked about the presence of other signs and
symptoms, such as vomiting, fever, and pain with special attention
to the number of wet diapers within the previous 24-hour period
■ Signs of systemic illness may also be evident
The nurse also explores the history, which includes:
■ Food allergies
■ Recent travel, especially to a foreign country or residing in an area
with untreated water
■ Dietary consumption, with special attention to the consumption of
poorly cooked food, poultry, shellfish, unpasteurized or
underpasteurized milk or juice, homecanned food, fresh produce,
and raw or undercooked eggs
■ Daycare attendance
■ Family members with similar symptoms
■ Medications
■ Pica
■ Recent changes in weight or growth patterns
■ Response to rehydration
Diagnosis
A thorough history that includes recent travel, daycare or school
illness contacts, family members with similar illnesses, ingestion of
medications and toxic substances, and a dietary history is included
in an interview to determine diagnosis. In addition, information
regarding the number of stools, frequency, and quality is elicited and
includes when the symptoms began.
The physical examination focuses attention to the abdomen and
perineum in addition to state of alertness, changes in the growth
pattern, and the hydration status of the child. Laboratory tests are
selected based on the suspected etiology and the overall health and
appearance of the child. No blood tests may be indicated for an
essentially well-appearing child. For a child demonstrating symptoms
of toxicity, stool for culture and sensitivity (C&S), serum electrolytes,
and a CBC with differential are suggested. Diarrhea with weight loss
suggests the need for serum electrolytes and CBC with differential.
Evidence of blood in the stool with or without a history of antibiotic
use suggests a need to assess stool for C&S, CBC with differential,
and serum electrolytes.
Prevention
Prevention of acute diarrhea includes proper hand washing, food
handling, and care of soiled diapers and clothing. In addition, some
episodes of acute diarrhea can be avoided by avoiding overfeeding
the child and use of excess juice in the diet.
Collaborative Care
NURSING CARE
Care of the child hospitalized for acute diarrhea includes
monitoring fluid intake and output, observing for signs of
dehydration, offering fluids as indicated, and monitoring IV infusions
if ordered. The skin integrity of the perineal and buttock areas must
be monitored for irritation related to frequent stooling, and good
perineal skin care must be provided.
MEDICAL CARE
Most incidences of acute diarrhea are self-limiting. Management of
viral and most bacterial causes is primarily supportive. Treatment of
acute diarrhea is determined by extent of the illness and the cause,
with attention to hydration and dietary needs as appropriate and with
prevention as a priority (Starr et al, 2020). Initially the priority is to
restore and maintain hydration. Oral rehydration is generally
attempted before IV hydration is initiated and is again related to the
acuity of the illness and its effect on the child.
Education on preventive measures is essential. The child and
parents need to be instructed on good hand hygiene. The nurse
must reinforce proper hand washing to include not only that which
follows toileting or diaper changes but also before and after eating
and in the preparation of foods. In addition, appropriate care of
soiled clothing and diapers is essential.
The most effective treatment for gastroenteritis for children in
schools, day care, and community is prevention through good hand
washing. Hand washing with water and soap in sufficient amounts to
cover all surfaces of the hands and fingers with 15 seconds of
rubbing that causes friction is to be done when hands are visibly
soiled, after using the restroom or diaper change, before eating, and
after caring for children with any type of secretions. Single-use
towels are used to dry the hands and turn off the faucet to avoid
recontamination.
Chronic Diarrhea
Chronic diarrhea is defined as three or more stools passed per day
for 14 days or longer, though healthy infants may pass five to eight
stools per day (Starr et al, 2020). Chronic diarrhea is usually
associated with a chronic condition, such as IBD; malabsorption
syndromes; overfeeding; formula protein intolerance; lactose
intolerance; food allergies; viral, bacterial, or parasitic agents;
radiation therapy; or immunodeficiencies.
Collaborative Care
NURSING CARE
The general nursing care of the child with chronic diarrhea is
similar to that of acute diarrhea with special focus related to the
underlying cause. As with acute diarrhea the child and parents need
to be educated on primary prevention.
MEDICAL CARE
Management of chronic diarrhea involves treating the underlying
cause. The treatment for toddler’s diarrhea is a change or reduction
in the child’s intake of fruit juices.
Child and parent instructions are similar to those provided for acute
diarrhea as they apply to the underlying cause.
Vomiting
Vomiting is the forceful expulsion of stomach contents. The type of
emesis assists in identifying the cause. Nonbilious vomit is typically
caused by infectious, metabolic, neurological, or psychological
issues (Starr et al, 2020). Bilious vomiting (vomit containing bile) is
more likely caused by an obstructive process. Bloody emesis is
usually evidence of active bleeding in the GI tract, such as PUD or
gastritis. The nurse communicates to the family that nausea and
retching often accompany vomiting. Regurgitation in contrast is a
more passive and effortless phenomenon. Table 16-1 lists the most
common causes of vomiting related to origin.
Signs and Symptoms

Specific manifestations and diagnosis related to vomiting vary as
greatly as the causes and origin of the illness. A thorough history
and assessment must include a description of the onset, duration,
quality and quantity, appearance, presence of undigested food, odor,
and evidence of a precipitating event. The child’s recent exposure to
illness, injury, or stress, in addition to family history of a similar
illness, needs to be determined. The parents or child are asked
about the relation of the vomiting to the time of day, meals, or other
activities. Associated symptoms, such as fever, diarrhea, ear pain,
headache, and signs of increased intracranial pressure or urinary
tract infection are also evaluated. Vomiting upon arising in the
morning is often associated with neurological involvement. The
nurse also asks the parent or child about medications currently being
taken to include over-the-counter, herbal, cultural, and homeopathic
remedies (Starr et al, 2020). The nurse assesses the abdomen for
the following:
TABLE 16-1
Common Causes of Vomiting
ORIGIN CAUSE
Upper GI • Gastritis
• Esophagitis
• Pyloric stenosis
• GERD
Small intestine • Intestinal malrotation with volvulus
Colon • Hirschsprung’s disease
• Intussusception
• Fecal impaction
Liver or pancreas • Hepatobiliary dysfunction
Infections • Bacterial enteritis
• Otitis media
• Urinary tract infection
• Viral gastroenteritis
• Hepatitis
• Sepsis
• Chronic sinusitis
Neurological • Hydrocephalus
• Brain tumor
• Migraine headache
• Head trauma
• Congenital malformation
• Cyclic vomiting syndrome
Other • Cow’s milk protein allergy
• Maternal drug exposure and withdrawal
• Toxic ingestion
• Appendicitis
• Inborn error of metabolism
• Pneumonia
• Drug or alcohol ingestion
• Eating disorders
• Pregnancy
• Diabetic ketoacidosis
■ Distention
■ Visible peristalsis
■ Bowel sounds; depending on the cause of the vomiting, bowel
sounds may be hyperactive or hypoactive
■ Signs of dehydration
■ Evidence of malnutrition
Diagnosis
In addition to a thorough history and physical examination,
diagnostic studies may include urinalysis and culture, CBC, serum
electrolytes, blood culture, liver function tests, and select abdominal
imaging depending on suspected cause of the vomiting. Plain
radiograph or ultrasonography of the abdomen may detect
anatomical abnormalities. Endoscopy of the upper GI tract can be
used if esophagitis is suspected. Further studies may include a
toxicology screen, rapid strep test/throat culture, pregnancy test, or
electroencephalogram depending on the suspected origin of the
vomiting.
Prevention
If vomiting is related to improper feeding technique, prevention can
be directed toward instructing the parents on proper formula
preparation and positioning the infant during feeding.
Collaborative Care
NURSING CARE
Nursing care is determined by cause and generally focuses on
careful observation and support. Care is taken to carefully position
the child who is vomiting to prevent aspiration. The nurse assesses
for signs of dehydration and carefully monitors fluid intake and
output. Oral hygiene may include rinsing the mouth or brushing the
teeth after vomiting to dilute the hydrochloric acid that comes in
contact with the teeth.
MEDICAL CARE
Management of vomiting is directed toward the treatment of the
cause and prevention of complications. The degree of dehydration is
determined and treated. For self-limiting causes of vomiting in
childhood, the bowel is allowed to rest. Rehydration is generally
initiated after 1 to 2 hours with nothing by mouth. Plain water, apple
juice, soda, milk, and sports drinks are avoided. Depending on the
child’s age and size, 0.5 to 2 oz of a rehydrating solution may be
offered at 15-minute intervals. Breastfed infants may be nursed more
frequently for shorter periods. Solids are avoided for 4 to 6 hours
after which reintroduction is begun with bland solids, which may
include complex carbohydrates, such as rice, wheat, cereals, yogurt,
cooked vegetables, and lean meats. Fatty foods and those high in
simple sugars are avoided.
If vomiting has been determined to be related to improper feeding
technique, the caregiver needs instruction on food or formula
preparation and a demonstration of correct positioning during and
after feeding.
Constipation
Constipation is the difficult or infrequent passage of hard stool,
which is often associated with straining, abdominal pain, or
withholding behaviors. Frequency alone is not a good diagnostic
criterion because children vary greatly in their stooling frequency.
The North American Society for Pediatric Gastroenterology,
Hepatology, and Nutrition (NASPGHAN) criteria for constipation is
delay or difficulty in passing stools for 2 or more weeks, causing
significant distress (Rosen et al, 2018).
Constipation accounts for 3% of pediatric primary care clinic visits
and 25% of pediatric gastroenterologist visits (Krebs et al, 2020).
Studies estimate the prevalence of chronic constipation in North
America to be between 2% to 27% of children with a peak between
the ages of 2 and 4. This condition is more common in males than in
females until adolescence, after which it is seen more frequently in
females (Rosen et al, 2018).
Constipation may occur secondary to an organic cause or in
association with a systemic condition. Strictures and Hirschsprung’s
disease are included among organic causes. Systemic conditions
that may be a factor in the development of constipation include
hypothyroidism, hypercalcemia caused by hyperparathyroidism or
vitamin D excess, and chronic lead poisoning. Drugs such as
antacids, diuretics, iron supplements, opioids, antihistamines, and
antiepileptics are also associated with constipation as a side effect.
Children with spinal cord pathology may experience a loss of rectal
tone and sensation.
MEDICATION
Medications Used for Vomiting
A combination of medications is used for sedation and the relief of pain,
nausea, and vomiting. This may include a combination of diphenhydramine
(Benadryl), lorazepam (Ativan), promethazine (Phenergan), ondansetron
(Zofran), and ketorolac (Toradol) with ranitidine (Zantac). For severe abdominal
pain, morphine may be added. Prophylactic medications for CVS include
cyproheptadine (Periactin), sumatriptan (Imitrex), or amitriptyline (Elavil) (Starr
et al, 2020).
Most constipation is considered idiopathic or functional with no

clear underlying cause. Environmental and/or psychosocial factors
such as travel, illness, dietary changes, and emotional factors may
cause chronic constipation. Children may also experience
constipation during toilet training, which is related to not wanting to
take time from play or from overenthusiastic toilet training. Dilation
and stretching of the rectum may come from repeated withholding.
This leads to a decreased sensation or urge to pass stool. Lack of
exercise and poor dietary fiber intake commonly cause constipation
in children.
Constipation in school-age children is often due to organic and
environmental factors. For example, fear of using school restrooms
or embarrassment in asking the teacher is a common cause of
constipation in early school-age children. Separation, change in
routine, and change in eating and sleeping patterns may all
contribute to the changes in bowel habits. Some children may try to
“hold” their stool until a later time. When they do finally try to
eliminate the stool, it may be very hard and painful. The longer the
child holds the stool and delays elimination, the harder and larger the
stool becomes and the more painful the process.
Signs and Symptoms
The major symptoms associated with constipation are poor appetite
and straining with stools. Soiling is more common with the diagnosis
of encopresis. Additional signs include:
■ Hard stools with occasional blood sometimes seen in the outer
surface of the stool
■ Changes in stooling pattern (i.e., size, frequency, amount, and
color)
■ Pain with defecation
■ Diarrhea leakage
■ Tenderness in the area of the colon and small intestine
■ Rectal fissures
■ Withholding behaviors such as crossing legs, squatting, hiding in a
corner, or dancing
Diagnosis
Diagnosis of constipation is based on the symptoms. An abdominal
radiography and barium enema may be ordered for children who do
not respond to treatment.
Prevention
Prevention of constipation can occur through good toileting habits
and reinforcement of sitting on the toilet for defecation as well as
maintaining a well-balanced diet, hydration, and age-appropriate
exercise.
Collaborative Care
NURSING CARE
Care of the child with constipation begins with a careful
assessment of bowel patterns, diet history, drug history, and
environmental factors. The nurse asks the parent to describe the
color, consistency, frequency, and characteristics of the stool.
MEDICAL CARE
Simple constipation can generally be managed by focusing on
dietary intake and keeping the bowel relatively empty. Occasional
constipation caused by dietary intake can be treated with adequate
intake of water and other fluids, which assist in regulating
elimination. A regular diet, rich in all nutrients coupled with an
adequate amount of water and other fluids, is the best way to ensure
normal bowel elimination patterns. Fresh fruit and vegetables add
fiber and can relieve constipation. Limiting dairy products such as
cheese can also provide relief. However, many children can be
“picky eaters” at times, preferring fast food or the same food for
every meal. This type of eating can lead to disruptive bowel patterns,
including constipation. Occasionally, stool softeners may be needed
to “train” the child and the bowels into a regular pattern of
elimination. Giving the stool softener at bedtime allows it to work
gently overnight to foster a morning elimination pattern. No
medication is used on a long-term basis without a physician’s
prescription or health-care provider’s guidance.
Chronic constipation may require strategies to restore a regular
stooling pattern, hence shrinking the distended rectum to a normal
size and promoting regular toileting practices. Therapy for chronic
constipation may include bowel cleansing and maintenance therapy
to prevent further stool retention. Initial treatment of chronic
constipation includes removing hard, impacted stool, which may be
accomplished through use of suppositories, enemas, and
occasionally the use of polyethylene glycol electrolyte solution
(GoLYTELY) administered orally or by nasogastric tube. A
combination of mineral oil and enemas may be used for severe
impaction for which suppositories are not effective. Rarely, surgical
removal is needed.
Once the impaction is removed, maintenance therapy includes use
of mineral oil, stool softeners, and laxatives. Stool softeners may not
be effective for severe constipation. The safest laxatives are milk of
magnesia and polyethylene glycol (MiraLax).
Bowel retraining includes developing good toileting habits and
reinforcement of sitting on the toilet for defecation. A regular toileting
time is established once or twice per day. The child sits on the toilet
5 to 10 minutes with positive behaviors reinforced.
Optimizing Outcomes
Constipation
A 2½-year-old child has not passed a stool in 5 days. The parents report that
the child has been eating and growing well and has no other symptoms of
illness. They report that the last stool passed was firm and appeared to cause
the child some discomfort. The parents also report no evidence of blood has
been noted in the stool. In addition, the parents began toilet training the child
approximately 3 weeks ago.
The best outcome for the family is to understand that the child is normal. The
nurse can discuss toilet training readiness, including not only physical readiness
but also mental and psychological readiness. In addition, the nurse can include
instructions regarding the importance of water and high fiber in the diet and the
avoidance of excessive refined carbohydrates.
Parent education is an important part of nursing care and includes
instruction on dietary needs, toileting practices, and bowel cleansing
as needed.
Gastroesophageal Reflux and Gastroesophageal Reflux Disease

Gastroesophageal reflux (GER) is the return of gastric contents from
the stomach through the lower esophageal sphincter back up into
the esophagus. Classifications of reflux includes physiological, also
called functional, and pathological reflux referred to as
gastroesophageal reflux disease (GERD). GER consists of
infrequent and episodic vomiting or spitting up and is a common
occurrence in many healthy infants. This can be caused by the
shorter distance for food to travel from the stomach to the
esophagus and the decreased lower esophageal sphincter (LES)
tone. As infants grow, a decrease in the incidence of GER is seen as
the esophagus elongates and matures. By contrast, forceful and
repeated vomiting in infants is not normal and should be taken
seriously (Rosen et al. 2018).
Functional or physiological GER involves painless, effortless
vomiting with no physical sequelae (Starr et al, 2020). Infants who
spit up or regurgitate stomach content while maintaining normal
nutrition meet the criteria for functional GER. Factors that affect the
occurrence of functional GER include small stomach size, short
esophagus, liquid diet, horizontal positioning, and frequent, large-
volume feedings.
Pathological reflux, or GERD, is frequent with associated physical
dysfunction. The diagnosis of GERD is generally considered when
reflux persists beyond 18 months of age and involves an increased
frequency and duration of episodes. GERD occurs in approximately
5% to 8% of newborns and has been associated with apnea and
other life-threatening events. GERD is often associated with
esophagitis, failure to thrive, and aspiration pneumonia and is noted
after there is a pathological and/or histological change because of
reflux. Children with GERD beyond 18 months are more likely to
experience symptoms similar to an adult’s.
The incidence of GER in healthy infants is approximately 40% to
50% as demonstrated by regurgitation followed by crying. The
incidence of GER peaks at approximately 4 months of age, then
steadily declines.
GERD is more common in premature infants and those born with
neurological impairments. GERD can be identified in as many as
70% of low-birth-weight infants (1,700 g) with up to 85% of those
infants becoming symptom-free by 1 year of age (Starr et al, 2020).
Reflux disease remains significant in 1% to 3% of older children.
The cause of GER is unknown and considered multifactorial.
Neuromuscular immaturity of the lower esophagus, age, hormones,
and intra-abdominal pressure are suggested as factors in the
development of GERD. The following information will focus mainly
on GER with some integration of information about GERD.
Signs and Symptoms

The most common symptoms of GER are vomiting and regurgitation
that is nonbilious and includes undigested formula or food.
Associated symptoms include:
■ Irritability and fussiness
■ Dysphagia or refusal to feed
■ Choking
■ Chronic cough
■ Wheezing
■ Apnea
■ Weight loss
■ Frequent respiratory infections
■ Bloody vomit or hematemesis
■ Hoarseness or sore throat
■ Halitosis
■ Chronic sinusitis and/or otitis media
Diagnosis
Diagnosis of GER is through history and physical examination. An
upper GI series may be used to rule out anatomical abnormalities,
but it does not provide information about the physiological function of
the esophagus and is considered an unreliable diagnostic test for
pathological GERD. Postswallowing reflux can be observed through
a barium swallow. A 24-hour intraesophageal pH monitoring study is
essential in the diagnosis of GERD. If esophagitis, strictures, or
Barrett’s esophagus is suspected, an endoscopy with biopsy may be
completed to confirm the diagnosis.
PROCEDURES ■ Enema
An enema is given to remove stool and/or gas from the bowel. The health-care
provider orders the enema and determines the next step(s) if the enema is
unsuccessful. For an infant, a catheter between 2.5 and 3.5 cm is used. For a
child the catheter size is 5 to 7.5 cm. A common type of enema is a Fleet’s®
Enema. Before the procedure, educate the parent and child (if appropriate) that
the enema is inserted into the rectum, given slowly, and that there may be a
feeling of abdominal distention.
The basic procedure includes the following important steps:
1. Use two patient identifiers to ensure the correct patient will receive the
enema.
2. The tip of the enema is lubricated, but more water-soluble jelly can be
applied as needed.
3. Apply a bed protector and ensure the child (depending on age) can readily
reach a bedside commode chair, bathroom, or use a bedpan. The infant is
diapered.
4. Gather hygiene supplies such as a basin, soap, water, towels, and
washcloths.
5. Perform hand hygiene and don gloves.
6. Provide privacy.
7. Raise the bed to a comfortable working height.
8. Separate the buttocks and locate the anus.
9. Gently insert the tip of the enema into the child’s rectum to the
recommended depth with the tip directed toward the umbilicus.
10. After instilling the solution, gently remove the tip.
11. After an appropriate interval, transfer him to the bedside commode chair,
bathroom, or bedpan.
12. Have the child expel the solution.
13. Clean the child’s perianal area and help him resume a comfortable position
in bed.
14. Measure the amount of returned solution and quality of the feces.
15. Dispose the used equipment and other items.
16. Remove gloves and perform hand hygiene.
17. Document the procedure in the child’s records.
Prevention
Preventive activities include instructing parents on proper formula
preparation, feeding, and positioning the infant during and after
feeding.
Collaborative Care
NURSING CARE
Healthy, well-nourished infants need no treatment for physiological
reflux. As the child grows and gains weight, typically the symptoms
of GER resolve. Physiological GER symptoms should resolve by 18
months of age. If symptoms of GER persist or interfere with the
child’s growth and development, then further evaluation for GERD
should occur.
Common interventions include providing parent support and
anticipatory guidance. The parents need to be reassured that there
is no underlying disease. For example, steps in managing GER with
no underlying structural problems may begin with evaluating and
changing the volume of the feeding such as offering small amounts
more often and burping frequently. Thickening of feedings with
cereal, although controversial, can provide sufficient calories while
reducing the volume. One teaspoon per ounce of dry infant cereal
may be added to 1 to 2 ounces of formula. Care must be taken when
adding cereal to formula because it increases the caloric density of
the formula and decreases the amount of fluid intake. Intra-
abdominal pressure increase can be avoided by positioning the
infant in an upright position (generally no higher than a 45-degree
angle) after feeding. In addition, right side-lying positioning facilitates
gastric emptying.
Nursing care for either GER or GERD includes a thorough
assessment of the infant’s growth measurements and developmental
patterns. Feeding patterns are evaluated, and the amount, type, and
frequency of feedings are established with the pattern of
regurgitation or emesis related to the feedings. In addition,
information about positioning and burping after feedings are
determined. A baseline respiratory status is important because of the
risk of aspiration associated with GERD.
MEDICAL CARE
If the infant experiences complications, pharmacological therapy
may be offered. Proton-pump inhibitors, such as omeprazole
(Prilosec), esomeprazole (Nexium), pantoprazole (Protonix), and
lansoprazole (Prevacid), provide effective medical therapy for
heartburn and esophagitis though are not recommended in the
treatment of otherwise healthy infants (Rosen et al. 2018). H2
inhibitors such as cimetidine (Tagamet) may also reduce heartburn
though are considered less effective. One particular H2 inhibitor,
Ranitidine (commonly known as Zantac), has been recalled due to
small traces of N-Nitrosodimethylamine (NDMA). Prokinetic drugs,
such as metoclopramide (Reglan), offer enhanced stomach
emptying and increased lower esophageal sphincter control though
the benefit is considered minimal.
SURGICAL CARE
Surgical treatment may be recommended for severe symptoms,
such as those that are life-threatening or unresponsive to
nonsurgical interventions. The surgical intervention of choice for the
treatment of GERD is a Nissen fundoplication (wrapping the
gastric cardia with adjacent portions of the gastric fundus) (Venes,
2021).
Much of the initial nursing care focuses on educating the parents
regarding dietary modifications, positioning, and pharmacological
therapy if prescribed. The importance of frequent burping and
suggested positions for burping is also discussed with the parents.
Depending on the age of the child and the nature of the diet,
education may also include information about dietary irritants (e.g.,
chocolate, caffeine products, citrus fruits, fruit drinks, and tomatoes).
If treatment includes use of thickened feedings, the nurse
demonstrates how to enlarge the hole in the nipple to better facilitate
this type of feeding. Parents may also need to be reminded to avoid
vigorous playing after feeding.
Hirschsprung’s Disease
Hirschsprung’s disease, also known as congenital aganglionic
megacolon, is caused by a congenital absence of ganglion cells (or
nerve innervation of the colon) that results in lack of motility in the
affected portion of the bowel. Hirschsprung’s disease is usually
limited to the distal colon. The absence of ganglion cells in the
affected portion of the bowel results in lack of nervous system
stimulation to that portion of the colon. This leads to abnormal or
absence of peristalsis in the involved segment and an inability of the
internal sphincter to relax. A complete or partial bowel obstruction
may occur as a result of this inability of the smooth muscles to relax.
This leads to an accumulation of bowel contents in the involved
segment of the bowel. The obstruction may extend proximally to
involve varying portions of the colon (Fig. 16-4).
Hirschsprung’s disease is the most common cause of neonatal
obstruction of the colon and accounts for up to 33% of all neonatal
obstructions (Gaylord & Yetman, 2018). The condition is familial, four
times more common in males, and more common in children with
trisomy 21 (Down’s syndrome).
Signs and Symptoms

The history of the child with Hirschsprung’s disease verifies the
following signs and symptoms:
■ Failure to pass meconium within the first 48 hours of life
■ Poor feeding
■ Chronic constipation
■ Down’s syndrome (Gaylord & Yetman, 2018) Physical findings
include:
■ Vomiting
■ Abdominal obstruction
■ Failure to pass stools
■ Diarrhea
■ Flatus
■ Explosive bowel movements
FIGURE 16-4 Hirschsprung’s disease.
In older children, the initial symptom is chronic constipation. The

child’s stools may be described as ribbon- or pellet-shaped and foul-
smelling.
Treatment
Treatment includes either a bowel program or a two-part surgery.
FOCUS ON SAFETY
Enterocolitis
Enterocolitis (inflammation of the small intestine and colon) is the most
ominous presentation of Hirschsprung’s disease. Enterocolitis may present in
an otherwise well infant with a history of constipation. The child with
enterocolitis may present with an abrupt onset of foul-smelling diarrhea,
abdominal distention, and fever. Rapid progression may indicate perforation of
the bowel and sepsis.
Diagnosis
Diagnosis in the newborn is suspected based on clinical presentation
or intestinal obstruction and failure to pass meconium. Radiographic
studies show evidence of a dilated loop of bowel. A barium enema
often demonstrates the transition between the dilated proximal colon
and the aganglionic distal segment, though this may not be evident
until age 2 months or later. Absence of ganglion cells is determined
by a biopsy. Rectal manometry and rectal suction biopsy are the
easiest and most reliable indicators of Hirschsprung’s disease. In
anorectal manometry, a balloon is distended in the rectum to
measure the pressure of the internal anal sphincter. In normal
patients, rectal distention initiates a reflex decline in internal
sphincter pressure. In patients with Hirschsprung’s disease, the
pressure fails to drop or there is a rise in pressure with rectal
distention.
Prevention
Because the condition is familial as well as associated with
chromosomal disorders, prevention includes comprehensive prenatal
care and counseling in families with a familial history of
Hirschsprung’s disease.
Collaborative Care
NURSING CARE
Initial care of the child with Hirschsprung’s disease involves
preoperative assessment of the child’s fluid and electrolyte status.
The child is placed NPO (nothing by mouth), and a nasogastric (NG)
tube is inserted. IV fluids and electrolytes are administered to
prevent and/or correct imbalances. Accurate intake and output are
maintained to include colostomy and nasogastric tube drainage.
SURGICAL CARE
Correction of Hirschsprung’s disease involves surgical resection of
the affected bowel with or without a colostomy. Surgical interventions
generally include a temporary colostomy followed by a subsequent
ostomy takedown and reanastomosis at age 6 to 12 months. Other
surgical options include excising the aganglionic segment and
anastomosing the normal proximal bowel to the rectum 1 to 2 cm
above the dentate line. Postoperative care includes routine post–
abdominal surgical intervention such as physical assessment, NPO,
pain management, wound care, and fluid maintenance. Patency of
the NG tube is maintained along with monitoring for abdominal
distention and assessing for return of bowel sounds.
The nurse instructs the parents how to care for the temporary
colostomy. The instructions include care of the skin, appliance
application, and referral to community resources. The parents also
need to be instructed on the symptoms of complications, such as
enterocolitis, leaks, and strictures at the site of anastomosis. Signs
of leaks include abdominal distention and irritability. Constipation,
vomiting, and diarrhea may indicate strictures. Signs of enterocolitis
may include abdominal distention and pain in addition to fever,
diarrhea, or shocklike symptoms.
MALABSORPTION DISORDERS
Lactose Intolerance
Lactose intolerance is an inability to digest milk and some dairy
products, which leads to symptoms of bloating, cramping, and
diarrhea (Hyams, Lorenzo, and Saps, 2016). This condition results
from a deficiency in the enzyme lactase, which is necessary for the
digestion of lactose in the small intestine where lactose is hydrolyzed
into glucose and galactose.
Developmental lactose deficiency can occur in infants born before
34 weeks of gestation and is related to the immaturity of the
intestinal tract.
Signs and Symptoms

Lactose intolerance can have any of the following symptoms:
■ Bloating
■ Cramping
■ Abdominal pain
■ Flatulence
■ Pain and diarrhea occur often within 30 minutes of the ingestion of
lactose-containing products
■ Recent history of viral gastroenteritis
■ Signs in infants include vomiting, distention, or abdominal pain
after ingesting lactose-containing formula or the ingestion of cow’s
milk by the breastfeeding mother
■ Severe watery diarrhea with stools positive for reducing substance
may be evident in infants with congenital lactase deficiency
Diagnosis
Lactose intolerance is diagnosed on the basis of the history and a
decrease in symptoms with elimination of lactose products from the
diet. Diagnosis is further confirmed with the reintroduction of lactose-
containing foods and a flare of symptoms, along with the breath
hydrogen test. This test measures hydrogen in the breath after a
challenge with the ingestion of 50 grams of lactose (Hyams,
Lorenzo, Saps, 2016).
Celiac Disease
Celiac disease, also known as gluten-induced enteropathy, celiac
sprue, or gluten-sensitive enteropathy, is a disorder in which the
proximal small bowel mucosa is damaged as a result of dietary
exposure to gluten. The disorder does not present until gluten
products have been introduced into the diet, usually between 6
months and 2 years of age. Celiac disease is a permanent
intolerance to gluten. The pathology shown with celiac disease
reveals a diffuse lesion of the upper small intestinal mucosa. Short,
flat villi; deepened crypts; and irregular vacuolated surface epithelial
layer and crypt hyperplasia are seen via light microscopy. As the villi
flatten out and atrophy, there is a decrease in the absorptive surface
of the intestine. Malabsorption with a decreased fat absorption
eventually affects the absorption of proteins; carbohydrates; and the
fat-soluble vitamins A, D, E, and K.
An estimated 1 in 300 people (up to 1% of the population) in the
United States has celiac disease, of which only a few are diagnosed.
Women are more likely to be affected than men. The disease is also
more common in persons of European descent and in those with
type 1 diabetes, autoimmune thyroiditis, trisomy 21, Turner’s
syndrome, and IgA deficiency (Hyams et al, 2016).
Signs and Symptoms

Early manifestations of celiac disease are nonspecific and include
anorexia, irritability, weight loss, and listlessness. Classic
presentation in the pediatric population begins around age 6 months
to 2 years and is characterized by GI manifestations as gluten
products are introduced into the diet. Classic symptoms include the
following:
■ Diarrhea
■ Abdominal distention and bloating
■ Steatorrhea, which is described as bulky, greasy, foul-smelling,
and putty-colored stool because of the large amount of undigested
fat content
■ Constipation
■ Vomiting
■ Abdominal pain
■ Anorexia
Atypical symptoms include:
■ Protuberant abdomen, loss of subcutaneous fat, hypotonia,
anorexia, lethargy, and muscle wasting because of protein losses
■ Anemia and bruising because of inadequate vitamin K absorption
■ Growth retardation
■ Osteoporosis
■ Delayed puberty development
■ Iron deficiency anemia
■ Abnormal liver function
■ Dental enamel defects
■ An atypical presentation of celiac disease may delay diagnosis
until adult years because the extraintestinal manifestations
overshadow the GI symptoms, which may be mild or entirely
absent
Diagnosis
The combination of clinical symptoms and serological markers may
suggest the diagnosis of celiac disease, though a small bowel biopsy
is essential to confirm the diagnosis and is performed before gluten
is eliminated from the diet (Hagopian et al, 2017). A positive biopsy
reveals atrophy of the villi, and deep crypts on the intestinal mucosa
is the definitive test (Starr et al, 2020). Laboratory studies detect
antibodies in addition to evidence of malabsorption and nutritional
deficiencies. The nurse understands that when gluten is removed
from the diet, these antibodies will disappear.
Prevention
Though celiac disease cannot be prevented, symptoms may be
reduced through careful dietary education and management to
include understanding and reading labels as well as being directed
to sources where gluten-free food may be obtained.
Collaborative Care
NURSING CARE
Care of the child and family dealing with gluten intolerance is
primarily directed at diagnosis, support, and education.
MEDICAL CARE
The treatment of celiac disease is a gluten-free diet. Since gluten
is found mainly in wheat and rye and to a smaller extent in barley
and oat products, it is recommended that they be eliminated from the
diet. Corn, rice, and millet are acceptable grains. Dietary consultation
may be helpful.
Tell parents that following a gluten-free diet can heal the damage to
the intestine and prevent further damage. The child and parents
need to be instructed on the hidden sources of gluten, which may be
found in many processed foods, such as thickening agents, soups,
and luncheon meats. Gluten is added to many foods as hydrolyzed
vegetable protein. Supplemental calories, vitamins, and minerals are
recommended during the acute phase. The nurse communicates to
the parents that normal amounts of fat are suggested. Improvement
is generally demonstrated within a week, though complete recovery
and histological normality may require 3 to 12 months (Hagopian et
al, 2017). Teach the family about adverse symptoms when gluten is
introduced to the diet, growth, and adherence to the gluten-free diet
(GFD). Monitoring the child at intermittent intervals is essential.
Optimizing Outcomes
Celiac Disease
Celiac disease requires a lifelong commitment to diet control. Providing optimal
outcomes for the child with celiac disease involves dietary guidance. For the
best outcome, instruct the child and parents on the importance of carefully
reading labels for hidden sources of gluten-based products. These can often be
found in common foods, such as ice cream, hot dogs, luncheon meats, soups,
and cookies.
Short Bowel Syndrome

Short bowel syndrome (SBS) is a malabsorptive disorder that results
from decreased mucosal surface area, usually caused by surgical
resection of the small bowel. Factors such as dysmobility and
overgrowth of bacteria can exacerbate the malabsorption. Volvulus,
gastroschisis, necrotizing enterocolitis, and atresias are the most
common causes of SBS in children. Crohn’s disease is also a cause
in older children. Trauma to the GI tract is a less common cause of
SBS.
Liver failure and recurrent infection are the most common causes of
mortality.
Signs and Symptoms

Malnutrition and diarrhea are the most common manifestations of
SBS. Additional symptoms include:
■ Steatorrhea
■ Diarrhea caused by carbohydrate malabsorption
■ Fatigue and lethargy
■ Foul-smelling stools
■ Flatulence
■ Weight loss
■ Potential for dehydration, acidosis, hyponatremia, and
hypokalemia resulting from inadequacy of the short bowel to
reabsorb fluid and electrolytes
Diagnosis
Diagnosis is confirmed by abdominal x-ray and ultrasound,
endoscopy, colonoscopy, and CBC that reveals anemia. A stool
sample may reveal presence of infection; blood; or unabsorbed
sugar, fats, and protein.
Prevention
Preventive care is directed toward avoiding or reducing
complications related to the disease process and treatment. This
may include educating parents on appropriate hydration, nutrition,
and medication compliance as well as care of the central line
catheter.
Collaborative Care
NURSING CARE
The focus of nursing care includes administration and monitoring
of nutritional therapy. Care must be taken to avoid the complications
of a central venous line (CVN) (a venous access device inserted into
the vena cava to infuse fluids and medicines) and total parenteral
nutrition (TPN) therapy (Venes, 2021) (Fig. 16-5). In addition, care
focuses on maintaining adequate nutrition and preventing
complications.
FIGURE 16-5 Total parenteral nutrition (TPN) is provided for the

child who is unable to maintain adequate oral nutritional intake.
Enteral feeding tube care is also important because care must be

taken to observe for signs of dislodgement, infection, or occlusion.
Feeding tolerance must also be included as part of nursing care.
Input, output, specific gravity, and weights are assessed daily by the
nurse. Stools are tested for occult blood, pH, and reducing
substances in addition to monitoring for vomiting, changes in the
appearance of the stools, and abdominal distention.
With prolonged hospitalization, the nurse needs to consider the
child’s emotional and developmental needs. Parents also need to be
provided with psychosocial support and education to assist them in
coping with the long-term effects of SBS. The plan of care includes
attention to interventions to promote family adaptation.
MEDICAL CARE
The use of TPN via a central line is part of the initial treatment of
SBS. The goal is to wean the child off IV nutrition progressing to
enteral feedings via nasogastric or gastrostomy tube as soon as
possible (Kwon et al, 2019).
The nurse communicates to the parents that the main purpose of
enteral nutrition is to promote adaptive growth of the small intestine.
Oral feedings may be started as tolerated for the infant to learn to
suck and swallow. Pacifiers are also encouraged for this purpose.
TPN may be gradually decreased as enteral and oral feedings are
increased.
Because children with SBS require long-term follow-up and care,
parental education focuses on caring for the central line once the
child is discharged. Additional instructions include assessing for
hydration and managing medications. Teach parents about using a
multidisciplinary approach that includes a gastroenterologist,
nutritionist, pediatric surgeon, social worker, and speech and
behavioral therapy. Home-care services provide the opportunity for
children with SBS to receive carefully monitored care at home. The
nurse may serve as a resource for connecting the family to the
appropriate home-care agencies, nutritional support services, and
supply sources.
Complications of a Central Venous Line

When the child has a CVL, the nurse observes the infusion site at least every 4
hours for complications such as infiltration, thrombophlebitis, fluid or electrolyte
overload, or air embolism. The site dressing and administration set are also
changed according to the institution’s policies.
HEPATIC DISORDERS
Biliary Atresia
Biliary atresia, or extrahepatic biliary atresia (EHBA), is an
idiopathic, progressive, inflammatory process that may involve
absence of some or all the major intrahepatic and extrahepatic biliary
ducts, resulting in fibrosis and obstruction. Biliary atresia is the
second most common liver disease diagnosed in infants with an
incidence that ranges from 1 in 10,000 to 15,000 live births. It is fatal
within the first 2 years of life if not corrected. The disease is more
common in premature infants. The exact cause of biliary atresia is
unknown. EHBA has two distinct presentations, postnatal and fetal,
with differing mechanisms of development suggested. Infections and
immune-related mechanisms are implicated in postnatal EHBS,
which represents 65% to 90% of cases. In the fetal form, there is a
congenital absence of patent biliary ducts.
Signs and Symptoms

The earliest clinical manifestation of EHBA and most outstanding
feature is jaundice, which can be first observed in the sclera.
■ Jaundice may also be evident at birth but usually is not apparent
until 1 to 2 weeks of age.
■ Urine is dark and stains the infant’s diaper.
■ Stools are lighter than normal and often tan to white in color.
■ The infant demonstrates poor weight gain and symptoms of failure
to thrive resulting from poor fat metabolism.
■ Pruritus (itching, burning, or tingling of the skin) and irritability are
present, which are often evidenced by an infant who is difficult to
comfort.
■ Hepatomegaly (enlarged liver) is an early symptom and the liver is
firm upon palpitation.
■ Splenomegaly (enlargement of the spleen) occurs later.
■ Ascites, bone fractures, and bleeding complications may occur
later in life.
Cirrhosis
The development of cirrhosis and progressive liver failure
characterizes chronic liver disease in childhood. Cirrhosis is a
pathological condition that occurs as an end stage to many liver and
inflammatory conditions such as biliary atresia and chronic hepatitis
leading to the development of diffuse hepatocyte injury, fibrosis, and
formation of nodules, which eventually distort the vasculature of the
liver leading to further complications such as portal hypertension.
Though chronic liver disease is rare in children, it includes a wide
range of disorders, such as malformations, genetic, drug-induced,
vascular, infection, and autoimmune disease (Krebs et al, 2020).
Severe liver disease is also a complication of hemophilia and cystic
fibrosis, which can lead to cirrhosis or irreversible damage. Chronic
inflammation or disease causes scar tissue formation, which leads to
impaired intrahepatic blood flow and ongoing necrosis resulting in
further cirrhotic changes.
Signs and Symptoms

Manifestations of cirrhosis vary depending on the cause:
■ General manifestations include jaundice, growth failure, muscle
weakness, anorexia, nausea and vomiting, weight loss, swelling,
and lethargy.
■ Impaired intrahepatic blood flow leads to anemia, abdominal pain,
edema, ascites, and GI bleeding.
■ If the cirrhosis is secondary to a disorder of fat metabolism, such
as obesity, hyperlipidemia, and insulin-resistant diabetes,
steatorrhea may be observed.
■ Portal hypertension and ascites are common symptoms of
cirrhosis in the child with biliary anomalies.
■ Splenomegaly is the most important sign of portal hypertension.
Splenomegaly may be demonstrated by the presence of anemia,
leukopenia, thrombocytopenia, and esophageal varices. These
conditions lead to easy bruising, epistaxis, and GI hemorrhage.
■ Jaundice, dark urine, and pruritus are symptoms of biliary
obstruction.
Diagnosis
Diagnosis of cirrhosis is based on history, physical examination,
laboratory values, and liver biopsy. Ascites, blood flow through the
liver and spleen, and patency of the portal vein can be confirmed by
Doppler ultrasonography, MRI or CT of the liver and spleen (Krebs et
al, 2020). Laboratory evaluation includes liver function tests, such as
bilirubin, aminotransferase, ammonia, albumin, cholesterol, and
prothrombin time. Liver biopsy may reveal evidence of nodules and
fibrosis; endoscopy may reveal esophageal varices and bleeding.
Prevention
catheter if needed.
Collaborative Care
NURSING CARE
Nursing care of the child with cirrhosis is similar to that of any child
with a severe life-threatening disease. Interventions include
monitoring for complications of malnutrition, hemorrhage, and
hepatic failure in addition to providing comfort measures and
emotional support for the child and family.
MEDICAL CARE
Because there is no successful treatment for cirrhosis, goals of
care management are similar to that of caring for a child with
hepatitis and directed at preventing and treating complications.
Malabsorption problems are treated with nutritional support, such as
a low-fat, low-protein diet and supplemental fat-soluble vitamins.
Fluid restrictions, diuretics, and low-sodium diet are used to treat
ascites. Blood and blood products are administered for the treatment
of bleeding complications, and hepatic encephalopathy is treated
with a reduced-protein diet.
SURGICAL CARE
The only definitive treatment for end-stage liver disease and
cirrhosis is a liver transplant, which improves the prognosis for many
children. A 90% 1-year survival rate has occurred as a result of a
combination of surgical techniques and the use of
immunosuppressive therapy. Emotional support is essential.
Parent education includes instruction on management of medication
side effects and compliance with medication. Education on nutritional
needs is important. The family may need referral for financial and/or
psychological support as well as recommendations as to where
available community resources can be located.
Portal Hypertension
Portal hypertension is a common complication of cirrhosis. It is
characterized by portal vein pressure increased to more than 5 mm
Hg greater than the inferior vena caval pressure by resistance to
blood flow to and from the liver. The increased pressure causes
collateral veins to form. Complications of portal hypertension include
GI bleeding and esophageal varices. Noncirrhotic causes of portal
hypertension include, but are not limited to, acquired abnormalities of
the portal and splenic veins, local trauma, peritonitis, pancreatitis,
portal or splenic vein malformations, hypercoagulable states, tumor
as a complication of bone marrow transplant or chemotherapy for
acute leukemia, and congenital hepatic fibrosis.
Signs and Symptoms

Signs and symptoms of portal hypertension vary with the underlying
cause and presentation.
Diagnosis
Common diagnostic studies are similar to those used to diagnose
cirrhosis.
Prevention
catheter if needed.
Collaborative Care
NURSING CARE
Nursing care of the child with portal hypertension is similar to that
of any child with a severe life-threatening disease. Interventions
include monitoring for complications of malnutrition, hemorrhage,
and hepatic failure in addition to providing comfort measures and
emotional support for the child and family.
MEDICAL CARE
Goals of care management are similar to that of caring for a child
with hepatitis and directed at preventing and treating complications.
Interventions include monitoring for complications of malnutrition,
hemorrhage, and hepatic failure in addition to providing comfort
measures and emotional support for the child and family. Bleeding
must be controlled if varices are present and may include transfusion
and use of vasopressor therapy.
Parent education includes instruction on compliance with medication
and observation for and management of medication side effects.
Families must be instructed on nutritional needs. The family may
need referral for financial and/or psychological support as well as
recommendations as to where available community resources can
be located.
Nonalcoholic Fatty Liver Disease

The most common form of chronic liver disease in children today is
nonalcoholic fatty liver disease (NAFLD), which is estimated to affect
10% of children in the United States. The prevalence is related to
obesity in the population with most cases occurring in overweight
children and is more common in children with type 2 diabetes
mellitus or hyperlipidemia. NAFLD is demonstrated by fatty changes
in the hepatocytes and varying degrees of inflammation, swelling,
and portal fibrosis (Kumar et al, 2016).
Signs and Symptoms

Children are often diagnosed during routine screening. NAFLD is
insidious; most children are asymptomatic with abnormalities found
upon a liver enzyme test or an abdominal ultrasound for an unrelated
complaint. Risk factors include obesity, insulin resistance,
hypertension, and dyslipidemia. General complaints include the
following:
■ Fatigue
■ Malaise
■ Upper right quadrant discomfort or epigastric pain
■ Central adiposity is present in 90% of children
■ Hepatomegaly is a common finding
Approximately 30% of children diagnosed with NAFLD
demonstrate acanthosis nigricans, which is indicative of insulin
resistance. Acanthosis nigricans is defined as a chronic inflammatory
skin disorder characterized by hyperpigmentation and hyperkeratosis
(Venes, 2021).
Diagnosis
Laboratory studies may include elevation of aspartate
aminotransferase/alanine transaminase (AST/ALT) ratio, increased
prothrombin time, decreased albumin levels, and increased serum
bilirubin. Ultrasound is selected as the imaging study of first choice
because of its lack of radiation exposure and cost compared with
MRI or CT scan. A liver biopsy may be used to confirm the findings
as well as differentiate NAFLD from alcoholic liver disease, though
efforts are made to avoid invasive procedures in children who do not
demonstrate evidence of excessive alcohol consumption or viral
hepatitis.
Prevention
The incidence of NAFLD can be reduced by decreasing the risk
factors associated with obesity, type 2 diabetes mellitus,
hypertension, and hyperlipidemia. Preventive activities may include
nutritional counseling, weight reduction, increased activity, and
medication compliance as appropriate to the cause.
Collaborative Care
NURSING CARE
Care of the child and family dealing with NAFLD is primarily
directed at early diagnosis, support, and education.
MEDICAL CARE
The goal of treatment is to prevent or reverse hepatic damage.
Treatment includes diet and exercise. Management includes weight
loss, control of hyperlipidemia and blood glucose levels, and
behavioral intervention. Nutritional counseling focuses on a low-in-
saturated-fat and high-fiber diet. Research suggests the benefit of
nutritional behavioral interventions in reducing liver fat (AAP, 2020).
NAFLD is considered a family disease because of lifestyle factors.
All family members need to be included in treatment and education,
which includes nutritional counseling, increasing activity, and
medication compliance.
Hepatitis
Hepatitis may be acute or chronic and involves an inflammation of
the liver that may be caused by viral, bacterial, fungal, or parasitic
infections or by chemical or drug toxicity. Six distinct viruses have
been identified as causing hepatitis: hepatitis A virus (HAV), hepatitis
B virus (HBV), hepatitis C virus (HCV), in addition to hepatitis D virus
(HDV), hepatitis E virus (HEV), and hepatitis G (HGV),
which are not common. HAV, HEV, and HGV cause only acute
infection. HBV and HCV cause chronic infections, whereas HDV has
both acute and chronic forms. Most cases of hepatitis in children are
caused by HAV and are most common in ages 5 to 14 years (Burns
& Dunn, 2018). HAV is found in the stool of infected individuals and
transferred by oral ingestion, which is easily spread in areas with
poor sanitation. Poor hygiene is also an important factor in the
spread of HAV. High-risk areas also include settings where there are
a number of children and infants in a common area, such as day-
care centers. Contact may occur directly through infected feces or
indirectly through food and water contamination. Outbreaks have
occurred in areas that have experienced sewage-contaminated
water, infected food handlers with poor hygiene, and shellfish caught
in water contaminated by sewage. The incubation period is 15 to 40
days (Kwon et al, 2019).
Signs and Symptoms

Characteristics for HAV, HBV, and HCV overlap considerably, are
characteristic of the preicteric phase, and include the following:
■ Headache
■ Anorexia
■ Malaise
■ Abdominal pain
■ Dark urine precedes the jaundice phase, which lasts approximately
1 week and usually precedes the onset of clinically detectable
disease.
The most common symptoms of the icteric phase include the
following and may last several weeks:
■ Jaundice
■ Hepatomegaly
■ Stools may appear clay-colored during this phase
■ Diarrhea is common in infants; constipation is more common in
older children
■ Poor weight gain
Prodromal symptoms (initial stages of the disease) often decline in
children during the icteric phase. Young children are often
asymptomatic or have a mild, nonspecific illness without icterus HAV,
HBV, and HCV.
Diagnosis
Diagnosis is based on history of exposure, symptoms, and
serological testing for markers of hepatitis A, B, and C and liver
function tests, specifically an elevation of ALT (an intracellular
enzyme involved in amino acid and carbohydrate metabolism), AST
(an intracellular enzyme involved in amino acid and carbohydrate
metabolism), and serum total bilirubin. Liver biopsy may be required
to establish the diagnosis and degree of disease, although it is rarely
indicated in the diagnosis of HAV (Venes, 2021). The nurse
understands that the presence of antigens or antibodies confirms
and differentiates the diagnosis of HAV, HBV, and HCV. Serum
immunological tests are not available to detect HAV, but there are
two HAV antibody tests: anti-HAV IgG and immunoglobulin M (IgM).
Anti-HAV is present at the onset and persists throughout life. A
positive anti-HAV test indicates the presence of a current infection,
immunity from a past infection, or immunization.
Prevention
Preventive measures include instructing the family on good hand
washing (the single most effective preventive measure), food
handling, careful disposal of excreta and stool or blood-contaminated
objects, and safe sexual activity. Hepatitis A vaccine is
recommended for routine immunization of all children beginning at
age 12 months and for children who may be living in high-risk
communities. Administer the second (final) dose 6 to 18 months after
the first. Unvaccinated children, 24 months and older, who are at
high risk should be vaccinated (American Academy of Pediatrics
[AAP], 2020). Hepatitis B vaccine is recommended for routine
immunization of all infants beginning at birth and for all children and
adolescents through age 18 who have not been previously
vaccinated.
Collaborative Care
NURSING CARE
Nursing care is directed at maintaining comfort and providing
adequate nutrition. The goal for management of viral hepatitis
includes early detection, support, and monitoring of the disease;
recognition of chronic liver disease; and prevention of spread of the
disease.
MEDICAL CARE
Management of hepatitis is primarily supportive because there is
no specific treatment and may include measures to provide rest to
the liver, hydration, and adequate nutrition while preventing
complications. Severe dehydration, vomiting, a prolonged
prothrombin time, or signs of encephalopathy are indications for
hospitalization.
Families need to be educated about preventive measures. Children
with mild symptoms can be cared for at home, which necessitates
the need to instruct the family regarding infection control, providing a
well-balanced diet, and providing rest. Children with HAV are not
considered infectious within a week after the onset of jaundice and
may resume school attendance at that time. The family also needs to
be instructed to avoid administering any medication to the child
because normal doses of drugs may become dangerous because of
the liver’s inability to process them.
ABDOMINAL TRAUMA: INJURIES

The leading cause of death in children and adolescents after the first
year of life is by injuries. Injuries are responsible for more than 50%
of all deaths in the 15- to 24-year age group. Motor vehicle injuries
are the primary cause of accidental death in the U.S. Abdominal and
GU injury represent about 10% of pediatric injuries, including
contusion or laceration to liver, spleen, and kidneys. Nursing care
measures include assessment, bedrest, pre- and postoperative care,
administration of medications, NG tube and TPN, and education.
Injuries to hollow organs are increasing, partly related to the
increasing number of improperly restrained children involved in
motor vehicle accidents. Both parents and children need to be
instructed on the proper use of seat belts, booster seats, and infant
car seats as well as on the use of protective gear when riding
bicycles, skateboards, or scooters.
SUMMARY POINTS
■ The GI system of the child is immature compared with that of an adult, leading
to variations in response to illnesses.
■ Pyloric stenosis, characterized by projectile vomiting and a palpable olive-
shaped mass in the epigastrium, is most common in the newborn period.
■ One of the most common causes of intestinal obstruction in infancy is
intussusception.
■ Anorectal malformations are usually evident at birth.
■ The most common type of hernia in children is an umbilical hernia.
■ Signs and symptoms of appendicitis include abdominal pain that begins in the
periumbilical area and moves to the right lower quadrant, accompanied by a
low-grade fever, nausea, and occasionally vomiting.
■ Treatment focus for IBD includes medication, nutrition, and often surgery.
■ Nursing care of the child with celiac disease includes education about the
gluten-free diet.
■ The complications of peritonitis and perforation from appendicitis can be
prevented by prompt recognition and diagnosis.
■ Care of the child with gastroesophageal reflux (GER and GERD) can be
managed by teaching the parents feeding and positioning methods to prevent
or reduce reflux.
■ Correction of Hirschsprung’s disease involves surgical resection of the
affected bowel with or without a colostomy.
■ Malabsorption disorders include lactose intolerance, celiac disease, and SBS.
■ Progressive cirrhosis and death occur from untreated biliary atresia in most
children by age 2.
■ Cirrhosis is a pathological condition that occurs as an end stage to many liver
and inflammatory conditions such as biliary atresia and chronic hepatitis.
■ Hepatitis may be acute or chronic and involves an inflammation of the liver.
Hepatitis may be caused by viral or bacterial infections, fungal or parasitic
infections, or chemical and drug toxicity.
■ About 10% of serious trauma cases involving children occur as a result of
abdominal and GU injuries, which include contusion or laceration to liver,
spleen, and kidneys.
REFERENCES
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schedule for persons aged 0 through 6 years. Retrieved from
http://www.aap.org/immunization/IZSchedule.html
Blosser, C. G., Brady, M. A., & Müller, W. K. (2018). Infectious diseases and
immunizations. In C. E. Burns, A. M. Dunn, M. A., Brady, N. B. Starr, & C. G.
Blosser (Eds.), Pediatric primary care (6th ed., pp. 410–432). St. Louis, MO:
Elsevier.
Chong, A. J., Fevrier, H. B., & Herrinton, L. J. (2019). Long-term follow-up of
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Esherick, Joseph, Slater, Evan, and David, Jacob. (2020). CURRENT practice
guidelines in primary care. (18th ed.). New York: McGraw Hill Education.
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Dunn, M. A. Brady, N. B. Starr, & C. G. Blosser (Eds.), Pediatric primary care
(6th ed., pp. 860–871). St. Louis, MO: Elsevier.
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and celiac disease autoimmunity. Pediatrics 140.
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Petersen-Smith, A. M., & McKenzie, S. B. (2018). Gastrointestinal disorders. In C.
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primary care (6th ed., pp. 795–844). St. Louis, MO: Elsevier.
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(Baltimore); 96:e8287.

Davis Advantage
CHAPTER 17

Cardiovascular Condition
I dedicate this chapter to the children with cardiac disease who I have
cared for as a nurse and nurse practitioner, and also as a mom of a
child with a congenital heart defect (CHD). My son went undiagnosed in
the first months of life before undergoing heart surgery. As a mom of a
heart warrior, this inspired my path toward nursing research in the hopes
of improving the lives of others affected by CHDs. This chapter is
dedicated to all the brave heart warriors and their families who support
and love them.
—Kristine Ruggiero, PhD, MSN, RN, CPNP-BC
CONCEPTS
Blood flow
Circulation
Cardiac defects
Cardiac disease
KEY WORDS
trabeculated
regurgitation
cardiac output
stroke volume
B-type natriuretic
peptide
positive inotropes
increased preload
increased afterload
stenosis
hypertrophy
prostaglandin (PGE:)
dilated (DCM)
or congestive cardiomyopathy
hypertrophic cardiomyopathy (HCM)
restrictive cardiomyopathy (RCM)
atherosclerotic
baroreceptors
postinterventional catheterization
LEARNING OBJECTIVES
■ Describe the anatomy and physiology and developmental aspects of the cardiac
system.
■ Discuss congenital heart disease (CHD) and its effect on a child’s growth and
development.
■ Examine the most common types of CHD in children conditions related to cardiac
diseases.
■ Prioritize developmentaly appropriate and holistic nursing care for children with
CHD and other acquired cardiac conditions.
■ Explore diagnostic and laboratory testing including the importance of
interventional cardiac catheterization procedures and medications for cardiac
conditions.
■ Develop teaching plans and discharge criteria for parents whose children have
cardiac conditions.
PICO(T)Questions
Use these PICO(T) questions to spark your thinking as you read

the chapter.
1. What are the (O) most important (I) teaching points nurses should explain to (P)
parents of children who are taking beta blockers for heart failure?
2. What are the (O) most important (I) evidence-based nursing interventions when
caring for (P) infants in the first week following surgery to repair congenital heart
defects?
INTRODUCTION
developmental aspects of the cardiac system. The discussion includes
an examination of the various cardiac diseases including
developmentally appropriate and holistic nursing care. Information about
diagnostic and laboratory testing and medications is given. Teaching
plans and discharge criteria for parents whose children have various
cardiac conditions are incorporated.
Children with cardiac problems are a complex population of patients
(Fig. 17-1). The heart is integral to all other bodily systems. While a child
can survive on one kidney or one lung, heart disease is not self-limited
and affects most other bodily systems. Cardiac diseases are often
associated with other syndromes (Table 17-1).
REVIEW OF THE HEART AND NORMAL CARDIAC

FUNCTION
Understanding the Heart Anatomy
A child’s heart contracts 60 to 180 times per minute depending on their
age. The heart never stops beating although it decelerates during rest
and sleep and accelerates during excitement, exercise, or illness.
Chambers
The heart consists of four chambers, two of which act as reservoirs
(atria) and two as pumping chambers (ventricles) to direct the blood flow
of the heart (Fig. 17-2).
The right atrium is a reservoir, or collecting chamber, for the
peripheral venous return. The right atrium receives deoxygenated blood
from the entire body (except the lungs) through the superior and inferior
vena cava and coronary sinus with an approximate oxygen saturation of
70%.
The left atrium receives fully oxygenated blood from the lungs through
the pulmonary veins, with an approximate oxygen saturation of 100%
(Venes, 2021). The ventricles are the remaining two chambers in the
heart. From the atria, blood empties into the ventricles through
atrioventricular (AV) valves. The right ventricle (RV) has smaller muscle
mass with trabeculated surfaces. The RV receives blood from the right
atrium and pumps it into the lungs via the pulmonary artery (PA). The
left ventricle typically is thicker with a smooth interior. The left ventricle
receives blood from the left atrium and pumps it into the systemic
circulation via the aorta (Venes, 2021).
Valves
There are four valves in the heart. Two are AV valves connecting the
atria and ventricles (Fig. 17-3). The tricuspid valve connects the right
atrium to the RV and is so named because it consists of three cusps or
“doors” that open to allow blood flow into the adjoining chamber and
then close to prevent backflow. The mitral valve, called a bicuspid valve
for its two cusps, connects the left atrium to the left ventricle. The aortic
and pulmonary valves are both tricuspid and are called semilunar valves
because each cusp looks like a half-moon. The pulmonary valve is
located at the junction of the RV and PA. It prevents regurgitation of
blood from the PA to the RV. The aortic valve, located at the junction of
the left ventricle and the ascending aorta, prevents regurgitation into
the left ventricle (Venes, 2021).
FIGURE 17-1 Child with severe CHD s/p repair at birth, 1 year of age,
and 3 years of age. Children with CHDs can have a good health-related
quality of life.
TABLE 17-1
Syndromes Associated With Cardiac Disease
SYNDROME/DISEASE/CHROMOSOMAL CARDIAC OTHER PHYSICAL
ABERRATIONS DEFECT/CONDITION FINDINGS
Down’s Syndrome AV canal, VSD Down’s facies,
developmental
delay
Noonan Syndrome Pulmonic valve Elfin facies, pectus
stenosis, LVH deformity, joint
laxity, undescended
testes, spine
abnormalities,
hypotonia, seizures
Williams’ Syndrome Supravalvular aortic Williams’ facies:
stenosis, PA stenosis include a small
upturned nose, long
philtrum (upper lip
length), wide mouth,
full lips, small chin,
and puffiness
around the eyes.
Hypercalcemia,
dental
abnormalities, renal
problems, sensitive
hearing, hypotonia,
joint laxity, overly
friendly personality
DiGeorge or Velocardiofacial Chromosome Interrupted aortic Decreased immune
arch, truncus response, low-set
arteriosus, VSD, PDA, ears, palate
TOF problems,
hypoparathyroidism,
hypocalcemia
Duchenne’s Muscular Dystrophy CM Generalized
weakness and
muscle wasting first
affecting the
muscles of the hips,
pelvic area, thighs,
and shoulders.
Calves are often
enlarged.
Marfan Syndrome Aortic aneurysm, Arms
aortic and/or mitral disproportionately
regurgitation long, tall and thin
with laxity of joints,
dislocation of
lenses, spinal
problems, stretch
marks, hernia,
pectus
abnormalities,
restrictive lung
disease
Trisomy 18 VSD, PDA, PS Multiple joint
contractures, spina
bifida, hearing loss,
radial aplasia
(underdevelopment
or missing radial
bone of forearm),
cleft lip, birth
defects of the eye
Trisomy 13 VSD, PDA, Omphalocele,
dextrocardia holoprosencephaly
(an anatomical
defect of the brain
involving failure of
the forebrain to
divide properly),
kidney defects, skin
defects of the scalp
CHARGE TOF, truncus Coloboma of the
arteriosus, vascular eye, Heart defects,
ring, interrupted aortic Atresia of the
arch choanae,
Retardation of
growth and
development,
Genital
abnormalities, and
Ear abnormalities
and deafness.
Fetal Alcohol Syndrome VSD, PDA, ASD, TOF Growth deficiencies,
skeletal deformities,
facial abnormalities,
organ deformities:
genital
malformations,
kidney and urinary
defects, central
nervous system
handicaps
VATER (VACTERLS) VSD and others Vertebral
anomalies, vascular
anomalies, Anal
atresia, Cardiac
anomalies,
Tracheo–
esophageal (T–E)
fistula, Esophageal
atresia, Renal
anomalies, radial
dysplasia, Limb
anomalies, Single
umbilical artery
Turner’s Syndrome CoA, ASD, AS Kidney problems,
high blood pressure,
overweight, hearing
difficulties, diabetes,
cataracts, and
thyroid problems,
lack of sexual
development, a
“webbed” neck, a
low hairline at the
back of the neck,
drooping of the
eyelids, dysmorphic,
low-set ears,
abnormal bone
development,
multiple moles
FIGURE 17-2 Chambers of the heart.
FIGURE 17-3 Valves of the heart.
Vessels
In addition to the chambers and the valves in the heart, major vessels
lead to and from the heart. The venae cava carry the blood from body
tissues to the right atrium. The superior vena cava enters from above
the heart and carries blood from the head, arms, and upper body. The
inferior vena cava enters from below the heart and carries blood from
the legs, abdominal organs, and lower part of the body. The PA is the
only named artery in the body that carries deoxygenated blood. It is
called an artery because it carries blood away from the heart, but
because it arises from the RV, it carries deoxygenated blood. It carries
this blood to the pulmonary capillary bed, where it interfaces with the
alveoli in the lungs and “picks up” oxygen. From the lungs, the blood
returns to the heart through the pulmonary veins into the left atrium (the
only veins that carry oxygenated blood). The blood leaves the left
ventricle through the aortic valve, through the aorta, and out to the body
(Fig. 17-4).
Normal Flow
It is important to understand the flow of blood through the cardiovascular
system because an interruption in any one of the vessels, valves, or
chambers causes a disruption in the cardiac output. Figure 17-5 shows
a schematic representation of normal blood flow through the heart.
Physiology
The simplest way to understand the physiology of the heart is to
comprehend that the purpose of the heart is to pump blood. This vital
pumping function provides a means to carry oxygen via the hemoglobin
to the tissues. Without oxygen delivery, cells die and ultimately body
systems fail. The heart must maintain cardiac output at all times.
Cardiac output is the amount of blood discharged from the left or
right ventricle per minute (Venes, 2021). Cardiac output is the product of
stroke volume (SV) and heart rate (HR) (CO = SV + HR).
Stroke volume is the amount of blood ejected by the left ventricle
with each heartbeat (Venes, 2021). Stroke volume is the product of
preload, afterload, and contractility (inotropy) (SV = Preload x Afterload
x Contractility).
FIGURE 17-4 Vessels of the heart.
FIGURE 17-5 Normal blood flow.
An altered cardiac output limits the blood’s ability to provide oxygen to

the tissues. Because HR and the size of the heart vary with the size of
the child, the volume of cardiac output will vary accordingly. A variety of
methods measure cardiac output with varying degrees of accuracy. The
Fick equation is the most accurate way to measure cardiac output (Fig.
17-6).
Preload, Afterload, and Contractility

The concepts of preload, afterload, and contractility are integral to the
understanding of heart disease, congestive heart failure (CHF), and the
treatment of these conditions. Most cardiac medications will affect one
or all of these properties of the cardiac cycle.
Preload is equivalent to the venous blood return to the atria from the
body and end diastolic volume of the heart. Afterload is the aortic
impedance or the wall stress.
Contractility is the force exerted at ejection, accounting for the end
diastolic volume and the wall stress.
PREVENTION OF HEART DISEASE IN CHILDREN

Some CHDs and heart disease in children can be prevented with good
prenatal care, low viral exposure, and prenatal vitamins, most
importantly folate. However, most often CHDs are attributed to genetic
causes, such as the 22q11.2 microdeletion that is associated with CHD,
neurocognitive deficits, cleft lip, and cleft palate (Cárdenas-Nieto et al,
2020).
FIGURE 17-6 Fick equation.
In addition, gene therapy may be developed in the future to prevent

the development of cardiac defects. However, children often develop
cardiac defects for no known reason, so prevention can be difficult.
Women planning on getting pregnant should maintain optimal health.
Smoking, excessive alcohol consumption, and illicit drug use should be
avoided. Exercise is always important. Women who are obese, smoke,
or have diabetes have an increased risk of delivering a child with a
cardiac defect. In addition, all women of childbearing years, whether or
not they are planning a pregnancy, should take folic acid supplements
(400 mcg/day). It is well documented that folic acid administration prior
to conception and during pregnancy will prevent or reduce the chance of
neural tube defects. This is also true of some cardiac defects. Existing
conditions such as diabetes, thyroid disease, mental illness, and
sexually transmitted diseases should be well controlled prior to
conception. Some medications to treat these diseases may be
teratogenic, and these drugs must be weaned or stopped under the
guidance of a physician or nurse practitioner.
In addition to good prenatal care, pulse two- or four-extremity pulse
oximetry screening has been proven an effective screening tool for the
detection of cardiac anomalies in the newborn. The majority will have a
degree of hypoxemia. This screening strategy has moderate sensitivity
and excellent specificity for the detection of critical CHD, as well as a
low false-positive rate. Critical CHDs are defined as neonates who
require cardiac surgery in the first year to maintain life. In addition,
respiratory and infective diseases are responsible for a large number of
positive test results.
CARING FOR THE CHILD WITH A

CARDIOVASCULAR CONDITION
Promoting growth and development for the child with a cardiovascular
condition involves a variety of interventions. Ruggiero and colleagues
(2017) showed that parents’ perceptions of the child’s CHD affected
outcomes of care. In this study, parents reported lower quality of life
scores on older children compared with younger children (p <.01). This
nurse-driven study provides practical recommendations and
demonstrates that nurses should focus their interventions in the
community on psychosocial health in older children with CHD and
physical health in younger children with CHD.
The child who has a cardiovascular condition requires adequate
sleep, nutrition, and rest to maintain optimal health and wellness. They
may require more rest than a healthy child because of activity
intolerance and fatigue from the underlying cardiac condition. To
optimize regular growth and development, activities should be tailored to
the child’s energy level. During low levels of energy, frequent naps and
quiet play may be warranted. In infants, crying can be stressful on the
child and quickly use up reserved energy. The nurse should educate the
family about being attentive to the child’s cry to conserve energy. In
addition, the nurse should educate the family about conserving energy
by grouping care activities for the child. Supplemental oxygen may be
indicated to alleviate shortness of breath with activity, promote rest, and
reduce stress. As frequent hospitalizations may be necessary, the nurse
should frequently assess the child for delays in growth and development
because of chronic hospitalization. The nurse should educate the family
about promoting healthy nutritional intake, limiting salt intake when
appropriate, prevention of infection and complications of the disease
process, and lifestyle changes required to prevent disease regression
and comorbidities.
CONGESTIVE HEART FAILURE

Many congenital and acquired cardiac conditions result in congestive
heart failure. Much of the basic nursing care of a patient with a cardiac
condition is dependent on the degree of the CHF.
Cardiac failure occurs when the heart can no longer fully accomplish
its intended purpose. CHF, or simply, heart failure, is characterized by
the inability of the cardiac muscle to perform its proper function of
moving blood forward. Blood is “congested” in a backward direction. The
heart’s pumping action is lost so the blood backs up into other areas of
the body such as the lungs or the liver. This backward congestion of
fluid eventually fills into the periphery. Congenital heart disease,
dysrhythmias, or other cardiac diseases such as cardiomyopathy (CM)
or Kawasaki’s disease can lead to CHF.
Signs and Symptoms

The signs and symptoms of CHF vary with age and whether the fluid is
more congested on the right or left side. Infants present with:
■ Poor feeding
■ Poor growth
■ Irritability
■ Shortness of breath or excessive sweating
■ In advanced stages, an enlarged liver or edema develops
Older children show:
■ Poor growth
■ Shortness of breath and exercise intolerance
Peripheral edema in children does not present in the same way as in
adults. Ascites rarely occurs in children except in the most dramatic
cases and more often in teenagers.
Babies and toddlers exhibit:
■ Puffy eyelids
■ Swelling of hands and feet
■ Bulging fontanelle
Diagnosis
Diagnosis includes patient history and physical examination findings
including vital signs (blood pressure and pulses may be diminished),
weight gain, or changes in breath sounds. Diagnostic measures include
B-type natriuretic peptide, chest x-ray exam, exercise test,
echocardiogram, magnetic resonance imaging (MRI), and cardiac
catheterization.
Collaborative Care
Nursing Care
Nursing care measures include keeping the child comfortable. Fluid
collections in the brain, periphery, and abdomen make the child irritable.
Often, a patient in CHF is restless because of an altered breathing
pattern related to fluid in the abdomen and in the pulmonary bed.
Therefore, implement oxygenation nursing interventions to ensure
appropriate oxygenation levels. Nursing care for the child with CHF
includes good skin care.
Careful monitoring and follow-up care are necessary in CHF. Because
of the risk of dehydration, fluid restriction is not often used in children.
Assessment Tool
Blood Pressure
Though one of the most important assessment tools for the pediatric cardiac
patient, accurate blood pressure monitoring may be the most difficult to achieve. A
systematic review of the evidence-based literature by Duncombe and colleagues
(2017) found that oscillometer-taken (or automated) blood pressures are equivalent
to that of auscultated blood pressures and can be used in the screening as an
effective assessment tool in obtaining pediatric blood pressures. In addition, other
important points to consider when measuring the blood pressure on a child:
• Cuff size: Select a cuff with a bladder width (measured top to bottom) that is at
least 40% of the arm circumference midway between the shoulder and the elbow.
This typically will allow cuff length coverage of 80% to 100% of the circumference
of the arm. Too small of a cuff gives false high measurements, and too large of a
cuff gives false lows.
• Manual versus automatic: Often when a child has tachycardia, the automatic
blood pressure cuff will not pick up the rapid pulse.
• Environment: A child may be frightened by the potential discomfort of a blood
pressure measurement. Remember to approach the child slowly and explain what
will be done. Even with these measures, the child is often crying, which gives an
inaccurate (often too high) reading.
• A blood pressure, when taken on a child, is always performed on a bare arm.
Medical Care
CHF is treated with medications because of the congenital defects.
Positive inotropes such as digoxin (Lanoxin), or even the stronger
dopamine drugs, are used when poor contractility is the cause of CHF. If
increased preload is the cause, then diuretics such as furosemide
(Lasix) or hydrochlorothiazide (Aquazide) may be used. Vasodilators
such as captopril (Capoten) or enalapril (Vasotec) are prescribed if
increased afterload is the causative factor. Often all three are used in
conjunction.
Surgical Care
Surgical repair for CHF is based on correcting the defect as outlined in
Table 17-2.
TABLE 17-2
Surgical Repairs of Cardiac Defects
REPAIR AND INTENDED DEFECTS POTENTIAL LONG-TERM
EFFECT IMPLICATIONS AND
SEQUELAE
PALLIATIVE REPAIRS
PA banding: VSD, single Eventual decreased O2
• A restrictive band is placed ventricle, TA saturations with growth and
around the main PA to aging, RV hypertrophy, if the
decrease uncontrolled band becomes too tight with
pulmonary blood flow and growth of the child. Excessive
prevent the development of flow to left PA and left pulmonary
pulmonary hypertension and HTN r/t stenosis of the right PA,
eventual right heart failure. related to possible migration and
encroachment on the right PA.
Possible revision of banding.
Blalock-Taussig shunt Cyanotic heart Mild PA distortion at site of

(modified): defects such as anastomosis, inability of shunt
• A Gore-Tex graft conduit is HLHS, TOF, size to increase with growth and
placed between the right or pulmonary atresia, aging, thrombus formation on
left subclavian artery and the TA Cyanotic heart graft site, potential coronary
ipsilateral PA to provide defects such as ischemia r/t pulmonary “steal” of
controlled pulmonary blood HLHS, pulmonary blood flow during diastole. Mild
flow. atresia, TA, single PA distortion at site of
• Sano shunt ventricle defects anastomosis, thrombus
• A Gore-Tex graft conduit is Single ventricle formation on graft site, inability
placed between the single physiology with of shunt size to increase with
ventricle and the PA to provide intact atrial septum, growth and aging. Eventual
controlled pulmonary blood un-repaired TGA. development of heart failure if
flow. further palliation or repair is not
• Atrial septectomy sought.
• A communication is surgically
created by tearing a hole or
incision between the left and
right atria. This encourages
mixing of blood flow at the
atrial level and encourages
pulmonary blood flow. More
invasive than ballooning of
septum as seen in Rashkind
procedure. Considered to be a
palliative procedure prior to
complete repair.
DEFINITIVE (OR COMPLETE) REPAIRS
Patch closures ASD, VSD, AV Incomplete closure of defect,
• Native cardiac tissue canal PDA dysrhythmia, potential for patch
(pericardium) or a prosthetic Coarctation of dehiscence, AV block (VSD
patch is sutured in place over aorta closures) Incomplete closure of
a septal defect to effectively ductus and associated residual
close the communication pulmonary shunting, mobilization
between the atria or ventricles. of device. Restenosis or
• Ductal ligation recoarctation of affected portion
• A tie or clip is placed around of aorta, transient spinal
the PDA and tightened to ischemia and associated
prevent excessive pulmonary paraplegia, paradoxical
blood flow from the aorta. hypertension, possible need for
• COA repair re-repair or angioplasty
• Narrowing in the proximal,
distal, or arch of the aorta is
reduced or eliminated via
surgical resection of stenosed
area, patch placement to
increase aortic diameter,
subclavian flap aortoplasty or
bypass grafting.
Valvuloplasty Destructive Incomplete or unsuccessful
• A malformed, damaged, or endocarditis, revision of affected valve;
stenotic valve is surgically valvular stenosis thromboemboli formation,
revised to correct the Endocarditis, failed additional valvular damage and
associated malfunction. Ross, valvular possible need for valve
• Artificial valve replacement stenosis replacement. Need for a lifetime
• A faulty or damaged native of replacement prosthetic valve
valve is replaced with a valve procedures, need for long-term
made of either human or oral anticoagulation,
animal tissue or a mechanical thromboemboli formation, aortic
valve. or pulmonary insufficiency.
Ross procedure • Destructive • Aortic/pulmonary valve
• A damaged or dysfunctional endocarditis, stenosis, gross valvular
aortic valve is removed and valvular aortic dysfunction, aortic or
replaced with the patient’s stenosis pulmonary insufficiency,
pulmonic valve, which is then potential for a lifetime of
replaced with a donor possible prosthetic valve
homograft valve. replacements, risk for heart
block.
• Konno procedure* • Any left- • Potential failure of aortic valve
• A faulty aortic valve is ventricular graft and persistent aortic
replaced with a prosthetic outflow tract stenosis, thromboemboli
valve while the narrowed obstruction such formation on grafted valves,
aortic root is enlarged via as aortic valve potential need for lifelong oral
patch placement to increase hypoplasia, anticoagulation, potential for
systemic blood flow. subaortic stenosis development of heart block,
aortic insufficiency.
• Damus-Kaye-Stansel • TGA with VSD; • Aortic insufficiency,
procedure Double outlet RV thromboemboli formation in
• Prosthetic conduits are placed (DORV) with VSD cases of complete aortic valve
between the proximal main PA closure, need for periodic
and the aorta and between the surgical conduit replacements,
RV and the distal PA. Existing coronary ischemia.
VSD is closed and the existing
aortic valve may be closed or
left unclosed. This procedure
attempts to reroute in
appropriate pulmonary and
systemic blood flow
• Rastelli • DORV, TGA +
• The main PA is divided from its VSD + subaortic
incorrect origin on the LV and stenosis/pulmonic
is reattached to the RV using stenosis truncus
a prosthetic conduit. A tunnel arteriosus type I
is then created between the Conduit
existent VSD and aorta, obstruction and
effectively rerouting blood resultant heart
from the LV to systemic failure,
outflow. dysrhythmia,
thromboemboli
formation, failure
of prosthetic
conduits to allow
increased flow
with growth and
aging, implicit
need for eventual
RV-PA conduit
replacements.
TGA Dysrhythmia, coronary artery
Arterial switch (ASO)
obstruction, LV ischemia and
• The great arteries (main PA
dysfunction, aortic insufficiency,
and aorta) are divided from
supravalvular pulmonic stenosis,
the LV and RV, respectively,
branch PA stenosis.
and reattached to their
appropriate locations on the
RV (MPA) and LV (aorta). The
coronary arteries are also
divided from the MPA and
transplanted to the neo-aorta.
STAGED REPAIRS
Modified Norwood Stage 1 repair for Coronary ischemia caused by
• The main PA is divided from HLHS diastolic “steal” of
the branch PAs and patched aortopulmonary shunt if BT
to the hypoplastic aortic arch, shunt is used, PA distortion,
creating a hybrid systemic cyanosis, aortic outflow
arterial outflow from the RV. obstruction, tricuspid
An atrial septectomy is insufficiency, potential stenosis
created via catheterization or of systemic-pulmonary shunt,
surgical incision to allow for failure to thrive, feeding
left to right shunting, so that difficulties, dysrhythmia.
oxygenated pulmonary venous
blood is directed toward
systemic outflow. A systemic–
pulmonary shunt (Sano or
Blalock-Taussig) is created to
allow PA blood flow because
the creation of single ventricle
physiology only has a direct
connection to systemic
outflow. This stage creates a
single ventricle that is
responsible for pulmonary and
systemic circulation.
Glenn Stage 2 repair for Elevated upper body venous

• The systemic–pulmonary HLHS, TA pressures related to increased
shunt (BT or Sano) is taken PVR, hypoxemia, upper body
down or ligated with clips. The swelling, headache,
SVC is connected to the dysrhythmia, stenosis at area of
branch PAs. The existent ASD SVC-PA anastomosis,
is enlarged if necessary to development of aortopulmonary
allow for continued left-to-right collateral vessels.
shunting of oxygenated blood
into the systemic outflow. This
stage attempts to reduce the
workload of the heart so that
the single ventricle is only
pumping to the systemic
circulation.
Fontan Stage 3 repair for Obstruction of conduit leading to
• The procedure attempts to HLHS, TA systemic venous pooling,
establish separate pulmonary thromboemboli formation,
and systemic circulations by dysrhythmia, systemic venous
attaching the IVC directly to hypertension, protein-losing
the RPA-SVC anastomosis enteropathy, right heart failure
with a Gore-Tex extracardiac leading to hepatosplenomegaly.
conduit. This allows for
passive flow of systemic
venous return directly to the
PAs and completely bypasses
the RA. The existent single
ventricle continues to receive
PA flow and pump to the
systemic circulation via the
neo-aorta constructed in
Stage 1 repair.
Other Fontan techniques route caval flow through a conduit partly routed through the
RA, which may lead to complications. Newer techniques bypass the RA completely.
Occasionally, fenestrations, or holes, are created between the IVC-RPA conduit and
the RA to allow for a “pop-off” of extra fluid, which is thought to prevent some
postoperative complications.
INFREQUENT REPAIRS
Blalock-Taussig shunt (Classic) Cyanotic heart Mild PA distortion at site of
• The right or left subclavian defects such as anastomosis, resultant ischemia
artery is divided from the aorta HLHS, TOF, to hand or arm on ipsilateral side
and attached to the ipsilateral pulmonary atresia, of anastomosis with associated
(same side) PA to provide TA limb length discrepancy and
controlled pulmonary blood perfusion, potential coronary
flow. ischemia related to pulmonary
“steal” of blood flow during
diastole.
Waterston-Cooley shunt Cyanotic heart Right PA distortion at site of

• A connection is created defects anastomosis, inadequate
between the ascending aorta pulmonary blood flow and
and the right PA to increase persistent cyanosis, excessive
pulmonary blood flow; now pulmonary blood flow and
considered obsolete as a development of pulmonary
result of development of hypertension, right PA stenosis
superior shunts. This and possible need for major
procedure is RARELY reconstructive surgery.
performed today.
Cyanotic heart Left PA distortion at site of
Potts shunt defects anastomosis, inadequate
• A connection is created pulmonary blood flow and
between the descending aorta persistent cyanosis, excessive
to the left PA to increase pulmonary blood flow and
pulmonary blood flow; now development of pulmonary
considered obsolete as a hypertension, difficulty of shunt
result of development of take-down.
superior shunts. This
procedure is RARELY
performed today.
INFREQUENT REPAIRS
Senning TGA Atrial dysrhythmias, baffle
• Conduits or baffles made from obstructions or leaks, right heart
pericardium or synthetic failure related to use of RV as
material are placed between systemic pump. Tricuspid or
the RA and the LV pulmonic mitral insufficiency,
outflow and between the LA thromboemboli.
and the RV aortic outflow.
These conduits allow
systemic circulation without
switching placement of the
great arteries.
Mustard TGA Atrial dysrhythmias, conduit

• Conduits or tunnels are obstructions or leaks, right heart
created between the RA and failure related to use of RV as
the LV pulmonic outflow and systemic pump. Tricuspid or
between the LA and the RV mitral insufficiency,
aortic outflow using atrial thromboemboli.
tissue. These conduits allow
systemic circulation without
switching placement of the
great arteries.
* Ross-Konno procedure combines replacement of aortic valve with native pulmonary

valve and aortic root enlargement. Source: © Judith M. Marshall (Data from Mavroudis,
Backer, & Idriss, 2013).
Discharge instructions include monitoring vital signs, recognizing signs
and symptoms, and uses and side effects of medication. Teach parents
that a good exercise plan may help to make the heart muscle stronger
and help to prevent the CHF. Even moderate walking is beneficial.
However, a vicious cycle may occur because the child may not feel well
enough to exercise or even walk, which leads to worsening symptoms.
When the parent understands the signs and symptoms, medication can
be given before the child reaches a critical state.
CONGENITAL HEART DISEASE

Congenital heart disease is a defect in the heart or great vessels, or a
noted disease pattern after birth. Congenital heart defects occur in
approximately 4 to 8 per every 1,000 live births (Dolk et al, 2020). The
nurse can recognize a CHD in various ways, including recognizing the
shunting pattern and the signs of cyanotic versus acyanotic CHDs
(Table 17-3).
Signs and Symptoms

Most signs and symptoms are related to the oxygenation status of the
defect. Overall signs and symptoms are also related to the contractility
state or if the patient is in heart failure. Congenital heart defects are
sometimes classified as cyanotic versus acyanotic; many, but not all,
cardiac defects involve mixing of blood. If the deoxygenated or venous
blood from the right side of the heart is forced into the left side of the
heart (called right to left shunting), as in cyanotic defects, the overall
oxygen saturation of the blood will drop. The range may vary from
normal (96%–100%) to as low as 70%. In acyanotic defects the
oxygenated blood shunts from the left to the right. This type of mixing
will not affect the overall oxygenation status.
TABLE 17-3
Cyanotic vs. Acyanotic Congenital Heart Defects
CYANOTIC ACYANOTIC
Definition Characterized by a Characterized by a
compromise in blood flow compromise in blood flow
through the pulmonary through the systemic
circulation. This includes circulation. This includes any
defects that distribute flow defects that distribute flow
away from (right to left away from (ex. left to right
shunt) or otherwise prevent shunt) or otherwise prevent
flow through pulmonary flow through systemic
circulation. circulation.
atrial septal defect
VSD
PDA
CoA
endocardial cushion defects
Examples truncus arteriosus
transposition of the great
vessels
TA
TOF
total anomalous pulmonary
venous return hypoplastic
left heart syndrome
Typical presentation Cyanotic defects are Symptoms of acyanotic
typically PDA-dependent heart defects include heart
and present upon closure of failure symptoms without
the PDA (usually within cyanosis. Younger pediatric
three days of birth). This patients often experience
typically occurs early in life increased respiratory
with cyanosis that cannot distress with feeding and
be corrected with increased perspiration. Older
supplemental oxygen. pediatric patients may
experience increased
exercise intolerance and
dypsnea. Left-to-right
shunting is observed.
In the presence of normal hemoglobin, a decrease in the oxygen

saturation to 85% will cause an outward sign of cyanosis (bluish
coloration) that appears around the lips, nose, and mouth of babies and
toddlers and in the nailbeds of older children. If the decreased oxygen
state is chronic, the child eventually will develop clubbing of the
fingernails. The longer and lower the oxygen saturation, the more
evident the clubbing. One physiological explanation for this change is
that the capillaries enlarge (dilate) to accommodate the low saturation in
an attempt to deliver more blood to the periphery (Banasik, 2017).
Another long-term effect of low oxygenation is polycythemia, the
increase in the red blood cell production in response to the low oxygen
output. The patient has hemoglobin levels greater than 15 g/dL. The
condition also causes thickening of the blood and predisposes the child
to thrombi and stroke. Low oxygenation and thickened blood will often
cause the heart muscle to work harder to circulate more oxygen. This
leads to muscular hypertrophy and eventually to pump failure.
Diagnosis
The diagnosis of a heart murmur usually starts with a referral after a
murmur is detected. Sometimes other symptoms are present, such as
shortness of breath or high blood pressure in children. Diagnostic
screening of suspected congenital defects includes a chest x-ray exam
and electrocardiogram (ECG). Most are confirmed by echocardiography
or cardiac catheterization. The echocardiogram gives information such
as location and size of the defect and can give indirect measurement of
pressure. A cardiac catheterization will give direct measurements of the
pressure in the chambers and vessels and gradients (difference of
pressure) across the valves. A magnetic resonance angiogram or
computed tomography angiogram provide additional information for
specific defects.
Collaborative Care
Nursing Care
Nursing care for the patient with CHD is similar for all types of lesions.
To avoid repetition, overall nursing care will be discussed here, and
specific nursing care topics will be outlined in each case. Nursing care
entails monitoring and maintaining the child’s oxygen and nutritional
status. Educate the family about the importance of rest periods and
managing the child’s fatigue. Emotional care is also essential for the
child and the family as well because this condition will most likely
involve many types of surgeries and many hospitalizations. Provide
emotional support by listening and supplying the family with resources
for understanding the disease and the prognosis and treatment plan.
When the family is interested, help them fulfill their spiritual needs. Even
if not religious, a family may request a spiritual person to be present in
the room.
Medical Care
Medical management usually focuses on treating the CHF that may
develop because of the specific defect and includes preload-reducing
agents such as furosemide (Lasix), positive inotropes such as digoxin
(Lanoxin), and contractile function agents such as carvedilol (Coreg)
(Table 17-4).
TABLE 17-4
Commonly Used Cardiac Medications
DRUG CLASS NAME OF DRUG
Class I - Na+ Channel Quinidine procainamide disopyramide phosphate
Blockers – 1A
Class I – Na+ Channel lidocaine mexiletine
Blockers – 1B
Class I – Na+ Channel propafenone flecainide
Blockers – 1C
Class II – Beta- propranolol atenolol metoprolol sotolol
Adrenergic Blockers
Class III – Prolongs amiodarone
Repolarization
Class IV – Calcium verapamil diltiazem
Channel Blockers
Miscellaneous digoxin – cardiac glycoside adenosine endogenous –
nucleoside
Drugs Used in Pump epinephrine levarterenol (norepinephrine)
Failure –
Vasoconstrictors
Drugs Used in Pump dopamine dobutamine milrinone
Failure – Positive
Inotropes
Drugs for Bradycardia isoproterenol
Epinephrine (see above) atropine
Diuretics furosemide chlorothiazide bumetanide
Drugs for Hypertension – amlodipine
Calcium Channel
Blockers
Drugs for Hypertension – captopril enalapril lisinopril
Ace Inhibitors
Angiotensin Receptor losartan
Blockers
Antithrombotic Agents warfarin (Coumadin) clopidogrel aspirin heparin enoxaparin
(Lovenox)
Hypercholesterolemia pravastatin cholestyramine nicotinic acid
Drugs
Source: Vallerand, A. H., & Sanoski, C. A. (2021). Davis’s drug guide for
nurses (17th ed.). Philadelphia, PA: F.A. Davis.
Surgical Care
In children with CHDs, surgical correction often involves the use of
valves, patches, or vascular conduits to establish anatomic continuity.
Cardiovascular anatomy of children with CHDs varies, which requires
tailored surgical operations for each patient. The nursing care to the
child related to postsurgical concerns is outlined in the following
sections.
Surgical repair of CHDs is outlined in each heart condition and is
found in Table 17-2.
Preoperative care for the child undergoing cardiac surgery is similar to
care of other surgical patients. A thorough history and physical are
essential to identify recent changes in the past medical history. Each
institution will develop a preop checklist. The nurse can also provide and
support the education given to the family regarding the type of surgery
and the process of the surgery (e.g., surgery time, recovery times, and
expectations).
Postoperative care of the child who has had reparative cardiac
surgery is complex and almost always includes an admission to the
intensive care unit.
Exercise and stress reduction are two nonpharmacological
approaches to CHDs. Although the only method to cure a defect is
through surgery, complementary or alternative methods may help the
patient to live a higher quality of life.
FOCUS ON SAFETY
The Patient With CHD
Safety measures when caring for a patient with CHD include placing the child on a
pulse oximeter, even if it seems the child does not have an immediate oxygenation
problem. The same holds true with a cardiac monitor. These children are at high
risk for deoxygenation and dysrhythmic episodes.
Discharge instructions and parent education include monitoring vital
signs and recognizing signs and symptoms of cardiac failure. The
parent will be given ranges of vital signs appropriate for the child’s age
and circumstance. For example, some patients may have a lower or
higher than expected range for their age because of the type of cardiac
disease. Parents should learn cardiopulmonary resuscitation.
If the child is discharged to home with oxygen, the parents will also
have a pulse oximeter in the home. The parent will be taught to observe
for subtle signs of CHF such as shortness of breath, decreased
appetite, irritability, swelling, and weight gain. Discharge instructions
include medication use, effects, and side effects. The nurse ensures
that the parent is receiving education about medications that is
appropriate for their learning style and comprehension level. Each
medication should be reviewed for specifics.
Postoperative teaching points will answer the family’s questions about
diet, exercise, activity, and return to school. A proper diet for a cardiac
patient includes balanced, healthy food choices for good bone healing
and limits junk food and empty calories. Fluid restriction is not
encountered as often as in the adult population but may be used for
patients in severe CHF or older children. Infants and younger children
can dehydrate much easier; therefore, this practice is avoided in this
age range.
Postoperative care also includes care of the surgical wound. In
general, the area is to be kept clean and dry, and often the Steri-Strips
are left in place until they fall off. The parents are taught how to watch
for wound healing and signs of infection, such as redness at the site or
fever.
Typically, when a sternal approach is used, the bone must be allowed
to heal for 6 weeks. This means an infant or baby must be cradled when
picked up or carried (i.e., avoid lifting the child from under the arms),
and older children should not use backpacks. Exercise guidelines are
specific for each condition and based on protection of the surgical site
and bone healing time. For older children, no-contact sports are allowed
in the first 6 weeks to 6 months after surgery until the bone is healed.
Occasionally, a child may be fitted with a protective vest to prevent
injury to the chest when returning to sports. The nurse teaches parents
that a good exercise plan might help make the heart muscle stronger
and prevent CHF. Parents are also taught that the child with a cardiac
condition may be incapable of certain strenuous exercises and may
need to modify or avoid physical activity. There may be a fine line
between encouraging the child to engage in physical activity for the
benefits and inhibiting the child from doing physical exercise for fear of
getting sicker. The nurse helps the parents balance the decision for the
types and amounts of exercise. Generally, the child may return to school
when the bone is healed.
The nurse provides parents with community-based resources to set
up home-bound schooling. Discharge education also includes support
systems for children who also have other conditions such as Down’s
syndrome.
SEGMENTAL CLASSIFICATION OF CONGENITAL HEART DEFECTS

In the United States, cardiac defects occur in 8 to 12 per 1,000 (1%) live
births (AHA, 2020a). There are several approaches to classifying heart
lesions. Table 17-5 outlines the segmental approach, which is organized
by the type of defective physical structure.
The traditional way of classifying heart defects is not always exact
because the shunting and flow may change over the natural course of
the disease process.
Left-to-Right Shunt Lesions

Atrial Septal Defect
Atrial septal defect (ASD) is a simple defect of the atria. During fetal
development, the septal wall forms between the fourth and eighth weeks
of life when two septae, the primum and secundum, stretch across the
center of the common atrium (Fig. 17-7). Eventually, these septae
overlap (but not completely) and form a small opening called the
foramen ovale. The foramen ovale is a necessary structure during fetal
life but should close within hours after birth. Sometimes the foramen
ovale may persist until 1 year of life. An ASD results when the two
septae fail to overlap properly. There are two variations of the defect
that differ in the location of the defect on the septal wall: primum ASD
(high on the septal wall) and secundum ASD (low on the wall).
TABLE 17-5
Classification of Cardiac Defects
CLASS NAME PREVALENCE TYPES OR ASSOCIATED
(% OF ALL FORMS DEFECTS
DEFECTS)
L–R Shunt Atrial–septal 5–10 (50–100) Secundum or PAPVR or mitral
defect VSD 20–25 (200– primum or sinus valve prolapse
PDA AV canal 250) 5–10 (50– venosus PDA, CoA, AV
Partial 100) 0.02 (0.20) Perimembranous, prolapse AV
anomalous <1 (10) muscular, regurgitation.
pulmonary multiple Large 30% of cases
venous return shunt or small occur with
Complete or Down’s
partial; balanced syndrome ASD
or unbalanced
TAPVR
Obstructive Pulmonary 5–8 (50–80) Valvular, VSD, Noonan
Lesions stenosis Aortic 0.05 (0.50) 5–10 subvalvular, syndrome
stenosis CoA (50–100) 0.01 supravalvular Bicuspid aortic
Interrupted (0.10) (PA) Valvular, valve, Williams’
aortic arch subvalvular, syndrome, IHSS
supravalvular Bicuspid AV,
Preductal, aortic
postductal, hypoplasia,
ascending aorta, VSD, PDA,
descending aorta abnormal MV
Type of PDA, VSD,
coarctation, types bicuspid AV, MV
A, B, C deformity,
truncus
arteriosus,
subaortic
stenosis
Cyanotic Transposition of 0.05 (0.50) 0.10 D type, L-type, ASD, VSD,
Defects the great (1.00) 0.01 PS or PA or PDA, PS May
arteries TOF (0.10) 1–2 (10– absent PV with be cyanotic or
Total anomalous 20) <1 (10) <1 PS Supracardiac, acyanotic if PS
pulmonary (10) <1 (10) <1 cardiac draining is mild ASD or
venous return (10) <1 (10) <1 into RA, cardiac PFO ASD, VSD,
TA Pulmonary (10) draining into the PDA, CoA, TGA
atresia Epstein’s coronary sinus, ASD, PFO or
anomaly infracardiac; PDA WPW, RA
Truncus obstructive hypertrophy,
arteriosus Variable RV sizes ASD Large
Single ventricle Variable degrees VSD, right aortic
Double outlet of displacement arch, DiGeorge
RV Splenic Types I—IV syndrome ASD,
syndromes showing various PS, PA, CoA,
placements of PA VSD, asplenia,
arising from the polysplenia,
aorta DILV or RV TGV VSD, PS
Types are by the Various
position of the redundant
VSD: subaortic cardiac
VSD, structures or
subpulmonary absence of
VSD, remote structures
VSD, subaortic
VSD with PS,
doubly committed
VSD Asplenia
and polysplenia
The numbers in the parentheses indicate the number of infants born with defects out of
100,000 live births. Source: copyright Judith Marshall (2014)
FIGURE 17-7 Atrial septal defect.

SIGNS AND SYMPTOMS
Possible symptoms of ASD include:
■ Possible murmur
■ Blowing to harsh systolic murmur heard best at second intercostal
space left sternal border
■ May radiate to apex or back
■ Possible RV heave or a thrill (abnormal tremor accompanying a
vascular or cardiac murmur felt on palpation) (Venes, 2017)
■ Possible right atrial enlargement caused by fluid overload from left-to-
right shunting through the opening in the atrial wall
■ Possible RV enlargement, which is the source of the RV heave
■ Right axis deviation (evidence of ventricular enlargement) on an ECG
recording
■ A fixed, split, second heart sound
■ Hepatomegaly as a result of this fluid overload
■ Signs and symptoms of cardiac failure (these signs gradually worsen
with time unless the defect is repaired)
■ Periorbital edema
■ Increased respiratory infections may be noted
■ Risk for stroke because of the tendency of blood pooling leading to
increased risk of thrombus formation
DIAGNOSIS
The ASD is confirmed by echocardiography or cardiac catheterization.
A chest x-ray exam and ECG support the diagnosis.
COLLABORATIVE CARE
Nursing Care
Nursing care focuses on postoperative management of the child. If a
closure device is used, the nurse is aware of the signs and symptoms of
complications of the device, such as bleeding, tamponade, or migration
of the device. Signs and symptoms such as chest pain, palpitations,
sudden hypotension, and dehydration or anemia warrant further
investigation.
Surgical Care
Without treatment, certain types of ASDs may close spontaneously in
the first year of life, and the child typically shows no outward signs of a
malformation. The ASD, if not closed spontaneously, can be closed with
a surgical procedure or interventional cardiology in which a closure
device is inserted.
Optimizing Outcomes
Postoperative Management
Provide immediate postoperative care in the intensive care unit:
• Record the vital signs frequently until the child is stable.
• Monitor fluid status. Accurately measure the intake and output of all fluids.
• Maintain vascular access systems via:
- A peripheral IV used to administer fluid and medications.
- A central venous pressure line inserted in a large vessel in the neck or groin and
used to measure central venous pressure in the right atrium.
- Intracardiac catheters inserted in the right atrium, left atrium, and PA and used to
measure the pressures inside the cardiac chambers that provide essential
information about cardiac output, blood volume, pulmonary pressures,
ventricular function, and drug therapy response.
• Maintain chest tubes that remove secretions and re-expand the lungs. Check
drainage for quantity and color.
• Assess for complications such as cardiac, neurological, pulmonary, renal, or
hematological changes, infection, or delayed growth and development.
• Assess and maintain respiratory status.
• Respiratory assessment is performed frequently, and oxygen is delivered via
mechanical ventilation.
• Suction secretions.
• Monitor blood lab values for postoperative bleeding and postpump electrolyte
imbalances.
• Assess for signs and symptoms of infection. Manage pain via comfort measures
and the administration of medication.
• Provide emotional support and information about home care.
• Consider the child’s level of development to provide developmentally appropriate
care.
• Ensure rest, which is essential to promote healing and decrease the workload of
the heart.
• Group nursing care to avoid imposing unnecessary fatigue and weakness.
COMPLICATIONS
Renal failure is considered when the output is less than 1 mL/kg per
hour along with an elevation in serum creatinine and blood urea
nitrogen. Postoperative hemorrhage is considered when there is
excessive chest tube drainage greater than 5 to 10 mL/kg in 1 hour or
more than 3 mL/kg per hour in 3 consecutive hours.
See Education/Discharge Instructions for Cardiovascular Conditions
in Children.
Ventricular Septal Defect

A ventricular septal defect (VSD) is the most common CHD. Fortunately,
it is one of the mildest. A VSD forms in much the same way as an ASD.
In fetal development, at the approximate gestational age of 4 to 8
weeks, the wall is formed when a superior and inferior limb (like a
divider) of tissue come together to create a wall between the two
chambers (Fig. 17-8). A defect in the formation of this wall can be a
single opening, or the wall may be fraught with multiple defects,
sometimes referred to as a Swiss cheese VSD.
The defect may be located anywhere on the ventricular septal wall.
Usually, those in the muscular septum close spontaneously. If left alone,
individuals can live a long, normal life. In the worst cases, the child
suffers from RV overload from left-to-right (acyanotic) shunting of blood
caused by the high-pressure gradient from the left to the right side.
Generally, a VSD is repaired surgically. However, in the future, the use
of a transcatheter closer device may be more common.
FIGURE 17-8 Ventricular septal defect.

SIGNS AND SYMPTOMS
VSD is mostly asymptomatic. Large VSD with a significant left-to-right
shunt may show signs of RV failure:
■ Poor growth
■ Easy fatigability
■ Recurrent pulmonary infections
■ Murmur
■ A harsh murmur along with a thrill at the lower left sternal border
■ Pansystolic
DIAGNOSIS
Diagnosis is based on an audible heart murmur along with other signs
and symptoms. Additional tests, such as a chest radiograph and ECG,
support the diagnosis. An echocardiogram, cardiac catheterization,
and/or cardiac MRI confirm the diagnosis.
COLLABORATIVE CARE
Nursing Care
Nursing care focuses on postoperative management of the child.
Surgical Care
Care of the child with VSD is similar to that of the child with ASD.
in Children.
Patent Ductus Arteriosus

A patent ductus arteriosus (PDA) is the simplest form of vessel defect
(Fig. 17-9). Remember that the ductus arteriosus is a normal structure
during fetal life. In utero, the pulmonary resistance is high because the
lungs are filled with fluid rather than air. The blood is oxygenated
through the placenta by the umbilical vein. Instead of the blood flowing
from the PA to the lungs, the ductus is a “pop-off valve for the large
volume of fluid. As the blood flow follows the “path of least resistance,”
the blood moves through the ductus, into the aorta, and out to the body
tissues. Directly after birth and the baby’s first breaths, the pulmonary
resistance drops and the blood flows from the PA into the lungs.
Because there is decreased flow through the PDA, the duct starts to
close. Changes in PGE1 level assist the closure as well. In 8% to 10%
of the population, the PDA remains open (Ruggiero et al, 2017). It can
take as long as 1 year for the PDA to close completely. The pediatric
cardiologist monitors the asymptomatic child up to 1 year for
spontaneous closure of the PDA.
FIGURE 17-9 Patent ductus arteriosus.
If a large PDA is not closed, severe long-term sequelae may ensue.

At birth, the pulmonary resistance is higher than the left-sided
pressures. As this gradient reverses, the left-sided pressure forces
blood toward the right side through the PDA. Eventually, the fluid
congests the right side of the heart and the pulmonary bed. The RV
hypertrophies as it attempts to mobilize fluid forward. The defect occurs
alone or in combination with coarctation of the aorta.
SIGNS AND SYMPTOMS
Symptoms of PDA can include:
■ The PDA murmur is distinctive in sound and location
■ Best heard at the left subclavicular margin
■ Described as machine-like, to and fro, or continuous
■ Frequent colds
■ Susceptibility to respiratory syncytial virus
■ Fatigue
■ Poor feeding
■ Poor growth pattern
■ Blood pressure reveals a wide pulse pressure
DIAGNOSIS
The presence of the characteristic machine-like murmur under the left
clavicle, along with symptoms of heart failure, leads to the diagnosis of
PDA. A chest radiograph shows an enlarged heart and evidence of an
excessive blood flow to the lungs. An echocardiogram confirms the
diagnosis, demonstrating the size of the ductus arteriosus and
enlargement of heart chambers because of the extra blood flow.
COLLABORATIVE CARE
Nursing Care
Nursing care focuses on postsurgical measures, such as caring for
wounds, monitoring vital signs, and ensuring adequate hydration and
nutrition. If the PDA is closed with a transcatheter closure device,
monitor for signs of migration. If the device dislodges, the child will
suddenly have a wide pulse pressure. At that point, the cardiac
interventionist is notified for further actions.
Medical Care
A PDA may be closed surgically or with a transcatheter device. The
PDA may also be closed using the medication indomethacin (Indocin).
MEDICATION
Subacute Bacterial Endocarditis Prophylaxis
If the child has a high risk for bacterial endocarditis, the physician provider will
prescribe antibiotics before dental work and surgery. Be aware of the published
American Heart Association (AHA) guidelines. In 2007, the AHA made sweeping
changes to the guidelines for prophylaxis needed for patients with known cardiac
disease, which are still the standard of care today.
ADVERSE EFFECTS
The American Heart Association (2020) currently recommends antibiotic
prophylaxis only in patients with the following high-risk cardiac conditions:
1. Patients with prosthetic cardiac valves
2. Patients with previous infective endocarditis
3. Cardiac transplant recipients with valve regurgitation due to a structurally
abnormal valve
4. Patients with CHD with:
• Unrepaired cyanotic CHD, including palliative shunts and conduits
• Totally repaired CHD repaired with prosthetic material or device
that has been placed by surgery or catheter intervention, during the
first 6 months after the procedure
• Repaired CHD with residual defects at the site or adjacent to the
site of a prosthetic patch or prosthetic device
Patients with these high-risk conditions should receive antibiotics for the following
procedures:
1. Dental procedures.
2. The 2007 AHA guidelines also recommended prophylaxis for invasive respiratory
tract procedures that involve incision or biopsy of the respiratory mucosa (e.g.,
tonsillectomy, adenoidectomy). Antibiotic prophylaxis has not been
recommended for bronchoscopy unless the procedure involves incision of the
respiratory tract mucosa.
3. Procedures of infected skin, skin structures, or musculoskeletal tissue.
in Children.
Atrioventricular Canal Defect
An AV canal defect (AVC) is also known as complete AVC or
endocardial cushion defect (ECD). This defect combines aspects of an
ASD and VSD but also involves the valves. In its simplest definition, an
AVC is a large hole in the center of the heart. Embryologically, the
endocardial cushion fails to form properly. There are openings on the
atrial wall and the ventricular wall, and the tricuspid and mitral valves
come together to form one large valve (Fig. 17-10). These defects are
often seen in children with Down’s syndrome (Pasquali et al, 2020). This
defect must be repaired surgically if the child is to live a normal life
span. Although the blood is mixed through this large open space, the
shunt is left to right and the child is not cyanotic. There are many
variations of this defect including partial ECD.
FIGURE 17-10 Atrioventricular canal defect.
SIGNS AND SYMPTOMS
Signs and symptoms of cardiac failure will gradually worsen with time
unless the defect is repaired:
■ Increased respiratory infections
■ Distended liver may be noted
DIAGNOSIS
A complete physical examination, including auscultation of the heart
and lungs, helps in the diagnosis. A heart murmur is verified. Additional
tests such as chest x-ray and ECG support the diagnosis. Tests such as
an echocardiogram, cardiac catheterization, and/or cardiac MRI confirm
the diagnosis.
COLLABORATIVE CARE
Nursing Care
Postoperative education also includes support systems for children who
also have concomitant Down’s syndrome.
Medical Care
Care of the child with AVC is more complex than that of the child with
ASD and or VSD. Prior to surgery, nursing care is geared toward
optimizing the cardiac output and ensuring adequate weight gain.
Care of the Child With Congenital Heart Defects
The hospital nurse most often cares for a child with a CHD when the child is
admitted for surgery. Occasionally, a child with a defect may be admitted for
reasons not related to the heart. The child is always monitored for signs of CHF
and measures taken to prevent fatigue, fluid overload, or infections. If a school
nurse has a student with a CHD, the cardiologist or cardiology nurse practitioner
submits letters to the school that outline the plan of care and any physical or activity
restrictions. Anyone caring for a child who is taking cardiac medications must
understand the effects, side effects, and proper dosing (see Table 17-4).
Optimizing Outcomes
Exercise Testing and Training in Children With Congenital Heart Disease

Doctors from Children’s Hospital of Boston conducted a review of literature
regarding cardiac rehabilitation programs for patients under the age of 18. Articles
were published between January 1981 and November 2010. A total of 16 clinical
studies were reviewed. The researchers were concerned that although cardiac
rehabilitation programs are widely accepted and shown to improve outcomes for
patients with acquired cardiac disease, very few programs exist for the pediatric
population of patients with CHD.
The overall recommendations found in the articles were that cardiac rehabilitation
programs should be at least 12 weeks in length, two to three times per week, and
lasting at least 40 minutes. One important discovery was that cardiac rehabilitation
programs were dramatically underutilized, and the value of such programs was not
appreciated. The researchers outlined a list of factors that potentially contributed to
the under-appreciation, such as a limited number of specialists or specialized
facilities and poor insurance coverage. Other factors included provider- or patient-
related factors. Patient factors were expense, logistics of getting to facility or having
time to get to facility, or parental anxiety born out of fear for their child’s ability to
exercise safely (Ruggiero et al, 2019).
in Children.
Obstructive Lesions
Coarctation of the Aorta
Coarctation of the aorta (CoA) is a narrowing or stricture of the
descending aorta distal to the carotid arteries. The coarctation is
classified by its location: preductal, ductal, or postductal (Fig. 17-11).
Normally, blood pressure (BP) in the legs should be higher or equal to
that in the arms. When a BP in the lower extremities measures greater
than 10 mm Hg less than that in the upper extremities, the practitioner
suspects a CoA (Park, 2016). Occasionally, the BP in the right arm is
higher than in the left. This usually occurs with a preductal coarctation in
which the blood flow to the left arm is supplied by the flow of blood
through the ductus, which is a lower pressure system. For this reason, if
only one upper extremity is used as comparison with the lower
extremities, it should be the right arm. If a child is hypertensive, CoA is
suspected.
FIGURE 17-11 Coarctation of the aorta.

SIGNS AND SYMPTOMS
Symptoms of CoA may include:
■ Murmur
■ Not always present
■ Systolic ejection murmur heard at upper right sternal border and let
sternal border
■ Cycle radiates to left axilla and left intrascapular area of the back
■ The child may show signs of CHF.
■ The child may have pain in the legs or cyanotic lower extremities.
DIAGNOSIS
The classic diagnostic feature of this defect is a high gradient, which
is the difference in the pressure measurements between the arms and
legs.
COLLABORATIVE CARE
Nursing Care
Nursing care focuses on postoperative management of the child. The
child is followed by the health-care provider for evidence of restenosis.
The nurse assists in this monitoring by proper evaluation of the upper
and lower blood pressures. Postsurgically, the child may have severe
rebound hypertension (HTN). The ventricles have become very
accustomed to pushing hard against the narrowed area in the aorta.
When this area is opened up, the heart muscle still wants to contract
strongly against the gradient. If there is nothing to push against, there is
still an abnormally high blood pressure. This is controlled by
antihypertensive agents for 6 months to a year after surgery and may be
required through life.
Medical Care
Pharmacological treatment includes afterload-reducing agents, which
control the blood pressure. Two such agents are captopril (Capoten) or
enalapril (Vasotec).
Surgical Care
Surgery is always indicated for this condition. Invasive treatment for
older infants and adolescents involves a balloon angioplasty and stent
placement.
in Children.
Pulmonic Stenosis
Pulmonic stenosis, or pulmonic valve stenosis, is a malformation of the
PA or pulmonic valve. The narrowing of the valve causes an increased
workload on the RV (Fig. 17-12), which in turn leads to CHF with
symptoms such as hepatomegaly. This condition is frequently
associated with Noonan syndrome and is part of the combination
condition called tetralogy of Fallot (TOF).
FIGURE 17-12 Pulmonary stenosis.
Valves may be congenitally malformed or become physically altered

because of disease. If the valve does not close properly, there may be
leakage called regurgitation or insufficiency when the valve is stiff or
stenotic. When the valve is insufficient, the ventricle must pump with
greater force to push blood through a stiff or “sticky” door. Because of
the backflow of blood, the ventricle pumps with a greater force of
contraction because there is more volume and thus more stretch
(Starling’s law). This constant increased force eventually tires the
cardiac muscle. The nurse is aware of the signs and symptoms of CHF.
Sometimes despite having an echocardiogram, it can be difficult to
determine valves that do not close properly until the heart muscle has
some time to develop and become more efficient (by about 3 years of
age).
SIGNS AND SYMPTOMS
A heart murmur is the most common sign of pulmonic stenosis. This
is typically a grade II to IV out of VI systolic murmur, sometimes with
ejection click.
During periods of increased blood pressure, such as with excitement,
exercise, crying, or fever, the child may experience dyspnea
(breathlessness) or in the most severe cases, brief moments of
cyanosis when the blood flow does not reach the pulmonary bed.
DIAGNOSIS
The diagnosis is confirmed by the presence of a heart murmur, by
ECG, and by echocardiogram. Cardiac catheterization measures the
degree of pulmonary stenosis. An ECG will show RV hypertrophy.
COLLABORATIVE CARE
Nursing Care
Care measures help the patient to reduce stressful situations that may
cause high blood pressure.
Surgical Care
Depending on the gradient (difference in the pressure measurements
between chambers or across the defect) and also on the type of CHD,
the cardiologist may choose to observe the child closely over time
before recommending an intervention. For example, if an ASD is mild to
moderate and not causing any negative symptoms for the child (such as
failure to thrive), then the cardiologist may take a “watch and wait”
approach. Many ASDs close spontaneously on their own when the child
is around age 5 or 6. After this time, it is unlikely the septal defect will
close without surgical intervention. Surgical interventions include balloon
angioplasty or valvuloplasty (a procedure that reopens narrowed blood
vessels and restores forward blood flow) or open-heart surgery.
Because this valve is in an area of low flow and low pressure, these
children often do well with one intervention but are monitored
periodically for restenosis.
in Children.
Aortic Stenosis
Aortic stenosis, or aortic valve stenosis (AS or AVS), is a malformation
and narrowing in the aorta or around the aortic valve (Fig. 17-13). A
narrowing in this area causes an increased workload on the left ventricle
that eventually leads to hypertrophy (increase in size) and heart failure.
This condition may also be acquired after birth. Variations of this defect
are supra- and subvalvar stenosis and have an association with
bicuspid aortic valve.
SIGNS AND SYMPTOMS
Aortic stenosis can be indicated by several symptoms:
■ A murmur may be audible.
■ During the systolic phase of the cardiac cycle, a click may be heard
and a thrill may be noted.
■ The child may have chest pain or fatigue and syncope on exertion.
■ Critical AS causes heart failure in neonates.
DIAGNOSIS
Diagnosis is based on the clinical findings and echocardiogram with a
chest x-ray exam and ECG supporting the diagnosis. An ECG may
show left ventricular hypertrophy. Cardiac catheterization is the definitive
test, also measuring the exact gradient.
COLLABORATIVE CARE
Nursing Care
Nursing care is based on medical and/or postoperative management.
In critical situations with very narrow valves, preload and afterload
reduction medication is indicated. Because this valve is in a high-flow,
high-pressure area, it is more critical to correct.
FIGURE 17-13 Aortic stenosis.
Surgical Care
A balloon angioplasty or valvuloplasty is performed to open the
narrow area with a balloon. Another treatment mode is surgical
intervention to repair or replace the valve. Aortic stenosis requires
lifelong monitoring.
in Children.
Cyanotic Congenital Heart Defects

Tricuspid Atresia
Tricuspid atresia (TA) is caused by an error in the formation of the
tricuspid valve. As a single defect, this condition is incompatible with life
because no blood from the right atrium reaches the RV and thus the RV
outflow tract leading to the PA and the lungs. For this reason, most
children born with TA also have comorbidity with a septal defect such as
ASD or VSD as well as a PDA. The deoxygenated blood must reach the
pulmonary bed to sustain life (Fig. 17-14).
SIGNS AND SYMPTOMS

The initial signs are dramatic; as the PDA starts to close in the hours
after birth, the child becomes severely cyanotic, dyspneic, and
tachycardic. A heart murmur is generally present at the left sternal
border that is pansystolic.
DIAGNOSIS
Tricuspid atresia may be discovered during a routine prenatal
ultrasound imaging or at birth based on the signs and symptoms.
Diagnostic testing includes ECG, echocardiogram, chest radiograph,
and cardiac catheterization.
COLLABORATIVE CARE
Nursing Care
Prostaglandins keep the PDA from closing, allowing blood flow from the
right side of the heart to reach the lungs. Use of this medication can
sustain an open PDA for a short time, but more definitive treatment with
a balloon septostomy or a shunt surgery will eventually be done.
Surgical Care
Tricuspid atresia requires emergency intervention. Initially, the
neonate is given PGE1 to keep the PDA from closing. In addition, if
there is no ASD or patent foramen ovale (PFO), an emergent balloon
atrial septostomy is performed to ensure survival. The next step is to
perform a systemic-pulmonary shunt if the pulmonary blood flow is
deficient or a PA band if the pulmonary blood flow is excessive.
Eventually a Glenn procedure may be done, and Fontan procedure is
the definitive surgery.
Pulmonary Atresia
Pulmonary atresia is a fatal defect if not corrected or palliated (treated to
reduce effect) early in life. Pulmonary atresia is absence of the
pulmonary valve, PA, or both (Fig. 17-15). The child must have an ASD
or PFO (the opening present in utero and at birth that closes
spontaneously) and/or a PDA to survive. A PDA will allow blood to flow
into the lungs for oxygenation.
If the pulmonary valve and/or PA are not present, the cardiac team
performs emergency procedures to save the child’s life. Initially, PGE1 is
infused to maintain patency (free flow) of the PDA. A balloon atrial
septostomy (formation of an opening in a septum) is then performed to
create an ASD (Venes, 2021). This procedure allows the flow of blood
from the right side to the left. Primary surgical repair includes a shunt
(diversion) or a conduit (channel). Later, a Fontan procedure (a
procedure used to repair complex single ventricle-type CHDs) may be
needed. See Table 17-2.
in Children.
FOCUS ON SAFETY
Survival of the Child
With any congenital defect, as long as there is mixing of oxygenated and
deoxygenated blood, the child survives. A more definitive surgery, such as a
Fontan procedure, is performed at a later date to correct the condition.
FIGURE 17-14 Tricuspid atresia.

FIGURE 17-15 Pulmonary atresia.
NURSING INSIGHT
Epstein’s Malformation
Epstein’s malformation occurs when the tricuspid valve is displaced into the RV
(Fig. 17-16). Typically, in this condition, an ASD is present. The ventricle and the
atria may become hypertrophied, and this condition is often associated with
supraventricular dysrhythmias, particularly Wolff-Parkinson-White syndrome. With
Epstein’s malformation, the child may live normally or require treatment. Surgical
intervention is the treatment of choice.
Total Anomalous Pulmonary Venous Return

Total anomalous pulmonary venous return (TAPVR) is a condition in
which the pulmonary blood flow returns to the heart through the right
atrium rather than the left (Fig. 17-17). The child usually has an ASD,
allowing the blood to flow back to the left ventricle and out to the body
tissues. As a consequence of the ASD, mixing of venous blood with
arterial blood may occur, causing a cyanotic condition. One problem for
a child with TAPVR is that a high volume of blood returns to the right
side of the heart, causing right-sided hypertrophy and enlargement. If an
ASD is not present, the health-care provider will create one with a
balloon septostomy. A variation of this condition is partial anomalous
pulmonary venous return (PAPVR), in which two of the veins return
blood to the left side and two of the veins return blood to the right side.
Other variations are simply in routing of the blood flow back to the heart.
Epsteins
FIGURE 17-16 Epstein’s malformation.

FIGURE 17-17 Total anomalous pulmonary venous return.
SIGNS AND SYMPTOMS
TAPVR can be indicated by several symptoms:
■ Murmur
■ Systolic ejection murmur heard best in pulmonic area that radiates
throughout lung field
■ Cyanosis
■ Lethargy
■ Poor and rapid breathing
■ Poor feeding
■ Frequent respiratory infections
■ Signs of heart failure
DIAGNOSIS
Diagnosis is based on signs and symptoms and diagnostic testing
including ECG, echocardiogram, chest x-ray exam, and cardiac
catheterization.
COLLABORATIVE CARE
Nursing Care
Surgical Care
The treatment for TAPVR is complete surgical repair (see Table 17-2).
Postsurgery, the child can live a full, normal life and is followed by the
health-care provider routinely (every 1 to 2 years) for any reoccurring
stenosis.
in Children.
Conal-Truncal Defects
Conal-truncal defects develop during the formation of the trunk
dissection. Embryologically, the PA and the aorta begin as a large
“trunk.” The ventricles then fold over, the atria rise into position, and the
great vessels form when the trunk twists around and forms a septum,
dividing the vessel into two walls. Transposition of the great vessels and
truncus arteriosus occur in children when there is a disruption in this
process.
Transposition of the Great Arteries or Vessels

Transposition of the great arteries or vessels (TGA or TGV) occurs in
utero when the signals cross, and instead of twisting, there is simply a
septation and the aorta arises from the right side of the heart and the PA
arises from the left (Fig. 17-18).
SIGNS AND SYMPTOMS
Symptoms appear at birth or soon afterward and include:
■ Cyanosis
FIGURE 17-18 Transposition of the great vessels.
FIGURE 17-19 Truncus arteriosus.
■ Poor feeding
■ Eventual clubbing of the fingers and toes
■ Murmur not always present
DIAGNOSIS
Diagnosis is based on signs, and diagnostic testing includes pulse
oximetry, ECG, echocardiogram, chest x-ray exam, and cardiac
catheterization. If an echocardiogram is done before birth, it is called a
fetal echocardiogram.
COLLABORATIVE CARE
Nursing Care
Nursing care focuses on postoperative management of the child. The
child’s condition is followed up by a health-care provider throughout life
to monitor for signs of stenosis around the anastomosis sites.
Surgical Care
The severity of the signs and symptoms direct the timing of treatment.
TGA in all cases must be surgically corrected, typically with an arterial
switch operation (ASO). This surgery is considered a definitive repair,
and the prognosis is good.
in Children.
Truncus Arteriosus
Truncus arteriosus is a complicated cyanotic lesion with a poor
prognosis if not treated surgically. In truncus arteriosus, the trunk has
neither twisted nor formed a septum. There are multiple variations of the
condition, classed I to IV, but the general physiology is that the aorta
and PAs are combined, with full mixing of blood (Fig. 17-19). Sometimes
the PAs arise from the aorta, either ascending or descending.
SIGNS AND SYMPTOMS
Symptoms of truncus arteriosus include:
■ Cyanosis
■ Congestive heart failure
■ Low cardiac output
■ Systolic ejection murmur with possible thrill at left sternal border
DIAGNOSIS
Diagnosis is based on signs and diagnostic testing that include pulse
oximetry, ECG, echocardiogram, chest radiograph, and cardiac
catheterization.
COLLABORATIVE CARE
Nursing Care
Surgical Care
This condition requires palliative and complete surgical repair (see
Table 17-2). Treatment for children includes aggressive medical regimen
with inotropic medications along with preload and afterload reduction.
in Children.
Tetralogy of Fallot
Tetralogy of Fallot (TOF) is a combination defect. Tetra is from the Latin
root “four” and Fallot is the name of the physician who defined it as a
syndrome or common grouping. An acronym to better remember the
four associated conditions that comprise this complex cardiac defect is
PROV: Pulmonary Stenosis, Right Ventricular Hypertrophy, Overriding
Aorta, and Ventral Septal Defect. This disorder begins as an outflow
tract disorder with the pulmonary stenosis. Since blood cannot
adequately exit the right side of the heart, this leads to the RV
hypertrophy. In addition because there is an opening between the
ventricles, this causes the aorta to exist over this septal defect as
opposed to off of the left side of the heart, leading to mixed (oxygenated
and deoxygenated) blood going out into circulation.
With advanced technology and early screening, this condition is
diagnosed at an early age. As recently as the 1980s, TOF was
undetected for many years, and in developing countries remains so
even today.
SIGNS AND SYMPTOMS
TOF can be indicated by the following symptoms:
■ Tachypnea
■ Dyspnea on exertion
■ Growth failure
■ Cyanosis after ductus arteriosus closes
■ Loud systolic ejection murmur that is described as harsh and radiating
■ Right ventricular hypertrophy (Fig. 17-20) caused by a stenotic vessel
and high pulmonary vascular resistance (PVR)
NURSING INSIGHT
Tetralogy of Fallot
A child with TOF can often have episodes called “TET” spells, which are cyanotic
events exacerbated by excitement and crying. This causes a sudden drop in
oxygenation in the periphery. The hallmark sign of TOF is cyanosis with crying or
playing, which can progress to fainting. This is relieved by squatting or drawing up
the legs. This causes an increase in the mixed blood leaving the heart for
circulation; therefore more deoxygenated blood is being distributed for circulation.
In the hospital setting, management of a TET spell may also involve other
measures to lower the HR, including administration of morphine. In the outpatient
setting, educating the parents about TET spells and how to position the child in the
knee-chest position is important.
DIAGNOSIS
Diagnosis of TOF is based on signs and symptoms such as cyanosis,
breathing difficulties, fainting, fatigue and weakness, slow growth, or
developmental delay. Tests, including ECG, echocardiogram, chest x-
ray exam, and cardiac catheterization support and confirm the
diagnosis.
COLLABORATIVE CARE
Nursing Care
Presurgical care involves preventing or minimizing symptoms
associated with the defect.
Surgical Care
See Table 17-2 for definitive surgical treatment.
in Children.
NURSING INSIGHT
Auscultation of Heart Murmurs
Most heart sounds are made through the opening and closing of valves or blood
flow through an abnormal opening. The typical points for auscultating heart sounds
are shown in Figure 17-21. When listening for each valve, the auscultation
landmarks are not located above the valve itself but in the direction of the flow of
blood. Therefore, the aortic and pulmonic valves are best heard above the valve
and the tricuspid and mitral sounds are best heard below the valve (Tables 17-6
and 17-7).
Complex Single Ventricle-Type Defects

Complex single ventricle defects are cyanotic conditions with full mixing
of oxygenated and deoxygenated blood. The main concern is that there
is only one physiological pumping chamber or ventricle. A VSD may be
present. In these conditions, palliative procedures allow the child to
grow until a definitive repair may be performed. Hypoplastic left heart
syndrome is a condition in this category.
Hypoplastic Left Heart Syndrome

Hypoplastic left heart syndrome is a life-threatening defect that must be
treated shortly after birth to sustain life. The ventricle is extremely small
or hypoplastic and unable to maintain an adequate cardiac output. The
RV must act quickly as the primary pumping mechanism of the cardiac
system (Fig. 17-22). This is possible only if there is a left-to-right
connection. If there is no ASD, an artificial shunt or pathway must be
created shortly after birth (see Nursing Insight: Pulmonary Atresia).
Prostaglandin (PGE1) is given to keep the PDA open. A Norwood
procedure is the first stage in the process along with a Blalock-Taussig
(BT) shunt. Eventually, a Glenn procedure provides more blood flow
and, ultimately, a Fontan procedure is performed. If these surgeries are
not suitable, the only other option for treatment is a cardiac
transplantation. Rarely, in the most severe cases, palliative or end of life
care measures are discussed with the family. Advocate for the family to
access these resources.
FIGURE 17-20 Tetralogy of Fallot.
FIGURE 17-21 Auscultation points.
TABLE 17-6
Heart Murmurs
LOCATION OF SOUND ASSOCIATED DEFECT PHASE
OR CONDITIONS
Aortic Ao valve stenosis Systolic
Subvalvular aortic stenosis Diastolic
Supravalvular aortic
stenosis
Aortic regurgitation
Pulmonic Pulmonary valve stenosis Systolic
ASD Diastolic
PA stenosis
Ao stenosis
CoA
PDA
PAPVR
TAPVR
Pulmonary ejection
murmur
Pulmonary fl ow murmur
Pulmonary insuffi ciency
Mitral Mitral regurgitation Systolic
Aortic stenosis Diastolic
MV Prolapse
Vibratory innocent
murmur
HOCM
Mitral stenosis
Tricuspid VSD Systolic
Tricuspid regurgitation Diastolic
TOF
Vibratory innocent
murmur
HOCM
Tricuspid stenosis
TABLE 17-7
Classifi cation of Murmurs
GRADE DESCRIPTION
1 Soft murmur, heard under quiet conditions usually by an
expert
2 Quiet murmur, heard even if it is noisy
3 Moderately loud murmur, easily heard
4* Loud murmur associated with a thrill
5 Very loud murmur heard with the edge of the stethoscope
tilted against the chest plus a thrill
6 Very loud murmur that can be heard with the stethoscope 5-
10 mm from the chest plus a thrill. Also may be heard
without a stethoscope.
*Diastolic murmurs are only graded to 4.
FIGURE 17-22 Hypoplastic left heart syndrome.
NURSING INSIGHT
Remembering the Names of Cardiac Defects

One way to remember cyanotic defects is to know that all defects starting with a “T”
are cyanotic defects. There is no special reason; it is just a convenient way to
remember which defects may be cyanotic.
CASE STUDY
Infant With a Heart Murmur

Abby, a 1-month-old infant, is seen in the community clinic for a heart murmur first
noted at birth. The clinic nurse obtains a history from the mother about the infant’s
weight gain, feeding patterns, and behavior. The mother reports that the baby has
“gained some weight, tires when feeding, and sleeps most of the time.” The nurse
then performs a nursing assessment and hears an aortic murmur. This type of
murmur is detected as an abnormal, soft blowing sound heard during the systolic
phase of the cardiac cycle. The murmur may be a sign of aortic valvular disease
such as aortic stenosis.
1. What suggestions can the nurse give Abby’s mother about feeding the baby?
2. Discuss important aspects about oral medication administration.
CARDIAC DISEASES
Children with cardiac diseases are at risk for alterations in growth and
development, nutrition, psychosocial functioning, and schooling. Other
risks include infection, acquiring other diseases, and even
cardiopulmonary arrest. Sometimes these children have significantly
altered lifestyles and undergo constant medical treatment.
Subacute Bacterial Endocarditis

Subacute bacterial endocarditis (SBE), also known as infective
endocarditis, occurs subsequent to a bacterial infection or introduction
of an infective agent into the child’s bloodstream. SBE is commonly
seen in patients with an unrepaired CHD or valve disease but can also
occur in normal hearts. The infection may be caused by an invasive
procedure such as surgery, urological procedures, or most often, dental
cleaning. The bacterium in the bloodstream adheres to a rough area in
the heart such as a stenotic valve or an area of turbulent flow. The
bacterium colonizes and causes tissue destruction.
Signs and Symptoms

SBE can have vague symptoms:
■ Low-grade fever
■ Malaise
■ Loss of appetite
■ Muscle aches
Acute illness can also indicate SBE:
■ High fever
■ Chills
■ Sweating
■ Stiff joints
■ Back pain
If SBE is a prolonged untreated illness:
■ Symptoms of heart failure occur (Venes, 2021)
Diagnosis
A thorough medical history and a physical exam are essential to
diagnosis. The history includes symptoms, questions about a heart
murmur or valve replacement, surgery, any recent risk factors for a
bacterial or fungal infection (e.g., dental procedures or catheter for
dialysis), recent fever, chills, or flu-like symptoms lasting more than 2
weeks. A physical exam may reveal eye hemorrhage petechiae, fluid in
the lungs, or signs of a stroke. Blood cultures to identify bacteria or fungi
in the bloodstream may detect endocarditis.
Prevention
Prevention of SBE starts with the understanding of the causative factors
of SBE. Parents of children with the risk factors of contracting SBE
should be proactive in obtaining the prophylaxis if deemed necessary.
Collaborative Care
NURSING CARE
Teach the family about the importance of preventive measures if their
child is at risk for SBE. When caring for a child with SBE, monitor vital
signs including temperature to assess for evidence of infection. A parent
may be worried about the prognosis of having SBE. The child may fully
recover or may be required to have a valve replacement if the valve is
damaged by the infective process. Be supportive of the parents’
emotional and spiritual needs in this situation by providing education
about what the future might hold.
MEDICAL CARE
SBE is treated with antibiotics, but the most effective approach is
prevention. The guidelines for administration and dosage of prophylactic
antibiotics are determined by the
American Dental Association (ADA) and the AHA. Guidelines for when
to prescribe prophylaxis treatment were updated in April 2007:
■ Patients with prosthetic cardiac valve
■ Patients who previously had endocarditis
■ Patients with CHD in the following categories only:
■ Unrepaired cyanotic CHD, including those with palliative shunts and
conduits
■ Completely repaired CHD with prosthetic material or device,
whether placed by surgery or catheter intervention, during the first 6
months after the procedure
■ Repaired CHD with residual defects at the site or adjacent to the
site of a prosthetic patch or prosthetic device (that inhibits
endothelialization)
■ Cardiac transplantation recipients with cardiac valvular disease or in
the first 6 months post-transplant
If valve destruction occurs, the valve may need to be repaired or
replaced.
The parents of a child with SBE should be counseled regarding how
to prevent future infections and how to recognize when an infection may
occur. Any febrile illness should be reported to the provider as soon as
possible. If the child sustained any valvular damage, follow-up visits
should be made at regular intervals, for example, every 2 to 3 months
initially and eventually moving to every 6 months or a year.
Kawasaki Disease
Kawasaki disease, also known as mucocutaneous lymph node
syndrome, is a multisystem disease affecting the cardiovascular system
(Fig. 17-23). Some evidence suggests an infectious trigger. Kawasaki
disease is more common in Japanese children and more prevalent in
the winter and spring (Harahsheh et al, 2020). The cause is unknown,
but a defective immune response to an infectious process is thought to
be responsible. Kawasaki disease is not congenital or contagious.
During the acute phase, diffuse vasculitis leads to long-term
cardiovascular problems in one out of every five patients affected. Once
the acute vasculitis and inflammatory response subsides, long-term
sequela of Kawasaki disease include aneurysm formation in arterial
vessels (all aneurysms are concerning, but most worrisome are those of
the coronary arteries), myocarditis, or rhythm disturbances.
With the onset of the coronavirus pandemic, clinicians and
researchers have come to learn that while children are largely spared
from this virus, some children have been affected by a rare but serious
inflammatory condition linked to COVID-19. In case studies, these
children tested positive for SARS-CoV-2 or had been exposed to the
virus (CDC, 2020). The presentation was very similar to Kawasaki
disease. The CDC is calling the condition multisystem inflammatory
syndrome in children (MIS-C), and the approach to treatment of this
syndrome has been with intravenous immunoglobulin (IVIG) and
supportive care measures (AAP, 2020).
Signs and Symptoms

Signs and symptoms of Kawasaki disease are the result of vasculitis
affecting all organ systems. Together with persistent fever (5 days or
more spiking to 104°F [40°C]), if the patient has four of the five signs
listed here, a Kawasaki diagnosis can be made:
FIGURE 17-23 Kawasaki disease. A, Palmar rash: redness and swelling
of the palms and soles of the feet. B, Strawberry tongue is a key
symptom of the disease.
■ Skin rash
■ Cervical lymphadenopathy, typically unilateral, greater than 1.5 mm in
diameter
■ Edema and erythema of hands and feet with eventual peeling of skin
■ Irritation and inflammation of the mouth with “strawberry tongue,”
erythema, and cracking lips
■ Conjunctivitis without exudate
Diagnosis
There is no specific test to detect Kawasaki disease. Children with a
fever along with other signs and symptoms in the presence of vessel
aneurysm are diagnosed with Kawasaki disease. A complete blood
count, erythrocyte sedimentation rate (ESR), ECG, and echocardiogram
are done to help to confirm diagnosis. Occasionally, cardiac
catheterization is indicated to diagnose aneurysm formation. Other
inflammatory diseases, such as Rocky Mountain spotted fever, scarlet
fever, or toxoplasmosis, need to be ruled out.
Prevention
Because the cause is unknown, it is difficult to discuss prevention. As
with any other type of disease, a proper, balanced diet, hydration, and
healthy living will aid the child in the healing process.
Collaborative Care
NURSING CARE
Physical care of a patient with Kawasaki disease centers on
supportive treatment of the symptoms and administering the prescribed
medications. Emotional and spiritual care may be necessary if the child
suffers the sequelae of aneurysms and the family is facing a lifetime of
treatment and monitoring. Preoperative care and postoperative care will
be required only if the child undergoes surgery for aneurysm repair.
Communicate to the family that the initial episode and the immediacy
of the treatment that was delivered determine the frequency of follow-up
visits to the health-care provider. Coronary bypass surgery is rarely
needed, and a very small number of children with Kawasaki disease-
related complications require a cardiac transplantation. Instruct the
family about precautions if the child is taking anticoagulant medications.
The child is monitored closely because of the risk of infection, bleeding,
and bruising.
MEDICAL CARE
Treatment of Kawasaki disease includes high-dose aspirin (ASA) that
is used to decrease inflammation causing the vasculitis as well as IVIG.
The passive immunity from IVIG is thought to help the patient immune
response. Other treatments such as steroids, plasma exchange, or
cytotoxic agents may be used if this initial therapy is ineffective (AAP).
The parents should be aware that follow-up visits are essential. If the
child is on anticoagulant therapy, appropriate blood testing and
monitoring should be adhered to. The child may have activity restrictions
if there are aneurisms involved.
FOCUS ON SAFETY
Thrombus Formation
Teach parents that children with aneurysm formation as a result of Kawasaki
disease require long-term follow-up for continued assessment related to other
vascular changes such as stenosis. Long-term use of anticoagulants such as
warfarin (Coumadin) or clopidogrel (Plavix) may also be used to prevent thrombus
formation in the engorged or aneurysmal vessels.
Cardiomyopathy
Cardiomyopathy (CM) is a condition in which the cardiac muscle
becomes dilated, hypertrophied, stiff, or inflamed. There are various
classifications and causes, but the end result is the same. The cardiac
muscle no longer functions adequately, and treatment must ensue to
sustain life.
Dilated (DCM) or congestive cardiomyopathy is the most common
form and is caused by weakened contractions leading to dilation of all
four chambers of the heart. The weakened contractions are caused by
myocardial damage as a result of toxic agents. Dilated cardiomyopathy
is caused by myocardial damage from chemotherapy, microbes,
bacteria, viruses, immunological defects, or nutritional disorders.
Hypertrophic cardiomyopathy (HCM) is usually a familial disorder. It
is a condition in which the ventricle is hypertrophied, swollen, or
thickened in the absence of other cardiac conditions. The pumping
mechanism of the ventricle is usually hyperdynamic, and the filling is
hindered because of thickening of the ventricle.
Restrictive cardiomyopathy (RCM) is the least occurring type of CM
and is characterized by unusually non-compliant ventricular walls that
fail to relax. The size of the ventricle is normal, but the atria are enlarged
because of the impaired diastolic filling caused by stiffness in the
ventricle (Park, 2016).
Signs and Symptoms
The child with CM has a variety of vague symptoms such as:
■ Weakness
■ Excessive tiredness
■ Exercise intolerance
■ Heart palpitations
■ Chest pain
■ Poor feeding
■ Slow weight gain
■ Syncope (fainting)
■ Light-headedness
Diagnosis
Diagnosis includes a complete physical examination that may reveal a
murmur, gallop, and venous congestion as demonstrated by
hepatomegaly or distended neck veins. An ECG may show right- or left-
sided enlargement and possible Q waves. Tachycardia, cardiac rhythm
disturbances, or ventricular ectopy is often seen. An echocardiogram
provides the exact diagnosis. A family history of CM or sudden death of
unknown causes in a family member may also alert the practitioner to
seek a definitive diagnosis for CM.
Prevention
CM often cannot be prevented because the causes are familial or
genetic. For CM caused by infections, families must know that any
infection in a child should be treated seriously and acted on as soon as
possible under the direction of a physician or nurse practitioner.
Collaborative Care
NURSING CARE
Nursing care measures include alleviating the symptoms with
prescribed medications and monitoring for worsening signs. After the
diagnosis, the child with CM is closely monitored for further
complications, preferably through a recognized CM program.
Communicate to the family that frequent echocardiograms are
warranted to assess the size and function of the ventricular wall and to
note improvement or deterioration of the condition. The family must also
understand that the child is placed on activity restrictions to prevent
overstimulation of the heart muscle (Park, 2016).
MEDICAL CARE
Medical management includes a medication regimen aimed at
improving function of the cardiac muscle. Angiotensin-converting
enzyme (ACE) inhibitors or angiotensin receptor blockers have positive
inotropic properties influencing the force of muscular contractility
(Venes, 2021) and must be continued until the muscle becomes
stronger; the need for these medications may be lifelong. Other medical
treatment includes beta-blocker therapy and nutritional supplementation,
particularly with carnitine (Carnitor or l-carnitine). Diuretic and inotropic
therapy is also recommended, except in the case of hypertrophic CM.
SURGICAL CARE
Cardiac transplant is the focus of surgical management.
MEDICATION: Carvedilol
(kar-ve-dil-ole) Beta (β)-Adrenoreceptor blocker, -
adrenergic
Indications: Carvedilol is indicated for the treatment of mild to severe heart failure
of ischemic or cardiomyopathic origin.
Actions: Beta blockers slow tachycardia and vasodilation; carvedilol decreases
peripheral vascular resistance, decreases renal vascular resistance, reduces
plasma renin levels, and increases atrial natriuretic peptide levels.
Therapeutic Effects: Increases stroke volume, decreases blood pressure, and
improves renal flow, decreases heart rate.
Contraindications and Precautions: Monitor for possible deterioration of CHF,
liver injury, bronchospastic disease, and thyrotoxicosis.
Adverse Reactions and Side Effects: Chest pain, dizziness, hyperglycemia,
bradycardia, nausea.
Route and Dosage:
ORAL: 0.07 mg/kg per dose
MAXIMUM DOSE: 0.5 mg/kg
Once or twice daily dosing
Reduce dose for bradycardia less than 55 beats per minute
1. Initiate with low dose and titrate up as tolerated.
2. Monitor blood pressure for 1 hour after initial dosing.
3. Monitor blood pressure, pulse, and ECG frequently.
4. Take with food.
Source: Vallerand, A. H., & Sanoski, C. A. (2021).
The education for patients with CM is similar to those with CHF. The
parents must adhere to the medication and follow-up regimen.
Discharge instructions and parent education include monitoring vital
signs and how to recognize signs and symptoms of cardiac failure. The
parent will be given ranges of vital signs appropriate for the child’s age
and circumstance. For example, some patients may have a lower or
higher than expected range for their age because of the type of cardiac
disease. Occasionally, the parent should learn cardiopulmonary
resuscitation (CPR) and how to measure basic vital signs such as HR,
respiratory rate, and blood pressure. If the child is discharged to home
with oxygen, the parents will also have a pulse oximeter in the home.
The parent will be taught to observe for subtle signs of CHF such as
shortness of breath, decreased appetite, irritability, swelling, and weight
gain.
Discharge instructions include medication use, effects, and side
effects. The nurse will ensure that the patient is receiving education
appropriate for their learning style and comprehension level. Each
medication should be reviewed for specifics.
The parents should be instructed about diet, exercise, activity, and
returning to school. A proper diet for a cardiac patient includes
balanced, healthy food choices for good bone healing and avoidance of
junk food and empty calories. Fluid restriction is not encountered as
often as in the adult population but may be used for the patient in severe
CHF or the older child. As discussed earlier, infants and younger
children can dehydrate much easier; therefore, this practice is avoided
in this age range. Exercise guidelines are based on tolerance levels for
each individual patient.
NURSING INSIGHT
Detecting Rheumatic Fever
Rheumatic fever (RF) is a group-A hemolytic streptococcal infection affecting
multiple body systems such as the heart, the joints, subcutaneous tissue, and, at
times, the nervous system. Typically arising as an acute pharyngitis, it occurs most
often in children aged 5 to 15 years. Two to three weeks after the initial infection,
the organism invades the bloodstream and deposits on the valves of the heart
(vegetation) causing permanent damage. The aortic and mitral valves are most
frequently involved. The signs and symptoms of RF coupled with a history of strep
pharyngitis lead to the diagnosis. Typically, five major criteria (called Jones criteria)
are present to give a diagnosis of RF:
• Arthritis (predominantly involving the large joints and is migratory [moves from
joint to joint])
• Carditis and valvulitis
• Sydenham’s chorea (jerky purposeless movements of hand, changes in
handwriting, emotional outbursts)
• Erythema marginatum (a circular red rash) with clearly demarcated raised edges
seen most often on the trunk
• Subcutaneous nodules (palpable nodules in the subcutaneous tissue)
There are four minor criteria:
• Arthralgia
• Fever
• Elevated ESR or C-reactive protein
• Prolonged PR interval
Prevention of RF is aimed at treating the initial strep infection early. Once a child
has had RF, prompt recognition of a new infection will prevent a second RF attack
and reduce the chances of progression of severity of heart disease. Heart failure
management is an important nursing care measure. Medical treatment for RF is
antibiotic administration and use of anti-inflammatory medications, specifically
aspirin.
Education and discharge instructions include telling parents that children who
have had RF may require a valve replacement during their lives. A valve replaced
in infancy or childhood must be replaced every 5 years to accommodate the child’s
growth. Valves replaced during adolescence can last up to 10 years.
ADDITIONAL CARDIAC CONDITIONS

Cardiac Trauma
Blunt cardiac trauma (BCI) is uncommon but can result from a variety of
injuries, such as a motor vehicle crash or sports activity. Seat belt use
has reduced the incidence of BCI, but even a child wearing a seat belt
or other protective equipment in a car can sustain cardiac trauma.
Cardiac trauma may also be seen in child abuse cases.
Cardiac trauma will occur in less than 5% of children with thoracic
trauma. The chest wall of a child has more compliance than adults, and
rib and sternal fractures are less common. This may cause an
underdiagnosis of trauma. Many cases self-resolve.
Damage to the heart muscle occurs as the result of a direct blow to
the thorax overlying the heart (e.g., a baseball or steering wheel).
Electrocution (injury from electricity) can also cause damage to the
cardiac muscle. In cardiac trauma, the particular damage to the heart
can be a ventricular rupture, a great vessel tear, damage to the
pericardial sac or coronary arteries, septal or valvular injuries, cardiac
tamponade, myocardial infarction, comorbidities or sternal fracture, or
dysrhythmias. Commotio cordis is a type of trauma caused by a small
dense object colliding with the chest at a rapid velocity, as is the case
with a baseball or hockey puck. This may produce a lethal dysrhythmia
if this occurs during the relative refractory period (most vulnerable) of
the cardiac cycle.
Signs and Symptoms

The signs and symptoms are related to the type of cardiac trauma
sustained and include:
■ Bruising
■ Pain, mild to severe (probably related mostly to surface
musculoskeletal pain)
■ Pulsus paradoxus or pulse deficit
■ Muffled heart sounds or murmur
■ Dysrhythmia
■ Hypotension
■ Severe cardiac shock
Diagnosis
The diagnosis is made based on a thorough history including the type of
trauma, force of trauma, associated injuries and symptoms, and loss of
consciousness. The diagnosis of the extent of cardiac trauma is made
with ECG; echocardiogram; cardiac enzymes, specifically troponin I;
and chest x-ray exam. All of these tests will indicate cardiac muscle
damage. A computed tomography or multigated acquisition scan may
be helpful in determining other injuries but does not correlate to
outcome. Other labs include a complete blood count to detect anemia
from hemorrhage.
Prevention
Prevention of cardiac trauma also goes hand in hand with safety.
Provide safety instructions about sports, crashes, and seat belt use to
parents for wherever the child lives, goes to school, and plays.
Collaborative Care
NURSING CARE
Nursing care is based on the extent and exact type of the injury. Initial
nursing care includes bedrest. Activity restrictions are enforced until the
cardiac muscle heals. In addition, antiarrhythmics, inotropic agents, and
pericardiocentesis (aspiration of fluid from the pericardial sac) may be
required. A cardiac rehabilitation program is recommended.
MEDICAL CARE
Medical management focuses on monitoring and giving medications
to prevent or alleviate CHF or dysrhythmias.
Education focuses on recognition of complications and preventing
further injury. The child may be fitted with a special vest to prevent
further contusion. The patient will have exercise restrictions for 2 to 4
weeks or more depending on the extent of the damage. The child may
be on extensive bedrest until the cardiac muscle heals.
Hypercholesterolemia–Hyperlipidemia
The etiology for hypercholesterolemia–hyperlipidemia in children is
classified as primary or secondary. A primary cause is hereditary
predisposition and children may develop atherosclerotic lesions as early
as infancy. Hypercholesterolemia is more often a result of secondary
causes. Secondary causes are exogenous (originating outside an
organ), endocrine, or metabolic disorders; liver diseases; renal
diseases; or other miscellaneous reasons such as anorexia nervosa or
collagen diseases. In addition, children with cardiac transplant form
atherosclerotic lesions at a very rapid rate and risk facing coronary
artery bypass graft, or worse, a second transplant surgery.
Communicate to the family that treatment of hyperlipidemia for children
with a transplanted heart is more aggressive than for the general
population. If the patient has received a heart transplant, ensure routine
lipid panels are performed.
Patient Education
Hypercholesterolemia-Hyperlipidemia
TOPIC: The nurse will educate the family about hypercholesterolemia-
hyperlipidemia.
• There are two types of primary hypercholesterolemia-hyperlipidemia: familial
hypercholesterolemia and familial combined hyperlipidemia. The standards for
childhood cholesterol levels are different from those for adults (Table 17-8).
• Although the standard levels are different, the treatment goals are similar to those
for adults and include diet modification, exercise, and medication. A
recommended balanced nutrition is one that provides less than 10% of total
calories from saturated fatty acids, 30% or less of total calories from fat, and less
than 300 mg of cholesterol each day. Help the family decrease the fat and
cholesterol intake to 7% of fatty acids, 25% or less of total calories from fat, and
less than 200 mg of cholesterol per day.
• Pharmacological treatment is recommended for children older than 8 years of age
whose low-density lipoprotein (LDL) cholesterol is high.
• Recommendations for screening children after age 2 and no later than 10 years
older are:
- At least one parent with high cholesterol
- A family history of early heart disease such as a male parent or grandparent
with CHD before age 55 or a female parent or grandparent with CHD before age
65
- Family history of diabetes, HTN, or obesity
- Child with obesity (greater than 85th percentile)
- Immunosuppressant drug use (AHA, 2014b)
Hypertension
High blood pressure, or HTN, is an elevated blood pressure and is
uncommon in children, though the incidence is rising along with
childhood obesity. The American Heart Association has current
recommendations for blood pressure assessment in children (AHA,
2020b).
Signs and Symptoms

HTN can manifest in a variety of symptoms. Signs and symptoms
depend on the underlying causes. Elevated blood pressure is a key
sign. A young child may be irritable. An older child may complain of:
■ Changes in vision
■ Dizziness
■ Headaches
Diagnosis
Taking a detailed medical and thorough family history is important in the
diagnosis of HTN. A child is hypertensive if the blood pressure is above
the 95th percentile for age, height, and gender. As a screening tool,
consider any reading greater than 20 mm Hg above normal blood
pressure for the child’s age. A teenager’s blood pressure is considered
high based on adult values for treatment purposes and follows the same
guidelines as adults. The extent of further testing is based on the degree
of blood pressure elevation. High blood pressure or HTN may indicate a
CoA, kidney disease, left ventricular hypertrophy, or early-onset familial
HTN. Some cardiology centers conduct HTN follow-up for families with a
strong history.
Prevention
HTN in children is usually related to an underlying physical cause such
as kidney disease or CoA. Prevention is reliant on monitoring to prevent
HTN in these settings, but often HTN is the first symptom.
TABLE 17-8
Cholesterol Levels in Children
DESIRABLE BORDERLINE ASSOCIATED
WITH HIGHER
RISK
Total cholesterol <170 170–199 200 or more
LDL cholesterol <110 110–129 130 or more
Source:American Heart Association, 2020.
Collaborative Care
NURSING CARE
Nursing care for the child with HTN is based on education about the
condition, diet, exercise, lifestyle modification, and medication. The
nurse is aware that vital signs will include more frequent blood pressure
measurements. The nurse uses proper technique of blood pressure
measurements and cuff size in children of all ages.
MEDICAL CARE
Medications for high blood pressure or HTN include beta blockers and
ACE inhibitors.
Education includes teaching parents to administer antihypertensive
medications on time and not skip doses to prevent rebound effect.
Education about the condition, diet, exercise, lifestyle modification, and
medication should begin as soon as the diagnosis is confirmed.
Pulmonary Arterial Hypertension

Pulmonary arterial hypertension (PAH) is a condition of high blood
pressure in the lungs. It may result from cardiac defects or may be
idiopathic (without recognizable cause). It is often associated with cor
pulmonale and is a severe disease resulting in death if not treated.
Normally, the desired pulmonary blood pressure is low, allowing blood to
flow easily from the right side of the heart. The pressure in the right side
of the heart is lower than in the left (the left reflecting the systemic blood
pressure). If the pressure in the lungs is high, as with PAH, the RV must
pump harder to force the blood to the lungs. Over time, this wears on
the ventricle and causes RV hypertrophy. Eventually, the heart fails and
congestive symptoms develop.
Signs and Symptoms

PAH often has multiple symptoms:
■ Shortness of breath (dyspnea), especially during exercise
■ Chest pain
■ Weakness
■ Fatigue
■ Dizziness
■ Leg swelling
■ Fainting episodes
Diagnosis
In the early stages of the disease, a physical exam may be normal
because diagnosis of PAH may take several months. However, as the
condition progresses, a physical exam shows a heart murmur,
enlargement of the neck veins, liver and spleen enlargement, leg
swelling, parasternal heave, ascites, and clubbing.
Diagnostic tests such a pulmonary arteriogram, echocardiogram,
chest radiograph, cardiac catheterization, and pulmonary function tests
may help confirm the diagnosis.
Prevention
Prevention is related to getting early and consistent care of cardiac
defects. Sometimes this condition is not preventable.
Collaborative Care
NURSING CARE
The patient’s prognosis is often poor, and they will face a lifetime of
medications. Focus on providing education and support for the family.
Focus care on reducing respiratory sequelae by providing for frequent
rest periods and monitoring the respiratory status carefully through vital
signs and pulse oximetry. Provide oxygen and adjust according to need.
The nurse will provide essential medications.
MEDICAL CARE
Treatment for PAH includes oxygen, which relaxes the arteries of the
lungs, and medications used specifically for PAH such as calcium
channel blockers that relax blood vessels.
MEDICATION
Medications Used for Pulmonary Hypertension
• Phosophodiesterase—type 5 (PDE-5) inhibitor. PDE-5 is found in the pulmonary
vascular smooth muscle and degrades cyclic guanosine monophosphate (cGMP).
When this chemical is inhibited, cGMP levels increase and cause smooth muscle
relaxation. This eventually decreases the PA pressure.
• Sildenafil (Revatio, Viagra)—most commonly used. Reconstituted at a
concentration of 2.5 mg/mL. Best ordered as “sildenafil” or “Revatio” rather than
“Viagra” for insurance purposes.
• Tadalafil (Adcirca, Cialis)
• Endothelin receptor antagonist, which relaxes PA vasculature:
- Bosentan (Tracleer)—liver function tests (LFTs) must be done monthly so you
may receive faxed LFT results. Bosentan is teratogenic category X so pregnant
women and women of childbearing age should not handle the medication (main
concern is in the dust). Medication dissolves in water, should not be crushed.
• Direct dilator of PA vascular beds:
- Inhaled treprostinil (Tyvaso)
- Treprostinil (Remodulin—IV or Subcutaneous)—half-life is 3 to 4 hours. Is
started in the hospital and then given as subcutaneous continuous infusion at
home.
- Prostacyclin, a direct-acting pulmonary vasodilator:
- Epoprostenol (Flolan)—The half-life is 2 to 3 minutes and is given IV. Children
can be on this medication at home if they have a peripherally inserted central
catheter line. This medication can never be stopped, for any length of time.
Parents are instructed on what to do if the infusion becomes interrupted.
Teaching points include discussion about diet, exercise, and medication.
The diet may be higher in calories to accommodate for the energy
expenditure of this pulmonary-related disease. The child may have very
low exercise tolerance. That does not mean the patient should not
exercise at all, but they may have to enroll in a specialized cardiac
rehab program.
Neurally Mediated Syncope
Neurally mediated syncope (NMS), also called vasovagal syncope, is a
condition caused by an exaggerated response to a normal bodily
function. In normal function, the baroreceptors in the carotid artery
regulate blood pressure during certain situations. When the body is
stressed during extreme heat, pain, fright, or prolonged standing, the
initial response is a release of epinephrine, stimulating the sympathetic
nervous system. A classic presentation is when a child faints when a
parent is brushing their hair. This stimulation in turn raises the blood
pressure. The baroreceptors send messages to control the blood
pressure. In NMS, the baroreceptor response is exaggerated, causing
the blood pressure and the HR to drop rapidly and significantly.
Signs and Symptoms

Symptoms of NMS include:
■ Temporary loss of consciousness (a fainting spell)
■ Seizure (rare)
Diagnosis
A thorough history and other tests rule out other diagnoses, such as
seizures or Long QT syndrome (LQTS). The definitive diagnosis of NMS
is made via the tilt test but can be made on history alone.
Diagnostic Tools
Tilt Test
NMS is diagnosed with a tilt table test. Assist the child by placing them in a supine
position on a table equipped with a foot board. The table may be tilted to an upright
position anywhere between 45 and 90 degrees. After a short time, the table is tilted
to a full 90-degree angle so that the child stands upright. This maneuver may or
may not reproduce the fainting or symptoms. If the tilt test is positive, the nurse will
see a remarkable drop in blood pressure or HR, and the child will experience
syncope or presyncope (dizziness or light-headedness). Prevention includes
maintaining good hydration and preventing situations that may lead to syncope.
Collaborative Care
NURSING CARE
Monitor for frequency, severity, and precipitating factors of syncope.
Nursing care for NMS may be as simple as increasing the child’s
sodium and water intake. It is important to communicate to the family
that NMS is concerning based on the potential for injury if the child loses
consciousness. If a teen with syncope is of driving age, in some states
the teen must be syncope-free for 6 months before driving again.
MEDICAL CARE
An adrenocorticosteroid such as fludrocortisone (Florinef) may be
given to retain fluid. The next level of medical treatment is a beta
blocker, which regulates the exaggerated response.
The family and the patient should be encouraged to learn to recognize
those activities that put them at greatest risk for a syncopal event. The
child should maintain adequate hydration, especially in the summer
heat. The patient is instructed not to stand in one place for a long time
and bend the knees or sit down if a syncopal event is imminent.
Long QT Syndrome
Long QT syndrome (LQTS) is an electrophysiological condition
predisposing the child to fatal dysrhythmias such as ventricular
tachycardia, torsade de pointes, and ventricular fibrillation (Fig. 17-24).
LQTS is a familial disorder, and if one child is affected, all siblings and
parents are tested for the disorder. There are a variety of known factors
and genetic chromosomal markers in a person with LQTS. LQTS is
among a group of channelopathies (defects of the ion channels on the
cardiac cell membrane). The child and family are most likely unaware
that they have this problem. Because sudden death is one of the
symptoms, the child’s first episode may be the last.
Signs and Symptoms

Symptoms of LQTS can include:
■ History of fainting triggered by intense emotions, vigorous physical
activity, swimming, auditory stimuli (such as a school bell), and upon
awakening
■ Palpitations
■ Seizure Sudden death
Diagnosis
An ECG is performed in all children with seizures of sudden onset,
fainting, or near-drowning episodes. The child may be asymptomatic
and may present at routine exam with a prolonged QT on ECG.
Prevention
Prevention of the dysrhythmias caused by LQTS is accomplished by
taking prescribed medications.
Medical Care
The primary treatment is medication. The most frequently used
medications are beta blockers. Treatment also includes pacemaker-
defibrillator (insertion) or left cardiac sympathetic denervation. It is
important that the nurse communicates to the family that the most
common cause of treatment failure is noncompliance with medication.
FIGURE 17-24 Prolonged QT.
Parents should make sure they are trained in CPR. In addition, they
should notify the school nurse about the child diagnosed with a LQTS or
any other cardiac concern, and care should be taken so that school staff
is trained in proper cardiopulmonary resuscitation techniques and an
automated external defibrillator placed in the school. In addition, any
child with a medical condition should have a 504 Accommodations in
place.
Rhythm Disturbances
Rhythm disturbances are an alteration in the normal electrical flow
within the heart. Figure 17-25 shows the normal electrical conduction
pattern identified as PQRST. Any alteration in this pattern will alter the
normal flow, filling, and emptying of the heart. This alteration in flow
affects the cardiac output.
Signs and Symptoms

Dysrhythmias can be indicated by:
■ Palpitations
■ CHF symptoms
■ Syncope
■ Dizziness
FIGURE 17-25 PQRST electrophysiology.
Diagnosis
Diagnosis is based on a rhythm interpretation of the ECG. The concern
with all dysrhythmias is the effect on cardiac output. All rhythm
disturbances can be grouped into three categories: too fast, too slow, or
absent. Lethal rhythms are those producing little or no cardiac output
and unless corrected will lead to cardiac death.
Tachycardia is the name for a fast HR. It describes any condition in
which the heart beats faster than the standard pediatric HR values and
includes sinus tachycardia, supraventricular tachycardia, atrial
tachycardia, atrial flutter, atrial fibrillation, junctional tachycardia, and
ventricular tachycardia. If the HR is too fast, the diastolic phase shortens
in relation to the length of the full cardiac cycle. The ventricle is not
allowed enough filling time; the SV is less, therefore decreasing the
cardiac output. The lethal rhythms in this category are torsade de
pointes and ventricular fibrillation.
Bradycardia is the name for a slow HR. This is any condition in which
the heart beats slower than the standard pediatric HR values. This type
of dysrhythmia most commonly includes sinus bradycardia and
junctional and idioventricular rhythms. In a bradycardic child, the cardiac
output is affected because the HR is slow. Initially, the body tries to
compensate by increasing the contractile force, thus increasing the SV.
Eventually, this will plateau or the cardiac muscle may not be strong
enough to compensate, as in CHF or CM. The lethal rhythms in this
category are asystole and agonal rhythms.
Blocks are disruptions in the flow of electrical current throughout the
heart. They include bundle branch block (BBB) and first-, second-, and
third-degree blocks. First- and second-degree type I blocks and BBB
may cause no interference in the cardiac output, whereas second- and
third-degree blocks are more severe and require intervention to maintain
adequate circulation. The latter rhythms will be lethal if not corrected.
Prevention
Prevention of the dysrhythmias caused by rhythm disturbances is
accomplished by taking prescribed medications. The family should be
instructed to avoid activities that will promote the rhythm disturbance
such as dehydration, increased exercise, or Valsalva maneuvers.
Collaborative Care
NURSING CARE
The nurse working in a cardiac area with children who experience
dysrhythmias and require cardiac telemetry can acquire specific
knowledge about the ECG and learn about basic dysrhythmia
interpretation. When caring for children on a cardiac floor or in the
intensive care unit, nurses can acquire more advanced information
through a course on 12-lead ECGs. Working with the clinical education
department to provide training in Pediatric Advanced Life Support and a
pediatric emergency course is essential.
Determine the baseline rhythm and recognize changes that will
facilitate the best outcome for a child with a dysrhythmia. Know
ramifications of these changes. Important critical thinking questions the
nurse can ask about rhythm disturbances are:
■ Is the rhythm potentially fatal?
■ Will it alter the cardiac output?
PROCEDURES ■ Obtaining a 12-Lead

Electrocardiogram (ECG)
PURPOSE
An ECG is a graphic display of electrical activity produced by changes in the
intracellular charge of the cardiac muscles. The components of an ECG are marked
with the letters PQRST. The abbreviations ECG/EKG are used interchangeably.
(The K is the abbreviation for the German kardio [cardiac].)
EQUIPMENT
A 12-lead ECG is a surface recording of the electrical activity of the heart.
Essentially, it is looking at the heart from different angles, by measuring the flow of
current from different directions. This is accomplished by putting leads on different
parts of the body and the chest. There are three groupings of leads: Limb Leads,
Augmented Leads, and Precordial or Vector Leads.
The Limb Leads are bipolar leads (requiring two leads to read) that are further
grouped into Lead I (Right Arm to Left Arm), Lead II (Right Arm to Left Leg), and
Lead III (Left Arm to Left Leg). Augmented Leads read from a combination of the
two other leads to the positive lead. These are further grouped into three directions.
These are aVR: right arm is positive and reads from the apex of the heart to the
apex; aVL: left arm is positive and reads across the RV toward the left ventricle;
and aVF: foot (left) is positive and reads perpendicular from the top to the bottom of
the heart in a cephalocaudal direction. Precordial leads are also known as V-Leads
or chest leads. These leads are unipolar and measure the electrical activity in the
transverse plane or a cross-section of the heart.
STEPS: SETTING UP THE MACHINE
1. First, set up the ECG machine.
RATIONALE: It is best to have the machine ready to go before placing the
electrodes on the child because it may be difficult to obtain an artifact-free
recording from an agitated child.
STEPS: PRIOR TO ATTACHING THE LEADS
1. Put in demographic data.
RATIONALE: To ensure that accurate data are recorded, the correct spelling of
the child’s name, date of birth, and the medical record number are important.
These items are all crucial components of proper identification of the patient.
From a legal standpoint, it will prevent errors in diagnosis and treatment plans.
2. Change leads view.
RATIONALE: The recording machines are typically set up as a 12-lead ECG,
with a continuous Lead II rhythm strip, as opposed to a 3-lead rhythm strip.
Make sure the machine is on the correct recording mode.
3. Set gain.
RATIONALE: The gain is 10 mm/mV for pediatrics, and every subsequent
recording should be the same. Do not compare two different 12-lead ECG
recordings done at different gains.
4. Set speed.
RATIONALE: The standard default speed should be set at 25 mm/second. The
recorder can be set for different speeds depending on the purpose of the
recording.
STEPS: LEAD PLACEMENT
1. Prepare the skin.
RATIONALE: Clean the chest lead placement area with alcohol or usual skin
prep, if necessary. If the patients have chest hair, as in adolescent boys, shave
the electrode areas.
2. Place the limb leads.
RATIONALE: Proper lead placement includes:
a. White – Right Arm or Shoulder
b. Black – Left Arm or Shoulder
c. Red – Left Leg or Abdomen
d. Green – Right Leg or Abdomen
3. Place the vector lead.
RATIONALE: Proper lead placement includes:
a. VI – 4th intercostal space, just to the right of the sternum
b. V2 – 4th intercostal space, just to the left of the sternum
c. V4 – On the midclavicular line and 5th intercostal space
d. V6 – On the midaxillary line, horizontal with V4
e. V5 – Between V6 and V4
f. V3 – Between V4 and V2
STEPS: RECORDING
RATIONALE: To ensure an accurate recording:
1. 12-Lead Recording
a. Make sure there is little to no movement.
2. Press the button for a Rhythm Strip.
STEPS: TROUBLESHOOTING
RATIONALE: When no signal or a poor signal is observed, the following is
considered:
1. Have the cables been correctly connected?
2. Is the equipment functioning correctly?
3. Could external electrical equipment interference be a problem?
4. Was skin preparation adequate?
5. Could the electrodes suffer from:
a) The gel drying out?
b) Poor adhesion?
TEACH PARENTS
Teach parents the reasons the procedure is being performed on the child.
ELECTROCARDIOGRAM (ECG). DOCUMENTATION
The baby had a 5-beat run of ventricular tachycardia, and the provider ordered a
12-Lead ECG. The underlying rhythm was sinus. The procedure was completed
according to protocol and the technician downloaded the data to the computer
system so the cardiologist may analyze.
There was no further evidence of ventricular tachycardia throughout the
procedure or afterward.
J. Marshall, RN
NURSING INSIGHT
Pulseless Electrical Activity

Pulseless electrical activity (PEA), formerly known as electromechanical
dissociation, is a condition in which the observer will see an electrical rhythm on the
cardiac monitor, but there is no cardiac output and therefore no pulse.
Pathologically, there is no communication between the electrical and mechanical
components of the heart. The nurse should remember to treat the patient, not the
rhythm. If this situation is noted, the nurse should obtain a blood pressure and
pulse rate and then consider the underlying causes. The underlying causes of PEA
are as follows (often referred to as the Hs and Ts):
• Hypovolemia
• Hypoxia
• Hydrogen ion (acidosis)
• Hypo-/Hyperkalemia
• Hypoglycemia
• Hypothermia
• Toxins
• Tamponade
• Tension pneumothorax
• Thrombosis (heart or lung)
• Trauma
Discovering and correcting the underlying causes will correct the PEA.
A normal irregular rhythm in which the rhythm varies with respiration

is called sinus dysrhythmia. Sinus dysrhythmia has no adverse effect on
the cardiac output.
■ The HR increases with inspiration. (Remember: “Inspiration“ and
“Increase“ both start with an “I.”)
■ The HR decreases with expiration.
What if the child presents to the pediatrician’s office with “an irregular
rhythm”? A simple, inexpensive, and noninvasive ECG will determine
the etiology of irregular rhythms. If the HR speeds up when asking the
child to take a breath and slows down when asked to exhale and hold it
out, the diagnosis can be made.
INVASIVE TESTS
Cardiac catheterization may be performed for a number of reasons. This
test can determine the pressures within the child’s heart vessels and
provide a radiographic picture of the anatomy by measuring the size and
shape of vessels, valves, and ventricles. A cardiac catheterization is
necessary to perform a myocardial biopsy. Corrective procedures, called
interventional catheterizations, may be performed in the cardiac
catheterization lab.
Collaborative Care
NURSING CARE
Be aware of specific aspects of caring for a child in the postcardiac
catheterization period. After cardiac catheterization, the child has a
pressure dressing placed in the groin area at the insertion site. If an
internal jugular vein is used, a small bandage covers the site on the
neck.
Monitor the HR, respirations, and blood pressure and make sure to
note that it is in the same measured range as precatheterization. If
tachycardia is identified postcatheterization, pain or dehydration is
considered to be the underlying cause. Acetaminophen (Children’s
Tylenol) is given for the pain. If the child is dehydrated, administer fluid
boluses per health-care provider’s order. Signs of infection are rare in
the first few hours postcatheterization.
Children with cardiac disease may be cyanotic so it’s important to
obtain a baseline oxygen saturation and monitor the child with that
number in mind. Some children with heart disease normally have a
value as low as 85%. Confirm the range of normal oximeter readings
with the health-care provider.
The child may be placed on cardiac telemetry if dysrhythmias were
induced during the catheterization. Normally, if the child has a
nonelectrophysiological diagnosis, any dysrhythmias seen during the
procedure disappear when the catheters are removed, but subsequent
monitoring may be required.
There are specific growth and development issues to consider
postcatheterization. After a cardiac catheterization, a child is required to
lie flat for up to 6 hours depending on the insertion site of the catheter.
The supine position minimizes the risk of bleeding through the insertion
site. A younger child may need to be restrained with leg immobilization
devices to keep the leg straight. Older children or adolescents are
usually cooperative, unless they are developmentally delayed.
Administer sedation if necessary to keep the child still, but this may
delay the discharge and holds certain risks. Generally, an infant or child
does well if the mother is allowed to stay at the bedside or hold the
child. Allowing the infant to feed is also calming.
Communicate to the family that after a cardiac catheterization, the
child will continue the same medications as before. If any devices such
as closure devices or stents remain in the body, the child will take a
baby aspirin for 6 months after the procedure. The aspirin prevents clot
formation while endothelialization occurs around the artificial device.
SBE prophylaxis precautions are followed by the health-care provider
for 6 months for device placement patients. Tell the family that after 6
months of placement of the device, no special precautions are needed.
Diagnostic Tools
The cardiac catheterization procedure takes place in a cardiac catheterization lab
where the child is sedated or anesthetized. First, an introducing sheath is placed in
a major vessel such as the femoral vein or artery. Next, a long hollow tube or
catheter is threaded through this sheath and into the heart. The physician uses
real-time radiographic study (fluoroscopy) to monitor the movement of the catheter
and to prevent perforation. During a cardiac catheterization, pressure is measured
in the ventricles and the vessels. The normal pressure of the left ventricle
correlates with the normal blood pressure for age. The normal pressures in the RV
and right and left atria are similar to those of an adult patient. Elevated pressures
can indicate a variety of illnesses and will usually support or refute the suspicions of
the diagnostician. For example, high pressure in the RV may indicate a VSD with
left-to-right shunting, PA stenosis, or PAH. Radiopaque dye is injected through the
catheter, and the flow of the dye is observed on fluoroscopy. The dye takes the
shape of the inside of the heart, giving a picture of the anatomy of the ventricle,
valves, vessels, and any defects that may be present.
The overall risks for the child undergoing a cardiac catheterization are minimal.
Because this is an invasive procedure, know the risks of bleeding, infection,
thrombus, dysrhythmia, perforation, stroke, or even death.
Postcatheterization, monitor the child’s pressure dressing in the groin

as well as the HR, respirations, and blood pressure (Box 17-1).
Angiography
Angiography helps to assess the structure and function of the ventricles,
vessels, and valves. It is also useful to determine size and location of
septal defects. After placement of the catheter in the heart, radiopaque
contrast medium is injected into the chambers and vessels of the heart.
If there is a defect, the contrast highlights septal openings, narrow
vessels, and extra vessels.
BOX 17-1
Typical Postcardiac Catheterization Medical

Orders
Admit to postsurgical observation unit.
VS every 15 minutes 4 times, then every 1 hour 4 times, then every 2 hours 2
times, then every 4 hours for 24 hours.
Check pulses with vital signs, especially on affected extremity.
Check pressure dressing along with vital signs for evidence of bleeding.
Keep O2 saturation above _______________.
Call house officer or resident on call for heart rate (age-related), blood pressure
(age-related) __________ (age and baseline dependent), and temperature ≥
101.1°F (38.4°C).
Call the hospitalist for complaints of abdominal pain or no urine output.
Give acetaminophen (Children’s Tylenol) for pain.
Give antiemetic per health-care provider orders for nausea.
Keep flat in bed for 6 hours.
Check pressure dressing with vital signs for bleeding. Call the hospitalist for
complaints of abdominal pain or no urine output.
Increase diet as tolerated.
Biopsy
Biopsy of the myocardium is performed routinely for children who have
had a cardiac transplant or to determine the cause of myocarditis or CM.
Children with cardiac transplant undergo routine biopsies to assess for
rejection. Several small pieces of myocardial tissue are removed and
analyzed by a laboratory specialist for cellular changes.
Closure Devices
It is possible to close simple congenital intracardiac communications or
shunts in the cardiac catheterization laboratory without major surgery.
Atrial septal defects and an opening called a PFO are closed with
transseptal closure devices. The cardiologist places these transseptal
closure devices across the septum and through the defect, then deploys
the device to form a seal around the opening. In the case of a PDA
closure, a plug-type device is used.
By approximately 6 weeks after the closure device is placed, the
child’s own tissue grows over the device, creating a seal through
endothelialization (growth of new tissue), and by 6 months a permanent
seal forms. Yearly follow-up visits to the cardiologist are recommended
along with an ECG, an echocardiogram, and possibly a chest
radiograph. The provider will explain the risk of embolization of the
device. Embolization occurs when the device becomes dislodged from
its intended location, migrating to the atria, PA, ventricle, or aorta.
Monitor for signs or symptoms of embolization and provide support with
education.
Opening Devices
Angioplasty or Valvuloplasty
Narrow vessels or valves may be opened or dilated with a balloon
angioplasty or valvuloplasty as an initial treatment, or a stent may be
placed in a vessel as a long-term treatment (Fig. 17-26). This treatment
is performed during a cardiac catheterization procedure. A special
catheter with a balloon is passed into the heart and into the narrow
vessel. The balloon is then inflated, causing the stenotic area to expand.
Sometimes the stenosis recoils days, months, or years after the balloon
procedure. The procedure may then be repeated, but this time, a stent
(a wire mesh tube) is placed over the balloon. The balloon is again
inflated, and the stent is left in place. This repair is permanent and
requires surgical extraction if removal is necessary.
FIGURE 17-26 Balloon angioplasty with stent.
Balloon Atrial Septostomy

Balloon atrial septostomy is an emergent palliative procedure necessary
to keep the child alive when the heart has no means of blood flow to the
pulmonary system or body such as in TA or hypoplastic left heart. A
catheter with a balloon is passed into the right atrium and pushed
across the septum or through a PFO, creating an entryway to the left
atrium. The balloon is inflated and then pulled forcefully across to the
right atrium, creating an opening large enough to accommodate blood
flow. Infusion of PGE1 is a palliative treatment prior to the septostomy to
keep the PDA open and allow blood flow to the pulmonary bed or to the
body.
Blood Pressure Postinterventional Catheterization

The child’s blood pressure should remain within normal limits postinterventional
catheterization. One specific measurement to watch is the pulse pressure, which is
the difference between the systolic and diastolic blood pressure. A normal pulse
pressure range is 40 mm Hg. Children with PDA have a wide pulse pressure
(greater than 40 mm Hg). After the closure of a PDA, the pulse pressure should be
within normal range. A sudden widening of the pulse pressure postprocedure may
indicate a dislodged or embolized device. This event requires urgent measures by
the physician or resident in-house, who must be contacted immediately.
Embolization of the device can cause stroke, thromboembolic events, or death.
Communicate to the family that the child’s growth must be considered before
placing a stent. Some stents are expandable and must be redilated at a later date to
accommodate for the growth of the child. If it is known that a child must have a more
definitive surgery, a stent may be placed, knowing that it will be extracted at a later
date. Risks include vascular tear or embolization of the device. Absorbable stents
are in the experimental phase.
SURGICAL INTERVENTIONS
Surgical repair may be palliative repair or complete anatomical repair.
Palliative repair is usually considered when the child is very young and
the complete anatomical repair is too complex for them to tolerate. The
surgeons perform a temporary, palliative repair to allow the child time to
grow and develop to a point when the more definitive procedure may be
tolerated. The child may be cyanotic after a palliative repair but less so
than if the surgery were delayed. These children are followed closely by
the cardiologist until the time when a complete repair may be done. A
complete repair is considered a cure or definitive treatment. However,
as the child grows or hemodynamic requirements change, a complete
repair may have to be revised.
Pacemakers
Pacemakers are used to treat cardiac conditions such as heart block or
severe bradycardia, sick sinus syndrome, lethal dysrhythmias, and
some junctional or idioventricular rhythms. Pacemaker therapy may be
internal or external, temporary or permanent; external pacing is always
temporary. The surgeon may elect to place temporary pacing wires if the
child has complications of heart block during surgery or if the surgical
area is near or on the conduction tissue.
Nursing Care
Communicate to parents that permanent pacemakers may be placed in
the abdomen in younger children and in the subclavicular area in older
children. Consideration is taken for children who are athletic because
the pacemaker generator must be protected.
Pacemaker generators must be replaced every 5 to 10 years. When a
pacemaker is placed in an infant, a replacement may be necessary 15
times in their lifetime. Currently the American Heart Association and
American College of Cardiology do not recommend pacemaker
placement for NMS.
Nursing care of the pacemaker postoperative patient is the same as
for any surgical procedure, including watching for signs of infection and
ensuring the incision remains intact. Communicate to the family that
follow-up care requires routine pacemaker testing as recommended by
the pacemaker center placing the device. Essential information for the
family is to understand that after initial follow-up procedures, evaluation
of the pacemaker is usually performed every 6 months to 1 year but can
be as often as every 3 months.
Cardiac Transplantation
Cardiac transplantation requires complex multidisciplinary management
and is used as a treatment for severe, life-threatening cardiac
conditions. Transplantation is performed only under the gravest
circumstances, in situations in which the child would otherwise die (Fig.
17-27).
A progressive heart transplantation program includes a CM treatment
program to prevent the need for transplantation. The transplantation
team attempts to correct the condition early on and to prevent the child’s
condition from progressing to the point of no return. It is certainly more
desirable to perform a transplant long before the child is gravely ill, but it
is also difficult to justify the need for transplantation to a family whose
child is playful and seems “normal” to them. Although survival rates
continue to improve, there are limitations.
Although transplantation saves lives and greatly improves the quality
of life, it is often said that transplantation is exchanging one disease for
another. Living with a transplanted heart is considered a chronic
condition, but it is manageable. The child and their family must follow a
strict regimen of medication, diagnostic tests, blood tests, and clinic
follow-up.
The four main complications of cardiac transplantation are:
■ Rejection
■ Infection
■ Post-transplant lymphoproliferative disorder
■ Transplant coronary artery disease
Nursing Care
The priority nursing intervention is to help the family understand the
importance of medication compliance. There is no room for a less than
rigorous approach when administering the medications. This is a difficult
endeavor, but the positive aspect is that the child will live. The
medication regimen includes as many as three antirejection medications
(immunosuppressants), antihypertensive drugs, electrolyte
supplements, diuretics, anticoagulants, and antihyperlipidemics. These
medications must be given every day. The immunosuppressant drugs
prevent the body’s immune system from rejecting the transplanted heart
muscle and must be given within a 1-hour window every 12 hours.
Another important nursing intervention is communicating to the family
about the frequent follow-up visits to the clinic, which will help ensure
close monitoring by the cardiac transplantation team. Sometimes the
child will come to the hospital as frequently as every week for follow-up
care.
FIGURE 17-27 Child after a heart transplant.
Myocardial rejection is the most severe consequence of cardiac

transplant and necessitates frequent follow-up and biopsies. Rejection
can lead to systemic failure, and depending on the grade, may require
hospitalization. Following the transplant, educate the family about
cardiac catheterization with myocardial biopsy that is performed as often
as every 2 weeks in the initial postoperative phase and during times of
rejection. The family also must understand that every year, coronary
angiography with cardiac catheterization is performed to assess for
coronary atherosclerosis, a side effect of the immunosuppressant drugs.
Myocardial rejection is the most severe consequence of cardiac
transplant. Myocardial rejection can lead to systemic failure, and
depending on the grade, usually requires hospitalization. This
necessitates frequent follow-up and biopsies.
Children who have received a transplanted heart are subject to many
emotional and psychological issues. Because it is difficult to live one’s
life with any heart defect or other chronic defects, imagine a life of a
child locked into this intensive medical regimen. Children who received
their transplant as infants or toddlers may be more adjusted
psychologically (because it is the only life they know) but may suffer
developmental delays. These children may have suffered brain anoxia
or are delayed because of frequent hospitalizations. Most children do
well, attending school and continuing on to college. Psychosocial
adjustment depends on the coping skills and support systems of the
child and the family. In addition, physical growth can be stunted because
of frequent prednisone dosing. Alterations in growth and development
also have an emotional impact on the child’s life.
NURSING CARE FOR THE CHILD WITH A CARDIAC

CONDITION IN THE HOSPITAL
The nursing plan of care for the child in the pediatric intensive care unit
(PICU) with a cardiac condition consists of assessment, outcomes,
intervention, and evaluation.
Caring for postcardiac surgical patients generally requires admission
to a PICU for recovery. PICU admission requires specific care by highly
trained nurses. The child typically stays in the PICU for approximately 2
to 3 days for simple repairs and 5 to 10 days for more complicated
repairs. The child is then transferred to a cardiac step-down or cardiac
care unit. If the child has other body system failures or does not respond
well to the surgery, very lengthy postoperative PICU admissions may
ensue. The PICU stay is also influenced by the child’s condition before
surgery or any perioperative complications. The patient in the PICU is
intubated, has chest tubes, a nasogastric tube, and Foley catheter.
There are also multiple peripheral and central IV lines and temporary
pacer wires. Postsurgical patients have a large dressing on the surgical
site (mid-sternum or lateral). When this dressing is removed, there are
usually Steri-Strips or Dermabond™ on the skin.
Nursing care for the child in the PICU integrates important concepts
such as assessment, nutrition, hygiene, activity, and psychosocial care.
Emphasis for care also includes taking vital signs, maintaining growth
and development, administering medications, performing lab tests, and
interpreting an ECG.
Optimizing Outcomes
Postoperative Vital Signs
The routine for vital signs (VS) in the PICU is much more rigorous than on a general
or telemetry floor. Typically, recovery of cardiac surgical patients takes place in the
PICU rather than in the postanesthesia unit. These patients may be very sick and
require close monitoring and a one-on-one patient assignment. The VS are taken
every 15 minutes for the first few hours, then every 30 minutes, and then every hour
until the child is stable. Adjust the frequency depending on the stability of the
patient. All changes in VS, no matter how subtle, are documented and reported to
the health-care provider.
Considerations for PICU Patients

Growth and development are a consideration for any hospital admission. Often,
PICU patients postcardiac surgery are heavily sedated or chemically paralyzed to
maintain stability. When caring for a sick child, it is important to consider the child’s
level of development. Soft music can be played for any child, and older children are
given explanations about any touching or procedures that will occur even if they
cannot respond. Encourage the parents to talk to the child, as well. It has been
documented that after sedated or chemically paralyzed patients are brought to
consciousness, the child can tell their caretakers about events and conversations
heard throughout the day. Never assume that your patient cannot hear what is said.
NURSING INSIGHT
Laboratory Values
Laboratory values are unstable among this patient population, and close monitoring
is necessary. Electrolyte measurement, particularly potassium, is perhaps the most
critical lab test in the initial postoperative period because the cardiac bypass
machine hemolyzes the cells, thus creating a high concentration of extracellular
potassium. Hemoglobin and hematocrit tests check for possible bleeding, and
coagulation factors can be affected by pump time. The child will probably be on a
ventilator, and arterial blood gases must be assessed frequently to determine the
concentration of the gases, like carbon dioxide and oxygen.
Transferring the Stable Child to a Surgical or Medical Unit

Commonly, a pediatric patient with a newly diagnosed cardiac condition
is treated in a tertiary care center for more specialized treatment. When
the postsurgical child becomes more stable, she or he is transferred to
the surgical or cardiac floor. The nurse on this type of unit is trained in
caring for cardiac patients, and the unit is equipped with telemetry
monitoring. The stable child requires less frequent vital signs monitoring
every 4 hours.
Optimizing Outcomes
Waking the Child During the Night for Vital Signs

The best outcome for a child with a cardiac condition is proper healing along with
adequate growth and development. Studies show that sleep is necessary for proper
healing and that a full sleep cycle allows certain hormones (cortisol and growth
hormone) and chemicals necessary for healing and growth (Banasik, 2017). Be sure
to assess if the child needs to be awakened during the night for vital signs or can be
allowed uninterrupted sleep. Many necessary vital signs can be taken directly from
the monitor while observation of respirations, color, and comfort can be assessed
without touching the child.
Medications given to patients on the medical/surgical unit usually do not require
constant monitoring or adjusting. Some children are admitted to a medical/surgical
unit for the sole purpose of starting a new medication and monitoring its effects. It is
also important to draw blood for laboratory analysis to track certain conditions that
may affect the cardiac system, such as anemia or coagulopathies.
COMMUNITY-BASED NURSING CARE FOR THE

CHILD WITH A CARDIAC CONDITION
Caring for the child with a cardiac condition in a community-based clinic
includes the following nursing measures:
■ Monitor HR, blood pressure, respiratory rate, and oxygen saturation.
Compare the vital sign values to the vital signs from previous visits.
■ Review medications and changes noted by the caregiver. Verify
medications and provide teaching about the medication. Ensure that
the family has enough refills and is receiving the proper dosage.
Occasionally, medications are adjusted during a phone triage visit.
Proper documentation is also essential. Medications are frequently
altered at clinic visits related to growth of the child. Adjustments may
also need to be made because of medical insurance requirements
and financial cost to the family.
Typically, the school nurse does not perform lab tests in the school
setting. Laboratory tests are performed in conjunction with the clinic
visit. Tests are ordered depending on the previous lab values and the
medications taken. In addition, there will be no ECG equipment in the
school, although if the child has a Holter monitor or event recorder in
place, the school nurse is responsible for reapplying electrodes or
helping the child complete a diary. The school nurse is familiar with the
location and use of the defibrillation equipment placed in the school.
MEDICATION
Warfarin (Coumadin)
Many children require warfarin (Coumadin) to prevent thrombus. The prothrombin
time (PT) and international normalized ratio (INR) are checked on a routine basis.
Shortly after initiation of warfarin (Coumadin), the PT/INR is checked frequently
until stabilized. After stabilization, the follow-up is usually every 1 to 3 months.
Communicate to the family that the response to warfarin (Coumadin) is affected by
diet. The present recommendations are to adjust the warfarin (Coumadin) dosage
rather than the diet. Also note if any changes have been made to the warfarin
(Coumadin) dosage.
Monitoring the Child at Home

If a Holter monitor or event recorder is ordered for home use, they are
applied in the clinic setting. Parents may also be given other recording
devices for home use, such as an apnea monitor or pulse oximeter.
Parents are advised not to become too preoccupied with these devices
and learn to rely on their own instincts or assessment skills. The child
may return to the clinic, where an echocardiogram is performed to
assess for changes in the chamber size or valve disease.
Electrocardiogram (ECG) monitoring includes a 12-lead ECG that
provides a snapshot view of potential or existing dysrhythmias and
estimated chamber size or strain on the heart muscle.
Returning to School
Inevitably, the child will return to school. Frequently, the school nurse or
other school officials will be called on to provide care for this child. At
the minimum, schools should have an automatic external defibrillator
device installed. The school nurse should check with the state, as many
states do not require defibrillators in schools. Personnel having direct
contact with the child should complete a CPR course. Often, it is the
school nurse who first identifies a cardiac problem when they hear a
murmur on a routine visit to the office or the child has a syncopal or
palpitation episode at school. A child with LQTS may have a first event
while participating in school activities such as physical education,
swimming, or even when the school bell is sounded, so the school nurse
must be prepared to respond immediately.
The school nurse also has other responsibilities. Typically, vital signs
in the school setting will coincide with administration of medication or an
untoward event. If there is an event, the school nurse is responsible for
stabilization until emergency medical service arrives on the scene.
Children may be taking medication frequently during the day, which
necessitates administration by the school nurse, who understands the
actions, interactions, and side effects of medications.
Patient Education
Caring for the Child With a Cardiac Condition at Home
TOPIC: Teaching the child and family about the cardiac condition is essential to
help ensure proper growth and development. Important information includes
cardiopulmonary resuscitation, vital signs, medications, the disease entity, and
resources.
VITAL SIGNS: Parents may still wake up during the night to take the child’s vital
signs, as is done in the hospital setting. There is rarely a need for a full-time nurse
for cardiac reasons alone, but a home health nurse may evaluate the child at
intervals to see if help at home is needed.
MEDICATION: Often, children with cardiac disease require lifelong medication
administration. Some require medication only until the surgery is completed and
within the initial postoperative period. As in the case with the cardiac transplant
child, the family must receive essential information related to the timing and the
routine of medication administration. In other cases, the cardiac drugs may be
given safely with basic instructions. Teach the family that one of the most important
aspects of medication administration is proper dosing. Many of the medications are
given in a liquid form. The medication dosing is done in milliliters (mL) or cubic
centimeters (cc) and not teaspoons (tsp) or other household measures, and the
parent is given a measuring device for administering these medications accurately.
Cardiopulmonary Resuscitation
CPR training provided by a certified CPR instructor or fire department
personnel is essential because many cardiac diseases predispose to
dysrhythmias.
The following are resources for families and children:
American Heart Association: www.heart.org

Cardiomyopathy Association: www.cardiomyopathy.org
Children’s Heart Society: https://www.childrensheartfoundation.org
Congenital Heart Information Network:
https://rarediseases.org/organizations/congenital-heart-information-
network-c-h-i-n/
Heart Rhythm Society: www.hrsonline.org
Heart Transplant: www.cota.org, www.ishlt.org
Kawasaki’s Disease: www.kdfoundation.org
March of Dimes: www.marchofdimes.com
Sudden Arrhythmia Death Syndromes (SADS) Foundation:
www.sads.org
Patient Education
Caring for Children With Cardiac Conditions
DIET: Balanced nutrition helps maintain a healthy weight and allows for nutrients,
which will boost the immune system. Reducing fat intake will help to lower
cholesterol and reduce the chance of additional strain on the heart caused by
atherosclerotic disease.
EXERCISE: In a child with a cardiac disease or defects, certain exercises can be
detrimental. Each patient has an individualized exercise plan tailored for their
cardiac disease.
GOOD SLEEP PATTERNS: Children, especially teenagers, should start to develop
a healthy sleeping pattern. Sleep allows for cortisol and growth hormone release,
which is essential for cellular repair. It also helps with stress reduction and allows
for proper lifestyle functioning and learning throughout the day.
STRESS REDUCTION: Maintaining a stress-free or low-stress lifestyle helps to
keep the blood pressure within normal range.
ALCOHOL, DRUGS, SMOKING: Teenagers are counseled to avoid alcohol, illicit
drugs, and smoking cigarettes or marijuana because all of these will have
detrimental effects on the circulation and oxygen-carrying capacity.
HOMEOPATHIC OR NUTRITIONAL SUPPLEMENTS: Any supplements used
should be reviewed with the child’s cardiologist prior to starting them as there is a
risk they may interact with other medications. Most of these supplements are not
regulated by the Food and Drug Administration, and there is no quality or quantity
control on the ingredients or consistency.
OTHER COMPLEMENTARY OR ALTERNATIVE THERAPIES: Complementary or
alternative therapies such as therapeutic touch, meditation, cupping, acupuncture,
or prayer may be employed by the family. These types of therapies can be
psychologically beneficial to the family and the child.
SUMMARY POINTS
■ The main concern with children with cardiac disease is that they have an
alteration in cardiac output affecting all cellular function.
■ CHD describes a congenital defect in the heart, valves, or great vessels. CHDs
are the most common birth defect, occurring in about 1% of all pregnancies and
approximately 1 in 170 live births.
■ Disease includes problems with the structure, function, and electrical conduction
within the heart.
■ Children with cardiac diseases are at risk for alterations in health such as growth
and development, nutrition, psychosocial implications, and schooling, and at an
increased risk for infection, acquiring other diseases, and even cardiopulmonary
arrest. Sometimes these children have significantly altered lifestyles and undergo
constant medical treatment. The nurse must have a good understanding of
common cardiac diseases in children and be able to provide essential nursing
care measures.
■ The nurse provides nursing care to the child who has undergone procedural
treatments with closure devices or surgery.
■ The nursing plan of care for the child with a cardiac condition consists of
assessment, outcomes, intervention, and evaluation.
■ Postcardiac surgical patients generally require admission to a pediatric intensive
care unit (PICU) for recovery. PICU admission requires specific care by highly
trained nurses.
■ When the postsurgical child becomes more stable, they are then transferred to the
surgical or cardiac floor.
■ The parents or other primary caregivers extend care into the home or community.
■ Teaching the child and family about the cardiac condition is essential to help
ensure proper growth and development. Essential information includes
cardiopulmonary resuscitation, vital signs, medications, the disease entity, and
resources.
REFERENCES
American Academy of Pediatrics (2020c). Coronavirus and Kids.
https://www.aappublications.org/news/2020/01/28/coronavirus.
American Heart Association (AHA). (2020a). Common Types of Congenital Heart
Defects. Accessed on 9/24/20 at: https://www.heart.org/en/health-topics/congenital-
heart-defects/about-congenital-heart-defects/common-types-of-heart-defects
American Heart Association (AHA). (2020b). Recommendations for blood pressure
measurement in humans and experimental animals.
doi:10.1161/_01.HYP.0000150859.47929.8e
American Heart Association (AHA). (2020c). Kawasaki disease. Retrieved from
http://www.heart.org/HEARTORG/Conditions/More/CardiovascularConditionsofChil
dhood/Kawasaki-Disease_UCM_308777_Article.jsp
Banasik, J. L. (2017). Pathophysiology (6th ed.). St. Louis, MO: Elsevier.
Cárdenas-Nieto, D., Forero-Castro, M., Esteban-Pérez, C., Martínez-Lozano, J.,
Briceño-Balcázar, I. (2020). The 22q11.2 microdeletion in pediatric patients with
cleft lip, palate, or both and congenital heart disease: A systematic review. Journal
of Pediatric Genetics 9 (1); 1-8.
Centers for Disease Control and Prevention (2020). Information for Health-care
Providers and Covid. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html
Dolk, H., McCullough, N., Callaghan, S., Casey, F., Craig, B., Given, J., Loane, M.,
Lagan, B. M., Bunting, B., Boyle, B., & Dabir, T. (2020). Risk factors for congenital
heart disease: The Baby Hearts Study, a population-based case-control study. PloS
One, 15(2), e0227908. https://doi-
org.treadwell.idm.oclc.org/10.1371/journal.pone.0227908
Duncombe, S. L., Voss, C., & Harris, K. C. (2017) Oscillometric and auscultatory blood
pressure measurement methods in children. Journal of Hypertension 35(2); 213–
224 doi: 10.1097/HJH.0000000000001178
Harahsheh, A. S., Dahdah, N., Newburger, J. W., Portman, M. A., Piram, M., Tulloh,
R., McCrindle, B. W., de Ferranti, S. D., Cimaz, R., Truong, D. T., & Burns, J. C.
(2020). Missed or delayed diagnosis of Kawasaki disease during the 2019 novel
coronavirus disease (COVID-19) pandemic. Journal of Pediatrics, 222.
https://doi.org/10.1016/j.jpeds.2020.04.052
Mavroudis, C., Backer, C. L., & Idriss, R. F. (2013). Pediatric cardiac surgery (4th ed.).
Oxford, UK: Wiley-Blackwell.
Park, M. (2016). The pediatric cardiology handbook: Mobile medicine series (5th ed.).
Philadelphia: Elsevier Mosby.
Pasquali, S. K., He, X., Mohamad, Z., McCrindle, B. W., Newburger, J. W., Li, J. S., &
Shah, S. S. (2012). Trends in endocarditis hospitalizations at US children’s
hospitals: impact of the 2007 American Heart Association Antibiotic Prophylaxis
Guidelines. American Heart Journal, 163(5), 894–899.
https://doi.org/10.1016/j.ahj.2012.03.002
Ruggiero, K., Hickey, P., Leger, R., Vessey, J. & Hayman, L. (2017). Parental
perceptions of disease-severity and health-related quality of life in school-age
children with congenital heart disease. Journal for Specialists in Pediatric Nursing
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through care coordination: Measuring care coordination of nurse practitioners.
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Venes, D. (2021). Taber’s cyclopedic medical dictionary (24th ed.). Philadelphia: F.A.
Davis.
Advantage
CHAPTER 18
Caring for the Child With an

Immunological or Infectious Condition
CONCEPTS
Immunity
Infection
KEY WORDS
antigens
antibodies
immune response
opportunistic infections
osteomyelitis
thrombocytopenia
idiopathic thrombocytopenic purpura (ITP)
autoimmune disorder
heliotropic
dysphagia
ligamentous laxity
anaphylaxis
infectivity
mode of transmission
incubation period
communicable period
pathogenicity
virulence
contact transmission
alopecia
LEARNING OBJECTIVES
immunological and infectious systems.
■ Examine the common conditions of the immunological and infectious systems.
■ Prioritize developmentally appropriate and holistic nursing care measures for
common conditions of the immunological and infectious systems.
■ Explore diagnostic and laboratory testing and medications for common conditions
of the immunological and infectious systems.
common immunological and infectious conditions.
PICO(T)Questions
Use these PICO(T) questions to spark your thinking as you read
the chapter.
1. What are the (O) key considerations nurses should explain to (P) parents about (I)
childhood immunizations?
2. What (I) nursing interventions are beneficial for school nurses working with (P)
students who are HIV positive to assist students with (O) optimal functioning?
INTRODUCTION
developmental aspects of the immune system. The discussion includes
an examination of the various infectious and immune conditions,
including developmentally appropriate and holistic nursing care.
Information about diagnostic and laboratory testing and medications is
given. Teaching plans and discharge criteria for parents whose children
have various infectious and immune conditions are incorporated.

The Effect of an Infectious Condition
The child with an infectious condition is usually isolated to control the spread of
disease. Isolation from peers limits exposure to play and social activities such as
school. Lack of social interaction can be detrimental to the child’s growth and
development. Nursing care for the child with an infectious condition focuses on
treatment of the infectious disease process and maintenance of normal growth and
developmental milestones. Because of the hypermetabolic state that accompanies
infection or illness, an adequate diet should be encouraged. The nurse should
initiate a high-calorie diet to promote a healthy immune system. Proper hydration
should be provided to reduce the risk of dehydration. The child should be given
adequate rest periods as needed during recovery. Quiet activities can be initiated if
the child has low levels of energy.
If the child is placed in isolation, the nurse should work with the child life therapist
and the family members to provide appropriate toys and stimulation to the child.
Social isolation limits the child’s ability to develop and maintain interpersonal and
verbal and nonverbal communication skills. Social interaction should be encouraged
when appropriate. The nurse should provide education about prevention strategies
and appropriate immunizations needed to reduce the rate of infection.
ANATOMY AND PHYSIOLOGY OF THE IMMUNE
SYSTEM
The immune system is made up of cells, tissues, and organs that work in
an organized manner to protect the body against invaders and infectious
organisms (Fig. 18-1). At birth, children have an intact, but often
immature, immune system. Infants do carry maternal antibodies until
approximately 6 months of age; however, they remain at a greater risk for
infection than the general population. Germs, including bacteria and
viruses, are foreign invaders, or antigens, which the immune system
recognizes and responds to by producing proteins called antibodies to
fight the antigens. Antibodies may be produced in the thousands but
sometimes disappear after they have destroyed the antigens. Memory
cells are cells that recall the original antigen and bring up the body’s
defenses if it invades the body again, and this level of protection is
known as immunity (Centers for Disease Control and Prevention [CDC],
2020).
The white blood cells (leukocytes) are part of the defense system.
There are two basic types: phagocytes (neutrophils are the most
common and fight bacteria) and lymphocytes (B lymphocytes and T
lymphocytes), which seek out and destroy organisms that might cause
disease. Leukocytes are produced or stored in the lymphoid organs:
lymph nodes, bone marrow, thymus, spleen, and tonsils. The leukocytes
circulate throughout the body via the blood. Antigens are foreign
substances that invade the body. When an antigen is detected, several
types of cells work together to recognize and respond to the invader.
Mature B lymphocytes independently identify foreign antigens and
differentiate into antibody-producing plasma cells (memory cells). Once
the B lymphocytes have produced antibodies, these antibodies
remember the invader so if the same antigen is presented to the immune
system again, the antibodies can respond. Although antibodies can
recognize an antigen, they are not capable of destroying it without the
help of mature T cells that are antigen-specific. Antibodies can also
neutralize toxins and activate a group of proteins that assist in killing
bacteria, viruses, or infected cells.
The protection offered by the immune system is called immunity. There
are three types of immunity: innate, adaptive, and passive. Innate (or
natural) immunity is a general protection and includes the physical
barriers of the body, like the skin and mucous membranes. The skin is
the first line of defense in preventing diseases from entering the body.
Adaptive (or active) immunity develops as children are exposed to
diseases or immunized against diseases through vaccination. Passive
immunity is acquired by the introduction of preformed antibodies into an
unprotected individual, and it lasts for a short period of time. For
example, passive immunity can occur from antibodies that pass from the
mother to the fetus through the placenta or newborns that acquire
immunity through breastfeeding.
FIGURE 18-1 Typical cell.
The Body’s Defense

The skin is the most important physical barrier and the body’s first line of
defense. It is the largest organ of the body and has several major
functions:
■ Protects the deeper tissues from injury
■ Protects the body from foreign matter invasion
■ Regulates temperature
■ Aids in water retention
■ Aids in synthesis of vitamin D
■ Initiates the sensations of touch, pain, heat, and cold
■ Has mucous membranes that provide a protective barrier against the
entry of pathogens
Mechanical and chemical barriers also help protect the child. For
example, tears, urine, vaginal secretions, and semen have a role in
primary defense against infection. The mechanical action of these fluids
flowing out from the body carries out unwanted intruders that may cause
disease. An example of a chemical barrier is the acidic secretions of the
stomach and digestive enzymes that serve to neutralize organisms taken
into the body through the mouth. Chemical barriers in the gastrointestinal
(GI) system can be maintained with good nutrition.
The body’s second line of defense is the immune response. The
overall purpose of the immune response is to defend the body against
microorganisms, parasites, and foreign cells such as cancer cells and
transplanted cells. Key to a normal immune response is the body’s ability
to recognize foreign substances as non-self and then to mobilize
defenses and attack the invaders. A deficiency in the immune response
may lead to serious illness in the pediatric patient.
Immunoglobulins
Immunoglobulins, also known as antibodies, are substances made by the
body’s immune system in response to diseases and other insults. The
major types of immunoglobulins are:
■ IgM is the first type of antibody made by the body in response to an
infection. This antibody helps other immune system cells destroy
foreign substances. An adult level is attained by 9 to 12 months of age.
■ IgG antibodies are important in fighting bacterial and viral infections.
An adult level is attained by 1 year of age.
■ IgA antibodies protect the body’s surface from foreign substances. An
adult level is attained by 5 years of age.
■ IgE causes the body to react against foreign substances such as
fungus spores, animal dander, and pollen. An adult level is attained by
early childhood.
What to Say
Why Are Children More Vulnerable to Infections?
Parents often ask why children are more vulnerable to infections. Not all situations
are alike, so it is important that the nurse tailor the response to the patient and
family. Here is sample information the nurse can share:
• Children have thinner skin that can more easily become irritated and
absorb microorganisms.
• Children younger than 5 have less resistance to infectious organisms

than older children and adults because of lower levels of
immunoglobulin A (IgA).
• Children younger than three have more difficulty regulating body

temperature than older children and adults because of immature
endocrine (sweat) glands.
Educating the family about the role of the immune system and the natural
processes that help the body maintain resistance to disease can help keep the
child’s immune system healthy. Nurses can support the child’s immune system
through nursing interventions such as meticulous skin care and measures that target
the maintenance of important barriers (Fig. 18-2).
CONGENITAL IMMUNODEFICIENCY DISORDERS

Congenital immunodeficiency disorders of childhood include a number of
rare disorders possibly associated with mutant genetic defects. These
disorders, grouped as primary immunodeficiency disorders (PID), may
result in lifelong impairment of immune system function. The impairment
causes an increase in incidence, severity, and recurrence of infections.
There are four main groups of PID:
■ Antibody deficiency, B lymphocyte defect
■ Combined deficiency, T and B lymphocyte defect
■ Phagocyte defect disorders (neutrophil or mononuclear cell disorders)
■ Complement defect disorders (bacterial protein disorders)
Antibody Deficiency: B-Cell Disorders

In B-cell disorders, inadequate immunoglobulins are present. Maternal
antibodies naturally protect newborns during the first few months of life;
thus B-cell disorders do not become apparent until after 3 to 6 months of
age, and some do not occur until later childhood or adulthood. In B-cell
disorders, the child usually has recurrent infections, beginning with
respiratory infections, sinus infections, and pneumonia. Some children
have chronic GI malabsorption syndromes and inflammatory bowel
disease (e.g., Crohn’s disease and ulcerative colitis).
FIGURE 18-2 Assessing and maintaining skin care is an important role of

the nurse.
Combined Deficiency T- and B-Cell Disorders

Diseases affecting B and T lymphocytes usually manifest before 6
months of age. Babies may have failure to thrive and suffer from severe
infections, including septicemia and meningitis. Other features of this
disorder cluster include recurrent candidiasis and prolonged diarrhea,
both of which may cause severe diaper dermatitis. In these disorders,
opportunistic infections caused by Pneumocystis jiroveci pneumonia
and Toxoplasma gondii are seen.
Phagocyte Defect Disorders

These disorders also can occur very early in a child’s life. They are
manifested with dermatitis, impetigo, mouth ulcers, pneumonia,
suppurative adenitis (infected lymph nodes), abscesses, and
osteomyelitis. Wounds in children with this immune disorder do not heal
properly.
Complement Defect Disorders

This group of disorders can arrive at any age in childhood. Severe
infections including meningitis, septicemia, and sinus or pulmonary
infections are common. Associated autoimmune disorders may occur,
including systemic lupus erythematosus, dermatomyositis, and
scleroderma.
Other Congenital Immunodeficiency Disorders

The onset of X-linked agammaglobulinemia occurs after 4 months of
age, typically in males with low or absent IgM, IgG, and IgA antibodies
and B lymphocytes. Treatment of these congenital immunodeficiency
disorders is lifelong with the administration of intravenous immune
globulin (IVIG) or (IV IgG [immunoglobulins]) (Fig. 18-3).
■ Autosomal recessive congenital agammaglobulinemia: This disorder is
characterized by low B lymphocytes and low or absent
immunoglobulins. The onset is before 6 months of age, with both
males and females affected. IVIG treatment is lifelong.
■ Hypogammaglobulinemia: Selective IgA deficiency is the most
common abnormality in this category, but there is no treatment specific
to IgA except antibiotics or sometimes IVIG. Acquired
hypogammaglobulinemia can stem from such disorders as nephrotic
syndrome. Some people have transient hypogammaglobulinemia and
need only antibiotics.
■ Severe combined immunodeficiency diseases (SCID): This category
includes T and B lymphocyte disorders, frequent prolonged diarrhea,
and failure to thrive. Without treatment, children with SCID will usually
die within the first years of life. Laboratory testing includes
hypogammaglobulinemia and lymphopenia. Natural killer cells and B
lymphocytes are often decreased. Pneumocystis jiroveci pneumonia
with cough, dyspnea, and hypoxia is common as is persistent candida
diaper dermatitis. Tonsils and lymph nodes may be absent. The main
differential diagnosis is with pediatric HIV. There are several variants of
SCID.
FIGURE 18-3 The nurse administers infusion therapy of IV
immunoglobulin to a child who has a primary immune deficiency.
Wiskott-Aldrich syndrome is an example of an X-linked

immunodeficiency syndrome occurring from genetic mutation but only
occurring in males. This disorder includes thrombocytopenia and
eczema, so the symptoms include potential bloody diarrhea, cerebral
hemorrhage, and later malignancies and autoimmune syndromes.
Differential diagnosis includes leukemia and idiopathic
thrombocytopenic purpura (ITP). Survival later than adolescence is
rare without treatment, which includes antibiotic prophylaxis with
trimethoprim sulfamethoxazole (TMP-SMZ) (Bactrim or Septra) for
Pneumocystis jiroveci pneumonia and IgG replacement therapy.
Splenectomy is a possibility to decrease thrombocytopenia, and stem cell
transplant can offer a cure.
Signs and Symptoms

A good way of identifying if a child has primary immunodeficiency is by
using Modell’s 10 Warning Signs of Primary Immunodeficiency:
■ Eight or more ear infections per year
■ Two or more serious sinus infections per year
■ Two or more months on antibiotics with little effect
■ Two or more pneumonias within 1 year
■ Failure of infant to gain weight or grow normally
■ Recurrent, deep skin or organ abscesses
■ Persistent thrush in the mouth or on the skin after 1 year of age
■ Need for IV antibiotics to clear infections
■ Two or more deep-seated infections
■ Family history of primary immunodeficiency
Diagnosis
Diagnosis of congenital immunodeficiency disorders is based on
symptoms of congenital immunodeficiency disorders that begin in
infancy. The actual diagnosis depends on the exact immune components
involved. Laboratory testing should include a full blood count and
immunoglobulin levels (especially IgA, IgG, and IgM). Additional tests will
be ordered depending on the suspected disorder.
Prevention
Most primary or congenital immunodeficiency disorders are genetic and
not preventable, but good prenatal care and education regarding care
can decrease the associated clinical manifestations.
Nursing Care
Nursing care for patients with congenital immunodeficiency disorders is
complex, depending on the disorder. Many of these affected children are
infants, and families are devastated by the diagnosis of these complex
disorders.
The nurse obtains blood samples for laboratory tests based on the
health-care provider’s order. A complete blood count (CBC) with
differential, immunoglobulin levels (IgA, IgG, IgM), T and B lymphocyte
tests, and protein electrophoresis is drawn to determine types of
immunoglobulin disorders. Additionally, pre- and postimmunization titers
for routine immunizations (e.g., tetanus, diphtheria, mumps, and rubella)
are drawn. These titers determine if the child has enough immunity to
form a response to these immunizations. The nurse is instrumental in
monitoring for frequency of infections, lack of response to antibiotic
therapies, and the development of more severe infections, such as
Pneumocystis jiroveci pneumonia. It is important to note that some live
vaccinations may be contraindicated in immune disorders.
The nurse tells the family that continued monitoring of growth and
development on standardized growth charts is done to assess for failure
to thrive or weight loss patterns. Family support and education are
essential to properly care for the child. Refer families to support groups
and healthcare specialists.
HUMAN IMMUNODEFICIENCY VIRUS (HIV [AIDS])

The HIV virus selectively targets and destroys helper T cells (i.e., T4 or
CD4), thereby destroying cellular immunity. The child is virtually
unprotected against a number of opportunistic infections and bacterial,
fungal, and viral diseases. Every system is potentially affected because
the HIV virus integrates itself into the patient’s genetic material.
However, the body’s immune response may raise CD4 (helper T cell)
levels for some time, creating a latent period that may last 10 years or
more before the child becomes sick. When CD4 levels drop, symptoms
begin to appear and the change from HIV to AIDS begins. The CDC
(2020) indicates that children who become infected with the HIV virus
between 13 and 25 years old survive longer than people who become
infected later in life. If a baby acquires HIV prenatally, the latency period
may be brief and the child becomes ill quickly, developing AIDS in the
first year of life with a poor prognosis. An estimated 40,000 people will be
diagnosed with HIV infection this year in the U.S. (CDC, 2019).
From the onset of the epidemic in the late 1970s through 1994, an
estimated 14,920 perinatally HIV-infected infants were born in the U.S.
(CDC, 2019). These numbers began to drop dramatically with important
research that discovered a way to prevent infections between pregnant
mother and child (treatment with AZT). Since this breakthrough, the
number of HIV-infected infants has remained steady at fewer than 200
new infant infections per year.
The decreased incidence of perinatal transmission demonstrates the
importance of screening for HIV infection in pregnancy and treating HIV-
positive pregnant women with these services. It is estimated that there
are approximately 8,500 HIV-positive pregnancies in the United States
each year, but fewer than 150 new infant HIV infections—a testament to
the effectiveness of U.S. prevention efforts (CDC, 2019). Work is still
ongoing to eliminate all new pediatric HIV infections in the United States
and keep children living with HIV happy and healthy.
NURSING INSIGHT
HIV in Infants
The following risk factors are associated with HIV in infants:
• Advanced maternal disease
• High maternal viral load
• Low maternal CD4+ count
• Prematurity
• In utero transmission
• High viral load in the first 2 months of life
• Lack of neutralizing antibodies
• Presence of p24 antigen
• AIDS-defining illnesses
• Early cytomegalovirus infection
• Early neurological disease
• Mycobacterium avium complex and anemia
• Failure to thrive
• Early-onset diarrhea
Signs and Symptoms

Signs of HIV in children can include any of the following:
■ Lymphadenopathy
■ Hepatosplenomegaly and hepatitis
■ Chronic diarrhea, with malabsorption
■ Oral thrush
■ Skin infections
■ Fevers
■ Recurrent infections, including mucous membrane and skin infections
■ Thrombocytopenia (see Box 18-1)
■ Developmental delay and loss of milestone achievements
BOX 18-1
Pancytopenia
Pancytopenia is an issue for children with HIV that may cause thrombocytopenia
(low platelet count). Intravenous immune globulin (IVIG) is used to raise the platelet
count. Another way to raise the platelet count is to use high-dose steroids.
Sometimes WBC abnormalities also occur, including neutropenia, leukopenia, and
lymphopenia. Epoetin alfa (Erythropoietin) is a newer medication that increases RBC
and WBC production in such cases.
Source: Fahrner, R., & Romano, S. (2010).
Resulting conditions include:

■ Cardiomyopathy
■ Nephropathy
Diagnosis
Diagnostic testing for HIV infection in children is necessary whenever the
virus is suspected. Diagnosis of HIV infection in children requires a
multipronged approach using appropriate testing and clinical observation.
In infants, the diagnosis can be complicated by the transmission of
maternal antibodies. The CDC developed a separate classification
system for pediatric HIV or AIDS in 1987 and then revised it in 1994 for
children younger than 13 years. Because of passively acquired maternal
antibodies in the first 18 months of life, there are separate criteria for this
age group because this may confuse the infant’s status with regard to
HIV infection.
Labs
HIV Testing in Infancy
The American College of Obstetricians and Gynecologists updated its guidelines on
HIV testing during pregnancy in 2015 as follows:
• Women should be tested for HIV during routine prenatal testing, on an
opt-out basis where possible.
• Women at high risk for HIV, including injection drug users and women
with multiple sex partners during their pregnancy, should be tested
again in the third trimester.
• Women who have not been tested should be offered rapid screening
when in labor. If the rapid test is positive, they should start
antiretroviral therapy while waiting for results from a confirmatory
test.
• All pregnant women should be screened for HIV infection as early as
possible during each pregnancy using the opt-out approach where
allowed.
• Repeat HIV testing in the third trimester is recommended for women
in areas with high HIV incidence or prevalence and for women at
known risk of acquiring HIV infection.
• Women who were not tested earlier in pregnancy or whose HIV status
is otherwise undocumented should be offered rapid screening on
labor and delivery using the opt-out approach where allowed.
• If a rapid HIV test result in labor is reactive, antiretroviral prophylaxis
should be immediately initiated while waiting for supplemental test
results.
• If the diagnosis of HIV infection is established, the woman should be
linked into ongoing care with a specialist in HIV care for
comanagement.
Assessment Tools
Diagnosis of HIV Infection in Infants
Diagnosis of HIV infection is aided by HIV culture or DNA/RNA polymerase chain
reaction (PCR); positive results are confirmed by repeating the test. In suspected
cases, HIV testing should occur in the newborn period (before the infant is 48 hours
old), at age 1 to 2 months, and again at age 3 to 6 months. Testing at 14 days after
birth may allow earlier detection of HIV in HIV-positive infants who had negative test
results within the first 48 hours of life. By approximately age 1 month, PCR testing
has a 96% sensitivity and 99% specificity to identify HIV (CDC, 2019).
For children age 13 and older, HIV antibody testing is the same as for
adults, using the enzyme-linked immunosorbent assay (ELISA) test that
identifies the presence of HIV antibodies. If the initial ELISA antibody test
is positive, it merits repeating, and if the repeat test is still positive, it is
necessary to add the Western blot test, which is a confirmatory indirect
fluorescent antibody test.
Other tests that are now available have less accuracy. They include an
oral fluid (not saliva) antibody test that needs a confirmatory Western
blot, a urine test that needs a confirmatory Western blot, a rapid test that
uses blood from a finger stick or oral fluid, and home testing kits. Only
one kit, Home Access HIV Test System, using a finger prick, is approved
by the Food and Drug Administration (CDC, 2020).
Prevention
The nurse should counsel pregnant women to follow the guidelines for
mandatory HIV testing. This is the most significant way to decrease
vertical transmission of HIV. The American Academy of Pediatrics
Committee on Pediatric AIDS and Committee on Adolescence has noted
that approximately half of all new HIV infections in the United States
occur among youth ages 13 to 24. Therefore, nurses are instrumental in
educating adolescents about HIV transmission, prevention, and testing,
including details about safe sex practices and condom use.
Collaborative Care
Nursing Care
Caring for children with HIV or AIDS is a complex process that includes
physical, psychological, and family care. The pediatric nurse assesses
the family’s support systems, coping mechanisms, and overall ability to
care for the HIV-infected child. Social stigma is frequently associated with
this diagnosis, and many families may feel isolated and face rejection.
Because the diagnosis and treatment for HIV cause a family crisis, it is
vital for the pediatric nurse to provide psychological support, monitor
infection, manage pain, provide developmental care, monitor nutrition
and immunizations, and focus on proper medication administration.
The primary concern for early and accurate identification of children
with HIV infection is beginning treatment. The goals of treatment for
children with HIV are to slow progression to AIDS, prevent further
infections, promote normal growth and development, prevent
complications including cancers, and prolong and improve quality of life.
If the mother is also infected with HIV, the nurse determines the best
way to care for both patients. Priority nursing care focuses on decreasing
the potential for opportunistic infection. HIV-infected children are at risk
for these infections that a child with normal immunity would not acquire.
Pneumocystis jiroveci pneumonia is the most common opportunistic
infection in children. The nurse must be ready to manage these
infections, often with prompt and vigorous antimicrobial therapy
According to current CDC (2020) HIV and Resources Guidelines, all
infants born to HIV-infected mothers are routinely started on a
prophylactic antibiotic regimen for this organism. Trimethoprim
sulfamethoxazole (TMP-SMZ) (Bactrim or Septra) is the agent of choice
for this treatment. Intravenous immune globulin (IVIG) has also been
used to prevent bacterial infections in young children. In addition, the
nurse teaches the family signs and symptoms of infection and
encourages them to limit the child’s exposure to large crowds of people
and to those with notable infections.
MEDICATION: Trimethoprim sulfamethoxazole

(TMP-SMZ) (Bactrim or Septra) (trye-meth-oh-
prim/sul-fa-meth-ox-a-zole)
1. Assess child for infection. Advise the family to notify the health-care provider for
any signs of infection.
2. Assess for allergy to sulfonamides.
3. Monitor lab values periodically throughout therapy. May produce elevated serum
bilirubin, creatinine, and alkaline phosphatase.
Source: Data from Vallerand, A. H., & Sanoski, C. A. (2021).
The pediatric nurse addresses infection control information for day-
care providers and school personnel about how to care for frequent
diarrhea and assess for candidiasis infections. These issues may create
problems with diaper changes and keeping the genital areas free of a
superinfection. Caretakers must use gloves properly and carefully, and
body secretions must be properly disposed of in biohazardous waste
containers. Universal precautions are enforced in all public areas and are
especially important during participation in contact sports, during
menstruation in girls, and for all sexually active teens.
Pain management is a significant care concern for children with HIV.
Pain in children can be multifactorial, resulting from inflammation or from
systemic manifestation of AIDS such as cardiomyopathy, drug toxicities,
invasive secondary infections, and medical procedures used to monitor
and treat the HIV infection. Most HIV-infected children report pain as a
factor affecting their daily lives. Successful management of pain is based
on the same principles of pain management found in other illnesses.
Diligence in identification of pain, goals, and strategies to manage pain,
implementation of nonpharmacological and pharmacological pain
management strategies, and ongoing pain assessments are all-important
in the plan of care. Pain control is a major factor in quality of life and
hence a primary goal for the nurse.
Developmentally appropriate preparation before painful procedures
has been shown to lower the anticipation of pain, thus decreasing the
pain experience. Child life specialists may assist the nurse to prepare the
child for procedures. Preparation may include diagrams, pictures,
handling equipment, meeting medical personnel, or visiting special
rooms, such as recovery or the intensive care units.
Distraction can be useful, particularly for younger children. Techniques
such as blowing bubbles, singing songs, blowing pinwheels, or reading a
favorite book may turn their attention away from the procedure. Family
members can be encouraged to participate in distraction by providing a
favorite toy.
Relaxation can be effective in pain control and actually decreases pain
in the child. Nurses can teach relaxation skills to parents early in the
course of HIV. A deep sense of relaxation can be obtained through
guided imagery or hypnosis. The nurse can encourage parents to use
relaxation books that will help them direct the relaxation exercise with
their child. Additional complementary and alternative therapies include
massage, acupuncture, and vitamin and other dietary supplements.
Children who are HIV-positive are adversely affected by malnutrition in
the form of either weight loss or obesity, underscoring the need for
continuous assessment and attention. Failure to thrive causes poor
weight gain, often with weight lower than the 5th percentile. The child can
experience chronic diarrhea, malabsorption-induced immunodeficiency,
and adverse GI effects of many HIV treatments. Causes of chronic
diarrhea include Mycobacterium avium-intracellulare, Giardia, and
Cryptosporidium. The nurse works closely with a nutritionist to develop a
plan to manage the child’s diet in interesting and vital ways.
Obesity is a common problem in children with HIV and a contributing
factor to immune dysfunction. Obesity occurs as a result of side effects
from some of the medications commonly used to treat HIV coupled with
decreased physical activity. Early involvement of a nutritional expert to
provide consultation with the family is beneficial. The nutritionist can
address specific nutritional needs and provide education about healthy
dietary choices. In addition, the nutritionist can perform a nutritional
assessment that includes monitoring heights and weights, evaluating
laboratory values, and screening for dietary difficulties.
Oral supplementation is recommended to proactively meet nutritional
goals of underweight children with HIV. The overall goal of oral
supplementation is to prevent malnutrition. In addition, aggressive oral
care is emphasized to prevent oral lesions that may add to decreased
intake. Another way to ensure adequate nutrition is the initiation of
parenteral (tube) feedings.
Knowledge about immunizations for the child with HIV is important. In
the past, HIV children did not receive live viral vaccines (e.g., MMR and
varicella) because of the concern that they could develop these
infections because of their immunosuppression. Now children can
receive these vaccinations if their immunity is good, depending on their
CD4 counts (T-cell counts).
Patient Education
CDC Recommendations for Childhood Vaccines
Current CDC (2020) recommendations for childhood vaccine administration for
patients with HIV are as follows:
Contraindicated vaccines
• OPV (oral polio) vaccine
• Smallpox vaccination
• BCG (bacille Calmette-Guérin) vaccination
• Live attenuated influenza vaccine (LAIV) (intranasal flu vaccine)
• Yellow fever vaccine might have a contraindication or a precaution

depending on the clinical parameters of the child’s immune function
• Withhold MMR and varicella in severely immunocompromised persons
• HIV-infected infants without severe immunosuppression should
routinely receive MMR vaccine as soon as possible upon reaching
their first birthday (consideration should be given to administering the
second dose of MMR vaccine as soon as 28 days after the first dose)
• MMR is recommended for all asymptomatic HIV-infected persons who
do not have evidence of severe immunosuppression (CD4 levels less
than 15%)
(CDC, 2020)
Recommended vaccines for children with HIV or AIDS include:
• Pneumococcal vaccination
• Consider Hib (if not administered in infancy)
• Meningococcal vaccination
(CDC, 2020)
Medical Care
Selected medications are used for children and adolescents who are HIV
positive or have AIDS (Table 18-1).
Highly active antiretroviral therapy, or HAART, has become the
cornerstone of medical treatment for HIV. Although these regimens keep
changing as new drugs are created, currently, combining at least three
drugs from two different classes is recommended. Unfortunately, many
HAART drugs carry serious adverse effects. More than 20 antiretroviral
drugs have been approved for pediatric use; greater than 15 of these
have availability in pediatric formulation or capsule size. The current
recommendation is to use a three-drug nucleoside reverse transcriptase
inhibitor (NRTI) regimen only when a non-nucleoside reverse
transcriptase inhibitor (NNRTI) or protease inhibitor (PI) cannot be used
as first-line treatment.
Symptomatic and supportive care of children with HIV or AIDS is similar
to that for children with immunodeficiency conditions. Palliative and
comfort care measures are essential. Proper hygiene, comfortable
clothing, good nutrition, play, rest, and social interaction are all important
aspects of care for the child. The nurse ensures good communication
between the family and health-care providers to facilitate a realistic
ongoing treatment plan.
Adolescents present their own specific challenges when infected with
HIV. Based on their desire to be independent, adhering to complicated
treatment regimens may be a struggle. The nurse works closely with the
adolescent to identify strategies for managing a complex medical illness
with the need to be independent and socialize with peers. Often, referral
to an adolescent support group is helpful for children in this age group.
It is critical to help the family access available resources including
social services, financial aid, spiritual support, insurance coverage, and
how to access community health clinics. Often, the acute care setting
nurse who is intermittently involved in the child’s care can initiate the
coordination of ongoing care by contacting a case manager to guide the
family through the complex health-care system. Although in the past,
children with HIV were commonly not told about the diagnosis, today
most patients live into adolescence and adulthood. Guidelines for helping
to tell children about their diagnosis through the American Academy of
Pediatrics (AAP) and other national AIDS or HIV foundations, such as
American Foundation for Children with AIDS (https://www.afcaids.org/)
and the Elizabeth Glaser Pediatric AIDS Foundation
(http://www.pedaids.org).
TABLE 18-1
Selected Medications for Children Who Are HIV Positive or Have AIDS
MEDICATION RATIONALE
An antibiotic used for prophylaxis TMP-SMZ (Bactrim or Septra) is used in the
and treatment of infection is TMP- prevention of Pneumocystis jiroveci pneumonia;
SMZ (Bactrim or Septra) major toxicities are thrombocytopenia and
neutropenia
Antiretroviral drugs (HAART) Nucleoside reverse transcriptase inhibitors (NRTI)
include: Non-nucleoside reverse transcriptase
inhibitors (NNRTI) Protease inhibitors (PI) Entry and
fusion inhibitors (FI) Integrase inhibitors (II)
Chemokine receptor antagonists
Zidovudine (AZT) This is a type of nucleoside reverse transcriptase
inhibitor
Lamivudine (Epivir) This is a type of nucleoside reverse transcriptase
inhibitor
Nevirapine (Viramune) This is a type of non-nucleoside transcriptase
inhibitor
Nelfinavir (Viracept) This is a type of protease inhibitor
Enfuvirtide (Fuzeon) This is a type of entry and fusion inhibitor
Raltegravir (Isentress) This is a type of integrase inhibitor
Collaboration With the Family and Care Team
Care of the child with HIV or AIDS is complex and best managed through
collaboration with the family and others (which may include a combination of nurses,
physicians, pain specialists, a psychologist, nutritionist, social worker, child life
specialist, and a schoolteacher). The family is encouraged to view the team
members as a collaborative team of professionals and then see themselves as
equal participants in their child’s care.
Nurse: Provides coordination of team and acts as the bridge between the family
and others, assists family and child in assuming an active role in care, identifies
conditions requiring intervention, provides treatments or referrals as needed, and
helps the family create a livable plan for their unique situation.
Physician: Provides and directs all medical care and monitors infections,
complications, and growth and development.
Pharmacist: Provides the medication and acts as a resource to help the family
understand drug actions, interactions, dosing parameters, and adverse side effects.
Pain specialist: Provides pharmacological and nonpharmacological management
for acute and chronic pain.
Psychologist: Assists the child and family to identify positive coping strategies for
living with HIV or AIDS.
Nutritionist: Provides early and ongoing support for nutritional needs.
Social worker: Provides support, community resources, and possible ways to
manage finances.
Child life specialist: Provides support for normal development and coping
strategies.
Schoolteacher: Assists family with a realistic educational plan through episodes of
illness.
NURSING INSIGHT
Stevens-Johnson syndrome
Stevens-Johnson syndrome, a potentially fatal syndrome, can be a side effect of
TMP-SMZ (Bactrim or Septra) or any type of sulfa. It can also be seen with other
medications or viral illnesses. Stevens-Johnson syndrome begins with high fever,
sore throat, cough, arthralgias, vomiting, and diarrhea. Next, erythematous macules
begin to spread from head and neck down to the trunk. These may develop into
hemorrhagic blisters and even involve the mucosa of the nose, mouth, and eyes.
Associated disorders include GI bleeding, renal problems, sepsis, pneumonitis, and
ophthalmological issues. Children with Stevens-Johnson syndrome must be
admitted rapidly to the pediatric intensive care unit for wound care, hydration,
electrolyte issues, pain management, and nutritional assistance. IVIG is the
treatment of choice for this sometimes-fatal reaction (Burns et al, 2020).
Medication adherence may be a problem with HIV-infected individuals of all ages.
Nurses can educate themselves about the medications and adverse effects, to best
support their patients. HIV medications are frequently changing, and the CDC is an
excellent source for current information (http://www.cdcnpin.org). For up-to-date
information on pediatric dosing for HIV medications, see the following CDC Web
site: http://www.cdc.gov/globalaids/docs/program-
areas/pmtct/Peds%20Dosing%20Guide.pdf.
AUTOIMMUNE DISORDERS
An autoimmune disorder is the immune response against one of the
body’s own tissues or cells. Autoimmunity results from the body’s inability
to distinguish self from non-self, wherein the immune system carries out
immune responses against normal cells and tissues. The disorders can
be organ-specific or systemic, as in systemic lupus erythematosus,
dermatomyositis, spondyloarthropathies, scleroderma, and hypermobility
syndrome. Other autoimmune disorders, signs and symptoms, and
nursing care measures are found in Table 18-2.

Systemic lupus erythematosus (SLE) is a multisystem chronic
autoimmune disorder of the blood vessels and connective tissue. The
basic pathophysiology of SLE includes autoantibodies that attach to the
body proteins, creating antigen-antibody complexes. These antigen-
antibody complexes are then deposited throughout the body, causing
widespread tissue damage. The exact cause of SLE is unknown,
although it is tied to genetic predisposition coupled with unidentified
trigger(s) that cause the disease to activate. Suspected triggers include
estrogen, infections, ultraviolet light, pregnancy, and certain drugs. The
signs, symptoms, and course of disease are variable and dependent on
the exact body systems that are affected, ranging from mild to life-
threatening. SLE has unpredictable periods of exacerbation (flare-ups)
and remissions (lessening in intensity or degree). SLE is most common
in adolescent and young adult females, African Americans, and
Hispanics.
Signs and Symptoms

The symptoms are highly variable in both presentation and severity.
■ Fever
■ Malaise
■ Chills
■ Fatigue
■ Weight loss
As the disease progresses, symptoms may include a characteristic
malar photosensitive rash (butterfly rash on the face); arthritis;
photosensitivity; serositis; proteinuria; immunological and hematological
disorders such as hemolytic anemia, lymphocytopenia,
thrombocytopenia, and vasculitis; and an abnormal antinuclear antibody
(ANA).
Diagnosis
Diagnosis is based on laboratory tests that include a complete blood cell
count with differential, metabolic chemistry panel, urinalysis, ANA, anti-
DNA antibody, complement 3 (C3), complement 4 (C4), quantitative
immunoglobulins, rapid plasma reagin, lupus anticoagulant, erythrocyte
sedimentation rate, cardioreactive protein, and antiphospholipid
antibodies. A negative ANA test excludes SLE diagnosis, while a positive
ANA test does not definitively indicate SLE because more tests must be
added to confirm the diagnosis.
TABLE 18-2
Autoimmune Disorders in Childhood
AUTOIMMUNE SIGNS AND SYMPTOMS MEDICAL
DISORDER MANAGEMENT
Spondyloarthropathy: Pain at tendon insertions—heel, tibial NSAIDs: ibuprofen
mostly found >age 10; tubercle; low back pain; sacroiliitis (Advil) or
+HLA B-27 test in 80% naproxen
(Naprosyn)
Enteropathic arthritis; Uveitis, stomatitis (aphthous ulcers in NSAIDs: ibuprofen
includes Reiter’s mouth), hepatitis, erythema nodosum (Advil) or
syndrome, celiac and naproxen
inflammatory bowel (Naprosyn),
disease (IBD)- methotrexate
associated arthritis (Rheumatrex),
infliximab
(Remicade)
Polyarteritis nodosa: Fever, painful nodules, purpura, Steroids (i.e.,
vasculitis, caused by myalgias/arthralgias, hypertension, prednisone,
streptococcus, hepatitis proteinuria, hematuria, cardiac and CNS prednisolone, or
B, parvovirus disease Medrol)
methotrexate
(Rheumatrex),
azathioprine
(Imuran),
cyclophosphamide
(Cytoxan)
Fibromyalgia: chronic Fatigue, sleep disturbance, headache, Low dose
pain syndrome musculoskeletal pain, trigger point pain, trazodone
“fuzzy brain” (Oleptro)
Source: Soep, J. B. & Hollister, J. R. (2009). Rheumatic diseases (Chapter 27). In W. W.

Hay, M. J. Levin, J. M. Sondheimer, & R. R. Deterding (Eds.). Current diagnosis and
treatment: Pediatrics (19th ed.). New York, NY: McGraw Hill.
Prevention
Prevention of exacerbations is the most important aspect for children
with SLE. It is important for the family to understand the importance of
rest and adequate nutrition to help maximize immune system function.
Collaborative Care
NURSING CARE
Managing pain and inflammation, treating symptoms, and preventing
complications are important nursing care measures. Excessive sunlight
and stress can exacerbate the disease, so the nurse communicates this
information to the child and family. SLE is a condition with varying signs
and symptoms, and it requires continued careful assessment to ensure
prompt recognition of an exacerbation. This disease often affects
adolescents, so the facial rash, fatigue, and arthritic changes may put the
child at risk for depression and altered body image.
MEDICAL CARE
Treatment of pain and inflammation in mild SLE is generally
accomplished with nonsteroidal anti-inflammatory medications (NSAIDs).
Antimalarial medications are also used in mild SLE to control symptoms
of arthritis, skin rashes, mouth ulcers, fever, and fatigue. Oral steroids
are commonly used to control the disease. Corticosteroids in forms such
as prednisone, prednisolone, or Medrol are highly effective in reducing
inflammation and symptoms, although they also have the serious side
effect of immunosuppression. During an exacerbation period,
corticosteroids may be initiated in high doses. After symptoms are under
control, the dose is tapered down to the lowest therapeutic level. It is
important to tell the parents that steroids must be tapered slowly when it
is time to discontinue the medication.
The most potent type of medication used to treat severe SLE includes
immunosuppressive agents. These medications are used when the
disease has reached a serious state in which severe signs and
symptoms are present. Immunosuppressive agents may also be
prescribed if there is a need to avoid corticosteroids. The decision to use
immunosuppressives requires serious consideration because of
significant side effects, primarily related to general immunosuppression.
Examples of immunosuppressive agents used in treatment of SLE
include azathioprine (Imuran), cyclophosphamide (Cytoxan), and
methotrexate (Rheumatrex). Each medication has unique and serious
risks such as bone marrow depression and hepatotoxicity. The nurse
must reinforce information on the action of the medication as well as the
side effects with the parents before administration of this medication.
Overall, children with SLE maintain good health, but the disease severity
is variable. In addition to medication, parental education also focuses on
palliative care and providing psychosocial support. It is important to tell
parents to maintain good nutrition for the child. Although there is no
specific diet for SLE, a balanced diet, low in salt (if the child becomes
hypertensive or nephrotic), is encouraged. Rest and exercise include
periods when the child is active during remissions and increases rest
during exacerbation. Avoidance of sun exposure is stressed because of
the photosensitive rash that occurs with SLE. Use of sunscreen is
important and planning outdoor activities in the shade or staying indoors
may be necessary. Because this condition may be difficult for the child
and family to cope with and understand, encouraging the expression of
feelings or joining a support group is encouraged. Parents should notify
teachers, coaches, and others about their child’s condition so they can
help monitor the child and obtain necessary treatment if needed. It is also
the nurse’s responsibility to help the child and family identify possible
triggers, such as sunlight and emotional stress and assist the family in
finding ways to avoid them. Referral to support groups helps the child to
adjust to life with SLE.
PROCEDURE ■ Oral Administration of Steroid

Medication
PURPOSE
Steroid medication is used to treat a variety of conditions, including allergic and
autoimmune disorders.
EQUIPMENT
• Gloves
• Patient identification label
• Oral medication
• Medication cup
STEPS
1. Wash hands and don gloves.
RATIONALE: Prevents the spread of bacteria.
2. Check the child ID band and use two patient identifiers.
RATIONALE: Prevents the accidental administration of medication to the wrong
child. Also, it alerts the nurse to potential medication allergies that could imply an
ordered medication should not be administered.
3. Ensure the correct dosage and route of medication.
RATIONALE: Steroid medication comes in liquid suspensions for younger children
and in tablet form for older children. As a general rule, the suspensions are bitter
in taste and may need to be followed by a sweet treat if allowable.
4. Prepare the medication according to the child’s developmental age.
RATIONALE: Use a clean medication cup to administer steroid pills or
suspension. The nurse may also mix the steroid suspension in a more palatable
food, such as applesauce or pudding. If in suspension, make certain that the
child receives the entire amount of the suspension in the food transport.
STEROIDS
Steroids must be tapered to avoid problems with the hypothalamic-pituitary-access
(HPA). If steroids are given at a high dose for a long period, the body will interpret
this as not needing to produce its own cortisol, which is dangerous. Steroid tapers or
short bursts of steroid dosing (usually no more than 5 days) eliminate interference
with the HPA and keep the body producing its own cortisol.
TEACH PARENTS
Teach the parents that children on steroid medications may be irritable, very
energetic, or have insomnia. It is essential to keep them away from infectious
disease sources, especially while on steroids because their immunity may be
altered.
Patient Education
Systemic Lupus Erythematosus Resources

The nurse encourages an adolescent recently diagnosed with SLE to contact a local
support group. In addition, several good resources are available online through the
organizations located at the following Web sites:
• Lupus Foundation of America http://www.lupus.org/
• National Institute of Arthritis and Musculoskeletal and Skin Disorders
http://www.niams.nih.gov
• SLE Foundation, Inc. http://www.lupusny.org/
• Association of Rheumatology Health Professionals, American College of
Rheumatology http://www.rheumatology.org/
• Arthritis Foundation http://www.arthritis.org/
Dermatomyositis
Dermatomyositis is a relatively uncommon autoimmune disorder found in
children and adults, characterized by muscle weakness and a distinctive
rash. In children, the most common age range for onset is between 5 and
15 years of age.
Signs and Symptoms

■ Proximal muscle weakness, especially in shoulders and pelvis
■ Heliotropic violaceous (red-purple) rash around eyes and upper
eyelids
■ Possible malar rash similar to SLE, with edema of face and eyes
■ Tenderness, stiffness of muscles, possible voice change, dysphagia
Diagnosis
Diagnosis is made clinically and requires the care of a rheumatologist.
Clinical presentation is most important, but the following laboratory tests
may be abnormal: liver function tests (elevated), white blood cell count
(elevated), lymphocyte count (depressed), hematocrit (low), albumin
(low), creatine kinase (elevated), and erythrocyte sedimentation test
(elevated). Further testing includes electromyelogram testing, muscle
biopsy, and magnetic resonance imaging of muscles, specifically the
quadriceps muscle.
Prevention
There is no known prevention for dermatomyositis. As an autoimmune
disease, it may be associated with other autoimmune diseases, with
interstitial lung disease, and with some cancers. Keeping the disease
stable with medication and regular health care may prevent more serious
sequelae and complications.
Collaborative Care
NURSING CARE
This chronic autoimmune disorder can cause significant physical
disabilities and possibly socially embarrassing facial and voice changes.
Emotional care involves providing therapeutic listening for these children
and support for coping mechanisms. Physical care involves monitoring
these children for adverse effects of the potent medications used to treat
this disorder, including long-term steroids and methotrexate
(Rheumatrex).
MEDICAL CARE
Dermatomyositis is treated with long-term steroid administration.
Steroids that are often used include methotrexate (Rheumatrex),
cyclosporine (Sandimmune), hydroxychloroquine (Plaquenil), and IVIG
when needed.
Parents are taught about medication management and potential side
effects that can occur as a result of long-term steroid use.
Hypermobility Syndrome
This childhood disorder is also known as ligamentous laxity and may
be a component of what is commonly termed “double-jointedness.”
Associated problems with this disorder include local or widespread pain,
chronic fatigue, sleep problems, and early-age degenerative arthritis.
Ehlers-Danlos syndrome and Marfan syndrome (elongated extremities
and increased risk for aortic aneurysm) are two varieties of hypermobility
syndromes. Potential accompanying disorders include irritable bowel
syndrome, mitral valve prolapse, easy bruising, and anemia.
Signs and Symptoms

Hypermobility syndromes are indicated by these symptoms:
■ Arthralgias
■ Intermittent joint pain after exercise
■ Occasional joint edema after exercise
Diagnosis
The child must meet five criteria: (1) hyperextension of knee, (2) palms
can be on floor with knees extended, (3) hyperextension of elbow, (4)
passive opposition of thumb to flexor surface of forearm, and (5) passive
hyperextension of fingers so they are parallel with extensor surface of
forearm. The Brighton Criteria and Beighton Scores are important
diagnostic parameters for hypermobility syndromes.
Prevention
No known preventive measures exist for this autoimmune disease.
Collaborative Care
NURSING CARE
Nursing care includes providing a graded conditioning program to
support joints and prevent them from hyperextending. Notify the child
and family that recurrent sprains and strains of joints, ligaments, and
tendons may take longer than usual to recover, and joint subluxation
(partial dislocation) is more common. This may require limitations on
sports and repeated orthopedic and physical therapy appointments. The
nurse should inform the parents about the possibility of severe pain, poor
balance, clumsiness, and early degenerative arthritis. Nurses should be
aware that children with this disorder may need to see physical
therapists, occupational therapists, rheumatology physicians, and
orthopedists. Children may have associated needs for counseling and
group support, as with the Hypermobility Syndromes Association.
MEDICAL CARE
Medical management consists of the proper knowledge about
medication administration. The nurse teaches parents about common
medications used for autoimmune diseases (Box 18-2).
Parents must understand that proper medication administration is an
important aspect of care for the child (see Box 18-2).
ALLERGIC REACTION
Anaphylaxis
Anaphylaxis is considered a medical emergency as the most severe
allergic reaction possible. Both IgE- and non-IgE-mediated activities
cause this life-threatening event, including the activation of mast cells,
basophils, eosinophils, histamine, leukotriene, cytokines, T lymphocytes,
and neutrophils, among other cells. Most importantly, this cascade of
events activates the heart, lungs, and vasculature in a detrimental
manner, including vasodilation, hypotension, and resultant shock.
Histamine can cause coronary artery vasospasm and shorten diastole.
Histamine stimulates bronchial smooth muscle contraction, causing
bronchospasm. Increased vascular permeability causes laryngeal
edema, closing the airway down. The body reacts violently to an antigen
(foreign substance) that causes a hyperacute allergic response. Fatalities
are caused by respiratory compromise and cardiovascular collapse, with
respiratory failure being more common in pediatric mortality. Most
reactions occur quickly after exposure, although food allergies can
manifest from 25 minutes after exposure to several hours later. Insect
stings and drug allergies cause the most rapid route to anaphylaxis, with
an average of 5 to 20 minutes to onset.
BOX 18-2
Medications for Autoimmune Disorders

NSAIDs: ibuprofen (Advil) or naproxen (Naprosyn)
Steroids (e.g., prednisone, prednisolone, Medrol)
Methotrexate (Rheumatrex)
Azathioprine (Imuran)
Cyclophosphamide (Cytoxan)
Infliximab (Remicade)
IVIG (IgG [Immunoglobulins])
Cyclosporine (Sandimmune)
Hydroxychloroquin (Plaquenil)
Pregabalin (Lyrica)
Anaphylaxis Triggers
Identification of the anaphylaxis-causing agent or event is essential and often
requires consultation with an allergist. Allergen immunotherapy given by an allergist
may itself cause anaphylaxis and thus must be cautiously administered and
monitored. Most common causes of anaphylaxis are insect stings or bites
(honeybee, bumblebee, wasp, yellow jacket, hornet, and fire ants). Other insects
that have less potential for causing anaphylaxis are bedbugs, spiders, mosquitoes,
or flies.
Vaccine reactions most commonly occur from the gelatin preservative in some
vaccines. Egg-allergic children may react to egg-containing vaccines such as
influenza and yellow fever. Reactions to preservatives, antibacterial agents, or
components of the vaccine, including neomycin, can prompt anaphylaxis.
The most common medications that can cause anaphylaxis are the antibiotics
from the penicillin family, followed by cephalosporin antibiotics, and then
sulfonamides (e.g., with TMP-SMZ [Bactrim or Septra]), macrolides (e.g.,
erythromycin and clarithromycin), and quinolones (e.g., ciprofloxacin). In older
children and teens, NSAIDs are the most common cause of a medication reaction.
People allergic to NSAIDs may also be allergic to aspirin, although children rarely
take aspirin.
Latex allergy, another allergic reaction, is less common, but exposure to latex in
gloves, medical equipment, and other household equipment can cause anaphylaxis
in children. Children who require multiple surgeries, who have congenital urological
malformations, and who have spina bifida (myelomeningocele is the most prevalent
type associated with latex allergy) are notably more allergic to latex. Latex allergy
can be less severe than anaphylaxis, resulting even in skin rashes and asthma
(AAP, 2020).
Signs and Symptoms

Signs and symptoms of anaphylaxis develop suddenly and require
prompt recognition and treatment:
■ Wheezing
■ Tachycardia
■ Hypotension
■ Cyanosis
■ Alteration in level of consciousness
■ Nasal congestion
■ Angioedema (swelling around mouth and oropharynx)
■ Facial edema
■ Anxiety
■ Hives and urticaria
■ Abdominal pain
■ Laryngospasm
■ A sense of impending doom
■ Vascular collapse and cardiac arrest
NURSING INSIGHT
Additional Signs and Symptoms of Anaphylaxis
Additional signs and symptoms that may occur with anaphylaxis include flushing,
pruritus, rhinorrhea, sneezing, allergic conjunctivitis, and headache. Occasionally, GI
symptoms such as abdominal cramping, nausea, vomiting, and diarrhea occur.
Diagnosis
Diagnosis of anaphylaxis must involve two body systems. Minor urticaria
(hives) is not considered one system but more severe urticaria is. Skin
prick testing is contraindicated if the child is anaphylactic to a substance,
as opposed to a lesser allergic reaction. It is important to differentiate
true food allergies to those caused by cell-mediated food hyper-
sensitivities (e.g., celiac disease, malabsorption syndromes, and food-
induced colitis, which have more GI symptoms). Also, it is important to
differentiate between oral allergy syndrome, in which patients get tingling
of the palate, tongue, lips, or oropharynx after ingesting certain foods, but
they never get anaphylaxis. True anaphylactic food allergies can be life-
threatening with respiratory or cardiac arrest, although some food
allergies are only manifested by urticaria and pruritus.
Prevention
Prevention of anaphylactic reactions is an essential component of
nursing care. Nurses should be vigilant about checking for allergies from
patients, family members, the medical record, and allergy bracelets.
Nurses should obtain excellent histories about allergic reactions and
should document them carefully and prominently for all health-care team
members to see. Some anaphylactic reactions occur upon first-time
exposure, but others, including some bee stings, occur only on the
second or subsequent exposures. If there is a family history of
anaphylaxis, the nurse should counsel the patient and other health-care
team members because the patient could well develop anaphylaxis also.
Emergency medicines such as epinephrine and fast-acting antihistamine
medications need to be available for immediate use. Patients with history
of anaphylactic reactions should wear ID jewelry detailing the reactions,
should carry wallet card identification of the anaphylactic reaction, and
should carry life-saving medicine with them (or in the case of young
children, the parents, school nurses, teachers, and other health-care
team members should have access to emergency medications).
Collaborative Care
NURSING CARE
For children who have experienced an anaphylactic reaction, the nurse
must provide follow-up care to families to prevent recurrences. If the child
has allergies that cannot be completely eliminated, a follow-up referral to
an allergist for desensitization treatments or a self-administration
epinephrine prescription, such as an EpiPen, is warranted. It is important
that parents are taught to recognize early indicators of anaphylaxis and
are confident in their ability to act quickly on this assessment.
FOCUS ON SAFETY
EpiPen
The EpiPen Jr® autoinjector is used for children experiencing a life-threatening
allergic reaction. In children < 30 kg, use the EpiPen Jr.; for children > 30 kg, use
the EpiPen. If in a hospital setting and administering an EpiPen to an overweight or
obese child, consider switching off the ½-inch needle and administer the
epinephrine with a 1-inch needle for more absorption.
Parents must notify the school nurse, day-care providers, coaches, and other
adult leaders who spend time with the child about the diagnosed allergy. A child
who is required to carry an EpiPen should always have two in case one doesn’t
work. Parents and children should know that once an EpiPen is administered they
must call 911.
MEDICAL CARE
Basic life support must be initiated with support of airway, breathing,
and circulation. Administration of oxygen and initiation of an IV therapy
with an isotonic crystalloid solution as soon as possible are standard
treatment. Epinephrine (Adrenalin) injection is administered IM or IV to
provide reversal of pulmonary bronchospasm and constriction of blood
vessels, thereby improving respiratory status and blood pressure.
Ongoing assessment for shock is necessary and can be treated via IV
fluid bolus. Occasionally, antihistamines and corticosteroids may be
added to further control symptoms after the initial stabilization. The
majority of children respond positively to the treatment and make a full
recovery.
In case of an allergic reaction, instruct the parent to administer the
medication exactly as directed and call 911 immediately. Other
education/discharge instructions include:
■ Instruct the parents to teach the child to know their triggers.
■ Review correct administration technique for the EpiPen or EpiPen Jr
(epinephrine).
■ Teach the child to self-inject the epinephrine medication and what to do
in case of an emergency.
■ Tell parents of children too young to self-inject and who are separated
from them to discuss the allergy and how to use an autoinjector with
another responsible adult.
Optimizing Outcomes
Peanut Allergies in School

Peanuts, tree nuts, fish, shellfish, cow’s milk, hen eggs, soy, and wheat represent
90% of food allergies. Many children outgrow these food allergies within the first
decade of life, with the exception of peanuts, tree nuts, and shellfish, which tend to
be allergens that persist throughout life. The rise in the prevalence of food allergies
over the past decades has focused attention on factors that may affect disease
development, most notably the gut microbiota.
Research is focusing on developing a tolerance to peanuts in those with
anaphylaxis to peanuts. Studies include examining fecal transplants for peanut
allergies as well as building up tolerance to peanuts through staged incremental
exposure (Rachid, Rima & Chatila, 2016). These studies play a crucial role in
promoting oral tolerance. Their alteration by such factors as cesarean section
delivery, diet, and antibiotics may influence disease development. Research with the
use of probiotics remains circumstantial with further studies needed (Rachid, Rima &
Chatila, 2016).
The pediatric nurse plays a critical role in collaboration with the family
and school personnel to create a safe environment for a child with
peanut allergy to safely attend school. The nurse assists the family in
establishing a coordinated plan including the following key components:
■ Educate the school staff regarding peanut allergies. Include all staff
who may be supervising this student and who may be in a position to
recognize and intervene in an emergency.
Outline an emergency plan specific for the student to include:
■ Specific instructions for staff in the event of a reaction
■ Two up-to-date EpiPens on hand
■ Identification and elimination of exposure to the allergen
■ Placement of emergency phone numbers in a designated area
■ A “peanut-free” zone in the cafeteria or a peanut-free table
■ Communication with parents who may provide snacks to the child,
such as parents of children in the same class, sports team, or club
MEDICATION: Diphenhydramine
(Benadryl)
(dye-fen-hye-dra-meen)
Indications: Relief of allergic symptoms caused by histamine release, including
anaphylaxis, allergic rhinitis, and allergic dermatoses. Relief of pruritus.
Actions: Antagonizes the effects of histamine at H1-receptor sites. Significant CNS
depressant and anticholinergic properties.
Therapeutic Effects: Decreased symptoms of histamine excess (sneezing,
rhinorrhea, nasal and ocular pruritus, ocular tearing and redness, and urticaria).
Contraindications and Precautions: CONTRAINDICATED IN: Hypersensitivity.
Adverse Reactions and Side Effects: Drowsiness, paradoxical excitation (more
common in children), anorexia, and dry mouth.
1. Provide child and family education regarding medication, caution not to exceed
recommended dose.
2. Inform parents that medication may cause drowsiness or excitability in child.
3. Provide education regarding common side effect of dry mouth. Management
strategies include frequent mouth care and oral rinses.
_________
INFECTIOUS DISEASES OF CHILDHOOD

The occurrence of infectious disease in children is the result of an
interaction between several factors including the child, the environment,
and the agent causing the illness.
Two main models are used to illustrate the interaction, most commonly
the epidemiological triangle (Fig. 18-4). In the epidemiological triangle,
the host, environment, and agent make up the three sides of an
equilateral triangle. The host is the organism from which a parasite
obtains its nourishment, the environment is the surroundings or
conditions that influence the organism, and the agent causes the actual
effect (disease) (Venes, 2021). This model illustrates the codependence
that these three factors have on one another and recognizes that a
change in any one of the three factors will influence the risk or probability
of a child contracting the disease.
Many factors such as age, gender, physical, and psychosocial factors
play a role in the susceptibility of the host to an infectious disease. The
normal development of the child’s immune system is also a major factor
in many infectious diseases, especially during the early childhood years.
The child has natural protection from maternal antibodies for up to the
first 6 months of life; therefore, any sign of infection that occurs during
this time is taken seriously and often an extensive medical work-up is
initiated. Also, children under 6 months of age who show signs of
infectious disease may be ill enough to be hospitalized because of some
compromise in their maternal and natural immunity.
The final element in the triangle, the agent, contains specific
information, including infectivity, pathogenicity, and virulence, that assists
the nurse in developing the appropriate plan of care. Infectivity includes
the mode of transmission, incubation period, and communicable period.
The mode of transmission is how the pathogen actually gains access
to the body. With this knowledge, the nurse can plan care to eliminate
unnecessary portals of entry (e.g., multiple IV sites) and thoroughly
inspect the skin for potential breaks that allow entrance of organisms.
Knowledge about the incubation period (period of time when an
organism invades the body and develops an onset of symptoms) and the
communicable period (the time that the child is able to transmit the
pathogen to others) allows the nurse to alert others that the child is
infectious and to isolate the child for a certain period.
Pathogenicity is the percentage of those children exposed to the
pathogen who will eventually develop the disease. This information is
helpful to the nurse in the community when assessing citywide
outbreaks. The nurse can notify schools, community centers, churches,
shopping malls, and other public places that an outbreak exists and that
it is best to avoid these areas, especially for high-risk children. Virulence
is the severity of the health problems caused by the agent. The more
virulent the disease the more necessary it is to curtail its spread. For
example, in winter during an influenza outbreak, a number of schools
close so they can be thoroughly cleaned and sanitized. Pathogenicity
and virulence are often key considerations in development and
implementation of public health programs.
The Chain of Infection model is also an important way to understand
transmission of infection (Fig. 18-5). This model illustrates the exact
steps that must occur for transmission and demonstrates possible ways
to stop transmission of the disease.
The first link shows that pathogenic microorganisms, whether viruses,
bacteria, or fungi, require a reservoir where the pathogen can grow.
Reservoirs may be human hosts, animals, and the soil. With knowledge
about the reservoir, the nurse can eliminate it to break the chain. A
mosquito abatement program to control West Nile virus is an example of
an attempt to alter the chain of infection via reservoir elimination. Public
health immunization campaigns are examples of a way to decrease the
reservoir for diseases.
The next two links in the chain involve the escape of the pathogen
from the reservoir into the host. Knowledge about the routes of
transmission (contact, droplet, airborne) enables the nurse to initiate
appropriate isolation precautions. Contact transmission refers to
infection that is contagious through skin, vomit, feces, urine, mucous
membranes, and wounds. Droplet transmission implies a spread of
organisms through close mucous membrane or respiratory secretions
contact, as exemplified by rhinovirus that can cause the common cold
and influenza. Airborne transmission refers to pathogens that may be
suspended in the air and therefore spread over long distances. Examples
of airborne transmission include measles, tuberculosis, and varicella.
FIGURE 18-4 Epidemiological triangle.

FIGURE 18-5 Chain of infection model.
The final link involves a susceptible host. Susceptibility of the host to

infection is decreased mainly via good general health practices such as
good hygiene, nutrition, overall good health, lack of immunity disorders,
and a decrease in stress. A listing of infectious diseases and nursing
care actions is shown in Table 18-3.
NURSING INSIGHT
Basic Guidelines for Infection Control
Infection Control Recommendation Summary of Useful Practices
Cleaning and disinfection Disinfect or sterilize surfaces, such as bed
rails, computer keyboards, nightstands,
phones, and toilets.
Cough etiquette/respiratory courtesy Wear masks and/or cover mouth and
nose when coughing or sneezing.
Maintain a distance of 3 feet from
others when you have a cold or flu.
Drug formulary restrictions Limit prescribing privileges for antibiotics
to designated specialists.
Hand hygiene Use alcohol-based rubs when
appropriate. Wash hands after contact
with any blood, body fluids, or
potentially contaminated items or
patients.
Isolation procedures Follow protocols for isolation of patients
who are bleeding, coughing, giving off
other excretions, secretions, or
potentially hazardous body fluids.
Segregate patients during outbreaks of
infectious diseases. Separate immune-
suppressed patients from others with
potentially communicable diseases.
Laundry/linen and food service Gather patient clothing, eating utensils,
management gowns, sheets, and towels without
contaminating other objects used in
patient care. Wear a gown and gloves
while collecting and washing laundry.
Perform hand hygiene after laundry
management procedures.
Personal protective equipment (PPE) use Wear gloves, goggles, gowns, masks, and
shoe covers while performing patient
care procedures whenever exposure to
blood, body fluids, aerosols, or
splashes is possible. Dispose of PPEs
in designated containers.
Resuscitation and invasive airway Avoid mouth-to-mouth contact with
management patients and wear PPE at all times,
such as particulate respirators or
masks. Disinfect or sterilize
endoscopes, intubation equipment,
nebulizers, face masks (e.g., for
continuous positive airway pressure or
supplemental oxygen), or other
respiratory care devices.
Sharps (management of needles, wires, Maintain sharps in open view to avoid
etc.) accidental injuries. Never recap or
manipulate needles used in patient
care. Dispose of sharp objects in
puncture-proof solid waste containers.
Source control Supply/apply anti-infective rubs or soaps
to patients to limit their colonization by
disease-causing bacteria.
Standard precautions Follow standard precautions during every
patient encounter.
_________
Source: Venes, D. (Ed.). (2021). Taber’s cyclopedic medical dictionary

online (24th ed.). Philadelphia, PA: F.A. Davis.
Infections
There are three types of infections: viral, fungal, and bacterial. Viruses
(e.g., influenza, common cold viruses, and HIV) are microorganisms that
are smaller than bacteria and do not grow without having a living cell as
a host. The virus replicates itself in other living cells of people, animals,
or plants. Fungal infections are pathological organisms including yeast
and dermatophytes, such as tinea (e.g., athlete’s foot and candida yeast
infections). Fungal infections are most likely to occur in children with a
compromised immune system (Venes, 2021). Bacterial infections are
caused by single-celled living microorganisms and include
Streptococcus, Staphylococcus, and Escherichia coli. Bacteria can be
found everywhere in the environment.
It is important to distinguish between viral, fungal, and bacterial
infections to administer the proper medication. Limited antiviral antibiotics
are available to treat some types of viral infections, antifungal agents are
used to treat fungal infections, and antibacterial antibiotics treat bacterial
infections.
Human beings become colonized with certain bacteria shortly after
birth. Some of these bacteria are beneficial and control other pathogenic
organisms. Examples of healthy bacteria in human intestines include
Lactobacillus, known as a probiotic if taken as a supplement. Infectious
agents, whether bacteria, viruses, or fungi, can cause disease if there is
a harmful proliferation of these pathogens that causes them to outweigh
normal immunity and normal harmless bacteria (Blosser, Brady, & Royal,
2020).
TABLE 18-3
Communicable Diseases in Childhood
DISEASE SIGNS AND NURSING CARE COMPLICATIONS
SYMPTOMS
Chickenpox (Viral) Malaise, fever, Nursing care is Immunocompromised
possible URI, supportive with children have a high
symptoms are antipruritic lotions, risk for complications
followed by a rash. baths, and (including those on
The rash is antihistamines. steroids for treatment
described as a “tear Some children of asthma).
drop on a rose.” It receive oral acyclovir The most common
Causative Agent— begins with a (Zovirax), which is complications are
Varicella-zoster virus, macule on a red not curative but can bacterial
a herpes virus (VZV) base, then slightly shorten the superinfections with
Epidemiology—Highly progresses to a disease duration and lesions, encephalitis,
contagious disease clear vesicle, and intensity. varicella, pneumonia,
Peak Incidence—Late later forms a crust. IV acyclovir is used and immune
winter and spring The lesions are for thrombocytopenia
Mode of Transmission severely pruritic, and immunocompromised purpura (ITP).
—Airborne, spread eruptions may child presenting with Use of aspirin-
through contact with continue to occur for chickenpox. containing
respiratory droplets up to 5 days. Must be used within medications has
and contact with Generally, the rash 24 hours of onset to been linked with
lesions first appears on the be effective. Reye’s syndrome in
Infection Control— face and trunk but Varicella-zoster children with
The incubation period may spread immune globulin Varicella-zoster
is from 10 to 21 days. anywhere on the (VZIG) may be given (chickenpox).
Children are body. within 72 hours of
considered exposure to
contagious 1–2 days immunocompromised
before the eruption of children. VZIG
lesions to the time provides only
when all lesions have temporary immunity.
crusted, or up to 7 Oral antihistamines,
days after baking soda, oatmeal
appearance of the baths and lotions,
rash. The period of such as Aveeno
communicability may baths and calamine
be prolonged in lotion are given to
children who are manage the itching.
immunocompromised.
Airborne and contact
precautions are
needed for
hospitalized children
during the period of
communicability.
Varicella vaccination
is increasingly used in
childhood and
adolescence, so the
incidence of varicella
has decreased over
time. However, it is
unclear whether this
vaccine provides
lifelong immunity.
Herpes zoster
(shingles) is
reactivated varicella
that can occur
especially in older
and
immunocompromised
individuals; this is a
result of the varicella
virus remaining
dormant in nerves
after the disease.
Diphtheria Signs and Hospitalization is Respiratory

(Bacterial) symptoms are mild required with IV compromise is
in partially antitoxin secondary to the
immunized or (hyperimmune endotoxin that is
severe in equine antiserum) produced and a
unimmunized and antibiotics membrane that
children. (erythromycin or covers much of the
Causative Agent— Low-grade fever, penicillin). upper airway.
Corynebacterium rhinorrhea, cough, All contacts are given The membrane toxin
diphtheriae bacillus sore throat, gray, prophylactic antibiotic can produce
Epidemiology—This adherent membrane treatment and myocarditis,
is a rare disease in in pharynx or immunization respiratory
the United States; it trachea, possible boosters. compromise, and
can occur from raw skin ulcers, peripheral and cranial
milk and milk hoarseness, stridor, neuropathies.
products. and pharyngitis are
Peak Incidence— common.
Occurs mostly in fall More severe signs
and winter in and symptoms
unimmunized or cause difficulty
breathing because
partially immunized of narrowing of the
persons. upper airway.
Mode of Transmission
—Transmitted
through respiratory
droplets, contact with
respiratory secretions,
contact with skin
lesions.
Infection Control—
The incubation period
is 2–7 days (or may
be longer), so if the
disease is suspected,
isolate the child.
Droplet and contact
precautions are used
for hospitalized
children.
Immunization with
recurrent boosters is
the only effective
means of control.
Infectious Signs and Steroids are Respiratory

Mononucleosis symptoms include considered in the compromise is
(Viral) fever, severe case of respiratory secondary to the
Causative Agent— exudative difficulty secondary to airway swelling and
Epstein-Barr virus pharyngitis, and occlusive pharyngitis exudative
(EBV) prominent cervical (but must be used pharyngitis, aseptic
Epidemiology—Most and often occipital cautiously). meningitis, and
persons become lymphadenopathy Bedrest and encephalitis.
infected with EBV lasting from 2–3 avoidance of Rarely, splenic
sometime during their weeks. strenuous activities, rupture occurs.
life (usually Fatigue and possible especially contact Possible
adolescence or young hepatosplenomegaly sports, is required mononucleosis
adulthood). are also seen. (because of risk of hepatitis.
Peak Incidence— A fine splenic rupture). Aseptic meningitis or
Ages 15–17 maculopapular rash encephalitis occurs.
Mode of Transmission may occur, There is a possible
—This disease is especially if the occurrence of
transmitted via patient is given thrombocytopenia
intimate contact with amoxicillin (Amoxil) and agranulocytosis.
the saliva of an or ampicillin
infected individual, (Unasyn).
but it is also infectious In the lab, a positive
from blood. monospot or
Infection Control— heterophile test and
The incubation period atypical lymphocytes
is 30–50 days. on a CBC/differential
Infected persons may are classic.
shed virus
intermittently and
without symptoms
throughout life.
No isolation beyond
standard precautions
needed.
There are other
diseases, such as
CMV, toxoplasmosis,
and HIV, that can
cause a mono-like
syndrome with similar
symptoms.
Rubella Signs and Supportive care is The riskiest

(virus)/German or 3- symptoms include a given with complications occur
Day Measles prodrome of mild antipyretics. prenatally, in the first
Two forms: congenital fever, sore throat, Isolate the child from trimester to 16th
and postnatal (after arthralgia, eye pain, others while disease week of pregnancy,
birth). GI upset. is active, usually for and include mental
Causative Agent— Lymphadenopathy up to 1 week after retardation,
Rubeola virus follows and is noted rash starts. deafness, eye
Epidemiology—Up to for the occurrence of disorders, cardiac
39 million cases postauricular nodes. defects, and stillbirth.
worldwide each year Other lymph nodes, Postnatal
Peak Incidence—In such as cervical and complications include
United States, mostly occipital nodes, can arthritis, ITP, and
at age 6 months become inflamed. encephalitis.
because infants are The rash is a fine,
not vaccinated yet. light-pink,
Mode of Transmission maculopapular rash
—This disease is on the face then
highly contagious. It is traveling to the chest
spread through and entire body.
placenta or
nasopharyngeal
secretions and
fomites.
Incubation period:
14–21 days.
Haemophilus Signs and Nursing care Death may occur

Influenzae Type b symptoms begin as includes antibiotic secondary to serious
(Bacterial) an upper respiratory administration. infections with
Causative Agent— infection. Prophylactic Haemophilus
Haemophilus Bacteria treatment with influenzae type b if
influenzae type b subsequently pass rifampin (Rifadin) is not treated.
Epidemiology—Highly into the blood and given to
contagious disease may be spread to unimmunized people
Peak Incidence— sites throughout the in the household.
Occurs most often in body.
spring and summer Symptoms of
with infants and infection are
children in day care. dependent on the
Mode of Transmission site and may include
— sinusitis, otitis
Spreads via direct media, upper and
contact or inhalation lower airway
of droplets from infections, septic
infected persons. arthritis, and
Infection Control— cellulitis.
The incubation period In infants this
is unknown, and the organism is a cause
disease is likely of sepsis.
contagious for up to 3
days following onset
of symptoms.
The infectious agent
may colonize in
respiratory tract of an
asymptomatic person.
This disease is
preventable with the
vaccine.
Influenza (Viral) Signs and Nursing care is Complications can

Causative Agent— symptoms have a supportive and include febrile
The flu is caused by rapid onset of a high includes antipyretics, seizures in young
influenza viruses A, fever, myalgia, bedrest, and keeping children.
B, and C. A and B arthralgias, the child isolated until Secondary bacterial
strains can cause headache, sore symptoms subside. pneumonia and
epidemics, while C throat, rhinitis, and Antiviral medications exacerbation of
(zanamivir and
causes only mild nonproductive oseltamivir underlying chronic
illness in children. cough. especially) reserved illness can be seen.
Subtypes including Otitis media and for children with Sepsis can happen in
H1N1, H1N2, and nausea and vomiting immunosuppression. infants.
H3N2 also exist. are common in These medications Myocarditis and
Recently, the virulent younger children are started within 48 death can occur.
H1N1 strain caused with influenza. hours of symptom
deaths and severe onset and are
disease, especially in effective in
young children, and it decreasing duration
is now incorporated and symptoms of flu.
into the flu vaccine.
Epidemiology—This
disease is highly
contagious. It occurs
most often in spring
and summer with
infants and children in
day care.
Peak Incidence—This
disease occurs more
often in the winter
months.
—This disease is
transmitted via direct
contact, droplets, and
fomites contaminated
with nasopharyngeal
secretions.
is typically 1–4 days.
Many types of flu are
largely preventable or
at least diminished
with the injectable or
intranasal vaccine.
The exact vaccine is
created each year
based on predictions
of flu types expected.
Mumps (Parotitis) Signs and Nursing care is The main

(Viral) symptoms are mild supportive and complication is
and systemic includes control of
including malaise, the signs and orchitis in post-
low-grade fever, symptoms. pubertal males.
anorexia, ear pain Hydration and good Sterility secondary to
and headache, and nutrition are this complication is
Causative Agent— pain with chewing. important care rare.
Paramyxovirus As the disease measures. Less common
Epidemiology—This advances, bilateral complications are
disease is highly or unilateral parotid oophoritis,
contagious. gland swelling pancreatitis,
Peak Incidence—Late appears; swelling myocarditis, and
winter to early spring, generally peaks deafness.
higher outbreaks around the third day
among college-age and lasts up to 6
persons if not days.
vaccinated
—The transmission of
this disease spreads
via droplets directly
from an infected
person (saliva and
respiratory
secretions). Virus
may be airborne
through infected
droplets.
The most contagious
period is from 2 days
before symptoms
begin to 6 days after
they end. Hospitalized
children require
droplet precautions.
Pertussis (Bacterial) The initial signs and Nursing care Complications in

symptoms include a includes the infants, especially
mild respiratory administration of those younger than 6
illness but with a antibiotics as ordered months, include
cough that has a by the health-care apnea, seizures,
classic “whooping” provider. severe pneumonia,
sound, which is a Infants younger than and pulmonary
Causative Agent— high-pitched 6 months of age and hypertension.
Bordetella pertussis inspiratory sound. those with severe In all children,
bacteria This persistent dry disease are bacterial pneumonia,
cough may last for hospitalized for close seizures,
Epidemiology—This months and includes observation of encephalopathy,
disease occurs in coughing paroxysms respiratory status. epistaxis, and even
unimmunized or and vomiting after Nursing care also death can occur.
partially immunized coughing. includes maintaining
persons, and open airway and
outbreaks of pertussis monitoring oxygen
more recently have saturation.
led to
recommendations for
older children and
adults to get re-
vaccinated with
booster doses of this
vaccine.
Adults and
adolescents who are
no longer immune
provide a major
reservoir for
pertussis.
It can also spread to
incompletely
immunized infants
and children, with
higher morbidity and
mortality.
—Transmission takes
place through close
contact with the
infected person and
aerosol droplet.
is 6–21 days.
Hospitalized children
should be placed on
droplet precautions
until the period of
communicability has
passed. Testing is
possible through
culture and PCR test.
Pneumococcal Signs and Nursing care Complications can

Disease (Bacterial) symptoms include includes the cause bacteremia in
Causative Agent— upper respiratory administration of children,
Streptococcus infection, high fever, penicillin (Bicillin), bronchiectasis, and
pneumoniae. pleuritic chest pain, which is used for airway compromise.
Epidemiology—This cough, chills, and certain strains of
disease is the leading dyspnea. pneumococcal
cause of bacterial Severe signs of disease.
pneumonias in respiratory distress Other treatments for
children except for are nasal flaring, pneumonias include
newborns. grunting, retractions, a wide range of
Peak Incidence— rales, decreased antibiotics as
Occurs in late winter breath sounds, determined by the
and early spring when tachypnea, health-care provider.
children spend more wheezing, and Inpatient pediatric
time in close quarters. stridor. patients will have IV
Mode of Transmission The cough may be fluids and antibiotics.
—This disease dry or productive Viral pneumonias do
spreads through and could include not respond to
contact with infected hemoptysis. antibiotics.
respiratory secretions. Treat viral
Infection Control— pneumonia with
The incubation period supportive care.
is 1–3 days.
There are 91
identified serotypes of
pneumococcus, and
three vaccines have
been developed that
address a number of
serotypes. The
vaccines are
commonly given to
young children and
are offered to older
children and teens
who may not have
received them, but
who are at high risk of
pneumococcal
disease.
Poliomyelitis (Viral) Signs and Nursing care is Complications

symptoms happen in supportive. include permanent
the central nervous During the paralysis, respiratory
system with either rehabilitation phase, arrest, and aseptic
nonparalytic or physical therapy can meningitis.
paralytic symptoms. maximize function.
Initially, children
present with
nonspecific
symptoms such as
low-grade fever and
sore throat. The
Causative Agent—
symptoms start
Enterovirus
mildly and then
Epidemiology—This
progress to transient
disease is most
pain and stiffness in
common in infants
the child’s neck,
and young children.
back, and legs.
Peak Incidence—In
Then symptoms
the United States, this
may get severe,
has no peak
progressing to
incidence because of
meningeal
vaccination. Prior use
membranes.
of live vaccination did
Signs of respiratory
transmit some cases
compromise may
of polio, but only
also occur.
inactivated vaccine is
Paralytic polio is the
now used.
most severe form
and includes severe
—This disease is
muscle pain
transmitted via fecal–
followed by paralysis
oral route primarily
in the legs but
but may also be
sometimes affecting
transmitted through
other muscles,
respiratory secretions.
including those used
in respiration.
Standard and droplet
precautions are used
for hospitalized
children to control the
infection.
Roseola (Exanthem Signs and Nursing care is Complications

Subitum) (Viral) symptoms may be supportive and include a high fever.
Causative Agent— asymptomatic or includes fever-
Human herpes virus 6 occur with just fever reducing measures.
or 7 and no rash. Monitor for febrile
Epidemiology—This Sudden high fever, seizures.
disease occurs usually 101°F
primarily in children. (38.3°C) to higher
Occurs any time of than 103°F (39.4°C)
the year. and lasts 3–5 days.
Peak Incidence—6– As fever begins to
15 months of age decrease, a
Mode of Transmission discrete, red,
—This disease is maculopapular rash
transmitted through that fades when
oral, nasal, and pressure is applied
conjunctival appears on the
secretions. trunk.
Infection Control— The rash then
Incubation is 9–10 spreads to head and
days. extremities and may
The most infectious last several days.
period is during the Other signs and
febrile period before symptoms include
rash develops. URI, cervical
Transmission of the lymphadenopathy,
disease is prevented and lethargy.
through standard
precautions and good
hand washing.
Rubeola: Measles Signs and Nursing care is Complications

(Viral) symptoms include supportive with include pneumonia,
the prodromal phase antipyretics, bedrest, otitis media,
lasting about 4–5 and increased fluids. mastoiditis,
days and a Ensure the room is encephalitis, and
moderate fever, dark if photophobia myocarditis.
cough, coryza, and occurs. Watch for Younger children,
conjunctivitis. complications and medically fragile
Causative Agent—
Koplik’s spots superinfections (otitis children, and children
Morbillivirus.
appear on the media and with underlying
Epidemiology—
buccal mucosa 2 pneumonia). immunosuppression
Occurs in outbreaks
days before the are at greater risk for
among unimmunized
onset of the rash complications.
populations.
(blue-white granules
Peak Incidence—
on erythematous
Peaks in winter and
base).
spring.
The rash stage
usually lasts about
—The mode of
3–4 days with a rise
transmission happens
in fever up to 105°F
through the
(40.5°C).
respiratory tract via
The rash first
droplets or direct
appears on forehead
contact with infectious
and behind the ears
secretions like blood
and then spreads to
or urine. This disease face, trunk, and
can also be upper and lower
transmitted via extremities.
fomites. After 4–7 days rash
Infection Control— begins to fade, and
The incubation period the temperature
is 8–12 days. begins to drop.
Airborne and contact Other common
precautions are symptoms can
recommended from 2 include anorexia,
days before onset of malaise, fatigue, and
symptoms until 5 generalized
days after lymphadenopathy.
appearance of the
rash (about 14 days
total).
Measles is a
reportable disease.
Scarlet Fever Signs and Nursing care Untreated strep

(Bacterial) symptoms include includes the infections may lead
acute onset with a administration of to retropharyngeal
fever, sore throat, antibiotics, as abscess, acute
rhinitis, headache, determined by the rheumatic fever,
and tender cervical health-care provider. acute
Causative Agent— nodes. Supportive nursing glomerulonephritis,
Group A beta- A sandpaper-like care is done for toxic shock
hemolytic streptococci rash appears 12–48 throat pain and fever. syndrome,
(GAS). hours after onset of bacteremia, and
Epidemiology—This symptoms. This rash necrotizing fasciitis.
disease is secondary is most prominent in
to a pharyngeal creases and
infection with GAS. blanches to touch.
Peak Incidence—This In 3–4 days, the
disease is seen most rash begins to fade,
frequently in late fall and the tips of toes
through spring. and fingers begin to
Mode of Transmission peel.
—This disease is On day 4 or 5 a
spread through direct bright red strawberry
contact with infectious tongue develops.
respiratory secretions.
is 2–5 days. Children
with untreated
infections remain
contagious for weeks
with the highest risk
of transmission during
the acute phase of
the illness.
Children should
remain home from
school until they have
been on antibiotics for
at least 24 hours and
remain afebrile.
Tetanus (Bacterial) Signs and Nursing care Complications

symptoms of includes the include potential for
Clostridium tetani administration of spasms in all muscle
produce a tetanus immune groups.
neurotoxin that globulin (TIG) Laryngospasm and
Causative Agent— affects the muscles to neutralize the respiratory muscle
Clostridium tetani. and nerves. neurotoxin. spasms may
Epidemiology—Rare Early signs are Antibiotics as compromise
in United States. headache and determined by the breathing and lead to
However, in other restlessness health-care provider death.
parts of the world followed by stiffness eliminate the bacillus
neonatal tetanus is of the neck and jaw. from the body.
still a significant risk. The stiffness then Surgical debridement
Mode of Transmission progresses to of the wound is done
—This disease occurs painful spasms of to control infection.
in humans through a the masticatory An antispasmodic
cut or deep puncture muscles agent such as
wound that comes in accompanied by diazepam (Valium) is
contact with soil difficulty opening the given to reduce
contaminated with the mouth and spasms.
Clostridium tetani dysphagia.
bacillus. Localized painful
Neonatal tetanus muscle spasm may
occurs in newborns begin to occur at the
delivered in site of the wound.
unsanitary conditions. This disease
Infection Control— eventually
The incubation period progresses up the
for tetanus is 2–14 trunk to the point of
days. opisthotonos (a
Prevention is severe spasm of
immunization and back muscles)
postexposure causing the back to
prophylaxis. arch.
As the neurotoxin
spreads widely
throughout the body,
seizures are
possible.
Signs and Symptoms

Although each infectious condition has unique signs and symptoms,
some symptoms are common in varying degrees among several
illnesses. These include:
■ Fever
■ Malaise
■ Anorexia
■ Pruritus (itching) from rashes
NURSING INSIGHT
Pathophysiology of a Fever
The hypothalamus is the thermostat of the body. As blood circulates through the
hypothalamus, it directs the various body organs to either conserve or dissipate the
heat depending on the blood’s temperature. If the body temperature is lower than
normal, vasoconstriction, or shivering, is initiated to conserve heat, and chills occur
to increase heat production. When a child has a fever (excess heat), the body’s
temperature, heart, and respiration rates increase. Vasodilation occurs, and the skin
becomes flushed and warm to the touch. When the fever “breaks,” the child may
start to perspire, and the heart and respiration rates return to normal.
Diagnosis
Diagnosis of an infectious disease is confirmed by type of infection, signs
and symptoms, and various diagnostic means.
Diagnostic Tools
Identification of an Infectious Disease
The following are a list of diagnostic tools used to diagnose infection:
• Lab studies to examine signs and symptoms of infection including:
- Complete blood count (CBC) with differential
- Urinalysis (UA) and urine culture: To assess for signs of infection in the urine
• Spinal fluid analysis: This may be used if the provider suspects a CNS infection
such as meningitis.
• Cultures from fluids, secretions, drainage (including blood, urine, sputum, nasal
fluids, and wounds): If a pediatric patient presents with signs of an infection and
has any wounds, incisions, drains, tubes, peripheral or central lines, these should
be cultured.
• Chest radiograph (CXR): If a child presents with signs of a respiratory infection or
nasal congestion/sputum production, consider culturing if they have a prolonged
infection that does not resolve after the initial treatment plan.
• Computerized tomography (CT): Should be performed to rule out respiratory
involvement. Used to examine for fluid collection, abscesses, or other signs of
infection.
Collaborative Care
NURSING CARE
Building on the scientific foundation of immunology, the nurse provides
specific care measures to promote immune function and to provide
education to families.
Simple nursing actions, such as good skin care and optimal nutrition,
help maintain the body’s natural immune response and barriers to
disease. The skin barrier is maintained by good hygiene measures such
as hand washing and caring for any breaks or openings on the skin
surface. Through good nutrition, the innate physical, chemical, and
mechanical barriers are preserved and the risk for infection is decreased.
Adequate nutrition also promotes prompt healing and decreases the
potential for skin breakdown. Maintaining barriers and the immune
response is particularly important in children whose immune systems are
not yet fully mature and for children who are at risk for
immunosuppression. Many children are more susceptible to disease in
their early years until they develop greater immunity.
Nursing care for the child with an infectious disease also centers on
accurate assessment, prevention of disease transmission, treating the
signs and symptoms, teaching families about universal precautions, and
preventing complications.
Assessment Tools
Key Components of Physical Assessment for the Child With an Infectious
Disease
VITAL SIGNS
• Temperature
• Heart rate
• Respiratory rate
• Blood pressure
• Pain
RESPIRATORY ASSESSMENT
• Upper respiratory infection symptoms
• Breath sounds
• Work of breathing
• Pulse oximeter reading
• Skin/mucous membrane color
• Secretions; color, character, amount
NEUROLOGICAL ASSESSMENT
• Febrile seizures
• Early identification of neurological complications
• Level of consciousness
GI ASSESSMENT
• Fluid intake
• Presence of vomiting or diarrhea
• Level of hydration
SKIN ASSESSMENT
• Presence of rash, pruritus, lesions
The nurse assists families in managing signs and symptoms. Fever is a

common early symptom of bacterial and viral infections but not of most
fungal infections. The nurse teaches parents about the use of
acetaminophen (Children’s Tylenol) or ibuprofen (Children’s Advil) to
treat fevers. Parents must be cautioned to follow the directions on the
medication label because there has been concern with overdosing
children on antipyretic agents. Cool, moist compresses to the head and
sponging or tepid baths can reduce the fever.
Malaise (weakness) tends to correlate with fevers, and providing a
quiet, restful environment during the acute phase of illness may assist
with this symptom. If the child is anorexic, offering small amounts of
fluids frequently helps keep the child hydrated. Sometimes a room-
temperature, lemon-lime soft drink or ice-pop will taste good and provide
relief to the child. Also, offering small amounts of favorite foods, soft
foods, or bland foods may help with the anorexia. If the anorexia
becomes worrisome to parents, the nurse can encourage them to contact
their health-care provider.
Pruritus is associated with many of the common infectious diseases
and can be a source of distress for the child and a potential site for
secondary infection because of skin breakdown. Parents may be advised
to keep the child’s fingernails short and place soft mittens on younger
children to prevent scratching. Oatmeal or Aveeno® baths may provide
some relief, as does Caladryl® lotion. Parents are advised to change bed
linens frequently and avoid use of harsh soaps during the time of illness
to avoid further irritation. Light clothing often helps keep perspiration and
heat rashes to a minimum. An oral antihistamine such as
diphenhydramine (Benadryl) may be useful in cases of severe pruritus.
MEDICAL CARE
Medical care for a patient with an infection will be specific for the actual
pathogen that is present. Once the pathogen is diagnosed, the physician
will order antibiotic therapy that is most appropriate for the patient and
the disease process. The physician will also prescribe appropriate
therapy to treat the symptoms associated with the disease process to
keep the patient as comfortable as possible.
The nurse educates families and day-care providers about standard
precautions. Emphasize hand washing, cleaning of toys and surfaces,
and proper disposal of diapers. The pediatric nurse also provides
education to families about the importance of excluding the child from
school and other activities during the illness. Sound knowledge about the
routes of transmission assists the nurse in developing a plan of care for
the hospitalized child that includes environmental precautions that
minimize the risk of transmission.
The administration of salicylates (aspirin) to children with acute viral
illnesses, especially influenza and varicella (chickenpox), is linked to
Reye’s syndrome. This syndrome causes increased intracranial pressure
and fat deposits in organs, causing children to become ill very quickly. It
is critical that nurses teach parents about Reye’s syndrome and provide
education regarding use of aspirin-free medications for control of fever in
children.
Complications
Although potential complications are specific to each illness, there are
general symptoms that are associated with many of the infectious
diseases. Children with infectious disease often are at risk for developing
a fluid deficit caused by a combination of anorexia, nausea, vomiting,
and sore throat. The nurse assists families in managing fluid deficit by
offering the child small amounts of liquids frequently and offering favorite
fluids to the child such as juice, soda, or water. Respiratory infections are
also common. A cool steamer, decongestants, or gentle nasal suctioning
with a bulb syringe may help diminish respiratory difficulty. Neurological
symptoms include general lethargy (sluggishness or tiredness) that may
progress to decreased responsiveness. Generalized irritability that
progresses to inconsolable crying, seizures, or meningeal symptoms,
including stiff neck and photophobia, may be present. Parents must be
instructed to call the health-care provider if these neurological symptoms
occur or the child is unresponsive.
VIRAL INFECTIONS
There are more than 400 types of viruses, which are the smallest
infectious agents currently known. When a virus enters a cell, it can
trigger a disease process immediately or remain dormant for many years.
The virus can enter any organ of the body by attaching to the cell
membrane and assembling the cells into a more mature form that can
affect other cells and take over cellular function. Viruses are responsible
for such diseases as fifth disease (erythema infectiosum),
cytomegalovirus (CMV), herpes simplex virus, herpes zoster, and
infectious mononucleosis.
Fifth Disease (Erythema Infectiosum)

This viral disease is common in childhood, caused by human parvovirus
B19. Most children do not get seriously ill with this virus, but children who
are immunocompromised may become very ill. Pregnant women who do
not have antibodies and acquire this disease from a child may
unfortunately lose their babies because of hydrops fetalis (fetal death).
Signs and Symptoms

Fifth disease is known as the “slapped cheek” virus because it begins
with a red rash on the face appearing as though the child’s cheeks were
slapped. The rash then spreads to the trunk and extremities, appearing
more as a macular (flat) lacy-appearing erythematous exanthema (rash).
Fever may occur and the rash, though usually gone in a week, can recur
with heat exposure for up to 4 months.
Diagnosis
Diagnosis is made through clinical appearance of the signs and
symptoms in most cases but can be accurately diagnosed with IgM
Parvovirus B19 antibodies in the serum within 30 days of rash onset.
Prevention
Avoid exposure to other children with fifth disease. Maintain good hand
washing techniques. Pregnant women must avoid all contact with fifth
disease as it can fatally injure the fetus.
Collaborative Care
NURSING CARE
Symptomatic relief, treatment of high fever, and warnings to keep
children away from pregnant women are the main nursing care
measures. The rash is not really uncomfortable. The nurse can help in
early identification of this disease because of its classic appearance. If a
pregnant woman has been exposed to this virus, she should see her
obstetrics provider immediately. Because the disease is spread by
droplet through coughing and sneezing, droplet precautions should be
instituted if a child is hospitalized. This usually implies the use of masks,
gloves, eyewear, and keeping the child in a single room.
MEDICAL CARE
Use of acetaminophen (Children’s Tylenol) or ibuprofen (Children’s
Advil) according to age-appropriate guidelines is useful for high fevers,
sore throat, and headache that may accompany this disease.
The nurse should instruct the patient and family to maintain safe hygiene
practices and use careful hand washing. The child should be kept away
from potentially pregnant females. The rash can last at least a week, and
it has been known to recur when the patient is exposed to heat. Do not
use aspirin-containing products for these children because of the risk of
Reye’s syndrome.
Cytomegalovirus Infections
Cytomegalovirus (CMV) is a member of the herpes family, which
attaches to host cells and causes disease. CMV is transmitted via close
contact with body fluids of an infected person. This virus may remain in a
latent form within the child’s body after the initial infection, and it can
reactivate, particularly with children who have immunodeficiency
situations, as occurs in HIV and organ transplantation. The disease is not
highly contagious, and transmission is easily prevented with good hand
washing. Congenital CMV is possible and is usually associated with
congenital defects such as vision or hearing damage. Children ages 1 to
3, teenagers, and pregnant women may have a high incidence of CMV
infection. Young children in day care are a reservoir for this disease.
Signs and Symptoms

Some babies born with CMV are asymptomatic, while others experience
hearing loss, a variety of neurological issues, and even intrauterine
growth restriction. Older children may experience symptoms similar to
infectious mononucleosis with fever, headache, rash, abdominal pain,
and even hepatitis. CMV can also cause pneumonia and self-limited GI
symptoms. Children with immune disorders can become seriously ill from
CMV, including fever and pneumonia. Retinitis, or inflammation of the
retina, can cause blindness in CMV infection associated with AIDS. CMV
hepatitis may also occur in transplanted livers.
Diagnosis
Urine, saliva, blood, and biopsy samples can be used for virus isolation
to make a diagnosis. CMV pneumonia is suggested by radiograph and
lung CT scan.
Prevention
CMV infection is a source of significant morbidity and mortality in
immunocompromised children. Good hand washing is the best
preventive measure. Disposable gloves should be worn when handling
linen or underclothes soiled with feces or urine. CMV-negative blood
should be provided to immunocompromised children.
Collaborative Care
NURSING CARE
The most common symptom after resolution of the acute phase of the
infection is fatigue, which may be present for as long as 18 months after
the primary infection. Because CMV can be transmitted by direct contact,
nursing care involves contact precautions and careful hand hygiene. The
nurse notes if the patient has any signs of immune deficiency, which
could have put them at risk of developing CMV infection. Inquire about
frequent sore throats, respiratory infections, enlarged lymph nodes, and
recurrent fevers, for example. The nurse should evaluate the patient for
potential need for acetaminophen or ibuprofen for symptom control. The
nurse should monitor the patient for vision changes, weight loss,
anorexia, nausea, vomiting, shortness of breath, chest tightness, fever,
and recurrent symptoms that can occur after the first signs of disease.
MEDICAL CARE
Ganciclovir (Cytovene), an antiviral agent, is primarily used in the
treatment of life-threatening CMV in the immunocompromised population
with CMV infection. Neutropenia, thrombocytopenia, and anemia are
possible adverse effects of this drug.
The nurse educates the patients and family members about the risks of
this disease and of the treatments. Teach the parent or caregiver to
handle diapers or underclothing carefully, with good hand washing to
prevent the spread of CMV. Universal precautions in acute and primary
care settings will help to decrease the risk of spread to other children and
women of childbearing age, where CMV infection can cause serious fetal
harm. Pregnant employees in day-care centers and hospital nurseries
should avoid caring for CMV patients. A patient with CMV will require
optometry evaluations of the optic fundus if they have HIV/AIDS.
MEDICATION: Ganciclovir
(Cytovene)
(gan-sye-kloe-vir)
Indications:
Treatment of CMV retinitis in immunocompromised children.
Prevention of CMV infection in transplant children at risk.
Actions: CMV converts ganciclovir to its active form inside the host cell, where it
inhibits viral DNA polymerase.
Therapeutic Effects: Antiviral effect directed against CMV-infected cells.
CONTRAINDICATED IN: Hypersensitivity to ganciclovir or acyclovir.
Seizures, headache, malaise, drowsiness, ataxia, GI bleeding, nausea, vomiting,
increased liver enzymes, neutropenia, thrombocytopenia, anemia, hypotension,
hypertension, and renal toxicity.
1. Pediatric dosing is not established.
2. Increased risk of bone marrow depression when used with antineoplastics or
zidovudine.
3. Assess child during treatment of signs of infection, bleeding, or development of
CMV retinitis.
4. Administer IV at slow rate, using in-line filter.
5. Advise child/family to notify health-care provider for any signs of bleeding.
_________
Source: Data from Vallerand, A. H., & Sanoski, C. A. (2021). Davis’s

drug guide for nurses (17th ed.). Philadelphia, PA: F.A. Davis.
Herpes Simplex Virus

The herpes simplex virus is extremely common, and it is estimated that
many people are infected with it during childhood. There are two types:
herpes simplex 1 and herpes simplex 2 (HSV-1 and HSV-2). Type 1 is
primarily associated with mouth, lip, and facial lesions. Type 2 is primarily
associated with genital lesions and neonatal cases through birth. The
types can be mixed, and each can be found in the other areas
mentioned. Type 1 infections are more commonly known as “fever
blisters” or “cold sores,” and frequently they recur in the nasolabial area
of the face with the presence of upper respiratory infections, fever, and
exposure to stress or sunlight. Type 2 lesions originate with sexual
activity. Herpes Type 1 is discussed here.
Signs and Symptoms

Small vesicles or erythematous form around the lips, base of nose, or in
the genital area, in most cases. They may have a prodrome of pruritus or
burning prior to developing, and most are painful when the vesicles
break. These vesicles crust over as they are healing.
Babies can have skin, eye, and mouth lesions. The progression of
disease in neonates is severe, causing risk for retinitis, encephalitis
(brain inflammation), and microcephaly (small brain). The herpes simplex
becomes disseminated (i.e., it invades the body).
Diagnosis
Diagnosis is obtained through culturing the fluid from the vesicles. It is
possible to type the HSV as either 1 or 2. Spinal fluid, Pap smears, and
Tzanck tests are other means to diagnose herpes simplex virus.
Prevention
Because herpes simplex is a contagious disease, observe careful hand
washing techniques and universal precautions. In acute care settings,
patients with herpes must not be exposed to immune-suppressed
patients because of the risk of disseminated herpes infections. The virus
can be transmitted by saliva and also by exposure to the mother’s
genitalia during childbirth. If a mother has a genital herpes outbreak
around the time of delivery, the baby may be delivered by C-section.
Collaborative Care
NURSING CARE
Careful hand washing and contact precautions (including avoiding
kissing and touching) are necessary because HSV lesions can be
infectious from saliva and from direct contact, especially with vesicular
fluid, onto mucosal surfaces, and through fissures in the skin. Teach
parents to use separate towels and glasses for these children. For
children with HSV-2, there may be concerns about inappropriate sexual
exposures.
For infants with neonatal disseminated HSV, the disease is very
serious and is fatal for half of all neonates with untreated HSV that
affects the central nervous system. Infants may suffer long-term
neurological sequelae (Blosser et al, 2020). Nurses should use gloves
when there are active herpes lesions in patients to avoid spreading
infection to themselves or other patients.
Nurses should report any facial lesions that are tracking up the child’s
face, cheek, or nose close to the eye, because herpes in the eye can
cause blindness if not treated immediately.
MEDICAL CARE
For children who have HSV-1 on the facial areas, the nurse may
administer topical prescription antiviral medications, such as acyclovir
(Zovirax) ointment or penciclovir (Denavir) ointment. These medications
are not curative, but they lessen the duration and pain of HSV-2 genital
lesions. Children, depending on their ages, may be also treated with IV,
topical, or oral antiviral agents, usually acyclovir (Zovirax). Famciclovir
(Famvir) and valacyclovir (Valtrex) are reserved for use in older
adolescents and adults for acute episodes. For disseminated newborn
infections, IV acyclovir (Zovirax) is the standard treatment, and long-term
use of this medication is under investigation (Blosser et al, 2020).
Remind parents and patients that herpes simplex is most often a
recurrent disease. While the first episode is generally the worst episode,
herpes simplex can recur. In some patients, there is never a recurrence,
but more commonly, the lesions will recur, and the frequency of
recurrence may be associated with the patient’s immune status and
degree of stress. Education includes avoidance of sharing toothbrushes
and lip cosmetics. Educate patients to avoid excessive sunlight because
it can cause recurrences of herpes labialis, and for those patients who
are sexually active, latex condoms should be recommended to prevent
genital transmission of herpes. It is not known if herpes can be spread
when there are no active skin lesions.
Herpes Zoster (Shingles)

The varicella-zoster virus (the same virus that causes varicella or
chickenpox) causes herpes zoster. This virus is seen in older children
and young adults. The first time the child is exposed to this virus, they
contract chickenpox. On a subsequent exposure, because of reactivation
of the virus, herpes zoster occurs.
Signs and Symptoms

Initial signs and symptoms include cutaneous vesicular lesions that
follow the nerve pattern on the face, trunk, and upper back area, usually
affecting only one side of the body. The lesions resemble herpes simplex
lesions, although they cluster in larger numbers normally and are more
painful. The classic presentation is considered “dew drops on a red
rose,” implying a clear fluid vesicle on top of an erythematous base.
There may be a prodrome of burning pain or pruritus before the lesions
appear. It is important to note that the child may experience pain from the
nerve involvement.
Diagnosis
Diagnosis of herpes zoster is based on patient history and physical
examination findings. It is important to obtain any history of having
chickenpox (varicella).
Prevention
Currently, the only prevention for herpes zoster is primary immunization
with varicella vaccine. Once a patient has had varicella illness, the
herpes virus remains dormant in nerve root endings and can resurface
as herpes zoster at any point in life. However, immunosuppressed
individuals, persons with other significant medical diseases, elders, and
persons under stress are the most common people who experience
herpes zoster.
Collaborative Care
NURSING CARE
Patients with disseminated herpes zoster infections may be
hospitalized. Otherwise, most patients can be taken care of in the home.
Nursing care includes measures to decrease the itching and pain. Cool
water compresses, cool baths, wet to dry Burrow’s solution dressings
three times a day, and calamine lotion can relieve the itching or burning
associated with herpes zoster. Acetaminophen (Children’s Tylenol) may
be given for pain. Do not administer aspirin products because of risk of
Reye’s syndrome. Acyclovir (Zovirax) is the treatment of choice for
children with herpes zoster. There are separate dosages for over and
under age 12, and acyclovir can be given by IV for fastest relief for
disseminated herpes. It may be given orally, dependent on age, for
recurrent episodes. The nurse must also observe the patients with
disseminated zoster for meningitis, encephalitis, deafness, and uveitis of
the eye.
MEDICAL CARE
Famciclovir (Famvir) or valacyclovir (Valtrex) are drugs administered to
inhibit viral DNA synthesis, thus limiting the disease symptoms and
duration, although no medications are curative. Acyclovir (Zovirax) is
most commonly used for children.
Postherpetic neuralgia is common during and subsequent to a herpes
zoster outbreak. It is neurological pain that can have a burning sensation.
Early use of antiviral medications such as acyclovir (Zovirax) will
decrease the chance of postherpetic neuralgia. If pain continues, the
patients need to report this to their health-care providers because there
are some medications that can improve neuralgia.
Patients with herpes zoster should stay away from anyone who has
not had varicella nor been immunized against varicella because there is
risk of causing varicella in those individuals. Recurrence of herpes zoster
necessitates a medical evaluation for underlying disease or immune
suppression.
Nurses should educate patients to avoid directly touching the lesions
or exposing another’s skin and mucous membranes to the lesions.
MEDICATION: ACYCLOVIR
(Zovirax)
(ay-sye-kloe-veer)
Indications:
PO: Recurrent genital herpes infections. Localized cutaneous herpes zoster
infections (shingles) and chickenpox (varicella).
IV: Severe initial episodes of genital herpes in nonimmunosuppressed patients.
Mucosal or cutaneous herpes simplex infections or herpes zoster infections
(shingles) in immunosuppressed patients. Herpes simplex encephalitis.
TOPICAL CREAM: Recurrent herpes labialis (cold sores). TOPICAL OINTMENT:
Treatment of limited non-life-threatening herpes simplex infections in
immunocompromised patients (systemic treatment is preferred).
Actions: Interferes with viral DNA synthesis.
Therapeutic Effects: Inhibition of viral replication, decreased viral shedding, and
reduced time for healing of lesions.
Avoid in hypersensitivity to acyclovir or valacyclovir. Use cautiously in preexisting,
serious, neurological, hepatic, pulmonary, and fluid and electrolyte abnormalities.
Renal impairment dose alteration if CCl less than 50 mL/minute.
Adverse Reactions/Side Effects:
CNS: seizures, dizziness, headache, hallucinations, trembling. GI: diarrhea, nausea,
vomiting, liver enzymes, hyperbilirubinemia, abdominal pain, anorexia. GU: renal
failure, crystalluria, hematuria, renal pain. Derm: Stevens-Johnson syndrome, acne,
hives, rash, unusual sweating. Endo: changes in menstrual cycle. Hemat: thrombotic
thrombocytopenic purpura/hemolytic uremic syndrome (high doses in
immunosuppressed patients). Local: pain, phlebitis, local irritation. MS: joint pain.
Misc: polydipsia.
1. Assess lesions before and daily during therapy.
2. Monitor neurological status in patients with herpes encephalitis.
3. Lab Test Considerations: Monitor BUN, serum creatinine, and CCr before and
during therapy. This may indicate renal failure.
_________
Source: Data from Vallerand, A. H., & Sanoski, C. A. (2021). Davis’s

drug guide for nurses (17th ed.). Philadelphia, PA F.A. Davis.
Infectious Mononucleosis
The Epstein-Barr virus is responsible for infectious mononucleosis, which
is communicable during the active phase of the illness (7–10 days).
Historically, infectious mononucleosis was first discovered as a disease
that was transmitted through kissing. Although it can occur at any age,
the disease is most commonly found in adolescents and young adults.
Signs and Symptoms

The cervical and often occipital lymph nodes become swollen, enlarged,
and tender. Other symptoms are tonsillitis or pharyngitis with significant
exudates, chills, fever (103.3°F [39.6°C]), headache, anorexia, and
malaise. Also, during the initial disease phase, the spleen may become
enlarged. Because rupture is possible, avoid palpating the spleen or
placing any pressure over the area. Mononucleosis hepatitis is also
possible in severe cases.
Diagnosis
The monospot test, or heterophile antibody test, was designed to detect
the disease. A positive test result confirms the disease. If necessary, a
blood test can be drawn to confirm the presence of Epstein-Barr virus.
Sometimes the monospot test does not turn positive early in the disease.
Therefore, it is useful to have a CBC and differential blood test because
atypical lymphocytes and sometimes an increase in monocytes are seen
on the differential cells early in the condition.
Prevention
Because mononucleosis is considered most communicable by saliva,
avoid kissing and close facial contact with patients with mononucleosis.
This virus can also be spread by coughing, sneezing, and sharing of
eating utensils. Adolescents who are not eating or sleeping properly,
particularly in the late high school and college years, seem to have
increased risk of infectious mononucleosis related to high stress and
lowered immunity.
Nursing Care
Children can experience general fatigue or weakness for up to 6 weeks
after the acute phase. Therefore, they must continue to include rest
periods and sufficient fluids during their normal daily routine. The nurse
communicates to the caregivers that sharing drinking cups with family
members and peers is not advisable, nor is close contact such as
kissing. Children and adolescents are typically removed from contact
sports that could injure the liver or spleen for as long as the disease is
active. Bedrest, maintaining hydration, decreasing fever, and isolation
are required during the acute phase of the illness.
The nurse should educate the patient and family about the necessity of
avoiding contact sports and roughhousing because of risk of rupture of
the spleen. Patients with infectious mononucleosis are often eager to
return to activities before their bodies are sufficiently healed, and it is
possible to relapse with worsening symptoms. Use of acetaminophen
should be avoided because of the greater risk of hepatotoxicity when the
liver is enlarged. Alcohol should be avoided because of the risk of
hepatomegaly.
FUNGAL INFECTIONS
Any disease introduced by a fungus is called a mycosis. Fungi are either
unicellular (yeasts) or multicellular (molds) and larger than bacteria.
Fungal diseases are categorized according to the body tissue they infect.
Most infections in children are superficial subcutaneous infections of the
skin, hair, nails, or mucous membranes associated with either
overgrowth of fungi normally present or introduced through breaks in the
skin. Superficial findings include slight itching, red or gray patches,
dryness, and brittle hair. Transmission is by the inhalation of spores.
Candida Albicans (Oral Thrush)

Most infants have natural yeast in their mouths called Candida albicans.
Because of the immature immune system in infants, the yeast in their
mouths can overgrow and cause an infection called oral thrush. This
fungal infection is quite common but can be exacerbated by steroid
inhalers or antibiotics. HIV patients are also at greater risk for thrush.
Signs and Symptoms

The main symptom is white plaques on the surface of the tongue and the
buccal (cheek) membranes.
Diagnosis
C albicans is diagnosed via a microscopic examination of the plaques
(Venes, 2021).
Prevention
The nurse educates parents about the prevention of oral thrush. If the
infant is bottle-fed, oral thrush can be prevented by thoroughly cleaning
the bottle nipples in hot water. If the infant is breastfed and the mother’s
nipples are sore and reddened, the nurse can encourage the mother to
contact the health-care provider about possible use of an antifungal
ointment on the nipples while the infant is also treated with nystatin
(Mycostatin). Pacifiers are thoroughly cleaned in hot water.
Collaborative Care
NURSING CARE
This fungal infection is painful, and the child may not eat well.
Maintaining nutrition is a priority nursing care measure for the child.
Small, frequent feedings and soft and bland foods during the infection for
the older child may help ensure good nutrition. A soft toothbrush or
gauze pad can be used to clean the mouth.
In babies with thrush, the baby’s mouth should be rinsed out with water
from a medicine cup after feedings. The baby’s hands should be washed
frequently with soap and water. Pacifiers and teething rings should be
boiled for 5 to 7 minutes after each use during the course of infection.
Toys that a child may chew on should be washed in hot, soapy water.
Candidal diaper rash may occur if a baby has thrush because both are
candidal overgrowths. If a baby is breastfeeding, the mother’s nipples will
need to be washed carefully, and if there are any cracks in the skin, there
is risk of passing the candidal infection to the mother, especially into the
breast ducts. Mothers with nipple thrush may need to be treated
simultaneously with their infected babies.
Nurses need to administer the candidal medication with a dropper for
infants and with instructions to swish and swallow the medications for
older children.
MEDICAL CARE
Nystatin (Mycostatin) is the medication that effectively treats thrush. It
is administered with a gloved finger using a swab placed on the buccal
membranes. The medication must be administered after feedings so it
will remain in contact with the fungi rather than being washed away
immediately during the feeding. Older children may be treated with
troches (lozenges that dissolve by sucking on them), pastilles, or
suspensions. Adolescents may be treated with fluconazole (Diflucan)
orally for 7 to 14 days, depending on the severity.
The nurse is aware that candidiasis can be a generalized infection,
especially in newborns, causing a bright red diaper rash. It must be
treated immediately to prevent it from becoming systemic. Parents are
taught that changing diapers frequently, exposing the area to air, and
applying nystatin (Mycostatin) ointment is important.
Fungal Infections
Tinea Capitis
Tinea capitis (Table 18-4) is also known as ringworm for its distinctive
round shape and capacity to spread on the skin, with central clearing of
the rash. This type of fungal infection is common and is known as a
dermatophyte. Tinea grow on the scalp (tinea capitis), hands (tinea
manuum), feet (tinea pedis), groin (tinea cruris), and skin (tinea corporis).
Children are most prone to tinea capitis. Tinea capitis can cause
alopecia (localized balding) because of loss of hair. Medical
management in children includes a topical over-the-counter antifungal
agent. Difficult cases are eradicated with oral medications such as
griseofulvin (Fulvicin).
Histoplasmosis
This fungal infection can occur when mold spores are inhaled and
converted to yeast in the lungs. High-risk areas of mold include cleaning
or excavating in old homes or schools, cutting firewood, gardening, and
exploring barns and caves. Signs and symptoms include weight loss,
fever, fatigue, dry cough and substernal chest pain, acute respiratory
distress syndrome, meningitis in infants, pericarditis, and arthritis
symptoms. Medical management for histoplasmosis includes
amphotericin B (Amphocin), and a pediatric infectious disease health-
care practitioner needs to monitor these children for complications.
Coccidioidomycosis
This fungal infection can occur from inhaling spore-forming molds into
the lungs from the soil. It is common, especially in the southwestern U.S.
states, and it is asymptomatic or self-limiting without treatment in most
patients. Signs and symptoms include fever, malaise, respiratory
distress, rash of erythema nodosum or erythema multiforme, weight loss,
arthralgia, headache, and confusion. If needed, medical management is
done with azole-type antifungal medications such as itraconazole
(Sporanox).
TABLE 18-4
Fungal Infections
FUNGAL LOCATION TREATMENT PARENT
INFECTION INFORMATION
Tinea Capitis Fungal infection that Oral griseofulvin Adolescents are
(Ringworm) begins as an infection of (Fulvicin) is taken warned not to use
a single hair follicle but with fatty food to alcohol because of
spreads rapidly in a increase absorption. tachycardia.
circular pattern and Selenium or Children do not need
produces a 1-inch- ketoconazole to be kept home from
diameter lesion. The shampoo is used to school.
circular pattern becomes prevent transmission Family members
filled with dirty-appearing in the household. must not share
scales, and the hairs CBC, liver function towels or combs.
involved break off. tests (LFTs), and Linens and clothing
Alopecia (hair loss) can BUN/creatinine must should be laundered
occur in patches, and be monitored when in hot water to
pustular lesions (kerions) the child is taking decrease spread
can also occur. This griseofulvin among family
infection goes from the (Fulvicin). members.
noninflammatory to the Hair regrowth takes
inflammatory stage over up to 12 months.
an 8-week period.
Tinea Pedis Fungal infection with skin Liquid preparations Antiseptic foot baths.
(Athlete’s Foot) lesions located between of clotrimazole Wear cotton socks.
the toes and on the (Lotrimin) are used. Change shoes
plantar surface of the tolnaftate (Tinactin) periodically.
foot. This condition may miconazole (Micatin) Use antifungal
begin as fine scale and powders or spray in
may macerate and shoes.
become superinfected. It Do not let others
is intensely pruritic. share personal items
such as footwear,
towels, clothes, or
sports equipment.
Wear sandals or
swim shoes in public
showers and
stockings or shoes in
locker rooms.
Tinea Cruris Fungal infection found on Cream, liquid, or Shower or bathe

(Jock Itch) the inner aspects of powder preparations frequently.
thighs, groin, and of clotrimazole Dry scrotal area
scrotum; pink, pruritic (Lotrimin) are used. thoroughly when
rash with fine scale and tolnaftate (Tinactin) damp.
sharp margins. miconazole (Micatin) Wear cotton
More common in underwear.
adolescent males, obese Do not let others
individuals, or with share personal items
chafing. such as footwear,
towels, clothes, or
sports equipment.
Tinea Corporis Fungal infection of the Topical clotrimazole Do not let others
(Epidermal epidermal layer of the (Lotrimin) share personal items
layer of the skin that has a circular such as footwear,
skin) lesion with a clear center towels, clothes, or
and scaly inflammation. sports equipment.
Source: Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2020).
Pediatric primary care (6th ed.). Philadelphia, PA: Elsevier.
Pneumocystis Jiroveci Pneumonia

This fungus typically causes pneumonia. There is a risk of this condition
in pediatric patients who are HIV and among other immunocompromised
children. Signs and symptoms include nonproductive cough, weight loss,
fever, chills, dyspnea, respiratory failure, tachypnea, and crackles and
rhonchi in lungs. Prophylaxis is commonly managed with TMP-SMZ
(Bactrim or Septra). Other agents used for severe cases include
parenteral pentamidine (Nebupent), atovaquone (Mepron), dapsone
(Dapsone), and clindamycin (Cleocin) plus primaquine (Phosphate
Tablets). Sometimes short courses of steroid therapy are used.
Immunocompromised patients who do not have HIV should also receive
prophylaxis.
BACTERIAL INFECTIONS
Common bacteria cause disease in the pediatric population.
Streptococcus pneumoniae, or pneumococcus, is an alpha-hemolytic,
aerotolerant anaerobic member of the genus Streptococcus.
Spneumoniae is a major cause of pneumonia and also responsible for
pediatric otitis media and sinusitis. Haemophilus influenza is a gram-
negative, coccobacilli bacterium and responsible for numerous cases of
pediatric otitis media as well as sinusitis. Moraxella catarrhal is of the
species catarrhalis in the genus Moraxella and also a cause of pediatric
otitis media and sinusitis. The group A P-hemolytic streptococcus
(Streptococcus pyogenes, or GAS) is a form of P-hemolytic
streptococcus bacteria. It is a gram-positive bacterium responsible for the
classic “strep throat.” It is also seen in a variety of other pediatric
disorders. This bacterium is also responsible for rheumatic fever and
rheumatic heart disease. Neisseria meningitidis, often referred to as
meningococcus, is a serious pathogen in the development of bacterial
meningitis, which is sometimes fatal. Sequelae of meningitis include
neurological issues and hearing deficits. Children and adolescents with
meningitis typically have high fever, extremely stiff neck (nuchal rigidity),
vomiting, and headache, with the later development of a rash that is
stellate, resembling stars. Rapid treatment for meningitis is required.
Bacterial meningitis must be differentiated from viral meningitis, which is
usually not as severe.
MEDICATION: Amoxicillin (used for

several types of childhood bacterial
infections) Amoxil, DisperMox, Moxatag
(a-mox-i-sill-in)
Indications: Treatment of skin and skin structure infections, otitis media, sinusitis,
respiratory infections, and genitourinary infections. Endocarditis prophylaxis.
Postexposure inhalational anthrax prophylaxis.
Actions: Binds to bacterial cell wall, causing cell death.
Therapeutic Effects: Binds to bacterial cell wall, causing cell death. Therapeutic
effects: Bactericidal action; spectrum is broader than penicillins. Spectrum: Active
against: Streptococci, pneumococci, enterococci, Haemophilus influenzae,
Escherichia coli, Proteus mirabilis, Neisseria meningitides, N gonorrhoeae, shigella,
Chlamydia trachomatis, salmonella, Borrelia burgdorferi, and H pylori Helicobacter.
CONTRAINDICATED IN: Hypersensitivity to penicillins (cross-sensitivity exists to
cephalosporins and other beta-lactams); tablets for oral suspension (DisperMox)
contain aspartame; avoid in patients with phenylketonuria.
Use cautiously in: severe renal insufficiency (pdose if CCr >30 mL/min); infectious
mononucleosis, acute lymphocytic leukemia, or CMV infection (risk of rash); OB,
Lactation: Has been used safely.
Adverse Reactions and Side Effects: CNS: SEIZURES (high doses). GI:
pseudomembranous colitis, diarrhea, nausea, vomiting, liver enzymes. Derm: rash,
urticaria. Hemat: blood dyscrasias. Misc: liver reactions including anaphylaxis, serum
sickness, superinfection.
Interactions: Drug-Drug: Probenecid: renal excretion and blood levels of amoxicillin
—therapy may be combined for this purpose. May alter effect of warfarin. May alter
effectiveness of oral contraceptives. Allopurinol may increase the frequency of rash.
1. Instruct patients to take medication around the clock and to finish the drug
completely as directed, even if feeling better. Advise patients that sharing of this
medication may be dangerous.
2. Pedi: Teach parents or caregivers to calculate and measure doses accurately.
Reinforce importance of using measuring device supplied by pharmacy or with
product, not household items.
3. Review use and preparation of tablets for oral suspension (DisperMox).
4. Advise patient to report the signs of superinfection (furry overgrowth on the
tongue, vaginal itching or discharge, loose or foul-smelling stools) and allergy.
5. Instruct patient to notify health-care professional immediately if diarrhea,
abdominal cramping, fever, or bloody stools occur and not to treat with
antidiarrheals without consulting health-care professionals.
_________
ANIMAL-BORNE INFECTIOUS DISEASES

Animals serve as a reservoir for certain infectious diseases, including
rabies, West Nile virus, and avian influenza. Nurses participate in
prevention of these diseases through education for families about
strategies that minimize exposure to infected animals, mosquitoes, and
infected birds.
Rabies
Rabies is an acute viral infection of the nervous system caused by
Rhabdoviridae Lyssavirus. The primary agent for this virus is carnivorous
wild animals. Transmission of this disease occurs through direct contact
with the brain tissue or saliva from infected animals. The typical
incubation period for rabies is 3 to 8 weeks but may extend for several
months. Transmission is primarily through saliva from a bite from the
infected animal, although contamination of mucous membranes,
including the eyes, mouth, and nose, and aerosol transmission have
occurred. When a potentially risky animal bite occurs, the animal is
captured, if possible, and tested for rabies while isolated. Death may
occur within days of the onset of symptoms of rabies. Treatment must be
initiated as soon as possible after exposure and before the onset of
symptoms.
Signs and Symptoms

Signs and symptoms are related to the infection of the central nervous
system, which causes fulminant brain disease and death.
Early symptoms include:
■ Nonspecific conditions, such as headache, fever, and general
weakness
Later symptoms include:
■ Anxiety
■ Insomnia
■ Confusion
■ Paralysis
■ Hallucinations
■ Agitation
■ Hypersalivation
■ Difficulty swallowing (CDC, 2020)
The respiratory tract is then affected, leading to spasms that cause
severe impairment of respiratory function, including respiratory arrest.
Diagnosis
Diagnostic tests are performed on samples of saliva, serum, spinal fluid,
and skin biopsies of hair follicles at the nape of the neck for rabies
antigen. Human saliva can also be tested for the virus by PCR, and
serum and spinal fluid may be tested for antibodies to rabies virus (CDC,
2020).
Prevention
Rabies prevention is twofold; all domestic animals that can receive rabies
vaccinations should receive them at the appropriate ages and intervals.
All people, particularly children, should be taught to stay away from wild
animals that may carry rabies. Reporting of unusual animal behaviors,
including mouth frothing, unprovoked attacks, and being around in
daylight if normally nocturnal, should occur. The local animal control
officer can be contacted to check any suspicious animal sightings. If an
animal has bitten a child or adult, the animal is usually destroyed, or if
caught, quarantined and checked for rabies signs. Some animals are
sacrificed to detect the presence of rabies.
Collaborative Care
NURSING CARE
The nurse cleanses the wound and administers human rabies immune
globulin (HRIG) and the rabies vaccine series. The nurse must instruct
the patient and family regarding follow-up and provide support to the
family as needed.
MEDICAL CARE
Exposure treatment for rabies includes wound cleansing with a
virucidal agent, administration of HRIG, and administration of a rabies
vaccine series. The rabies postexposure vaccinations consist of 4 doses
of rabies vaccine given on the day of the exposure. These vaccines are
then administered again on days 3, 7, and 14. These vaccines are highly
effective if given rapidly after exposure to rabies (CDC, 2020).
FOCUS ON SAFETY
Postexposure Treatment for Rabies
Because of the traumatic nature of treatment postexposure, seriousness of rabies,
and poor prognosis, exercising caution with unknown animals is essential. Most
exposures to rabies occur through bites of wild animals, which allow contaminated
saliva to enter the bite wound. If an animal has injured a child, parents must contact
the health-care provider immediately.
Cat Scratch Disease

This infection is common in the pediatric age group where children are
playing with and holding kittens or cats. The bacterium Bartonella
henselae is the source of infection through a cat scratch or bite in which
cat saliva penetrates the human skin.
Signs and Symptoms
Within 3 to 10 days, a papule or vesicle (blister) develops at the site,
followed by regional lymphadenopathy (lymph node enlargement), which
can last for months. Because many children are scratched or bitten in the
hands and forearms, the most common nodes involved are the
epitrochlear nodes (near elbow) and axillary nodes (under arms), which
drain the hands and arms but also the neck or groin. Sometimes only
one node is inflamed. The child may have a fever.
Diagnosis
Diagnosis is based on signs and symptoms and sometimes diagnostic
testing with lymph node biopsy. Laboratory testing can be done in
suspected cases of cat scratch disease. The tests include an enzyme-
linked immunosorbent assay to detect serum antibodies. This test is not
always accurate, and it can take at least 2 weeks and up to 8 weeks to
develop a positive titer.
Prevention
Children are taught to avoid rough play with cats, and any scratches or
bites should be cleansed with antiseptic solutions immediately. There is
some evidence that flea-infested cats are at higher risk for transmitted
cat scratch disease, so flea prevention should be instituted.
Collaborative Care
NURSING CARE
The nurse treats the wounds and assesses the lymph nodes. Because
there are more serious sequelae possible, including hepatosplenomegaly
(liver and spleen enlargement) and encephalopathy, the nurse must
observe the patient carefully for fever, headache, neck stiffness, and
abdominal pain especially. It is important to note that
immunocompromised patients may become much more ill with this
disorder.
MEDICAL CARE
Antibiotics such as azithromycin (Zithromax) and erythromycin may be
ordered to decrease the risk of a bacterial infection. Additional
medications that can be used for older children include doxycycline, and
for those over age 18, quinolones such as Cipro can be used.
Education/Discharge Instruction
Nurses can teach patients and families about proper administration of
medication and about preventive care to avoid another episode of cat
scratch disease.
West Nile Virus

West Nile virus causes an infection that is spread by mosquitoes that
become infected when they bite infected birds. Standing, stagnant water
is a risk factor for the breeding of these mosquitoes. The incubation
period for West Nile virus is 2 to 14 days, and the risk is highest to
immunosuppressed children and adults. In rare cases, the virus can lead
to encephalitis, meningitis, myocarditis, and hepatitis.
Signs and Symptoms

Nonspecific symptoms can be mild, including:
■ Fever
■ Weakness
■ Headache
■ Myalgia
■ Anorexia
■ Nausea
■ Vomiting
Diagnosis
Diagnosis of West Nile virus is confirmed by specific IgM antibody in
serum or in cerebrospinal fluid. Serial cultures are needed to watch
changes during acute and convalescent samples.
Prevention
West Nile virus is most associated with mosquito-borne illness, so during
the seasons (often late summer and early autumn) when it is most risky,
children may not be allowed outdoors for recess or for after-school
activities. It is also advisable for parents not to keep any sources of free-
standing water in their yards because they are breeding grounds for
mosquitoes.
Collaborative Care
NURSING CARE
Nurses must educate people on the risks of West Nile virus, preventive
care, and observation for worsening symptoms (Burns et al, 2020).
MEDICAL CARE
Treatment is supportive based on the signs and symptoms. Most
patients who are infected with West Nile virus recover without incident.
Less commonly, nearly 1 in 150 people infected with West Nile virus may
develop severe symptoms including headache, high fever, neck stiffness,
disorientation, tremor, seizures, muscle weakness, paralysis, numbness,
vision loss, and coma. These severe symptoms may last several weeks
and require hospitalization, IV fluids, and respiratory and neurological
support (CDC, 2020). Severe sequelae include meningitis and
encephalitis, with the risk of permanent neurological defects. Infants born
from women who were infected during pregnancy need to be evaluated
for congenital defects.
Responding to parental concerns, nurses can help them plan strategies
for minimizing exposure to mosquito bites. Of particular concern is also
minimizing possible side effects related to systemic absorption of insect
repellents. Although diethyltoluamide (DEET)-containing insect repellents
are most effective as preventative agents, they can be neurotoxic; there
are numerous organic and nontoxic natural insect repellents available
that some parents prefer to use for children. Advise parents to keep their
children dressed with long-sleeved shirts and pants during the peak
season; mosquito nets can also be used for baby carriers.
Patient Education
Use of Insect Repellents
Concerned about exposure to insect bites and the possibility of infectious disease
transmitted through this route, parents at times apply insect repellents such as
DEET directly on their children. “Insect repellents containing DEET (N, N-diethyl-m-
toluamide, also known as N, N-diethyl-3-methylbenzamide) with a concentration of
10% appear to be as safe as products with a concentration of 30% when used
according to the directions on the product labels.” The AAP recommends that
repellents with DEET not be used on infants younger than 2 months old. The nurse
provides education about the application of insect repellents. The insect repellent
must be applied to the child’s clothing. Applying the insect repellent to the clothing
decreases the chance of systemic absorption (through the skin) of a potentially
harmful substance. DEET has been known to cause neurotoxicity, especially in
children, if absorbed through the skin. There are organic and safer insect repellents
available, but none have the efficacy of DEET.
Influenza Pandemics
Influenza pandemics are recurring events. In the past century, influenza
pandemics occurred in 1918, 1957, and 1968. Humans can become sick
when infected with viruses from animal sources, such as avian influenza
virus (subtypes H5N1 and H9N2) and swine influenza virus (subtypes
H1N1 and H3N2). The avian influenza, known commonly as bird flu,
refers to an influenza virus that occurs naturally in birds worldwide.
Although occurring chiefly in infected poultry, certain subtypes of the
virus may mutate and transfer to humans. Because this strain of virus
has not been previously circulated in the human population, the potential
for an influenza pandemic is present. More than 600 cases of avian flu
have been identified since 2003, notably in Asia, Europe, the Near East,
and Africa. This flu can be highly fatal, but it is thought to be very rarely
transmitted from human to human (CDC, 2020). The swine flu has been
previously rare in human beings but presents similarly to typical flu. It is
most often seen in people who work with pigs, and notable risks for
children include petting zoos, fairs, and raising pigs for show or clubs
(CDC, 2020). Because of a genetic mutation going from swine to people,
this disease developed rapidly in 2009 and is also called “variant flu.” In
2009, a variety of swine flu, known as H1N1, became a worldwide
pandemic. In the 2012 to 2013 influenza reporting time, even though
H1N1 is now included in the routine flu vaccination, 138 children died of
flu (all types) (CDC, 2020). Severe pneumonia and acute respiratory
distress are also possible.
Avian Influenza: Diagnosis
Diagnosis includes “a viral swab from the throat or nose of the ill person
early in the disease. This swab is sent out to a lab for culture or
molecular testing. Also, lower respiratory tract specimens can be
analyzed for critically ill patients. Serum tests for antibody levels done at
two different times may suggest avian flu” (CDC, 2020).
Swine Influenza (HINI Variant): Diagnosis

Rapid flu tests are available, but sometimes the results are not accurate.
A flu swab should be taken from a nasopharyngeal test. Accuracy
depends on the test quality, the sample collection method, and how
much virus the person may be shedding at the time of the test.
Sometimes diagnosis is made solely based on clinical symptoms,
especially during the time of flu epidemics.
Prevention of Pandemic Flu

A campaign to prevent pandemic flu involves careful hand washing, use
of alcohol-based hand sanitizers, and covering the mouth when coughing
or sneezing. Strong immunization campaigns to vaccinate all people
eligible for vaccination are the most important aspect of prevention.
Public education, often involving nurses, is essential in dispelling myths
about flu vaccination and educating the public on how to prevent flu.
Testing for flu is an important part of understanding and tracking the
epidemiology of influenza. Continued research is needed to find more
effective influenza vaccines.
Collaborative Care
NURSING CARE
Nurses should not administer aspirin to any patients with influenza,
especially those younger than age 21, because of the risk of Reye’s
syndrome. Acetaminophen is generally safe to use for fever control,
headache, and arthralgias associated with influenza. Encourage intake of
liquids and foods as tolerated. Warm liquids may be soothing for sore
throats. Children with influenza should not be in day care or school until
they are fully over the disease to prevent contagiousness.
Nurses must observe for risk of serious sequelae, especially in
children. These include neurological and respiratory issues because of
the potential for rapid decline and death in children.
MEDICAL CARE
Treatment of flu includes supportive and symptomatic care, including
aggressive treatment of complications such as pneumonia. Two influenza
medications may also be used: oseltamivir (Tamiflu) and zanamivir
(Relenza). These neuraminidase inhibitors are active against both
influenza A and B types.
Educate the public about the risks of influenza, no matter which type.
Also, nurses can inform the public about the highest risk populations,
who should definitely be vaccinated against influenza each year or
monitored carefully if they have contraindications to the vaccine:
■ Children younger than 5, but especially younger than 2 years of age
■ Pregnant women
■ Adults over 65
■ American Indians and Alaskan natives
■ Children and adults with chronic medical conditions such as asthma,
chronic lung disease, neurological disorders, sickle cell anemia and
other blood disorders, renal and hepatic disorders, metabolic diseases,
cardiac diseases, and immune-deficient disorders
■ Children and teens younger than 19 years of age on long-term aspirin
therapy (because of Reye’s syndrome)
■ People on long-term steroid therapy (CDC, 2020)
Provide medication instructions:
■ Zanamivir (Relenza) is approved for use in patients age 5 and older.
■ Oseltamivir (Tamiflu) is approved for patients age 2 weeks and older.
■ Older influenza medications, amantadine and rimantadine, are not
considered highly effective and may not cover H1N1 flu variants.
■ Oseltamivir (Tamiflu) and zanamivir (Relenza) are indicated for use if
the virus has been active for less than 48 hours. They will not cure the
flu, but they may lessen its severity by slowing the spread of the virus.
These medications may also be used preventively for people over age
1 and who have been exposed to the flu.
■ Oseltamivir (Tamiflu) is given in suspension or capsule forms, usually
twice a day for 5 days. Common side effects include nausea, vomiting,
GI upset, and diarrhea.
■ Zanamivir (Relenza) is given in an inhaled form within 48 hours of flu
symptom onset, especially from age 7 and up. It also can be used
preventively for patients age 5 and older if exposed to flu. It is inhaled
twice a day for 5 days. For prevention, it is inhaled once daily for 10
days. Patients with asthma and other respiratory conditions usually
have a contraindication to the use of Relenza.
IMMUNIZATIONS
There is a direct correlation between infant immunization rates and the
rates of diseases that have become preventable by immunization.
Diseases such as polio and smallpox have been essentially eradicated in
the United States. Although polio immunization is still given, smallpox
immunization is no longer required. In other parts of the developing
world, however, some of these diseases are still present. The
cornerstone of infectious disease prevention in pediatrics is an
immunization program in which the child receives the necessary
vaccines. Vaccines are produced by using weakened or killed microbes,
inactivated toxins, or subunits of disease-causing microbes. The goal of
an immunization program is to bring about active immunity to guard
against the onset of a specific antigen. The immune system response
occurs through an exposure to a naturally occurring antigen or artificially
through a vaccine-mediated exposure.
Patient Education
Preparing for an Influenza Pandemic
HOW TO: Actions taken by individuals and communities help to decrease the effect
of an influenza pandemic. Nurses can work with families to provide them the
information needed to prepare adequately. ESSENTIAL INFORMATION: When
working with families, the nurse can:
1. Discuss the differences between seasonal flu and pandemic flu.
2. Describe actions being taken by the health-care community to monitor and
prepare for the pandemic and encourage families to take an active role.
3. Assist families to establish their own plan for care in the event of a pandemic
including:
- Store a 2-week supply of food and water for the family.
- Maintain a supply of needed medications.
- Maintain a supply of over-the-counter medications needed to treat symptoms of
flu.
- Establish a plan for family members living alone.
4. Encourage families to become involved with community groups to help prepare
and plan for the pandemic.
5. Reinforce basic infection control techniques to limit spread of influenza.
6. Provide families with links to CDC resources with preparation checklists.
Encourage them to use the checklists to assist in preparation.
An understanding about the different types of vaccines can assist the

nurse in planning care that maximizes the effectiveness of immunization
and anticipates possible complications that can occur. Traditional
vaccines include inactivated vaccines, live attenuated vaccines
(weakened), and toxoids. Inactivated vaccines are produced when the
disease-causing microbe is killed but is still capable of inducing the
human body to produce antibodies (e.g., inactivated poliovirus vaccine).
They are very safe and require little special handling. These types of
vaccines stimulate a relatively weak immune response. For this reason,
repeated boosters are required.
The live virus (attenuated) vaccine is made by using a disease-causing
organism that is not killed but is grown under special conditions designed
to decrease virulence (e.g., measles vaccine). Vaccines made with live
organisms require special care, such as refrigeration. Live vaccines have
the potential for mutation, allowing the organism to revert to a more
virulent form. Because of the increased risk of mutation, live vaccines are
not recommended for children (or adults who have close proximity to the
child) with compromised immune systems.
A toxoid vaccine is used in an inactivated form and is effective in
producing an immune response geared toward a toxin-producing
organism. The toxoid has been treated with either heat or a chemical to
weaken its toxic effect but retains its antigenicity (e.g., tetanus toxoid).
More recent vaccine development has produced subunit vaccines,
polysaccharide vaccines, conjugate vaccines, and recombinant vaccines.
Subunit vaccines use only a portion of the virus or bacterium to produce
the desired immunological response without the undesirable effects that
occur with some of the other surface antigens (e.g., Bordetella pertussis
vaccine included in the acellular DPT). The subunit vaccine produces
immunity to B pertussis with less risk so it may be more safely given to
infants and young children. Some bacteria possess a polysaccharide
outer capsule that protects them from recognition and phagocytosis by
the immune system. Organisms with this coating include Haemophilus
influenzae type b (Hib), Streptococcus pneumoniae, and Neisseria
meningitides, each of which may produce a very serious case of
pneumonia or meningitis in infants or young children.
Polysaccharide vaccines (Pneumovax), made from portions of the
polysaccharides making up the protective capsule of these organisms,
have long been available and are effective in producing immunity in
children older than 2 years of age. At exposure, the polysaccharide
capsule does not elicit a T-cell response; the duration of immunity is
variable and not lifelong. In addition, these antigenic components are not
recognized by the immune systems of children younger than 2, who are
at highest risk for serious pulmonary or neurological infection resulting
from these bacteria.
The development of conjugate vaccines has provided an option for
protecting infants and young children. The conjugate vaccine links a
recognizable antigen with the “hidden” bacterial antigen, thereby
enabling the immature immune system to identify the bacteria as non-self
and respond. In this way, the infant’s T cells may identify the otherwise
unrecognizable antigen, providing both an improved primary response
and conferring immunological memory. An example of a conjugate
vaccine used in children younger than 2 years of age is the Hib vaccine.
Before the advent of this vaccination, pediatric meningitis resulting from
Hib infection was a common cause of morbidity in infants.
Production of the recombinant vaccine uses genetic engineering to
insert the genes for production of the antigens desired into a low-virulent
vector. The vector then can be used to easily produce quantities of the
antigen for further purification into a subunit vaccine. The only
recombinant vaccine currently used is hepatitis B virus (HBV). The HBV
surface antigen is injected into yeast cells that produce quantities of the
antigen for use in vaccination against hepatitis B.
Nursing Care
Prevention is key to preventing infectious diseases through
immunizations. The Advisory Committee on Immunization Practices
develops and revises the immunization guidelines each year. There are
four primary health-care provider immunization schedules:
■ Ages birth to 6 years
■ Ages 7 to 18 years
■ Combined ages birth to 18 years
■ Catch-up schedule ages 4 months to 18 years
Specific immunization schedules are updated every year and can be
found on the CDC website.
The primary nursing goal related to vaccinations for children is to
ensure up-to-date immunizations for all children based on their health
status. The pediatric nurse has several roles in the area of immunization,
including addressing family concerns about vaccines. The nurse also
plays a key role in organizing and carrying out vaccination programs and
distributing accurate and timely information regarding childhood
immunizations. The nurse reminds parents when the next immunizations
are due. In addition, the nurse must use the current immunization
schedule and recognize that the complicated schedule may pose some
challenges for parents.
Parents are bombarded with online information about the types and
safety of immunizations. The nurse must stay abreast of current
information and discuss the parents’ concerns, as well as stay actively
involved in statewide reporting of adverse effects of the vaccine.
Over the years, an increasing number of immunizations that have been
marketed, especially for children. Newborn infants now receive a
hepatitis B vaccine, and many of the other vaccines are started at 2
months of age. Many are given in a primary series to develop the child’s
immunity in their early years. Some, but not all, are followed with booster
doses later in childhood, adolescence, and adulthood. The pediatric
nurse is familiar with pediatric immunizations and each year’s updated
immunization schedule. See Table 18-5 for detailed information about
vaccination.
TABLE 18-5
Vaccines
VACCINE TYPE VACCINE BRAND NAME(S) AVERAGE AGES GIVEN (SEE
CDC ANNUAL CHARTS FOR
SPECIFICS BECAUSE THIS
CHANGES)
Hepatitis A 1. Hepatitis A: VAQTA; Havrix 1. Ages >12 months for both
Hepatitis B 2. Hepatitis B: Engerix B; 2. Approved for all ages
Recombivax HB 3. Ages >18 years
3. Hepatitis A & B combination:
Twinrix
Diphtheria 1. Diphtheria, Tetanus Toxoid, and 1. Tripedia: ages 6 weeks to 7

Tetanus Acellular Pertussis DTaP: years; Infanrix: ages 6 weeks to
Pertussis DAPTACEL; Infanrix; Tripedia. 7 years; DAPTACEL: ages 6
2. Diphtheria, Tetanus Toxoid, and weeks to 6 years
Acellular Pertussis (DTaP) + 2. Ages 6 weeks to 6 years
Hepatitis B + Inactivated Polio: 3. Ages 4 to 6 as fifth dose of
Pediarix DTaP and fourth dose of IPV
3. DTap + Inactivated Polio: 4. Booster for ages 11–64
KINRIX 5. Booster for ages 10 and older
4. Tetanus Toxoid, Reduced
Diphtheria, and Acellular
Pertussis: Adacel
5. Tetanus Toxoid, Reduced
Diphtheria, and Acellular
Pertussis: Boostrix
6. There are other varieties for
adults with just diphtheria and
tetanus or tetanus alone.
Measles 1. Measles alone: Attenuvax 1. Ages 12 months and older

(rubeola) Mumps 2. Measles, Mumps + Rubella: 2. Ages 12 months and older
Rubella MMR II 3. Ages 12 months to 12 years
(German 3. Measles, Mumps, Rubella + 4. Ages 12 months and older
measles) Varicella: ProQuad 5. Ages 12 months and older
Varicella 4. Mumps alone: Mumpsvax 6. Ages 12 months and older, with
5. Rubella alone: Meruvax II optional second dose
6. Varicelle alone: Varivax
Haemophilus 1. Haemophilus B: ActHIB 1. Ages 2–18 months

influenzae type b 2. Haemophilus B: Hiberix 2. Ages 15 months to 4 years
(Hib) 3. Haemophilus B: PedvaxHIB 3. Ages 2–71 months
4. Haemophilus B + Hepatitis B: 4. Ages 6 weeks to 15 months
Comvax
Pneumococcus 1. Pneumococcal Polyvalent: 1. For >50 years or >age 2 with

Pneumovax 23 increased risk for
2. Pneumococcal 7 Valent: pneumococcal disease
Prevnar 2. Ages 2, 4, 6 and 12–15 months
3. Pneumococcal 13 Valent: 3. Ages 6 weeks to 5 years for
Prevnar 13 otitis media prevention; Ages 6
weeks to 17 years for invasive
disease prevention >age 50 for
pneumonia/invasive disease
prevention
Polio Inactivated 1. Inactivated polio: IPOL 1. As young as 6 weeks

(Live oral polio
no longer used
in United States)
Gardasil or Quadrivalent HPV: Gardasil 1. Approved ages 9–26 years in

Cervarix for HPV Bivalent HPV: Cervarix boys and girls
(optional) 2. Approved ages 9–25 in girls
Meningitis 1. Menveo 1. Ages 2–55 years

(usually required 2. Menactra 2. Ages 9 months to 55 years
before college or 3. Menomune 3. Ages 2 years and up
dormitory *All three varieties cover slightly
housing) different subtypes.
Influenza 1. Influenza Trivalent A + B 1. Fluzone is approved age 2

(optional) injection: Fluzone, Fluviron, years and up; Fluviron is
Fluarix and others approved for age 4 years and
2. Influenza Quadrivalent A + B: up
Fluarix Quadrivalent 2. Approved for 3 years and up
3. Live intranasal Trivalent A + B: 3. and 4. FluMist is approved for
FluMist ages 2–49 years
4. Live intranasal Quadrivalent A
+ B: FluMist Quadrivalent
Rotavirus 1. Rotarix: 2 oral doses 1. Approved for 6–24 weeks

vaccines 2. RotaTeq: 3-dose series 2. Approved for 6–32 weeks
Source: Food and Drug Administration Biologics/Vaccines/Approved Products (2020).

The primary immunizations of childhood are:
■ Hepatitis A and B
■ Diphtheria
■ Tetanus
■ Pertussis
■ Measles (rubeola)
■ Mumps
■ Rubella (German measles)
■ Haemophilus influenzae type b
■ Pneumococcus
■ Polio
■ Gardasil or Cervarix (optional)
■ Meningitis (usually required before college or dormitory housing)
■ Influenza (optional)
Optimizing Outcomes
Pertussis Vaccine
A new version of adult pertussis vaccine has been created (Tdap) to be given with
tetanus and diphtheria updates. This vaccine is acellular, or weakened, because
many children experienced significant adverse effects from full pertussis vaccine in
the past.
Influenza Vaccine
Influenza-related complications in children ages 24 months and younger are just as
dangerous as they are for those people age 65 and older.
Vaccine Combinations
A variety of combined immunizations are available to decrease the number of
injections a child receives at a given time. The benefit of combined vaccines is
reduction in number of injections overall and improved vaccination timeliness and
coverage. However, there is one main disadvantage to combination vaccinations,
which is increased risk of adverse reactions. For example:
• The MMR and Varicella vaccines are available in a combination product, MMRV,
with the brand name of ProQuad.
• Kinrix is the brand name of the combination of DTap-IPV.
• Pentacel contains DTap, IPV, and Hib.
The nurse is diligent in maintaining current knowledge about the medication’s
action and potential side effects and any contraindications to immunizations. In
addition, the nurse is skilled in the actual administration of the vaccine. Setting up
immunization clinics and long-term tracking of children who have and have not
received immunizations is important as well as accurate documentation and follow-
up care.
Addressing parental concerns about the safety of vaccination is a major
role of the pediatric nurse. Over the past 25 years, the number of
childhood vaccines given has more than doubled. Children may now
receive approximately 24 vaccines during the first 2 years of life (AAP,
2020). Many parents are concerned their child’s immunity cannot
withstand so many vaccinations so close together. Some parents believe
it is better for children to actually experience the disease and gain natural
immunity, but this is untrue and potentially dangerous.
Patient Education
Education About Immunizations
HOW TO: Increasing immunization administration and compliance requires that the
nurse work with the family to address the administration of the vaccine as well as
their educational concerns.
ESSENTIAL INFORMATION: When working with families the nurse can:
• Discuss the actual administration and potential side effects of the vaccine with the
parents.
• Develop programs and materials that educate parents about immunizations.
• Identify opportunities for administering immunizations by providing immunization
clinics in nontraditional settings such as churches, synagogues, mosques,
community centers, or shopping malls.
• Provide opportunities and encourage parents to communicate their concerns about
immunizations.
• Encourage parents to investigate immunizations using reputable Web sites and
other resources.
• Assist the parents in understanding how to keep track of immunizations and when
the next immunizations are due.
• Assist parents in investigating funding resources for immunizations (this is a
possible barrier to immunization for many families).
Local adverse immunization effects are mild and occur most frequently
(soreness, redness, and pain at the site of injection). These effects can
be managed through local application of heat or ice to the site. Systemic
effects are less frequent and include fever and mild irritability. These are
managed with acetaminophen (Children’s Tylenol) administration before
immunization, continuing every 4 hours as needed for 24 hours. An
allergic reaction is rare but serious. The pediatric nurse and parents
should watch for signs of an allergic response and seek medical
assistance immediately should their child exhibit any of the following
symptoms: high fever; altered mental status, including excessive
irritability, lethargy, non-responsiveness, or seizures; increased work to
breathe; hoarseness or wheezing when breathing; hives; or pale or cool
skin.
The immunizations are administered according to manufacturers’
recommendations. During the immunization process, the nurse takes the
time to address the unique concerns of each family. The parent’s role
after immunization is to understand and treat side effects. It is important
for the nurse to communicate to parents when to call the health-care
provider. Once parental concerns have been addressed, the child can be
released from the clinic when there are no signs of adverse reaction.
RESISTANT ORGANISMS
In recent years, the incidence of infections with antibiotic-resistant
organisms has steadily increased in the United States and in many
countries around the world. Several factors have been associated with
the genesis and spread of these organisms. On a global scale, bacterial
resistance, as a result of misuse, is an escalating problem in many
countries providing an ever-increasing reservoir for resistant organisms
to thrive.
Antibiotic-resistant organisms can be transmitted directly from an
infected or colonized person (as in nasal colonization), from a health-
care worker, or from fomites: inanimate objects such as durable medical
equipment, stethoscopes, name badges, and jewelry worn by health-care
workers. Health-care providers and others can carry methicillin-resistant
Staphylococcus aureus (MRSA) in the nares and on the skin without
becoming ill, but this can pass MRSA on to more susceptible individuals.
Patients on ventilators often are colonized with resistant bacteria. It is
vital for the nurse to recognize the risk factors for antibiotic resistance:
being hospitalized, having prior antibiotic therapy, and living in a long-
term-care facility.
Signs and Symptoms

When infected, patients exhibit the same types of symptoms as with
drug-susceptible organisms, but the organisms have more resistance to
standard antibiotic therapies.
Diagnosis
MRSA is diagnosed through laboratory culture and clinical appearance.
MRSA has both a hospital strain and a community-acquired strain. These
bacteria are genetically altered, resulting in increased resistance to
standard antibiotics. These strains, as well as drug-resistant
Streptococcus pneumoniae, are the most common resistant organisms
seen in pediatric patients. Vancomycin-resistant enterococci is another
common type of resistant organism, found mostly in acute care settings.
In most cases, a purulent lesion that is suspicious for being MRSA
contaminated should be incised, drained, and cultured for full diagnosis
and appropriate treatment.
Prevention
Careful hand washing is the most important preventive activity for
resistant organism disease. Alcohol-based hand sanitizers and foam
cleaners are used throughout health-care facilities. Careful infection-
control surveillance by acute and chronic care facilities includes
implementing isolation procedures, taking appropriate cultures, and close
monitoring. Within the community, nurses can promote public awareness
and infection control measures in addition to teaching the public to finish
antibiotic treatments and use antibiotics appropriately. Not finishing the
full prescribed course of the antibiotic can lead to increasing resistance.
Nursing Care
Nurses are the bridge between the actual infection and public health
awareness. The CDC (2020) has implemented core strategies to reduce
the spread of MRSA (Table 18-6).
Communicable and immunological treatments include care measures
for a child with MRSA:
■ Isolate the child by assigning the patient to a private room.
■ Use standard precautions throughout the hospital stay.
■ Wash hands with a chlorhexidine-soap solution.
■ Don disposable, nonsterile gloves when coming in contact with body
fluids or wounds.
■ Wear a protective gown when entering the patient’s room.
■ Wear a filtered mask if the child has a productive cough or if handling
respiratory secretion.
■ Caps and overshoes are not required.
■ Change protective garments between patients.
■ Close the patient’s door.
■ Keep all equipment such as thermometers, stethoscopes, and
sphygmomanometers in the patient’s room and disinfect or destroy
after use.
■ Place laundry in water-soluble bags and use designated waste bags.
■ Use labeled biohazard bags for contaminated waste or specimens that
are collected and need to be sent to the laboratory.
■ Special precaution for food trays and dishes and utensils is not
needed.
■ Avoid transfer to other areas if possible. However, if transport is
necessary, use standard precautions.
■ Document pertinent data.
■ Notify the environmental services department to thoroughly clean the
room after discharge.
TABLE 18-6
Core Strategies to Reduce the Spread of MRSA
Assess hand- Ensure easy access to soap and water/alcohol-based hand gels
hygiene practices • Education for health-care personnel and patients
• Observation of practices, particularly around high-risk
procedures (before and after contact with colonized or infected
patients)
• Feedback—”Just in time” feedback if failure to perform hand
hygiene observed
Implement contact Use of gown and gloves for patient care, don equipment prior to
precautions room entry
• Remove gown and gloves prior to room exit
• Assign a single room (preferred) or cohort placement for
MRSA-colonized/infected patients
• Use of dedicated nonessential items may help decrease
transmission because of contact with these fomites (e.g., blood
pressure cuffs, stethoscopes, and IV poles and pumps)
Recognize Patients can be colonized with MRSA for months

previously colonized • There is no single “best” strategy for discontinuation of isolation
patients precautions for MRSA patients
• Recognizing previously colonized or infected patients who have
not met criteria for discontinuing isolation allows them to be
subject to interventions in a timely fashion
Rapid reporting of Facilities should have a mechanism for rapidly communicating

MRSA lab results positive MRSA results from laboratory to clinical area
• Allows for rapid institution of interventions on newly identified
MRSA patients
Providing MRSA To improve adherence to hand hygiene

education for health- • To improve adherence to interventions (e.g., contact
care providers precautions)
• Encourage behavioral change through a better understanding
of the problem
Source: Centers for Disease Control and Prevention (CDC).
What to Say
Home Care Instructions
The nurse provides home care instructions to the parents of a 2-year-old child
presenting with symptoms of a viral illness. The parents tell the nurse they are
unhappy with the health-care provider’s decision not to prescribe antibiotics. Not all
situations are alike; the nurse can tailor interaction to the situation.
• Tell me more. What has been your past experience with treating similar illnesses?
• What are your concerns with this illness? What do you believe will happen if
antibiotics are prescribed to treat your child at this time?
• What are your plans to care for your child? Under what circumstances will you
contact your health-care provider to discuss a change in treatment plan?
SUMMARY POINTS
■ Many infectious disorders and immune diseases especially affect the pediatric
population.
■ The immune system acts as the body’s primary defense system and includes
concepts such as active and passive immunity, immunoglobulins, and immune
response.
■ Congenital immunodeficiency disorders have four main groups of disorders
associated with mutant genetic abnormalities. These children face lifelong
compromise in their immune response, leading to increased risk of infectious disease.
■ HIV is the primary cause of AIDS in infants and children. This disease spectrum
causes increased risk of life-threatening opportunistic infections from bacteria, virus,
and fungi.
■ Autoimmune disorders involve the body creating an immune response against its own
tissues or cells.
■ Anaphylaxis is the most severe type of allergic reaction, often causing hypotension,
shock, and possibly cardiorespiratory arrest.
■ Infectious diseases are common in children, in part because of the immaturity of the
immune system.
■ Pandemic infections, including avian influenza and swine flu, have affected the health
of people of all ages, but children are particularly at risk for serious and sometimes
fatal outcomes.
■ Animal-borne infectious disease remains a significant risk for the pediatric population.
■ The cornerstone of infectious disease prevention in pediatrics is an immunization
program in which children receive necessary vaccines.
■ Excessive global use of antibiotics has led to increased antibiotic resistance and the
appearance of resistant organisms such as MRSA.
REFERENCES
American Academy of Pediatrics (AAP): Immunization Schedule (2020). Retrieved from
https://www.aap.org/en-us/advocacy-and-policy/aap-health-
initiatives/immunizations/Pages/Immunization-Schedule.aspx
Blosser, C. G., Brady, M. A., & Royal, R. B. (2020). Infections, diseases, and
immunizations. In C. E. Burns, A. M. Dunn, M. A. Brady, N. B. Starr, & C. G. Blosser
(Eds.). Pediatric primary care (6th ed.). Philadelphia: Elsevier Saunders.
Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (Eds.). (2020).
Pediatric primary care (6th ed.). Philadelphia: Elsevier Saunders.
Centers for Disease Control and Prevention (CDC). (2020). Retrieved from
https://www.cdc.gov/vaccines/index.html
Centers for Disease Control and Prevention Screening recommendations and
considerations referenced in treatment guidelines and original sources. (2018).
Available at: https://www.cdc.gov/std/tg2015/screening-recommendations.htm.
Accessed March 23, 2020.
Centers for Disease Control and Prevention: Screening for HIV infection. (2019) .
Available at: https://www.cdc.gov/hiv/guidelines/testing.html
Fahrner, R., & Romano, S. (2010). HIV infection and AIDS. In P. J. Allen, J. A. Vessey,
& N. A. Schapiro (Eds.). Primary care of the child with a chronic condition (5th ed.).
St. Louis, MO: Elsevier Mosby
Food and Drug Administration Biologics/Vaccines/Approved Products. (2020) .
Retrieved from
http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM09383
3
Knowledge of HIV testing guidelines among US internal medicine residents: A decade
after the Centers for Disease Control and Prevention’s routine HIV testing
recommendations. (2018). AIDS Patient Care STDS. 32(5):175–180.
Kofoed, P., & Thomsen, J. (2020). Leaving the responsibility of booking appointments to
parents in a paediatric diabetes outpatient clinic resulted in a deterioration of
metabolic control. Pediatric Diabetes, 21(2), 390–394. https://doi-
org.treadwell.idm.oclc.org/10.1111/pedi.12968
Lazar, N. R., Salas-Humara, C., Wood, S. M., Mollen, C. J., & Dowshen, N. (2018).
Missed opportunities for HIV screening among a cohort of adolescents with recently
diagnosed HIV infection in a large pediatric hospital care network. J Adolesc Health.
2018;63(6):799–802
Ng, S. M. (2018). Technology, telemedicine and social media are tools to improve health
outcomes, education and patient engagement in a paediatric diabetes service.
Practical Diabetes, 35(3), 97–100. https://doi-
org.treadwell.idm.oclc.org/10.1002/pdi.2171
Rachid, R., & Chatila, T. (2016). The role of the gut microbiota in food allergy. Current
Opinion in Pediatrics (28)1. 10.1097/MOP.0000000000000427.
Soep, J. B., & Hollister, J. R. (2009). Rheumatic diseases (Chapter 27). In W. W. Hay,
M. J. Levin, J. M. Sondheimer, & R. R. Deterding (Eds.). Current diagnosis and
treatment: Pediatrics (19th ed.). New York: McGraw Hill.
Starr, N. B., Blosser, C. G., Brady, M. S., Burns, C. E., Dunn, A. M. & Petersen-Smith,
A. M. (2016). Gastrointestinal disorders. In C. E. Burns, A. M. Dunn, M. A. Brady, N.
B. Starr, & C. G. Blosser (Eds.). Pediatric primary care (6th ed.). Philadelphia:
Elsevier Saunders.
Van Name, M. A., Cheng, P., Gal, R. L., Kollman, C., Lynch, J., Nelson, B., &
Tamborlane, W. V. (2020). Children and adolescents with type 1 and type 2 diabetes
mellitus in the Pediatric Diabetes Consortium Registries: Comparing clinical
characteristics and glycaemic control. Diabetic Medicine: A Journal of the British
Diabetic Association, 37(5), 863–867. https://doi-
org.treadwell.idm.oclc.org/10.1111/dme.14233
Venes, D. J. (2021). Taber’s cyclopedic medical dictionary (24th ed.). Philadelphia: F.A.
Davis.

Advantage
CHAPTER 19
Caring for the Child With an Endocrinological or

Metabolic Condition
CONCEPTS
Metabolism
Nursing
Assessment
Endocrinology
KEY WORDS
hypothalamus
pituitary gland
parathyroid glands
adrenal glands
gonads
pituitary hypofunction
growth hormone deficiency
pituitary hyperfunction
antidiuretic hormone (ADH)
diabetes insipidus (DI)
hyponatremia
hypothyroidism
Hashimoto’s thyroiditis
Graves’ disease
thyroid storm
hypermetabolic
Addison’s disease
primary adrenal insufficiency
congenital adrenal hyperplasia (CAH)
hyperaldosteronism
islets of Langerhans
diabetic ketoacidosis (DKA)
Kussmaul’s respiration
LEARNING OBJECTIVES

■ Describe the anatomy and physiology and developmental aspects of the endocrine system.
■ Examine the common conditions of the endocrine system.
■ Prioritize developmentally appropriate and holistic nursing care measures for common conditions of the
endocrine system.
■ Explore diagnostic testing, laboratory testing, and medications for common conditions of the endocrine
system.
■ Develop teaching plans and discharge criteria for parents whose children have common endocrine
conditions.
PICO(T) Questions
1. What are (O) the evidence-based practices that nurses should teach (P) adolescents with diabetes who
are going to be (I) using an insulin pump?
2. On average, do (P) 8-year-old children with type 1 diabetes demonstrate (O) the same level of accuracy
(I) in measuring their blood glucose levels (C) compared with their parents?
INTRODUCTION
This chapter provides a review of the anatomy, physiology, and developmental aspects of
the endocrine system. The discussion includes an examination of common endocrine
conditions including developmentally appropriate and holistic nursing care. Information about
diagnostic and laboratory testing and medications is given. Teaching plans and discharge
criteria for parents whose children have common endocrine conditions are incorporated.
The endocrine system is composed of multiple organs throughout the body. These organs
secrete hormones that regulate various bodily functions. Hormones are proteins consisting
of amino acid chains or steroids derived from fatty (cholesterol-derived) substances.
Hormones act as “messengers,” moving from system to system coordinating the functions of
many parts of the body. In caring for children, it is important to remember that the endocrine
system controls growth and development as well as energy use and energy stores; it also
controls levels of sugar, salt, and fluids in the bloodstream. Hormones regulate a child’s
response to stress or physical trauma and play a vital role in sexual development.

The Effect of Endocrinological Conditions
The child with an endocrinological condition may experience variations in normal growth and development,
particularly with physical growth. Growth changes are closely associated with deficiencies in the pituitary
hormone and can result in delayed skeletal growth or short stature, associated with hypopituitary
deficiencies, or accelerated growth, associated with pituitary hyperfunction.
The nurse must recognize the cause of the alterations in growth as complications of the endocrinological
condition and not necessarily associated with disturbances in growth and development. Nursing care should
include assessment and measurement of normal growth patterns including height, weight, head
circumference, and body mass index (BMI). The nurse should also assess for the presence of abnormal
physical characteristics for age and body build. Proper administration of medications is required to correct
disturbances in hormone levels and should be closely regulated by the nurse. The nurse should educate the
child and the family about medical treatment and target goals for growth and development.
Optimizing Outcomes
Rechenberg et al examined the associations among general and diabetes-specific stress and glycemic
control (HbA1c), self-management, and diabetes-specific quality of life (QOL) in adolescents with T1D
(Rechenberg et al, 2017). Adolescents completed validated measures of general and diabetes-specific
stress, self-management, and diabetes-specific QOL. HbA1c levels were obtained from medical records.
Results of this study showed that over 50% of the sample scored at or above criteria for high general and
diabetes-specific stress. Higher general and diabetes-specific stress was significantly associated with higher
HbA1c, poorer self-management activities, and lower diabetes-specific QOL. Diabetes-specific stress
accounted for a significant proportion of the variance in HbA1c, while general stress did not. General and
diabetes-specific stress accounted for 40% of the variance in diabetes-specific QOL. The conclusion of this
study showed that general and diabetes-specific stressors are common in adolescents with T1D. Health-
care providers must be mindful of the sources of stress that adolescents with T1D face daily. General stress
and diabetes-specific stress should be differentiated and may require different interventions to improve
coping and outcomes.
The child with an endocrinological condition may experience emotional distress because
of alterations in hormone levels, bullying from peers, and low self-esteem. Nursing care
should include assessment of the child’s emotional well-being and acceptance of the
disease process. The nurse should assess for emotional distress of the child and make
referrals to psychological counseling when indicated.
ANATOMY AND PHYSIOLOGY REVIEW OF THE ENDOCRINE

SYSTEM
The glands that make up the endocrine system include the hypothalamus, pituitary gland,
thyroid, parathyroids, adrenal glands, pineal body, and reproductive glands (ovaries and
testes) (Fig. 19-1). The hypothalamus is located in the center of the brain and is the main
control center of the body. Its function is to communicate the messages of the central
autonomic nervous system to the organs and glands of the endocrine system, thus
maintaining homeostasis throughout the body.
The pituitary gland is connected to the hypothalamus by a stem-like structure. It has two
parts: the anterior and the posterior pituitary. It is said that the pituitary gland is the “master”
because of its effect on growth and the functions of other glands in the body. The thyroid
gland is located in the front of the neck just below the larynx. The two lobes of the thyroid are
connected by an isthmus, which is a small band of tissue. The thyroid produces two
hormones called thyroxin (T4) and triiodothyronine (T3).
There are four parathyroid glands, two embedded on the posterior side of each lobe of the
thyroid gland. The parathyroid glands produce parathyroid hormone (PTH) and are
responsible for calcium regulation. The adrenal glands are located on the top of each
kidney. Each gland has an outer (cortex) portion and an inner (medulla) portion. The
hypothalamus controls the adrenal glands by directing the anterior pituitary to release
adrenocorticotropic hormone (ACTH) releasing hormone. The adrenal cortex and the
medulla produce different hormones. The pancreas is located in the abdomen, just behind
the stomach near the duodenum. It functions as both an endocrine without ducts gland by
secreting hormones and also as an exocrine gland, which has ducts. As an endocrine gland,
it secretes both insulin and glucagon, which are carried to the cells through the bloodstream.
These two pancreatic hormones have antagonistic effects on metabolism. The pancreas
also functions as an exocrine gland, producing and secreting digestive enzymes directly into
the small intestine through ducts.
The gonads, namely the ovaries in females and the testes in males, produce several
steroidal sex hormones. Generally, these sex hormones produce and regulate changes in
the male and female body at puberty.
Table 19-1 discusses the hormones secreted by the endocrine system and related
physiology. Some of these endocrine glands secrete more than one hormone, and some
hormones function in more than one way. Endocrine physiology is based on the function of
each hormone and an intricate feedback regulation. Feedback is the process by which an
organ or tissue either reacts positively or negatively based on the response or action of the
target cells or the circulating hormone. Stress, temperature, and nutritional status can
influence feedback regulation. Figure 19-2 shows examples of positive and negative
feedback (Passanisi et al, 2020).
PATHOPHYSIOLOGICAL CONDITIONS OF THE ENDOCRINE

SYSTEM
Conditions of the endocrine system are a result of either overproduction or underproduction
of the hormones or stimulating hormone. Endocrine diseases are also caused by the hyper-
or hyporesponse of the target organ or cell. A critical nursing assessment is essential to
competent nursing care (Table 19-2).
Conditions of the Anterior Pituitary

The anterior pituitary gland is responsible for the production of many hormones that
influence and regulate growth, metabolic activity, and sexual development. Conditions of the
anterior pituitary will cause growth hormone deficiency (GHD), gigantism, or precocious
puberty.
Pituitary Hypofunction
Pituitary hypofunction, or hypopituitary, causes GHD, an endocrine condition caused by a
decreased production of growth hormone (GH). Children with this condition present with
short stature (below the 5th percentile) and demonstrate delayed skeletal growth. Short
stature, occurring in 2.5% of children, is a common reason for pediatric endocrine evaluation
(Kang et al, 2019). One cause of short stature is pediatric GHD. The incidence of GHD is
roughly 1 in 7,000 births. The condition is also a symptom of several genetic diseases,
including Turner syndrome and Prader-Willi syndrome.
FIGURE 19-1 Anatomy and physiology of the endocrine system.
TABLE 19-1
Hormones and Their Functions
HORMONE PRODUCED BY OR FUNCTION AND TARGET OTHER FEEDBACK
STORED IN ACTION ORGAN OR LOOP REGULATION
(PHYSIOLOGY) CELL FACTORS
Growth hormone– Hypothalamus Causes release of GH Anterior GHRH and
releasing hormone from somatotrophs in pituitary somatostatin have
(GHRH) the anterior pituitary antagonistic effects on
the production and
release of GH
Somatostatin Hypothalamus Inhibits GH and TSH Anterior GHRH and

pituitary somatostatin have
antagonistic effects on
the production and
release of GH
Thyrotropin- Hypothalamus Stimulates production Anterior Thyroid hormone levels

releasing hormone and release of TSH pituitary Dopamine can
(TRH) stimulate or inhibit
release
Inhibition of serotonin
GABA
Somatostatin
CRH
Corticotropin- Hypothalamus Stimulates production Anterior Stress ACTH levels

releasing hormone and release of ACTH pituitary
(CRH)
Gonadotropin- Hypothalamus Causes release of FSH Anterior FSH

releasing hormone and LH pituitary LH
(GnRH) Testosterone
Estrogen
Progesterone
Antidiuretic hormone Hypothalamus/posterior Acts directly on target Renal Regulated by osmotic

pituitary cells increasing collecting pressure of plasma
membrane permeability ducts and (osmolality)
to water distal tubules Osmoreceptors in
hypothalamus mediate
the response
Set point influencing
stimulation:
Concentrated body
fluids = release of ADH
= increased
reabsorption of water
Dilute body fluids =
inhibition of ADH =
decreased reabsorption
of water
Oxytocin Hypothalamus/posterior Effects not as important Uterus, breasts Progesterone levels

pituitary in children Stimulation of nipples
Stimulates milk ejection Stimulation of cervix by
Stimulates smooth fetus
muscle contraction of
the uterus at birth
Assists in maternal
attachment
Found in seminal fluid
Growth hormone Anterior pituitary Causes growth of ALL All cells in Hypothalamus:
body tissues that are body, liver, GHRH
capable of responding IGF-1 Somatostatin
to it Sleep
Promotes mitosis and Exercise
cellular growth Physical activity
Affects metabolic Trauma
processes by increasing Stress
the rate of protein
synthesis, thus
decreasing protein
catabolism, slowing
carbohydrate use, and
increasing mobilization
of fats
Increases use of fats for
energy
Increases linear growth
acting on the growth
plates of long bones
Secretion (pulsatile and
circadian) greatest
during sleep (stages 3
and 4) and adolescence
and least during old age
Stimulates production of
insulin-like growth
factor-1 (IGF-1)
somatomedin
Thyroid-stimulating Anterior pituitary Stimulates the thyroid to Thyroid TRH

hormone (TSH) produce and secrete Dopamine Somatostatin
thyroid hormone Thyroid hormones
Adrenocorticotropic Anterior pituitary Stimulates production of Adrenal glands Glucocorticoids

hormone (ACTH) glucocorticoids
Prolactin Anterior pituitary Stimulates breast Breasts May be related to

growth Stimulates milk immune response
production Estrogen
Dopamine
Luteinizing hormone Anterior pituitary Stimulates ovulation Testes, Pulsatory regulation of

(LH) ovaries, GnRH when levels of
sex hormones are
adequate
Follicle-stimulating Anterior pituitary Stimulates maturation Testes, ovaries Pulsatory regulation of

hormone (FSH) of ovarian follicle and GnRH when levels of
sperm production sex hormones are
adequate
Thyroxine (T4) Thyroid gland Influences metabolic Affects cells in Hypothalamus:

Triiodothyronine (T3) rate Needs iodine for body in pituitary-thyroid
production metabolism, feedback system
growth, TSH released by
development; anterior pituitary
specific TRH produced by the
systems: hypothalamus
cardiac,
neurological,
reproductive
Parathyroid Parathyroid glands Helps maintain Bones, Serum calcium levels

hormone (PTH) homeostasis through kidneys, Reciprocal with PTH
regulation of calcium intestines levels
PTH PTH and calcitonin are
Acts on bones and antagonistic
renal tubules increasing
serum calcium levels
In bone, increases
osteoclastic activity
releasing calcium from
bone into the
extracellular fluid
In kidneys, increases
calcium reabsorption
(decreasing urine
calcium levels)
Stimulates activation of
vitamin D (increasing
intestinal calcium
absorption)
Calcitonin Parathyroid glands Increases bone Bone, kidneys Concentration of

formation by ionized calcium
osteoblasts
Inhibits bone
breakdown by
osteoclasts
Decreases serum
calcium levels
Promotes conservation
of hard bone
Insulin Islets of Langerhans Facilitates diffusion of All cells Glucose levels in blood
(beta cells of pancreas) glucose into the cells (hyperglycemia or
Increases uptake and hypoglycemia)
decreases release of
amino acids, thus
inducing protein
synthesis
Has role in lipid
formation
Stimulates secretion of
somatomedin
Glucagon Islets of Langerhans Increases blood Liver Glucose levels in blood

(alpha cells of glucose Stimulates (hypoglycemia or
pancreas) breakdown of glycogen hyperglycemia)
Stimulates Elevated amino acids in
gluconeogenesis blood that lead to
Stimulates lipolysis gluconeogenesis
Exercise
Cortisol— Adrenal cortex Primarily affect glucose All cells, liver Hypothalamic secretion
glucocorticoids metabolism of CRH
Influence use of fats Pituitary secretion of
and proteins ACTH
Anti-insulin: raise blood Physiological and
sugar psychological stress
Decrease glucose Renin-angiotensin
uptake by fat and system (mineral)
muscle cells
Increase glucose
synthesis
Gluconeogenesis:
production of energy
(glucose) from amino
acids (protein)
Protein catabolism
releasing muscle stores
of proteins – provides
amino acids
Lipid catabolism
Increase cholesterol
Immune and
inflammation functions
Fetal lung maturation
and surfactant
production
Cognitive functions
Aldosterone— Adrenal cortex Maintain normal salt Distal tubule of Extracellular potassium
Mineralocorticoids and water balance, the kidney ion concentration
sodium retention, and Angiotensin II
potassium excretion
Sex steroids— Adrenal cortex Have minor role in Secondary sex Estrogens Thyroid
androgens development of organs, hormone Pregnancy
secondary sex seminal Estrogen-containing
characteristics vesicles, brain, preparations
Are main source of bone, breasts Androgens
androgens in girls and Synthetic progestins
women (norethindrone,
norgestrel, desogestrel,
norgestimate)
Glucocorticoids
Growth hormone
Insulin
Obesity
Acromegaly
Hypothyroidism
Hyperinsulinemia
Epinephrine and Adrenal medulla Increase heart rate Heart, blood Regulated by the
norepinephrine Increase contractile vessels, lungs, sympathetic nervous
force of heart all cells system
Dilate bronchioles Exercise
Increase metabolism Bleeding
Lipolysis Low blood sugar Stress
Decrease gastric
motility
Decrease motor
function (not essential)
Vasoconstrict
(norepinephrine)
Source:Adapted from Johns Hopkins Medicine (2021).

Growth hormone deficiency is treatable (Robinson et al, 2019). Diagnosis of GHD in
conjunction with other pituitary deficiencies (i.e., multiple pituitary hormone deficiency
[MPHD]) and/or organic pathologies such as central nervous system (CNS) tumor is
generally straightforward. Tools for diagnosis include radiographic assessment of bone age,
measurement of insulin-like growth factor 1 (IGF-I) and IGF binding protein 3 (IGFBP-3),
provocative GH testing, cranial magnetic resonance imaging (MRI), and, in certain cases,
genetic testing. Growth velocity and the degree of short stature are primary considerations in
the decision to pursue testing for GHD. In addition, there are many other causes both
congenital and acquired, including trauma, CNS infections, and tumors in the region of the
hypothalamus or pituitary, as well as secondary causes such as cranial irradiation and
transient causes such as psychosocial deprivation.
FIGURE 19-2 Positive and negative feedback loops.
SIGNS AND SYMPTOMS
Usually, in the neonatal period, infants with GHD are of normal birth weight and length.
The delayed or absent growth is first assessed in the first 2 years of life. Delayed growth of
less than 2 inches (4 to 5 centimeters) in a year should be evaluated further. Assessment
must be done carefully and consistently at each visit to the pediatrician. The rate of growth
can be measured using the metric system to increase the preciseness of the measurement.
If a child’s height or weight plateaus (i.e., stays the same), further evaluation is warranted.
Other signs and symptoms of GHD include:
■ Delayed closure of the anterior fontanelle
■ Delayed dental eruption
■ Greater weight-to-height ratio
■ Increased abdominal (truncal) fat Decreased muscle mass
■ Poor development of bridge of nose, giving a pixie-like appearance
■ Protrusion of the frontal skull bones
■ Delayed puberty, including a high-pitched voice and a small penis or testes in boys
■ Hypoglycemia
It is important to alert the health-care provider about episodes of frequent or recurrent
hypoglycemia, prolonged jaundice, or micropenis in the neonatal period because these may
indicate the possibility of congenital hypopituitarism.
PROPER GROWTH ASSESSMENT

It is imperative that the nurse plot the child’s height and weight accurately at each
outpatient visit on the appropriate growth chart. If the child is of short stature (below the 5th
percentile) and is not chartable on the usual chart or has a syndrome known for short
stature, the nurse should plot these measurements on the appropriate growth curve. Growth
curves can be found on the CDC.gov website. It is important to use the same growth chart at
each visit. Weigh the patient the same way each time; for example, an infant is completely
undressed (including diaper), and a young child is dressed in underwear only. Standardized
techniques for measuring height are used in the clinical setting.
TABLE 19-2
Critical Nursing Assessment of the Endocrine System
BODY SYSTEM SYMPTOMS PHYSICAL EXAMINATION FINDINGS
General assessment Recent weight gain or loss, fatigue, Obesity, thinness, and dehydration
malaise, weakness, fevers,
intolerance to heat or cold, increased
sweating, or night sweats
Skin, nails, and hair Changes in skin pigment; excessive Pigment differences in the skin; skin
dryness or moisture, itching; recent excessively warm, moist skin, diaphoretic,
hair loss or change in the texture of or smooth
the hair on head or body; changes in In hyperthyroidism, rough, dry, and flaky
nail shape or brittleness of nails skin
In hypothyroidism, dull, coarse, and brittle
hair
In hirsutism, abnormal or absent genital
hair in puberty; pitted, grooved, or brittle
nails
Head Headache, dizziness, or vertigo Frontal lobe bulging or bossing

In hyperparathyroidism, flat fontanelle
Eyes Redness, dryness, bulging, and visual Exophthalmos, redness, visual impairment,
disturbances lid lag, and periorbital edema
Ears No history of findings directly related No physical findings directly related to the
to the endocrine system endocrine system
Nose Stuffy nose No physical findings directly related to the

endocrine system
Mouth and throat Mouth sores do not heal; difficulty with Enlarged tongue, fine tremors of the
swallowing; hoarseness or voice tongue, and fruity breath odor
change
Neck Swelling in the neck or goiter and pain Thyroid enlargement; unilateral or bilateral
and tracheal displacement; “buffalo hump”
Difficulty in assessing the thyroid in an
infant because of the short neck
Breast Breast development either early or Early breast development before age 8 yr,
late delayed breast development, neonatal
breast development (from transplacental
estrogen; normal finding), or gynecomastia
in boys
Respiratory, thorax, lungs No history of findings directly related Skeletal deformities related to parathyroid
to the endocrine system gland dysfunction
Cardiovascular Palpitations, tachycardia, and high Tachycardia, bradycardia, hypertension

blood pressure with a bounding pulse
Peripheral vascular Coldness, numbness, tingling, and Cool, delayed capillary refill, and
discoloration of the hands and feet discoloration of the hands or feet
Gastrointestinal Decreased or increased appetite, A full, round abdomen

increased thirst, nausea, vomiting,
abdominal pain, diarrhea, and weight
gain or loss not related to food intake
or deliberate dieting
Urinary Frequency, nocturia, polyuria; kidney No physical findings directly related to the
stones; and pain in the flank, groin, or endocrine system
suprapubic region or low back
Genitalia Testicular pain or lumps, Are ambiguous genitalia present? Are the
undescended testicles; unusual genitalia swollen, or is the scrotum
menstrual history (When did asymmetric? Is the penis large for the boy’s
menarche start [at what age]? What age (precocious puberty)? What does
was the date of last menstrual period Tanner staging show?
and what was the duration? Has there
been any amenorrhea? Has a
gynecological examination been
performed?)
Neurological Tremor, tic, coordination problems, Peripheral neuropathy, hyperactivity of

numbness or tingling, memory deep tendon reflexes
disorder, nervousness, mood change, In hyperthyroidism, hypoactivity of deep
psychosis, or seizures tendon reflexes In SIADH, asymmetric
pupils
Hematological No history of findings directly related No physical findings directly related to the
to the endocrine system endocrine system
Endocrine History of endocrine disorders and/or Abnormal examination of the testes,

need for or current use of hormone ovaries, or thyroid gland
replacement therapy
Musculoskeletal Broken bones noted from unusual Skeletal deformities related to parathyroid
circumstances; joint pain or stiffness; gland dysfunction, spasms, current or
muscle pain or cramps; weakness; recent fractures in various stages of
and gait problems healing, limited range of motion, and spine
and back deformities
Source: Adapted from Wilson, S. & Giddens, J. (2017). Health assessment for nursing practice (6th ed.). St.
Louis, MO: Elsevier.
DIAGNOSIS
A diagnostic work-up begins with a review of all previous growth charts to determine the
rate of growth. Special attention is given to children in less than the 5th percentile or to any
child whose growth has ceased, which is evidenced by a flat line or plateau on the growth
chart. Bone age determination by radiograph of the wrist, knee, or hand is usually less than
the child’s chronological age, thus indicating a delayed skeletal maturation. Magnetic
resonance imaging (MRI) of the brain is performed to rule out a brain tumor. Table 19-3
outlines specific laboratory tests for endocrine conditions to confirm the diagnosis. Other
pituitary function tests, which stimulate or suppress GH release, are performed. The GH
stimulants are typically insulin or arginine. The suppression test is done after giving glucose.
Other stimulants include arginine, levodopa (L-dopa), clonidine, and glucagon. When peak
GH levels are less than 10 nanograms per liter (ng/L) after stimulation, the diagnosis is
confirmed.
PREVENTION
GHD is not preventable in most cases. Caring for the child with GHD should include family
education with the goals of controlling stress, preventing and monitoring for signs of GHD
insufficiency, and promoting age-appropriate development. The child’s growth is monitored
with each checkup. Parents need to be cognizant of the potential for emotional stress
caused by small stature. Parents also need to be instructed on ensuring that the child
complies with hormone replacement therapy as well as potential side effects of the
treatment.
TABLE 19-3
Common Laboratory Tests for Endocrine Conditions
HORMONE FUNCTION/DESCRIPTION COMMON PURPOSE OF TEST SIGNIFICANCE OF
PRODUCED TESTS OF RESULTS AS
ENDOCRINE RELATED TO THE
FUNCTION ENDOCRINE
SYSTEM
ADRENAL GLANDS
• Aldosterone • Salt, water balance Aldosterone • Evaluate Increased Levels
levels (normal hypertension of • Adenomas
values vary by unknown cause
• Bilateral hyperplasia
age) • Suspected
of aldosterone-
hyperaldosteronism
secreting cells
• Suspected • Secondary to
hypoaldosteronism conditions caused
by increased renin
levels (e.g., diuretic
or laxative abuse)
• Cirrhosis
Decreased Levels
• Addison’s disease
• Hypoaldosteronism
• Diabetes
• Excess secretion of
deoxycorticosterone
• Turner’s syndrome
• Cortisol • Stress reaction Cortisol and • Determine adrenal Increased Levels
Challenge Tests hyperfunction (e.g., • Adrenal adenoma
• ACTH Cushing’s disease)
• Cushing’s syndrome
stimulation, rapid • Determine adrenal
• Hyperglycemia
test hypofunction (e.g.,
Addison’s disease) • Stress
• CRH stimulation Decreased Levels
• Dexamethasone • Addison’s disease
suppression • Hypopituitarism
• Metyrapone • Adrenogenital
stimulation syndrome
• DHEA-S • Body hair development at DHEA-S levels • Evaluate for Increased Levels
puberty (normal values androgen excess, • Cushing’s disease
vary by age and including congenital
• Hirsutism
gender) adrenal hyperplasia
• Polycystic ovary
and adrenal tumor
• Evaluated for female • Anovulation
infertility, • Ectopic ACTH-
amenorrhea, producing tumors
hirsutism • Hyperprolactinemia
• Virilizing adrenal
tumors
Decreased Levels
• Adrenal insufficiency
• Pregnancy
• Psychosis related to
adrenal insufficiency
• Epinephrine and • Blood pressure regulation, Catecholamines: • Assists in diagnoses Increased Levels
norepinephrine stress reaction, heart rate blood and urine of some tumors and • Diabetic acidosis
levels (levels pheochromocytoma • Hypothyroidism
vary by age) • Used to evaluate • Some tumors and
acute hypertensive pheochromocytoma
episodes • Strenuous exercise
Decreased Levels
• Autonomic nervous
system dysfunction
• Orthostatic
hypotension
HYPOTHALAMUS
• Growth • Stimulates growth Growth hormone Assists in diagnoses Increased Levels
hormone- hormone production by stimulation and of • Acromegaly
releasing the pituitary suppression tests • Acromegaly • Anorexia nervosa
hormone (normal values • Dwarfism • Cirrhosis
(GHRH) vary by age and • Growth retardation • Uncontrolled
gender) in children diabetes
• Gigantism in • Gigantism (pituitary)
children • Hyperpituitarism
HYPOTHALAMUS
• Used to monitor • Stress
treatment of growth • Ectopic GH
retardation secretion from
neoplasms
Decreased Levels
• Adrenocortical
hyperfunction
• Dwarfism (pituitary)
• Hypopituitarism
• Thyrotropin- • Stimulates Thyrotropin Assists in diagnosis of Increased Levels
releasing TSH (TSH) levels • Congenital • Congenital
hormone (TRH) production in the pituitary hypothyroidism hypothyroidism in
• Hypothyroidism or neonate
hyperthyroidism • Ectopic TSH-
• Pituitary or producing tumors
hypothalamic • Primary
dysfunction hypothyroidism
• Secondary
hyperthyroidism
related to pituitary
hyperactivity
• Thyroid hormone
resistance
• Thyroiditis
Decreased Levels
• Graves’ disease
• Primary
hyperthyroidism
• Secondary
hypothyroidism
• Excessive thyroid
hormone
replacement
• Corticotropin- • Stimulates ACTH Refer to Cortisol Refer to Cortisol and Refer to Cortisol and
releasing production by the pituitary and Challenge Challenge Tests Challenge Tests
hormone (CRH) Tests under the
adrenal glands
• Gonadotropin- • Stimulates LF and FSH Human chorionic • Assists in Increased Levels
releasing production by the pituitary gonadotropin diagnosing HCG- • Ectopic HCG-
hormone levels (levels vary producing tumors producing tumor
(GnRH) by week of • Confirms pregnancy
• Erythroblastosis
gestation) • Assists in fetalis
diagnosing ectopic • Multiple gestation
pregnancy or pregnancy
threatened or
• Pregnancy
incomplete abortion
Decreased Levels
• Assists in
• Ectopic pregnancy
determining whether
• Incomplete abortion
hormone levels are
adequate to • Intrauterine fetal
maintain pregnancy demise
• May help detect • Spontaneous
neural tube defects abortion
prenatally • Threatened abortion
• Prolactin • Inhibits prolactin Prolactin levels • Assists in diagnoses Increased Levels
inhibitory production (levels vary by of the primary • Increased adrenal
hormone (PIH, age and gender) hypothyroidism insufficiency
Dopamine) • Evaluation of (secondary to
postpartum lactation hypopituitarism)
failure
• Anorexia nervosa
• Breastfeeding
• Hypothalamic and
pituitary disorders
• Primary
hypothyroidism
• Insulin-induced
hypoglycemia
• Pituitary tumor
• Pregnancy
Decreased Levels
• Severe hemorrhage
after obstetric
delivery that causes
pituitary infarction
(Sheehan’s
syndrome)
HYPOTHALAMUS
• Arginine • Water balance Antidiuretic • Assists in the Increased Levels
vasopressin hormone level diagnosis of • Pain, stress, or
(AVP), also malignancy exercise
called associated with • Nephrogenic
antidiuretic syndrome of diabetes insipidus
hormone (ADH), inappropriate ADH • Disorders involving
produced by the secretion the central nervous
hypothalamus, • Differentiates system, thyroid
stored and between neurogenic gland, and adrenal
secreted by the and nephrogenic gland
pituitary diabetes insipidus • SIADH
• Detects CNS Decreased Levels
trauma or disease
• Nephrotic syndrome
that may be
• Pituitary diabetes
demonstrated by
insipidus
impaired ADH
secretions
OVARIES
• Estrogen • Female sexual Estradiol levels • Assists in Increased Levels
characteristics (levels vary with diagnosing adrenal • Adrenal and
age and gender) and estrogen- estrogen-producing
producing tumors tumors
• Feminization in
children
• Gynecomastia
• Hyperthyroidism
Decreased Levels
• Primary and
secondary
hypogonadism
• Turner’s syndrome
• Progesterone • Female sexual Progesterone • Evaluates for risk of Increased Levels
characteristics levels (levels early or • Congenital adrenal
vary with age, spontaneous hyperplasia
gender, and abortion
• Ovarian tumors
pregnancy stage) • Identifies for risk of
ectopic pregnancy Decreased Levels
• Galactorrhea-
amenorrhea
syndrome
• Primary or
secondary
hypogonadism
• Threatened abortion
PANCREAS
• Glucagon • Glucose regulation Fasting and • Assists in the Increased Levels
postprandial diagnosis of • Acromegaly
glucose (blood glucagon deficiency
• Acute stress
sugar) (levels and suspected renal
• Cushing’s syndrome
vary with age in failure
• Diabetes
infants and
• Glucagonoma
young children)
• Pancreatic
Glucagon levels
adenoma
(levels vary with
age) • Pancreatitis
• Pheochromocytoma
• Renal disease
• Shock and trauma
• Strenuous exercise
• Thyrotoxicosis
• Vitamin B1
deficiency
Decreased Levels
• Galactosemia
• Glucagon deficiency
• Hereditary fructose
intolerance
• Hypopituitarism
PANCREAS
• Hypothyroidism
• Malabsorption
syndrome
• Maple syrup urine
disease
• Poisoning resulting
in severe liver
disease
• Starvation
PARATHYROID GLANDS
• Parathyroid • Regulates blood calcium Parathyroid • Assists in diagnoses Increased Levels
hormone (PTH) levels (levels of causes of primary • Primary or
vary with age) and secondary secondary
hyperparathyroidism hyperparathyroidism
Decreased Levels
• DiGeorge syndrome
• Hyperthyroidism
• Nonparathyroid
hypercalcemia
• Secondary
hypoparathyroidism
PITUITARY GLAND
• Prolactin • Milk production Refer to Prolactin • A blood test that • In women, a
levels under the measures the level prolactin test is
hypothalamus of the hormone in ordered if she
the body displays symptoms
of prolactinoma, a
benign tumor on the
pituitary gland, or if
she is having
infertility problems,
irregular menstrual
periods, or to rule
out problems with
the pituitary gland or
hypothalamus
• In men, a prolactin
test is ordered if
they display the
symptoms of
prolactinoma or to
investigate testicular
or erectile
dysfunction or to
rule out problems
with the pituitary
gland or
hypothalamus
• Growth hormone • Stimulates childhood Refer to Growth • Measures the • Too much growth
(GH) growth, cell production, Hormone under amount of human hormone during
helps maintain muscle the hypothalamus growth in the blood childhood can cause
and bone mass in adults a child to grow more
than normal and too
little growth
hormone can cause
a child to grow less
than normal
• ACTH • Stimulates cortisol Refer to Cortisol, • Measures the level • A higher than
production by the adrenal challenge tests, of normal level of
glands and DHEA-S adrenocorticotropic ACTH may indicate
under adrenal hormone (ACTH) in the adrenal glands
glands the blood are not producing
enough cortisol as in
Addison’s disease
or Cushing’s
disease. A lower
than normal level of
ACTH may indicate
the pituitary gland is
not producing
enough cortisol as in
hypopituitarism
• TSH • Stimulates thyroid Thyroid- • Assists in the Increased Levels
hormone production stimulating diagnoses of • Congenital
hormone levels hypothyroidism, hypothyroidism
(levels vary with hyperthyroidism,
• Primary
age) and pituitary
hypothyroidism
dysfunction
• Thyroiditis
• Secondary
hyperthyroidism
related to
hyperactive pituitary
Decreased Levels
• Graves’ disease
• Primary
hyperthyroidism
• Secondary
hypothyroidism
PITUITARY GLAND
• LH, FSH • Regulation of testosterone Luteinizing • Assists in Increased Levels
and estrogen, fertility hormone levels differentiating • Gonadal failure
(levels vary with between primary
and secondary
age and gender causes of gonadal • Primary gonadal
as well as failure dysfunction
menstrual phase • Used to evaluate • Anorchia
in women) precocious puberty, Decreased Levels
both male and • Anorexia nervosa
female infertility, and • Malnutrition
response to therapy • Pituitary or
used to induce hypothalamic
ovulation dysfunction
• Severe stress
Follicle- • Assists in Increased Levels

stimulating differentiating • Gonadal failure
hormone levels between primary
• Gonadotropin-
(levels vary with and secondary
secreting pituitary
age, gender, and causes of gonadal tumors
menstrual phase) failure (i.e., pituitary • Klinefelter’s
or hypothalamic)
syndromes
• Used in fertility
testing • Orchitis
• Evaluates early • Precocious puberty
sexual development • Primary
and maturation hypogonadism
failure • Turner’s syndrome
• Assists in Decreased Levels
diagnosing • Anorexia nervosa
menstrual • Anterior pituitary
disturbances and hypofunction
gynecomastia • Hypothalamic
disorders
disease
• Sickle cell anemia
• Pregnancy
TESTES
• Testosterone • Male sexual Testosterone • Assists in Increased Levels
characteristics levels (levels diagnosing • Adrenal hyperplasia
vary by age and hypergonadism,
• Adrenocortical and
gender) precocious puberty,
gonadal tumors
and male infertility
• Hyperthyroidism
• Differentiates
between primary • Idiopathic sexual
and secondary precocity
hypogonadism • Polycystic ovaries
Decreased Levels
• Anovulation
• Cryptorchidism
• Delayed puberty
• Down syndrome
• Klinefelter’s
syndrome
• Primary and
secondary
hypopituitarism
• Malnutrition
THYROID GLAND
• T4 (thyroxine) • Helps regulate the rate of Total and free • Assesses for signs Increased Levels
metabolism thyroxine levels of hypothyroidism or • Hyperthyroidism
(T4) (levels vary hyperthyroidism
• Hypothyroidism
with age and • Monitors response
treated with T4
gender) to therapy for
hypothyroidism or • Thyrotoxicosis
hyperthyroidism caused by Graves’
disease
• Obesity
• Excess intake of
iodine
• Acute psychiatric
illness
• Hepatitis
Decreased Levels
• Hypothyroidism
• Strenuous exercise
• Late stage
pregnancy
THYROID GLAND
• T3 • Helps regulate the rate of Total and free • Assists in Increased Levels
(triiodothyronine) metabolism triiodothyronine diagnosing T3 • Hyperthyroidism
levels (T3) (levels toxicosis and • Iodine deficiency
vary with age and assessing for TSH • Pregnancy
pregnancy status) and T4 • T3 toxicosis
• Treated
hyperthyroidism
Decreased Levels
• Hypothyroidism
• Malnutrition
• Late stage
pregnancy
• Calcitonin • Helps regulate bone Calcitonin and • Assists in Increased Levels
status, blood calcium Calcitonin diagnosing • Hypercalcemia
Stimulation Tests hyperparathyroidism • Thyroid cancer
(levels vary by and thyroid cancer
• Chronic renal failure
gender) • Used to monitor
serum calcium • Pancreatitis
levels • Pernicious anemia
• Pheochromocytoma
• Thyroiditis
Decreased Levels
n.a.
Sources: Van Leeuwen & Bladh (2021). Davis’s comprehensive handbook of laboratory and diagnostic tests
(9th ed.). Philadelphia, PA: F.A. Davis Company.
COLLABORATIVE CARE
Nursing Care
Assist the child in reaching the goals of treatment, which are that the child achieves a
normal growth rate and eventually reaches a normal adult height. Another important aspect
of nursing care includes patient and family teaching about the condition and its treatment
and providing as much support as possible. Parents need to be taught about GH
replacement therapy, its preparation, and administration of the subcutaneous injections. Just
as with other daily subcutaneous injections, rotating sites, potential side effects, and actions
to take if necessary must be taught to the parents. Parents are prompted to use strategies to
decrease the child’s stress regarding the daily injections. Help the patient and family plan
and understand individual patient goals and the progress made toward achievement.
Typically, the most important goal is improved growth and psychological acceptance of body
image. Help the family to monitor the status of these vital outcomes.
Medical Care
Medical management includes the administration of human recombinant GH (replacement
therapy with daily subcutaneous injections). Recombinant human GH is a safe treatment for
children with idiopathic short stature, but it is not without its adverse reactions. Be aware of
all possible side effects of replacement GH, including increased intracranial pressure (ICP),
gynecomastia, arthralgia, and edema. Children who complain of a headache must be
carefully monitored because this may be the only sign of ICP. Managing these side effects
may require a temporary reduction or cessation of the GH dose. This therapy can decrease
a child’s sensitivity to insulin, causing hyperglycemia. Other side effects of human GH
medications are outlined in Table 19-4.
Children with GHD can be small-framed and of short stature. Supporting the family to help
the child attain a positive self-image is of the utmost importance. The nurse helps the child
realize that self-determination and confidence, not height, achieve goals. Classmates can
sometimes be insensitive to the child’s feelings and can even tease the untreated short child.
Adolescence, because of the focus on body image, can be an especially difficult time. It is
best to begin treatment as early as possible before the psychological effects of short stature
may have a lasting effect.
Encourage parents to take the child with GHD to the dentist regularly because the GH
treatments cause the child’s teeth to be softer and much more susceptible to cavities.
Families can also benefit from appropriate supportive resources.
TABLE 19-4
Side Effects of Human Growth Hormone Medications
SYSTEM ADVERSE REACTIONS
Cardiovascular • Mild edema of the hands and feet
• Hypertension
Central Nervous System • Headache

• Intracranial hypertension
• Insomnia
• Fever, malaise, and dizziness with the use of somatropin (Zorbtive)
Dermatological • Rash
• Increased growth of preexisting nevi
• Local lipoatrophy or lipodystrophy with subcutaneous administration
• Exacerbation of psoriasis with use of somatropin (Saizen)
Endocrine and Metabolic • Hyperglycemia

• Hypothyroidism
• Insulin resistance
Gastrointestinal • Pancreatitis
• Flatulence, vomiting, nausea, abdominal pain, gastritis, gastroenteritis,
pharyngitis with the use of somatropin (Zorbtive)
Hematological • Slight risk of developing leukemia
Local • Pain at injection site
Neuromuscular and Skeletal • Arthralgia

• Carpal tunnel syndrome
• Pain in the hip and back
• Scoliosis
• Myalgia
• Weakness
Otic • Otitis media
Renal • Glycosuria
Respiratory • Rhinitis
Miscellaneous • Flu-like symptoms

• Hypersensitivity reactions
Sources: Taketomo, C. K., Hodding, J. H., & Kraus, D. M. (2019). Pediatric & neonatal dosage handbook: A
comprehensive resource for all clinicians treating pediatric and neonatal patients (26th ed.). Hudson, OH: Lexi-
Comp; Vallerand, A. H., & Sanoski, C. A. (2021). Davis’s drug guide for nurses (17th ed.). Philadelphia, PA:
F.A. Davis.
What to Say
Helping Children Express Themselves
Children can be apprehensive about daily injections of any kind. It is important for the nurse to be as honest
as possible regarding the GH treatments. For example, a nurse does not tell a child that an injection will not
hurt. The nurse can help the child express their feelings by asking the following questions:
• “How do you feel?”
• “What do you tell your friends about your condition and the GH medication?”
• “How have you changed since the GH treatments began?”
• “What advice do you have for other children beginning GH treatment?”
A Team Approach
If the nurse feels more resources are needed to support the patient and family, they can make a referral for
additional support. These are usually done by making referrals for social work or for psychological
counseling if warranted.
Pituitary Hyperfunction
Pituitary hyperfunction, or precocious puberty (early or premature), is a condition that
occurs with overactivity of the pituitary gland. Generally, puberty occurs between 8 and 13
years of age in girls and between 91/2 and 14 in boys. In girls, precocious puberty begins
when any of the following secondary sexual characteristics develop before 8 years of age:
breasts, armpit or pubic hair, mature external genitalia, and the first menstruation. In boys,
precocious puberty begins when any of the following secondary sexual characteristics occur
before 9 years of age: mature external genitalia; growth of body hair, including facial,
underarm, abdominal, chest, and pubic hair; increase in size of and mass of muscles;
deepening of the voice; and change in the shape of the face and skeleton.
Most often, precocious puberty is idiopathic in girls. The incidence is about five times
higher in girls than in boys (Kaiser, 2020). Precocious puberty may be caused by CNS
abnormalities, or lesions such as a benign hypothalamic tumor; other types of brain tumor; or
brain injury. Other known causes include postinfections (encephalitis or meningitis);
congenital adrenal hyperplasia (CAH); tumors of the ovary, adrenal gland, or testicle;
exogenous sources; or androgens.
SIGNS AND SYMPTOMS

Similar characteristics of precocious puberty appear in boys and girls as well as ones
specific to each sex. In boys, the following signs and symptoms may be seen:
■ Facial hair
■ Penile growth
■ Increased masculinity
■ Testicular enlargement
■ Voice changes
In girls, these characteristic signs and symptoms are likely:
■ Breast development
■ Onset of menarche
■ Ovary enlargement
■ Cysts on ovaries
Commonly seen in both boys and girls are the following:
■ Axillary hair
■ Pubic hair
■ Body odor
■ Acne
■ Emotional lability
■ Mood swings
■ Growth spurts in height
Advanced bone age equals increased skeletal growth, which in turn equals increased
height initially. If untreated, epiphyseal plates (growth plates) close early and growth stops.
DIAGNOSIS
Blood tests to diagnose this condition include measurement of luteinizing hormone (LH),
follicle-stimulating hormone (FSH), testosterone, or estradiol. Testing to stimulate the release
of gonadotropins confirms the diagnosis. In addition, radiological studies are used to
calculate the child’s bone age. Because of the high incidence of CNS involvement, skull
computed tomography (CT) and/or MRI is usually indicated.
The nursing assessment includes a complete history and assessment of the child’s
pubertal status. This includes a Tanner staging of sexual maturation documenting breast,
genital, pubic hair, and testicular development. Growth charts demonstrate the exact age of
the linear growth spike. The history also includes exposure to hormones, CNS infection or
trauma, and the family history of the age at puberty onset.
PREVENTION
Pituitary hyperfunction cannot be prevented. Some of the risk factors for precocious
puberty, such as sex and race, can’t be avoided. Others can be reduced by ensuring that the
child avoids external sources of estrogen and testosterone such as can be found in
prescription medications for adults or dietary supplements containing estrogen or
testosterone. Medication compliance, stress reduction, and maintaining a normal weight are
also preventive activities.
FOCUS ON SAFETY
Exogenous Hormones
Many commercially purchased female products contain estrogen. Facial creams, hair products, and other
“beauty” aids can contain hormones or placenta extracts. Some shampoos specifically marketed to African
Americans have been found to contain hormones. Children can readily absorb enough of these exogenous
hormones to present with precocious puberty.
The nurse must alert parents of the dangers of hidden toxins in everyday products that can harm their
children. They must also be cognizant of “endocrine disruptors,” which are found on the National Institute
of Environmental Health Sciences (NIEHS) Web site (www.niehs.nih.gov/).
COLLABORATIVE CARE
Nursing Care
The nurse assists in providing treatment for precocious puberty. Help monitor the success
of the treatment by using the correct growth charts and facilitating blood levels of
gonadotropins and sex steroids. When treatments are stopped, puberty promptly begins.
Consistent, accurate record keeping of the child’s growth rate must be documented because
while on treatment, the child’s growth rate declines. Continue to assess and document the
progression or regression of the child’s secondary sex characteristics. Nursing care also
focuses on the accuracy of medication delivery. Provide accurate information to both the
child and the family about medication preparation, action, and administration techniques.
Medical Care
Treatment for CNS tumors may involve resection or radiation of the lesion. Pharmaceutical
treatment includes gonadotropin-releasing hormone (GnRH) agonists, which, in the past,
were given via subcutaneous injection daily or as a depot injection once every 3 to 4 weeks.
More recently, a 3-month formulation has shown great promise. Histrelin or Supprelin LA is a
permanent implant device that automatically releases the inhibitor subcutaneously over the
course of the year. The child is monitored by an endocrinologist and returns each year for a
new implant until they reach an age when puberty will normally occur. These treatments
suppress the release of gonadotropins by acting on the pituitary gland (Taketomo, Hodding,
& Kraus, 2019). Treatments cause a decrease in growth rate and a stabilization or
regression in development of secondary sexual characteristics; size of the breasts, ovaries,
uterus, and testes as well as erection frequency all decrease.
It is important to approach the child in a manner appropriate to their level of emotional and
cognitive development. Information provided to both the child and family includes the
physical changes that the child is experiencing as well as on the child’s disturbed body
image. Help is given to the child and family about manner of dress. Loosely fitting clothing
may help to conceal the abruptly changing body image. The nurse can also make referrals to
a therapist.
Depending on the age of the child, they can be included in the teaching as much as
appropriate. Providing information about normal development during puberty helps the
caregivers and the child understand the physical and emotional changes that occur with the
early onset of puberty. Most importantly, the nurse guides the family toward evidence-based
methods and away from fads and crazes.
Optimizing Outcomes
Financial Resources
Helping the parents identify financial resources for assistance if necessary ensures the best outcomes of the
care and treatments given. GnRH analog depot treatments are very costly and can range from $700 to
$1,000 per injection. These treatments are usually covered by the insurance companies, but some require
the injection to be given in the health-care provider’s office. For those with limited insurance resources,
some pharmaceutical companies provide assistance and give treatments at limited or no cost.
Conditions of the Posterior Pituitary
Diabetes Insipidus
Antidiuretic hormone (ADH) acts on the kidneys to conserve water by controlling the
kidneys’ urine output. ADH is secreted by the hypothalamus and stored in the posterior
pituitary gland before it is released into the bloodstream. When sufficient ADH is secreted,
the amount of urine output is decreased to avoid dehydration. Diabetes insipidus (DI) is a
hypofunction of the posterior pituitary gland and is classified by either a deficient production
of ADH or lack of response to ADH. Neurogenic (central) DI occurs when the production or
secretion of ADH is insufficient because of damage to the pituitary gland or hypothalamus.
Nephrogenic DI is the lack of the kidney’s appropriate response to normal levels of ADH. In
children, this is most often a genetic cause that is discovered early in life (Sharma et al,
2019). When a child has DI, insufficient ADH results in excessive production of extremely
dilute urine, causing the child to be excessively thirsty.
Central DI (or neurogenic) is caused by damage directly to the pituitary gland, such as
head injury, neurosurgery, a genetic disorder, and other diseases. Nephrogenic DI is related
to a problem in the kidney caused by drugs or chronic disorders, such as kidney failure,
sickle cell disease, or polycystic kidney disease. Generally occurring suddenly, DI can be a
result of either medical or surgical conditions. The most common surgical causes include:
■ Damage caused by neurosurgery (i.e., hypothalamus or pituitary gland)
■ Brain injury or tumor excisions
The most common medical causes include:
■ Hypothalamus malfunction (insufficient ADH production)
■ Pituitary gland malfunction (ADH is not released into the bloodstream)
■ Vascular abnormalities or cerebral vascular accident, or “stroke”
■ Infection
■ Encephalitis—brain inflammation
■ Meningitis—inflammation of meninges
■ Sarcoidosis—inflammation of the lymph nodes and other tissues throughout the body
■ Tuberculosis—infectious disease
■ Family heredity—genetic defect
SIGNS AND SYMPTOMS

Diabetes insipidus causes an excessive production of extremely dilute urine leading to
excessive thirst. Symptoms in the infant include the following (ADA, 2020):
■ Poor feeding
■ Fussiness
■ Frequent saturated diapers
■ Vomiting
■ Constipation
Symptoms in the older child and teen may include:
■ Irritability
■ Excessive thirst (polydipsia)
■ Excessive urine production (polyuria)
■ Craving for cold water
■ Enuresis (nocturnal bed wetting)
■ Nocturia
Children of all ages may experience:
■ Vomiting
■ Constipation
■ Fevers
■ Dry skin
■ Weight loss (ADA, 2020)
DIAGNOSIS
After a complete history, physical examination, and daily log of fluid and dietary intake and
output patterns (polyuria greater than 2 L/m2), the first morning urine is usually collected
after an overnight fast and subsequently tested for urine specific gravity. The serum is also
tested for osmolarity and sodium. Hyperdilute urine (specific gravity of 1.005 or less) with
elevated serum osmolarity (greater than 290 Osmol/kg) and serum sodium (as high as 170
mEq/L) confirms the diagnosis. Diagnosis can be difficult in infants because they naturally
excrete dilute urine. A 24-hour urine collection determines total daily urine output.
Dehydration
Dehydration can be seen in all cases, causing the infant or child to be irritable with many other
manifestations, including dry mucous membranes, decreased skin turgor, decreased tears when crying,
sunken fontanelle, and tachycardia. If dehydration is severe, the child’s pulse may be “thready” and very
rapid. Hypotension may also be present and could lead to hypovolemic shock. If dehydration occurs, it is
important to administer IV fluids.
FOCUS ON SAFETY
Ways to Prevent IV Infiltration

Inserting an IV in children can be challenging. The IV insertion sites are small and delicate. In addition,
during an insertion, a child may wiggle or thrash around, making the procedure difficult. The vessel walls
can become easily damaged. Ways to prevent IV infiltration include:
• Use clear tape to secure the IV site.
• Use an armboard to secure the site.
• Avoid using butterfly needles for infusions.
• Assess the site and surrounding tissue hourly.
• Avoid opaque restrictive dressing wrapped around the site.
• Use a vein viewer or a transilluminator when inserting an IV.
• Tape the IV insertions area securely enough to stabilize the site without causing constriction.
Diagnostic Tools
Diagnosis of Diabetes Insipidus
The definitive diagnosis of DI can be made with a water deprivation test. This test will also discern the type
of DI (i.e., neurogenic or nephrogenic). This test requires close supervision of the patient’s vital signs,
weight, and lab tests (i.e., urine and serum osmolality as well as serum sodium as often as every hour). The
usual protocol for monitoring is every 2 hours for the first 4 hours, and then hourly. During this test, the child
may become febrile and develop hypotension. The test starts after breakfast and the first void. After body
weight, serum osmolality, and sodium are measured, the child is deprived of fluid until dehydration occurs.
The child is weighed according to protocol, which may be as often as every 2 hours, allowing no more than
2% to 5% loss of body weight.
Each time the child voids, the urine is measured for volume, osmolality, and specific gravity. The serum
sodium and osmolality are obtained after the first 4 hours and then every 2 hours following. The test can be
stopped if the specific gravity is 1.020 or higher, urine osmolality is greater than 600 mOsmol/kg, serum
osmolality is greater than 300 mOsmol/kg, serum sodium is greater than 145 mEq/L, body weight loss is
greater than 5%, the child shows signs of volume depletion, or there are time constraints. The infant
younger than 6 months is not deprived of water more than 6 hours, a child between 6 to 24 months is not
deprived longer than 8 hours, and the child older than 24 months is not deprived more than 12 hours. Upon
termination, the weight, vital signs, plasma sodium, plasma and urine osmolality, and urine specific gravity
are obtained. A specimen is also sent for levels of plasma ADH, which is increased after dehydration tests
in patients with hereditary nephrogenic DI.
This test is not done on newborns or young infants. The alternate test is to give desmopressin and
measure the urine osmolality at baseline and every 30 minutes for 2 hours. If there is no increase in the
urine osmolality (at least 100 mOsmol/L above baseline) the infant may have hereditary nephrogenic DI.
Subsequent DNA testing for mutation will confirm the diagnosis (Sharma, et al. 2019).
PREVENTION
Prevention of DI may not always be possible. In many cases, the condition is present at
birth (congenital). DI may also be caused by head trauma, neurosurgery, or infection.
Medication compliance and access to water are needed to prevent dehydration. Children
and families also need to plan ahead by carrying water with them and by keeping a supply of
medication available everywhere (e.g., school or travel). A medical alert bracelet or medical
alert card is also encouraged.
COLLABORATIVE CARE
Nursing Care
It is important for the nurse to remember that a diet low in solutes helps this condition.
Generally, infants are given breast milk because it is naturally low in solutes. Protein content
in diets should be about 6% of an infant’s diet and only 8% of a young child’s caloric intake.
This should be enough to allow normal growth but not cause a solute excess.
Closely monitor the child for subtle signs of impending dehydration or fluid imbalance by
closely monitoring urine output and fluid intake. This is best done through daily weights. This
nursing task is performed using standard conditions (e.g., same scale, infant completely
undressed including diaper, and young child in underwear with socks only). Output
measurements must also be exact and include weighing diapers in grams for infants. All
urine is caught in a container or urinal to enable precise measurement in milliliters. Any
diapers containing stool are identified. Each institution may have a unique protocol on
measuring mixed stool and urine diapers. Accurate documentation is essential to
professional communication.
Caring for a child during the water deprivation test can be difficult. The child becomes very
irritable because of thirst, and it may be difficult for the child to understand why they cannot
drink. It will take patience on the part of the parents and nursing staff as the child becomes
more and more irritable. The nurse and parents can alternate holding and comforting the
child as well as using distraction methods.
This condition demands close monitoring of the fluid and electrolyte balance to prevent
complications (Sharma et al, 2019). Family involvement is the key to successful home
management. Common gastrointestinal illnesses that either increase fluid needs or decrease
intake must be identified, and the nurse must alert parents to the seriousness of these
conditions that can lead to life-threatening fluid and electrolyte imbalances.
Hypernatremic Dehydration
Poor skin turgor or tenting of abdominal skin is not always seen. When the child has hypernatremic
dehydration, skin turgor is not decreased despite the state of dehydration (Sharma et al, 2019).
Hypernatremia places the child at an increased risk for seizures. If left untreated, DI can cause a child to
have brain damage and impaired mental function such as retardation, attention-deficit/hyperactive disorder
(ADHD), short attention span, or restlessness (Sharma et al, 2019).
Medical Care
The health-care provider will differentiate between central (neurogenic) and nephrogenic
DI before decisions are made regarding treatments and nursing care. For central DI, when
polyuria is persistent, intranasal, parenteral, or oral doses of desmopressin (DDAVP) are the
treatments of choice. The diuretic hydrochlorothiazide (Microzide) is given in combination
with chlorpropamide (a sulfonylurea compound) to decrease urine volume by up to 75%.
Accurate administration of medications is a key factor when providing nursing care. The
intranasal form of desmopressin (DDAVP) may be difficult to give. Special care is taken to
give the medication accurately and to teach the parents proper administration.
Nephrogenic DI is not treated with DDAVP because of the pathology of the receptor sites,
thus making the kidney unresponsive. In this setting, thiazide diuretics, a potassium-sparing
diuretic, such as amiloride (Midamor), and a nonsteroidal prostaglandin, such as
indomethacin (Indocin) or aspirin, are all useful treatments.
Patient and parent teaching, as with most conditions, is important. Early discovery and
care of the child with DI is important. This condition demands close monitoring of the fluid
and electrolyte balance to prevent complications. Family involvement is the key to successful
home management. Helping the family by beginning a log of accurate intake, output, and
daily weight while the child is still hospitalized can be the greatest asset and can optimize
outcomes for this very challenging care situation. Parents must be taught to replace fluids in
the very young child or infant because these patients cannot be relied on to accurately
express thirst nor can these patients obtain a drink on their own.
Collaboration With Parents
Collaboration with the parents helps to manage the child’s care at home. It is important to keep the health-
care provider alerted to episodes of dehydration. Early recognition of the disease, in addition to the ability to
recognize excessive fluid losses and then replace these losses, is the key to long-term survival. A dietitian
and pediatric endocrinologist will work closely with the health-care provider and the family to care for the
child.
Syndrome of Inappropriate Antidiuretic Hormone

Syndrome of inappropriate antidiuretic hormone (SIADH) is caused when excessive levels of
ADH are produced and is rare in children. ADH normally causes the kidneys to conserve
water. This syndrome causes water retention and electrolyte imbalance—specifically
decreased serum sodium. This is counterintuitive because despite a decrease in osmolality
and electrolytes, the body is still producing excessive ADH, causing more water
reabsorption, thus leading to even more dilution and decrease in osmolality. Eventually, this
results in water intoxication. The hypersecretion can be from overproduction in the
hypothalamus or oversecretion from the posterior pituitary (Sharma et al, 2019).
MEDICATION
Accurate Administration of Intranasal Medication Doses
Intranasal desmopressin (DDAVP) can be administered through a rhinal tube. Ensure the child blows their
nose before the medication is given. Positioning the child on the side while the medication is given
enhances the absorption of the medication.
SIADH occurs most frequently in children with neonatal hypoxia, CNS infections, or
intrathoracic disease in association with certain drugs (e.g., chlorpropamide, vincristine,
imipramine, and phenothiazines) and can occur in postoperative patients (Pintaldi et al,
2019). Among premature neonates, the syndrome most often accompanies brain injury and
is closely associated with intracranial hemorrhage. It can also be caused by hypoxia and
positive pressure ventilation. In other cases, some medications (diuretics) and chemotherapy
may produce ADH. Other causes may include meningitis, encephalitis, brain tumors,
psychosis, head trauma, Guillain-Barré syndrome, damage to the hypothalamus or pituitary
gland during surgery, lung diseases, and positive pressure ventilation.
SIGNS AND SYMPTOMS

Children experience and express symptoms differently. Symptoms of SIADH may include:
■ Seizures
■ Headache
■ Muscle cramps
■ Weakness
■ Personality changes such as irritability, combativeness, confusion, drowsiness,
hallucinations, stupor, and coma
Other signs and symptoms may include:
■ Increased blood pressure
■ Weight gain with no externally visible edema
■ Decreased urine output despite a high specific gravity
■ Fluid and electrolyte imbalance
As the electrolyte (especially sodium) levels decrease, the child becomes lethargic and
confused. Often, if the child is old enough, complaints of a headache are also common.
Eventually, altered levels of consciousness followed by seizures and coma can be seen.
DIAGNOSIS
SIADH is diagnosed through laboratory testing.
Diagnostic Tools
Serum Levels
Laboratory serum levels are monitored and a diagnosis is confirmed with the following values:
• High urine osmolality (greater than 1,200 Osmol/kg)
• High urine specific gravity (greater than 1.030)
• Urine sodium continues to reflect the intake of sodium despite low serum sodium
• Low serum osmolality (less than 275 mOsmol/kg)
• Low serum sodium (less than 135 mEq/L)
• Decreased blood urea nitrogen (less than 10 mg/dL)
• Decreased hematocrit
• Serum bicarbonate remains steady
• Serum potassium is usually normal
PREVENTION
Because there is no clear underlying cause for SIADH, prevention
includes attention to safety related to head trauma, good prenatal
care, and avoidance of infectious diseases. Careful attention and
recognition of symptoms, which may be experienced by the child
with head trauma or infectious diseases, and referral or notification
of the primary care provider can lead to quicker initiation and
response to treatment.
COLLABORATIVE CARE
Nursing Care
Fluid restriction is the most difficult aspect of nursing care. This
restriction can be challenging to maintain, especially if the child is old
enough to reach the sink or water fountain. Fluid intake by all routes
must be recorded as intake. The nurse must meticulously monitor
and record all intake and output. Sometimes, the placement of a
Foley catheter is necessary or weighing soiled diapers in grams is
needed to ensure accurate measurements of output. The nurse must
remember to obtain the weight of a clean diaper so that it can be
subtracted from that of the soiled diaper weight before recording the
output. The child’s family members must also be made aware of fluid
restrictions and the need for careful monitoring and recording of
intake and output.
Certain medications are given with meals to prevent any
unnecessary fluid intake. If the child is thirsty, they can be offered
hard candy to suck, providing the child’s medical condition does not
contraindicate the sugar. To prevent water reabsorption in the
intestines, tap water and saline enemas are avoided. Irrigate all oral
tubes with normal saline rather than with water to prevent pulling of
sodium, thus creating an even greater electrolyte imbalance. Oral
mucous membranes can be kept moist by providing frequent mouth
care. Avoid alcohol-based mouthwashes because these dry out the
mucous membranes. The nurse must also monitor the child’s
nutritional status. A diet high in sodium and protein is encouraged
because this increases urine excretion.
Neurological assessments are also imperative. Assessing level of
consciousness, headache (if child can verbalize), and seizure activity
can be indications of severe electrolyte imbalance. Seizure
precautions must be set up and implemented at the bedside.
Finally, the nurse evaluates the child for fluid retention. When fluid
retention is suspected, monitoring of input and output (I&O), baseline
weight, and daily weight is essential. The nurse evaluates patients
for edema in dependent areas and assesses the child’s lungs to
detect overhydration and monitor skin turgor carefully. Each of these
assessments must be clearly communicated to subsequent health-
care provider and the nurse who will assume care for the child.
FOCUS ON SAFETY
Hyponatremia
It is critical to remember that hyponatremia (low serum sodium of less than
125 mEq/L) may cause seizures in the child with SIADH. Keeping the serum
sodium level near normal is the goal of treatment. The pediatric nurse must be
thorough and accurately track intake, output, and daily weights of the child.
Along with the primary health-care provider, an endocrinologist, often a
nephrologist, a neurologist, and possibly a pediatric intensive care specialist
may need to be consulted if the child manifests severe clinical, neurological
symptoms.
Medical Care
Medical management includes treating the underlying cause or
disorder in addition to correcting the fluid and electrolyte imbalance.
Fluid restriction is the cornerstone of care for a child with SIADH.
Fluids are generally reduced to two-thirds of maintenance levels.
Hypertonic sodium chloride solution is given if severe hyponatremia
and severe neurological disease are present. Corticosteroids are
given only when adrenal insufficiency is present. Vasopressin is
effective in altering permeability of the renal collecting ducts, which
allows for the reabsorption of water. Oral urea therapy has also been
found to be an effective and safe treatment in children.
Educating parents about the importance of fluid balance is a
significant aspect of teaching the care of a child with SIADH. The
family must also be taught that a daily weight of the child is the most
important indicator of fluid balance. Maintaining fluid balance and
avoiding excessive fluid intake is also emphasized. Be sure to
include hidden sources of water in foods to optimize the outcomes of
this child’s care. Family members are taught to measure the urine
output accurately, using whatever is appropriate for the child (e.g.,
diaper weights or urinal use). In addition to teaching all the care
aspects for the child with SIADH, include basic information about
SIADH and its causes, signs, and symptoms.
Conditions of the Thyroid
Hypothyroidism
Hypothyroidism is defined as thyroid insufficiency. When thyroid
hormone deficiency is detected at birth it is called “congenital
hypothyroidism.” Babies with congenital hypothyroidism are born
with an underactive or absent thyroid gland. Because thyroid
hormone plays such an important role in brain development and
growth, all babies born in the United States, Canada, and other
developed countries undergo a screening test to check thyroid
function shortly after birth. Early detection and treatment of
hypothyroidism generally result in normal growth and development.
If left untreated, hypothyroidism can lead to a goiter. The thyroid
gland secretes thyroid hormones, which control the speed of
metabolism. Brain development, as well as the normal growth of the
child, depends on normal levels of thyroid hormone. Hypothyroidism
was once referred to as cretinism and was thought to be a major
cause of severe mental retardation, but this view is not held today.
Infants can be born with congenital hypothyroidism; acquired
hypothyroidism can develop in children of any age. In older children
and young adults, hypothyroidism can also cause diverse symptoms
including slowed heart rate, chronic tiredness, and inability to
tolerate cold. The child may feel physically tired and mentally
fatigued, which may impair learning (NIH, 2020).
Hashimoto’s thyroiditis is the most common cause of acquired
hypothyroidism in children ages 6 and older in the United States.
Also known as autoimmune or lymphocytic thyroiditis, this condition
had an estimated prevalence of 1.3% in a study of 5,000 children
aged 11–18 years (Lee, 2020). Females are more often affected
than males, with a peak incidence during adolescence. Other causes
of acquired hypothyroidism include thyroidectomy, subacute
thyroiditis, cranial or spinal radiation, or exposure to goitrogenic
drugs such as lithium, iodine, thioamides, or resorcinol.
SIGNS AND SYMPTOMS
Hypothyroidism has varying levels of manifestations from subtle
(in infancy) to overt (as the child matures). In an infant, the signs and
symptoms include:
■ Prolonged newborn jaundice
■ Poor feeding
■ Constipation
■ Cool, mottled skin
■ Hypotonia
■ Increased sleepiness
■ Decreased crying
■ Larger fontanelles
■ Umbilical hernia
■ Large, thick tongue
As the child begins to grow and mature, manifestation of
hypothyroidism may include:
■ Short stature for age
■ Delayed dentition
■ Delays in major developmental milestones
■ Weight gain
■ Hypotonia
■ Puffy facial features
■ Severe mental retardation
■ Protruding abdomen
■ Umbilical hernia
■ Thick, dry, scaly, pale, or mottled skin
■ Sparse, coarse, dry, or brittle hair
Symptoms in the older child are more overt and much like those
found in the adult. These symptoms include:
■ Bradycardia
■ Fatigue
■ Hypothermia
■ Hoarse voice
■ Dry, flaky skin
■ Puffiness in the face (especially around the eyes)
■ Impaired memory and difficulty in thinking (appears as a learning
disability)
■ Drowsiness, even after sleeping through the night
■ Delayed or arrested puberty
■ Heavy or irregular menstrual periods (in girls at the age of puberty)
■ Constipation
DIAGNOSIS
Congenital hypothyroidism is usually detected during the routine
newborn screening. Every state in the United States requires routine
neonatal screening by the measurement of thyroid-stimulating
hormone (TSH) values in the cord blood or through a heel stick.
Positive newborn screening results are confirmed by a serum
sample. Abnormally low levels of thyroxine (T4) and high TSH
confirm the findings. Further diagnosis may include a scan of the
thyroid gland to establish the cause of congenital hypothyroidism,
though it is not necessary because it does not affect the treatment.
PREVENTION
It is essential that the nurse is aware that congenital
hypothyroidism is an important cause of mental retardation.
Complications are preventable with the earliest identification and
subsequent treatment. Educating parents regarding the signs and
symptoms helps to identify the condition early so treatment can be
started as soon as possible. It is important to inform families who
have infants with this condition that lifetime treatment does prevent
mental retardation. Newborn lab results must be assessed, and
follow-up for any abnormal results is mandatory. The most common
cause of hypothyroidism in the United States is Hashimoto’s
thyroiditis, which cannot be prevented. Although hypothyroidism is
not preventable, intellectual disabilities and delayed growth and
development may be reduced or prevented through prompt
recognition and treatment.
COLLABORATIVE CARE
Nursing Care
Nursing care is based on the child’s response to the illness. The
main focus of care is to educate the family on the importance of
compliance with the medication regimen, periodic monitoring of
thyroid function, and on establishing a normal pattern of growth
without complications.
Medical Care
The focus of medical management is treatment with thyroid
hormone replacement therapy. Children with hypothyroidism are
treated with levothyroxine sodium (Synthroid). Doses are determined
based on age and weight. Iodine supplementation is also appropriate
in some cases. The easiest supplements are given in the diet. The
goal of treatment is normal hormone levels within the infant’s first 4
weeks of life. Frequent visits to the health-care provider for follow-up
blood tests and adjustments of the dose are necessary. Once the
child’s hormone levels are properly adjusted, return outpatient visits
are needed every 2 to 3 months for the first 3 years of life. Thyroid
hormone treatment may be needed for life; treatment is simple,
inexpensive, and easily monitored.
Educating the parents about the disorder and the treatment plan is
the focus of teaching. Parents need to be instructed on methods that
can be used to administer the medication as well as about adverse
effects. Parents are taught proper administration of the medication.
The pills can be crushed in a spoon, dissolved with a small amount
of water or other liquid immediately before administration, and
administered to the child with a syringe, dropper, or nipple (Taketomo
et al, 2019).
Parents need to be informed that careful and regular monitoring of
the child’s growth, weight gain, and developmental milestone
progression helps to validate that the dosing and medication
administration are sufficiently accurate to achieve positive results.
Laboratory blood tests of T4 and TSH every 4 to 6 months during the
first year of life and every 2 to 4 months afterward also keep close
track of the child’s hormone levels. Parents are encouraged to seek
early evaluation and intervention to any problems that become
readily recognizable. Educating the parents completely at the very
beginning regarding the diagnosis, its signs and symptoms, care,
treatment, and outcomes of care ensures that they know what to
watch for and are aware of the most effective care possible. For
children whose condition is not rapidly diagnosed or treated, the
return of normal thyroid function may take a long time. The child may
exhibit dramatic changes in behavior. Continued care by the health-
care provider, the endocrinologist, and a psychotherapist may be
necessary.
Graves’ Disease
Graves’ disease, an autoimmune disorder, is the most frequent
cause of hyperthyroidism in children. It may occur at any time during
childhood, but its frequency increases with age, peaking during
adolescence. Antithyroid drugs (ATDs; methimazole or carbimazole)
are usually recommended as the initial treatment and are generally
well tolerated. The overall frequency of relapse is higher in children
than in adults, with remission achieved in only 30% of children after
a first course of treatment for about 2 years. More prolonged medical
treatment may increase the remission rate to up to 50%. The
identification of factors predictive of relapse, such as severe
biochemical hyperthyroidism at diagnosis and the absence of other
autoimmune conditions, has facilitated the identification of patients
requiring long-term ATD treatment or alternative therapy. Alternative
treatments (mostly radioactive iodine, rather than thyroidectomy) are
considered in cases of relapse after an appropriate course of ATD,
lack of compliance, or ATD toxicity. Future research on the
management of patients should focus on improving compliance with
drug treatment through educational strategies, improving knowledge
of the long-term effects of the various treatment options on thyroid
gland morphology and function, potential morbidities, future
pregnancies, and QOL. A better understanding of the
physiopathology of this disorder should improve remission rates and
patient management and lead to the identification of factors
predicting the likelihood of remission.
SIGNS AND SYMPTOMS

Excessive thyroid hormone affects all organ systems of the body.
Symptoms of Graves’ disease are identical to those of
hyperthyroidism, with the addition of three other symptoms. Although
these symptoms present somewhat differently in each child, they
include:
■ Goiter (enlarged thyroid gland that may cause a bulge in the neck
and dysphagia)
■ Raised, thickened skin over the shins, back of feet, back, hands, or
face
■ Swollen, reddened eyes that bulge (exophthalmos)
Other signs and symptoms can include:
■ Tachycardia with palpitations
■ High blood pressure
■ Moist skin
■ Increased perspiration
■ Shakiness and tremor
■ Hyperreflexia
■ Audible thyroid bruit
■ Nervousness
■ Confusion
■ Emotional lability
■ Poor concentration and decreased school performance
■ Hyperdefecation
■ Increased appetite accompanied by weight loss
■ Difficulty sleeping
■ Constant stare
■ Sensitivity of eyes to light
■ Changes in menstrual periods
MEDICATION
Accurate Administration of Hormone Tablets
Hormone tablets (or any pills) are not mixed in a full bottle of formula. It is best
to avoid ruining the taste of the infant’s sole source of nutrition. Second, placing
the medication in a full bottle will require the baby to drink the entire bottle to
obtain the entire dose. Leaving even a small amount of formula on the bottom
of the bottle could mean that the child may be underdosed. Most drug
references state that hormone tablets mix very unevenly in solution, and it is
difficult for them to stay in suspension. It is best to crush and mix it in a small
amount of fluid immediately before administration. The solution is then drawn
up into an oral syringe and given before the feeding.
DIAGNOSIS
As with other thyroid conditions, blood levels of thyroid hormones
confirm the diagnosis. These hormones are elevated. TSH levels are
decreased because the high levels of T3 and T4 inhibit the anterior
pituitary’s production of TSH.
PREVENTION
Because Graves’ disease is an autoimmune condition, the best
prevention is careful observation to better facilitate diagnosis and
management. The nurse must be aware that infants born to women
with a current or past history of Graves’ disease may present with
neonatal Graves’ disease. In addition, research suggests a genetic
predisposition to Graves’ disease. Careful attention and recognition
of symptoms and referral or notification of the primary health-care
provider can lead to quicker initiation and response to treatment. In
addition, complications and exacerbation of symptoms may be
prevented by educating the parents and child on the proper use of
medication and on proper diet and rest.
COLLABORATIVE CARE
Nursing Care
Physical assessment is first and foremost in the care of the child
with Graves’ disease. The astute nurse may identify these children
when they are referred for evaluation of symptoms of ADHD. A
complete history including school performance, easy distractibility,
and sleep pattern disturbances will aid in the ongoing care of the
child. Once the child is diagnosed, the parents and child are taught
the importance of following the prescribed treatment regimens. The
nurse knows that treatment for hyperthyroidism is individualized for
each patient. Ultimately, the goal of treatment is to restore the thyroid
gland functioning in which the production of thyroid hormone is at
normal levels.
It is essential for the nurse to recognize the signs and symptoms
of both hyperthyroidism and hypothyroidism. A sudden release of
thyroid hormones can result in a thyroid storm, which can lead to
heart failure and shock. A sudden onset of restlessness, fever,
diaphoresis, and tachycardia is reported immediately because this
may indicate a thyroid storm. The only indication for care in the
hospital as an inpatient is if the child with hyperthyroidism
experiences a thyroid storm.
FOCUS ON SAFETY
Thyroid Storm
A thyroid storm is a rare and potentially fatal complication of hyperthyroidism.
It typically occurs in patients who experience a precipitating event such as
surgery, infection, or trauma. A thyroid storm must be recognized and treated
on signs and symptoms alone because laboratory confirmation often cannot
be obtained in a timely manner. Patients typically appear markedly
hypermetabolic with high fevers, tachycardia, nausea and vomiting,
tremulousness, agitation, and psychosis if untreated. Patients may also
become stuporous or comatose with hypotension.
Medical Care
Medical management is directed at decreasing thyroid hormone
levels and includes treatment with antithyroid medication, radioactive
iodine therapy, and subtotal thyroidectomy.
Treatment may include:
■ Antithyroid medications (PTU-propylthiouracil or MTZ-
methimazole) to help lower the level of thyroid hormones by
blocking the synthesis of T3 and T4. Pharmacotherapy has been
used effectively but has side effects (Table 19-5). Severe effects
can be fatal.
■ Radioactive iodine therapy (in the form of a pill or liquid), which
damages thyroid cells (destruction can take 6 to 18 weeks) to
decrease the production of thyroid hormones.
■ Surgery to remove the overactive nodule of the thyroid (subtotal
thyroidectomy).
■ Beta-blocking agents (Inderal) to block the action of thyroid
hormone on the body (these drugs do not change the levels of
thyroid hormone in the blood but make the patient feel better by
relieving tachycardia, restlessness, and tremors).
Surgical Care
The surgical option is used as a last resort when other treatments
have not resulted in permanent remission or when the parents
cannot comply with the medication regimen. Surgery may be
recommended for the child experiencing adverse effects from
antithyroid medication or if they have experienced a relapse after 2
years of treatment. This requires a sensitive approach to the family
and entails a thorough discussion between the primary health-care
provider and family. Some providers believe that total thyroidectomy
is the preferred, definitive treatment for patients with Graves’
disease.
Children with Graves’ disease primarily receive outpatient
treatment. The parents need to know the significance of continuing
the medication regimen even after the symptoms of hyperthyroidism
have resolved. Parents must also be taught to watch for medication
side effects. The importance of routine blood tests must also be
emphasized as well as following through with all return visits to the
health-care provider. If referrals are made, the importance of keeping
these appointments must be stressed.
Even though the child is being treated for hyperthyroidism, the
signs and symptoms of hypothyroidism must also be taught to the
family so they can identify if treatments become toxic. Emergency
numbers and referrals must be provided to the family in case severe
reactions occur.
The importance of a low-stress, low-pressure environment is also
reinforced because increased tension could exacerbate the
symptoms. The child may also exhibit sudden bursts of emotion such
as crying, excitement, or irritability. The family is taught to expect
these feelings and that the
TABLE 19-5
Side Effects of Antithyroid Medications
MILD EFFECTS SEVERE EFFECTS (CAN BE FATAL)
Skin rash Agranulocytosis (sore throat, high fever)
Mild leukopenia Lupus-like syndrome
Loss of taste Hepatitis
Arthralgia Hepatic failure
Loss/abnormal Glomerulonephritis
hair pigmentation
ill child is not able to control them. The importance of discussing

feelings with the child is stressed to minimize these outbursts.
Parents are instructed to notify the child’s school nurse and teacher
about these feelings. The school nurse may need to be involved in
the medication regimen during school operational hours. In this case,
a note from the child’s health-care provider is required. The teachers
must also be alerted to the child’s illness and the potential lack of
focus in class. It may even be necessary to have the child tutored so
that the child is able to catch up to the lessons.
Conditions of the Parathyroid
Hypoparathyroidism
Hypoparathyroidism is a rare condition in which there is inadequate
production of PTH. It can also occur when the PTH that is produced
cannot be used by the body or the kidneys and bones cannot
respond to the production of PTH. This deficiency of PTH decreases
the calcium level in the blood and increases the phosphate levels.
Hypoparathyroidism may be either inherited or acquired. It can
result from a variety of causes:
■ Underdeveloped parathyroid glands at birth (inherited)
■ Medical treatment (radiation to thyroid gland, drug treatment,
thyroid or parathyroid surgery) (acquired)
■ An underlying medical condition such as cancer, neck trauma,
Wilson’s disease (high level of copper in tissues), an excess of iron
in tissues, and low levels of magnesium (acquired)
■ Idiopathic (i.e., the parathyroid suddenly stops functioning for no
known reason)
■ Associated with other conditions (e.g., DiGeorge syndrome)
DiGeorge syndrome is an example of a defect in parathyroid gland
development, composed of hypoparathyroidism, T-cell abnormalities,
and cardiac anomalies.
SIGNS AND SYMPTOMS
The following signs and symptoms often appear in children with
hypoparathyroidism:
■ Poor tooth development
■ Vomiting
■ Headaches
■ Mental deficiency
■ Seizures
■ Uncontrollable, painful spasms of the face, hands, arms, and feet
■ Irritability
■ Muscle rigidity
■ Apnea causing irregular cyanosis
DIAGNOSIS
A thorough history and physical is completed. Care is taken to
assess for the presence of muscle spasms, twitches, or a history of
seizure activity. History or presence of vomiting with abdominal
distention is noted as well as episodes of apnea with or without
cyanosis. Blood work, including calcium (low), phosphate (high),
magnesium (low), and low PTH, confirms the diagnosis. Bone or soft
tissue abnormalities (increased bone density) are evaluated with
radiographs and CT scans. A 12-lead electrocardiogram (ECG) may
reveal a prolonged QT interval.
PREVENTION
There is no action that can be taken to prevent either hereditary or
sustained acquired hypoparathyroidism. With vitamin D therapy and
supplemental calcium, most people will have minimal symptoms.
Complications can be prevented or reduced by instructing the
parents and child on the importance of reporting symptoms such as
tingling or burning sensation in fingers, toes, or lips and muscle
twitching or cramping as well as medication compliance and follow-
up.
COLLABORATIVE CARE
Nursing Care
Hypocalcemia, which produces the symptoms of
hypoparathyroidism, such as seizures, tetany, and laryngospasms,
requires IV calcium. The nurse must continuously monitor the child
with telemetry for cardiac arrhythmias and blood pressure for life-
threatening hypotension. Seizure precautions are maintained until
calcium levels approach a normal level. Once serum calcium levels
are greater than 7.5 mg/dL, the IV calcium can be stopped.
FOCUS ON SAFETY
Calcium Administration
It is important for the pediatric nurse to scrupulously check the IV site for
accurate placement because infiltration of the IV calcium supplements causes
extravasation and sloughing of the tissue around the site. IV calcium
supplements must be properly calculated, diluted, and administered strictly
according to the hospital’s standards of care and protocols. Oral calcium and
vitamin D are administered as soon as possible. Monitor the success of the
oral forms of calcium and vitamin D for at least 24 hours after IV calcium is
stopped because “rebound” hypocalcemia can occur. The nurse must be alert
for subtle changes in the child’s status.
NURSING INSIGHT
Assessing for Hyperreflexia of Muscles
Assess for hyperreflexia (increased action of the reflexes) by tapping on the
facial nerve. If there is a spasm of the facial muscles, this is a positive
Chvostek sign (facial muscle spasm) and confirms the fact that the child has
muscle pain, cramps, and probably twitches. These muscle manifestations may
progress to numbness and tingling of the hands and feet as well as stiffness.
Remember infants and small children cannot express these manifestations and
therefore just cry to communicate pain.
Medical Care
The goal of medical management is to maintain the calcium in a
low-normal range while avoiding hyperphosphatemia. In the acute
phase of hypoparathyroidism, calcium is administered IV; diuretics
may be prescribed in that circumstance as well to prevent
overexcretion of calcium in the urine and to reduce the amount of
calcium and vitamin D needed. The active form of vitamin D, 25-
dihydroxyvitamin D, is preferred in the treatment of
hypoparathyroidism. Urinary calcium secretion is monitored to avoid
the risk of renal parenchyma calcification. Long-term medical care
includes medication administration of calcium and vitamin D multiple
times a day as well as regular checks of serum and urine
electrolytes. The child is monitored for the development of long-term
complications (e.g., cataracts and soft tissue calcification) as well as
nephrolithiasis, which can affect renal function.
Teaching the families about the disease, its signs and symptoms,
and the importance of lifelong treatment optimizes the outcomes of
the child’s care. A lifelong regimen of dietary or supplemental
calcium and vitamin D is usually required to restore calcium and
mineral balance. If phosphorus levels are extremely elevated, a diet
may be given that excludes high-phosphorus foods such as eggs
and dairy products.
Hyperparathyroidism
Hyperparathyroidism is rare in children. Primary hyperparathyroidism
is more common in females and in adolescents. It is caused by
overactive parathyroid glands that produce high levels of PTH, which
results in increased levels of serum calcium. The excess calcium
leads to osteoporosis and osteomalacia (both bone-weakening
diseases). High levels of PTH cause the bones to demineralize,
which increases the serum calcium levels. PTH also acts on the
kidney to conserve calcium and excrete phosphate. Another result of
the increased serum calcium is the development of kidney stones.
Kidney stones form because of the high levels of calcium excreted
into the urine by the kidneys. Primary hyperparathyroidism may
develop as a result of one of the following conditions:
■ Single or multiple benign tumors in the parathyroid glands
■ Parathyroid hyperplasia (excessive growth of normal parathyroid
cells)
■ Parathyroid malignancies (rare)
■ Certain endocrine disorders, such as types I and II multiple
endocrine neoplasia syndromes
SIGNS AND SYMPTOMS

At least 50% of patients with primary hyperparathyroidism have no
symptoms, and approximately 1% of cases go undiagnosed. When
symptoms do occur, they are generally attributed to persistently high
levels of calcium. Symptoms include:
■ Bone and joint pain
■ Bone loss leading to osteoporosis with possible bone fractures
■ Muscle weakness
■ Abdominal discomfort because of pancreatitis
■ Heartburn
■ Constipation
■ Lack of appetite
■ Peptic ulcers
■ Kidney stones
■ Excessive thirst
■ Excessive urination
■ Depression
■ Anxiety
■ Memory loss
■ Excessive drowsiness or fatigue
DIAGNOSIS
Although this diagnosis is frequently delayed in children, it is
usually detected when the child becomes symptomatic. Children with
symptoms of renal colic or nephrolithiasis are evaluated for
hyperparathyroidism. Evaluation of elevated blood calcium and PTH
levels is diagnostic in children. If radiographs are performed, the
child’s bones may show signs of rickets (Fig. 19-3).
PREVENTION
There is no known prevention for primary hyperparathyroidism, but
early recognition of the symptoms may promote compliance with
treatment and reduce overall complications. People who are at risk
for this condition should avoid dehydration. Risk factors generally
refer to adults and include being older, female, obese, and having
depression, though inherited endocrine problems can also lead to
hyperparathyroidism.
COLLABORATIVE CARE
Nursing Care
Nursing care consists of medical and surgical management.
Nursing care focuses on fluid management and consistent
monitoring of the child’s intake, output, and electrolyte balance.
Medical Care
Because hyperparathyroidism is demonstrated by hypercalcemia,
initial treatment focuses on reducing osteoclastic bone reabsorption.
Initial management may include the use of medications, such as oral
phosphate, pamidronate, calcitonin, or etidronate disodium to treat
hypercalcemia associated with hyperparathyroidism. Administration
of IV fluids and diuretics may assist with the increased excretion of
calcium in children not in renal failure. A diet low in calcium may also
be ordered.
Surgical Care
Parathyroidectomy is effective and restores the normal blood
calcium levels. This surgery has few complications and is the
treatment of choice in children with primary hyperparathyroidism.
Unfortunately, if diagnosis is late, this surgical procedure cannot
reverse the late effects of hyperparathyroidism on other organs such
as the kidneys.
Preoperative care includes increasing the child’s intake and
careful monitoring of I&O. The nurse also monitors IV fluids and
dietary restrictions. Urine is strained when renal calculi are
suspected. Monitor the child for safety in the presence of muscular
weakness. Postoperative care of the child after removal of the
parathyroid glands is focused on airway management and frequent
assessments for respiratory distress or airway obstruction because
of edema at the surgical site. As with all surgical procedures,
continue monitoring for signs of infection and hematoma.
The child and family are taught to consistently observe for signs
and symptoms of hypocalcemia. Learning to administer calcium
supplements is invaluable because this treatment may be needed for
life. Family members are taught to realize that frequent blood draws
may be necessary initially to monitor calcium and phosphorus levels.
The nurse can explain to the family that eventually the lab work can
be done less frequently, but it needs to be stressed that these blood
tests are an important part of the continued health care of the child.
The primary health-care provider may recommend that the child take
nutrition supplements because primary hyperparathyroidism can
cause vitamin deficiencies. Vitamins C and K as well as manganese
are necessary for normal bone formation.
Conditions of the Adrenals
Acute Adrenocortical Insufficiency

Adrenal crisis may be caused by any of the following: rapid
withdrawal from steroid therapy, sepsis, surgical stress, bleeding into
the adrenal glands, pituitary necrosis, or thyroid hormone
replacement in someone with adrenal insufficiency. The following
factors increase the chance of developing adrenal crisis: septic
shock, adrenal insufficiency, and use of steroid medications. If the
child has any of these risk factors, the health-care provider must be
notified.
SIGNS AND SYMPTOMS
The child in adrenal crisis may exhibit any of these symptoms, but
it is important for the nurse to remember that these symptoms may
also be caused by other, less serious health conditions. However, it
is vital to report any of the following signs and symptoms to the
health-care provider:
■ Weakness
■ Ongoing fatigue
■ Nausea
■ Vomiting
■ Weight loss
■ Low blood pressure
■ Abdominal pain
■ Fever
■ Confusion or coma
■ Diarrhea
■ Cyanosis
■ Dehydration
FIGURE 19-3 A radiograph taken to diagnose rickets.
DIAGNOSIS
Tests to diagnose adrenal crisis may include chest radiograph, CT
scan of the abdomen, and blood tests that detect ACTH and
electrolyte levels, red blood cells, and other autoimmune or
endocrine disorders.
PREVENTION
Prevention of adrenal crisis involves ongoing assessment of the ill
or hospitalized child with a history of CAH. Parents are educated to
recognize symptoms that indicate the beginning of an acute adrenal
crisis as well as the need for “stress” doses of hydrocortisone when
their child has a febrile illness, surgery, or trauma. If the child is
hospitalized, the nurse must notify the health-care provider if adrenal
crisis is suspected.
COLLABORATIVE CARE
Nursing Care
Be cognizant of the fact that this crisis can be fatal and may
quickly appear. The nurse must ensure continuous assessment;
recognition of the signs and symptoms is essential. It may be
necessary to take the child’s vital signs every 15 minutes, always
carefully watching for the most subtle signs of the onset of shock.
Subtle signs of shock may include a slight cooling of the hands and
feet along with a decrease in skin color. For example, the infant’s
periphery may go from pink to extreme pallor. The nurse must
monitor IV fluid rates and remain in constant communication with the
health-care provider so that responses to the treatments are known
and counteracted if necessary.
Medication administration is also a significant part of nursing care.
Medications are given as prescribed by the health-care provider.
Once the child has stabilized, clear, oral fluids can be initiated slowly.
It would defeat the purpose if, in the child’s eagerness to drink, they
began to vomit again. For this reason, encourage the child to drink
slowly. If the child refuses to drink, other forms of liquid such as ice
pops, frozen ice, gelatin, or broth may give the child incentive to take
fluids orally. In this situation, parents are often in a state of confusion
and shock because the treatments and changes in their child’s
condition occur rapidly. Keep the parents informed by providing
frequent updates on the child’s condition as well as an explanation of
the treatments. To decrease the parents’ fear, noting slight
improvements in the child’s status helps them remain positive.
Because neurological symptoms can be so devastating, remind the
parents that these are only temporary and that paralysis can be
reversed once the child is stabilized.
Recognize that fluid shifts may also occur quickly, so lab values
must be reviewed often. Cortisone and sodium chloride treatments
are often given rapidly to rectify ominous situations. A consequence
of this rapid treatment is an abnormally low potassium level, such
that the child may be at risk for flaccid paralysis or seizures.
Continue ongoing observation and frequent assessment of the child.
Medical Care
Initially, steroid IV hydrocortisone (A-Hydrocort) and antibiotic
drugs are needed to treat an adrenal crisis. If the child is vomiting or
unconscious, the nurse gives these medications by injection or IV.
Because of fluid loss, the child is given IV fluids to reverse
dehydration, electrolyte imbalances, and hypovolemia. If the child is
in severe crisis and has a decreased blood pressure, vasopressor
may be used to raise the child’s blood pressure quickly by
vasoconstriction. When these conditions are corrected and the child
is stable, cortisone medications and sodium chloride may be given
orally. Sodium balance is maintained by replacing aldosterone with
synthetic steroids that aid in sodium retention.
Labs
Potassium Depletion
Because treatments for adrenal crisis cause potassium depletion, it is crucial
to keep a close watch on the child’s lab values. Be mindful of the warning
signs of hyperkalemia and hypokalemia (apnea, cardiac arrhythmias,
paralysis, poor muscle control, and weakness).
Discharge preparation is started as soon after the crisis as
possible. Keep in mind the readiness of the parents to learn. Be sure
that the parents are ready to listen and learn about the care of the
child at home. In some cases, it may be necessary to wait until the
parents feel secure about the fact that their child will be going home
under their care. Parents and the child need to be taught as
appropriate that medication will be required throughout the child’s
life. Parents may also benefit by being taught how to give
hydrocortisone IM, which may be needed if the child vomits. Explain
the need for careful monitoring of the child in the presence of illness,
stress, or surgery because this may require the necessity of
contacting the health-care provider for an adjustment in dose.
Parents need to know that some teens do not take prescribed
medication doses because of the side effects. The nurse can
reassure parents that this may happen and to call the primary
pediatrician if it does. Provide parents with information about
obtaining a medical ID bracelet or necklace for the child.
Chronic Adrenocortical Insufficiency

Chronic adrenocortical insufficiency, or Addison’s disease, is the
result of an underactive adrenal gland. An underactive adrenal gland
produces insufficient amounts of cortisol and aldosterone.
Cortisol is a steroid hormone that helps to control the body’s
metabolism of fats, proteins, and carbohydrates; suppresses
inflammatory reactions in the body; and affects immune system
functions. Aldosterone is a steroid hormone that controls sodium and
potassium in the blood.
The onset of this disease may occur at any age. Most of the time,
the cause of the disease is unknown. Most Addison’s disease cases
are caused by the actual destruction of the adrenal glands through
cancer, infection, an autoimmune process, or other diseases. Other
causes may include the following:
■ Use of corticosteroids as a treatment (such as prednisone) may
cause a slowdown in production of natural corticosteroids by the
adrenal glands and mimic Addison’s disease.
■ Certain medications used to treat fungal infections may block
production of corticosteroids in the adrenal glands, causing signs
and symptoms similar to those of Addison’s disease.
■ Rarely, Addison’s disease is inherited as an X-linked, recessive
trait; the gene responsible for the condition is located on the X
chromosome and passed down from a healthy female carrier to
her sons, who are affected. In this form, symptoms typically begin
in childhood or adolescence.
Failure to produce adequate levels of cortisol can occur for
different reasons. Corticosteroids play an important role in helping
the body fight infection and promote health during physical stress.
The problem may be caused by a disorder of the adrenal glands
themselves or by inadequate secretion of ACTH by the pituitary
gland. The lack of adrenal hormones may cause:
■ Elevated levels of potassium
■ Extreme sensitivity to the hormone insulin, which is normally
present in the bloodstream, and may lead to low blood sugar levels
■ Increased risk during stressful periods, such as surgery, infection,
or injury
Primary Adrenal Insufficiency
Most cases of primary adrenal insufficiency are caused by the
gradual destruction of the adrenal cortex, the outer layer of the
adrenal glands, by the body’s own immune system. Primary adrenal
insufficiency (Addison’s disease) is uncommon in the United States.
Retrospective case review in one U.S. urban center suggests that
Addison’s disease secondary to CAH occurs in approximately 1 per
16,000 infants (Tafuri, 2020). Adrenal insufficiency occurs when at
least 90% of the adrenal cortex has been destroyed. As a result,
often both glucocorticoid (cortisol) and mineralocorticoid
(aldosterone) hormones are lacking. Sometimes only the adrenal
gland is affected, as in idiopathic adrenal insufficiency. In other
cases, additional endocrine glands are also affected, as in
polyendocrine deficiency syndrome.
SIGNS AND SYMPTOMS
It is important to note that mild symptoms of Addison’s disease
may manifest only when the child is under physical stress. The most
common symptoms of Addison’s disease may be seen individually or
in any combination. Each child experiences symptoms very
differently. Classic signs of Addison’s disease include
hyperpigmentation, hyponatremia, poor vascular tone,
hypoglycemia, ketonemia, and hyperkalemia. The nurse needs to
regularly observe for any of the following symptoms (NIH, 2020):
■ Weakness
■ Fatigue
■ Dizziness
■ Rapid pulse
■ Dark skin that is first noted on hands and face
■ Black freckles
■ Bluish-black discoloration around the nipples, mouth, rectum,
scrotum, or vagina
■ Weight loss
■ Dehydration
■ Intense salt craving
■ Muscle aches
■ Nausea
■ Vomiting
■ Diarrhea
■ Cold intolerance
When assessing for shock in children with a dark complexion, the
nurse must remember to look at the palms of the hands, soles of the
feet, and lips to ascertain color changes; pale or bluish skin tone is
common.
If left untreated, Addison’s disease can lead to severe abdominal
pain, extreme weakness, low blood pressure, kidney failure, and
shock, especially when the child experiences physical stress.
Although the symptoms of Addison’s disease may resemble other
problems or medical conditions, it is best for the nurse to encourage
the parents to consult the child’s health-care provider to confirm the
diagnosis.
The symptoms progress slowly and may be ignored until a
stressful event such as an illness or an accident causes the child’s
condition to worsen. This is called an Addisonian crisis, or acute
adrenal insufficiency. In most cases, symptoms are severe enough
that patients seek medical treatment before a crisis occurs. However,
in a few children, symptoms first become readily apparent during an
Addison’s disease crisis.
DIAGNOSIS
Aside from the clinical symptoms and the signs found on physical
examination, including low blood pressure, a diagnosis of Addison’s
disease is usually confirmed by laboratory tests. Typically, a patient
has low blood sodium, high potassium, and low blood sugar. The
initial test for adrenal insufficiency is the measurement of serum
cortisol levels. The serum cortisol level is drawn in the morning
between 6 and 8 a.m. The levels are the highest at this time because
of circadian rhythm. Cortisol levels greater than 20 mg/dL are
considered normal, whereas levels less than 3 mg/dL are diagnostic
of Addison’s disease. Levels lower than this must be considered
within the clinical context.
PREVENTION
Preventive measures in caring for the child with Addison’s disease
are through education with the goals of controlling stress, preventing
and monitoring for an Addison’s crisis, and maintaining growth and
development. Parents need to be cognizant of stress in the
environment, which may include febrile illnesses, surgery, injury, and
emotional stress. Stress increases the body’s demand for cortisol.
Parents also need to be instructed on ensuring that the child
complies with hormone replacement therapy. In addition, parents can
be instructed on the administration of IM hydrocortisone in the case
of vomiting. If the child becomes ill, injured, or needs surgery, the
health-care provider is notified regarding the potential need for
dosage adjustment.
COLLABORATIVE CARE
Nursing Care
Nursing care of the hospitalized child in adrenal crisis is similar to
that of the child with congenital adrenal insufficiency. When a child is
hospitalized in an adrenal crisis, the focus of nursing care is on fluid
and electrolyte replacement. Closely monitor for signs of
hypovolemic shock. The nurse understands that peripheral
circulation must be checked often. Frequently, hourly assessments
help the nurse detect subtle changes that can be the earliest
indicators of potential imbalances not yet detected by laboratory
tests.
Medical Care
Addison’s disease is treatable with oral forms of the missing
hormones. Cortisol (Solu-Cortef) is available in tablet form, and it is
given two to three times a day. This medication helps maintain the
child’s blood glucose levels.
If the patient has an illness accompanied by vomiting, an IM
injection of cortisol (Solu-Cortef) must be given at home. Then the
patient must be taken to an emergency room for further treatment.
All patients or their parents must have a dose of Cortisol (Solu-
Cortef) available at home and be instructed on the proper technique
to administer it during a crisis.
Parents need to be aware of the diligent commitment of giving the
child medications routinely and regularly. They must plan medication
delivery into their day so that it is never forgotten. The morning rush
to school, the bus, or car-pool may not be the best time to plan
cortisol replacements. Parents must also know that the drug cannot
be stopped suddenly, and that if the child is unable to ingest it
because of vomiting, the injectable hydrocortisone must be given IM.
Teaching IM injections is also necessary. Another important aspect
of parent teaching involves providing information on the side effects
of the drug as well as on the signs and symptoms of adrenal crisis. A
home free of stress is the best environment for a child with Addison’s
disease because the body needs increased cortical hormones during
times of stress and the child’s body is unable to produce the
hormone. During times of emotional stress or physical stress, the
parents may have to give additional hormone replacements.
Because dehydration and stressful situations are the likely triggers of
a crisis, instruct parents to keep the child well-hydrated in situations
such as extreme heat, exercise, or influenza. These conditions are
discussed before discharge so that the parents feel in control when
at home.
One of the best recommendations to make to parents when caring
for a child with Addison’s disease is to purchase a medical alert
bracelet or tag for the child to wear. This would ensure that the
treatment of a child in crisis would not be delayed. It is also important
to teach the family and the child about electrolyte loss (especially
sodium) during vigorous exercise or on extremely hot days when the
child would perspire. Eating more salty food and drinking more water
in hot weather helps the child maintain a mineral balance in the
body, which will ward off a crisis.
Optimizing Outcomes
Hormone Treatment
The best outcome of care for the child is optimized with adequate hormonal
treatment. Hormone treatment helps maintain a normal growth pattern. Even
though a child with Addison’s disease rarely grows beyond the 5th percentile,
development during puberty is normal (Tafuri, 2020).
FOCUS ON SAFETY
Cortisone Insufficiency
When caring for this child, whether in the hospital or clinic, the pediatric nurse
must be aware of the signs and symptoms observed before an adrenal crisis:
headache, dizziness, and nausea or vomiting (stomachache) or “wobbly
knees.” By the time the child exhibits extreme weakness and mental
confusion, the adrenal crisis is imminent. Parents also need ongoing support
to manage the care and the medications of a child with Addison’s disease.
This is often very frightening for parents. A well-thought-through plan can help
the parents be ready for any emergency.
The Child With Addison’s Disease
Along with the primary care provider, the endocrinologist is an important
member of the team. Including the parents as members of this team will ensure
that they will feel in better control of potential crisis situations. As the child
matures and becomes a teenager, it is essential to include them as well so that
the child is educated and understands the consequences of skipping doses of
medication or of stress. The child also needs to be competent to administer
emergency, injectable doses of the cortisone.
Cushing’s Syndrome
Cushing’s syndrome is a rare disorder seldom seen in persons
younger than 20. This condition occurs when there is too much
cortisol in the body. When diagnosed in young children it is often
caused by an adrenal tumor or more commonly prolonged use of
glucocorticoids like prednisone or other steroid therapy (Tafuri,
2020). Glucocorticoids are often used to treat chronic diseases such
as asthma. Other causes include tumor on an adrenal gland that
makes too much adrenocorticotropin hormone or certain chronic
conditions such as inflammatory bowel disease, lupus, or rheumatoid
arthritis (Knoble et al, 2018).
Although the true etiology of Cushing’s syndrome is not clear,
causes may include the oversecretion of the pituitary, causing an
excessive amount of serum ACTH, or of the adrenal gland, causing
an overload of glucocorticoids, usually tumor-related. Long-term
administration or large doses of corticosteroids may also cause a
child to present with Cushing’s syndrome. If a child’s adrenal glands
are insensitive to normal levels of cortisone, then levels can become
dramatically abnormal (Knoble et al, 2018).
SIGNS AND SYMPTOMS

The signs and symptoms of Cushing’s syndrome develop
gradually, so insidiously, in fact, that it may be years before the child
shows clearly visible signs of Cushing’s syndrome. The hallmark
symptom of Cushing’s disease in children is plateau of vertical height
with continued increase in weight. Often children are hypokalemic,
causing alkalosis because of potassium excretion, and
hypercalcemic, caused by excessive amounts of urinary calcium.
Common signs and symptoms of Cushing’s syndrome include:
■ Weight gain
■ Pendulous abdomen
■ Fatigue
■ Muscle wasting
■ Weakness
■ Thin extremities
■ Round “moon” face
■ Facial flushing
■ Fatty pad between shoulders (buffalo hump)
■ Pink or purple stretch marks (striae) on abdominal skin, thighs,
breasts, and arms
■ Thin and fragile with little subcutaneous tissue, causing easy
bruising and slow healing
The child may exhibit the following:
■ Depression
■ Anxiety
■ Irritability
■ Euphoria
■ Frank psychoses
■ Irregular or absent menstrual periods in females
■ Erectile dysfunction in males
NURSING INSIGHT
Signs and Symptoms of Cushing’s Syndrome
Hyperglycemia may eventually lead to latent or overt diabetes, high blood
pressure, or arteriosclerosis. Because of the excess production of androgens,
signs and symptoms related to secondary sexual characteristics can also be
seen.
DIAGNOSIS
Children who are being evaluated for Cushing’s syndrome must be
seen by a pediatric endocrinologist because test result adjustments
must be considered before the diagnosis is confirmed. Levels of
cortisone are recorded so that escalating levels are clearly seen.
A 24-hour urine collection is a valuable tool to determine if the
child’s urine is clear of free cortisol. Because 24-hour urine
collections can be very difficult to obtain in an infant and child, the
test may need to be duplicated to obtain reliable results. It is
important to remember that to correctly interpret the results of the
24-hour urinary free cortisol (UFC), the results must be “corrected”
for the child’s body surface area (Mayer, Kahkoska, Jefferies et al,
2018).
Because cortisone is released by the child’s body in response to
stress, several other conditions could cause high UFC levels, for
example, physical stress, such as overexertion or obesity, and
emotional stress such as depression (Ghandi, 2017).
Cortisol levels can also be measured in a child’s saliva by taking
both a midnight and morning sample. Levels are usually at the
lowest point at midnight and the highest in the morning (Ghandi,
2017). This normal pattern is lost in children with Cushing’s
syndrome and the midnight levels are not significantly different from
the morning levels.
Diagnosis is based on the results of not only urine and saliva
screening but also on serum blood levels, including fasting blood
glucose and electrolyte levels as well as a bone scan for
osteoporosis and a radiograph of the skull for an enlarged sella
turcica. An MRI of the pituitary as well as a CT scan of the child’s
adrenal glands may also be performed.
COLLABORATIVE CARE
Nursing Care
Nursing care depends on the cause and the treatment of the
illness. If the child has a surgical intervention, nursing care involves
preoperative assessments and fluid hydration as well as
postoperative assessments, pain control, and medication regimens.
When a child’s adrenal glands have been removed, cortisol
replacement is necessary. This medication is best given early in the
morning or every other day to decrease the side effects. This
regimen closely mimics the body’s normal diurnal pattern of
cortisone secretion. The nurse needs to teach the child and family
about the disease, its cause, and subsequent treatments. If a
surgical intervention is indicated, thorough preoperative and
postoperative teaching must be done. Often the operating room is a
frightening place for children. Many hospitals perform this teaching
well before the procedure and have children tour and touch
equipment when they are relaxed, which enables the day of the
procedure to go much more smoothly.
Medical Care
Management varies depending on the cause with the goal of
resolving hormone balance and reversing the symptoms of
Cushing’s syndrome. If the cause of Cushing’s syndrome is long-
term steroid therapy, treatment is directed at reducing the dose to
the lowest possible therapeutic level needed to treat the underlying
condition (Mayer et al, 2018). Treatments may include
pharmaceuticals that inhibit the production of cortisol. Surgical
excision is the treatment of choice for pituitary or adrenal gland
tumors. If surgery is not possible, radiation therapy is used.
Surgical Care
Tumors in either the pituitary or the adrenal glands require surgical
excision. Referrals to a neurosurgeon are necessary.
Teaching parents how to give the medication, including the
injectable for an emergency situation, helps gain the confidence
necessary to manage a child recovering from Cushing’s syndrome. It
is important to inform the parents that the “Cushing-like” appearance
will decrease as the child recovers. Finally, it is very important to
alert the parents to watch for signs of adrenal insufficiency. If
corticosteroid treatments are stopped, the child will exhibit signs of
adrenal insufficiency. Encourage the family to have the child wear
medical alert identification at all times.
Congenital Adrenal Hyperplasia

Children born with congenital adrenal hyperplasia (CAH) lack the
ability to produce cortisol. The condition begins early during the fetal
gestational period, and the infant is born with the disease. With this
deficiency, or lack of cortisol, the negative feedback system fails,
causing an excessive amount of corticosteroid-releasing hormone to
be secreted from the hypothalamus as well as ACTH from the
anterior pituitary. Overproduction of ACTH in turn causes the adrenal
glands to become hyperplastic, causing an excessive amount of
androgens to be secreted.
SIGNS AND SYMPTOMS
Generally, the male infant has no physical differences until later in
childhood when the early development of pubic hair, penile
enlargement, or both are accompanied by accelerated linear growth
and advancement of skeletal maturation. At birth, a female may have
malformed external genitalia. The clitoris is enlarged, and there may
be a fusion of the labial folds; this can give the female a male
appearance externally. Internally, the uterus, fallopian tubes, and
ovaries are normal.
Symptoms of cortisol deficiency include:
■ Weight loss
■ Weakness
■ Poor appetite
■ Hypoglycemia
■ Cool, clammy skin
■ Dizziness
■ Confusion
Symptoms of aldosterone deficiency include:
■ Vomiting
■ Poor feeding
■ Lethargy
■ Dehydration
■ Skin hyperpigmentation
■ Fatigue
DIAGNOSIS
Although prenatal screening is used to diagnose CAH as early as
possible, false positives indicate that the health-care provider must
be cognizant of the clinical signs and symptoms postnatally; milder
cases may be missed by the newborn screening programs.
Chromosomes can be studied microscopically to determine the
child’s gender.
PREVENTION
Preventive measures in caring for the child with congenital adrenal
insufficiency include education with the goals of controlling stress,
preventing and monitoring for signs of adrenal insufficiency, and
maintaining growth and development. Stress increases the body’s
demand for cortisol, so parents need to be cognizant of stress in the
child’s environment, such as during febrile illnesses, surgery, injury,
and emotional stress.
COLLABORATIVE CARE
Nursing Care
Nursing care is similar to that of the child with Addison’s disease.
Health-care professionals must maintain a positive atmosphere from
the moment the baby is born. In the delivery room, a positive
emotional tone has a lasting effect on the parents’ understanding of
this disease. Care is directed at preventing and monitoring for acute
adrenal crisis and educating the parents about the importance of
medication compliance.
Medical Care
Nearly all children diagnosed with CAH are treated with
replacement of glucocorticoids. By alleviating the deficiency of
cortisol, the negative feedback loop suppresses ACTH secretion and
thus prevents adrenal stimulation. The mineralocorticoid
fludrocortisone (Florinef) or hydrocortisone (A-Hydrocort) is also
given. Neither of these drugs has significant side effects at
replacement doses. Side effects are seen only when doses exceed
those necessary for replacement. If the levels are above normal, the
child can acquire acne, an elevated blood pressure, or even growth
retardation. Because all females with CAH are fertile, surgical repair
can be performed once the replacement of hormones has begun.
Usually it is done before the girl’s first birthday, and if necessary, may
be further corrected before menarche.
Because these medications need to be given throughout the
child’s life, parents need to be instructed to give the medication
regularly. Often, making the administration part of the family’s routine
will ensure that the medication is not forgotten. The alternative route
to the oral medication, namely the IM medication, must also be
taught in the event that the child has an illness in which oral doses
are contraindicated. Emergency procedures, including IM injection of
hydrocortisone, must be taught to the parents. It is essential for the
family to know that if the medication cannot be given at all, the child
must be taken to the emergency department of the closest hospital
for treatment. It is always good advice to recommend that the child
wear a medical alert bracelet.
What to Say
Congenital Adrenal Hyperplasia
It is important to address CAH and the decision about whether to wait to
perform surgical correction until the child can participate in the discussions.
Questions to consider include:
• Because the surgery is usually cosmetic in nature, what harm would there be
to wait?
• What are the consequences of early surgical repair?
• Will the nerve endings to the female’s clitoris be damaged?
• What effect will the early surgery have on the child’s sexuality in later life and
on the sexual identity of the child?
Obviously, the decision is very complex and requires careful thought. The
nurse can also examine personal thoughts about what makes up a child’s
sexuality.
Much parental teaching is needed not only regarding the

medication and its various route and administration methods but also
about this chronic illness and its treatment, as well as pre- and
postoperative teaching if genital reconstruction is done. Emotional
support of the parents is also essential for this lengthy process.
Family education, including for the siblings and grandparents,
must be provided, and the nurse can best help the parents address
these family members. Referring to the infant as a “beautiful baby”
will help the parents accept the baby as early as possible.
Patient Education
Parent Teaching for Hydrocortisone (A-Hydrocort) Administration
• Medication must be used as prescribed.
• Parents must know to always have the injectable hydrocortisone available at
home, school, and wherever the child travels.
• An emergency kit is kept on hand at all times with a cortisol supply (IM
cortisol) to administer to the child during acute illness, vomiting, diarrhea, or
during stressful circumstances.
• Administer the medication on time because this follows the child’s body’s
normal cortisol release patterns.
As with any lifelong illness, it is important for the parents to

acknowledge the importance of regular checkups. The primary
pediatrician and the endocrinologist, pharmacist, dietitian, and nurse
can work together to support the entire family to reach their
maximum potential.
Hyperaldosteronism
Hyperaldosteronism produces excessive secretion of aldosterone,
which may be caused by an adrenal tumor or syndrome that is a
result of an enzyme deficiency. Similar to other endocrine disorders,
hyperaldosteronism becomes symptomatic with excessive sodium
levels and deficient potassium levels as well as fluid retention.
SIGNS AND SYMPTOMS
The following are associated with excess cortisol:
■ Weight gain
■ Growth failure
■ Osteopenia
■ Delayed puberty
■ Acne
■ Purple striae
■ Hirsutism
■ Compulsive behavior
The following findings are associated with fluid retention:
■ Hypervolemia
■ Headache
■ Hypertension
■ Nocturnal enuresis
■ Low specific gravity
The following findings are associated with hypokalemia:
■ Muscle weakness
■ Paresthesia
■ Episodic paralysis and tetany
■ Polydipsia
■ Polyuria
DIAGNOSIS
When a young child presents with hypertension, the health-care
provider must rule out adrenal tumors. In addition to the
hypertension, the child presents with hypokalemia and polyuria; if
these conditions fail to respond to ADH administration, the clinical
diagnosis of hyperaldosteronism is suspected. Diagnostic findings
may include elevated plasma and urinary aldosterone and an
abnormal glucose tolerance test. Imaging with MRI or CT may assist
with diagnosis when a tumor is suspected.
Labs
Hyperaldosteronism
Lab results indicate decreased potassium level, increased aldosterone level,
and decreased renin activity. Urinalysis reveals an elevated aldosterone level.
A CT scan of the child’s abdomen reveals an adrenal mass, and an ECG
shows abnormalities that can occur with low potassium levels.
PREVENTION
Preventive measures in caring for the child with
hyperaldosteronism include education with the goals of preventing
and monitoring for the adequacy of blood pressure control and
treatment of hypokalemia as well as maintaining growth and
development. Parents also need to be instructed on ensuring that
the child complies with hormone replacement therapy. Genetic
counseling is provided when familial hyperaldosteronism is identified.
COLLABORATIVE CARE
Nursing Care
Nursing care and treatment are similar to those for chronic
adrenocortical insufficiency. Initially, the potassium depletion is
replaced, and the diuretic spironolactone (Aldactone) causes
diuresis and thus blocks the aldosterone effects by preserving
potassium and promoting sodium and water excretion.
Any child admitted with hypertension is observed closely for the
signs and symptoms of hyponatremia and hyperkalemia. Excessive
thirst, bed wetting, or unexplained weakness raise suspicions in the
nurse that the child has a serious illness. When vital sign
assessments do reveal hypertension, it is important to notify the
health-care provider immediately and continue frequent vital signs
until a provider performs a thorough physical. Once the diagnosis is
confirmed, the nursing care focuses on preoperative care and
teaching. The treatment plan must be followed, but more importantly,
it must be taught to the family because the child will often need
medication that must be adjusted for growth for the duration of the
condition.
Postoperative care focuses on the child’s immediate status and
care on continual assessments of fluid balance, incision site, and
adherence to the medication regimen. If diuretics are ordered, it is
best to administer them as early in the day as possible to avoid bed
wetting at night. Because the potassium supplements can be difficult
to swallow, mixing them with strong flavored juice helps make the
medication more palatable.
Medical Care
Treatment of hyperaldosteronism depends on the cause. Medical
management may include use of glucocorticoids such as
spironolactone. Spironolactone is the most effective drug for
controlling the effects of hyperaldosteronism, though it may interfere
with puberty.
Surgical Care
In the presence of a tumor, surgical excision of the affected
adrenal gland or tumor is recommended. Once the gland or tumor is
excised, it is common for the child to experience hypoaldosteronism
postoperatively. Hyperkalemia is also seen in this period because of
the potassium replacements. Children may need mineralocorticoid
supplementation for several months after the removal of the adrenal
gland or tumor. Although postoperatively the blood pressure
declines, it may not be sustained and may also need to be controlled
with a sodium restriction diet, or antihypertensive medications.
The medication regimens are the focus of parent teaching (e.g.,
give diuretics early in the day). Alerting the parents to subtle signs of
electrolyte imbalances is the best weapon against serious
consequences. Parents should know the signs and symptoms of
hypo- and hyperkalemia. The parents can also meet with a dietitian
to discuss high-potassium foods that can be included in the child’s
diet. Being open and available to answer questions or to help the
parents in any way is the best support that can be given to the
family.
METABOLIC CONDITIONS
Metabolic conditions of the pancreas most often involve the
destruction of the islets of Langerhans (contain insulin-producing
beta cells), which causes a failure to produce and secrete enough
insulin to digest the carbohydrates, proteins, and fats eaten by the
child (Fig. 19-4). Diabetes is one of the leading causes of chronic
illness in the United States. Previously, diabetes was classified as
child (type 1—insulin dependent) or adult (type 2—noninsulin
dependent) depending on the time of onset and insulin dependency.
Today classification is much more complex because either type can
affect a person of any age and can be either insulin dependent or
noninsulin dependent.
■ Type 1 diabetes mellitus: caused by cell destruction resulting in
definite insulin dependency
■ Type 2 diabetes mellitus: caused by insulin resistance in which the
body fails to recognize and use insulin properly

Type 1 diabetes mellitus is one of the most common chronic
diseases in childhood and is caused by insulin deficiency resulting
from the destruction of insulin-producing pancreatic beta cells. Type
1 diabetes is an autoimmune disease that arises when a child with a
particular genetic makeup is exposed to any precipitating event,
such as infection—particularly viral—or other environmental factors
such as diet. Insulin deficiency results from the destruction of insulin-
producing pancreatic beta cells. The age of presentation of
childhood onset T1DM has a bimodal distribution, with one peak at 4
to 6 years of age and a second in early puberty (10 to 14 years of
age). Approximately 45% of children present before age 10
(Robinson et al 2019).
Unique challenges in caring for children and adolescents with
diabetes differentiate pediatric from adult care. These include the
obvious differences in the size of the patients, developmental issues
such as the unpredictability of a toddler’s dietary intake and activity
level and inability to communicate symptoms of hypoglycemia, and
medical issues such as the increased risk of hypoglycemia and
diabetic ketoacidosis (DKA) (Mayer-Davis et al, 2018). Because of
these considerations, the management of a child with type 1
diabetes must account for the age and developmental maturity of the
child. Although most children with type 1 diabetes present with the
classic signs and symptoms of hyperglycemia without accompanying
acidosis, approximately 30% of children in the United States present
with DKA.
Diagnosis
Primarily, elevated postprandial or random blood glucose levels
(usually in excess of 200 mg/dL) and elevated hemoglobin levels
(HbA1c) (equal to or greater than 7.0%) are indicative of diabetes
mellitus). A fasting blood sugar may be equal to or greater than 126
mg/dL. Urine glucose and ketones may also be increased. The child
generally presents with the complaint of the usual triad of symptoms
(polyuria, polydipsia, and polyphagia). Per health-care provider
order, repeat fasting blood glucoses because at least two random
elevated blood glucose studies help make the final determination of
the diagnosis.
Prevention
Type 1 diabetes is not preventable, though people with type 1
diabetes can help prevent or delay the development of complications
by keeping their blood sugar within a target range. Prevention
includes adherence to dietary expectations and regular checkups,
which include monitoring for changes in blood pressure and
cholesterol. Additional preventive measures include the avoidance of
smoking and compliance with immunizations as well as with the
annual flu shot and pneumococcal vaccine. In the case of
adolescents or children old enough to administer their own insulin,
parents need to ensure that the child is compliant and following the
medication regimen (Fig. 19-5).
FIGURE 19-4 Mechanism of insulin.
FIGURE 19-5 How to inject insulin.

Assessment Tools
Assessing Blood Sugar
Hypoglycemia (Low Blood Sugar)
• Cold, pale skin (cold sweat)
• Light-headedness
• Shakiness or hand tremors
• Sudden hunger (crave salt or sweet)
• Emotional outbursts (personality changes)
• Drowsiness or extremely tired
• Pounding heartbeat or palpitations
• Nervousness or dizziness
• Anxiety or irritability
• Sweating
• Headache, mental confusion, difficulty concentrating
• Numbness or tingling of lips or mouth
• Poor coordination or staggering, unable to walk
• Slurred or slow speech
• Dilated, enlarged pupils
• Fainting (needs emergency treatment immediately)
Hyperglycemia (high blood sugar)
• Loss of appetite, nausea, or vomiting
• Increased thirst, even if consuming a large amount of liquids
• Weakness, stomach pains or aches
• Heavy, labored breathing
• Fatigue, tired, often sleepy
• Large amounts of sugar in urine
• Ketones in urine
• Frequent urination
• Blurred or double vision
Collaborative Care
Nursing Care
Nursing care is individualized based on the needs of the child and
family; therefore, child care is organized around monitoring,
stabilization, and education.

Nursing Care Related to Developmental Issues With Type 1 Diabetes
THE INFANT AND TODDLER
• Management is up to caregiver(s)
• Consistency in intake is important, particularly carbohydrates
• Food can become a battleground between the caregiver(s) and child
• Carbohydrate consistency rather than a specific food group offers more
flexibility than a structured meal plan
• Diluted insulin may be required for some infants
• Establish rituals and routines
• Find a specific place to perform blood tests and keep the supplies
• A toddler will feel more in control if able to predict and participate in activities
• Signs and symptoms of hypoglycemia may be mistaken for the toddler’s
temper tantrum
The Preschooler
• Characteristics of this age are increased motor maturity, friends, and magical
thinking
• They understand simple explanations, which can allay fears
• Stress that the diabetes is not caused by being bad
• Play therapy using dolls and equipment will help them express feelings
• Need meal and snack supervision
• May be able to identify physiological feelings associated with hypoglycemia
• High-energy activities make them susceptible to hypoglycemia
• Caregiver(s) needs to be prepared with carbohydrates as well as emergency
medicines
AGE-APPROPRIATE DIABETES TASKS
• Chooses and cleans finger for puncture
• Helps by holding still for injection
• Identifies a word or phrase to describe feeling of hypoglycemia
• Helps by choosing foods
The School-Age Child
• Incorporate the diabetes into a busy school day
• Care needs to be unobtrusive to avoid singling out the child
• Encourage the family to communicate with school personnel
• A school nurse needs to supervise blood glucose monitoring and insulin
injections and educate others to recognize and treat hypoglycemia
• Caregiver(s) and the school nurse must plan ahead for field trips, school
parties, and athletic events (e.g., send snacks, emergency medicine, and
phone numbers)
• Performs finger puncture and blood glucose test
• Chooses injection site according to rotation schedule
• Pushes plunger on insulin syringe after the needle is inserted by parent or
gives own injection
• Performs ketone testing
• Recognizes the need to eat on time to avoid hypoglycemia
• Knows treatment for hypoglycemia
The Adolescent
• Peer group acceptance and body image are important issues
• Risk-taking behaviors are common
• Challenging authority is common
• Missed injections, omitted tests, irregular meals, and dietary splurges are
common
• Late adolescence is marked by future orientation and fewer peer group
demands
• Shift from caregiver(s) responsibility to the adolescent taking responsibility for
their condition
• Identify what is important to the adolescent (e.g., appearance, athletic ability,
endurance, or weight)
• Records blood glucose values in diary
• Performs insulin injection
• Draws up and injects insulin
• Looks for patterns in blood glucose values
• Recognizes when to test for ketones
• Initiates treatment for ketones (fluids)
• Chooses correct foods for meals and snack
• Adds extra snack for increased activity
• Can choose appropriate foods at school and social gatherings
Medical Care
The goals of medical management include optimal glycemic
control, normal growth and development, minimizing complications,
education, and attainment of emotional adjustment to diabetes. The
treatment regimen includes monitoring blood sugar for
hypoglycemia, hyperglycemia (Table 19-6), and HbA1c and
establishing control through nutrition and meal planning, insulin
therapy, exercise, prevention of complications, and education.
TABLE 19-6
Hypoglycemia and Hyperglycemia
CLINICAL CONDITION MANIFESTATIONS CRITICAL NURSING
ACTIONS
HYPOGLYCEMIA
Too much insulin for Rapid onset • Give 15 grams of
amount of food eaten Irritable carbohydrates (1/2 glass
Nervous orange juice)
Injected insulin into Shaky feeling, tremors • Recheck blood glucose in 15

muscle minutes
Too much activity for Difficult to concentrate • If blood glucose is >70 mg/dL,
insulin dose Difficult to speak give another 15 grams of
carbohydrates
Too much time between Behavior change • Recheck again in another 15

meals Confused minutes
Repeats over and over
Too few carbohydrates Unconscious Seizure • If unconscious, give IM

eaten glucagon
Illness or stress Tachycardia Shallow

breathing Pale, sweaty
Hungry Headache
Dizzy
HYPOGLYCEMIA
Blurry or double vision

Photophobic
Numbness of mouth or
lips
HYPERGLYCEMIA
Too little insulin for the Gradual onset • Give additional insulin at usual
food eaten Lethargic injection time
Sleepy
Illness or stress Slow response • Use sliding scale doses for

Confused specific level of blood glucose
Too many Breathes deeply and • Increase fluids

carbohydrates eaten rapidly Skin flushed and
dry
Meals too close Mucous membranes dry • If ketones are elevated, give
together an extra insulin injection
Too many snacks Thirsty, hungry,

dehydrated
Insulin given just under Weak, tired, headache

skin
Too little activity Abdomen hurts Nausea

and vomiting Blurry
vision Shock
MEDICATION
Blood Glucose and Ketone Monitoring
The ADA has recommended that the health-care provider weigh the benefits of
lowering the child’s blood glucose levels against the unique risk of
hypoglycemia. Children with type 1 diabetes may lack the capacity to recognize
and respond to hypoglycemic symptoms so blood sugar is monitored
frequently. Hypoglycemic unawareness is a unique challenge for all pediatric
health-care professionals and parents. Home glucose monitoring occurs three
to six times per day (Fig. 19-6). With home testing, glucose control is more
exact than in the past. The importance of home monitoring is a vital aspect of
care. Parents can be reassured that the glucose monitor is generally covered
under most insurance plans.
Urine testing for ketones is performed at least every 3 hours

during a child’s illness. Ketones also must be checked whenever
blood glucose readings exceed 240 mg/dL or when the child
experiences unexplained weight loss even if they are well. Ketones
in the urine are indicative of insulin deficiency.
Insulin
Many factors influence the child’s insulin requirements. Insulin needs
are affected by the child’s nutritional intake and physical energy
expended as well as the child’s emotional and stress levels that
accompany normal activities like growth spurts, puberty, and illness.
Despite these variables that make insulin regulation extremely
difficult, it is the foundation of treatment for a child with type 1
diabetes.
Many types of insulin are available today (Table 19-7). Generally,
the type of insulin used for each individual patient is based on the
child’s blood glucose levels and the child’s lifestyle. Combinations of
short, intermediate, and long-acting insulin (premixed) are given
subcutaneously throughout the day to simulate the body’s natural
release of the hormone (Table 19-8).
■ Humalog/NovoLog insulin is a short-acting insulin. It is clear and
usually taken immediately before meals. This regular insulin works
so quickly that it can even be taken after meals. It is usually used
for children who are picky eaters or toddlers who do not always eat
the same amount of food and thus can take the insulin right after
they eat.
■ Regular insulin is a rapid-acting insulin, which is also clear and
begins to act quickly; it merely takes slightly longer to reach its
peak than Humalog or NovoLog.
■ NPH insulin is an intermediate insulin. It is cloudy and absorbs
more slowly. It is made with a protein, enabling its slow release.
Even though the peak and the duration can vary from child to child,
generally when this insulin is taken in the morning it does not take
effect until the afternoon.
■ Ultralente insulin peaks somewhat more slowly than the previous
NPH. It can be given at dinner, and its effects can help maintain a
normal blood glucose level until morning.
■ Lantus insulin is long-acting. It is a clear insulin that lasts 24 hours
with steady levels, giving it nearly no peaking action. It is like NPH
in that it is consistent and predictable in its action but can vary
within the same child in the time it takes to peak from one day to
the next. Lantus, like all types of insulin, is given subcutaneously,
but because it cannot be mixed with any other insulin, it must be
given as a separate injection.
■ Lente, NPH/Regular, and NPH/Humalog are premixed insulin
combinations that give the child the benefit of more than one type
of insulin with a single injection. The premixed varieties are usually
used by families who do not want to have to draw from several
bottles.
FIGURE 19-6 Home monitoring requires parents to perform glucose

checks on the child with diabetes.
EXAMPLES OF MEDICAL ORDERS FOR INSULIN ADMINISTRATION
■ Apidra Insulin 100 units/mL – give 1 unit(s) for every 12 grams of

carbohydrates eaten
■ Apidra Insulin 100 units/mL – give 1 unit(s) for every 50 mg/dL BS
over 150 (BS 300 minus 150 = 150/50 = 3 units)
■ Lantus Insulin 100 units/mL – give 5 units now
■ Lantus Insulin 100 units/mL – give 5 units at bedtime
Lantus insulin (dosage determined by health-care provider) is
given daily at the same time once. In the case of an infant or toddler,
the insulin is given after the meal based on the carbohydrate intake.
Insulin must be given by subcutaneous injection. Parents are
taught to expect that their child may need one to four injections per
day and that, generally, the more injections, the greater the blood
glucose control. Children can be fearful of injections. Parents need
time, patience, and encouragement. Give support to parents and
caregivers while they give an injection to boost their confidence.
With some children and adolescents, insulin pump use is
increasing because the delivery of insulin is steady throughout the
day, which most closely resembles the body’s natural response.
Recent research has shown that with proper training and follow-up,
insulin pump therapy provides a lasting and effective treatment
modality. Because pumps can be easily mistaken for a cell phone,
pager, or iPod, communication with schoolteachers regarding the
use and occasional beep is essential (Fig. 19-7).
Caregiver knowledge is associated with better glucose
control/outcomes in young children with diabetes. Education is the
main route by which a family achieves the best glucose control for
the child with type 1 diabetes. The better the blood glucose control,
the less often the child will experience complications. Education
must focus on insulin types, use, administration, and schedule; meal
planning, including the balance of carbohydrates, proteins, and fats;
physical exercise; blood glucose monitoring; and extremity care.
Children with diabetes could use alternative therapies to help
manage blood glucose levels and to prevent any of the
complications associated with the condition:
■ Lifestyle changes, particularly diet and exercise
■ Medications, namely insulin for individuals with type 1 diabetes
■ Stress reduction and relaxation techniques
■ Acupuncture for pain from nerve damage
TABLE 19-7
Insulin
INSULIN NAME INSULIN ONSET PEAK DURATION
TYPE EFFECT
Humalog/NovoLog Rapid-acting 10–15 minutes 55 minutes 4 hours
Regular Short-acting 30 minutes 95 minutes 6–9 hours
NPH Intermediate- 2–4 hours 6–8 hours 12–15 hours

acting
Ultralente Intermediate- 4–6 hours 8–20 hours 24–36 hours

acting
Lantus Long-acting 1–2 hours 2–22 hours 24 hours
Source: Chase, H. P., & Eisenbarth, G. S. (2011). Diabetes mellitus. In W. W. Hay,

M. J. Levin, J. M. Sondheimer, & R. R. Deterding (Eds.), Current diagnosis &
treatment, New York, NY: Lange Medical Books/McGraw-Hill.; Jospe, N. (2011).
Endocrinology. In K. J. Marcdante, R. M. Kliegman, H. B. Jenson, & R. E.
Behrman (Eds.), Nelson’s essentials of pediatrics (6th ed., pp. 625–669).
Philadelphia, PA: Elsevier.
TABLE 19-8
Premix Insulin
INSULIN INSULIN TYPE ONSET PEAK EFFECT DURATION
NAME
Lente Premixed 1–2 hours 3–14 hours 18–20 hours
70/30 Premixed 30 minutes Variable 12–18 hours

NPH/Regular
75/25 Premixed 10–15 minutes 1–8 hours 12–15 hours

NPH/Humalog
Source: Chase, H. P., & Eisenbarth, G. S. (2011). Diabetes mellitus. In WW. Hay,
M. J. Levin, J. M. Sondheimer, & R. R. Deterding (Eds.), Current diagnosis &
treatment, New York, NY: Lange Medical Books/McGraw-Hill.
FIGURE 19-7 Wearing an insulin pump is a good way for children to
regulate glucose levels.
MEDICATION
Insulin Dosage and Frequency
Although the dosage of insulin is based on the individual needs of the child or
adolescent, the precise dose needed for each individual child cannot be
predicted. For children, common maintenance doses of insulin range from 0.5
to 1.0 unit per kilogram per day in divided doses (Taketomo et al, 2019).
For adolescents, common maintenance doses of insulin depend

on weight and increased need for insulin during a growth spurt. An
adolescent may require less than 1.2 units/kg/day during a growth
spurt. A nonobese adolescent may require 0.4 to 0.6 units/kg/day,
and an obese adolescent may require 0.8 to 1.2 units/kg/day
(Taketomo et al, 2019). If 2 doses of insulin are the goal of treatment,
then usually 60% to 75% of the insulin is given before breakfast with
the remainder given with the dinner meal.
Stressful life events can worsen diabetes in several ways. For
example, stress stimulates the nervous and endocrine systems in
ways that increase blood glucose levels and disrupt healthy
behaviors (e.g., eating habits). Stress management is an integral
part of the treatment of diabetes. Studies have shown that diabetics
who participate in biofeedback sessions are more likely to reach
normal blood glucose levels. Although other studies have produced
results that contradict this, researchers and clinicians generally
agree that long-term stress is likely to worsen diabetes and that
biofeedback, tai chi, yoga, and other forms of relaxation may help
motivate people with diabetes to change their habits to manage their
condition.
Patient Education
Family Education for Type I Diabetes
• Teach children and families how to count carbohydrates.
• Teach children and families about exercise in relation to insulin dosage and
diet. Exercise plays an important role when regulating glucose levels. Blood
glucose levels are decreased during periods of exercise. Children require less
insulin. Children with type 1 diabetes who exercise must monitor their blood
glucose levels carefully. Monitoring of the glucose levels must occur before,
during, and after exercise. Vigilant monitoring may prevent a hypoglycemic
reaction. It is also important for children with diabetes to balance their
carbohydrate intake and exercise to maintain normal blood glucose levels.
The nurse can help children and families learn about a meal plan that
accounts for age, size, weight, exercise level, medications, and other
psychosocial and medical issues in relation to their exercise pattern.
• Teach children and families about blood glucose and ketone monitoring.
Monitor blood glucose levels three to six times per day. Monitor urine ketones
whenever blood glucose readings exceed 240 mg/dL, when children
experience unexplained weight loss, or if the child is ill.
• Teach children and families about the management of this chronic illness. The
focus of follow-up care is helping children reduce symptoms and prevent or
prolong the appearance of long-term complications. Standard follow-up care
is determined on an as-needed basis, and children are seen by a health-care
provider at least every 3 months for glucose and symptom monitoring.
• Teach children and families about DKA. DKA is a combination of
hyperglycemia, ketosis, and acidosis resulting from severely deficient insulin
in either type 1 or type 2 diabetes. Children are hospitalized so be sure to
provide support to the family during this crisis.
PROCEDURE ■ Teaching Parents How to
Inject Insulin
PURPOSE
To teach parents how to inject insulin
EQUIPMENT
• Insulin bottle from refrigerator (remove up to 1 hour before injection to allow it
to warm to room temperature)
• Appropriate syringe (U-30, U-50, or U-100)
• Alcohol wipes
• Container for the dirty, used syringe
STEPS
1. Check the expiration date on the insulin bottle. RATIONALE: Ensures that
the insulin has not expired.
2. Wash hands.
RATIONALE: Prevents the spread of bacteria.
3. Clean rubber stopper on insulin bottle with alcohol wipe.
RATIONALE: Promotes asepsis.
4. Remove syringe cap and pull air into the syringe. Line up the end of the
black plunger to the exact amount of the insulin dose needed.
RATIONALE: Ensures accurate dosage of insulin to be drawn up.
5. Put the syringe needle through the bottle rubber top and push syringe
plunger so that all the air goes from the syringe into the bottle.
6. Turn the insulin bottle upside down and pull the syringe plunger so that the
insulin enters the syringe until the top of the black plunger exactly lines up
with the dose of insulin to be given.
7. Remove every air bubble, always checking that the dose is exact.
RATIONALE: Exact dosing is essential in managing the child’s condition.
8. Choose (or let the child choose) the site of the injection.
RATIONALE: Allowing the child to participate may help them feel more in
control of the condition.
9. Clean the injection site with an alcohol swab. RATIONALE: Alcohol will
decrease the presence of microorganisms.
10. Pinch up the skin slightly and gently, with the syringe at a 90-degree angle
(perpendicular) to the skin, and with a dart-like motion, insert the needle into
the skin and release the skin.
RATIONALE: Ensures proper medication administration.
11. Slowly inject the dose of insulin.
12. Discard the used syringe in a hard, rigid container with a tight-fitting lid.
TEACH PARENTS
If the child expresses that the injection is painful, the following measures can
be taken to decrease the pain:
• Inject room temperature insulin.
• Clear even the tiniest air bubbles from the syringe.
• Let the alcohol dry completely before injection.
• Tell the child to relax muscles in area of injection (the more tense the muscles
during injection, the more painful the procedure).
• Use syringe-like dart to pierce skin quickly.
• Do not change the needle direction during insertion or withdrawal.
• Never reuse syringes.
• Rotate sites with each injection (giving the insulin in the same place twice in 1
day can cause unnecessary discomfort for the child and undue stress on the
tissue).
• Document exactly where each injection was given to avoid the same place
more than once a day.
• Create and keep a Diabetes Management Notebook with the plan and a place
to record daily blood sugar values as well as doses of insulin administered
including injection site. For example:
Date Blood Blood Insulin Dose Injection Given By
Glucose Glucose Given and Site
A.M. P.M. Time
8/9/15 144 4 units regular Right mid- Mom
at 0700 arm
8/9/15 144 > 4 units regular Left mid- Dad

4 units thigh
NPH 1230
Patient Education
Dealing With a Hypoglycemic Crisis
HOW TO: Recognize the signs of hypoglycemia (child is pale, sweaty, dizzy,
“shaky” [tremors], confused, irritable, numb on lips or mouth, and can have an
altered mental status)
• Check blood glucose level.
• If blood glucose is below 70 mg/dL, rapidly give one of the following sources
of carbohydrates (about 10 to 15 grams each), the right amount to treat
hypoglycemia:
- 1/2 to 3/4 cup of orange or grape juice (a juice box is good when one is
away from home)
- 2 glucose tablets or 2 doses of glucose gel
- 2 to 4 pieces of hard candy
- 5 gumdrops
- 1 to 2 tablespoons of honey
- 1 small box of raisins
- 6 oz regular (not diet) soda (about half a can)
- 2 tablespoons of cake icing
• Recheck blood glucose in 15 minutes; if reading is still below 70 mg/dL, then
give another glass of juice.
• Recheck blood glucose again after another 15 minutes.
• When blood glucose returns to at least 80 mg/dL, a more substantial snack
(nonconcentrated sugar) may be given (e.g., cheese and crackers, bread and
peanut butter, etc.) if the next meal is more than 30 minutes away or if a
physical activity or exercise is planned.
• If the child is unconscious, glucagon is given either subcutaneously or IM
(ADA, 2020).
A Team Approach to Type 1 Diabetes
The care of a child with type 1 diabetes is very complex. A team approach with
the family at the core of the team is paramount. Based on age, the child is
included in the plan and the care as much as possible (whenever appropriate).
The most effective team consists of several members across the specialties
within the hospital including primary pediatrician, pediatric endocrinologist,
diabetes nutritionist and nurse educator, exercise physiologist, and mental
health professionals for psychological support as needed. Lines of
communication must be kept open to best serve the family and the child. It is
also vital to include other significant adults (living in the home) into the diabetic
child’s plan of care.
The glucose balance of a child with type 1 diabetes is daunting

(Table 19-9). Because glucose control highly depends on monitoring
and regulating the child’s diet, exercise, and insulin dose and
administration, the significant people in the child’s daily life must
know the plan. That is, the child’s teachers, coach, school nurse,
counselor, principal or assistant, and even the “lunch mom” must
know the appropriate parts of the plan to help actualize it. A child is
not to be left unsupported at any time. Whatever the child is involved
in away from the home, the responsible adults must know the
appropriate care of the diabetic child.

Unlike type 1 diabetes mellitus, type 2 diabetes mellitus is caused by
the body’s resistance to recognize and use insulin rather than a
deficient production of insulin as in type 1. For years, type 2 diabetes
was labeled as “adult-onset,” but in the past several decades there
has been an alarming increase in type 2 diabetes in young people.
Insulin resistance occurs when the individual cells do not recognize
the insulin molecule and resist its influence. The cell membrane does
not allow the insulin to initiate the normal enzymatic reactions that
cause metabolism. The glucose cannot be used by the cells, the
cells begin to be “starved,” and the blood glucose levels slowly but
steadily rise.
It is estimated that over one-third of all people with type 2 diabetes
are undiagnosed. Though the incidence of type 2 diabetes is rare in
children under 10, the increase of type 2 diabetes in the adolescent
population has been dramatic over the past decade according to the
American Diabetes Association and the Centers for Disease Control
and Prevention.
Populations at higher risk for type 2 diabetes include African
American, Hispanic/Latina Americans, Native American Indians, and
Asian/Pacific Islander Americans according to the National Institutes
of Health. Other risk factors include obesity; sedentary lifestyles;
high-caloric, lipid-rich diet; and family history.
Signs and Symptoms

Children with type 2 diabetes often have no symptoms, and their
condition is detected only when a routine exam reveals high blood
glucose levels or complications appear. Occasionally, a child with
type 2 diabetes may experience some of the following symptoms,
which tend to appear gradually over time:
TABLE 19-9
Plasma Blood Glucose and A1C Goals
PLASMA BLOOD GLUCOSE GOAL RANGE (MG/DL)
AGE MORNING BEDTIME/OVERNIGHT HEMOGLOBIN RATIONALE

GROUP BEFORE A1C%
(YEARS) MEALS
Toddlers and 100–180 110–200 >8.5% High
preschoolers risk/vulnerability
(0–6 years) to
hypoglycemia
School age 90–180 100–180 >8% Risk of

(6–12 years) hypoglycemia
and low risk of
complications
prior to puberty
Adolescents 90–130 90–150 >7.5% Risk for severe

and young hypoglycemia
adults (13– Developmental
19 years) and
psychological
issues
Lower goal
>7.0% is
reasonable if it
can be
achieved
without
excessive
hypoglycemia
Sources: American Diabetes Association (ADA) (2013). Standards of medical care

in diabetes—2013. Diabetes Care, 36, Suppl 1, 11–66.
■ Numbness or burning sensation of the feet, ankles, and legs

■ Blurred or poor vision
■ Impotence
■ Fatigue
■ Poor wound healing
■ Obesity
■ Unexplained weight loss
■ Headache
■ Symptoms of sleep apnea
In some cases, symptoms may mimic type 1 diabetes and appear
more abruptly. These symptoms include:
■ Polyuria
■ Polydipsia
■ Nocturnal enuresis or nocturia
■ Yeast infections
■ Whole body itching
Diagnosis
The American Diabetes Association (ADA) has established criteria
for type 2 diabetes testing in children:
■ Overweight defined as a BMI greater than 85th percentile for age
and sex, weight greater than 85th percentile for height, or weight
greater than 120% of ideal weight for height, plus two of the
following risk factors:
■ Family history of type 2 diabetes in a first- or second-degree
relative
■ Race/ethnicity (Native American, African American, Latino, Asian
American, Pacific Islander)
■ Signs of insulin resistance or a condition associated with insulin
resistance such as acanthosis nigricans (black-brown velvety skin
condition on the back of the neck, axillae, or arms caused by too
much insulin in the blood), hypertension, dyslipidemia, polycystic
ovary syndrome, or small-for-gestational-age birth
■ Maternal history of diabetes or gestational diabetes mellitus
Blood glucose testing begins at about age 10 years or at the onset
of puberty if younger and should be done every 3 years. The
preferred test is the fasting blood glucose level (ADA, 2020).
Diagnosis is confirmed with fasting blood glucose results equal to or
greater than 126 mg/dL or two random blood glucose readings equal
to or greater than 200 mg/dL.
Prevention
Type 2 diabetes can be delayed or prevented through a healthy
lifestyle. The risk of developing diabetes and related complications
related can be reduced through diet, physical activity, and
maintaining a healthy weight. A large prevention study looked at
persons with a high risk for diabetes and demonstrated that the
development of type 2 diabetes was reduced by 58% during a 3-year
period through weight loss, increased activity, and lifestyle changes.
Increased awareness of the escalating type 2 diabetes crisis in the
pediatric population can give the nurse the necessary tools to begin
to fight this problem. Nurses, no matter what their care setting or
work environment, teach the public about the value of weight control,
active lifestyles, and role model a healthy example for teachers,
families, and most importantly, children.
Collaborative Care
NURSING CARE
Care of the child with type 2 diabetes may occur in a variety of
settings and varies related to the developmental age of the child and
the family’s response to the diagnosis. Education is the focus of care
and will need to involve those who provide care to or interact with the
child, such as parents, teachers, and day-care providers. Managing
diet, exercise, lifestyle, and medication compliance as well as
preventing complications are the focus of child and family education
(Fig. 19-8).
The child and parents are provided with information about the
disease, prognosis, self-care, the importance of follow-up,
monitoring, and treatment needs. Refer to type 1 diabetes for more
detail regarding nursing care as appropriate for the child’s needs.
FIGURE 19-8 Preschooler with balloon at Diabetes Day Education
Program learning more about diabetes.
Consistent monitoring for complications of diabetes is a critical

component of the care of a diabetic child. The nurse must be alert to
the signs and symptoms of complications. The signs of acute
complications include hypoglycemia, weight loss, and DKA. Long-
term complications involve the degradation of vital body systems,
including cardiopathy, nephropathy, neuropathy, and retinopathy.
Many complications can have devastating effects, including growth
failure, delayed puberty, menstrual disturbances, emotional
disturbances, cataracts, impaired cognitive function, hyperlipidemia,
and breakdown or buildup of subcutaneous tissue at injection sites.
Communicate not only with the primary health-care provider but
with the endocrinologist, the nutritionist, the diabetic nurse educator,
the pharmacist, the social worker, the school nurse, and the home
health nurse, so that everyone is knowledgeable about the individual
needs of each particular child and their family.
MEDICAL CARE
The management of type 2 diabetes can vary depending on the
severity of the disease. With normal or near normal HbA1c levels,
nutritional teaching, such as decreasing calories, and behavior
changes, especially increasing activity, are pivotal to successful
therapy. Current pharmacologic treatment options for youth-onset
type 2 diabetes are limited to two approved drugs—insulin and
metformin. Presentation with ketoacidosis requires a period of insulin
therapy until fasting and postprandial glycemia have been restored
to normal or near-normal levels. Metformin therapy may be used as
an adjunct after resolution of ketosis/ketoacidosis. Initial treatment
should also be with insulin when the distinction between type 1
diabetes and type 2 diabetes is unclear and in patients who have
random blood glucose concentrations ≥250 mg/dL (13.9 mmol/L)
and/or A1C ≥8.5% (69 mmol/mol) (Davidson, 2020). Insulin is
needed when the glycemic target is not met on metformin alone.
When insulin treatment is not required, initiation of metformin is
recommended. The Treatment Options for Type 2 Diabetes in
Adolescents and Youth (TODAY) study found that metformin alone
provided durable glycemic control (A1C ≤8% [64 mmol/mol] for 6
months) in approximately half of the subjects. To date, the TODAY
study is the only trial combining lifestyle and metformin therapy in
youth with type 2 diabetes; the combination did not perform better
than metformin alone in achieving durable glycemic control
(Davidson, 2020).
Teaching lifestyle modification must include the entire family to
ensure compliance. The ADA recommends increasing physical
activity with the goal of engaging in moderate activity such as
walking. Dietary recommendations include limiting the intake of
sugar-sweetened drinks, reducing intake of fat and calories, and
increasing dietary fiber (ADA, 2020).
With a mildly elevated HbA1c level (5.7%–6.4%), an oral
hypoglycemic agent such as metformin (Actoplus Met) may be given
(ADA, 2020). The medication, in combination with lifestyle
modification, usually successfully lowers the blood glucose level.
With severe presentation (greater than 9.0%), treatment is similar to
that of type 1 diabetes. Insulin is given either IV or subcutaneously
until the child is stabilized.
Teaching the child, parents, teachers, counselors, coaches, and
clergy is the primary focus of nursing care. Healthy eating habits and
increasing activity in a sedentary lifestyle are very difficult. All of this
must be done without compromising normal growth and
development while improving the QOL.
Provide diabetes education for both the parent and child. (Table
19-10). For example, to optimize outcomes of care, the nurse should
interview both the parents and child to recognize factors that may
make compliance difficult, including unhealthy eating habits or
sedentary lifestyle practices.
Approximately 30% of pediatric patients who have type 1 diabetes
present with DKA (Mayer-Davis et al, 2018). This condition is a
complex combination of hyperglycemia, ketosis, and acidosis
resulting from severely deficient insulin in either type 1 or type 2
diabetes (although it is extremely rare in type 2 diabetes). The
abnormal metabolism of carbohydrates, protein, and fat that leads to
very high glucose levels causes DKA. It is important to know that
DKA is the leading cause of death in children with type 1 diabetes.
In many cases, ketoacidosis occurs with young children who have
difficulty verbalizing the classic signs and symptoms.
Signs and Symptoms

It is important to note that in toddlers, the classic manifestations of
DKA are often absent. In addition, the signs and symptoms may be
difficult for the child to verbalize. Many times, the disease goes
undetected because of its slow onset. When the family does have a
diagnosis of diabetes, a complete history, especially noting
compliance with insulin regimens and the name of the
endocrinologist, is essential. Signs and symptoms of DKA include
the following:
■ Fatigue
■ Malaise
TABLE 19-10
Teaching Parents, the Child, and the Adolescent About Diabetes
Parent Outcomes: Child and Adolescent Outcomes:

• Manage the child’s diabetic condition • Learn to manage diabetic care
• Set realistic goals for the child and • Learn to set realistic goals at and
entire family away from home
• Acquire confidence about providing • Acquire confidence about self-care
diabetic care
TOPIC THE NURSE WILL THE CHILD CAN: THE
TEACH THE ADOLESCENT
PARENT(S) CAN:
ABOUT THE:
The Diabetic • Type of diabetes • Give a simple • Give a more

Condition • Treatment plan explanation of the complete
based on age and disease explanation of the
growth and • Begin to learn disease
development diabetic self-care • Perform diabetic
benefits of healthy self-care
lifestyle
Nutrition • Importance of • Begin to learn • Make appropriate

breastfeeding and how to make food choices
dietary needs appropriate food • Know guidelines
during growth and choices for meal and
development • Begin to learn the snack planning
• The principles of guidelines for • Understand social
carbohydrate and meal and snack eating habits
medications in planning • Apply the
relation to daily • Begin to principles of
lifestyle understand social carbohydrate and
• The principles of eating habits medications in
carbohydrate • Begin to learn relation to daily
exchange about the lifestyle
principles of • Apply the
carbohydrate and principles of
medications in carbohydrate
relation to daily exchange
lifestyle
• Begin to
understand
carbohydrate
exchange
Activities • Way activity and • Begin to • Limit television or
glucose levels understand computer gaming
interact sedentary • Engage in active
• Way younger activities such as games or
children have high television or activities such as
energy levels that computer gaming walking and
affect blood should be limited sports that
glucose levels • Begin to promote better
• Way habits such understand that health
as walking and playing active
sports can games or
promote better engaging in
health activities such as
walking and
sports promote
better health
Medications • Way insulin acts • Begin to • Supervise self

and its adverse understand the related to diet and
reactions need for frequent insulin
• Way insulin is supervision • Plan diet and
dosed related to diet and medication
• Way to administer insulin around lifestyle
insulin • Begin to • Recognize the
• Way insulin is understand how need for
stored to plan diet and additional
• Way to create a medication carbohydrates or
medication around lifestyle insulin depending
schedule to fit the • Begin to on the glycemic
family’s lifestyle understand the state
need for
additional
carbohydrates or
insulin depending
on the glycemic
state
Hypoglycemia and • Signs and • Begin to • Understand and

Hyperglycemia symptoms of understand the respond to the
hypoglycemia and signs and signs and
hyperglycemia symptoms of symptoms of
and how to hypoglycemia and hypoglycemia and
respond to the hyperglycemia hyperglycemia
situation and learn how to
respond to the
situation
Medical Emergency • Cause and • Learn about the • Understand and

response to cause and respond to
diabetic response to diabetic
ketoacidosis diabetic ketoacidosis
ketoacidosis
Chronicity • The risk of long- • Begin to • Understand and

term, uncontrolled understand the respond to the
diabetes such as risk of long-term, risk of long-term,
the effect on uncontrolled uncontrolled
neurological and diabetes such as diabetes and the
vascular systems the effects on effects on
neurological and neurological and
vascular systems vascular systems
Psychosocial • Way to give • Learn to manage • Manage the

Adjustment responsibility to the diabetic diabetic condition
the child for the condition based based on lifestyle
condition as it on lifestyle and and personal
relates to personal preferences such
developmental preferences such as dating, sex and
maturity as peer alcohol, and
• Way to teach relationships and tobacco and drug
others how to daily activities at use
manage the and away from • Understand how
diabetic condition home peer pressure
• Way to • Learn about the affects the
incorporate importance of management of
diabetic care into weight control diabetes
the family’s • Learn to • Manage weight
lifestyle with incorporate control
minimal stress healthy habits into • Incorporate
• Way to find everyday lifestyle healthy habits into
parental relief everyday lifestyle
periodically so • Understand how
parents can “get puberty and
away” hormonal
changes affect the
diabetic condition
Sources: Adapted from Atkinson, A., & Radjenovic, D. (2007). Meeting quality
standards for self-management education in pediatric type 2 diabetes.
DiabetesSpectrum, 20(1), 40–46.
■ Abdominal pain
■ Polydipsia
■ Polyuria
■ Polyphagia
■ Weight loss
■ Fever
Other signs and symptoms include:
■ Altered mental status (the child may be alert or in a coma)
■ Tachycardia
■ Tachypnea
■ Hyperventilation (Kussmaul’s respiration)
■ Normal or low blood pressure
■ Increased capillary refill time
■ Poor perfusion
■ Lethargy
■ Weakness
■ Acetone (fruity) odor of breath, which indicates metabolic acidosis
Diagnosis
Diagnosis is confirmed with a blood glucose of greater than 250
mg/dL, ketonuria, or ketonemia with a serum bicarbonate level of
less than 18 mEq/L. Blood pH is less than 7.34 and indicates the
degree of acidosis.
FOCUS ON SAFETY
DKA is caused by insulin deficiency. Infection is the most frequent factor
associated with the development of DKA, particularly in known diabetics.
Aggressive evaluation for infection is always necessary. Antibiotic therapy
should be strongly considered until the culture results are known. The
following patient-related issues can also be considered:
• Patient has poor compliance with existing insulin regimens
• Patient exhibits underlying endocrine changes of adolescence
• Thelarche—before puberty, just at the beginning of rapid growth
• Adrenarche—activity of the adrenal cortex intensifies and hormones increase
(at about 8 years of age)
• Menarche—the first menstruation usually occurs between 9 and 17 years of
age
• The caregiver’s lack of competence
• Insulin pump failure may occur
• Insulin noncompliance
• Prescription or illicit drug use
• New-onset diabetes
Prevention
Diabetic ketoacidosis can be prevented by close monitoring and
control of blood sugars, especially in the presence of infection, other
serious illnesses, trauma, or stress (Tauschmann, 2020). In addition,
DKA may be prevented by taking extra insulin or other antidiabetic
medication as prescribed by the health-care provider. The health-
care provider is contacted to assist the family and child in seeking
prompt attention as needed.
Collaborative Care
NURSING CARE
Care of the patient with DKA is based on four essential
physiological principles:
■ Restore fluid volume
■ Return child to a glucose utilization state by inhibiting lipolysis
■ Replace the child’s body electrolytes
■ Correct acidosis and restore acid-base balance
Children in DKA are unstable. Fluids and electrolytes can shift
rapidly, and the acid-base balance can fluctuate. Because of this
instability, the nurse needs to carefully assess signs and symptoms
and be prepared to revise treatment protocols as prescribed by the
provider. The nurse can expect to rapidly change IV solutions and
the need to adjust the plan before one therapy is completed. The
outcome of care is to restore hemodynamic and acid-base balance
slowly, reducing the acidosis and restoring the child to a normal
stabilized state.
The diabetic child in DKA is usually in the intensive care unit. The
pediatric intensive care unit nurse must assess the child rapidly,
frequently, and thoroughly. The focus of nursing care is to replenish
the intravascular volume. Fluid status can be determined by the
child’s weight, skin turgor, pulse rate, level of consciousness, and
blood pressure. As fluid and electrolyte deficits are carefully
replaced, the child slowly returns to an acid-base balance status.
Ongoing maintenance fluids are then given.
Nursing assessment of acidosis can be ascertained by the
presence of Kussmaul’s respiration, flushed cheeks, acetone
(fruity) breath, and complaints of back and abdominal pain. The
bedside nurse is responsible for observing and documenting the
child’s response to each intervention. This requires a skilled nurse
who understands and is comfortable with the care of a child in DKA.
With a child in DKA who is possibly comatose and is in the
intensive care unit, stress levels of the parents and caregivers are
increased. The nurse must stay calm and think clearly. Assessments
may need to be made every 15 minutes. One aspect of assessment
that is essential to know is the sound of Kussmaul’s respiration.
Kussmaul’s respiration is very deep and laborious. In an attempt to
correct the metabolic acidosis, the respiratory system works hard to
“blow off” excess carbon dioxide. When a child breathes this way,
some say it sounds like a locomotive.
With the diabetic child in the intensive care unit, many members of
the health-care community collaborate to prevent future episodes.
Keeping lines of communication open between parents and health-
care providers and realizing that the plan is ever-evolving keeps
everyone focused on the best possible outcomes for each child.
MEDICAL CARE
Blood glucose is monitored every hour with the blood glucose goal
results at approximately 100 to 180 mg/dL. When the child’s blood
glucose returns to a value below 200 mg/dL, 5% dextrose may be
added back to the maintenance IV. Some health-care providers
prefer a two-bag system hanging at the bedside, one IV bag with and
one without glucose. Given through a Y-port, the nurse is able to
infuse either one fluid or the other or both if the child needs them.
Serum potassium levels must also need to be checked every 2 to
4 hours. Initially, DKA causes the child to be hyperkalemic. Acidosis,
dehydration, and decreased insulin levels cause an increase in
extracellular concentration, though potassium is depleted in the child
with DKA. As the dehydration and acidosis improve, and insulin and
glucose are given, the child becomes hypokalemic. When the child’s
urinary output is adequate, potassium may be added to the IV fluids.
With normal potassium levels, the child in DKA may need potassium.
With abnormally low potassium levels, the ill child may need as
much as 20 to 40 mEq/L. Placing the child on telemetry and
obtaining an ECG may be needed to monitor for lethal arrhythmias.
Insulin infusions are begun at 0.1 unit/kg per hour. As the
hyperglycemia and acidosis are corrected, the insulin rate is
decreased. The insulin infusion is continued until the pH and the
acidosis are corrected.
The child’s electrolytes are carefully monitored, and the acid-base
balance is checked and documented every 2 to 4 hours. As the DKA
is resolved, usually in 24 to 48 hours, and the child tolerates oral
fluids, the insulin administration is switched to a subcutaneous
regimen.
Education is directed at preventing DKA. Families must be taught to
check and recheck blood glucose levels or urine ketone levels any
time the child is sick (vomiting) or if a blood glucose result is greater
than 240 mg/dL. Ideally, the parents are taught and become
comfortable with the child’s management plan before discharge.
Meals and insulin administration are planned to give the child the
most normal blood glucose level on average (HbA1c). Parents need
to know that long-term complications occur when blood glucose is
abnormally high and that keeping the blood glucose at as normal a
level as possible is the best protection their child can receive.
CASE STUDY
Child With Type 1 Diabetes

It is the middle of December and a young family is busy with holiday
preparations. The children only have a week left of school before the holiday
break. Three-year-old Amelia begins to cry. She appears ill, with flushed skin
and a temperature of 102.1°F. She recently vomited and refuses to eat or drink
anything, even her favorite juice. The mother calls the clinic and states, “My
daughter has vomited twice and is a newly diagnosed type I diabetic. I cannot
get her to drink; what should I do? I think she may have the flu.”
1. What is important to relay to the mother?

2. How can the mother convince the child to drink fluids?
3. What should the mother do for the fever?
4. Should the mother call 911 or take the child to the emergency department?
SUMMARY POINTS
■ The endocrine system controls a child’s growth and development.
■ Hormones regulate a child’s response to stress and physical trauma.
■ Diabetes insipidus is a hypofunction of the posterior pituitary gland, which can
be caused by either a deficient production of ADH or lack of response to ADH.
■ Dehydration is a severe problem, causing the infant or child to be irritable with
many other manifestations, including dry mucous membranes, decreased skin
turgor (tenting of abdominal skin in infant), decreased tears when crying,
sunken fontanelle, and tachycardia. The nurse must act quickly to avoid
serious consequences of hypotension and shock.
■ The pediatric nurse must be thorough and accurately track intake, output, and
daily weights of the child because hyponatremia (low serum sodium less than
125 mEq/L) may cause seizures in the child with syndrome of inappropriate
ADH.
■ It is essential that the nurse is aware that congenital hypothyroidism is an
important cause of mental retardation. Complications are preventable with the
earliest identification and subsequent treatment.
■ Adrenal crisis is a life-threatening condition in which the anterior pituitary
gland does not make enough ACTH. Adrenal crisis is a medical emergency,
and children with adrenal crisis require immediate treatment.
■ With proper administration, pharmaceutical treatments can be successfully
used with many endocrine disorders. The nurse must ensure that the
medications are given accurately and that parents are taught techniques
correctly.
■ Educate parents regarding the signs and symptoms of endocrine conditions
for the condition to be recognized early and treated as soon as possible.
■ Insufficient amounts of cortisol and aldosterone cause Addison’s disease.
■ Diabetes is one of the leading causes of chronic illness in the United States.
■ Type 2 diabetes is caused by the body’s inability to recognize and use insulin
rather than a deficient production of insulin as in type 1 diabetes and has
become an epidemic in the pediatric population.
■ Diabetic ketoacidosis is the presenting complaint in nearly one-fourth of all
newly diagnosed pediatric patients with type 1 diabetes mellitus.
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St. Louis, MO: Elsevier.

Davis Advantage
CHAPTER 20
Caring for the Child With a Neurological

or Sensory Condition
CONCEPTS
Brain
Neurologic
Cognition
Headache
Neurons
KEY WORDS
unconsciousness
persistent vegetative state
cerebrospinal fluid (CSF)
intracranial pressure
papilledema
pediatric Glasgow Coma Scale (GCS)
hypothermia
craniotomy
seizure
pseudoseizure
aspiration
cholinergic crisis
meningocele
myelomeningocele
laminectomy
spastic cerebral palsy
ataxic cerebral palsy
athetoid cerebral palsy
mixed cerebral palsy
hypotonia
hypertonia
retinal hemorrhage
strabismus
anisometropia
tonometry
tympanogram
LEARNING OBJECTIVES
neurological system.
■ Examine common conditions of the neurological system.
conditions of the neurological system.
■ Explore diagnostic testing, laboratory testing, and medications for common
conditions of the neurological system.
common neurological conditions.
PICO(T) Questions
1. What are (O) evidence-based practices for (P) nurses caring for an infant
suspected of suffering from (I) abusive head trauma?
2. What are (I) beneficial strategies that nurses can teach (P) parents of children with
spina bifida to (O) optimize bowel function?
INTRODUCTION
This chapter provides a review of the anatomy and physiology of the
nervous system followed by a discussion of factors that influence
alterations in consciousness. An examination of the various neurological
conditions with developmentally appropriate and holistic nursing care is
included. This chapter also provides a review of the alterations related to
nontraumatic neurological conditions and sensory and language
disorders. Information about diagnostic and laboratory testing and
medications is given. Teaching plans and discharge criteria for parents
whose children have various neurological conditions are incorporated.
Neurological conditions can happen at any time of growth and
development and may lead to poor long-term developmental outcomes
for the child. Competent neurological assessment and recognition of
neurological conditions are done by highly skilled nurses so the child can
meet their most realistic potential.
THE NERVOUS SYSTEM

The nervous system comprises the central nervous system (CNS), which
consists of the brain and spinal cord and the peripheral nervous system
(PNS) (Fig. 20-1). The PNS consists of the cranial nerves, the spinal
nerves, and peripheral nerves, and is subdivided into the sensory-
somatic nervous system and the autonomic nervous system. The brain is
a network of nerve cells called neurons, which consist of axons and
dendrites. Axons take information away from the cell body, and dendrites
bring information to the cell body. Brain tissue may be white or gray.
White matter consists of axons that are coated with myelin, which allow
nerve impulses to travel rapidly, and gray matter is made of neuronal cell
bodies and surrounds the cerebral hemispheres, forming the cerebral
cortex. Areas of gray matter are also found deep in the brain and include
the basal ganglia (affect movement), the hypothalamus (maintains
homeostasis and regulates blood pressure, heart rate, and temperature),
and the thalamus (processes sensory impulses and sends them to the
cerebral cortex). Another important structure of the nervous system is the
spinal cord.
FIGURE 20-1 Anatomy and physiology of the neurological system.
The spinal cord is a mass of nerve tissue encased in a vertebral

column, and the cord contains sensory and motor pathways. The spinal
cord does not extend the length of the vertebral canal. A disruption in the
pathway from the brain to the PNS and spinal cord results in altered
neurological function.

The Effect of Neurological Conditions
The child with a neurological condition such as cerebral palsy (CP) is at greater risk
for limited intellectual development than typically developing children because of
impaired physical mobility and altered sensory and perceptual changes. Intellectual
capacity affects daily-life functioning; verbal, memory, and literacy skills; functional
mobility; self-care; and social functioning. With limited intellectual capacity, the child
is highly likely to have decreased growth and development.
Nursing care of the child with a neurological condition should focus on maximizing
the child’s intellectual, cognitive, and motor abilities through comprehensive
rehabilitation services. The nurse understands that impaired physical mobility is
associated with decreased muscle control and strength. Physical therapy is required
to assess and treat motor dysfunction. The nurse should implement range-of-motion
exercises and position the child to promote tendon stretching to encourage mobility,
increase circulation, and prevent contractures. The nurse understands that activities
of daily living and play promote motor growth and development. The nurse should
encourage the child to use fine and gross motor skills while completing these tasks
such as eating with a utensil and getting dressed. The nurse should allow time for
the child to complete the task. The nurse should position toys that encourage rolling
and reaching. Education about keeping physical therapy appointments and wearing
proper brace wear and adaptive equipment is important.
The nurse understands that sensory and perceptual changes are caused by
cerebral damage. The nurse should assist with acceptance and learning of
alternative methods for living with diminished vision or hearing. The child can benefit
from varied forms of sensory and perceptual input. Technologies such as tablet
devices and personal computers have provided new ways for children with sensory
changes to communicate and interact. The nurse should encourage the use of these
adaptive devices to enhance sensory input. The nurse should educate the family
about maximizing the usage of the child’s intact senses when possible.
ALTERED LEVEL OF CONSCIOUSNESS

Consciousness comprises two components: arousal and thought
content. Arousal or level of consciousness (LOC) is awareness of the
environment by which the child is alert and responsive to environmental
stimuli. LOC is controlled by the reticular activating system and the
cerebral hemispheres of the brain. A child may experience various levels
of consciousness depending on the neurological condition. An alteration
in content of thought may be caused by internal or external factors
including structural, metabolic, and psychogenic. Structural factors are
abnormalities of the anatomy of the brain. Metabolic factors include
infections, trauma, congenital anomalies, vascular anomalies, and toxins.
Psychogenic factors are influenced by psychological disturbances within
a child.
Altered LOC is a significant indicator of neurological dysfunction. The
most common cause of altered LOC in children is infection of the brain
and meninges (American Academy of Pediatrics [AAP], 2021. When
determining the etiology of an altered state of consciousness, organic
and functional causes are evaluated. Abnormal responses and nursing
actions to assess the state of consciousness are identified in Table 20-1.
Unconsciousness is a state in which a child’s cerebral function is
depressed. Unconsciousness ranges from a stupor (aroused only with
vigorous or unpleasant stimulation) to a coma (state of unconsciousness
when the child cannot be aroused even by painful stimuli).
The unconscious child requires astute and continuous monitoring. The
nurse carefully monitors vital signs, LOC, reflexes, and pupil reaction. In
addition, the nurse carefully and meticulously documents the objective
data obtained to determine any deterioration that may alter therapy. The
cause of the patient’s unconscious state guides the nursing care and
medical management. Also, a nurse should assess the child for any
seizure activity that may occur as a result of cerebral ischemia and
edema. A persistent vegetative state is a complete unawareness of the
environment accompanied by sleep-wake cycles.
INCREASED INTRACRANIAL PRESSURE

Whether the pathological process is structural or metabolic, increased
intracranial pressure (ICP) can lead to secondary (preventable) brain
injury. Therefore, prompt diagnosis and aggressive treatment of
increased ICP are essential to limiting secondary brain injury in children
with a neurological insult. A delicate balance exists between the volume
of the intracranial vault and the contents including the brain, blood, and
cerebrospinal fluid (CSF). The CSF is the fluid of the brain and spinal
cord that supplies nutrients and removes waste products and also serves
as a watery cushion that absorbs shock to the CNS. The intracranial
pressure is the pressure of the CSF in the subarachnoid space between
the skull and the brain. The cranium and vertebral body form a rigid
container, and if any of its contents increase, an increase in ICP occurs.
As brain volume expands, some compensation is possible as CSF and
blood move into the spinal canal and extracranial vasculature. The
normal ICP is 0 to 10 mm Hg. Once the ICP reaches approximately 20
mm Hg, small increases in blood volume can result in extreme elevations
in ICP (Fig. 20-2).
Increased ICP can have devastating and long-term consequences for
the child and family. Infants and children whose fontanelles have not
closed are able to compensate for increased ICP for a short time. The
child’s fontanelles bulge, and cranial sutures may spread apart to
accommodate the increased volume.
Signs and Symptoms

The clinical features of ICP vary according to the child’s age and the rate
at which the pressure increases. The signs and symptoms of a child with
increased ICP are related to cerebral edema and ischemia and appear in
Table 20-2.
TABLE 20-1
States of Consciousness Technique and Patient Response
STATE TECHNIQUE RESPONSE
Alertness Speak in a normal tone of An alert patient answers appropriately
voice while opening his eyes and responding
fully.
Lethargy Speak in a loud voice A lethargic patient opens his eyes but
appears drowsy; answers questions
appropriately but falls asleep easily.
Obtundation Shake gently to arouse An obtunded patient opens his eyes and
looks at the stimuli; appears slightly
confused; alertness and interest in
surroundings are decreased.
Stupor Use painful stimuli A stuporous patient only responds to

painful stimuli; verbal responses are
absent or slow; responsiveness to painful
stimuli ceases.
Coma Apply repeated painful A comatose patient does not respond to

stimuli internal or external stimuli; they remain in
an unaroused state with eyes closed.
Source: Kochaneck, P. M., Carney, N., Adelson, P. D., Ashwal, S., Bell, M. J., Bratton,
S., et al. (2020). Guidelines for the acute medical management of severe traumatic
brain injury in infants, children, and adolescents (2nd ed.). Pediatric Critical Care
Medicine, 13, S1–S82.
FIGURE 20-2 Algorithm for increased intracranial pressure.
NURSING INSIGHT
Cushing’s Triad
A child with significantly increased ICP may exhibit Cushing’s triad. Symptoms of
Cushing’s triad are hypertension (with widening pulse pressure), bradycardia, and
an irregular respiratory pattern. Cushing’s triad is a late sign and usually indicative of
impending herniation (the displacement of the brain through the foramen magnum)
(Venes, 2021).
Diagnosis
The diagnosis of increased ICP is based on signs and symptoms
exhibited by the child and diagnostic test results. Papilledema (a mass
of blown-out blood vessels located around the optic nerve) is an
important sign of increased ICP. This finding can be observed when the
nurse assesses the child’s eyes with an ophthalmoscope.
TABLE 20-2
Signs and Symptoms of Increased Intracranial Pressure in Infants
EARLY SIGNS AND SYMPTOMS LATE SIGNS AND SYMPTOMS
Headache Further decrease in LOC
Emesis Bulging fontanelles (infant)
Change in LOC Decreasing spontaneous movements
Decrease in GCS score Posturing
Irritability Papilledema
Sunsetting eyes Pupil dilation with decreased or no

response to light
Decreased eye contact (infant) Increased blood pressure
Pupil dysfunction Irregular respirations
Cranial nerve dysfunction Cushing’s triad (late, ominous sign)
Seizures See Table 20-3-Types of Seizures and

Signs and Symptoms
Diagnostic Tools
Determining Increased Intracranial Pressure
Magnetic resonance imaging (MRI) or computed tomography (CT) is used to
determine the etiology and severity of increased ICP. As a rule, CT contrast is
avoided in the presence of intracranial bleeding. The child’s ICP can also be
monitored by inserting an intracranial catheter.
Prevention
Safety and injury prevention, educational strategies, and anticipatory
guidance on safety issues are essential to decrease preventable injuries
in children.
Collaborative Care
Nursing Care
Closely monitor the pediatric patient with increased ICP because
changes in the neurological status can occur very quickly and may have
life-threatening consequences. The nurse’s initial assessment provides a
baseline by which the child’s progress is evaluated. The goals of the
child’s care are to provide general supportive care and prevent
secondary injury.
When caring for the child with an altered state of consciousness,
carefully monitor the child’s neurological status by assessing LOC with
the use of a pediatric Glasgow Coma Scale (GCS). The pediatric GCS
consists of three components of assessment: eye opening, motor, and
auditory/visual responses (Fig. 20-3).
FIGURE 20-3 The pediatric Glasgow Coma Scale.
When performing an assessment using the pediatric GCS, the nurse

assigns a numeric value to each of the levels of response (1–15).
■ Score of 9–15 (unaltered state of consciousness)
■ Score of 8–4 (state of coma)
■ Score of 3 or below (deep coma)
Coma scale scores may fluctuate if a change in neurological state
occurs, including cerebral ischemia; the administration of medications,
including paralytics and sedatives; and a regaining of consciousness.
The nurse carefully monitors, measures, and documents vital signs,
LOC, reflexes, and pupil reaction as prescribed by the health-care
provider or dictated by facility policy. The frequency of vital sign
measurement is dependent on the etiology, neurological status, and
cerebral involvement. Any change in vital signs needs to be evaluated
because the child’s condition can deteriorate rapidly. The child’s vital
signs may need to be assessed every 15 minutes or more often if the
neurological state or physical state is unstable. If the child’s condition is
stable, vital signs are measured every 2 hours (Fig. 20-4).
Cerebral infections can cause elevated temperatures so the child’s
temperature must be measured every 2 to 4 hours. Antipyretics such as
acetaminophen (Children’s Tylenol) or ibuprofen (Children’s Advil) are
administered by the nurse to lower the child’s temperature. Cooling the
environment, applying a hypothermic blanket, and providing a tepid bath
can also be used to decrease body temperature.
FIGURE 20-4 Caring for the unconscious child.
The head of the bed can be elevated 15 to 30 degrees and the child’s
head maintained in a midline position to prevent jugular compression and
facilitate venous drainage. Perform passive range-of-motion exercises at
least every 2 hours to prevent development of contractures.
A priority for any child with an alteration in consciousness is obtaining
and maintaining a patent airway. Inadequate oxygenation or excess
carbon dioxide causes cerebral blood vessels to dilate, resulting in an
increase in ICP. The child is intubated if the GCS less than 8 (Jain,
2020). In addition, if the child is intubated, monitor the ventilator
equipment. It is important to maintain normal ventilation in children.
Sometimes positive end expiratory pressure is necessary to maintain
oxygenation saturations above 95%.
The nurse meticulously monitors respiratory status including
respiratory rate and rhythm, use of accessory muscles, apnea, breath
sounds, and level of oxygenation. A child in a light coma still may be able
to cough and swallow and maintain adequate respiratory function. A child
in a deep coma may be unable to swallow or adequately handle oral
secretions. It is important to note that the gag reflex of an unconscious
child may be impaired. The airway must be suctioned to remove
secretions that may obstruct the airway or that may be aspirated. Be
careful when suctioning the child’s airway because ICP may increase.
If the child’s condition deteriorates, hyperventilation, with a bag valve
mask (e.g., Ambu Resuscitator”), may be performed until the ICP
decreases. Hyperventilation is aimed at keeping a low level of serum
PCO2 so that cerebral blood flow decreases and reduces cerebral blood
volume, thereby reducing ICP. Prolonged hyperventilation is avoided
because it may cause hypotension as a result of decreased venous
return. Mild hyperventilation may be prescribed by some health-care
providers. If the child is not intubated, supplemental oxygenation will be
necessary. If possible, the child should be positioned on the side to
decrease possible airway obstruction.
A child who cannot maintain respiratory function needs to be
mechanically ventilated. The child may need ventilator assistance for
only a short time or may be dependent on the ventilator indefinitely.
When caring for a mechanically ventilated child, monitor the arterial
blood gases. Administer medications to sedate or relax the child to
prevent injury related to manipulation of the endotracheal tube or
accidental extubation.
The unconscious child who is intubated for an extended period of time
requires a tracheostomy. The nurse performs tracheostomy care for
these patients. The nurse changes the child’s position at least every 2
hours and performs chest physiotherapy to prevent respiratory
complications of atelectasis and pneumonia.
FOCUS ON SAFETY
Assessing for Hypothermia
When using a hypothermic blanket, monitor the patient’s temperature continuously
to prevent hypothermia (a body temperature below 95°F [35°C]). Hypothermia
causes shivering and increased ICP.
FOCUS ON SAFETY
Care Measures
Two care measures are important for patient safety: (1) never place the patient’s
head lower than the body; this position significantly increases the patient’s ICP, and
(2) administer IV fluid cautiously because hypertonic IV solutions have an osmotic
effect. Normal saline, lactated Ringer’s solution, and albumin are primarily used.
Hypotonic IV fluids (a combination of dextrose [5% or 10%] and sodium chloride
[0.22% or 0.3%]) are avoided because they cross the blood-brain barrier, resulting
in increased cerebral edema and ICP.
If a child has increased ICP and inadequate circulation, fluid

administration takes priority over concern about cerebral edema. Fluid
restriction is contraindicated in children who are poorly perfused with
brain pathology or are hypovolemic (have an insufficient amount of fluid
in the circulatory system) because hypovolemia results in decreased
cerebral perfusion. The nurse closely monitors fluid balance by
accurately measuring and recording intake and output.
The child with increased ICP is predisposed to seizures. Monitor for such
factors as frequency, severity, and type of seizure. The nurse places the
child under seizure precautions, which includes padded side rails or bed
rails, oxygen and suction equipment readily available, IV access, and
anticonvulsant medications at the bedside according to physician
prescription.
Medical Care
The nurse administers antiseizure medications such as phenytoin
(Dilantin) as prescribed by the health-care provider. This medication
controls seizures but may cause gingival hyperplasia, which is a long-
term effect. The nurse observes for swelling and bleeding of the child’s
gums and provides good dental hygiene. Parents must be taught about
the necessity of performing proper hygiene when their child is taking this
medication. Also, medications must be administered to decrease
cerebral edema based on the health-care provider’s order. A drug
frequently prescribed is mannitol (Osmitrol).
MEDICATION: Mannitol (Osmitrol)
(man-i-tol)
Classifications: Osmotic diuretic, diagnostic agent
Indications: Reduction of ICP and treatment of cerebral edema
Actions: Increases the osmolality of the glomerular filtrate, preventing the
reabsorption of water and resulting in a loss of sodium chloride and water
Contraindications: Use cautiously with hypersensitivity, anuria, and active
intracranial bleeding
Incompatibilities: Do not add to blood products
Adverse Reactions and Side Effects: CNS: Confusion, headache; ENTT: blurred
vision; CV: chest pain, pulmonary edema, tachycardia; GI: nausea, thirst, vomiting;
GU: renal failure, urinary retention, dehydration, hyperkalemia, hypernatremia,
hypokalemia, hyponatremia; LOCAL: phlebitis at the IV site
Route and Dosage: Reduction of intracranial/intraocular pressure: 1 to 2 g/kg as a
15% to 20% solution over 30 to 60 minutes.
1. Do not administer electrolyte-free mannitol with blood products. If blood is
administered, add at least 20 mEq of NaCl to each liter of mannitol.
2. Confer with physician regarding placement of an indwelling Foley catheter (except
when used to decrease intraocular pressure).
3. Administer by IV infusion undiluted.
Evaluation/Desired Outcomes:
1. Urine output of at least 30 to 50 mL/hr or an increase in urine output in
accordance with patient parameters set by physician
2. Reduction in ICP
3. Reduction in intraocular pressure
4. Excretion of certain toxic substances
_________
Source: Vallerand, A. H. & Sanoski, C. A. (2021). Davis’s drug guide for

nurses (17th ed.). Philadelphia, PA: F.A. Davis.
Barbiturates may also be administered to reduce ICP. Barbiturates

cause the blood vessels in the brain to constrict, but the blood vessels in
the rest of the body to dilate. Carefully monitor volume status and blood
pressure. The use of steroids with increased ICP is controversial.
Corticosteroids have no effect on cytotoxic brain edema resulting from
metabolic, infectious, or hypoxic-ischemic disorders. The child with
increased ICP may require analgesia and sedation. The child who is
hospitalized for increased ICP is usually in an intensive care unit or in an
area where they are closely monitored. Overstimulation from the child’s
environment, in addition to fear and pain, may increase the ICP.
Pain and agitation are treated aggressively if increased ICP is present.
Nursing actions that may increase ICP include endotracheal suctioning,
bathing, and positioning. If the child’s ICP becomes dangerously high,
the child is sedated and, if necessary, paralyzed. Narcotics such as
morphine (Astramorph) or fentanyl (Sublimaze) and benzodiazepines
such as lorazepam (Ativan) are titrated to the desired effect.
Optimizing Outcomes
Intracranial Pressure Monitoring

A pressure line is inserted to accurately monitor ICP. Several types of monitoring
devices are available, including intracranial bolts, intraventricular catheters, and
intraparenchymal fiberoptic catheters. Intracranial pressure monitoring is indicated
for the child who has a GCS score <8, who exhibits signs of increasing ICP, who is
post-major neurosurgical procedures, or who has a high probability of having
increased ICP. The best outcome for ICP monitoring is to maintain cerebral perfusion
pressure between 50 and 70 mm Hg, for an ICP <20 mm, and monitor for
occurrences such as herniation or bleeding.
Surgical Care
A craniotomy (an incision through the cranium) is recommended only
when all other measures have been unsuccessful. A complication of a
craniotomy is herniation of the brain through the defect, leading to further
edema and an increase in ICP. After a craniotomy, assess the child for
signs and symptoms of infection and increased ICP postoperatively. The
nursing care measures discussed earlier also apply to postoperative care
of the child.
Provide education that incorporates knowledge of head injury and
postprocedural care for the child as well as prevention measures,
medications, referrals, and potential complications.
SEIZURE DISORDERS AND EPILEPSY

A seizure is an electrical disturbance within the brain, resulting in
changes of motor function, sensation, or cognitive ability. Seizure activity
is classified according to the area of the brain experiencing the abnormal
electrical activity and the neuromuscular sensory and psychogenic
alteration from the electrical conduction disturbance. The incidence and
onset of seizure disorders varies by age and underlying physical or
pathological condition. Seizures may be genetically linked in susceptible
children, or the etiology may be unknown. Seizures can result from a
traumatic brain injury (TBI), an infection in the CNS, toxic ingestion,
endocrine dysfunction, atrial-venous malformation, or an anoxic episode.
Neonates may develop seizures because of intrapartum or postpartum
anoxic episodes, maternal ingestions or exposure to teratogens, and
prenatal infections. Hypoglycemia and congenital malformations can also
cause neonatal seizures in the first month of life.
According to the Institute of Medicine of the National Academies, an
estimated 2.2 million Americans have epilepsy, with approximately
150,000 new cases diagnosed in the United States each year.
Approximately 1 in 26 people will develop epilepsy at some point in their
lives, and the onset of epilepsy is highest in children and older adults.
Febrile seizures are the most common first-time seizure in childhood.
A simple febrile seizure is a brief (less than 15 minutes), generalized
episode that occurs only once during a 24-hour period in a febrile child
without any evidence of metabolic imbalance, history of prior febrile
seizure, or intracranial infection. A complex febrile seizure lasts longer
than 15 minutes and recurs within 24 hours. Children may experience a
febrile seizure between the ages of 6 months to 5 years, but the most
common occurrence is in the first 1 to 2 years of life. The exact etiology
of febrile seizures has not been clearly identified. There may be a family
history of seizure activity or febrile seizures.
Antipyretics and anticonvulsant therapy may be administered, but this
treatment is controversial in prophylaxis therapy and prescribed more
frequently in complex febrile seizures. There is a slightly increased
incidence of epilepsy in children with febrile seizures over the general
population, especially if other types of seizures or abnormal CNS
development are present in the child or the family.
Signs and Symptoms

Seizures are classified as generalized or partial (focal) (Table 20-3).
Diagnosis
Seizures are diagnosed clinically with the use of neurological testing,
used to determine the etiological epileptic focal center in the brain
causing the abnormal electrical activity. In-depth testing of the
neurological system helps to classify the type of seizure and determine
appropriate anticonvulsant therapy. The neurological exam to diagnose
seizures consists of a cranial nerve assessment, deep tendon reflex,
sensory and motor response, LOC, and hearing and pupil checks. A CT
scan or an MRI is performed to look for CNS malformation, lesions,
neoplasms, hemorrhage, trauma, foreign body, or edema. An
angiography is done to assess for arteriovenous malformations that may
be hereditary. New-onset seizures may suggest malignant neoplasms
and warrant emergent neuroimaging.
Electroencephalogram (EEG) is the accepted standard test for
diagnosing a seizure disorder. The EEG evaluates the electrical activity
of the brain while the brain is in a sleepy or drowsy state and also when
stimulated (Fig. 20-5). Loud noises, bright lights, and rapid flashing
images are presented during the procedure, and the resulting electrical
brain wave response is graphed. This information is useful to the
neurologist in diagnosing the type of seizure activity, especially if the
history and exam do not support a clear diagnosis. Video EEG can also
be done if the EEG is inconclusive or if the child experiences sleep and
waking onset seizures. Positron emission tomography is performed if
brain structures require outlining or mapping before a surgical procedure
but is not routinely indicated for seizure evaluations. Pseudo-seizures,
or false seizures, are evaluated as neurological episodes until
determined to be psychological or not pathological in nature and etiology.
TABLE 20-3
Types of Seizures and Signs and Symptoms
TYPE OF BRAIN SIGNS AND SYMPTOMS
SEIZURES LOCATION/CAUSE
Partial (Focal) Localized to one area One area is affected: hands, lips, wrist,
arms, or face. Impaired loss of
consciousness at onset.
Partial complex Temporal lobe Loss of consciousness and loss of

(psychomotor) awareness or surrounding. Changes in
behavior (lip smacking, picking,
inappropriate mannerisms, confusion)
follow the seizure.
Partial simple Lasts 5 minutes, child only remembers the

aura. Automatisms are noted. No loss of
consciousness or awareness. Motor signs
are isolated to one area of the body and
then spread to the rest of the body. May
experience senses such as buzzing
sounds, tingling, flashing lights, anxiety,
fear, or anger.
GENERALIZED
Tonic-clonic Genetic predisposition or Partial simple and complex seizures evolve
brain injury secondary to to generalized seizures. Aura is
anoxia experienced followed by loss of
consciousness and tone. Patient falls to
the floor with tonic-clonic muscle
contractions. Patient is postictal and
confused after the seizure is over. Loss of
urine may occur.
Atonic: loss of Sudden drop to the floor caused by loss of

muscle tone, motor muscle tone. Seen in children 2 to 4
drop attacks. years of age.
Absence (petit No loss of consciousness but experiences
mal) loss of awareness. Nonconvulsive. Periods
of staring or minor movements lasting
seconds. May occur several times a day,
interferes with learning and schoolwork.
Tonic Stiffening of the body that is sustained,

involving all four extremities.
Myoclonic Metabolic etiology Single or multiple jerks or flexion of limbs.

Clonic Intermittent rhythmic jerking, 1–3 per
second, may start in one body location and
move or migrate to another location.
Myoclonic and Complete or total lack of movement.

akinetic
FIGURE 20-5 The EEG evaluates the electrical activity of the brain while
the brain is in a sleepy or drowsy state and when stimulated.
Prevention
The CDC notes that in nearly two-thirds of the cases of epilepsy, a
specific underlying etiology is not found. Preventable events such as
traumatic and/or anoxic brain injuries, brain infections, or stroke are
causes of epilepsy.
Collaborative Care
Nursing Care
The nurse completes a detailed history of the seizure event, an in-depth
review of the child’s prenatal and postnatal history, and review of
systems. The event history must include antecedent events that may
have precipitated the seizure, such as dehydration, video-gaming,
exercise, or any ingestion of substances that may cause seizures.
Information regarding the type of activity during the seizure, any loss of
consciousness, loss of urine, noises made, cyanosis, and history of
present illness is also retrieved from the persons who witnessed the
event. Because of the genetic predisposition of some types of seizures, a
family history and type of seizure activity must be obtained. The
neurological exam is completed by the physician or a neurological
specialist.
Seizure management is a collaborative effort among the nurse, the
medical team, the primary care provider, and the family. Specific nursing
care for a child with seizures is determined by the type of seizure. If the
etiological agent for the seizure is pathological in origin, seizures are
managed medically until the cause can be resolved. If the cause is a
brain tumor, the mass is excised. If the cause is endocrine dysfunction, it
is resolved. If infection is present, appropriate antibiotic therapy is
initiated. If the cause of the seizure is unknown and a structural
abnormality is not present, the child is placed on an anticonvulsant
therapy specific for the type of seizures being experienced.
FOCUS ON SAFETY
Seizure Precautions
• Maintain airway patency; ensure nothing is placed in the child’s mouth during a
seizure. A loose tooth may be aspirated or knocked out. Suctioning may be
necessary after the seizure is over.
• Monitor oxygenation saturation; the child’s color should remain pink. The pulse
oximeter should read 95% or greater and the heart rate is normal or slightly
raised.
• Administer IV medications. When administering IV medications during a seizure,
give the medication slowly to reduce the risk of side effects such as respiratory or
circulatory failure.
• Raise and pad the side rails when the child is in a bed or the crib; the child needs
to be protected from injury (Fig. 20-6).
• Teach parents about the importance of having the child wear a medical alert
bracelet. The child who has seizures should wear a medical identification bracelet
at all times.
• Also provide emotional support to the child and family. Allow the child and family
to express their feelings, offer a support group, and remind the family to treat the
child as normally as possible.
EMERGENCY CARE FOR THE CHILD HAVING A SEIZURE
1. In the community setting, call 911.
2. In a hospital, use the designated emergency number.
3. Maintain a patent airway. If the airway is occluded, open the airway with a jaw
thrust maneuver. Administer oxygen if needed and available. Do not put anything
in the mouth. If the situation warrants emergency medical care, qualified health-
care personnel can insert an appropriate-sized oral airway.
4. Loosen restrictive clothing to ensure adequate circulation to essential body
organs.
5. Administer medications such as diazepam (Valium), lorazepam (Ativan), or
fosphenytoin (Cerebyx) as ordered by the physician. These medications are not
administered to a neonate because they are toxic as a result of immature liver
function.
6. Monitor respiratory status and circulatory status throughout the seizure.
7. Position the child in a lateral position to prevent aspiration (entry of secretions
into tracheobronchial passages) (Fig. 20-7).
8. Inform the child that they have just had a seizure. Tell the family that the child
may still be confused and disoriented for a short time.
9. Stay with the child. Support is essential because a seizure is frightening to both
the child and family.
10. Document all important details about the seizure, the care provided, and the
condition of the child after the seizure and give notification to the physician.
Airway management and client safety are priority nursing interventions

for the child experiencing a seizure. The child needs continuous
monitoring of respiratory status because seizure medications can cause
a decreased LOC, apnea, and hypotension. Additionally, after the
postictal phase, the child may need to be reoriented.
FIGURE 20-6 An important nursing care measure is padding the side

rails.
FIGURE 20-7 When the seizure is over, place the child in the recovery
position on the left lateral recumbent position.
The hospitalized child receives continuous cardiac, respiratory, and

oxygen monitoring. Centrally located monitoring on the nursing unit for
ease of observation in case of seizure activity is necessary. Baseline
seizure activity for some children may be several seizures a day without
compromise. The child must be continually monitored while an inpatient.
All caregivers of children with seizures must be instructed in CPR.
Medical Care
Antiepileptic drug (AED) therapy is the main treatment for seizure
management in children with epilepsy. Many medications are available
and have varying therapeutic effects on the brain (Table 20-4).
Monotherapy (one drug) is the desired goal of epilepsy treatment.
However, polytherapy (more than one drug) may be initiated when a
child has intractable epilepsy or seizure control is improved with the
synergistic effects of two antiepileptic medications.
TABLE 20-4
Commonly Prescribed Antiepileptic Drugs (AEDs)
TYPE OF MEDICATION DOSE RANGE ADVERSE NURSING
SEIZURE REACTIONS CARE
Partial Complex carbamazepine 10–30 mg/kg Drowsiness, Give with food
(Psychomotor) (Tegretol) per day in nausea, liver but not with
divided doses. changes, milk.
Increase until increased
best response appetite.
is achieved.
valproic acid 0.1 mg–0.2 Confusion, Always give

(Depakene) mg/kg/day in ataxia, with food and
two or three nystagmus, monitor serum
divided doses nausea, gingival drug levels.
per day. hyperplasia, Teach parents
bleeding about oral
disorders. hygiene and
wearing a
medical alert
tag. Teach
parents to
watch for
adverse effects
indicating
toxicity.
phenytoin 5 mg/kg per May cause Always give

(Dilantin) day in two to dizziness, with food and
three divided drowsiness, or monitor serum
doses. physical drug levels.
incoordination. Teach parents
Avoid abrupt about oral
discontinuation of hygiene and
use. Daily wearing a
multivitamin is medical alert
recommended tag. Teach
while on this parents to
medication. watch for
adverse effects
indicating
toxicity.
Give with water,
juice, or milk.
phenobarbital Infants 5–6

(Luminal) mg/kg per day
in one or two
divided doses.
fosphenytoin Children 1–6

(Cerebyx) years,
6–8 mg/kg per
day in one or
two divided
doses.
Loading dose
of 10–20
mg/kg. Then 4–
6 mg/kg per
day.
Generalized valproic acid May be an Monitor for

Tonic-Clonic (Depakene) and inexpensive sleepiness,
carbamazepine medication. hyperactivity,
(Tegretol). drowsiness, and
phenytoin school
(Dilantin). performance
phenobarbital changes.
Ketogenic diet Causes a high Nausea, This diet is hard

high in fat and level of vomiting, to maintain for
low in protein and ketones, which headache, a long period of
carbohydrates. decreases drowsiness, time because of
myoclonic or dizziness. the lack of food
tonic-clonic variety and
seizure activity. difficulty of food
preparation and
parental
involvement.
Absence (Petit ethosuximide 3–8 mg/kg per Avoid antacids.

Mal) (Zarontin) or day
valproic acid
Partial Simple topiramate 1–3 mg/kg per Weight loss, Avoid

(Topamax) day dizziness, antidepressants
diarrhea, and antacids.
cognitive
dysfunction.
Many anticonvulsant medications can become toxic when taken daily.

Baseline liver function, renal function, and hematological values are
assessed before initiation of pharmacotherapy and retained for future
reference. Anticonvulsant drug serum levels are also monitored to
maintain therapeutic levels. Children may outgrow a certain dosage and
begin having seizures because of lowered serum levels. Drug serum
levels are assessed every 3 to 6 months.
In refractory cases of epilepsy, other supplemented treatments such as
vagus nerve stimulation or the ketogenic diet (high-fat, adequate-protein,
low-carbohydrate) may be implemented.
Surgical Care
Epilepsy surgery is most commonly performed when a seizure focus is
located in a single area of the brain.
Medication information such as type of medication, dose, route, and
frequency of dosing must be explained to the parents. The regimen must
also be adhered to in the day-care setting. The child is not left alone until
the seizures have been controlled and they are seizure-free for several
months. Adolescents may drive (depending on state laws) and
participate in sports as long as therapeutic serum anticonvulsant drug
levels are within normal range and the adolescent is seizure-free for at
least 6 months.
School nurses and teachers are informed about the child’s seizure
condition and follow institutional procedures if the child experiences a
seizure in school or day care. School nurses should have an updated
and individualized seizure action plan in place for all children with a
history of seizures. Medical alert identification bracelets are worn by
younger children and may be worn by older children and adolescents.
INFLAMMATORY NEUROLOGICAL CONDITIONS

Meningitis
Meningitis is an inflammation of the structures in the CNS caused by an
infectious process. The meninges are composed of three membranes
that cover the brain and protect it from injury and infection: the dura
mater, arachnoid mater, and pia mater. These structures house
arterioles, venules, and CSF that protects, bathes, and provides
chemical functional support for the brain and its contents. Meningitis is
either septic or aseptic. Septic or pyogenic meningitis is caused by a
bacterial pathogen such as Streptococcus pneumoniae, Neisseria
meningitidis, Escherichia coli, or Haemophilus influenzae type B. Aseptic
meningitis is caused by a known or unknown viral agent typically
presenting at peak seasonal viral illness intervals in the fall and winter.
Meningitis can develop at any time during childhood. During the
neonatal period, meningitis results from a pathogen transmitted during
the labor and delivery process or while in utero. The most common types
of neonatal meningococcal infections are caused by herpes simplex,
group B beta-hemolytic Streptococcus, and E coli. In older infants and
children, a peak incidence of S pneumoniae is noted in the winter
months. In summer months, bacterial organisms such as N meningitidis
and nonbacterial agents such as rhinoviruses and adenoviruses are
more prevalent. Haemophilus influenzae type B, once a deadly
pathogen, has almost been eradicated now with scheduled routine
childhood immunizations.
Bacterial meningitis is the result of bacterial dissemination from a
nasopharyngeal or a hematological inoculation. The pathogen migrates
into the CSF and imbeds in the subarachnoid space. The body reacts to
the infiltration with a severe inflammatory response and white blood cell
proliferation. Systemic septicemia, surgical procedures involving the
CNS, a penetrating wound, otitis media, sinusitis, cellulitis of the scalp or
facial structure, dental caries, pharyngitis, and orthopedic diseases and
procedures are also antecedent events leading to bacterial meningitis.
The etiological pathogen in viral, or aseptic, meningitis is a viral agent.
The most common pathogens are herpes and adenovirus; in most cases
the etiological agent is unknown. Some cases are the result of partially
treated bacterial meningitis. Clinically the child with viral meningitis
presents with the same vague or subtle symptoms; however, the child
does not become toxic or as acutely ill as the patient with bacterial
meningitis. Diagnosis is based on CSF analysis, CSF gram stain, and
culture. Results are typically negative unless a viral agent is identified. If
left unrecognized and untreated, meningitis may progress rapidly to a
critical state depending on the age of the patient and the etiological
pathogen. Younger infants and children succumb rapidly to meningitis,
and children with meningococcemia, H influenzae type B, and E coli
become toxic and deteriorate quickly if untreated.
Labs
Cerebrospinal Fluid Analysis
A lumbar puncture is performed to collect CSF. Normal CSF is clear and colorless.
In infections, CSF pressure may be increased, and it may appear cloudy. Increases
in CSF protein and decreases in glucose are commonly seen in bacterial
meningitis.
Signs and Symptoms

A child with meningitis may initially appear to be mildly ill with general
vague or subtle signs and symptoms such as:
■ Fever
■ Headache
■ Stiff neck
■ Lethargy and/or irritability
■ Nausea and/or vomiting
Diagnosis
Conduct a review of the current illness with specific information obtained
regarding duration of symptoms, ill contacts in the family or school
settings, seizures, loss of sleep or weight, anorexia, emesis, behavioral
changes, and immunization status. A complete blood count (CBC)
reveals an elevated white blood cell count and any clotting deficiencies.
A disseminated intravascular coagulation panel is collected to rule out a
coagulation disorder when the child presents with petechial hemorrhage,
shock, and meningococcemia. Blood cultures are obtained to identify the
potential hematological origin. A lumbar puncture is also performed for
CSF analysis including chemistry and cell counts as well as culture and
gram stain for bacterial or viral diagnosis. Meningitis is diagnosed based
on the results of the lumbar puncture.
Assessment Tools
Kernig’s or Brudzinski’s Sign
Classic findings on examination for a child suspected of meningitis include a positive
Kernig’s or Brudzinski’s sign. These exams indicate meningeal irritation resulting in
hyperreactive reflexes. The test for Kernig’s sign (Fig. 20-8A) is conducted with the
child lying supine with the hips flexed. As the nurse straightens the leg, the child
either cries out or resists the leg extension. If the child experiences pain behind the
knee as the knee is fully extended, this is an abnormal finding. Bilateral increased
resistance and pain on extension of the knee is a positive Kernig’s sign and may
indicate meningeal irritation.
Brudzinski’s sign (Fig. 20-8B) is conducted with the child lying flat. The nurse
attempts to raise the head toward the child’s chest and place the chin on the chest.
If there is pain or resistance, the child immediately flexes the hip and knee. If the
child exhibits flexion of the hips and knees when the nurse performs the maneuver,
meningeal inflammation may be present.
FIGURE 20-8 Classic findings on examination for a child suspected of

meningitis include A, a positive Kernig’s or B, Brudzinski’s sign.
Prevention
The pneumococcal conjugate vaccine is a routine childhood
immunization that is effective at preventing pneumococcal meningitis.
Additional recommendations for the meningococcal vaccination include
children age 2 and older with immunodeficiency and those under 21 who
have not been vaccinated.
Collaborative Care NURSING CARE

Essential nursing care includes assessing neurological status at least
every 2 to 4 hours. The child’s LOC and the use of a pediatric GCS, pupil
response, and overall activity provide clues to the child’s neurological
status (e.g., increase in ICP or response to antibiotic and fluid therapy).
In small infants, ICP can be subjectively monitored by palpating the
anterior fontanelle while the patient is lying supine. If the fontanelle is
tense and bulging, this may suggest increased ICP, particularly when
combined with photophobia, irritability, a high-pitched cry, anorexia, and
emesis. Infants with open fontanelles and an enlarging head
circumference during or post–meningitis infection may indicate
hydrocephalus and must be monitored. The child with an increasing
head size and symptoms of increased ICP requires radiological
evaluation such as a CT scan or MRI (Fig. 20-9). To prevent additional
increased ICP, the child’s room is kept quiet, dim, and without loud or
noxious visual, auditory, or olfactory stimuli.
MEDICAL CARE
The onset of seizure activity associated with meningitis is managed
medically, and seizure precautions are maintained at all times. The child
with meningitis may develop new-onset seizures and is treated with
anticonvulsant therapy. The child is also kept NPO (nothing by mouth)
until nausea and vomiting have been resolved. Comfort care includes a
dim room, antipyretic therapy for fever management, nutrition as
tolerated, and emotional and social support. Care for malaise includes
massage, nonsteroidal anti-inflammatory drugs, warm baths, and rest.
FIGURE 20-9 The child with an increasing head size and symptoms of
increased ICP requires radiological evaluation, such as a CT scan.
Treatment for meningitis varies depending on whether it is viral or

bacterial in origin. A lumbar puncture with CNS analysis confirms the
diagnosis. Viral meningitis is often self-limiting, and treatment is
supportive. Bacterial meningitis is treated promptly with IV antibiotics.
Household members and others who have come in close contact with
someone diagnosed with meningococcal meningitis are advised to take
antibiotics to prevent becoming infected.
SURGICAL CARE
Surgery is usually delayed in a child with acute brain infection unless
ICP and cerebral edema compromise outcomes. Factors predisposing
an individual for the development of nosocomial meningitis are reviewed
and care taken to minimize the development of meningitis after
craniotomy.
Infections of the CNS can cause distress to the family. Educate the family
and the child about the disease, injury prevention, and early detection of
complications. Explain that long-term parenteral access is maintained
with a peripherally inserted central catheter, and IV antibiotics can be
continued at home with the assistance of a home health nurse.
Encephalitis
Encephalitis is usually viral in origin and occurs with an acute febrile
illness characterized by cerebral edema and infection of surrounding
meninges. Less common etiologies are fungal, bacterial, and parasitic
infections; exposure to toxins or drugs; and cancer. The most common
types of viral encephalitis are caused by arthropod-borne viruses
(mosquito-borne) and the herpes simplex type I. Systemic viral illnesses
such as rabies, mononucleosis, and poliomyelitis may also result in
encephalitis. Depending on the source of the encephalitis and the
severity of the illness, signs and symptoms of the virus develop within
hours to weeks after exposure. Encephalitis caused by bacteria usually
results in a more serious illness.
Complications From Encephalitis or Meningitis
Complications resulting from encephalitis or meningitis may include motor or
cognitive deficits, seizure disorders, hearing or vision loss, memory loss, and
paralysis. If a child has permanent or ongoing sequalae, the treatment plan is often
multidisciplinary to optimize their health-related quality of life.
Signs and Symptoms

The signs and symptoms experienced by children vary from mild to life-
threatening. The severity of the illness depends on the child’s age,
immune system stability, underlying cause, and duration of illness.
■ Confusion
■ Headache
■ High fever
■ Photophobia
■ Lethargy
■ Nuchal rigidity
■ Seizures
■ Coma
Diagnosis
The diagnosis of encephalitis mimics signs and symptoms of other
neurological disorders. When obtaining a history and physical, ask the
parent about exposure to possible sources of encephalitis. Assess the
child’s skin for lesions that might be vector bites. Ask the child and family
about possible exposure to mosquitoes, bats, or other sources of
encephalitis. The family needs to be questioned about outdoor play,
camping trips, unvaccinated pets, wild animals, medication, and recent
illnesses. MRI or CT is used to determine any cerebral edema, shifts
within the brain, or focal lesions. The health-care provider may also order
cerebral fluid analysis, an EEG, and lab work. Brain biopsy typically
offers a definitive diagnosis.
Prevention
To help prevent viral encephalitis, educate parents and others in the
community on prevention methods and early detection and intervention.
Community Education About DEET
Educate parents and others in the community about DEET to help prevent viral
encephalitis. Insect repellents containing DEET (N, N-diethyl-m-toluamide, also
known as N, N-diethyl-3-methylbenzamide) should be used according to the
directions on the product labels. The American Academy of Pediatrics recommends
that repellents with DEET not be used on infants younger than 2 months old.
Collaborative Care
NURSING CARE
Be astute when caring for a child with encephalitis because of the
rapid neurological changes that may occur with the illness. Provide care
and support for the child and the family during the acute and
convalescent phases of the disease process. During the acute phase of
the disease, administer IV fluids, medications, and nutrition (Table 20-5).
Seizure precautions must be initiated because of cerebral edema and
increased ICP. To decrease ICP, perform interventions such as ongoing
neurological assessments, ensuring the child is afebrile and seizure-free,
maintaining hemodynamic stability, and positioning the child to avoid
neck-vein compression. Also carefully monitor the child’s fluid and
electrolyte balance and watch for syndrome of inappropriate antidiuretic
hormone (SIADH).
MEDICAL CARE
Treatment for encephalitis is determined by the etiology. Viral
encephalitis is treated with an antiviral medication such as acyclovir
(Zovirax). Encephalitis of a bacterial origin is treated with a narrow-
spectrum antibiotic. Other medications that may be prescribed are
antipyretics, anticonvulsants, analgesics, and anti-inflammatory agents.
SURGICAL CARE
Maintaining effective cerebral perfusion and decreasing ICP is the goal
of treatment. However, surgical decompression may be necessary for
sustained increased ICP and cerebral edema.
TABLE 20-5
Neurological or Nontraumatic Condition Medications
DRUG ACTION DOSAGE LABORATORY MAIN SIDE
RECOMMENDATIONS MONITORING EFFECTS
Baclofen Reduction of PO 2–7 y.o.: 10–15 Monitor Transient
(Lioresal) skeletal mg/d divided q8h, may periodic serum drowsiness;
spasms increase by 5–15 mg/d glucose and abrupt
associated divided q8h; ≥8 y.o.: liver function discontinuation
with upper 10–15 mg/d divided tests of intrathecal
motor q8h, may increase by administration
neuron 5–15 mg/d q3d (max may result in
lesions 60 mg/d); also high fever,
available for intrathecal altered mental
pump administration status,
exaggerated
rebound
spasticity, and
muscle rigidity
Carbamazepine Partial, PO <6 y.o.: 10–20 Serum Allergic rashes;

(Tegretol) generalized mg/kg/d, gradually therapeutic nausea;
tonic-clonic, increase, max 35 range: 5–12 diplopia; blurry
and mixed mg/kg/d in 3–4 divided mcg/mL vision;
seizures doses; 6–12 y.o.: 100 Monitor CBC, drowsiness;
mg bid, gradually serum aplastic anemia;
increase to 400–800 electrolytes, leukopenia
mg/d in 3–4 divided liver function (transient);
doses (max 1 g/d) test agranulocytosis
Lamotrigine Partial If given with valproic None Dizziness;

(Lamictal) seizures, acid: PO 2–16 y.o.: 0.2 ataxia;
Lennox- mg/kg/d × 2 wk, then somnolence;
Gastaut 0.5mg/kg/d × 2 wk, headache;
syndrome, then 1 mg/kg/d (max 5 nausea;
adjunct mg/kg or 250 mg/d) diplopia; blurred
therapy for If given with any vision; rhinitis;
tonic-clonic, anticonvulsant other Stevens-
absence, than valproic acid: PO Johnson
myoclonic 2–16 y.o.: 1 mg/kg bid syndrome
seizures × 2 wk, then 2.5 mg/kg
bid × 2 wk, then 5
mg/kg bid (max 15
mg/kg/d or 400 mg/d)
Levetiracetam Partial PO 4–16 y.o.: 20 Monitor Asthenia;

(Keppra) seizures as mg/kg/d in 2 divided periodic CBC, headache;
adjunct with doses, may increase by liver function somnolence;
other AEDs 20 mg/kg every 2 wks test behavioral
up to 60 mg/kg/d changes
Mannitol Reduction of 1–2 g/kg as a 15%– Closely monitor Fluid and

(Osmitrol) intracranial 20% solution over serum and electrolyte
pressure and 30–60 min urine imbalance;
cerebral electrolytes and hyponatremia
edema kidney function
Oxacarbazepine Partial PO 4–16 y.o.: 8–10 Monitor Somnolence;

(Trileptal) seizures as mg/kg/d divided bid periodic ataxia;
monotherapy (max 600 mg/d) sodium, T4 headache;
or adjunct to gradual increase to level dizziness;
other AEDs target dose (divided nausea
bid) based on weight:
20–29 kg 900 mg/d;
29.1–39 kg 1,200
mg/d; >39 kg 1,800
mg/d
Phenobarbital Generalized Child: PO/IV 3–8 mg/kg Serum CNS

(Phenobarbital) tonic-clonic, Neonate: PO/IV 3–4 therapeutic depression;
partial mg/kg/d (max 5 range: 15–40 somnolence;
seizures, mg/kg/d) mcg/mL irritability;
and status Status epilepticus – cognitive
epilepticus Child: IV 15–18 mg/kg impairment;
in single or divided rash;
doses (max 20 mg/kg) agranulocytosis;
Neonate: IV 15–20 respiratory
mg/kg in single or depression
divided doses
Phenytoin Generalized PO/IV, 15–20 mg/kg Serum Drowsiness;

(Dilantin) tonic-clonic loading dose, then 5 therapeutic rashes;
and some mg/kg in 2–3 divided range of 10–20 nystagmus;
partial doses mcg/mL hirsutism; folate
seizures Monitor deficiency;
periodic CBC gingival
and CMP hyperplasia;
agranulocytosis;
aplastic anemia
Topiramate Partial PO 2–16 y.o.: 1–3 Monitor Fatigue; speech

(Topamax) seizures mg/kg at hs × 1 wk, periodic CBC problems;
used as then increase by 1–3 somnolence;
adjunct mg/kg/d in 2 divided dizziness;
doses every 1–2 wks to ataxia;
a target range of 5–8 psychomotor
mg/kg/d slowing;
confusion;
nystagmus;
difficulty
concentrating;
memory
difficulties
Valproic acid Absence, PO/IV 15 mg/kg/d in Serum Sedation;

(Depakene) mixed, divided doses when therapeutic drowsiness;
Divalproex myoclonic, total daily dose >250 range 50–100 nausea;
sodium complex mg, increase at 1 wk mcg/mL vomiting;
(Depakote) partial intervals by 5–10 Monitor prolonged
seizures mg/kg/d (max 60 periodic CBC bleeding time;
mg/kg/d) with platelet pancreatitis;
count, CMP bone marrow
depression
Sources:Vallerand, A. H., & Sanoski C. A. (2021). Davis’s drug guide for nurses (17th
ed.). Philadelphia, PA: F.A. Davis.;Van Leeuwen & Bladh, M. L. (2021). Davis’s
comprehensive handbook of laboratory and diagnostic tests (9th ed.). Philadelphia, PA:
F.A. Davis.
Parents are given instructions about discharge referrals and signs of
infection or changes in LOC. Health instruction for this condition involves
primary prevention strategies to prevent another occurrence as well as
monitoring for any potential seizure activity.
Reye’s Syndrome
Reye’s syndrome is a rare illness that progresses quickly and does not
have a favorable outcome. Reye’s syndrome is primarily associated with
the administration of acetylsalicylic acid (aspirin) during viral illnesses
and affects children between the ages of 4 and 14 years of age. A
decline in the incidence of Reye’s syndrome has been evident in the
recent past, primarily because of the decreased administration of
acetylsalicylic acid and parental education about the disease.
Reye’s syndrome affects all organs of a child’s body but causes the
most damage to the brain and liver. The brain is affected by an increase
in ICP, and other organs are affected by an accumulation of fat. The
disorder is considered a two-phase illness because it usually occurs in
conjunction with a viral infection, especially varicella (chickenpox) or
influenza (flu). The child usually develops symptoms several days after a
viral illness.
Signs and Symptoms

The signs and symptoms of the illness are a result of hyperammonemia,
hypoglycemia, and an increase in short-chain fatty acids found in the
serum after the liver becomes involved. Symptoms of Reye’s syndrome
include:
■ Restlessness
■ Vomiting
■ Drowsiness
■ Seizures
■ Loss of consciousness
There are several stages of Reye’s syndrome. The child may progress
through all of the stages or stop at any stage if treatment is effective.
NURSING INSIGHT
The Stages of Reye’s Syndrome
Stage I: Lethargy, vomiting, drowsiness, liver dysfunction
Stage II: Disorientation, combativeness, aggressiveness, delirium, hyperactive
reflexes, hyperventilation, shallow breathing, stupor, liver dysfunction
Stage III: Obtundation, coma, decorticate posturing, hyperventilation Stage
IV: Deepening coma, large and fixed pupils, decerebrate posturing, loss of ocular
reflexes, liver dysfunction
Stage V: Loss of deep tendon reflexes, seizures, flaccidity, respiratory arrest,
usually no liver function
Diagnosis
Because a number of inherited metabolic diseases present with many of
the same symptoms as Reye’s syndrome, these illnesses need to be
excluded before a diagnosis of Reye’s syndrome can be made. When
obtaining a history and physical, ask about recent viral illnesses and the
use of any medications containing acetylsalicylic acid. Perform a
complete neurological assessment. A definitive diagnosis of this
syndrome is established with a liver biopsy obtained during the illness or
at autopsy. Other diagnostic tests that are ordered are serum tests
including liver enzymes, blood glucose, ammonia level, coagulation
studies, and others to exclude metabolic inherited disorders. The child
may have a lumbar puncture to rule out infections, including meningitis
and encephalitis.
Prevention
Medications containing aspirin are not given for the treatment of any viral
illness in childhood. Many over-the-counter medications contain
salicylates (aspirin) so it is important to instruct parents to read the
medication label carefully and consult with the pharmacist or health-care
provider if they are uncertain of the contents of the medication.
Collaborative Care
NURSING CARE
Be sure to perform a neurological assessment because of the high
incidence of increased ICP and brain injury. The child’s LOC, seizure
activity, and reflex function are assessed to determine the stage of the
illness. If the child is experiencing respiratory difficulty, monitor the
oxygen saturation concentration with the use of pulse oximetry.
Supplemental oxygen is administered via nasal cannula. If the child’s
condition worsens, the child may need intubation and mechanical
ventilation. The health-care provider may insert an arterial line to monitor
blood pressure and obtain arterial blood gases. Remember to assess the
insertion site for complications of infection and leaking. The nurse
initiates seizure precautions if the child demonstrates signs of increased
ICP. Invasive procedures are performed, and the child is handled
carefully because of the risk of bleeding as a result of liver involvement.
Emotional support is provided to the child and parents.
MEDICAL CARE
To reduce the risk of increased ICP, carefully administer IV fluids. The
IV fluids may include glucose to correct hypoglycemia and potassium,
chloride, and sodium to correct electrolyte imbalances. Corticosteroids
are prescribed to decrease cerebral edema and inflammation, and insulin
may be administered to increase glucose metabolism. Diuretics may be
prescribed to enhance fluid elimination, resulting in decreased ICP.
There is an excellent chance of recovery when Reye’s syndrome is
diagnosed early and treated promptly. Health instruction for this condition
involves teaching parents to avoid administering aspirin or aspirin-
containing medications as well as reviewing medication labels carefully.
What to Say
“Can I Give My Child Aspirin?”
For many years, childhood illnesses and discomforts were managed with the
administration of aspirin (acetylsalicylic acid) because it is a component in many
over-the-counter medications to relieve fever, muscle aches, and nausea (Table 20-
6). If a parent asks, “Can I give my child aspirin?” the nurse responds, “No product
containing acetylsalicylic acid is given to any person younger than 19 years of age
experiencing a viral illness because of the risk of Reye’s syndrome. It is important
for you to always check the medication label or ask the pharmacist if the medication
contains aspirin.”
Guillain-Barré Syndrome
Guillain-Barré Syndrome (GBS) is a rare neurological disorder in which
the body’s immune system attacks part of its PNS, producing antibodies
against its own nerves, resulting in muscle weakness or paralysis that
proceeds in an ascending fashion. GBS can range from a very mild case
with brief weakness to nearly devastating paralysis, leaving the person
unable to breathe independently. As such, it can be a loss of function
that can range from fatigue and lethargy to complete paralysis of the
lower limbs extending upward, affecting upper motor and sensory neuron
pathways.
School-age children are most susceptible, and more males than
females are affected. The exact cause of GBS is unknown. The
syndrome may follow an antecedent gastrointestinal or respiratory
illness. Inflammatory mediators penetrate the Schwann cells in the nerve
axons, causing demyelination (removal of the myelin sheath of nerve
tissue) and denuding (loss of nerve covering) of the neuronal pathways,
resulting in decreased conduction of sensory and motor peripheral and
spinal pathways. Areas of nerve involvement are assessed and
monitored as nerve function and sensation is blocked or slowed.
Signs and Symptoms
Signs and symptoms of GBS usually progress quickly with muscle
weakness that begins in the lower extremities and moving upwards in an
ascending fashion. It is characteristically described as an ascending
paralysis.
■ Muscle weakness
■ Numbness
■ Paresthesias
■ Paralysis
TABLE 20-6
Medications Containing Acetylsalicylic Acid
NONPRESCRIPTION PRODUCTS PRESCRIPTION PRODUCTS
Alka-Seltzer Darvon
Excedrin Norgesic
Pepto-Bismol Robaxisal
Anacin Talwin
Kaopectate Butalbital
BC Percodan
Pamprin Roxiprin
Lortab
propoxyphene
Soma
■ Areflexia in arms and legs

■ Hypotension
Diagnosis
Diagnosis of GBS is based on clinical and laboratory procedures.
Elevated CSF protein levels in the absence of infection support the
clinical diagnosis. Sensory and motor nerve conduction studies, such as
electromyography, define the subtype classification and degree of
inflammatory involvement; results will demonstrate blocked impulses or
conduction slowing along the peripheral motor and sensory nerve
endings (NINDS, 2020).
Prevention
The exact trigger of GBS is unknown, but it is thought to follow a viral or
bacterial infection. Vaccinations against the flu also have been
documented as precipitating factors. Outcomes improve if the disorder is
diagnosed and treated early.
Collaborative Care
NURSING CARE
Vigilant clinical monitoring related to the progression of motor, sensory,
and functional losses and the degree of respiratory compromise are the
priority nursing assessments. As GBS progresses, monitor pulse
oximetry, respiratory function, ease of breathing, and lung sounds for
potential atelectasis leading to pneumonia. Respiratory support is
provided with intermittent positive pressure breathing, cough assist, and
incentive spirometry. Frequent repositioning is also required every 2
hours. To maintain urinary output, it may be necessary to use an
indwelling urinary catheter or intermittent clean catheterization.
Parenteral or enteral nutrition is maintained if the child is unable to meet
nutritional intake needs or is experiencing dysphagia.
Be sure to assess the pain level in the child. GBS is painful and
requires opioid analgesia that is administered on a scheduled basis to
treat the severe neuralgia. Children with GBS may underreport the pain
associated with the neuritis and expect the nurse to understand their
discomfort, so be sure to proactively manage the pain in GBS.
Immobilization can lead to muscular contracture and loss of function
after the inflammation has subsided. Passive range-of-motion exercises,
frequent position changes, and hand and foot orthotics or splints may be
used temporarily to preserve function and prevent contractures. Skin
integrity over bony prominences or pressure areas must be monitored
and managed aggressively with padding, close inspection, and frequent
repositioning. Age-appropriate developmental activities are provided
daily as the child is able. Offer visual and auditory stimulation frequently
to meet the child’s cognitive, social, and emotional needs. School work,
crafts, and books provide respite from the boredom and may prevent
behavioral and emotional disorders related to the debilitation and
limitations of the disease.
MEDICAL CARE
Supportive measures are the hallmark of care for patients with GBS.
Plasma exchange and IV immunoglobulin therapies shorten the disease
duration, support the recovery phase, and reduce the duration of
disability. Corticosteroids are initiated to slow the inflammatory response.
Family education is extremely important because the rate of recovery
may be prolonged depending on the degree of disease involvement.
Counseling on expectations upon discharge is critical to promote positive
patient outcomes.
Juvenile Myasthenia Gravis

Juvenile myasthenia gravis (MG) is an autoimmune disease in which
antibodies are directed against the postsynaptic membrane of the
neuromuscular junction, resulting in muscle weakness. It is relatively
uncommon in childhood and has many clinical features similar to those
seen in adults. Juvenile MG causes weakness of skeletal muscles and
can lead to a variety of symptoms. The muscles most frequently affected
are those used for eye movement, chewing, swallowing, and breathing.
Signs and Symptoms

Common symptoms of MG in children are:
■ Ptosis
■ Diplopia
■ Difficulty swallowing, chewing, and speaking
■ Weakness or paralysis of skeletal muscles
Diagnosis
The diagnosis of juvenile MG is based on the clinical symptoms and the
course of characteristic progressive weakness. Diagnosis is confirmed
by electrophysiology and nerve conduction studies. Antibodies to
acetylcholine receptor antibodies may also be detected in the serum. An
edrophonium (Tensilon) test may corroborate the diagnosis. When
Tensilon (edrophonium chloride), a short-acting anticholinesterase, is
administered IV, there is marked improvement of the muscle weakness.
Prevention
Prevention is difficult because the exact cause of juvenile MG is
unknown. However, there is a link with tumors of the thymus gland, and
CT scan of the chest is performed to rule out thymoma.
Collaborative Care
NURSING CARE
Monitor for the major complications of MG, which involve the airway.
Clinical monitoring related to the progression of fatigue, motor function,
and respiratory compromise is the nurse’s priority. The muscle weakness
and fatigue typically worsen during the day or at times of stress. It is
important to identify factors that may cause exacerbations or “flare-ups.”
Emphasize the importance of rest. Additionally, nursing interventions
focus on monitoring respiratory function and status, nutritional needs,
and preventing complications.
MEDICAL CARE
Acetylcholinesterase inhibitors (neostigmine or pyridostigmine) are
used to treat the symptoms and to prevent exacerbations.
Plasmaphoresis or IV immunoglobulins are other effective treatments for
acute illness. Medication dosing is arranged so that peak action is during
mealtime. Because the medication is given during mealtime, carefully
observe the child to monitor for aspiration and eating difficulties. The
child and parents are taught the importance of strict administration of
medications and potential side effects, which include nausea, vomiting,
diarrhea, abdominal cramps, and increased salivation.
FOCUS ON SAFETY
Distinguishing Cholinergic Crisis From Myasthenic Crisis
Be able to distinguish cholinergic crisis (pronounced muscular weakness and
respiratory paralysis caused by excessive acetylcholine found in patients with MG
as a result of overmedication with anticholinesterase drugs) from myasthenic crisis.
A serious complication of MG is muscle weakness and respiratory failure.
Myasthenic crisis is often caused by undermedication, perhaps because of a
skipped dose of medication, but could also be precipitated by an illness or infection.
SURGICAL CARE
Because of the presumed role of the thymus in the pathogenesis of
MG, thymectomy is usually performed if a thymoma is present. After
surgery, typical postoperative care focuses on thorough assessment,
addressing pain control, maintaining hydration, and giving comfort care
measures.
Provide education that includes health instruction related to the course of
the disease. Family members are taught to recognize symptoms that
may indicate an exacerbation, such as increased muscle weakness.
Additional instructions for strict adherence to the anticholinesterase
medication dosing schedule should be included.
Botulism
Botulism is a rare but serious infection from ingesting spores of the
bacteria Clostridium botulinum in contaminated food products (honey) or
soil. There are several forms of botulism: food-borne, infant, and wound.
Infant botulism may range from mild to severe and often occurs in babies
younger than 6 months.
Signs and Symptoms

Symptoms may range from mild constipation to impaired neurological
function and respiratory failure.
■ Afebrile
■ Constipation
■ Weakened cry
■ Weakness (drooping eyelids)
■ Descending paralysis
Diagnosis
Diagnosis is often made based on history, clinical symptoms, and
physical examination. A stool sample can confirm diagnosis.
Electromyography is used to help confirm the diagnosis.
Prevention
The American Academy of Pediatrics recommends that honey not be
given to a child younger than 12 months of age.
Collaborative Care
NURSING CARE
Nursing interventions are focused on promoting recovery and reducing
risk of respiratory complications. Treatment is supportive in mild cases.
Supportive treatment includes airway management and strategies to
reduce the risk of health-care-associated infection. Most children fully
recover without any complications. However, recovery may be prolonged
after a severe illness.
MEDICAL CARE
Administration of a human botulinum immunoglobulin may be indicated
in more severe cases to decrease the sequelae. Botulism immune
globulin is a sterilized solution made from human plasma. It contains
antibodies capable of neutralizing neurotoxins type A and B.
Health instruction for this condition includes preventive education. If the
child received immunoglobulin, parents are cautioned to avoid live
vaccinations for approximately 5 months after administration.
DEVELOPMENTAL NEUROLOGICAL CONDITIONS

Spina Bifida
Neural tube defects (NTDs) are a group of birth defects in which
malformations of the brain and spinal cord occur and the structures lack
protection of soft tissue and bone. NTDs develop when the neural tube
fails to close during fetal development. Usually, the nerves below the
defect are impaired, although some sparing of nerves with subsequent
partial functioning may occur. Spina bifida is the most common
permanently disabling birth defect in the United States, accounting for
approximately two-thirds of all NTDs. No two people affected by this
disorder are alike. Spina bifida is derived from the Latin words meaning
“cloven backbone.” It is a congenital spinal deformity occurring early
during gestation (18 to 28 days). The etiology of the disorder can be
multifaceted, including environmental and genetic risks. Environmental
predisposing factors include exposure to prolonged hyperthermia, poor
nutrition, diabetes mellitus, and the consumption of seizure medications
during early pregnancy. It occurs when a developing baby’s spinal cord
fails to develop or close properly during fetal development.
Spina bifida (SB) is a condition where the bones in the vertebral
column do not fully cover the spinal cord. There are four types of spina
bifida: occulta, closed neural tube defects, menigocele, and
myelomeningocele. Spina bifida occulta usually occurs at the level of
the fifth lumbar and first sacral vertebrae. Symptoms can sometimes be
seen on the skin above the spinal defect. They include an abnormal tuft
of hair, a birthmark, or protruding spinal cord tissue.
When treatment is necessary, it’s done through surgery to close the
defect. Other treatments focus on managing complications.
If the child has a meningocele, a protruding sac is located on the
cervical, thoracic, or lumbar spine at the level of the defect and a thin
layer of muscle and skin usually covers the lesion. Meninges
(membranes) protrude through the defect in the spine, but no
involvement of neural elements is present. Neurological functioning is
usually not affected.
A myelomeningocele is the most severe form of spina bifida and is
evident on delivery. The meninges protrude through the defect, and the
meninges contain spinal cord elements. It appears as a very pronounced
skin defect, usually covered by a transparent membrane, and may even
have neural tissue attached to the inner surface. The higher the defect is
located on the spine, the greater the loss of spinal cord function because
usually no neurological function is found below the defect. The bony
prominences of the unfused neural arches can be felt at the defect’s
lateral border. When the child is born, the membrane covering the defect
may be intact or may leak CSF. If the membrane is not intact, the risk for
infection and neuronal damage is increased. Until the defect is surgically
closed, CSF may accumulate, which results in further dilation and
enlargement of the sac, and further neuronal damage may occur. The
involvement of the spinal cord has greater implications for the function of
the child during childhood.
Signs and Symptoms

The signs and symptoms demonstrated by children with spina bifida vary
depending on the level of the lesion and the type of defect. Spina bifida
occulta is the least severe form, and signs and symptoms include:
■ Visualization of meningocele or myelomeningocele
■ Weakness
■ Paralysis
■ Sensory loss
The signs and symptoms of severe spina bifida include:
■ Visualization of the myelomeningocele
■ Neurological deficits
■ Hip and joint deformities
■ Impaired bowel and bladder function
Diagnosis
After 12 to 14 weeks of pregnancy, prenatal diagnosis can be made if the
defect is visible through ultrasound examination. During pregnancy,
maternal serum testing of alpha-fetoprotein is performed to determine
the presence of an NTD. An elevated alpha-fetoprotein level may
indicate an NTD because open neural defects leak this substance into
surrounding amniotic fluid, and a small portion is absorbed into the
mother’s blood. On delivery, the defect is usually visible, and a diagnosis
is made. The defect is examined to determine the type and severity of
the defect, and contents of the sac are assessed for meninges, CSF, and
spinal cord. An MRI or a CT scan identifies the neurological structures
contained in the sac.
Prevention
Spina bifida may be prevented by controlling environmental factors that
increase the risk of a woman having a child with the disorder. It is
imperative the pregnant woman receive education on these risk factors.
Women who are pregnant should decrease exposure to hyperthermia
(e.g., saunas and hot tubs). A pregnant patient with diabetes mellitus
must be closely monitored. The patient must understand the importance
of maintaining blood glucose levels within a normal range by adherence
to an appropriate diet, exercise regimen, and medication therapy. Some
antiseizure medications may result in spina bifida. A woman receiving
these medications needs to notify the physician immediately if she
becomes pregnant so the medication therapy can be altered. Every
woman of childbearing age is advised to ingest 400 mcg of folic acid per
day to prevent neural tube birth defects. Good nutrition is also an
important preventive measure, and sources of folic acid include green
leafy vegetables, liver, legumes, orange juice, fortified breakfast cereals,
and multivitamins.
Collaborative Care
NURSING CARE
Upon delivery, the nurse assesses the defect for the type of contents
in the sac and measures the defect. A priority nursing concern is
prevention of injury and infection of the sac. The sac must be assessed
for indications of infection including redness, purulent drainage, bleeding,
and necrosis. If the sac ruptures and leaks CSF, the patient is at risk of
developing meningitis.
FOCUS ON SAFETY
Preventing Injury of the Sac
After birth, as quickly as possible and using sterile techniques, cover the defect with
a sterile nonadhesive dressing moistened with sterile saline to maintain moisture
and prevent drying. The dressing is changed every 2 to 4 hours as prescribed and
when soiled. Place the newborn in a prone position and do not place a diaper over
the defect to prevent pressure on the sac, rupture, and infection of the sac.
Evaluate the orthopedic function of the newborn. A low thoracic lesion

may cause total flaccid paralysis of the lower body. A small sacral lesion
may cause only patchy areas of decreased sensation in the feet.
Movement or lack of movement of the extremities is assessed and
documented. The child may have contractures of the hips, knees, and
ankles, and the hips may be dislocated. Prevent joint contractures or
further joint contractures by performing passive range-of-motion
exercises but do not perform range-of-motion exercises with the hips
because hip displacement is common. Clubfeet is a common orthopedic
complication of spina bifida because the fetus cannot move the lower
extremities in utero. As the child gets older, locomotion is facilitated with
the use of braces, wheelchairs, and walkers.
The bladder and bowel function of children with spina bifida may be
affected to varying degrees. During the neonatal period, assess the
voiding and defecation patterns of the newborn. The newborn who
constantly dribbles urine may have a neurogenic bladder and may
experience urinary retention and overflow with a risk of urinary tract
infections. A newborn who voids at spaced intervals may be able to
achieve some level of urinary continence later in life because there is
some innervation of the bladder.
FOCUS ON SAFETY
Do Not Obtain a Rectal Temperature
Do not obtain a rectal temperature of a child with spina bifida because rectal
irritation and rectal prolapse may occur.
Constipation and impaction are common complaints associated with

spina bifida. The child’s diet needs to include fiber and fluid. If
constipation occurs, stool softeners and laxatives are administered. A
child with spina bifida may not be able to feel the urge to defecate, and
bowel incontinence may result. The child may need to wear diapers, and
as they get older, psychosocial disturbances including depression,
embarrassment, and shame may be experienced. If adequate
innervation of the bowel exists, bowel training is attempted.
MEDICAL CARE
Treatment is dependent on the form of spina bifida. Children with the
mildest form, spina bifida occulta, often do not need treatment. The initial
goals of treatment include reducing neurological deficits and preventing
complications.
A child with more pronounced spina bifida is at risk for neurological
complications, including meningitis, because of the possibility of infection
of the CSF and meninges and the possibility of hydrocephalus because
an obstruction to CSF absorption may occur. According to the Spina
Bifida Association, approximately 70% to 90% of children with
myelomeningocele develop hydrocephalus. Early signs of infection
include irritability, elevated temperature, and lethargy. IV antibiotics are
administered to prevent infection preoperatively and postoperatively.
Anticholinergics may also be administered to improve urinary continence
while antispasmodics may be given to control bladder spasms. The
patient who is in a wheelchair for the majority of the day is prone to skin
breakdown of the coccyx because of pressure. Areas where orthopedic
devices apply pressure need to be padded well and assessed frequently.
SURGICAL CARE
A laminectomy (the excision of a vertebral posterior arch, usually to
remove a lesion or herniated disk) and closure of the defect is performed
as soon after birth as possible to preserve the neurological function
present, prevent infection or rupture, improve the appearance, and allow
for easier handling of the baby.
Preserving skin integrity is an important nursing responsibility.
Preoperatively, ensure no pressure is placed on the vulnerable defect.
Postoperatively, the surgical incision is protected by not applying
pressure on the area. Perineal irritation and skin breakdown may occur if
incontinence is a problem. Check the perineum for stool and urine and
change the diaper as needed. The infant’s vital signs and neurological
function are monitored closely to identify changes that may indicate
infection. Perform dressing changes using sterile technique and assess
the surgical site for redness, purulent drainage, and odor. The site must
also be assessed for CSF leakage.
Because hydrocephalus may develop after surgical repair, measure
the infant’s head circumference as prescribed. Assess the fontanelles for
bulging and cranial sutures for separation. The infant is maintained in a
position that does not place pressure on the surgical site. Provide
postoperative pain management because when the infant cries, ICP
increases. Pain management must be administered carefully so
neurological impairment does not occur.
FOCUS ON SAFETY
Latex Allergy
Children with spina bifida demonstrate sensitivity to latex. The proposed theory is
that these individuals become sensitized after repeated exposure to latex early in
life. Nurses caring for children with spina bifida provide a latex-free environment.
Referrals can be made so families can obtain information regarding a latex allergy.
Helpful organizations include the Spina Bifida Association of America and the
American Latex Allergy Association.
Parents are given instructions for postprocedural care and instructed to
report signs of infection or worsening neurological deficits. Health
instruction includes education on common medical problems that occur
with spina bifida as well as interdisciplinary follow-up for these
conditions, which include mobility, skin care, and bowel and bladder
function. Referral to community resources and support groups may be
beneficial in helping parents adjust to living with a chronic illness.
Hydrocephalus
The term hydrocephalus is derived from the Greek hydor (water) and
kephale (head). CSF is formed and secreted by the choroid plexus (the
ventricle’s highly vascular lining). Newborns produce approximately 25
mL of CSF per day, and children produce between 25 and 500 mL per
day. After it is secreted, the CSF circulates through the intracranial vault
and the spinal cord. In hydrocephalus, there is an increase of CSF
production, impedance to CSF absorption, or an obstruction of flow. As
the fluid volume increases in the ventricles, pressure increases within the
intracranial vault. Many functions are served by the CSF, including
buffering of the brain, helping maintain normal chemical balances, and
assisting in the maintenance of the important blood-brain barrier.
Congenital anomalies, including Chiari I and II malformations, Dandy-
Walker syndrome, and aqueductal stenosis, are the most common
causes of hydrocephaly during the neonatal and early infancy periods.
Acquired hydrocephaly occurs after birth and in infancy, usually resulting
from intraventricular hemorrhage as a result of prematurity. Other causes
of acquired hydrocephaly include tumors, head injury, bleeding, and
infections.
There are two categories of hydrocephalus. Communicating
hydrocephalus occurs when there is full communication between the
subarachnoid space and ventricles. The causes of communicating
hydrocephalus are defective absorption of CSF (most often),
overproduction of CSF (rarely), and venous drainage insufficiency
(occasionally). Noncommunicating hydrocephalus occurs when CSF flow
within the ventricular system or the ventricular outlets to the arachnoid
space is prevented. Noncommunicating hydrocephalus occurs when
there is obstruction of the flow of CSF (extraventricular or
intraventricular) and includes tumors, anatomical malformations, or
cerebral edema. Most cases of hydrocephalus are obstructive.
Signs and Symptoms

The signs and symptoms of hydrocephalus vary based on the child’s age
and the cause and rate of hydrocephalus development (Fig. 20-10). The
child may demonstrate signs and symptoms of increased ICP if the
disorder is severe enough:
■ MacEwen’s sign (tapping on the skull near the junction of the frontal,
temporal, and parietal bones yields an unusually resonant sound)
■ Difficulty holding the head upright
■ Prominent forehead
■ Head enlargement
FIGURE 20-10 Signs and symptoms of hydrocephalus.
Diagnosis
Congenital hydrocephalus can be diagnosed with ultrasound during a
prenatal examination or be discovered during infancy or even early
childhood. Hydrocephalus is discovered by observing the signs and
symptoms exhibited by the patient, such as increasing head
circumference inconsistent with normal growth.
Diagnostic Tools
Hydrocephalus
The primary means of diagnosis is through imaging studies (e.g., CT, MRI, and
ultrasound), which usually reveal enlargement of ventricles. A cisternogram
(radiographic evaluation) is used to evaluate CSF flow dynamics in the child’s brain
and spinal cord. During the procedure, dye is injected into the subarachnoid area
around the brain. Once the dye has circulated through the CSF path, a series of
pictures is taken. The procedure is performed to reveal CSF concentration, leakage,
obstruction, and pressure.
A lumbar puncture is used to examine CSF and measure pressure.

The health-care provider performs transillumination to show
abnormalities of the various areas of the child’s head. Thinning or
separation of the bones of the skull is identified with radiographs of the
skull. An ultrasound of the brain possibly may show ventricular dilation,
hydrocephalus, or intraventricular bleeding.
Prevention
To reduce the risk of hydrocephalus, pregnant females are encouraged
to obtain early prenatal care and follow-up for early detection. If the child
has a ventriculoperitoneal shunt, preventing and promptly treating
infections is essential.
Collaborative Care
NURSING CARE
Carefully examine the child to identify the presence of any immediate
life-threatening symptoms. These symptoms exhibited by the child may
be indicative of increased ICP or infection. Perform nursing actions
related to increased ICP and the proposed course of treatment. The
child’s head circumference is obtained and documented to identify any
major changes that need to be evaluated.
MEDICAL CARE
Medical treatment is not effective in long-term treatment of chronic
hydrocephalus.
Acetazolamide (Diamox) and furosemide (Lasix) medications affect
CSF dynamics by decreasing CSF secretion. Isosorbide (Dilatrate or
ISMO) increases CSF reabsorption, although its effectiveness is
questionable.
Assessment Tools
Head Circumference Measurement
Birth to 3 months Head circumference increases 2
cm/month (0.75 inch)
Note the average head size at birth is 33–
38 cm (12–14 inches)
4–6 months Head circumference increases 1

cm/month (0.4 inch)
Note the average head size at 6 months is
43 cm (17 inches)
6 months to a year Head circumference increases 0.5

cm/month (0.2 inch)
Note the average head size at 1 year is 46
cm (18 inches)
By 1 year of age the child’s head size has increased by 33%.
SURGICAL CARE
A procedure performed to relieve increased ICP is called endoscopic
third ventriculostomy. An endoscope is introduced and used to visualize
the floor of the ventricle, and a fenestration is made that allows the CSF
to flow around the obstruction.
The main surgery for hydrocephalus is the placement of a
ventriculoperitoneal shunt (Fig. 20-11). A ventricular shunt means a
catheter is placed in the lateral ventricle where a one-way valve is set at
a desired pressure to drain the CSF. Then, a distal catheter that
terminates in the peritoneal cavity or alternate drainage site is placed.
The peritoneal cavity is the preferred site for placement of the distal
catheter because of easy accessibility and decreased risk of
complications.
FOCUS ON SAFETY
Alternate Shunt Placements
Sites for shunt drainage placement, other than the peritoneal cavity, are the right
atrium of the heart and the pleural space of the lungs. The alternate sites pose the
risks of pleural effusion, emboli, pneumothorax, respiratory distress, and
endocarditis.
Preoperatively ensure support of the child’s head. The child requires

frequent position changes of the head because hydrocephalus causes
the skin of the scalp to thin, and prolonged pressure may result in
impaired skin integrity. Prior to the shunt surgery, do not use scalp veins
for IV therapy because the IV may be located near the surgical site.
FIGURE 20-11 A child may have a shunt placed to drain excessive

intracranial CSF.
The child who is to receive a ventricular shunt receives a preoperative

IV antibiotic to help prevent development of infection. During the
preoperative period, medications including acetazolamide (Diamox) and
furosemide (Lasix) may be prescribed to decrease the production of
CSF. These medications are sometimes used to postpone the need for
shunt insertion.
FOCUS ON SAFETY
Complications of a Ventriculoperitoneal Shunt
The placement of a ventriculoperitoneal shunt can present complications such as
hemorrhage, subdural hematoma, CSF leakage, bradycardia, and injury to
structures located in the area of surgery. The child is monitored because the
fenestration may close or narrow resulting in enlarged ventricles and increased ICP.
The child may also be at risk for meningitis and encephalitis post-operatively
because the shunt is placed in the ventricles of the brain and any introduction of
infectious agents causes a potentially life-threatening illness. In one study of 64
pediatric patients followed over 15 years, only 15.5% of patients did not require a
revision during the follow-up period, and 17.3% of patients required three or more
revisions (Paff, Alexandru-Abrams, Muhonen, Loudon, 2018). The most common
causes of shunt failure in both pediatric and adult populations are obstruction
followed by infection. Infections tend to cause early shunt failures, and catheter
occlusion typically accounts for late shunt failures (Paff et al, 2018).
In the postoperative period, neurological assessment is paramount.

Irritability, lethargy, or other alterations in neurological function may be
indicative of meningitis or increased ICP. Assess and document the
child’s vital signs and neurological assessments every 15 minutes or as
prescribed by the surgeon. The child’s head circumference is measured
daily, and the fontanelles are assessed for bulging and the sutures
examined for separation. Because of the possibility of a shunt
malfunction, an ophthalmologist examines the child’s eyes to detect
pressure on the optic nerve, which, if not treated promptly, causes
irreversible damage. Safety precautions are implemented because pain
and fever may cause the child to become disoriented.
PROCEDURE ■ Measuring Head Circumference

PURPOSE
Measuring head circumference is an important component of evaluation of a child’s
growth as well as their health status.
EQUIPMENT
• Flexible, nonstretchable tape measure
• Child’s chart
STEPS
1. Obtain a flexible, nonstretchable tape measure (preferably one in which one end
inserts into the other end).
2. Allow the parent to hold the child in their arms or lap. RATIONALE: Parents
holding the child may help decrease the child’s anxiety.
3. Remove braids, barrettes, or other hair decorations. RATIONALE: The hair must
lie flat to obtain an accurate measurement of head circumference.
4. Place the tape measure over the most prominent part of the occiput (back of the
head) and just above the supraorbital ridges (above the eyebrows). RATIONALE:
The landmarks ensure accurate measurement.
5. Pull the tape measure snugly to compress the hair and underlying tissues.
RATIONALE: Ensures accurate measurement.
6. Read the measurement to the nearest 0.1 cm or 1/8 inch.
7. Document the measurement on the chart.
Clinical Judgement Alert If an abnormal circumference is found based on the

child’s age, reposition the tape and measure the head circumference again. The
new measurement should agree with the first measurement within 0.2 cm or 1/4
inch.
TEACH PARENTS
To help ensure an accurate head circumference measurement, teach the parents
how to hold the child firmly while offering verbal comfort and encouragement.
DOCUMENTATION
9/10/10 1200 Head Circumference 43 cm (17 inches) —T. Martin, RN
When positioning the child, elevate the head no higher than 30

degrees to prevent ventricular decompression and place the child on the
nonoperative side to prevent pressure on the shunt. If increased CSF
occurs, the physician may prescribe for the child to be elevated higher
than 30 degrees. The shunt may be manually purged but only in extreme
cases because of the risk of a subdural hematoma.
When assessing the abdomen, auscultate for hypoactive or absent
bowel sounds to identify a paralytic ileus. Obtain an abdominal
circumference measurement to assess for distention. To promote
accuracy, put a mark on the abdomen so the tape measure is placed in
the same spot every time. If peritonitis develops, the child may complain
of diffuse abdominal pain and tenderness along with nausea and
vomiting.
When taking vital signs, pay attention to an elevated temperature and
rapid pulse rate. Peritonitis results in leukocytosis (an increase in white
blood cells); therefore, lab results are closely monitored. Observe for
signs of hypovolemia and shock resulting from loss of electrolytes and
fluids into the abdominal cavity and assess for rebound tenderness and
muscle rigidity.
Postoperatively, the child receives IV antibiotics and is monitored for
infection. Observe for redness along the shunt tract in addition to
palpating for warmth to assess for infection. Other signs of shunt
infection are fever, irritability, lethargy, abdominal discomfort, and apnea.
The most common organisms that cause CSF infections in infants and
children are Staphylococcus aureus and Staphylococcus epidermidis.
Adolescents are more likely to experience an infection resulting from
Propionibacter acne, which is a slow-growing infection of the CSF.
FOCUS ON SAFETY
Shunt Infection
Common signs and symptoms demonstrated by a child with a shunt infection
include decreased LOC, irritability, increased ICP, seizures, poor feeding, and an
alteration in vital signs.
Communicate to the parents that a child with hydrocephalus needs
continuous monitoring and assessment because hydrocephalus is a
lifelong disorder. Educate parents so they can recognize complications of
hydrocephalus, including increased ICP and shunt malfunction (e.g.,
kinking and plugging within the ventricle from tissue or exudate or
obstruction at the distal end from thrombosis or displacement of the
tubing because of growth). Shunt infection can happen at any time but
most often occurs 1 to 3 months after placement. Instruct parents to
assess for common signs and symptoms (e.g., nausea and vomiting,
headache, change in customary behavior, lethargy, unresponsiveness, or
elevated temperature). Explain that the child will not be able to
participate in contact sports because of the possibility of shunt damage.
The importance of safe transport and positioning is also emphasized,
and a special car seat may be required.
Cerebral Palsy
Cerebral palsy (CP), the most common permanent physical disability of
childhood, is characterized by physical impairment and mild to severe
physical and mental dysfunction. Symptoms of CP can occur a bit
differently in each child. A child may have muscle weakness, poor motor
control, or shaking (spasticity) of the arms or legs. A child may also have
muscle stiffness in the form of stiff legs or clenched fists. The United
Cerebral Palsy Foundation (2020) estimates that approximately 500,000
children under the age of 18 currently have CP; about two to three
children out of every 1,000 have CP (United States studies have yielded
rates as low as 2.3 per 1,000 children to as high as 3.6 per 1,000
children) (CerebralPalsy.org, 2020). In addition, approximately 10,000
babies born each year will develop CP.
CP is a nonprogressive neurological disorder that results from brain
injury before cerebral development is complete. CP can result from a
brain injury (anoxic insult) occurring not only during the prenatal period
but also during the perinatal and postnatal periods (up to the first 2 years
of life) (Levy, 2020; Valentine et al, 2020). Prenatal risk factors include
asphyxia, infections (e.g., rubella, cytomegalovirus, and toxoplasmosis),
intracranial hemorrhage, blood incompatibility, and trauma. The perinatal
risk factors for CP are low birth weight, birth at less than 32 weeks of
gestation, and intracranial hemorrhage. Postnatal risk factors include
viral encephalitis, bacterial meningitis, falls, child abuse, and motor
vehicle crashes.
The amount of disability varies because some children with CP may
only have minimal disability and can lead relatively normal lives while
others require extensive assistance. There are four types of CP. Spastic
cerebral palsy is the most common type. A child with spastic CP has
stiff muscles because of increased muscle tone, and the muscles are
predisposed to contracture. Children with this type of CP have poor
control of posture, coordinated movement, and balance. Spastic CP is
often classified according to the limbs affected (i.e., diplegia, hemiplegia,
quadriplegia, monoplegia, and triplegia). Children with spastic diplegia
(both legs are involved) have difficulty walking because of tight muscles
in the hips and legs and may have scissoring (legs turn inward and cross
at the knees) (CerebralPalsy.org, 2020; CDC, 2020).
Children with ataxic cerebral palsy have difficulties with balance and
depth perception. They walk with an unsteady gait, demonstrate poor
coordination, and often have fine motor control problems. Athetoid
cerebral palsy (CP) or dyskinetic CP is characterized by uncontrolled
involuntary writhing movement of extremities. In severe cases, the facial
muscles may be affected, and drooling, speech difficulties, and grimacing
may occur. In mixed cerebral palsy, a child has two or more types of
CP. Some of the common symptoms of mixed CP are difficulty or inability
to walk, speech difficulty, swallowing problems, breathing difficulties,
bowel or bladder incontinence, seizures, vision problems, learning
disabilities, hearing deficits, attention or behavioral problems, and
impaired senses (Fig. 20-12).
Signs and Symptoms

The signs and symptoms vary depending on the area of the brain
involved and the extent of damage.
■ Muscle rigidity
■ Muscle spasticity
■ Poor control of posture
■ Ataxia
Diagnosis
Diagnosis of CP is primarily based on clinical symptoms demonstrated
by the child and a history of delay in reaching developmental milestones.
The child may exhibit various muscular hypotonia (low muscular
tension) or hypertonia (high muscular tension). A child with CP may
demonstrate hand preference by 6 months of age instead of12 months.
An important sign of CP is persistence of some primitive infant reflexes
(i.e., Moro and crossed extensor reflexes) because these reflexes
normally disappear between 6 months and 12 months of age. CT, MRI,
and cerebral ultrasound are tests used to diagnose alterations in brain
integrity that are often present with CP.
FIGURE 20-12 The child with cerebral palsy has physical impairment
and has mild to severe physical and mental dysfunction.
Prevention
While the exact cause of CP is unknown, there are risk factors that may
increase the risk of having a child with CP (Levy et al, 2020). The nurse
provides education about various risk factors, including infection during
pregnancy, premature birth, and injury and stresses the importance of
routine prenatal counseling and visits.
Collaborative Care
NURSING CARE
The child with CP has some degree of muscular dysfunction. Splints
and braces may be necessary to facilitate muscle control and improve
body functioning. Assistive devices are necessary to allow the child to
perform these tasks, including large-handled brushes and toothbrushes.
Encourage the child to perform self-care tasks. Clothing should be easy
to manipulate. To reduce muscle spasms and prevent fatigue, allow
frequent rest periods.
Children with CP may or may not demonstrate intellectual deficits. The
degree of deficit depends on the severity of brain injury. Participating in
activity programs helps incorporate play into exercise. Toys are chosen
based on cognitive, not chronological, age. The environment needs to be
safe because the child may not comprehend the concept of danger.
A child with CP may experience feeding problems because of impaired
muscle control and strength. If the child can feed independently, they are
encouraged to do so. Utensils with large handles may be used for easier
manipulation. The child must be fed in an upright position and not hurried
while eating because of the danger of aspiration. Assistance is provided
by standing behind the child and guiding the hand to the mouth. Stabilize
the mandible in a child with poor facial muscle control by placing a hand
on the child’s mandible.
MEDICAL CARE
Administer medications that reduce muscle spasms. Skeletal muscle
relaxants may be used for short-term control with older children and
adolescents. Dantrolene (Dantrium) is administered to decrease
spasticity, but the child must be monitored for hepatic impairment. The
use of baclofen (Lioresal) has proven to be an effective muscle relaxant.
Baclofen (Lioresal) can be administered intrathecally via an implanted
infusion pump to provide continuous and controlled relief. The advantage
of Baclofen pumps in the management of children with CP includes a
higher dose of Baclofen that can be administered directly to the site
(intrathecally) in the spinal column and therefore avoid some of the
adverse side effects of oral Baclofen such as the risk of liver toxicity and
GI upset (Valentine et al, 2020).
Neurolytic agent nerve blocks provide a temporary decrease in
spasticity for localized applications. Paralysis of specific muscles can be
achieved by the injection of botulinum (Botox), but the long-term effects
have not been determined. Antianxiety medications such as diazepam
(Valium) may be administered to older children and adolescents to
reduce excessive motion and tension. Children with CP are at increased
risk for seizures and may require use of antiseizure medications.
SURGICAL CARE
The child who does not respond to conservative management may
need surgical intervention. Surgical procedures provide joint stability and
balanced muscle power and may include tendon lengthening, release of
spastic wrist flexor muscles, and correction of spastic hip adduction.
Selective dorsal rhizotomy (severing of dorsal sensory fibers that have
an abnormal response resulting in spasticity) may be performed to
improve the child’s ability to sit, stand, and walk.
Provide education that incorporates knowledge of expected growth and
development as well as early detection of deterioration and signs and
symptoms of infection. The health-care needs of a child with CP are
complex and will require a multidisciplinary approach to improve health
and functional outcomes.
CASE STUDY
Infant Amy Moore, 9 months old, has been referred to a neurologist by a pediatrician
for evaluation. The neurologist questions the infant’s mother about her pregnancy,
the birth, and Amy’s physical and psychosocial development. The mother states Amy
is her first child, and she had a complicated pregnancy. She was diagnosed with
cytomegalovirus at 26 weeks of gestation and pregnancy-induced hypertension at 28
weeks. She delivered Amy at 32 weeks because of rapid progression of the
hypertension. At birth, Amy weighed 2 pounds and 9 ounces, and her Apgar scores
at birth were 3 and 6. Based on her initial assessment, Amy was transferred to the
neonatal intensive care unit (NICU) and remained there for 65 days. Amy was
mechanically ventilated for 26 days and received enteral feedings. While in the
NICU, Amy had a small intraventricular hemorrhage. Amy weighed 4 pounds and 10
ounces when discharged. The mother states that she is concerned about Amy’s
physical and psychosocial development. Physical assessment findings are as
follows: poor eye contact, anterior fontanelle soft spot, slight drooling of oral
secretions, mild head lag, few facial expressions, hypotonic extremity muscles, and
right-handedness noted.
1. What risk factors predisposed Amy to CP?

2. What physical assessment findings demonstrated by Amy are indicative of CP?
NEUROLOGICAL INJURIES
Long-term sequelae secondary to hypoxic brain injury remains a major
problem in the management of children with neurologic injury. Provide
education and support to assist the family in caring for a child with
neurological impairment. The child may need rehabilitation and long-term
follow-up.
Traumatic Brain Injury

Traumatic brain injury (TBI) is the leading cause of death in children in
the United States. Each year, many children from 0 to 14 years of age
experience varying degrees of brain injury. Approximately 470,000
children are seen in emergency departments for accidents involving a
head injury and 37,000 of those evaluated are hospitalized (CDC, 2020).
The primary causes of pediatric TBIs are motor vehicle crashes, bicycle
accidents, sports trauma, violence, and falls. Any child with a TBI must
be evaluated for child abuse (Fig. 20-13).
Traumatic brain injury occurs when a jolt or blow to the head disrupts
the normal function of the brain. The effects of a TBI may be as mild as a
brief loss of consciousness or as severe as a vegetative state or death.
The degree of disability varies with the severity and mechanism of the
injury, but a realm of physical and emotional deficits may be evident for
years after the injury occurs (Popernack, Gray, & Reuter-Rice, 2015).
There are many challenges for TBI survivors and their families,
including significant financial and emotional burdens. Nursing plays an
integral role in nursing care coordination and management of a child with
a TBI, especially helping affected children transition from acute care
through long-term rehabilitation.
A TBI can be classified as penetrating (e.g., bullet entering the brain)
or blunt injury (e.g., fall from a tree). A TBI is further classified as primary
or secondary. Primary injury occurs directly from the trauma, and
secondary injury is a result of complications (e.g., cerebral ischemia and
hemorrhage). Children are predisposed to head injury because their
heads are larger in relation to their body size, they have a more unsteady
gait, and they have thinner, softer cerebral tissue. Direct brain injury
occurs when the skull vault is penetrated. A skull fracture may or may not
be present. Indirect brain injury results when structural deformation
occurs. Rotational acceleration and deceleration forces are usually
present in motor vehicle crashes, and they produce tearing and shearing
injuries of the brain (CDC, 2020).
FIGURE 20-13 Traumatic brain injury.
Signs and Symptoms

Symptoms of TBI can include:
■ Scalp laceration
■ Alteration in LOC
■ Seizures
Diagnosis
A CT or MRI identifies intracranial bleeding, compression of cerebral
tissue, the presence of penetrating foreign objects, and skull fractures.
An EEG is prescribed to determine if the child has brain activity
abnormalities. Intracranial pressure monitoring, cerebral blood flow, and
cerebral perfusion pressure are measured if increased ICP is present.
Cerebral oxygenation is monitored with the use of jugular venous bulb
saturation and concentration or near infrared spectroscopy.
Prevention
The health-care team can incorporate injury prevention education and
anticipatory guidance into encounters with the child and family.
Community-based primary prevention educational initiatives increase
awareness and can reduce the risk of exposure. Effective preventive
measures (e.g., helmets, seat belts and car seats, effective sporting
equipment, and home safety inspection) can reduce the risk of TBI.
Collaborative Care
NURSING CARE
The child with a TBI needs immediate care to prevent life-threatening
complications or death. Airway patency is a priority. Deliver supplemental
oxygen via a bag-valve-mask device, per order, until the airway is
established. Assessment of the child’s neurological status is imperative.
Use the pediatric GCS to evaluate neurological status. The child’s pupil
size and reactivity are assessed, and a difference or change is reported.
Reflexes are assessed to determine brainstem involvement, and if the
brainstem is injured, the child’s prognosis is poor. Palpate the skull to
identify any fractures or depressions. Signs of a basal skull fracture
include leakage of CSF from the ears or nose, hemotympanum (blood in
the middle ear), mastoid ecchymosis (Battle’s sign), and periorbital
ecchymosis (raccoon eyes) (Hussain, 2018). Assess the patient for
increased ICP and ensure appropriate measures are implemented.
MEDICAL CARE
Under the direction of medical orders, the child may need to be
intubated and mechanically ventilated if a patent airway is not possible
because of injury to the neck or pharynx, if LOC is depressed, or if the
neurological state is expected to deteriorate. The attending health-care
provider may recommend that the nurse insert two large-bore IV needles
and administer isotonic fluid to maintain adequate circulation. IV fluids
are warmed if hypothermia is a concern. If the child does not respond to
fluid boluses or blood loss is greater than 30% of the child’s total blood
volume, blood products are administered (Paff, Alexandru-Abrams,
Muhonen, Loudon, 2018).
FOCUS ON SAFETY
Basal Skull Fracture
Do not insert a nasogastric tube if a basal skull fracture is suspected because the
tube may enter the brain through the fracture. Insert an orogastric tube if needed
instead.
TBI is a leading cause of disability. Discharge education will be specific
to the degree of brain injury. A multidisciplinary team will guide
rehabilitation. Parents are given emotional support and resources to
prepare them for challenges they may encounter taking care of a child
who has suffered a brain injury.
Abusive Head Trauma

Abusive head trauma (formally referred to as shaken baby syndrome) is
a nonaccidental injury caused by picking up an infant or child by the
shoulders or upper torso and shaking them. Abusive head trauma results
from major rotational forces and angular deceleration encountered when
an infant is shaken forcefully. The injury may be intentional or
unintentional. Most victims of shaken baby syndrome are younger than 6
months of age, and the source of the abuse is usually the father or a
male acquaintance of the mother. The prognosis for an infant depends
on the severity of the injury and response to medical therapy.
Complications a child may experience are neuromotor impairment, visual
impairment, and developmental delays.
Signs and Symptoms

Symptoms of severe cases of abusive head trauma include:
■ Seizure activity
■ Apnea
■ Bulging or full fontanelles
■ Coma
■ Hemorrhage (retinal or intracerebral)
■ Bradycardia
■ Complete cardiovascular collapse
Symptoms of less severe cases of abusive head trauma include:
■ Vomiting
■ Hypothermia
■ Poor feeding
■ Increased sleeping
■ Lethargy
■ Irritability
■ Difficult to arouse
Diagnosis
To diagnosis abusive head trauma, a CT scan or MRI is used to
determine if a subdural or subarachnoid hemorrhage is present. An
ocular fundoscopic exam is used to assess for retinal hemorrhage, a
classic sign of abusive head trauma. Retinal hemorrhages only occur
with few injuries, one is high velocity impact, such as motor vehicle
accidents (MVA) or coup countercoup injuries often seen when shaking a
baby’s head back and forth in shaken baby syndrome (SBS).
NURSING INSIGHT
Abusive Head Trauma
Recognizing abusive head trauma can be challenging. The hallmark of abusive
head trauma is an absence of external trauma to the head, face, and neck of an
infant along with massive intracranial or intraocular bleeding. Additionally, it is
important to note the children less than 1 year of age are at greater risk of abusive
head trauma as well as children with medical complexity or those with other
disabilities. Common signs of intracranial injury include retinal hemorrhages.
Another red flag for abusive head trauma in the pediatric patient is inconsistencies
between the health history and physical examination findings. If the physical findings
do not correlate with the caregiver’s account of the injury, this should be further
investigated as nurses are mandated reporters of suspected child abuse and
neglect.
Prevention
Identifying risk factors and increasing awareness of potential stressors
parents and other caregivers may experience while caring for an infant
are important measures in preventing this type of injury. Teaching
parental skills related to coping with a crying infant is also a crucial
preventive measure.
Collaborative Care
NURSING CARE
Nursing care of abusive head trauma involves initiation and
maintenance of respiratory and cardiovascular support, if necessary.
Upon admission, assess for increased ICP and visible injuries. Gathering
a health history and critical information about the abusive event is
essential.
The child may have long-term impairment. Long-term impairment
requires ongoing therapy that may consist of total care of self-care
deficits, gastrostomy tube feedings, a tracheostomy, and pressure ulcer
prevention. Additionally, prevention of complications such as infection,
contractures, or decreased muscle tone for children in a vegetative state
is important. The long-term outcome for a child with abusive head trauma
may be uncertain. The child may have minimal deficits or complications
or they may experience severe and life-altering complications. The
child’s prognosis is affected by many variables, including the degree of
cerebral involvement, areas of the brain affected, severity of intracranial
hemorrhaging, and medical management provided.
MEDICAL CARE
Initial care measures include maintaining oxygenation, inserting a
nasogastric or orogastric tube, assessing for seizure activity and
implementing seizure precautions, and maintaining adequate fluid and
nutritional intake. Documenting the data is also important as nurses are
legally and ethically required to report any incidences of probable abuse
to the appropriate child welfare and law enforcement agencies.
The nurse must honestly address parental concerns and questions and
provide information about agencies that can assist and support them.
The parents need to realize the child may never return to the prior level
of cognitive and physical functioning. Discharge instructions regarding
home management and monitoring, indications to see the health-care
provider, and follow-up appointments are given to the caregiver. Of the
infants who survive, long-term neurological complications may include
cognitive and behavioral disturbances, motor and visual deficits, and
seizures; therefore, the family must be provided with community
resources.
Spinal Cord Injury

The incidence of spinal cord injury (SCI) is based on pediatric
demographics, gender, and age of the child. SCIs are seen more in the
summer with bike riding, swimming and diving activities, football playing,
and motor vehicle collisions. Spinal cord injuries have been associated
with traumatic births and child abuse in children younger than 1 year of
age. SCIs are also associated with fighting with guns and knives and
other forms of violence.
SCI involves injury to the spinal cord in any or all the following regions:
cervical, thoracic, lumbar, or sacral. SCIs are caused by direct or indirect
force causing a contusion or bruising, compression, hemorrhage, or
significant vascular damage resulting in paresthesia (loss of sensation)
or paralysis (loss of function) below the level of injury.
There are four types of SCIs: (1) cord resection, when the spinal cord
is completely severed; (2) cord laceration, caused by a blunt instrument
such as a knife; (3) cord contusion, caused by swelling and edema; and
(4) cord injury, in which there is no necrosis or obvious injury.
There are three phases of SCI injury: acute, secondary, and chronic.
The acute phase begins at the immediate time of injury and lasts through
a few days later and is characterized by damage to the tissues resulting
in cell necrosis. Immediately after the insult, there is hemorrhage and
edema combined with electrolyte and fluid shifts. The cord then
experiences a spinal shock that lasts for 24 hours. The secondary phase
occurs at the time of injury and continues over several weeks. The child’s
neurological status at this phase determines recovery outcomes. The
chronic phase is marked with scarring and progression or regression of
function. Understand that complete resection of the spinal cord results in
complete loss of motor function and sensation below the area of injury.
Regardless of the mechanism of injury, the result is either temporary or
permanent loss or alteration of autonomic, motor, and sensory function.
Signs and Symptoms

Signs and symptoms vary depending on the level of the injury.
Immediately following the injury, the patient temporarily loses spinal
reflex activity below the level of the injury, causing a disruption of
sympathetic nervous system function. This results in vasodilation,
hypotension, and bradycardia. This is referred to as spinal shock and
subsides with the return of the reflexes. The severity of the symptoms
depends on whether the entire cord is injured (complete) or only partially
injured (incomplete). Injuries at any level can cause:
■ Increased muscle tone (spasticity)
■ Loss of normal bowel and bladder control (may include constipation,
incontinence, or bladder spasms)
■ Numbness
■ Sensory changes
■ Pain
■ Weakness or paralysis Diagnosis
The International Standards for Neurological and Functional
Classification of Spinal Cord Injury identify two levels of spinal cord loss
and function. Tetraplegia, currently replacing the term quadriplegia, is
caused by an SCI at the cervical level that involves all four extremities.
Paraplegia is the result of thoracic, lumbar, or sacral injury loss of
function and sensation in the lower extremities.
The clinical diagnosis of SCI and SCIWORA (Spinal Cord Injury
without Radiographic Abnormality; a term that denotes objective clinical
signs of posttraumatic spinal cord injury without evidence of fracture on
x-ray), is made both clinically and radiologically. Loss of motor function,
sensation, and anal tone clinically define the level of injury and degree of
involvement. A radiological examination with spine series, CT scan, or
MRI identifies the type of injury, the presence of hemorrhage or
inflammation, and the degree of bony involvement, if any.
Prevention
Public awareness efforts targeting both children and parents are
essential in primary prevention strategies. Many spinal cord injuries can
be prevented by implementing safe injury control practices. Providing
education about the leading causes of SPI and ways to prevent them
may influence behavior changes and adoption of these measures to
prevent injuries.
FOCUS ON SAFETY
Autonomic Dysreflexia
Autonomic dysreflexia is a stress syndrome caused by massive amounts of stimuli
overloading the autonomic system, which results in hyperactive sympathetic
stimulation. This leads to a myriad of symptoms such as extreme anxiety,
headache, visual and auditory sensation changes, nausea, seizures, hypertension,
peripheral vascular dilation or flushing, and bradycardia. This situation is an
emergent condition requiring immediate management of hypertension, cardiac, and
neurological complications.
Collaborative Care
NURSING CARE
The priorities of SPI care are attention to airway management,
breathing or ventilatory support, circulation support, disability
identification, and exposure of known and unknown physical limitations.
Immediate cervical (c-spine) immobilization is maintained continuously.
Treat an SCI with full-body immobilization and maintain with lumbar-
thoracic-sacral orthotics, which are rigid body casts that maintain
neuromuscular alignment until the injury is resolved.
Provide emotional and social support because the child with an SPI
and their family have unique collective and individual needs. The
younger child does not understand the loss of function immediately and
is more concerned with parental presence and fear issues. The older
child understands the loss of function and sensation and is more
cooperative and eager to return to normal living as much as possible.
Encourage older children and adolescents to participate in their own care
as much as possible. All daily activities such as bathing, dressing, eating,
grooming, and bowel and bladder contents elimination are performed by
the older child as they are able.
The adolescent presents a unique developmental challenge. The
realization about the loss of friends, athletic participation, and social
disruption may place the teen at risk for depression, withdrawal,
isolation, and suicide. Look for these changes and recommend
antidepressant medication to promote optimal function and return to a
healthy emotional status. The child with SCI requires lifelong care and
support. This places financial, mental, physical, and emotional strain on
the family. Recognize caregiver role strain and offer or encourage respite
care for the caregivers as needed.
MEDICAL CARE
If a child has a high cervical injury or if an open airway cannot be
maintained, a temporary or permanent tracheostomy is necessary for the
child to breathe. Mechanical ventilation may be a lifelong need for
patients with a high C4 injury. Cardiovascular and circulatory support is
maintained with adequate fluid resuscitation, inotropic medications, and
blood products to maintain circulation, cardiac output, and renal function
during the immediate posttraumatic event.
Also monitor appropriate daily fluid intake and output measurements
and ensure adequate daily fluid requirement needs are met. Enteral
feedings may be needed until the child is able to chew and swallow
without threat of aspiration. A child with altered oral pharyngeal motility
or dysphagia may require an oral pharyngeal motility study before oral
feedings.
The child with an SCI may be placed in skeletal traction or a halo
device for immobilization and alignment of the spine. Methylprednisolone
(Medrol) may be used after the initial injury to reduce spinal cord
inflammation. Pain management is also a priority. Early respiratory
physiology is initiated to minimize complications.
NURSING CARE
Generally, there are two back surgery approaches: open back surgery
and minimally invasive spine surgery. In SCI, an open back approach is
used. The goal of this surgery, following an SCI, is to stabilize the bony
elements of the spine and relieve pressure on the spinal cord.
Spinal Cord Injury
Nursing care of the child with an SCI is an interdisciplinary approach.
Multidisciplinary teams manage the aspects of care together to promote continuity
and coordination of care. The child works together with the family; medical team;
physical, speech, occupational, and respiratory therapists; and social workers to
coordinate the services needed for individualized care, focusing on achieving patient
outcomes and optimizing resources.
SCI patients will require extensive rehabilitation to achieve a maximum
level of functioning. In preparation for discharge home, educational
resources and information on resources and preventing secondary
complications will be beneficial to help the patient, family, and caregivers
manage the lifelong, complex care needs of the child.
NONTRAUMATIC NEUROLOGICAL CONDITIONS

Headaches
Headaches are common during childhood and become more common
and more frequent during adolescence. Triggers of primary headaches
have been identified as lack of sleep, stress, exercise, hunger, loud noise
or persistently loud noises, weather changes, and hormonal changes
caused by menstrual cycles in females. Secondary headaches are
associated with an organic disorder such as trauma, vascular changes,
infectious processes, substance use, brain neoplasms, or psychogenic
issues. A detailed health history and neurological examination is
essential because more than 98% of children with brain tumors have
objective assessment findings (Paff et al, 2018). Headaches are further
classified into subtypes based on descriptive symptoms and frequency of
disturbances.
Tension Headache
Tension headaches are common among school-age children and are
associated with stress. A tension headache is located in the back of the
head at the base of the skull and can include:
■ A dull, moderate pain
■ Pain may radiate bilaterally, just above the neck and shoulders
■ Affected sleep for children with these headaches
Loss of vision, nausea, photophobia, and auditory sensitivity are not
associated with tension headaches.
Migraine Headache
Migraine headaches are another type of headache and can be present in
the preschool or school-aged child. Most often, there is a family history of
migraines.
Signs and symptoms of migraine headaches include:
■ Radiating pain located on one side of the head with a throbbing or
pulsating quality.
■ Preceding aura accompanied by nausea, vomiting, diaphoresis, pallor,
photophobia, and auditory sensitivity. (Aura may be sensed by a
noxious smell, bright lights, or a change in vision.)
Not easily remedied with rest alone and typically require prophylactic
and acute management.
NURSING INSIGHT
Signs and Symptoms of Migraine Headaches
A range of other signs and symptoms can help in the diagnosis of migraine
headaches. A classic finding in the health history is that when the child has a
headache, they wish to lie in a dark, quiet room with a cold towel placed over the
face. Other signs and symptoms include:
• Throbbing and/or pulsing pain, usually unilateral
• Nausea
• Vomiting
• Photosensitivity
• Sound sensitivity
• Blurred vision
• Abdominal pain (also called abdominal migraine)
Cluster Headache
Cluster headaches are a series of headaches over a period of weeks or
months that vary in intensity and can be very debilitating.
Signs and symptoms of cluster headaches include:
■ Unilateral pain, behind one eye, resulting ptosis (drooping), pupil
constriction, erythema, and edema of the affected eye
■ Rhinorrhea with clear drainage in the absence of an upper respiratory
illness
Headache Diagnosis
Headache diagnoses are based on clinical symptoms according to the
ICHD-II criteria. Diagnosis is based on inclusion and exclusion of clinical
criteria. Clinical diagnosis is difficult with a young child because of
cognitive and communication barriers. A history of headache signs is
difficult to piece together because the symptoms may mimic those of
other minor pediatric illnesses. Neuroimaging studies are warranted with
sudden severe onset of headaches, history of trauma, family history of
brain neoplasms or vascular malformations, change in neurological
function, signs of increased ICP or visual disturbances, new seizure
onset, unexplained ataxia, or alterations in LOC.
Diagnostic assessment begins with a full neurological examination,
history of present illness, family headache history, review of symptoms,
and headache history including patterns, antecedent events, and
symptom management. Decisions for diagnostic neuroimaging, lumbar
puncture, or EEG testing are based on patient data obtained at the time
of the neurological evaluation. Routine neuroimaging is not indicated in
the presence of a normal neurological exam.
Prevention
Child and family education can target ways to prevent headaches.
Migraine prophylaxis includes identification and management of
headache triggers and medications such as topiramate (Topamax),
sumatriptan (Imitrex), ergotamine (Cafergot), nonsteroidal anti-
inflammatory drugs, antiemetics, and sedative analgesics.
Collaborative Care
NURSING CARE
Combined pharmacological and nonpharmacological therapies along
with child and family education can successfully manage the child with
primary headaches. Nonpharmacological therapies include lifestyle
modification and psychotherapeutic measures. Educate the family on
recognition of headache aura, prophylaxis strategies, and management
intervention, including medication, relaxation strategies, and
environmental modifications (e.g., noise reduction and dim or dark
room). Evaluate the effectiveness of the medication and monitor for
adverse reactions. Treatment also involves rest and stress-reduction
strategies such as soothing baths, music, guided imagery, or massage
therapy.
MEDICAL CARE
Acute episodes are treated with acetaminophen (Children’s Tylenol)
and ibuprofen (Children’s Advil). Other pharmacological prophylactic
medication such as beta blockers, calcium channel blockers,
antidepressants, and anticonvulsants or a combination of these can also
help the child cope with primary headaches. IM or intranasal
dihydroergotamine is used for moderate to severe migraines in
adolescents. Pharmacology therapy is individualized to the child’s needs.
Health education for this condition includes ensuring medications are
taken as prescribed. Keeping a record of headaches is helpful to observe
improvements and evaluate for contributing factors.
SENSORY CONDITIONS
Eye Disorders
Children may experience a myriad of common eye disorders. The parent
may notice an abrupt change or changes in vision function. Children are
not acutely aware of changes in vision or eye disturbances and may not
voice complaints of vision difficulty unless there is an injury. Common
childhood eye disorders are classified as refractive disorders,
astigmatism, amblyopia, strabismus, or organic diseases (Table 20-7).
TABLE 20-7
Common Acute Eye Disorders
EYE CAUSE/ORGANISM SIGNS AND TREATMENT
DISORDER SYMPTOMS
Conjunctivitis An inflammation of Excessive tearing, Apply warm soaks to
the conjunctiva erythema, and remove crusting, use
caused by bacterial, edema with clear, good hand hygiene and
viral, or allergic watery discharge, apply cool compresses to
agents. yellow or green edematous eyes.
drainage, and eyelid Antibiotic ointment or
crusting. Bacterial solutions are used for
and viral agents are bacterial infections.
difficult to Family education
discriminate clinically includes good hand
without a culture. hygiene before and after
Viral usually seen in touching the eye,
children older than 6 nonsharing of personal
years of age with a items such as
clear watery pillowcases and
drainage. Allergic: washcloths, and careful
cobblestoning and disposal of used tissues
pallor of the and wipes. Older children
conjunctiva, pruritus, who wear contact lenses
watery clear or use cosmetics must
drainage. discard used materials
and begin use of new
materials after the
infection has resolved.
School attendance is
permissible after the
discomfort and drainage
has subsided, usually
after 24 hours of
treatment. If symptoms
are not improved in 24 to
48 hours the family seeks
additional follow-up
medical care.
Conjunctivitis associated
with herpes may be
treated with oral or
parenteral antiviral
agents. Herpetic
ophthalmicus is one of
the leading causes of
vision loss in children.
Allergic conjunctivitis is
treated with allergen
avoidance and
antihistamines.
Neonatal Chemical irritation Purulent drainage Prophylactic antibiotic

Conjunctivitis– caused by maternal either white or ointment is used in all
Ophthalmia sexually transmitted yellowish. neonates. Lack of
Neonatorum diseases acquired at treatment can cause eye
birth. Chlamydia, damage.
gonorrhea, herpes.
Stye A localized Painful, Apply warm, moist

inflammatory erythematous lesion compresses with an
swelling of one or on the lid margin. antibiotic ointment. Good
more of the glands of Slight edema, some hand hygiene is
the eyelid. They are lymph node necessary.
mildly tender and tenderness or
may discharge some induration.
purulent fluid (Venes,
2021).
Chalazion Granuloma of the Hard, small nodule Applying warm moist

meibomian gland on on either eyelid may compresses and
the eyelid. Cause be painful. massage, with antibiotic
unknown. ointment, may resolve
the condition
spontaneously. Surgical
removal or steroid
injections may be used to
reduce size and
symptoms such as
ptosis.
Blepharitis Staphylococcal Erythematous eyelid Apply an antibiotic

Marginalis infection of the lid margin with crusted ointment to the lower
margin. eye drainage. affected eyelid. Apply
warm, moist compresses
to remove crusting
drainage.
Keratitis Inflammation and Very painful, An ophthalmologist must

infection of the excessive tearing, examine the cornea to
corneal layers photophobia, and monitor or treat potential
caused by bacterial, erythema. scarring and prevent loss
viral, fungal, or of vision.
foreign body
infiltration.
Periorbital Inflammation of the Edema, pain, Use IV antibiotic therapy

Cellulitis subcutaneous erythema in the skin for 7 days.
tissues and skin and orbital folds of
about the eye may the affected eye.
be bacterial or viral.
Blocked Tear Obstruction of the Tearing, yellow Apply warm compresses

Duct nasolacrimal tear drainage, crusting, and gently massage the
duct causing small bump in the lacrimal sac with the
inflammation or inner canthus of the forefinger, milking any
cystitis. affected eye. Usually exudates toward the
unilateral, may be nose. This condition may
painful. require probing of the
duct by an
ophthalmologist if no
improvement is noted in
6 months.
Source: American Academy of Pediatrics (AAP), (2020).
Refractive Disorders
Refractive errors are the most common category of vision disorders in
children. Light refraction is the bending of light as it passes through a
lens. As light passes through an opening in the pupil, the lens directs the
light to the retina to initiate vision. In very young infants, the light rays fall
behind the retina because of the shallowness of the eye.
HYPEROPIA
Most children are hyperopic (farsighted). The severity of hyperopia
diminishes as the child ages. Risk factors for refractive error include
retinopathy of prematurity and family history of high refractive error.
Signs and Symptoms
Signs and symptoms of hyperopia include:
■ Unclear vision at close range
■ Clearer vision at a far range
■ Trouble focusing on projects requiring close range vision, prompting
loss of interest (in young children)
Diagnosis
If a child reports headaches, dizziness, or eye strain after doing
schoolwork, hyperopia is suspected, and a referral is made for complete
vision assessment. Hyperopia usually diminishes by age 5 but in some
cases may persist.
Prevention
Parents play a key role regarding early diagnosis and prevention. If
parents notice visual disturbances in the child such as unclear vision at a
close range or difficulty focusing on projects, it is important to take the
child to a health-care provider for further assessment.
Collaborative Care
The main care for these children is wearing glasses with corrective
convex lenses. The lenses focus the light rays on the retina to correct the
refractive disorder. Routine follow-up examinations are important.
Tell parents that refractive errors are treated with corrective lenses.
Parents should also know refractive surgery may be performed in
children to prevent amblyopia.
MYOPIA
About a third of children in the U.S. develop myopia (nearsightedness)
during their school years, particularly if there is a familial history of
myopia. In myopia, light rays do not reach the retina, which causes
blurred vision at a far range and clear vision at a close range. This
condition continues to progress in severity until puberty when
progression plateaus. An important risk factor for the development of
simple myopia is a family history of myopia.
Signs and Symptoms
Signs and symptoms of myopia include:
■ Squinting
■ Complaints of difficulty seeing objects that are far away
■ Inability to see the blackboard, television, or street signs but able to
clearly read a book or a computer screen at close range
Diagnosis
Vision screening begins about 3 years of age or earlier if there are risk
factors of visual impairment.
Prevention
To prevent permanent visual impairment, early detection through
screenings is essential. Preventive measures also include parental
education about the warning signs of vision problems.
Collaborative Care
Myopia or blurred distance vision and reduced distance visual acuity
can be improved with appropriate minus-power lenses.
Laser assisted surgery keratomileusis (LASIK) is available for the
adolescents if desired. The age for LASIK surgery is controversial. If the
procedure is performed before full eye growth maturity has been
reached, additional surgery may be needed.
Parental education includes the importance of follow-up care and
options available for correction of myopia. Schedule follow-up
appointments for the child and stress the importance of keeping these
appointments. Also, provide community resources to families about
where to purchase corrective lenses. If the family cannot afford corrective
lenses, contact a case manager who can help the family.
ASTIGMATISM
Astigmatism is an irregular curvature or uneven contour of the eye
resulting in impaired light refraction. The cause is unknown. Astigmatism
may be present at birth or acquired. Light rays are unevenly distributed in
the eyes, causing blurred vision at all distances. This condition is
associated with birth hyperopia and myopia.
Signs and Symptoms
Signs and symptoms of astigmatism include blurred vision at all
distances, even with corrective lenses.
Diagnosis
If a child complains of headaches, blurry vision, or dizziness after
doing close work or difficulty reading, they are referred to an
ophthalmologist for exact diagnosis. Diagnosis is confirmed with history
and thorough ophthalmological examination.
Prevention
Prevention and early detection of astigmatism through school and
community screenings are recommended to decrease preventable
childhood visual impairment.
Collaborative Care
Correction of astigmatism includes corrective lenses and routine
follow-up examinations to monitor for amblyopia.
Parents are given education on the importance of follow-up care and
treatment options available for correction of astigmatism. They are also
instructed to promote eye protection and report any changes in visual
acuity to the health-care provider, which may include the pediatrician
and/or ophthalmologist.
Amblyopia (“lazy eye”) is one of the most common monocular eye
disorders in children leading to loss of vision. Strabismus and
anisometropia are the most prevalent forms of amblyopia in children.
Strabismus, or a cross-eyed appearance, results in malalignment of the
eyes (see later discussion). Anisometropia is a condition in which the
refractive power of the eyes is unequal (Venes, 2021). If the refractive
errors are significantly different in one eye, the child becomes dependent
on the eye that is more easily focused, leading to an irreversible loss of
vision potential. Vision screening is strongly recommended by the
American Academy of Pediatrics (2020) over the course of childhood to
detect amblyopia early enough to allow successful treatment. Because
many affected children are asymptomatic, early detection of abnormal
visual function requires effective screening throughout early childhood.
Treatment is initiated during the preschool years if possible. The success
of amblyopic therapy diminishes after age 6 (Kochaneck et al, (2020).
STRABISMUS
Strabismus is a condition of nonparallelism in the different fields of
gaze causing visual lines to cross even when focused on the same
object. Weakened or misaligned extraocular muscles pull the eyes in
different directions, resulting in a cross-eyed appearance. The child
attempts to compensate for this unequal vision by preferentially choosing
to use one eye and not the other eye. When the child focuses on an
object, one eye wanders away from the focused object while the other
eye looks straight ahead. The child then experiences two separate
images instead of one and develops a stronger eye.
Strabismus occurs in 2% to 7% of children, affecting males and
females equally, and has an inherited pattern in about half of the cases
(Kochaneck et al, 2020). Pseudostrabismus is an appearance of crossed
eyes but is a result of physical attributes such as prominent epicanthal
folds and a flattened nasal bridge. Children outgrow this condition over
time. True strabismus does not change without intervention and can lead
to amblyopia and loss of vision (U.S. Institute of Medicine, 2020). Any
other disease that causes vision loss may also cause strabismus.
Signs and Symptoms
Signs and symptoms of strabismus include:
■ Persistent squinting
■ Head tilting
■ Clumsiness
■ Decreased visual acuity
Intermittent strabismus is seen in normal children younger than 3
years of age when the child is tired, ill, or with a sudden change in light
or distance.
Diagnosis
Childhood screening is begun as early as 3 to 6 months of age. The
corneal light reflex test and the cover test are performed to detect
strabismus, but the cover test is the most reliable. The cover test is more
sensitive in that eye movement is noted in response to covering and
uncovering the child’s eye while focusing on an object. This test requires
the child’s cooperation. The cover test is performed by having the child
focus on a toy or favorite object and covering one eye. If the uncovered
eye moves, that eye was not fixated on the object and strabismus is
suspected. Three forms of strabismus describe the eye deviation noted
on an exam:
■ Esotropia: eye turns toward the midline of the face or nose
■ Exotropia: eye turns away from the midline of the face
■ Hypertropia: eye turns toward the forehead or a downward turning
Assessment Tools
Hirschberg Asymmetrical Corneal Light Reflex Test
The Hirschberg asymmetrical corneal light reflex test is performed by holding a
penlight or flashlight in front of the child’s face. The light reflection is noted on the
cornea in both eyes. Symmetrical placement on both eyes at the same time and in
the same location on each eye designates negative corneal light reflex exam results
and indicates normal muscle alignment. Positive asymmetrical corneal light reflex
test results occur when the light falls slightly medially to the center of the pupil on
the iris. The presence of an asymmetrical corneal light reflex is a positive exam and
is suggestive of strabismus. A cover test is then performed.
Prevention
Early identification and recognition of all suspected strabismus cases
are critical to prevent vision loss. To prevent visual loss, a family history
of strabismus is done. Parents need to understand that farsightedness
may be a contributing factor suggestive of strabismus.
Treatment of strabismus involves ocular patching of the stronger eye
to force the weaker eye to work independently and “exercise” to
strengthen extraocular muscles. Occlusion therapy is conducted under
the care of a pediatric ophthalmologist (Fig. 20-14). Patching is most
successful if implemented before age 3 to 4 years. Glasses are also
prescribed for the child.
MEDICAL CARE
Botulinum toxin A (Oculinum) (Botox) may also be used for treatment
of strabismus in children. Botox can be used in conjunction with or as an
alternative to surgery. The toxin is injected into the extraocular muscle,
causing misalignment, and produces a temporary muscle shortening
resulting in a parallelism of vision. The Botox effects last for up to 3
months and repeat injections may be performed. Potential complications
include retrobulbar hemorrhage, ocular needle penetration, and ptosis.
FIGURE 20-14 Occlusion therapy or patching of the normal eye is done
to restore strength and function to the lazy eye.
SURGICAL CARE
If conservative therapy is not effective, eye muscle repair surgery may
be needed.
Provide families and children with referral sources, support groups,
information, and schooling. School-based screening programs are
essential for early detection, identification, and initiation of treatment of
strabismus-related eye disorders. The school nurse may also be involved
when treatment is needed during school hours.
NYSTAGMUS
Nystagmus is a rapid, irregular, involuntary eye movement caused by
a disorder of the CNS that may be congenital or acquired. There are
many types of nystagmus.
Congenital nystagmus is usually mild and nonprogressive and persists
into adulthood. Brain injuries are the most common cause of acquired
nystagmus. Any child who develops nystagmus early in life is evaluated
for an underlying CNS cause. Prognosis is based on the etiological
cause.
Signs and Symptoms
Signs and symptoms of nystagmus include:
■ Eyes that rotate in a lateral direction, clockwise or counterclockwise
direction, up and down, or any combination of these movements.
■ Repetitive and involuntary eye movement that may be managed by
gaze redirection.
Diagnosis
If an identifiable cause is not clear, neuroimaging, such as an MRI, is
warranted to rule out the possibility of a neoplasm.
Prevention
Preventive measures include providing information to families that
nystagmus can be inherited or may develop after an accident or illness
and is often a symptom of an underlying eye or medical problem. If low
vision is suspected, parents must seek medical advice from a health-
care provider to prevent further visual loss.
Collaborative Care
NURSING CARE
Acquired nystagmus treatments are based on the existing etiology and
may include pharmacological, optical, and surgical approaches.
Significant refractive error is corrected with glasses or contact lenses.
SURGICAL CARE
Extraocular surgery may correct some forms of congenital nystagmus.
Goals of surgery include increasing visual acuity, alleviating an abnormal
head position, or decreasing the amplitude of nystagmus.
Before discharge, parents will receive instructions about home care,
medications, and recognizing signs of complications.
CATARACTS
A cataract is a clouding or a haziness of the corneal lens. Significant
irreversible vision disorders are caused by cataracts. Cataracts can be
located unilaterally in one eye or bilaterally in both eyes. Cataracts can
be acquired or congenital, resulting in partial or complete occlusion, or
both. Acquired cataracts can be caused by maternal infection acquired
during pregnancy, trauma to the eye, radiation, or systemic diseases.
Some cataracts are a result of family inheritance patterns. Congenital
cataracts are present in neonates with syndrome anomalies or mothers
with TORCH (toxoplasmosis, rubella, cytomegalovirus, herpes simplex or
HIV) infection during pregnancy. Congenital cataracts can be autosomal
dominant in genetically linked families. However, X-linked and recessive
genetic situations have been reported.
Signs and Symptoms
During an eye exam with an ophthalmoscope, a cataract is usually
visualized by the examiner. Signs and symptoms of cataracts include:
■ Abnormal or absent red reflex
■ Excessive tearing and extraocular movements
■ Strabismus
■ Abnormal cover test
■ Photophobia
■ Decreased visual acuity
Diagnosis
A pediatric ophthalmologist performs a complete eye examination.
Diagnosis is made when the lens appears cloudy or there is a white or
dulled red reflex.
Prevention
Early detection and diagnosis of a congenital cataract prevent loss of
visual acuity. Prevention also includes a referral to a pediatric
ophthalmologist when low vision is suspected.
Collaborative Care
NURSING CARE
In cataract care, a change in eyeglasses and/or more lighting may
effectively improve vision. The child who is undergoing a cataract
removal is usually admitted to the outpatient surgery unit. Prior to the
procedure, nursing care includes preparing the child and family for
surgery, administering any medications, and providing health education
regarding recovery and limitations of activity. Preoperative visual status
baseline is also obtained.
SURGICAL CARE
In most cases, a laser procedure is performed to remove the cataract.
Because the eye is still growing, a permanent lens is not placed until eye
growth has reached maturity. When the eye has reached full
development, the child can return to surgery where a small incision is
made in the eye to place a permanent lens. The child can wear a
standard corrective contact lens until a permanent lens can be placed.
Postoperative nursing care for the child includes monitoring nausea,
emesis, pain, hemorrhage, and signs of infection. Keep the child free
from wrenching, coughing, crying, and active play that can cause
increased intraocular pressure (IOP). Postoperative eye drops also
include a steroid preparation to reduce inflammation and prevent
adhesions. Mydriatic eye drops prevent adhesions of the pupils, and
topical antimicrobial eye solutions prevent infection. Postoperative
education for the family and child includes signs and symptoms of
infection, hemorrhage, increased IOP, and activity restrictions until
cleared by the health-care provider.
Follow-up care of the child is based on loss of visual acuity. Some
children need glasses for correction of refraction errors. Other children
may need an antiglaucoma medication to prevent IOP development. If
amblyopia is evident, the nonsurgical eye is patched to force the
operative eye to “exercise,” which strengthens the extraocular muscles.
GLAUCOMA
Glaucoma is an increase of the IOP in the eye caused by an
obstruction or impaired outflow of aqueous humor (clear fluid), which
leads to retinal damage and eventual necrosis of the optic nerve. Optic
nerve cupping is seen with ophthalmoscope examination. The eye
enlarges because of increased IOP, causing a thinned, cloudy-appearing
cornea. The sclera may appear bluish. Glaucoma can be congenital or
acquired. Some cases of pediatric glaucoma are caused by eye trauma
or from surgical procedures. Congenital or infantile glaucoma is a rare
condition presenting with corneal opacification (or clouding), corneal
enlargement, and eye pain. Another rare type of congenital glaucoma is
when the iridocorneal (the junction of the iris and the cornea) angle of the
eye at the canal of Schlemm causes an obstruction of outflow of
aqueous humor from the eye. This condition appears in the first year of
life and, if left untreated, results in blindness.
Signs and Symptoms
Signs of infantile glaucoma include a triad of symptoms:
■ Buphthalmos (enlarged eye globe)
■ Epiphora (excessive tearing)
■ Photophobia (sensitivity to light)
Diagnosis
A complete eye examination is performed by a pediatric
ophthalmologist. Tonometry (measurement of tension) is used to
evaluate IOP.
Prevention
Although childhood glaucoma is rare, some types of pediatric
glaucoma are hereditary. Preventive measures include obtaining a
thorough family history. Early detection and treatment are essential to
prevent low vision and preserve good vision.
Collaborative Care
NURSING CARE
The child who is undergoing surgery for glaucoma is usually admitted
to the outpatient surgery unit and then may be transferred to the pediatric
floor. Prior to the procedure, nursing care includes preparing the child
and family for surgery, administering any medications, and providing
health education regarding recovery and limitations of activity.
Preoperative visual status baseline is also obtained.
SURGICAL CARE
Early surgical intervention is done to remove obstructions and allow
the flow of aqueous humor into the canal of Schlemm. Provide
preoperative, family-centered care and education about the condition.
Prior to the procedure, the child is premedicated with a topical anesthetic
to obtain a reliable eye pressure measurement. Also before surgery,
prevent IOP increase by maintaining a quiet, calm environment with dim
lighting. Anti-glaucoma medications provide temporary relief of IOP.
Postoperatively analgesia is given for pain as well as using anxiety
reduction strategies such as distraction, massage, music, and parental
presence. Favorite toys, pacifiers, and blankets are used to comfort the
child.
Prior to discharge, teach the parents about eye dressings,
medications, signs and symptoms of infection and increased IOP, activity
limitations, and follow-up care.
NURSING INSIGHT
Foreign Bodies
When a child has a foreign body penetrating the eye, careful history of the injury and
assessment dictate immediate action. An intraocular penetration injury or laceration
(tear) to the cornea or eye globe requires an immediate transport to the local
emergency room. An eye shield is used to prevent further trauma, and all bleeding
must be controlled before transport.
In foreign body penetration, vision loss is prevented by prompt medical treatment.
The triage nurse must be able to recognize an emergent situation from a none-
mergent injury. If a foreign body is visualized in the conjunctival sac, a physician can
carefully remove the object using a cotton-tipped applicator or warmed normal saline
irrigation. Glass particles are removed carefully using a cotton-tipped applicator.
Sand, gravel, and dirt are flushed with warm normal saline. Foreign bodies need to
be removed meticulously to avoid a corneal abrasion.
Hearing Disorders
Hearing Loss
Hearing loss is one of the most common disabilities in the United States.
Early detection and intervention are essential to maximize outcomes.
Hearing loss can be caused by several factors:
■ Genetic causes
■ Nongenetic causes (meningitis or maternal TORCH infections during
pregnancy, in particular cytomegalovirus)
■ Idiopathic or unknown causes
Fluid accumulation in the middle ear from allergies or colds can be a
contributing factor for hearing impairment in children. Seventy-five
percent of children experience at least one ear infection before the age
of 3. Hearing loss affects approximately 17 children in 1,000 under 18
years of age. Two to three children per 1,000 are born with hearing
abnormalities. Of these children, 90% are born to parents who can hear
(AAP, 2020; National Institute on Deafness and Other Communication
Disorders, 2020).
Hearing loss may also be caused by conduction abnormalities
associated with structural anomalies of the inner and outer ear or
sensory neural hearing loss caused by central nervous system
dysfunction. Central nervous system dysfunction includes damage to the
cerebral cortex, brainstem, or cranial nerve VIII. Hearing loss is also
seen with severe neurological insult from trauma, anoxia, infections, or
malformations.
A hearing disorder can involve a combination of both conductive and
sensorineural abnormalities. Sensorineural hearing loss is a common
sequela of bacterial meningitis, affecting approximately 10% of these
children. Rapid identification and prompt treatment can prevent post–
meningitis hearing loss. Hearing loss is quantified in terms of severity
and degree of functional disability and may be unilateral or bilateral.
SIGNS AND SYMPTOMS

Common signs and symptoms of hearing loss include:
■ Child lacks the startle reflex
■ Child does not turn toward source of sound
■ Child does not follow verbal directions or respond when called by
name
■ Child has delayed speech or speech that is difficult to understand
■ Child has difficulty with articulation
DIAGNOSIS
Hearing loss is determined by otoscopic examination and audiological
testing. A routine otoscopic examination is performed by a health-care
provider to evaluate the presence of a middle ear effusion or otitis media
(Fig. 20-15). Part of the otoscopic examination also involves the use of
the pneumoscope to assess for tympanic membrane (TM) mobility.
If the hearing loss continues to be suspected, a tympanogram
(radiographic examination of the eustachian tubes and middle ear after
introduction of a contrast medium) may be completed (Venes, 2021). The
tympanogram evaluates the TM compliance to air pressure. An eartight
probe containing a small speaker, microphone, and air pump is placed
into the external auditory canal. The probe then determines the flexibility
of the TM in response to positive and negative pressure levels. The
normal result is a mountain peak plotted on a graph depicting the
positive and negative pressure levels. A flat or absent mountain peak
suggests a conductive hearing loss caused by obstruction.
FIGURE 20-15 A routine otoscopic examination of the child is performed
by a health-care provider to evaluate the presence of middle ear infection
or otitis media.
Diagnostic Tools
Audiological Testing
Audiological testing may include one or several procedures:
The otoacoustic emissions test or an auditory brainstem evoked response (ABER)
performed by a licensed, certified audiologist further defines the degree of hearing
loss. This is a very reliable test that measures acoustic responses produced by the
inner ear and cochlear function. A small probe is placed in the outer ear canal and
senses sounds that are reflected or echoed back out of the ear. This bounced back
sound is the otoacoustic emission that may spontaneously occur or be evoked.
The automated ABER records electrical activity in response to auditory stimuli
received from electrodes placed on the scalp. The electrical impulse reflects
cochlear, auditory brainstem, and cranial nerve VIII vibration pathways. The ABER
places a series of clicking sounds through earphones placed over the infant’s or
child’s ears. The sounds are then converted to waveforms and detected as electrical
activity by the scalp sensors. The strength of the stimulus level is in the normal voice
and hearing range of 35 to 50 dB. The ABER is useful for screening newborns with
congenital hearing loss or postneonatal intensive care therapies such as mechanical
ventilation.
Audiography can be performed in children older than 3 years of age
who are able to cooperate and follow directions. This test requires the
child to raise his hand in response to normal hearing tones. The
screening is performed under the supervision of a clinically competent
audiologist, speech pathologist, or appropriately supervised personnel.
PREVENTION
Early detection and intervention for children with hearing loss have
been recommended by the Centers for Disease Control and Prevention
(2020). A universal infant hearing screening before 1 month of age is
recommended. Newborn readiness for discharge includes a hearing
screening evaluation. If newborn hearing loss is suspected, a more
extensive audiological evaluation is recommended by 3 months of age.
Adolescents are encouraged to turn down radios, stereos, and personal
music devices such as iPods, MP3 players, and cell phones to prevent
hearing loss.
COLLABORATIVE CARE
Nursing Care
Simple conduction loss caused by cerumen (earwax) impaction can be
treated with over-the-counter preparations, water irrigations, and foreign
body removal. Nurses provide emotional, educational, and collaborative
support for the child with a hearing loss and their family. Sign language
services may be required as well as visual aids that support nonverbal
communication and lip reading. The family needs to investigate home
safety measures that protect the hearing-impaired child from inadvertent
injury. Supervision may be required at all times. Other assistive
communication techniques include lip reading, finger spelling, and cuing.
The family can use cued speech, a visual communication system that
uses hand and mouth shapes along with gestures to cue a sound or a
consonant. This serves as a supplement to lip reading and sign
language.
Medical Care
Medical management of hearing loss begins by 6 months of age.
Appropriate treatment for hearing loss is based on underlying
pathological conditions, presence of organic diseases, severity of the
hearing loss, degree of frequency loss, and any CNS abnormalities. Ear
infections are treated with appropriate antimicrobial therapy with close
follow-up to monitor for the hearing loss or language delays as well as to
monitor response to therapy.
Surgical Care
Children who have chronic ear infections may have surgery to restore
inner ear function with myringotomy tubes placed in the TM for effusion
drainage and pressure equilibrium. Stapedectomy (excision of the stapes
to improve the hearing) and tympanoplasty (restores function to the
sound-transmitting mechanism of the middle ear) have been shown to be
effective in restoring the hearing for conduction disorders. Severe to
profound hearing loss is treated using cochlear implants that provide
sound awareness and support speech development. Cochlear implants
carry a risk of meningitis.
To relieve anxiety, parents will need preparation of what to expect with
a child undergoing general anesthesia and instructions on caring for a
child with tympanostomy tubes for preventing complications.
NURSING INSIGHT
Communicating With the Hearing-Impaired Child
Nurses can use these strategies to facilitate open communication:
• Recognize behavioral cues suggestive of hearing loss.
• Obtain the child’s attention before speaking.
• Face the child when talking.
• Position yourself at the child’s eye level.
• Talk slowly and loudly.
• Modify the environment; unnecessary noises are reduced.
• Offer emotional support: A child with a hearing loss may face a potential stigma
associated with the communication difficulty.
LANGUAGE DISORDERS
Communication is a process of complex interaction involving the
exchange of information, feelings, ideas, and interactions. Verbal speech
together with a language framework provides the basic component of
communication. Nonverbal gestures, tones, and body movements
provide as much if not more communication than words. Language
development is the process of giving and receiving of information as well
as processing and organizing meaning to exchange information,
thoughts, and feelings. The ability to understand what is said is receptive
language. The ability to clearly speak to others is expressive language.
Speech impairment is an inability to make voice sounds or produce
quality sounds; children may experience any combination of hearing,
speech, and/or language disorders.
Children understand more than they can express at a very early age
because language is learned last. Most of a child’s speech should be
clearly understood by 3 to 4 years of age. Most communication skills are
learned by age 5.
NURSING INSIGHT
Quick Reference Tool for Language Development
The child’s language should be understood:
• 50% of the time by age 2 years
• 75% by age 3 years
• 100% by age 4 years
Sentences should be as long as the child’s age (three words at age 3, for
example).
Signs and Symptoms

Children with a receptive language disorder may have:
■ Difficulty understanding what others are saying
■ Problems following directions that are verbally given to them
■ Difficulty organizing their thoughts
Children with an expressive language disorder have difficulty using
language to express their thoughts or needs and may exhibit:
■ Difficulty forming sentences
■ Trouble finding the correct words when speaking
■ A decreased vocabulary compared with other children of the same age
Diagnosis
Diagnosis determines that the communication skills are considered
delayed and the child is not meeting predictable developmental
sequencing for their age.
Prevention
Prevention centers on early detection and intervention for young children
with a language disorder. Early discovery of hearing loss can prevent
other forms of delay in child development such as social or emotional
development.
Collaborative Care
The nurse is in a key position to recognize speech and language
developmental delays. Knowledge about development milestones assists
the nurse in recognizing children who are at risk or experiencing a
difficulty. The overall nursing goal of early recognition is to prevent
communication, language, and literacy delays that significantly affect the
child at an early age, potentially for life.
Patient Education
Language Disorder
HOW TO: Tell the family that a language disorder is a child’s impaired ability to
understand or use words correctly, to express one’s self, to follow directions, to
understand words, or any combination of these conditions.
• Help the child learn how to say speech sounds correctly.
• Help the child improve language comprehension such as increasing vocabulary.
• Help the child with conversational and storytelling skills.
• Help the child and family understand the disorders may affect the child’s
educational and social interactions.
Advise the family about how to find a speech pathologist in the community;
schools, rehabilitation, community and private clinics, and home services may be
utilized to meet the child’s needs.
The emphasis of parent teaching is to provide therapy support and
encourage the child. Nurses may provide education and supportive
community resources for parents to help enhance the child’s
communication skills, develop goals for effective therapy at home, and
help with transition to school.
SUMMARY POINTS
■ Increased ICP can have devastating and long-term consequences for the child.
■ A seizure is an electrical disturbance within the brain, resulting in changes of motor
function, sensation, or cognitive ability.
■ Encephalitis is usually viral in origin and occurs with an acute febrile illness
characterized by cerebral edema and infection of surrounding meninges. Signs and
symptoms of encephalitis include disorientation, confusion, headache, high fever,
photophobia, lethargy, aphasia, hallucinations, seizures, nuchal rigidity, and coma.
■ Guillain-Barré syndrome (GBS) is a rare self-limiting disease characterized by clinical
manifestations of ascending muscle weakness and/or paralysis.
■ There are two categories of hydrocephalus. Communicating hydrocephalus occurs
when there is full communication between the subarachnoid space and ventricles.
Noncommunicating hydrocephalus occurs when CSF flow within the ventricular
system or the ventricular outlets to the arachnoid space is prevented. Most cases of
hydrocephalus are obstructive.
■ CP is a nonprogressive neurological disorder that results from brain injury occurring
before cerebral development is complete.
■ The priorities of trauma care for a child with an SPI are initiated with primary attention
to airway management, breathing and/or ventilatory support, circulation support,
disability identification, and exposure of known and unknown physical limitations.
■ Headaches are common during childhood and become more common and more
frequent during adolescence. Headaches are classified as primary or secondary and
further classified into subtypes according to the International Classification of
Headache Disorders (ICHD-II).
■ Children may experience a myriad of common eye disorders, which may present as
an abrupt change or changes in vision function.
■ Hearing loss is one of the most common disabilities in the United States. Early
detection and intervention are essential to maximize. Early detection and intervention
for young children with a language disorder prevent many forms of delay in child
development.
REFERENCES
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Online. Retrieved from https://www.pediatriccareonline.org/pco/ub/view/Point-of-
Care-Quick-Reference/397246/0/altered_mental status
Centers for Disease Control and Prevention (CDC). (2020). Pediatric TBI Guidelines.
Retrieved from
https://www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html
The Epilepsy Foundation. (2020). Retrieved from http://www.epilepsy.com/
Goranitis, I., Best, S., Stark, Z. et al. (2020). The value of genomic sequencing in
complex pediatric neurological disorders: A discrete choice experiment. Genetic
Medicine. https://doi.org/10.1038/s41436-020-00949-2
Hussain, E. (2018). Traumatic brain injury in the pediatric intensive care unit. Pediatr
Ann. 47(7):e274_e279. doi:10.3928/19382359-20180619-01
Individuals With Disabilities Education Act. (2004). 20 U.S.C. § 1400.
Institute of Medicine of the National Academies. (2012, March). Epilepsy Across the
Spectrum: Promoting Health and Understanding. National Academy of Sciences.
International Headache Society. (2020). IHS Classification ICHD-II. Retrieved from
http://ihs-classification.org/en/
Jain, S., & Iverson, L. M. (2020). Glasgow Coma Scale. [Updated 2020 Jun 23]. In:
StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK513298/
Kochaneck, P. M., Carney, N., Adelson, P. D., Ashwal, S., Bell, M. J., Bratton, S., et al.
(2020). Guidelines for the acute medical management of severe traumatic brain
injury in infants, children, and adolescents (2nd ed.). Pediatric Critical Care
Medicine, 13, S1–S82.
Levy, M. L., Levy, D. M., & Manna, B. (2020). Pediatric cerebral aneurysm. In:
StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2020 Jan-. PMID:
30725770.
National Institute of Neurological Disorders and Stroke. (2020). Cerebral palsy.
Retrieved https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-
Sheets/Guillain-Barr%C3%A9-Syndrome-Fact-Sheet
National Institute on Deafness and Other Communication Disorders. (2020). Statistics
about hearing, balance, ear infections, and deafness. Retrieved from
www.nidcd.nih.gov/health/statistics/
National Reye’s Syndrome Foundation. (2020). Retrieved from
http://www.reyessyndrome.org
Normal Growth of Young Children – Pediatrics – About.com, 2020.
Paff, Alexandru-Abrams, Muhonen, & Loudon, (2018). Interdisciplinary Neurosurgery
13, 66–70.
Popernack, M. L., Gray, N., & Reuter Rice, K. (2015). Moderate-to-severe traumatic
brain injury in children: Complications and rehabilitation strategies. J Pediatr Health
Care. 29(3):e1–7. doi: 10.1016/j.pedhc.2014.09.003. Epub 2014 Oct 28. PMID:
25449002; PMCID: PMC4409446.
United Cerebral Palsy Foundation. (2020). Cerebral Palsy Source. Retrieved from
http://www.cerebralpalsysource.com/About_CP/facts_cp/index.html
United States Institute of Medicine. (2020). Strabismus Treatment. Retrieved from
Vallerand, A. H., & Sanoski C. A. (2021). Davis’s drug guide for nurses (17th ed.).
Valentine, J., Davidson, S. A., Bear, N., Blair, E., Paterson, L., Ward, R., Forbes, D., &
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with cerebral palsy and GMFCS level II after long-term Botulinum toxin type A use.
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laboratory and diagnostic tests (17th ed.). Philadelphia: F.A. Davis.
Venes, D. (2021). Tabers cyclopedic medical dictionary (24th ed.). Philadelphia: F.A.
Davis Company.

Advantage
CHAPTER 21

Musculoskeletal Condition
CONCEPTS
Inflammation
Mobility
KEY WORDS
compartment syndrome
poikilothermia
spica hip cast
cast syndrome
open reduction
osteomyelitis
fontanelle
tenotomy
recanalization
superolateral
osteotomy
synovitis
Marfan’s syndrome
apophysis
osteoblasts
remodeling
Kirschner wire (K-wire)
articular
Cobb’s angle
acromioclavicular joints
LEARNING OBJECTIVES
■ Describe the anatomy, physiology, and growth and developmental aspects of
infant, child, and adolescent musculoskeletal systems compared to adult
musculoskeletal systems.
■ Describe the pathophysiology, etiology, clinical manifestations, and
management of various musculoskeletal alterations frequently seen in
pediatric patients.
■ Prioritize, design, implement, and evaluate developmentally appropriate and
holistic nursing interventions for the child with altered musculoskeletal
conditions.
■ Describe characteristic assessment findings that indicate musculoskeletal
alterations in a child, and describe the diagnostic testing, laboratory testing,
and medications used for treatment for the child with altered musculoskeletal
function.
have various musculoskeletal conditions.
PICO(T) Questions
Use this PICO(T) question to spark your thinking as you read the chapter.
Does the (I) rate of pin site infection in (P) children with skeletal traction (O)
change if pin care is given with antibacterial soap and water every 4 hours (C)
compared with pin care every 8 hours with half-strength hydrogen peroxide
cleansing and Xeroform gauze?
INTRODUCTION
developmental aspects of the musculoskeletal system. The
discussion includes an examination of the various musculoskeletal
tract conditions including developmentally appropriate and holistic
nursing care. Information about diagnostic and laboratory testing and
medications is given. Teaching plans and discharge criteria for
parents whose children have various musculoskeletal conditions are
incorporated.
Considerations for the Child With a Musculoskeletal Condition
Various musculoskeletal conditions can limit or impair a child’s mobility and
hinder their overall growth and development. Immobility may occur from the
disease process or from treatments such as casts, traction, and pins. Impaired
mobility affects the child’s ability to maintain normal developmental milestones
in motor function and movement. An understanding of when children meet
these milestones, especially in gross motor development, is important when
caring for the child with an alteration in musculoskeletal function. Failure to
meet these milestones in a timely manner can indicate hypotonia, cerebral
palsy, or a neuromuscular disorder such as muscular dystrophy. Any regression
or loss of any milestone is a cause for concern and further evaluation.
Research has shown that a family-centered therapy approach is important
for significant improvement in therapy responses (Collins, 2020). Family-
centered therapy includes the involvement of the parents and family members
in the identification of the child’s impairments and developmental milestones as
well as the development of an appropriate intervention plan. Significant
improvements in outcomes have been identified when parents are actively
involved with such therapies.

MUSCULOSKELETAL SYSTEM
Movement is made possible by the musculoskeletal system, which
consists of the bones, joints, ligaments and tendons, and muscles
(Fig. 21-1). These structures provide protection for the vital organs
inside the body. Children are more likely to suffer from conditions of
the musculoskeletal system than adults because their
musculoskeletal systems are still growing. On the positive side,
fractures in a child’s growing bones heal much faster than those in
an adult. Conversely, if the fracture penetrates the growth plate in a
child, growth of that bone is interrupted. Some conditions involving
the musculoskeletal system may be short-term and have only a
slight effect on the child’s mobility. Other conditions may have a
significant effect and be debilitating and long-term. Additionally, the
nurse should consider the effect that an impairment in the
musculoskeletal system can have on a child’s overall growth and
development.
Pediatric Differences in the Musculoskeletal System

To better understand the treatment and care needed for pediatric
musculoskeletal injuries, it is important to have a sound
understanding of the difference between the pediatric and adult
musculoskeletal systems. The main difference is that children’s
bones are growing in both length and width while adult bones have
stopped growing. Another difference is that the periosteum of the
child’s bone is much stronger than that of adults, making bone
displacement with a fracture less likely in a child than an adult.
Skeletal growth is stimulated by pituitary growth hormone. Growth
of the long bones occurs at the epiphyses, located at the ends of the
bones and separated from the main portion of the bone by cartilage.
Any injury to the epiphysis can cause permanent length inequality.
Infant bones are only 65% ossified at 8 months of age and are not as
firm as those of an older child. In addition, the skull is not fused at
birth, and the sutures of the cranium do not fuse completely until
approximately 12 to 18 months of age (with the anterior fontanelle
closing). Prior to this period, sutures can separate with increased
intracranial pressure.
In addition to these changes, muscle tissue is mostly completely
developed at birth, and growth occurs by an increase in size (not
number) of muscles. Improved posture control occurs with further
development of the neurologic system and an increase in muscle
growth and control. This often serves as good indicator for
neuromuscular development.
Bones
Bones are classified by their size and shape. Long bones are found
in the extremities, including the fingers and toes. Most childhood
disorders are located in the long bones. Short bones are located in
the ankle and wrist. Flat bones are located in the skull, scapulae,
ribs, sternum, and clavicle. Irregular bones are the vertebrae, pelvis,
and facial bones. Long bones consist of the epiphysis (rounded, end
portion), the diaphysis (long, central portion), and the metaphysis
(thin portion between the epiphysis and the diaphysis). Long bones
grow in length at the epiphyseal plate. Growing bones produce
calluses and tend to heal quickly (due to the rich blood supply from
the thick periosteum). Since children’s bones are not completely
ossified, fractures in children younger than age 1 are uncommon
unless a result of extreme force. This may result from child abuse or
pathophysiology such as cancer.
FIGURE 21-1 Skeletal system anterior and posterior views.
Bones need nutrients to grow. Calcium is a main component of

bones and is required for bone formation, resorption (bone
breakdown by osteoblast cells), and remodeling (new bone replacing
old bone by osteoclast cells). Calcitonin, parathyroid hormone,
vitamin D, other minerals, and enzymes all play a role in the
processes of resorption and remodeling. The central part of a long
bone contains the marrow. Red marrow produces red and white
blood cells and platelets. Yellow marrow produces fat cells. Bone
cells die and the necessary production of blood components is
interrupted if there is no blood supply to the long bones. Pediatric
bones are covered by a thick periosteum that gives children’s bones
an excellent blood supply. The periosteum provides nourishment to
the bones. Children have a thicker periosteum compared to adults,
which often keeps their bones from becoming displaced when
fractured.
Joints
A joint is where two or more bones have contact with one another
and allow for movement. Joints are classified as structural and
functional, providing mechanical support. It is important to establish
any joint pain or swelling on physical assessment. Various pediatric
musculoskeletal or rheumatologic conditions can cause joint pain
and swelling, some benign and others more serious such as septic
arthritis.
Ligaments and Tendons

Ligaments are fibrous bands of connective tissue linking two or more
bones or cartilages together. They provide stability to a joint during
both movement and rest. The blood supply to ligaments is very
small, and they lack elasticity. Therefore, an injury to a ligament can
take a long time to heal. Tendons are also fibrous connective tissue
that attaches muscles to bones and other parts. The tendons have
very little blood supply, and an injury to a tendon can also involve a
lengthy recovery.
Muscles
Muscles consist of striated muscles and smooth muscles. Skeletal
muscle is a type of striated muscle that attaches to tendons. Skeletal
muscles are used to create movement through contraction by
applying force to bones and joints. These muscles can contract
voluntarily (by somatic nerve stimulation) or involuntarily through
reflexes. Smooth muscle is a type of muscle found in the walls of all
the hollow organs of the body (except the heart). Smooth muscles
are involuntary muscles under the control of the autonomic nervous
system. For example, smooth muscles regulate the flow of blood in
the arteries, move food through the gastrointestinal tract, and expel
urine from the bladder.
Parents must learn about making adaptations in the home
environment to ensure a safe environment and allow the child as
much movement as possible. The family also needs psychosocial
support to assist them in coping with the child’s ongoing
musculoskeletal condition. Help the family and the child achieve the
best possible psychosocial outcome by arranging for home nursing
care, physical and/or occupational therapy, and ways to obtain
durable medical equipment.
Care of a Child With a Musculoskeletal Disorder
While the child is hospitalized with a musculoskeletal condition, care involves
collaboration with the interdisciplinary team members, each with a specific role.
The physical therapist assists the child with gross motor movement, teaches
them passive range-of-motion (ROM) exercises, and arranges for ambulation
aids and wheelchairs. The occupational therapist works with the child’s fine
motor development and makes splints and orthotics that fit the child. The child
life therapist is instrumental in helping with diversion activities to keep the child
calm during painful procedures such as blood draws. To help the transition
home, the social worker communicates with the family about coping techniques
and community resources to use with the child at home after discharge.
The nurse works with this care team to help develop the care plan, support
the child and family by providing ongoing psychosocial support in care for the
child’s musculoskeletal condition, and prepare the child and family for
discharge with ongoing nursing care and teaching related to discharge
planning.
IMMOBILIZING DEVICES
Casts, boots, splinting devices, skin traction, skeletal traction, and
distraction devices are several effective methods used to immobilize
an extremity when treating pediatric musculoskeletal conditions.
Different benefits and risks are associated with each of these
methods, and each requires the initiation of specific nursing
interventions.
Casts
Casts are a solid mold applied for immobilization purposes for
fractures, dislocations, and other injuries. Casts are made of either a
synthetic material such as fiberglass or plaster of Paris. Fiberglass is
preferred because it is lighter in weight and dries within 30 minutes.
Plaster of Paris casts take about 10 to 72 hours to dry.
There are four categories of casts: upper extremity, lower
extremity, spinal or cervical, and total body (Fig. 21-2). An upper
extremity or lower extremity cast provides absolute immobility of the
affected extremity (Fig. 21-3). A complex or extensive fracture may
require a rigid spinal or cervical cast for a long period of time. A total
body cast such as a spica hip cast (also called a spica cast)
immobilizes the hips and thighs so that bones or tendons can heal
properly after hip surgery. A bilateral long-leg cast with an abduction
bar (crossbar connects the cast together at ankle level) is also used
for significant immobilization. Both the spica hip and bilateral long-
leg cast with an abduction bar encase both legs to the toes.
FIGURE 21-2 Type of cast.
FIGURE 21-3 The child in a bilateral short leg cast with an abduction
bar.
When a child is placed in a total body cast with an abduction bar, it

is easier for parents to manage care than when a child is in a spica
hip cast with no bar. Teach parents that the cast needs to be
changed periodically. The two most common reasons to change a
cast are when it becomes soiled or wet. Also, incision sites under a
cast need to be assessed for infection. This includes checking for a
foul odor, drainage from inside the cast, or staining through the cast.
Cast Complications
The major complication is compartment syndrome. Compartment
syndrome develops when pressure within a closed fascial
compartment is raised when inflammation occurs in the tissue that is
surrounded by the fascia. This causes a decrease in blood flow and
perfusion to the muscle that is surrounded by the fascia.
Intracompartmental pressure increases, and blood flow to the tissue
distal to the affected compartment can stop, thereby causing
ischemia and eventually necrosis. There are two assessments that
can be performed. The first is the neurovascular assessment (Box
21-1). The second is to assess for the 5 Ps:
■ Pain unrelieved by narcotics
■ Pallor
■ Pulselessness
■ Paresthesia
■ Poikilothermia (body temperature that varies with the temperature
of its surroundings)
Application of ice and elevation can help alleviate the risk of
compartment syndrome. Any child at risk for compartment syndrome
has the extremity elevated and ice applied. Administration of narcotic
pain medication after pain assessment can also be implemented.
Collaborative Care
NURSING CARE
Nursing care of the child in a cast begins with the child and family.
For example, allow a preschool-age child to apply a cast to a doll.
Then, give the child time to play with the casted doll before applying
the cast to the child. When a child has any type of cast, perform a
neurovascular assessment with vital signs. A neurovascular
assessment is also done any time neurovascular compromise is
suspected.
BOX 21-1
Performing the Neurovascular Assessment

• Pain—Does the child complain of pain in the affected limb? Is it relieved by
narcotic medication? Does it become worse when fingers or toes are flexed? If
yes, notify physician immediately (compartment syndrome).
• Sensation—Can the child feel touch on the extremity? Is two-point
discrimination decreased? If yes, notify the physician immediately
(compartment syndrome).
• Motion—Can the child move fingers or toes? Lack of movement may indicate
nerve damage.
• Temperature—Does the affected limb feel warm? Does it feel cool? A cool
extremity may change to feeling warm if a blanket is placed over it and the
extremity is elevated. If the extremity is still cool after these interventions, there
is poor circulation.
• Capillary refill time (CRT)—Apply brief pressure to the nail bed and note how
quickly pink color returns to the nail bed. CRT of less than 3 seconds is the
norm. If CRT is greater than 3 seconds, circulation is poor.
• Color—Note the color of the affected limb. Compare it to the color of the
unaffected limb. Pink is the norm. If the color is paler than in the unaffected
limb, circulation is poor.
• Pulses—Check pulses distal to the injury or cast. If the pulse is difficult to
locate, assess with a Doppler. If the cast covers the foot or hand, it may not be
possible to check the pulse, but the other neurovascular assessment can be
implemented.
After the cast is applied, facilitate drying of the cast by leaving the
cast open to air. The cast has a hollow sound when it is dry. Children
treated with a fiberglass spica hip cast are placed in the bed with
pillows to support the lower extremities. During the drying phase and
ongoing cast care, the child is turned every 2 hours. Frequent turning
helps to facilitate drying and prevents cast syndrome if the child is in
a spica hip cast. At times, the cast is bivalved, meaning that it is cut
down one or both sides with scissors to allow for expansion. The
bivalved procedure is done to alleviate pressure, monitor for
infection, or to help maintain proper hygiene. After the cast is
bivalved, the affected extremity is elevated when the child is in bed,
in a chair, or in a wheelchair. Never use a hair dryer to facilitate cast
drying. The heat from the hair dryer can cause a burn injury under
the cast.
Instruct the family that careful handling of the cast is an important
intervention that prevents dents in the cast. Dents can cause
pressure points on the tissue under the cast and ultimately result in a
pressure sore.
Elevation of the affected extremity helps with the child’s pain
control and prevents damage caused by pressure. If the child has a
single-extremity cast, a waterproof plastic sleeve can be used to
protect the cast and provide a seal during bathing. It is also
important to explain to parents of a child in a cast that the child
needs to be held. Help parents adjust to holding their child with a
cast.
Hygiene is a major concern for a child in any type of cast but
especially a spica hip cast or bilateral long-leg casts with an
abduction bar. Understand that protecting the proximal edges of the
long-leg casts and the perineal area of the spica hip cast from soiling
is a key hygienic intervention that is achieved by petaling or bivalving
the cast.
Modifications for a Child in a Spica Hip Cast

Modifications need to be made for a child in a spica hip cast. The
spica hip cast prevents the child from sitting normally, so parents
need a way to help their child adapt. One suggestion for modification
is a toddler car seat that does not have sides. Toddler car seats help
the small child with a spica hip cast sit fairly normally. They also
have a five-point restraint system. Another suggestion is allowing a
child to sit in a wagon with side rails. Feeding a child in a spica hip
cast can also be a challenge. Placing the child in the prone position
on the floor is a good modification and makes it easier for the child to
feed independently. Allowing the child to have supervised time while
prone on a blanket helps maintain developmental milestones.
Bathing the child with a cast is also an important nursing
intervention. If the child has a small extremity cast, a typical bath can
be taken as long as the cast is protected from water (Fig. 21-4). A
large plastic bag can be placed over the cast during the bath. The
best method is to purchase a plastic cast cover at a pharmacy. They
come in pediatric sizes for long and short arm or leg casts. The hole
is small but expands to allow the casted extremity to be inserted, and
then it contracts to prevent water from entering. The child also keeps
the extremity outside the edge of the tub while bathing or showering;
however, it is the least effective of the three methods discussed. If
the child is in a bilateral long-leg cast with an abduction bar or a
spica hip cast, teach the parent how to bathe the child by giving a
sponge bath. In addition, frequent diaper changes help prevent
complications such as skin breakdown and infection. Good perineal
care is essential for children of all ages.
FIGURE 21-4 Cast cover for showering.
The child is prone to constipation because of inactivity while

immobilized in a cast. Teach the family about the importance of good
fluid intake, a diet high in fiber, and calling the health-care provider
about laxatives or stool softeners if needed.
Sometimes the child experiences itching under the cast. Itching
can be prevented by keeping the skin in good condition by turning
the child every 2 hours and keeping the cast clean and dry. It is
important to tell parents that some children try to push items under
the cast to scratch the area. Teach the parents and the child that
absolutely nothing is placed in the cast. If the itching is severe,
instruct the parent to call the health-care provider about medication.
Cast care also includes caring for the child during cast removal.
Explain to the child that the sound of the cast saw is loud and can be
frightening. It is difficult for the child to believe that the saw will not
cut their skin. Reassure the child that they will not be injured during
cast removal. When the cast is removed, the child’s skin is dry and
flaky and the muscles are weak and possibly stiff. It is important to
consider the child’s emotions about the cast because the child may
have grown used to it and think of it as a part of him.
Cast syndrome is a complication that can occur when a child has
been placed in a spica cast. This syndrome occurs when a portion of
the duodenum is compressed between the superior mesenteric
artery and the aorta, causing vomiting, abdominal distention, and
bowel obstruction. Cast syndrome can be prevented with three
nursing interventions:
■ Frequent repositioning
■ Fluids and increased fiber in the child’s diet
■ Cutting a “belly hole” or a window in the cast to allow for abdominal
expansion
Principles of Traction
The main purpose of traction is to reduce dislocations and
immobilize fractures in the child. During the application of traction,
one body part is pulled in one direction (traction) against a
counterpull in the opposite direction (countertraction). The traction
and the countertraction are the actual weights and pulleys. There are
two main types of traction: skin traction and skeletal traction.
Skin Traction
Skin traction is used for an extremity with strapping material applied
to the limb. Skin traction is used for short periods of time. Bryant’s
traction, one type of skin traction, is used to treat developmental
dysplasia of the hip, shortened limb, and femur fractures in children
younger than 2 to 3 years of age. The child must weigh less than
26.4 lb (12 kg) to use Bryant’s traction. In Bryant’s traction, the child
lies supine with thighs flexed and the hips slightly off the bed.
Moleskin straps are applied to the child’s calves, and the pull is in
only one direction. The nurse understands that the child’s body is the
countertraction. In modified Bryant’s traction, the hips remain on the
bed, but the legs are abducted.
Teach the parents that diapering needs to be modified. To achieve
this, a small diaper or peri-pad is placed in the perineal area with all
edges of the cast outside this small diaper. Then a larger diaper is
placed outside the smaller diaper and taped in the normal fashion.
Ensure that the perineal edges of the cast remain outside the diaper.
Russell’s traction is another type of skin traction that is used when
the child weighs more than 26.4 lb (12 kg), most often to stabilize
femur fractures until a callus forms. With this type of traction, the
child lies supine with hip flexed and abducted. There are two lines of
pull in Russell’s traction, and the hips need to remain in alignment
(Fig. 21-5). The child has a trapeze secured on a crossbar above the
bed to assist with repositioning and maintaining upper body strength.
In this type of traction, a sling is placed under the knee. The
placement of the sling is assessed frequently. Countertraction is
increased with the foot of the bed elevated and the head of the bed
flat.
NURSING CARE
Nursing care for the child in skin traction requires a neuromuscular
assessment to the affected extremity every 4 hours. Watch for
numbness in fingers and toes, which may indicate compartment
syndrome. For any child in traction, it is necessary to assess
circulation, sensation, pain, pallor, cyanosis, movement, and
decreased pulse every 2 to 4 hours.
Ensure that the traction weights are checked and hanging free and
that the child is in alignment with the traction. Skin traction needs to
be removed and reapplied every 4 hours.
Perform skin care every 4 hours. The skin under the straps needs
to be inspected and treated with rubbing alcohol to remove the body
oils, which might cause the straps to slip. Pay close attention to bony
prominences that can break down easily. Do not massage bony
prominences, and ensure protective foam is in place in these areas.
If the child has ACE wraps, protect the ACE wraps from urine and
stool. Have two sets of ACE wraps for the child; keep one set
washed and be ready to use the spare ACE wrap in case the first
ACE wrap becomes soiled. While the child is in traction, initiate
diversional activities to keep the child occupied while in traction (e.g.,
movie videos, board and video games, puzzles, blocks, and other
toys that are easy for the child to handle).
Skeletal Traction
Skeletal traction is used when more pulling force is needed than can
be withstood by skin traction. Since the advent of newer orthopedic
devices that achieve similar outcomes as skeletal traction and allow
the child to be cared for at home rather than in the hospital, skeletal
traction is rare, typically only used when the weight of the traction
needs to be more than 5 lb.
In children, skeletal traction is used for long periods of time until
the bone is ready for casting or open reduction (surgery to place
the bones in their proper position). Many children needing skeletal
traction have sustained multiple injuries. In skeletal traction, a pin is
placed through the bone distal to the fracture. It is extremely
important to note that with skeletal traction, the weights cannot be
removed. There are three common forms of skeletal traction:
Crutchfield tongs, 90/90 femoral traction, and Dunlop traction.
Crutchfield tongs are used in the management of cervical and
thoracic fractures. The tongs are placed into the child’s skull (Fig. 21-
6). The pull is along the axis of the spine. The traction usually hangs
off the head of the bed. The countertraction is the body. The tongs
need to be assessed every 8 hours and as needed for placement
and looseness. Use logrolling to turn the child in Crutchfield tongs.
When this type of traction is used, pin care (gently cleansing the
wound with saline-moistened gauze and applying antibiotic ointment
with a cotton-tipped applicator if prescribed by the physician) needs
to be done every shift. Neurovascular signs need to be assessed
every 4 hours (more often if needed) because of the pressure on the
spinal cord. Other important nursing care measures include pain
control, meeting nutrition and elimination needs, providing proper
hygiene, maintaining developmental milestones, giving emotional
support, and allowing for spiritual care. The family can be
encouraged to express feelings of worry, helplessness, and
frustration.
FIGURE 21-5 The child in Russell’s traction (with trapeze).
FIGURE 21-6 Crutchfield tongs are used in the management of

cervical and thoracic fractures.
The 90/90 femoral traction is most commonly used to treat femur

fractures and complicated femur fractures. A pin is placed in the
femur, distal to the fracture. Weights are attached to a sling that
supports the calf and also to the pin that causes the traction (Fig. 21-
7). The body is the countertraction. Femoral traction is more effective
in children older than 6 years of age. Often femoral traction is used
for the first 2 to 3 weeks after a femur fracture until enough of a
callus forms. After a callus forms, a spica hip cast is applied. Perform
pin care every shift or according to the hospital policy. Also be sure
to meet the holistic health needs of the child and family.
Maintaining the child in this type of alignment can be challenging.
Sometimes restraints must be used to keep the child in proper
alignment. If restraints are needed, hospital policy needs to be
strictly followed and an order obtained from the health-care provider.
Generally, a hospital restraint policy states that the restraints need to
be removed every 2 hours for 10 minutes while the child is awake
and every 4 hours for 10 minutes while the child sleeps. The restraint
order also needs to be renewed by the physician every 24 hours. A
better solution than restraints is constant supervision by parents,
family members, friends, and hospital staff. Often a hospital will have
a volunteer program or a child life specialist who can help with
diversion activities.
Dunlop traction is used in the management of a supracondylar
fracture of the humerus. In this type of traction, a pin is placed in the
humerus, distal to the fracture. Weights are attached to the forearm
and to the pin that causes the traction. The body is the
countertraction (Fig. 21-8).
Volkmann’s ischemia can occur with children in Dunlop traction.
The child complains of numbness, tingling, and a decreased
sensation in the ingers. An important nursing intervention is to ask
the child to wiggle the ingers to help relieve the discomfort.
FIGURE 21-7 The 90/90 femoral traction is most commonly used to

treat femur fractures and complicated femur fractures.
FIGURE 21-8 Dunlop traction is used in the management of a
supracondylar fracture of the humerus.
NURSING CARE
Assessment is the key nursing care measure for a child in skeletal
traction. Neurovascular status must be assessed carefully every 1 to
2 hours for the first 48 hours and then every 4 hours after that if
there is no compromise in circulation. Know the symptoms of
compartment syndrome and report them to the physician
immediately.
Be sure to understand the principles of traction and the reason
why the traction has been applied. Maintaining the alignment of the
traction with the child can be a challenge. By nature, children are
unable to remain still in bed for extended periods of time. Realign the
child in the bed often. Emphasis is on ensuring that the shoulder, hip,
and leg are in a straight line with the lines of traction. Diversional
activities are essential in assisting the child to maintain proper
alignment. Collaboration with the child life specialist also helps the
child. Maintaining the traction also involves assessing the desired
line of pull with the relationship between the distal part and the
proximal part. The nurse ensures that:
■ The ropes are in the center part of the pulley, taut, and intact,
without knots.
■ The pulleys are checked often to be sure they are in their original
place and that the wheels of the pulley move freely.
■ The amount of the weights is correct and that they are hanging
freely.
■ The bed is positioned with the head or the foot of the bed elevated
as ordered so that the correct amount of pull is achieved with the
traction and countertraction.
■ The skeletal traction is not removed. If a child needs to be moved
or if the traction needs to be adjusted, contact the health-care
provider.
To prevent skin breakdown, place the child on an alternating-
pressure mattress or a foam mattress overlay. A nursing assessment
of the child’s body is done to look for redness or breakdowns,
especially on bony prominences receiving the greatest pressure.
Wash and dry the child’s skin daily or more frequently if needed.
Change the child’s position every 2 hours to relieve pressure.
Assess pin sites every 8 hours for signs and symptoms of infection
to prevent osteomyelitis.
Managing the child’s pain is essential, so use pharmacological and
nonpharmacological care measures. Also use good judgment about
the administration of pain medication by not waiting too long to
administer it and being alert for any adverse side effects. Effective
pain control methods include epidural with bupivacaine (Marcaine)
and a narcotic such as morphine sulfate (Astramorph) or
hydromorphone (Dilaudid). Antispasmodics such as diazepam
(Valium) will give relief to the child with muscle spasms. Ask the
parents to participate in pain assessment and pain management by
offering comfort measures. Diversional activity also might help
manage pain. Be sure to involve the child life specialist in this aspect
of care. Work collaboratively with the physical therapist to perform
passive and active ROM exercises to prevent weakness in
uninvolved extremities. If pain is under control, the child may be able
to perform minimal activities of daily living while on bedrest.
Pin site infection has been a problem for nursing practice. Hospital
policy and procedure manuals each have a specific procedure to
follow to help prevent this problem. A few multicenter studies have
been done to determine which method is in fact most effective. The
use of skeletal traction has declined greatly in the past 15 years, so
there are few studies regarding the best method to use for pin care.
Maintaining good nutrition is essential for the child in skeletal
traction. The hospital nutritionist can visit with the family to discuss
healthy meals. The child may tolerate six small meals and healthy
snacks instead of the traditional meal schedule. Offer the child
healthy drinks and snacks. A sticker reward chart is an effective
measure to encourage good nutrition and reward healthy food
choices. The child also needs to be assessed for regular elimination
to ensure they do not become constipated or acquire a urinary tract
infection. Also, be alert to the child in skeletal traction because
serious complications can occur. Osteomyelitis (inflammation of
bone and marrow, usually caused by infection) is a major, serious
complication. Prevent complications such as pneumonia, circulatory
compromise, ischemia, and problems of disuse with uninvolved
extremities. Any circumferential dressing has a potential to cause
impaired circulation, so dressings are assessed for tightness.
Restrictive bandages or devices are also assessed to ensure they
are neither too tight nor too loose. Prepare the family for discharge
and offer psychosocial support.
COMMON MUSCULOSKELETAL CONDITIONS IN

CHILDREN
Children are by nature active, and the musculoskeletal system plays
a major role in their growth and development. Children mature at
different rates, with differences in height and weight between various
ages and stages of development. When children of varying sizes
play sports together, the risk for injury may increase. Approximately
60 million school-age and adolescent children participate in
organized sports each year in the U.S., with an estimated 8.6 million
injury episodes more commonly affecting males (Patel, Yamasaki,
and Brown, 2017). Injuries to the lower extremities are most common
(42%) followed by the upper extremities (30%) and head and neck
(16%). As kids grow bigger and stronger, the potential for injury
increases, largely because of the amount of force involved. Children
are more susceptible to injuries because they may not have the
complex motor skills used for most sports until after puberty and their
still-growing bodies are more vulnerable to injuries (Patel, Yamasaki,
and Brown, 2017).
When the child’s ability to interact with the environment is
impaired, such as through a musculoskeletal system disorder, they
are at risk for impaired growth and development. Alterations in the
musculoskeletal system may be related to a congenital or acquired
defect. This chapter is organized by craniofacial abnormalities
(craniosynostosis, plagiocephaly, and torticollis), defects of the foot
(metatarsus adductus and clubfoot), and deformities of the hip
(developmental dysplasia of the hip [DDH], Legg-Calvé-Perthes
disease [LCPD], and slipped capital femoral epiphysis [SCFE]).
Plagiocephaly
The newborn infant’s skull is composed of bony plates separated by
sutures. In plagiocephaly, the cranial sutures are overriding, which in
severe cases can impede brain growth (Martiniuk et al, 2017). The
volume of the brain quadruples during the first two years of life. By
about three months of age, the posterior fontanelle closes, followed
by anterior fontanelle closure at approximately 12 to 18 months of
age. Most cases of plagiocephaly are positional, often due to the
infant lying on their back. In April 1992, the American Academy of
Pediatrics recommended the Back to Sleep campaign,
recommending all newborns sleep on their back to reduce the risk of
sudden infant death syndrome (SIDS).
Signs and Symptoms

The child who has plagiocephaly may display:
■ Full or bulging fontanelle
■ Bony ridges along the affected sutures
■ Facial abnormalities including bulging forehead and brow on one
side, or uneven cheekbones, eye sockets, or lower jaw
■ Prominent blood vessels in the scalp
Collaborative Care
MEDICAL CARE
The child should wear a corrective helmet. If the overriding sutures
do not improve by age 4 months, a molded helmet is the
recommended treatment. A helmet does not squeeze the baby’s
skull but gently helps correct the shape of the head by allowing
growth in the flattened areas.
NURSING CARE
Teach parents how the child should wear the helmet and that to
get the most benefit from this treatment, most babies need to wear it
about 23 hours a day for about 3 to 6 months. Providing education to
parents of infants about the importance of varying a baby’s head
position and encouraging “tummy time” when infants are awake can
help prevent plagiocephaly.
Craniosynostosis
Craniosynostosis is a craniofacial disorder and is defined as the
premature fusion of one or more cranial sutures (Yilmaz et al, 2019).
Premature closure of cranial sutures can result in incomplete brain
development that may lead to complications including seizures, brain
damage, mental delay, complex deformities, strabismus, and visual
and breathing problems.
Signs and Symptoms

Symptoms may include:
■ Full or bulging fontanelle
■ Sleepiness (or less alert than usual)
■ Scalp veins may be very noticeable
■ Increased irritability
■ High-pitched cry
■ Changes in head circumference
Diagnosis
Diagnosis is often made based on physical exam, and sometimes a
CT is ordered to assess for brain abnormalities.
Medical Treatment
If the sutures are open and the head shape is abnormal, sometimes
a molded helmet can correct the brain growth and the shape of the
skull. However, for most babies, surgery is the primary treatment.
Nursing Care
Most children with this will need surgery (a craniotomy). Nursing care
should focus on pre-op and post-op care of the child.
Torticollis
Torticollis (“twisted neck”) is characterized by a stiff neck causing a
lateral flexion contracture of the cervical spine musculature. It can be
congenital or acquired. Congenital torticollis, a fibrosis of the
sternocleidomastoid muscle that rotates the newborn’s head to the
opposite side, becomes evident during the first 2 weeks after birth.
Babies may develop positional plagiocephaly (asymmetrical head
shape) or frontal bulging. Spinal misalignment can lead to other
orthopedic problems (Sargent et al, 2019). Spasmodic torticollis has
recurrent and transient spasms. Delayed development can occur
because the child is unable to turn their head to see, hear, and
touch.
Signs and Symptoms

Signs and symptoms of torticollis include:
■ Twisted or wry neck
■ Spasmodic torticollis has recurrent and transient spasms
Diagnosis
Diagnosis is made beginning with assessing the development of the
infant. Next, an examination is performed with special attention to
the neurological and eye assessments. Radiographs and a magnetic
resonance imaging (MRI) scan of the spinal cord and brainstem will
usually be performed if there are developmental delays noted or
when the torticollis has no known cause.
Prevention
There are no preventive measures for congenital torticollis.
Collaborative Care
NURSING CARE
Nursing care is supportive to physical therapy. Provide support
through teaching and ensuring that the parents understand the
treatment measures and prescribed exercises. Additional nursing
care should include education around “tummy time” to help
strengthen babies’ neck muscles, which has been shown to
decrease acquired torticollis (Sargent et al, 2019).
MEDICAL CARE
The main medical management is physical therapy. Treatment
with botulinum toxin (Botox) also has been effective in inhibiting the
spasms of the muscle (Sargent et al, 2019).
SURGICAL CARE
Surgery has been effective by dividing the sternocleidomastoid
muscle (Sargent et al, 2019). Nursing care for the child undergoing
surgery is to provide the typical pre- and postoperative care,
including monitoring of vital signs, care of the suture line, and
assessing for the return of bowel sounds and postoperative voiding.
Advance the diet to the appropriate food choices for the child’s age.
Administer pain medication and use diversional activities for
nonpharmacological pain control.
Inform the family that physical therapists perform interventions to
strengthen muscles, correct imbalances, increase cervical spine
ROM, and increase posture. Active stretching, positioning strategies,
functional play, and neurodevelopmental interventions are used to
treat this disorder.
Clubfoot
Congenital talipes equinovarus (TEV), otherwise known as clubfoot,
is a complex deformity of the ankle and foot in which the hindfoot
and forefoot are rotated inward with an arched midfoot while the foot
is pointed downward (Ruggiero & Ruggiero, 2020). This birth defect
has an incidence of approximately 1 in 1,000 babies in the United
States each year. About half of all babies born with clubfoot have it in
both feet. The most recent research discusses both genetic and
environmental factors including increased risks with issues that
cause vascular disruption such as maternal obesity, maternal
smoking, amniocentesis before 20 weeks, or chorionic villus
sampling (Pavone et al., 2018). There is also a possibility that the
position of the fetus in utero influences the formation of clubfoot.
There are four main classes of clubfoot determined by the cause and
the response to treatment:
■ Postural—benign form, usually resolves with stretches and casting
■ Idiopathic—true congenital clubfoot with varied severity
■ Neurogenic—usually with spina bifida
■ Syndromic—associated with other anomalies and leads to rigid
feet (Pavone et al, 2018).
Signs and Symptoms

In clubfoot, the foot:
■ Is plantar flexed
■ Has an inverted heel
■ Has an adducted forefoot
■ Is rigid and cannot be manipulated into a neutral position
Diagnosis
Historically, clubfoot diagnosis was made at birth upon physical
exam. Increasingly, foot abnormalities are identified at the 20-week
prenatal ultrasound.
Prevention
Because this is a genetic disorder, there are no preventive
measures, although some risk factors such as maternal smoking can
be avoided.
Collaborative Care
NURSING CARE
Treatment is begun as soon as possible after birth. Clubfoot can
be treated with serial casting (replacing plaster casts) on the affected
extremity(s) at specified intervals to permit progressively greater
ranges of joint motion so that the maximum range needed for
function may be restored. Overcorrection or stretching of ligaments
to put the foot back to the neutral position is the goal with serial
casting. While casted, the affected extremity is manipulated into a
more normal position, and a cast is applied to hold this position. In
the beginning, the cast is changed frequently and eventually reduced
to a less-frequent basis until overcorrection of the position is
achieved.
Nursing care for a child undergoing nonsurgical management of
clubfoot also includes passive ROM and care of the cast application
after manipulation. Because manipulation of the affected extremity
with serial casting can cause discomfort while the muscles and
ligaments are being stretched, pain medication is indicated.
Neurovascular assessments (including assessing for swelling) must
be done every 1 to 2 hours for the first 24 to 48 hours after cast
application and every 4 hours thereafter until a new cast is placed.
After application, the cast is left open to air to aid in the drying
process, and the extremity is elevated.
MEDICAL CARE
While treatment has evolved in the management of clubfoot, serial
casting to manipulate the foot back to the neutral position is the
standard of care. Dennis J. W. Brown, MD (Australian surgeon), also
used forceful correction then followed by his famous splint (Fig. 21-
9). Ignacio V. Ponseti, MD, of the University of Iowa, developed a
technique in the 1940s in which he abducted and dorsiflexed the
foot. Currently, after the manipulation of the foot, a cast is applied.
The cast is then molded around the heel while the forefoot is
abducted. The knee is flexed to 90 degrees. Compliance is key to
successful treatment of clubfoot, as casts must be changed weekly.
The Browne splint is often used after the final cast has been
removed. These splints are worn for 23 hours per day until the child
is about 3 years of age.
FIGURE 21-9 Browne splint.

SURGICAL CARE
Severe cases of clubfoot may require surgery when the infant is 9
to 12 months of age. An orthopedic surgeon lengthens the tendons
to help ease the foot into a more normal position using a tenotomy
(the operation of cutting and repositioning a tendon) of the Achilles
tendon for lengthening. A tendon transfer can also be performed to
prevent foot inversion and adduction of the metatarsus.
What to Say
Talipes Equinovarus (clubfoot)
The most severe and most common form of clubfoot is TEV. The foot defect
can be unilateral (more common) or bilateral. A mother has just delivered a
baby with clubfoot. The parents are in the delivery room and are visibly upset.
The parents are most likely in a state of shock and denial. The family does not
understand what implications this has for their newborn. The nurse asks
questions such as:
1. “How are you feeling at this time?”
2. “After you rest, would you like to talk more about the baby’s condition?”
3. “What do you know about clubfoot and the treatment?”
4. “Can I stay with you to offer support while you hold the baby?”
In either case, serial casting or surgery, instruct the family to keep
the cast clean. The young child needs to be diapered in such a way
that the cast is outside the edges of the diaper. Double diapering and
changing the diaper frequently are also methods to keep the cast
clean. The older child may have to change underwear frequently. It is
not feasible to bathe the child in a tub of water with bilateral long-leg
casts with an abduction bar so a sponge bath is given. Provide the
family with emotional support. Distraction techniques and age-
appropriate toys can help the child to handle the long recovery
process.
Patient Education
The Child With Clubfoot Wearing a Cast
Teach the parents how to care for their child with a clubfoot who is wearing a
cast. Instruct the parents to:
• Give the child emotional support and reassurance that they can return to
normal activities soon after the cast is removed.
• Maintain the child’s normal development by playing, reading, and spending
quality time.
• Keep the cast and surrounding area clean and dry, and reposition the child
every 2 hours.
• Elevate the affected extremity and use good hygiene to prevent skin
breakdown.
• Notify the health-care provider if the child has a fever, signs and symptoms of
infection, or unrelieved pain.
• Take the child to the health-care professional if the cast is damaged (soft,
loose, or cracked) or cast syndrome is suspected.
• Follow-up care is essential.
• Inform the parents that there may be a potential for reoccurrence of the
clubfoot.
• Teach the parents about the importance of monitoring cast complications.
It is also important to stress that the child needs to continue with

growth and developmental milestones. The infant or child can be
placed on a blanket on the floor and explore their surroundings while
supervised. Adjustments can be made so that the infant or child can
continue to develop gross motor, fine motor, cognitive, and language
milestones.
Metatarsus Adductus (Varus)

Metatarsus adductus, also known as metatarsus varus, is the most
common congenital foot deformity in newborns with a reported
prevalence of one to two cases per 1,000 births (Marshall, Ward, and
Williams, 2018). In metatarsus adductus, the front half of the foot, or
forefoot, is rotated or turned inward, often a result of abnormal
positioning in utero. It is more common in the first-born child and
often noted on the newborn physical assessment. The foot can often
be manually manipulated back to the “neutral” position. This is not
the case with clubfoot. This deformity may cause a pigeon-toe or in-
toeing in a child if left untreated. Because children with foot
deformities have an increased risk of hip deformities as well, a
thorough hip exam should be performed on all children with
metatarsus adductus (Marshall, Ward, & Williams, 2018).
Signs and Symptoms

Signs of metatarsus adductus include:
■ High arch
■ Visibly curved and separated big toe
■ Forefoot turned inward
Medical Management
Management of metatarsus adductus depends on the degree of
severity but often requires stretching of the turned foot or wearing
shoes on the opposite feet. Surgery is rarely required to treat this
condition but may be performed in children over the age of 6 who
have significant pain with ambulation due to metatarsus adductus.
Nursing care involves identifying the defect so that early
treatment/therapy can begin, as well as educating parents about the
disorder.
Developmental Dysplasia of the Hip (DDH)

Developmental dysplasia of the hip (DDH) describes bone disorders
related to abnormal development of the hip that may occur at any
time during fetal life, infancy, or childhood. Examples include a
partial or slightly subluxed acetabulum, a subluxed acetabulum, or a
completely dislocated hip. The incidence of DDH is approximately 1
to 2 infants per 1,000 live births in the United States (Groarke et al,
2017; Vaquero-Picado et al, 2019). Girls are affected more often
than boys, and a positive family history increases a child’s risk for
having DDH. Up to 40% of babies with breech presentation or
intrauterine positioning have DDH (Anderton, Hastie, & Paton, 2018).
For this reason, babies who are born breech will have a postnatal
ultrasound to rule out DDH.
Early diagnosis and treatment are critical to provide the best
possible functional outcome. Persistence of hip dysplasia into
adolescence and adulthood may result in abnormal gait, decreased
strength, and increased rate of degenerative hip and knee joint
disease (Vaquero-Picado et al, 2019).
Signs and Symptoms

Signs of DDH may include:
■ On physical exam: Positive Ortalani or Barlow sign are indicative
of DDH. These exam findings are only reliable in the first 3 months
of age.
■ Ortalani maneuver: Limited abduction of the affected hip is noted
when the hips are flexed, and the legs are abducted. This is used
to assess dislocation of the hip.
■ Barlow maneuver: Adduction bringing the leg inward and
downward, while attempting to disconnect the hip outside the
acetabulum.
■ Galeazzi sign: When both legs are bent, there is a discrepancy of
the height of the knees and the affected leg is shorter than the
other.
■ Unequal gluteal folds: Turn baby prone and observe for alignment
of gluteal folds.
■ In older children, a positive Galeazzi sign, unequal leg length, and
a positive Trendelenburg are signs of DDH.
Treatment
Treatment starts as soon as the condition is recognized because
early recognition and treatment yield the best outcomes of care. The
main treatment up to 6 months of age is an abduction brace.
Delaying treatment may increase the severity of the deformity. The
most used brace is the Pavlik harness, which must be worn 23 out of
24 hours a day for several weeks. Pavlik harness is the standard
treatment for children up to 6 months of age as it is the most
effective treatment for DDH, with success rates greater than 90%
(Vaquero-Picado et al, 2019). The Pavlik harness places the infant’s
acetabulum tightly inside of the greater trochanter, forming a tightly
seeded ball and socket joint. If this fails, closed reduction and hip
spica casting is usually done. After the age of 18 months, treatment
usually consists of open reduction and hip reconstruction surgery.
The Pavlik harness ensures hip flexion and abduction and does not
allow hip extension or adduction. It maintains correct position of the
femoral head in the acetabulum. Nurses should:
■ Teach parents/caregivers to remove and apply harness
appropriately; only remove for bathing and skin checks.
■ Teach skin assessment.
■ Encourage cuddling infant to promote cognitive development and
infant/caregiver bonding.
Collaborative Care
NURSING CARE
As part of the care team, nurses are well-positioned to detect DDH
in early infancy during the newborn assessment. Any concerns in the
assessment should be brought to the attention of the attending
provider or advanced practicing clinician. The primary nursing goal is
teaching parents to apply and maintain the Pavlik harness. Parents
are instructed to NOT adjust the harness.
Regular skin care including skin checks to inspect and prevent for
the risk for skin breakdown. Always place the diaper under the
straps. The practice of using multiple diapers with the Pavlik harness
is outdated and not evidence-based practice. If a hip spica cast is
necessary, then cast care and maintenance is necessary. It is also
important for the nurse to help the parent-child bonding by promoting
adequate and age-appropriate activities and nursing care for the
child being treated for DDH.
MEDICAL CARE
Physical therapy can be used to help increase strength and
flexibility around the joint. This can potentially decrease pain and
discomfort. Physical therapy can also help the older child to align
and strengthen the area around this joint for better stability.
If the Pavlik harness was not successful, the child will need
surgery. In the older child, hip injections (a combination of anesthetic
and a corticoid steroid) can help to reduce pain and inflammation in
the hip joint but will not correct hip dysplasia.
Legg-Calvé-Perthes Disease
Legg-Calvé-Perthes disease (LCPD) is considered a multifactorial
condition caused by genetic and environmental factors, which may
be a precursor to the disease. LCPD has an insidious onset that
starts with an interrupted blood supply to the femoral head. This
leads to avascular necrosis of the femoral head.
Legg-Calve-Perthes disease usually occurs between the ages of 3
to 12, with the highest rate of occurrence at 5 to 7 years. It affects 1
in 1,200 children under the age of 15 (Ruggiero & Ruggiero, 2020).
Legg-Calve-Perthes disease occurs most commonly in male
patients, with a male-to-female ratio between 4:1 and 5:1. It is
bilateral in 10% to 20% of affected cases. Caucasians and Asians
are more commonly affected than children of other races.
There are four stages of LCPD:
■ Aseptic necrosis (flattening of the femoral head) is the precipitating
factor. It lasts several weeks and presents with synovitis and a
decrease in ossification in the nucleus of the femoral head
secondary to ischemia
■ Revascularization can occur rapidly through recanalization (re-
establishment of an opening through a vessel that had been
previously occluded) of the existing blood vessels within a few
weeks, or it can last 6 to 12 months when new blood vessels are
formed. This phase is associated with increased joint space,
increased cartilage thickness, and a decrease in size and density
of the femoral head.
■ New bone formation lasts 1 to 2 years. Collapse and
superolateral (above and to the side) displaced head; avascular
bone is reabsorbed.
■ Regenerative phase includes reconstitution of femoral head with
remodeling and final healing.
Signs and Symptoms

In LCPD, the child complains of:
■ Hip or knee soreness or stiffness
■ Pain that increases with activity and decreases with rest
■ A painful limp
■ Quadriceps muscle atrophy
■ Joint dysfunction
■ Limited ROM
Diagnosis
A radiograph establishes the initial diagnosis LCPD. The definitive
diagnosis is made by MRI and radiographic studies, which show
osteonecrosis.
Prevention
There are no preventive treatments for this condition. It can take 18
months to 4 years for this condition to resolve.
Collaborative Care
NURSING CARE
Obtaining a history is important in assessing the child with
possible LCPD. This history will uncover how long the child has been
limping and the severity of the pain. The child describes the pain as
increasing in intensity with activity and decreasing with rest. The
nurse’s assessment of ROM will help determine limitations on
abduction and internal hip rotation. An assessment of the thigh and
buttock area will reveal a wasting of the muscles. A shortening of the
extremity on the affected side indicates that the femoral head has
collapsed. The goal of nursing care is to keep the femoral head in
the acetabulum. A containment brace is often used for this.
Otherwise, supportive treatment and protecting the joint are the
standard of care for LCPD.
When the child is receiving conservative hospitalized care, assess
the skin for breakdown. Preparing the child and family for a
radiographic exam and MRI is done. If the child is being treated with
a brace, collaboration with the orthotics team (a team of experts who
teach others how to use orthopedic appliances) is required. The child
is maintained on bedrest to reduce the inflammation and restore
motion. Pain management is included in the nursing plan of care.
MEDICAL CARE
Early medical treatments focuses on periods of hospitalization and
complete non-weight-bearing. Later, medical management involves
increased weight-bearing and using a brace that is worn for 2 to 4
years. Another type of medical management involves the child
remaining in a Montreal abduction plaster cast for a year or more.
This type of cast allows weight-bearing with the femoral head and is
determined not to be harmful in the healing process. One problem
with this cast is the need for multiple clinic visits and hospitalizations
for repeat casting, followed by the need to regain hip and knee
motion. The Toronto brace can replace casting, allowing for full knee
flexion while maintaining hip placement. Less frequently, traction or a
spica cast is used.
SURGICAL CARE
Surgical osteotomies (cutting through a bone) are performed to
reposition the femoral head to maintain optimal position for healing.
A femoral or Salter osteotomy is performed for LCPD. After surgery,
a spica hip cast is required, so implement the usual postoperative
care measures in addition to the care of a child in a cast. Pain relief
is achieved with the administration of nonsteroidal anti-inflammatory
drugs (NSAIDs) such as ibuprofen (Children’s Advil).
Ongoing management after discharge from the hospital consists of
conservative therapy for 1 to 3 years. Communicate to the family that
initially the child will need to avoid weight-bearing activities and
maintain mobility restrictions. While the child has mobility
restrictions, ROM is implemented. Because it is difficult for a child to
remain on bedrest, emotional support and diversional activities are
essential. It is also important to teach the family about home care.
Discuss the importance of adaptive play. After the physician has
communicated that the condition has resolved, the child can return to
normal activity in about 3 to 4 months.
Optimizing Outcomes
Visiting Nurse
After diagnosis in the health-care practitioner’s office, the child with LCPD is to
be cared for at home by a visiting nurse and physical therapist. The visiting
nurse can:
• Assess the family support systems while the child and family are in their
own environment.
• Ensure that the family is able to provide the care needed.
• Ensure compliance with the use of the conservative devices.
• Ensure the non–weight-bearing status of the child.
• Assess the knowledge of the parents and child about ongoing care.
• Encourage the use of creative quiet activities and hobbies.
• Arrange for physical therapy for ROM exercises and to ensure that the child
is safe while walking with a non–weight-bearing device.
• Ask the family about follow-up care with the physician.

Slipped capital femoral epiphysis (SCFE) is the most common hip
disorder in adolescents, occurring in about 10.8 per 100,000
children. SCFE usually occurs in those 8 to 15 years of age and is
one of the most commonly missed diagnoses in children (Aprato et
al, 2019). When this condition occurs, the capital femoral epiphysis
(top of the femur) slips through the epiphysis (growth plate) in a
posterior direction. Male and obese children have a higher incidence
of SCFE. It is hypothesized that the hormones of puberty coupled
with being overweight or obese causes a gradual or sudden slippage
in the femur across the growth plate (Aprato et al, 2019). This is of
significant concern because of the increased risk of fracture through
the adolescent growth plate, which would lead to a leg-length
discrepancy. Conditions associated with SCFE are hypothyroidism,
renal osteodystrophy, and postradiation therapy.
Signs and Symptoms

SCFE symptoms appear gradually. Acute slip symptoms are present
for less than 3 weeks. Chronic slip symptoms are present for more
than 3 weeks.
■ Pain in the groin or referred pain to the thigh or knee is the child’s
primary presenting complaint. This occurs because the child is
externally rotating the leg to relieve pressure on the hip joint. The
parent usually notices that the child is limping and favoring that
extremity.
■ During examination, the child complains of pain during internal
rotation of the hip.
■ The hip does not fully rotate internally, and abduction is limited.
■ The affected leg may be shorter if the child has a moderate or
severe slip.
Diagnosis
Radiographic studies are used to diagnose SCFE. Typically, the frog-
leg lateral view will show a mild step-off of the anterior femoral
epiphysis with its corresponding metaphysis in a posteroinferior
direction (Aprato et al, 2019).
Assessment Tools
SCFE is classified by stage and severity:
STAGE
• Preslip—The child complains of weakness in the leg, or pain in knee or hip
when standing or walking for long periods of time. Acute slip—The child falls
and then reports hip pain.
• Chronic slip—The femoral head gradually slips off the femoral neck and then
remodels for the incorrect position.
• Acute-on-chronic—Slow progressive slip that then becomes more displaced
when the child falls.
Prevention
There are no preventive measures that can be taken because the
cause is idiopathic.
Collaborative Care
NURSING CARE
Once a child has been diagnosed with SCFE, no weight-bearing is
permitted. Assist the family in adjusting to the sudden hospitalization,
non-weight-bearing status of the child, and the impending surgery.
The goal of nursing care is to prevent further slippage. No ROM is
attempted if the child has an acute slip because it may cause further
damage. Communicate to the family that the hip cannot be reduced
manually because that will cause further damage to the femoral
head. Bedrest with the child in traction decreases synovitis
(inflammation of a synovial membrane) in the hip. If the child has an
acute slip, split Russell’s traction may be instituted for a few days
before surgery.
SURGICAL CARE
When a child has been diagnosed with SCFE, surgery is the
treatment approach. Pinning the bone across the epiphyseal plate is
the best treatment for SCFE. Surgery (pinning) is the intervention of
choice for a child with mild to moderate SCFE. The pinning consists
of a percutaneous insertion of a large screw or pin into the femoral
head to hold it in place. There is a small incision, and the child stays
in the hospital for less than 24 hours. After 1 week, the child may
bear full weight and the pin is removed later.
With severe SCFE, an osteotomy is required, which consists of a
breaking and resetting of the bone. This prevents further slippage
and restores hip motion to normal. It is a much more extensive
surgery, requiring a longer hospitalization and prolonged
immobilization.
After surgery, postoperative pain management is managed with IV
narcotics and changed to oral narcotics once the child is tolerating
liquids and solid food. Also monitor the neurovascular status
frequently and collaborate with physical therapy to teach the child
crutch walking. The physical therapy initiates ambulation with
crutches. After that, continue ambulation with the child who is using
crutches.
The child is discharged when pain is controlled with oral narcotics
and the child can ambulate safely with crutches. It is helpful to
arrange for a visiting nurse to ensure that the child can ambulate
safely with crutches at home. If the child still needs assistance with
ambulation at home, a physical therapist can visit the home and
reinforce teaching.
Pectus Excavatum
Pectus excavatum is a congenital condition consisting of a posterior
depression of the sternum and affecting the adjacent costal
cartilages. It is the most common congenital deformity of the chest,
but the cause is not clearly understood. Infants and young children
rarely complain of symptoms that would affect their ability to
participate in activities. However, older children and adolescents
develop cardiorespiratory symptoms during physical exercise.
Signs and Symptoms

Signs and symptoms of pectus excavatum can include:
■ Sunken chest wall at the sternum
■ Fatigue
■ Chest pain
■ Tachycardia
Some children only present with the sunken chest wall as a
symptom.
Diagnosis
A chest radiograph, pulmonary function test, CT scan of the chest,
stress test, laboratory studies such as chromosome or enzyme
studies, electrocardiogram, and an echocardiogram are used to
make the diagnosis.
Prevention
Because it is a congenital deformity, there are no known preventive
measures.
Collaborative Care
NURSING CARE
Nursing care is supported with physical therapy. Mild or moderate
cases are treated with an exercise and posture program with follow-
up every 6 to 12 months. A posture program teaches individuals
about proper posture and body alignment enhancement. Fitted back
braces may be required for the pediatric patient.
SURGICAL CARE
Surgical management involves a reconstruction of the chest wall.
The Nuss procedure or an open repair called the modified Ravitch
technique is typically used for severe cases. When the Nuss
procedure is performed, a substernal tunnel anterior to the heart is
created using thoracoscopy. A prebent, convex steel bar is inserted
and rotated into place through the thoracoscope. Its function is to
elevate the sternal depression and is fixed securely to the chest wall.
This bar remains in place for 2 to 3 years to ensure a permanent
remodeling of the sternum. The open technique requires open chest
surgery in which the sternum is repositioned with an osteotomy and
the costal cartilage is reformed as well. A wire or a strut is placed
under the sternum to keep it in place.
Postoperative care of the orthopedic pediatric patient includes
assessment of vital signs, pain, monitoring of surgical site, return of
bowel sounds, and postoperative voiding. Postoperatively, advance
the diet as tolerated according to age. Administer pain medications
and use diversional activities as a useful method for
nonpharmacological pain relief.
Respiratory care includes assessment and methods to increase
lung expansion to prevent pneumonia. An incentive spirometer is
used for the school-age and adolescent child (Fig. 21-10). Younger
children are not able to understand how to use the incentive
spirometer, so use creative measures to encourage expansion of the
lungs (e.g., blowing a pinwheel, bubbles, a musical instrument, or a
small folded paper triangle across the bedside table).
Discharge teaching includes how to care for the child after discharge
such as assessing for signs and symptoms of infection that would
require the parent to notify the health-care provider. Discuss when
the child should return to the health-care provider for follow-up.
Polydactyly/Syndactyly
Polydactyly is a condition in which the child has more than the
normal number of fingers or toes. Syndactyly is defined as the fusion
of one or more fingers or toes. This condition could be a result of a
congenital disorder or a result of a severe burn injury where scarring
fused the two phalanges together.
Signs and Symptoms

In polydactyly, one or both hands and/or one or both feet has six or
more fingers or toes. In syndactyly, two or more phalanges of the
fingers or toes are fused together. The fused bones appear as one
digit with an extra-wide nail and finger or toe. It can occur on one or
both hands and/or one or both feet. It can occur as a result of a
congenital deformity or as a result of a burn injury where the bones
of the fingers or toes have fused together.
FIGURE 21-10 Blowing into incentive spirometer helps expand the

lungs and prevent pneumonia.
Diagnosis
Diagnosis is made by visualization of the digits.
Prevention
Prevention of polydactyly is not achievable because it is a congenital
defect. However, if it occurred as a result of a burn injury, preventing
the burn injury would prevent the defect.
Collaborative Care
NURSING CARE
Offer parents support until a decision is made about corrective
surgery. If the decision is made to not repair the defect with surgery,
the child will live with the defect. The child is adaptable and may
adjust to the deformity without difficulty, or ongoing support may
need to be continued through counseling.
SURGICAL CARE
Treatment is to surgically remove the extra finger or toe. The
procedure is performed by a hand surgeon (with reconstructive
surgery background) or an orthopedic surgeon. The surgery for
syndactyly is more complex than surgery for polydactyly. The skin,
muscles, nerves, tendons, ligaments, blood vessels, and the bones
must be separated. Sometimes the bones are shorter, so the
surgeon will perform an osteotomy and place a distractor. The
distractor consists of pins that are placed in the two bone fragments.
A wire is passed through connections at the end of each of the pins.
Once the callus has started to form, the health-care provider turns
the device so that the two bone fragments are distracted from each
other. Usually, a quarter of a turn with an Allen wrench is done twice
per week. After about 6 weeks, the desired length has been
achieved and the device and wires can be removed under
anesthesia. Skin grafts are placed at the time of the initial surgery to
close the wound where there is a shortage of skin. Standard
postoperative care is provided with special attention to the surgical
area and graft site if applicable.
Discharge teaching helps parents feel more comfortable caring for
their child at home. It is important to review the management plan,
principles of bone healing, how to perform a neurovascular
assessment, and how to care for the Kirschner wires (K-wires) using
pin care techniques.
Dislocated Radial Head

Dislocated radial head is a form of dislocation. The head of the
radius slips and becomes dislocated as a result of an injury. As with
all other dislocations, it is a complete separation of the bone from the
articular surfaces of the joint. Subluxation is only a partial
displacement of the joint. The most frequent sites of dislocation or
subluxation are the thumb, elbow, shoulder, wrist, finger, knee, and
hip. If the dislocation is a result of trauma, damage to blood vessels,
nerves, ligaments, and soft tissue surrounding the joint can occur.
Neurovascular compromise can occur to the extremity distal to the
injury. There is a genetic predisposition to dislocation such as a child
with Marfan’s syndrome (a hereditary degenerative disorder of
connective tissue, bones, muscles, and ligaments).
Signs and Symptoms

Signs and symptoms of dislocated radial head include:
■ Severe pain
■ Inability to move the affected limb
■ Abnormal contour of the joint
■ Bruising at the joint
Diagnosis
Diagnosis is made by a radiograph of the affected area. Prevention
Prevention can occur by avoidance of the injury that would cause the
dislocated radial head.

It is important to obtain an accurate history regarding the details of
the injury from the child and the caregiver. Time of injury as well as
the description, angle of force, and the child’s immediate sensations
will aid in the management of the injury. It is also important to obtain
information about any previous dislocation or subluxation injuries.
MEDICAL CARE
In a mild case, the affected area is stabilized in a splint for 10 to 14
days. After that, intense active ROM is used to regain full use of the
extremity.
SURGICAL CARE
Surgery consists of an open reduction and internal fixation to
stabilize the fracture or dislocation. Bone grafting from the iliac crest
may be necessary to connect the head fragment to the radial shaft.
Monitor the neurovascular status frequently after the injury and after
the reduction or intervention. Ensure that the child maintains proper
positioning of the extremity.
Review the management plan, principles of bone healing, how to
perform a neurovascular assessment, and care of the suture line.
Soft Tissue Injuries

Soft tissue injuries (sprains and strains) are unusual in young
children. These injuries are more often seen in the adolescent age
group. The growth plate of the epiphysis is weaker than the
ligaments in younger children because of the new bone formation
and is prone to fracture rather than sprains or strains. With puberty,
skeletal growth declines, and the growth plates begin to close. The
growth plates become less susceptible to injury, and the ligaments
and tendons become more susceptible to injury. The ankle is the
most frequently sprained or strained joint. The prognosis is good for
first- and second-degree sprains. Severe sprains (third-degree) have
an increased risk of recurrent injury, persistent instability, and
traumatic arthritis.
Signs and Symptoms

Sprain and strain share some signs and symptoms, but it is
important to differentiate the two. Signs and symptoms of sprain
include:
■ Pain
■ Swelling
■ Bruising
■ Instability
■ Loss of the ability to move and use the joint
Signs and symptoms of strain include:
■ Pain
■ Limited motion
■ Muscle spasms
■ Muscle weakness
■ Swelling
■ Cramping
■ Inflammation
Diagnosis
A history is obtained from the child and the parents. The history and
a physical exam reveal important information about the injury,
swelling, and local hemorrhage at the injury site. The child’s most
painful area is examined last. An x-ray exam is performed if there is
an obvious fracture or misalignment.
Assessment Tools
Sprains are classified according to severity as follows.
FIRST DEGREE
• Mild
• Ligament is stretched and the affected joint is stable
• Minimal pain, swelling, ecchymosis
• Full ROM and weight-bearing SECOND DEGREE
• Moderate
• Ligament is partially torn and joint laxity is present
• Moderate pain, swelling, ecchymosis
• Motion is slightly limited and painful
• Mild joint laxity with tenderness over the joint
• Inability to bear weight THIRD DEGREE
• Severe
• Ligament is completely torn and joint is unstable
• Significant swelling and severe ecchymosis occurs within the first 30 minutes
• Severe pain over the joint makes examination difficult
• Cannot bear weight or otherwise use the extremity
Prevention
Because a sprain is the result of an accident, preventing the accident
would prevent the initial injury. Pre- and post-workout stretching will
help to keep joints pliable. After healing the initial injury, prevention
of a reinjury is the most effective. Using techniques such as the
prophylactic use of an ankle brace and physical therapy for
stretching and strengthening exercises will strengthen the joint.
Collaborative Care
NURSING CARE
Immediately after the initial injury, it is most important to use the
RICE acronym:
R—Rest; resting the injured extremity prevents further injury and
allows the ligament to heal
I—Ice; ice for the first 48 hours, keep ice packs in place for 15-
minute intervals to decrease swelling
C—Compression; apply an ACE wrap or some other method to
apply pressure to the affected joint to help reduce swelling
E—Elevation and early motion of the affected joint; elevation
reduces swelling and early motion of the affected joint helps
keep the full ROM
MEDICAL CARE
Immobilization of the joint is recommended based on the severity
of the injury. Mild sprains are immobilized with external support with
an elastic bandage, brace, or ankle lacer. Moderate sprains require a
posterior splint or cast for 2 to 3 weeks in conjunction with crutches.
Severe sprains require conservative or surgical management with a
cast for 4 to 6 weeks and no weight-bearing activities. Early motion
after the injury, with gentle stretching and a strengthening program,
speeds recovery.
Collaboration with the physical therapist is necessary in caring for
the child with a soft tissue injury. The physical therapist teaches the
patient quadriceps and hamstring exercises, an ROM program for
ankle injuries, and crutch walking. To prevent nerve damage, the
physical therapist ensures that the patient bears weight on their
hands, not the axillae.
The nurse has an important role in teaching home care for the child
with a soft tissue injury. Teach the proper technique for wrapping the
affected joint and ensure that it is followed. Communicate to the
caregiver that it is important to start wrapping the area distally and
work up to the proximal area beyond the level of the injury. The child
needs a physical activity restrictions school note for the physical
education teacher and coach. If the child has a mild sprain, sports
activities can be resumed in 2 to 3 weeks. If the child has a
moderate sprain, the child can participate in partial weight-bearing
activities using crutches and return to full weight-bearing and sports
activities gradually. If the child has a severe sprain, sports activities
can be resumed in approximately 4 to 8 weeks.
Sports Injuries
Sports injury may involve fractures, sprains, and strains as well as
knee and elbow injuries.
The increase in popularity of competitive sports, recreational
sports, and cheerleading has significantly increased the number of
overuse injuries, sprains, strains, and dislocations. The causes of
these injuries may be a result of inadequate health physicals,
hazardous practice and play areas, training and practice errors,
improper safety equipment, improper nutrition, overtiredness, and a
limited awareness or concern for the possible risk factors.
A child who participates in sports in which the legs are being used,
such as skiing, soccer, football, or track, is at risk for a knee injury
such as a tear in the anterior cruciate ligament (ACL). The injury
occurs when the ACL is stretched or torn during a sudden twisting
motion when the feet stay planted one way and the knee turns the
opposite way.
A child who participates in sports in which the arms are being
used, such as baseball, basketball, or tennis, is at risk for an elbow
injury. This injury is commonly known as “Little Leaguer’s elbow.”
This sport injury involves a repetitive forward motion of the arm, and
the child is not able to extend the elbow fully. This is because of
injury to the muscle consisting of tiny tears and contractures.
Signs and Symptoms

A ruptured or torn ACL causes:
■ Instability and pain in the knee
In an elbow injury, signs and symptoms are:
■ Pain and tenderness
■ Loss of full extension of the elbow (24 to 48 hours after the injury)
Diagnosis
Diagnosis of a sports injury is based on an x-ray exam followed by
an MRI.
Prevention
Because sports injuries are the result of an accident, preventing the
accident while participating in a particular sport would prevent the
injury. Pre- and post-workout stretching will help to keep joints,
muscles, tendons, and ligaments pliable.
Collaborative Care
NURSING CARE
Management for a knee injury depends on whether the injury is
mild or severe and whether there was a twisting action involved in
the injury. A mild injury is treated with rest and ice. A topical
anesthetic is applied locally to minimize pain, and oral pain
medication can be given. After 24 hours, heat is applied, which aids
in healing.
MEDICAL CARE
If the injury is more severe and the knee joint fills with fluid, a
physician will aspirate the excess synovial fluid. A cast may need to
be applied to completely immobilize the joint. It takes the same
length of time for a severe ligament injury to heal as a bone;
therefore, the cast remains in place for about 8 weeks.
If the injury involved a severe twisting motion, the kneecap may be
dislocated (slips around to the posterior side of the knee). The knee
appears deformed and a health-care provider slides the kneecap
back into place immediately. The child is placed in a leg immobilizer
for about a week. If this type of injury occurs frequently, surgery on
the ligaments is necessary. Quadriceps exercises, which consist of
straight leg-raising exercises, help prevent a kneecap dislocation
from occurring again.
For an elbow injury, exercises to strengthen the flexor muscles
help prevent further injury. Children need extra protection against
injury to the epiphyseal plates until they have fused (between the
ages of 14 and 17 years of age). To prevent elbow injuries, children
who participate in ball sports need time to warm up. Pitching
breaking balls and curve balls is discouraged. Pitching is also limited
to six innings per week with a 3-day rest period between games.
Management of the “Little Leaguer’s elbow” consists of applying ice
for 15 minutes three times per day. Administering an anti-
inflammatory agent may help the child be comfortable. Cortisone
injections into the joint can also be helpful, but only a limited number
can be used. Management for a more severe case consists of rest
and immobilization of the elbow until pain, tenderness, and limited
movement disappear. Permanent damage to the epiphyseal line and
an elbow deformity can be the result of this injury.
SURGICAL CARE
An arthroscopy is performed to examine the joint and repair torn
ligaments or cartilage with an arthroscope. This method is a
minimally invasive surgical procedure on a joint. Small incisions are
made so the joint is not fully opened. The recovery time is
significantly reduced because this type of procedure lessens trauma
to the connective tissue. Scarring is also reduced because of the
small incisions.
Review the management plan, principles of healing, how to perform
a neurovascular assessment, and care of the suture line. If a joint is
immobilized, instruct the patient and family on how to care for the
patient with the immobilizer and any special instructions on the use
of the immobilizer. Maintaining the extremity in an elevated position
is also an important instruction.
Osgood-Schlatter Disease
Osgood-Schlatter disease, a common cause of knee pain, is a
problem of overuse in active older school-age children or
adolescents (Fig. 21-11). It is more prevalent in boys and occurs in
boys between the ages of 12 and 15 years and in girls between the
ages of 10 and 12 years (Hsu et al, 2019). It is commonly described
as a childhood repetitive use injury that causes a painful lump below
the kneecap. Osgood-Schlatter disease mostly affects children
experiencing growth spurts. Children who play sports in which they
regularly run and jump are most at risk. The condition usually
resolves on its own once the child’s bones stop growing.
FIGURE 21-11 Osgood-Schlatter “bump.”
This condition causes an irritation of the patellar ligament at the

tibial tuberosity. It is caused by a repetitive injury resulting in
inflammation and small avulsions (tearing away) of the bone. The
cycle continues with new bone forming each time of the injury and
the body attempts to heal. Osgood-Schlatter disease does not result
in long-term complications, and the prognosis is good. Sports activity
does not have to be eliminated but must be reduced enough to
control the pain. When pain is tolerable, a gradual increase in
exercise may occur but must be titrated to a level that is tolerable for
the child. Occasionally, in severe cases, pain in the knees during
running or jumping can continue for many years.
Signs and Symptoms

Signs and symptoms of Osgood-Schlatter disease include:
■ Pain below the kneecap that is aggravated by activity and relieved
by rest
■ Pain when asked to squat or extend the knee against resistance
■ Symptoms resolve around the time skeletal growth ceases (about
puberty)
Diagnosis
A radiograph of the knee is performed to rule out a tumor. History
and the presenting symptoms assist in making this diagnosis.
Prevention
This occurs in the “right child” (usually a genetic pattern) at the “right
age” (usually preadolescence and just before a big growth spurt)
doing the “right activity” (usually involves running or jumping).
Because it is genetic in origin and strikes preadolescents, it is not
possible to prevent the disease. However, early recognition can help
minimize the severity of the disease.
Collaborative Care
NURSING CARE
Pain management is an important nursing action for a child with
Osgood-Schlatter disease. The pain medication of choice is an
NSAID. The knee is iced after exercising. An elastic wrap or
neoprene sleeve over the knee during activity also helps to relieve
the pain. After radiographic study is performed, conservative
management is continued such as rest and ice to the knee. Physical
therapy may be needed, and athletes may have their kneecaps
taped for added stability during sports.
SURGICAL CARE
Generally, these children can be treated effectively without
surgery. However, when pain continues over the tibial tubercle, a
painful ossicle has formed. The surgery is performed after the child
has reached bone maturity to avoid damage to the epiphyseal plate
(Hsu et al, 2019). A radiograph shows the ossicle and an apophysis
(an offshoot or projection especially from a bone) is performed,
which consists of the excision and trimming of the apophysis.
Teach the family about activity limitations. Provide support by helping
the child cope with the restrictions on activities and social
interactions. The nurse collaborates with the physical therapist to
teach the child exercises to strengthen the upper body. The physical
therapist also teaches the child to perform lower extremity
isometrics. These exercises help the child maintain strength while
the injured knee heals. Once the symptoms improve, the child
returns to normal activities.
Fractures
Musculoskeletal injuries are one of the most frequently encountered
problems in pediatrics, with fractures accounting for a surprisingly
large percentage of these injuries. A fracture occurs when bone is
subjected to more energy than it can absorb. Pediatric nurses must
have a good understanding of normal bone growth and development
and recognize common mechanisms of injury and fracture patterns
seen in children. Nearly 20% of children who present with an injury
have a fracture. The immature skeleton has several unique
properties that directly affect the management of fractures in
children. The most common causes of fractures are falls and motor
vehicle and bicycle crashes. There are differences between a
fracture in a child and a fracture in an adult. A child’s bone heals
faster because of a thicker periosteum (increased blood supply to
the bone) and because the epiphyseal plate (growth plate) is still
open. However, any damage to the epiphyseal plate can result in a
limb length discrepancy, joint incongruity, and a progressive angular
deformity of the limb.
Signs and Symptoms

Classification of fractures involves identifying the locations and
description of the fracture. The location is where the fracture occurs
along the shaft of the bone. The signs and symptoms of fractures are
described in terms of the amount of injury.
What to Say
Severity of the Fracture
Communicate to the family that the severity of the fracture depends on the
amount of force placed on the bone and the strength of the bone, the size of
the bone, and the direction of the force. Once a bone is fractured, an
inflammatory response occurs. Osteoblasts (bone-forming cells) activate
within 24 hours to begin making new bone. A callus forms during the first few
weeks. Complete callus formation and establishment of compact bone takes 4
to 12 weeks. Remodeling (rounding off angles and filling in hollows) continues
for up to 1 year. In children, the ends of the bone do not need to be perfectly
aligned because the bone has an enhanced ability to remodel.
Diagnosis
A fracture is suspected by presenting symptoms, trauma history, and
physical examination of the child. Radiograph exam is the primary
method to diagnose fractures. When a radiograph is performed, at
least two views are taken (anteroposterior and lateral). The joints
above and below the suspected fracture must be included in the
radiographic evaluation. Computed tomography (CT) scans, MRI,
fluoroscopy, and myelograms are also used to diagnose fractures.
Assessment Tools
Classification of Fractures by Location
EPIPHYSEAL
Type I
Separation of epiphysis
May be mistaken for a sprain
Does not usually affect growth
Type II
Fracture separation of the epiphysis
Circulation remains intact
Does not usually affect growth
Type III
Fracture through the epiphysis into the joint
Does not usually affect growth if reduced properly
Type IV
Fracture through epiphysis into the joint and the metaphysis
Open reduction and internal fixation necessary
Type V (rare occurrence)
Crush injury to epiphyseal plate
Results in premature closure of the epiphyseal plate
Growth arrest occurs

DIAPHYSIS
Proximal
Midshaft
Distal
Prevention
Fractures can be prevented by teaching parents to buckle children
correctly in child safety seats. Using protective gear for contact
sports may help prevent fractures. Preventing falls in young children
is also important. Teach children safety while biking and walking.
Collaborative Care
NURSING CARE
Obtain a history from the child and family describing how the injury
occurred. In cases in which maltreatment is involved, it is helpful to
ask the child how the injury occurred in the absence of the caregiver.
Depending on the type and location of the fracture, children
generally heal without complications.
Nursing care involves preventing complications such as limping,
decreased ROM, and nerve deficits. Other complications that can
occur with fractures are shock, fat emboli, deep vein thrombosis,
pulmonary embolism, and infection. Late complications that can
occur are mal-union, nonunion, refracture, joint stiffness, reflex
sympathetic dystrophy, loss of reduction, posttraumatic arthritis,
delayed union, and pseudoarthritis.
MEDICAL CARE
Specific, closed reduction, medical management depends on the
type and location of the fracture. If the bones are not displaced, no
reduction of the fracture is needed. If the bones are displaced, a
reduction of the fracture is needed, in which the ends of the bone are
placed close together or aligned. In either case, the bone must be
immobilized.
After closed reduction, perform frequent checks to assess for pain,
numbness, or tingling. Nursing actions that can help to prevent
complications and restore function are frequent neurovascular
assessments, notifying the health-care provider of any changes,
elevating the affected extremity above the level of the heart, and
applying cold packs (15-minute intervals) for the first 24 hours after
the injury.
SURGICAL CARE
Open reduction includes internal fixation that is used to stabilize
the bone ends until healed. Internal fixation is achieved with
percutaneous pins or with screws, plates, or rods. For example, an
intramedullary fixation rod can be placed in the shaft of the femur.
After the bone has healed, the hardware can be removed.
Immediately after the open reduction, the affected bone must be
immobilized to maintain the position of the fracture, prevent rotation
and shearing of the fracture, and permit active muscle contraction.
Immobilization is achieved with splints, braces, casts, external
fixators, or traction. Immobilization relieves pain and allows for ease
of movement of the unaffected areas of the body. It is important to
mobilize the child as quickly as possible to avoid hazards of
immobility.
Clinical Judgement Alert
Compartment Syndrome
The classic sign of compartment syndrome (related to casting) is an unrelenting
pain that is unrelieved by narcotics. This is one of the 5 Ps that were described
earlier in this chapter. The priority intervention for compartment syndrome is
prevention. Prevention is achieved by elevating the extremity to prevent
excessive swelling and performing frequent neurovascular checks. When
compartment syndrome occurs, notify the health-care provider immediately.
Caring for a Child With a Fracture in a Cast
• Elevate the extremity with the cast on pillows for at least the first 24 hours
(Fig. 21-12).
• Avoid indenting the cast.
• Assess the extremity for swelling and discoloration.
• Observe the extremity for sensation and movement.
• Notify a health-care professional immediately if abnormalities are noted.
• Follow activity restrictions.
• Do not allow the affected limb to hang down for any length of time.
• Prevent the child from putting anything inside the cast.
• Keep a clear path for ambulation.
• Ensure the child uses crutches appropriately.
• Encourage rest.
• Encourage good nutrition to promote healing (Table 21-1).
• Encourage quiet activities.
• Ensure child moves joints above and below cast.
A child life specialist can initiate play to help reduce the anxiety of a child
with a fracture. They can assist the child with working through fears and
frustrations with medical play, art therapy, and distraction.
Social services personnel may also be available to assist the family on
admission to the emergency department and can continue to support the family
during the child’s hospitalization. At discharge, they can arrange for
transportation and identify helpful community resources. A schoolteacher or
tutor can assist a child who is hospitalized for an extended period. A physical
therapist will ensure that the child is safe while walking with crutches and
provide passive and active ROM exercises to the other extremities. Once the
cast is removed, the physical therapist will institute exercises to increase
muscle strength in the affected extremity.
FIGURE 21-12 A cast is applied to the affected extremity to keep it
immobile while healing.
Discharge teaching helps parents feel more comfortable caring for
their child at home. It is important to review the management plan,
principles of bone healing, how to perform a neurovascular
assessment, and cast care. Parents need to be taught about
adaptations to the home environment that need to be in place to
ensure the child’s safety. Teach the family that nutrition can be
addressed by providing a well-balanced diet with protein, calcium,
and iron. The physical therapist can visit the home and help the
family learn methods for transfer and use of assistive devices at
home.
CASE STUDY
The Child With a Fracture Who Has Complications
A 12-year-old child was admitted with a femur fracture. They have a morphine
sulfate (Astramorph) patient-controlled analgesia (PCA) that has a dose that is
safe and effective. The leg is elevated on two pillows, and ice packs are in
place. The nurse performs a neurovascular assessment with the first morning
vital signs. During the following hour, the child complains that on the numerical
pain scale, the pain is 10 out of 10. The nurse checks the history recorded on
the PCA pump and determines the requested number of doses. The
neurovascular assessment reveals that the pulse is absent and the extremity is
cool and pale. The capillary refill time is greater than 3 seconds (Fig. 21-13).
1. What is occurring with this child?

2. What does the nurse do first?
3. If this is determined to be compartment syndrome, what will occur?
4. How can the nurse help the child and family during this emergency situation?
TABLE 21-1
Daily Nutritional Requirements for Musculoskeletal Health
NUTRIENT TODDLER PRESCHOOL SCHOOL TEEN TEEN BOY
AGE GIRL
Protein 13 g 19 g 34 g 46 g 52 g
Sources and amounts: meat, poultry, and fish (7 g per oz), eggs (6 g), dried beans
and peas (8 g per ½ cup), tofu (4 g per ½ cup), milk (8 g per cup), yogurt (11 g per
cup), American cheese (6 g per oz)
Iron 7 mg 10 mg 8 mg 15 mg 11 mg
Sources and amounts: liver (6.7 mg per oz), ground chuck (1 mg per oz), iron-
fortified cereal (6 mg per ¼ cup), lentils (1 mg per ½ cup), kidney beans (2.6 mg
per ½ cup)
Calcium 500 mg 800 mg 1,300 mg 1,300 mg 1,300 mg
Sources and amounts: milk (290 mg per cup), yogurt (207 mg per ½ cup),
cheddar cheese (204 mg per oz), ice cream (85 mg per ½ cup), spinach (120 mg
per ½ cup)
Vitamin D 200 units 200 units 200 units 200 units 200 units
Sources and amounts: synthesized from skin exposure to ultraviolet light; added
to some foods and supplements; salmon (149 units per oz), canned tuna (50 units
per oz)
Vitamin C 15 mg 25 mg 45 mg 65 mg 75 mg
Sources and amounts: orange (70 mg per medium raw), orange juice (63–97 mg
per ¾ cup), green pepper (60 mg per ½ cup raw), strawberries (49 mg per ½ cup),
kiwi (70 mg each), broccoli (39 mg per ½ cup raw)
Sources: Data from American Heart Association (AHA) (2020); National Academy
of Medicine (2017)
FIGURE 21-13 The nurse assesses capillary refill time.
Osteomyelitis
Osteomyelitis is a bacterial infection of the bone and the tissues
around the bone and bone marrow requiring immediate treatment.
Worldwide incidence ranges between 1/1,000 to 1/20,000
population, with 50% of cases occurring in children younger than 5
(Popescu et al, 2020). This disease occurs most commonly in
healthy children and can cause massive destruction of bone, sepsis,
and possibly death. Osteomyelitis often involves the long bones in
the lower extremities in children, but it can involve any other bone in
the body.
Although many bacteria can cause osteomyelitis, the most
common bacteria is Staphylococcus aureus, accounting for
approximately 70% to 90% of patients (Popescu et al, 2020).
Bacteria lodge and multiply in the middle of the bone where
circulation is sluggish. The infection spreads to the ends of the
bones and can destroy the epiphyseal plate in children. The
inflammatory process produces pus, edema, and vascular
congestion in the area of infection (Fig. 21-14). Pressure in the bone
increases and eventually cuts off the blood supply, causing necrosis.
The body attempts to lay down new bone over the necrotic bone.
The prognosis is good if the osteomyelitis is treated promptly with IV
antibiotics. However, when the infection weakens the bones,
pathological fractures can develop.
The following can cause acute osteomyelitis:
■ An open fracture
■ Penetration of the skin by a contaminated object
■ A septic joint
■ An infected wound
■ Bacterial infection from somewhere else in body, like dental caries
■ Blunt trauma
Signs and Symptoms

Signs and symptoms of osteomyelitis include:
■ Pain in the affected bone
■ Fever
■ Irritability
■ Guarding the affected limb
FIGURE 21-14 Sequence of osteomyelitis development. A, Infection
begins. B, Blood flow is blocked in the arc of infection, and an
abscess with pus forms. C, Bone dies within the infection site, and
pus continues to form.
■ Localized tenderness, redness, warmth, and pain on palpation

■ Occasionally, soft tissue swelling around the area
Diagnosis
Osteomyelitis is suspected when the child presents with the signs
and symptoms. The child’s history may reveal a fall or bumping of
the affected extremity. History also reveals a recent infection such as
a cold or otitis media. Radiographic exam and a bone scan confirm
the diagnosis. Blood cultures help determine the causative bacteria.
Prevention
Osteomyelitis can be prevented by ensuring that a wound that may
be deep enough to allow bacteria to come in contact with a bone or
joint is treated with sufficient antibiotics so that it does not spread to
the bone or joint.
Collaborative Care
NURSING CARE
The main nursing care for osteomyelitis is to administer a course
of broad-spectrum antibiotics. Antibiotics are begun after blood
cultures are drawn. The exact antibiotic prescribed will depend on
the causative bacteria. The child is hospitalized while on antibiotic
therapy. It is important to evaluate the child’s response to the
antibiotic therapy about 2 or 3 days after the initial dose. If the child
demonstrates a good response to the IV antibiotic therapy, more
blood cultures are drawn, IV antibiotics are stopped, and the child
continues therapy on oral antibiotics for 4 to 8 weeks at home.
MEDICAL CARE
If the child demonstrates poor response to the IV antibiotic
therapy, antibiotic therapy is continued for a much longer period.
Monitor laboratory values such as the erythrocyte sedimentation rate
(ESR). This lab study is a good indication of whether the infection is
resolving. As the infection resolves, the ESR decreases to normal.
Palliative measures such as rest, oral pain medication, good
nutrition, and diversional activities can also help the child tolerate the
lengthy hospitalization.
SURGICAL CARE
Surgical management for osteomyelitis usually requires surgery
for debridement and temporary stabilization of the bone with a
Kirschner wire (K-wire), which is a steel wire placed through a long
bone to apply traction to the bone, with an antibiotic implanted in the
bone cement. Further surgery is performed to reconstruct the bone
using a distractor and an external fixator (Popesco et al, 2020).
Postoperative nursing care includes monitoring vital signs, pain,
effect of pain medication, surgical wound, pin care if necessary,
return of bowel sounds, and postoperative voiding as well as
advancing diet to appropriate diet for age. Distraction is a good
nonpharmacological pain relief technique. This child receives IV
antibiotics. Insertion of a peripherally inserted central catheter
(PICC) line is usually needed. This will allow the child to be
discharged home with a visiting nurse and home infusion therapy
service. Collaborate with the case manager to coordinate these
services. If the child does not bear full weight, then physical therapy
will also be involved to ensure that the child is able to safely
ambulate with crutches or a pediatric walker.
The nurse has an important role in teaching home care for the child
with osteomyelitis. The child may be discharged on a regimen of
home IV antibiotics. Teach parents about the importance of antibiotic
compliance because this requires a sustained commitment from the
family. Antibiotics that can be scheduled every 8 to 12 hours may
have a better compliance rate than more frequently scheduled
antibiotics. The child may return to school if the antibiotics are on a
12-hour schedule. A home schoolteacher or tutor is needed if the
antibiotics are scheduled more frequently.
Juvenile Arthritis
Juvenile arthritis is an autoimmune inflammatory process with
unknown origin but is thought to be triggered by an infection. Peak
onset occurs in two different age groups (between 1 and 3 years of
age and between 8 and 12 years of age). Females are affected twice
as frequently as males. Symptoms can range from very mild to very
severe. Juvenile arthritis is not a childhood version of rheumatoid
arthritis. The prognosis of juvenile arthritis is considered good.
Success related to how the child and family cope with the condition
is based on how well the child meets developmental milestones. If
juvenile arthritis occurs in a younger child, growth retardation is more
likely to occur.
The child with juvenile arthritis has a pattern of remissions and
exacerbations. The prognosis for children with juvenile arthritis is
that 60% to 70% will have remissions. Approximately 45% will still
have active disease 10 years after diagnosis, which results in
disability in adulthood. Three different types are described in Table
21-2.
Signs and Symptoms

Signs and symptoms of juvenile arthritis include:
■ Joints that are swollen, tender, and warm to touch
■ Joints that are stiff and have loss of motion, especially in the
morning
■ Limited ROM
Systemic signs and symptoms include:
■ Malaise
■ Fatigue
■ Lethargy
■ Late afternoon fever with a temperature spike up to
TABLE 21-2
Types of Juvenile Arthritis
POLYARTICULAR OLIGOARTHRITIS SYSTEMIC
ONSET
Number of Joints Five or more Four or fewer Any number
Involved
Joints Affected Usually small joints Usually large joints, Any joint
of fingers and knees, ankle, elbow
hands Usually particular
Weight-bearing joint on one side of
joints Same joint on body
both sides
Sex Affected Girls more than Girls more than Boys and girls
boys boys (most equally
common type)
Body Temperature Low-grade fever Low-grade fever High spiking fever

lasting for weeks or
months
Other Symptoms Stiffness and Iridocyclitis (eye Macular rash on

minimal joint inflammation) chest, thighs
swelling Painless joint Inflammation of
Rheumatoid swelling with little heart and lungs
nodules on elbow redness Anemia
or other body area ANA titer (possible) Enlarged lymph
receiving pressure HLA antigen nodes, liver, and
from chairs, shoes (possible in boys) spleen
Rheumatoid factor Rarely rheumatoid
in 20% of cases factor and ANA titer
ANA titer is Elevated WBC
possible
Elevated WBC,
complement, and
erythrocyte
sedimentation rate
Diagnosis
There is no actual test for juvenile arthritis; therefore, diagnosing
juvenile arthritis is difficult. The diagnosis is made by excluding other
conditions that may cause similar symptoms or other possible
causes such as viral infections. Any child with joint swelling or pain
that has lasted longer than 6 weeks is assessed for possible juvenile
arthritis. The child protects the affected joint and may even refuse to
walk if the joint is a weight-bearing joint. The child may also have a
rash.
The white blood count (WBC) and ESR are important laboratory
values to monitor. The character, frequency, and severity of systemic
and articular (joint capsule) manifestations are critical factors in
diagnosing juvenile arthritis. Radiographs or bone scans to detect
changes in bones and joints are used in diagnosis.
Prevention
Because the onset of the disease is not clearly understood, there are
no known preventive measures.
Collaborative Care
NURSING CARE
Nursing care is supportive and includes pain management. If the
child is hospitalized, monitor the child’s vital signs, pain and
effectiveness of pain medication, and response to therapies.
Distraction is also an effective nonpharmacological pain relief
measure. Encouraging the child to maintain and continue
development is an important nursing role. Collaboration with Child
Life Services is a key nursing intervention.
Labs
Blood and Body Fluid Analysis for the Child With Alterations in
Musculoskeletal Conditions
Diagnostic Function of the Indications Normal Values
Test Test
Complete blood Blood sample Low platelets indicate Platelets: 150,000–
count (CBC) evaluates many a bleeding disorder. 400,000/uL
aspects. A high WBC count WBC: 4,500–
indicates a bacterial 10,000/uL
infection or septic
arthritis.
CBC differential Breaks down WBC A high monocyte count 0% for bands and
into various indicates a long-term 31%–57% for
types (five total). infectious process. segs
Numbers indicate Lymphocytes indicate Presence of bands
a percentage of an increase in viral ishighly
total WBC. illness. indicative of a
Indicates the type Eosinophils indicate an bacterial
of infection. allergic or parasitic infection
condition.
Basophils indicate a
chronic inflammatory
condition.
Neutrophils (polys).
Bands are immature
neutrophils.
Segs are mature
neutrophils.
(Left-shift describes an
increase in the band
neutrophils.)
Suggests a severe
bacterial infection
such as sepsis.
C-Reactive Measures a protein A normal level is 0–1.0 Over 10 mg/L
protein (CRP) in blood that is mg/dL or less than indicates an
released when 10 mg/L. infection is
an infection is present
present.
Calcium and Measures the Low levels may Calcium: 8.5-11
phosphate amount of these indicate rickets. mg Phosphorus:
minerals. 3.0–4.5 mg/dL
Rheumatoid Measures the If positive, may Negative
factor (Rh body’s indicate juvenile
factor) autoimmune arthritis. Not all
response to an children with juvenile
antigen. arthritis have a
positive Rh factor.
Erythrocyte Measures the Elevated indicates 0–10 mm/hr
sedimentation speed at which septic arthritis. May
rate (ESR) RBCs settle out also indicate
in solution. infection.
Blood cultures Measures whether Can identify an No growth
microorganisms organism causing
grow out in the infection. Forty
lab. percent of children
with septic arthritis
have a positive
blood culture.
Bone biopsies Diagnose tumor or Osteomyelitis. Bone Normal bone cells
infection of the tumor.
bone.
Fluid aspiration Diagnose an Drainage is purulent. Clear fluid No
from joints infection of the Culture of fluid is growth from
joint or drain positive. culture
fluid from joint to
relieve pressure.
MEDICAL CARE
Medications are a key factor in the management of the child with
juvenile arthritis. Medical management is supportive. Application of
heat and passive and active ROM exercises will help to keep the
child with juvenile arthritis as active as possible. Physical therapy will
play an important role in the care of these children.
MEDICATION
Medications for Juvenile Arthritis
• NSAIDs (nonsteroidal anti-inflammatory drugs). Only a few NSAIDs have
been approved for use with juvenile arthritis. The approved NSAIDs are:
- Ibuprofen (Children’s Advil): Safe dose range 30–50 mg/kg/day in 3–4
divided doses per day with a maximum dose of 2.4 g/day for children 6
months to 12 years. Safe dose range 400–800 mg 3–4 times daily with a
maximum dose of 3,600 mg/day for children older than 12 years.
- Naproxen (Aleve): Safe dose range is 10–15 mg/kg/dose every 12 hours
with a maximum dose of 1,000 mg/day in children over 2 years of age.
Safe dose range of 250–500 mg twice daily with a maximum of 1.5 g/day
for adults.
- Tolmetin (Tolectin): Safe dose range is 20 mg/kg/day in 3–4 divided doses
initially, followed by a maintenance dose of 15–30 mg/kg/day in 3–4
divided doses. Safe dose range is 400 mg three times per day initially,
followed by a maintenance dose of 600–1,800 mg/day in 3–4 divided
doses with a maximum dose of 2,000 mg/day.
- Choline magnesium trisalicylate (Trilisate): Safe dose range is 30–60
mg/kg/day in 3–4 divided doses for children. Safe dose range is 3 g/day at
bedtime or in 2–3 divided doses.
- Indomethacin (Indocin): Safe dose range is 1–2 mg/kg/day in 2–4 divided
doses with a maximum of 4 mg/kg/day in children greater than 2 years.
Safe dose range is 25–50 mg 2–4 times daily in adults.
- Diclofenac (Cataflam): Safe dose range is 50 mg 3–4 times daily for adults.
• If an NSAID is selected, it is usually chosen based on dosing schedule,
patient preference, or medication taste because there is a lack of agreement
on the best NSAID for patients with juvenile arthritis.
• Disease-modifying antirheumatic drugs (DMARDs) are agents that prevent or
relieve rheumatism. Some of the more commonly used DMARDs are:
- Methotrexate (Rheumatrex): Safe dose range is 10 mg/m2 once weekly,
initially and may be increased to 20–30 mg/m2 in children. Safe dose
range is 7.5 mg weekly, maximum dose of 20 mg/week and is decreased
when a response occurs. It is effective in polyarticular JA and has been
used for the past 10 years. The most common side effect of methotrexate
(Rheumatrex) is gastrointestinal symptoms.
- Cyclophosphamide (Cytoxan): Safe dose for PO induction is 2–8
mg/kg/day in divided doses for 6 days or longer. Maintenance of 2–5
mg/kg twice weekly in children. Safe dose for PO is 1–5 mg/kg/day for
adults.
- Sulfasalazine (Azulfidine): Safe dose range is 30–50 mg/kg/day in 2
divided doses. Initiate therapy at 1/4–1/3 of planned maintenance dose
and increase every 7 days until maintenance dose is reached. Not to
exceed 2 g/day in children 6 years or older. Safe dose is 500 mg–1 g/day
for 1 week then increase by 500 mg/day every week up to 2 g/day in 2
divided doses. If no benefit, then increase to 3 g/day in 2 divided doses for
adults.
- Infliximab (Remicade): Safe dose range is 3 mg/kg followed by 3 mg/kg 2
and 6 weeks after initial dose and then every 8 weeks. May be adjusted up
to 10 mg/kg if partial response in adults. May be used with methotrexate
(Rheumatrex).
• New drugs potentially available for use with juvenile arthritis are:
- Leflunomide (Arava) is an immunosuppressant. Loading dose is 100 mg
daily for 3 days. Maintenance dosing is 20 mg/day. If intolerance occurs it
may be decreased to 10 mg day. The side effects of these drugs are
diarrhea, elevated liver enzymes, alopecia, and rash. They have been
approved for use in adult patients with adult RA but have not yet been
approved for use with children. There is a teratogenic potential that would
be of concern with children, particularly adolescent girls.
- Etanercept (Enbrel). Safe dose in children 4–17 years is via SC injection
and is 0.8 mg/kg/week up to 50 mg as a single injection if the child weighs
more than 63 kg. If the child weighs between 31 and 62 kg, and then 0.8
mg/kg/week in two injections either the same day or separated by 3–4
days. If the child weighs less than 31 kg, then 0.8 mg/kg/week as a single
injection. Safe dose in adults is via SC injection and is 50 mg once weekly.
It has been found to reduce the signs and symptoms of moderately severe
to severe polyarticular juvenile arthritis. It is a potent inhibitor of tumor
necrosis factor, which is a key proinflammatory cytokine found in the
synovial tissue of patients with juvenile arthritis.
- Prednisone (Deltasone): Safe dose range is 0.1–2 mg/kg/day in 1–4
divided doses in children. Safe dose range is 5–60 mg/day as a single or
divided dose in adults.
• Other corticosteroids are potent and administered at the lowest possible dose
and for the shortest possible period of time. Side effects such as Cushing’s
syndrome, osteoporosis, increased risk of infection, glucose intolerance,
cataracts, and growth retardation can occur.
_________
Source: Vallerand, A. H., & Sanoski, C. A. (2021). Davis’s drug

guide for nurses (17th ed.). Philadelphia, PA: F.A. Davis.
SURGICAL CARE
Surgery is generally not indicated for children with juvenile arthritis
although some cases may require joint replacement. Postoperative
nursing interventions include monitoring vital signs, caring for the
suture line, and assessing for the return of bowel sounds and
postoperative voiding. Monitor fluid status as well as advance the
diet as appropriate for the child’s age. Administer pain medication
and use diversional activities for nonpharmacological pain control.
Juvenile arthritis requires teaching the child and family about the
disease and proper care. Teach caregivers how to assess the child’s
joints for warmth, tenderness, pain, and limitations in ROM. The
family must be alert for increasing irritability, guarding, and refusal to
bear weight, and take action by encouraging rest when these
symptoms arise. Help parents learn proper positioning of the
inflamed joints and the appropriate application of heat or cold. A
physical therapist can design an exercise program with isometric
exercises and passive ROM. Part of home care also includes the
need for a diet high in fiber, protein, calcium, and adequate fluid
intake. Develop a plan of care that aids parents in providing age-
appropriate activities and reinforces independent activities. After an
exacerbation, the child needs to be encouraged to resume pre-
exacerbation activities. It is best to involve the child in the decision-
making process as much as possible. Psychosocial adjustment of
the child is assessed by school performance and peer activities.
Attending professional counseling sessions or support groups can be
encouraged.
Scoliosis
Scoliosis is a nonpainful lateral curvature of the spine and is the
most common spinal deformity in children. The spine either curves
laterally in only one direction (C curve) or in two opposite directions
(S curve). There is a lateral deviation and rotation of each vertebra,
which accentuates the deformity. Idiopathic scoliosis is common in
female children and in families in which another member has been
affected by scoliosis. Idiopathic scoliosis is the predominant form,
and there is no recognizable cause. Unequal leg lengths, such as
untreated developmental dysplasia of the hip (DDH), can cause
scoliosis. Congenital scoliosis is related to vertebral anomalies. It
can also be associated with other congenital anomalies, such as
myelomeningocele (spina bifida), osteogenesis imperfecta (OI), or
MD. Paralytic scoliosis occurs in association with neuromuscular
diseases such as cerebral palsy, paraplegia, and quadriplegia.
Signs and Symptoms

Signs and symptoms of scoliosis include:
■ Unequal shoulder heights
■ Scapula prominences
■ Rib prominences
■ Chest asymmetry
■ Leg length discrepancy
■ Skin has hairy patches, nevi, café au lait spots, lipomas, and
dimples
Diagnosis
Diagnosis is confirmed by radiography. The physician looks at the
Cobb’s angle (a measure of the curvature of the spine in degrees).
The number of degrees helps the physician decide what type of
management is necessary. A curve of the spine that is 10 to 15
degrees is considered mild, and the child will be assessed for
scoliosis at regular checkups until pubertal maturation and growth
are complete. A curve between 15 and 40 degrees (mild) will
generally suggest a back brace. A curve of more than 40 degrees
(severe) revealed by x-ray exam requires management, and the
child is referred to an orthopedic surgeon.
Prevention
Idiopathic scoliosis has no known cause, so prevention is not
possible.
Collaborative Care
NURSING CARE
Scoliosis screening is a critical nursing action. The child is
evaluated for scoliosis screening at each health-care maintenance
visit until the child reaches bone maturity (McCarthy & Kelly 2019).
The evaluation begins with a general inspection of the back in the
standing and sitting positions. Asymmetries are noted. Differences in
shoulder height are measured from the floor to the
acromioclavicular joints (the joint between the acromion and the
acromial end of the clavicle) bilaterally. Head alignment is also
evaluated. The head should be in the midline and align perfectly over
the sacrum. The spine should be seen during flexion, extension, and
side-bending motions. Tanner’s stage and age of menarche in girls is
also noted. Assessing rib heights in both the thoracic and lumbar
regions is done. The spine is palpated for deviations not easily seen.
Both iliac crests are palpated simultaneously to determine if there is
an uneven pelvis. Watch for limping during ambulation. Assess for a
high arch, which may indicate a tethered spinal cord. If scoliosis is
suspected, a neurological exam needs to be performed by
evaluating motor, sensory, and reflex functions of both upper and
lower extremities. Assess for the abdominal reflex and the anal wink
reflex also. Severe scoliosis can lead to respiratory compromise
because the lung under the shortened side of the body will not be
able to fully expand. Severe scoliosis can also have a negative effect
on the hips and knees (Fig. 21-15).
FIGURE 21-15 The child is asked to bend at the waist with arms
hanging loosely. This is called the Adam’s position or the bend-over
test. Scoliosis is obvious in this adolescent.
MEDICAL CARE
Bracing and exercise are the usual medical treatments for mild
cases of scoliosis. Bracing stops the progression of scoliosis. The
molded brace is worn 23 hours per day. The patient may only
remove the brace to shower. The adolescent wears a special T-shirt
under the brace to prevent skin irritation. The major problem with
bracing is body image. Many adolescents do not want to wear the
brace at school or while they are with their friends. Communicate to
the child and family that compliance with bracing improves the
outcome for this condition. Inform family members that the best way
to increase compliance is to include the adolescent in decision-
making when possible. Exercises recommended by a physical
therapist help the back muscles gain strength.
SURGICAL CARE
The health-care provider may suggest that surgery be delayed as
long as possible because the fusion of the vertebrae will stop spinal
growth. However, a spinal fusion is necessary when pulmonary
function becomes compromised, sitting or walking becomes difficult
because of poor balance, pain becomes severe, curves are noted as
severe by x-ray exam, and for cosmetic reasons. Instrumentation (an
application of metal screws, bolts, or wires to straighten the spine) is
usually performed with the spinal fusion. The instrumentation holds
the vertebrae in place until the fusion has healed.
When surgery is scheduled, the nurse helps the child and parents
understand what may happen before and after the procedure. Prior
to surgery, a tour of the intensive care unit (ICU) can help alleviate
the child’s anxiety. It is also important to stress that after surgery the
child will have an indwelling urinary catheter in place. Teach ROM
exercises before surgery.
In the postoperative phase, the child remains in the ICU overnight.
Assess vital signs and neurological status every 1 to 2 hours after
surgery. Once the child is stable, they are transferred to the inpatient
area where vital signs and neurological assessments continue to be
performed every 4 hours. Monitoring fluid balance and renal function
is important because the kidneys are hypo-perfused during surgery.
The child may also have had blood transfusions.
The child may also have a chest tube in place. The chest tube will
be hooked up to suction at first and then placed on water seal. When
drainage has ceased, the chest tube is removed. Radiography is
usually performed the day after chest tube removal to ensure that no
pneumothorax is developing. Incentive spirometry, CPT, and
coughing and deep breathing exercises are used to prevent
atelectasis and pneumonia. Also assess for signs and symptoms of
infection every 4 hours, such as fevers, chills, redness and pain at
the incision site, and drainage from the incision site.
Assess circulation in the child’s lower extremities, the incision, the
bowel sounds in all four quadrants, and the softness of the abdomen
each time vital signs are assessed. Any changes in the
neurovascular status and signs of redness, swelling, drainage, or
dehiscence (separation of the suture line) must be reported to the
physician.
Pain from a spinal fusion surgery can be severe. Various methods
are used to control pain in the postoperative patient. Continuous
infusion of an opioid can be used for nonverbal patients. PCA is
effective and commonly used for those patients who are able. In
some cases, an epidural with bupivacaine (Marcaine) anesthetic
alone or combined with an opioid such as morphine sulfate
(Astramorph) or hydromorphone (Dilaudid) is used with success (Fig.
21-16). Pain management is usually switched to the oral route by
postoperative day 3.
The patient may be required to wear an orthotic brace.
Collaboration with the orthotist is necessary to ensure that the brace
fits properly. Check for pressure points under the brace for the first
couple of days after implementation of the brace. ROM exercises are
also performed to keep the uninvolved extremities from becoming
weak.
Ambulation is permitted (usually about 5 days postoperatively).
Early mobilization is important in the care of the child who has had a
spinal fusion to prevent atelectasis, pneumonia, pulmonary emboli,
phlebitis, and skin breakdown. Perform passive ROM to all
extremities. To turn the patient, use the logrolling technique.
Positioning of the patient is also an important nursing action. The
patient must be turned using the logrolling technique. Logrolling
involves two or more nurses turning the patient in complete unison.
The head, shoulders, hips, and legs are turned as one unit, thereby
keeping the back in a straight line as the patient is turned (Fig. 21-
17).
The nurse arranges for home care. Important information that is
included in a discharge-teaching plan is:
■ A caregiver must be home with the child at all times until the
health-care provider determines if it is safe to leave the child
unattended (based on age and recovery).
■ The child will need durable medical equipment for the home
environment, such as an elevated toilet seat and shower chair.
■ A hospital bed may also be needed in some circumstances.
■ Activity restrictions such as:
■ No twisting or bending
■ No lifting of heavy objects
■ No contact or high-impact sports for 2 years
■ The child may return to school about 4 to 6 weeks after surgery.
■ Teach parents to be alert for unfavorable signs such as:
■ Pain
■ Infection
■ Difficulty breathing
FIGURE 21-16 While the child is receiving narcotics, the nurse

monitors oxygen saturation.
FIGURE 21-17 The patient must be turned using the logrolling
technique.
■ Teaching the family about the brace care including the signs and
symptoms of skin breakdown.
■ Instruct the caregiver that the patient’s head is not raised more
than 30 degrees without the jacket brace.
■ Provide the family with information about community resources
that are available.
■ Arrange for counseling for the adolescent, particularly if there is
noncompliance with wearing the brace.
■ Encourage the adolescent to be as active as possible in their care
based on health-care provider’s orders.
■ Stress to the parents that it is important to keep follow-up
appointments.
Kyphosis
Kyphosis is a nonpainful spinal curvature in the sagittal plane. It is
commonly described as “hunchback.” Slight kyphosis is found in the
normal spine. Families usually seek treatment when the kyphosis
becomes noticeable. In children, kyphosis is caused by a congenital
or acquired condition. Some congenital causes of kyphosis are
ankylosing spondylitis, metabolic disorders, OI, spina bifida, Paget’s
disease, and Scheuermann’s disease, which causes juvenile or
adolescent kyphosis because there are wedge-shaped vertebrae in
the thoracic region. In acquired kyphosis, the child can voluntarily
bend the spine to correct the curvature. In addition, no underlying
evidence of structural changes is seen with acquired kyphosis.
Kyphosis is potentially serious because of the risk of progressive
deformity.
Signs and Symptoms

Signs and symptoms of kyphosis include:
■ Uneven shoulder height in the child
■ Complaints of pain in the thoracic region
Diagnosis
Kyphosis is most commonly diagnosed in early adolescence during
routine back screening for scoliosis. If kyphosis is suspected, a
complete examination includes a complete orthopedic and
neurological exam. Radiographs confirm the diagnosis and are used
to follow progression of the disease. If the curve exceeds 50
degrees, it is considered abnormal (kyphotic).
Prevention
There are no preventive measures that can be taken because the
cause is idiopathic.
Collaborative Care
NURSING CARE
Nursing care is similar to the nursing care of the child with
scoliosis.
MEDICAL CARE
Nonsurgical management is recommended for acquired kyphosis
when the curve is between 50 and 70 degrees. It is possible to treat
the child with continued observation and thoracic hyperextension
exercises, or a brace may be needed.
SURGICAL CARE
Surgical management is recommended when the curve is greater
than 70 degrees. Anterior-posterior spinal fusion is the surgery of
choice. The child with congenital kyphosis does not respond well to
bracing, so surgery is necessary. The nursing care for the child with
a surgical repair for kyphosis is the same as for the child with
scoliosis, and standard postoperative measures are provided.
Education and discharge instructions are similar to those for
scoliosis.
Lordosis
Lordosis is a spinal curvature in the sagittal plane (Fig. 21-18). It is
seen in conjunction with flexion contractures of the hip, scoliosis,
obesity, DDH, and SCFE. Slight lordosis is present in the normal
spine and is not considered a major deformity.
Signs and Symptoms

Lordosis is commonly described as “swayback,” an excessive
backward cavity of the spine.
Diagnosis
The parents may first notice that the child’s clothing is not fitting
properly. This may precipitate a visit to the primary care provider. If
lordosis is suspected, the full diagnostic exam includes a full
orthopedic and neurological examination. Radiographs confirm the
diagnosis and are used for follow-up progression of the disease.
MRI, CT scans, and nuclear scans can also be used to determine a
more detailed view of the spine in the back.
FIGURE 21-18 Slight lordosis is present in the normal spine and is
not considered a major deformity.
Prevention
The cause is unknown but has been thought to be associated with
poor posture and a congenital predisposition to the development of
lordosis. Prevention involves reducing the predisposing factors such
as obesity, MD, DDH, or neuromuscular disorders.
Collaborative Care
NURSING CARE
Reducing the predisposing factors can also be temporarily
achieved with postural exercises and support garments. Teaching is
an important nursing function. As with scoliosis, teaching is
necessary regarding the use and care of the back brace. Exercises
along with the use of a back brace are also important.
MEDICAL CARE
Medical management incorporates observation. As with scoliosis,
once the spinal abnormality has been identified, the health-care
practitioner monitors the curvature. Physical therapy is instituted to
provide exercise programs to maximize physical function. If the
curvature is stable and less than 30 degrees, observation is the
treatment of choice. If the curvature is greater than 30 degrees and
is worsening, bracing is instituted. As with scoliosis, compliance with
the bracing protocol is imperative in achieving the best possible
outcome.
SURGICAL CARE
As with scoliosis, surgery is indicated in the most severe cases of
lordosis. Surgery is similar to the surgery to correct scoliosis. Bracing
after surgery is also generally required.
Because the surgery is similar to scoliosis surgery, nursing care and
education/discharge teaching are basically the same as for patients
recovering from scoliosis surgery.
Osteogenesis Imperfecta
Osteogenesis imperfecta (OI) is an inherited connective tissue
disorder with many phenotypic presentations. It is often called “brittle
bone disease.” Severely affected patients suffer multiple fractures
with minimal or no trauma, and infants with the worst form of OI die
in the perinatal period. Mild forms of OI may manifest with only
premature osteoporosis (Trejo, Rauch, & Ward 2018). OI is a group
of autosomal dominant diseases characterized by excessive fragility
of the bones causing a high rate of fracture. It occurs equally in all
races and is equally prevalent between males and females. It is a
biochemical defect that causes a decrease in the synthesis of
collagen. It affects all connective tissue in the body. Children may
become disabled as a result of the severe deformities.
Any undue stress on the bone causes a fracture (e.g., changing
the infant’s diaper can cause a femur fracture). The fracture heals
within the normal period, but the bone lacks the normal strength.
Bone deformities such as bowing and growth pattern disturbances
occur. Some newborns die of complications caused by the extreme
fragility of the bones. When caring for an infant who presents with a
fracture, it is important to rule out OI as an organic cause of the
fracture, as well as child abuse as an inorganic cause of the fracture.
Prognosis for patients living with OI depends on the severity of the
disease. Patients with moderate to severe (types III to IX) disease
have an increased risk of premature death in both childhood and
adult life compared with the general population. Shortened life span
may be related to immobility and thoracic deformities in a subset of
patients with moderately severe disease. These problems create an
increased risk of severe pulmonary infections and subsequent loss
of lung function.
Signs and Symptoms

Signs and symptoms of OI include:
■ Severe osteoporosis
■ Fractures
■ Lax joints
■ Small, weak muscles
Diagnosis
Diagnosis is based on the severity of clinical symptoms and the level
of disability. There are five major types of OI based on severity and
the mode of genetic transmission. A unique feature of this disease is
the lack of bruising or swelling, only tenderness at the fracture site.
Laboratory studies are not useful in the diagnosis of OI.
Radiographic studies show multiple normal callus formations at new
fracture sites, evidence of previous fractures, and skeletal
deformities. In addition, radiographs will reveal generalized
osteopenia, which is an insufficiency of bone. A collagen biopsy will
confirm the diagnosis.
Prevention
There are no known preventative measures as this condition is
genetic, although studies underway are exploring early stem cell
transplantation in utero. The main goal of therapy is to prevent
fractures and further bone demineralization and bone loss as well as
maximize mobility.

Important nursing interventions include teaching the parents of an
infant diagnosed with OI to watch for signs of a fracture.
Communicate that the signs of fracture include irritability, fever, and
refusal to eat. Tell parents of an older child that signs to watch for are
pain, swelling, and possible deformity at the site. Body composition
is a risk factor for increased bone fractures in these children. These
children typically have a decreased amount of calcium and vitamin D
intake. Individualized nutritional support is recommended to help
increase the intake and absorption of calcium and vitamin D.
MEDICAL CARE
Patients with OI should undergo regular surveillance for potential
complications so that appropriate interventions can be initiated as
soon as possible. These include being managed by a
multidisciplinary team including physical therapists, medical and
surgical specialists, and nursing. Children with OI should see an
orthopedist at least once a year, and more frequently if they are on
bisphosphonates. In addition, they should see a neurologist yearly
and patients with OI Type II or greater should see a cardiologist
yearly.
Medical management also consists of pharmacotherapy.
Bisphosphonates such as pamidronate (Aredia), alendronate
(Fosamax), and zoledronic acid (Reclast) have been successful in
preventing further bone resorption and are the mainstays of therapy
now for children with OI. Studies are ongoing using bisphosphates.
Bisphosphonate (Reclast) is an inhibitor of osteoclastic bone
resorption and is used in management for moderate to severe forms
of OI. The best regimen and the long-term outcomes of
bisphosphonate (Reclast) therapy are unknown. Management with
bisphosphonate (Reclast) is an adjunct therapy for children with OI
and is used in conjunction with physical therapy, rehabilitation, and
orthopedic care. Other therapies being researched are using growth
hormone, increased vitamin D intake, maintaining physical activity,
and potential gene therapy.
SURGICAL CARE
Surgical management includes an operation to reduce fractures,
correct spinal deformities, and straighten long bones. Intramedullary
rodding of the femur is not a perfect solution but can provide stability
to a deformed bone. A solid intramedullary rod is easier to insert but
does not grow with the child and needs to be replaced every 2 to 4
years. A telescoping intramedullary rod is more complicated to insert
but can be adjusted as the child grows.
If the child is going for surgery to reduce and immobilize a fracture,
ensure that the child is adequately hydrated with IV fluids.
Postoperative care involves frequent vital sign and neurovascular
assessments. Pain management is also an important nursing action.
IV narcotics are administered as indicated. If the child is old enough
to use a PCA, it is used to keep pain control at a more constant,
therapeutic level. When the child is able to tolerate solid food, pain
medication is changed to an oral narcotic such as acetaminophen
(Children’s Tylenol) with codeine. Children with OI have excessive
fluid loss through their skin, so they have a much greater need for
hydration. Assess hydration status with every vital sign assessment.
Communicate to parents that the child may be small for their age
because of this disease. In addition, development may be delayed
because of increased dependence on parents and decreased social
interactions. Play and physical therapy are used with these children;
the family can play with the child. The physical therapist directs ROM
and muscle-strengthening exercises. The physical therapist also
helps the child regain mobility after surgery or a fracture and ensures
that the child can use the ambulatory devices safely. If deformities
are present, ambulatory devices such as a walker or wheelchair may
be necessary.
Encourage parents to receive genetic counseling. Causing a
fracture is the biggest fear of these parents. Focus information
toward the specific type of OI. Specific instructions about how to hold
their infant, change the infant’s diaper, and position their infant to
reduce the possibility of fracture are reviewed to help parents feel
comfortable caring for their infant. The goal is to achieve a balance
between protecting the child from fractures and allowing the child to
live as normal a life as possible.
FOCUS ON SAFETY
Falls
Children in general are at great risk for falls while hospitalized. The Pediatric
Fall Risk Tool is used to determine the fall risk. It is performed during the initial
assessment and then reassessed when there is a change in the child’s status.
The Pediatric Fall Risk Tool assesses:
• History of falls within the past 3 months (Score 0 = No or 3 = Yes)
• Physical alterations (Score 0 = No or 3 = Yes) to any of the list below:
- Surgery with admission
- Underlying medical condition of seizures
- History of vertigo or syncope
- Guillain-Barré syndrome
- Multiple sclerosis
- Alteration in visual acuity
• Functional Status: altered mobility (Score 0 = None, 1 = Weak, 2 = Impaired
or age-specific, learning to walk, 3 = Crutches, walker, brace, or orthostatic
hypotension)
• Equipment (Score 0 = No or 3 = Yes)
- IV, saline lock, IV pole, Foley catheter
• Cognitive/Psychosocial (Score 0 = oriented to own ability, 2 = Neurological
limitations because of illness or behavioral concerns)
- Impaired mental status
- Developmental delay
- Behavioral concerns
- Depression
- Oppositional deficit behavior
• Medications that alter equilibrium (Score 0 = No, 3 = Yes)
- Anticonvulsants
- Narcotics
- Antipsychotics
- Sedatives
- Chemotherapy
- Hypotensive medications
When this score is determined, it will reveal a number between 0 and 17. If
the score is between 0 and 7, the child is at low risk for falls; if it is greater
than or equal to a score of 8, then the child is at high risk for falls.
Ensure that the bed is the correct size in the lowest position with the wheels
locked. Side rails need to be up when the child is in the bed or crib. Clothes
need to fit, and the child needs to wear skid-proof footwear. All IV tubes,
drains, and catheters need to be secured. Ensure that spills and clutter are
cleaned up. Teach the patient and family about these safety measures. If the
child is in the high-risk category, all the low-risk interventions need to be
implemented as well as the following interventions:
• Hourly rounds to check on the child and attend to their needs are important.
• The child does not get out of bed without assistance.
• Evaluate whether patient care sitters may be necessary.
• All unnecessary equipment and furniture is removed from the room.
• Determine the need for physical therapist or occupational therapist consults
or the need for a psychiatric or social worker for any behavioral issues.
• Request the assistance of the child life therapist for play activities.
• A special wristband on the child and a sign on the door can flag others that
the child is at risk for a fall.
SUMMARY POINTS
■ Growth and development of the musculoskeletal system play a major role in the
normal growth and development of the child.
■ Nurses play an important role in assisting the parents to find methods to help the
child maintain normal growth and development as well as adapting or
overcoming musculoskeletal system impairment.
■ Care of a child with a musculoskeletal disorder involves collaboration with the
interdisciplinary team members, each having a specific role.
■ When caring for a child with a musculoskeletal condition, a neurovascular status
must be assessed carefully and every 1 to 2 hours for the first 48 hours. A
thorough neurovascular status consists of pain, sensation, motion, temperature,
capillary refill time, color, and pulses.
■ Clubfoot is a term used to describe a foot deformity diagnosed in newborn
infants. The most severe form of this condition resembles a “club” and is called
TEV. It requires long-term follow-up because there is a residual lifelong atrophy
of the calf muscle.
■ Nursing care for a child undergoing nonsurgical management of clubfoot
includes passive ROM and care of the cast application after manipulation.
■ There are four stages of LCPD: aseptic necrosis, revascularization, new bone
formation, and the regenerative phase. It is a self-limiting disease, and it can
take from 18 months to 4 years for the child to emerge from it. The child needs
to participate in non-weight-bearing activities during the course of the disease.
■ Nursing care of the child with SCFE includes bedrest, assisting the family in
adjusting to the sudden hospitalization, non-weight-bearing status of the child,
and the impending surgery. After surgery, monitor the neurovascular status
frequently and manage pain.
■ Nursing diagnoses for a child with a fracture include risk for injury related to
external devices, impaired physical mobility related to external devices, and risk
for impaired skin integrity related to external devices.
■ In pectus excavatum, surgery is performed to elevate the sternal depression and
secure it to the chest wall. A bar remains in place for 2 to 3 years to ensure a
permanent remodeling of the sternum.
■ The surgery for syndactyly is more complex than surgery for polydactyly. The
skin, muscles, nerves, tendons, ligaments, blood vessels, and bones must be
separated. Sometimes the bones are shorter so the surgeon will perform an
osteotomy and place a distractor. The distractor consists of pins that have been
placed in the two bone fragments.
■ Dislocated radial head is a form of dislocation. The head of the radius slips and
becomes dislocated as a result of an injury.
■ Soft tissue injuries are sprains and strains and are unusual in young children.
Sprains and strains are often seen in the adolescent age group.
■ The increase in popularity of competitive sports, recreational sports, and
cheerleading has significantly increased the number of overuse injuries, sprains,
strains, and dislocations.
■ The major signs and symptoms of Osgood-Schlatter disease include pain below
the kneecap that is aggravated by activity and relieved by rest and pain when
asked to squat or extend the knee against resistance.
■ Congenital torticollis becomes evident during the first 2 weeks after birth.
Delayed development can occur because the child is unable to turn their head to
see, hear, or touch.
■ All types of osteomyelitis require immediate treatment.
■ The child with juvenile arthritis will have joints that are swollen, tender, and warm
to touch and limited ROM. The joints will have a loss of motion and will be stiff,
especially in the morning. Intermittent joint pain that lasts longer than 6 weeks is
suspected for juvenile arthritis.
■ Treatment of transient synovitis of the hip includes limiting activity so the child is
more comfortable. However, there is no danger of untoward effects if the child
maintains normal activity. Nonsteroidal anti-inflammatory medications (NSAIDs)
can be prescribed to reduce pain.
■ In Duchenne’s muscular dystrophy, the symptoms first appear after the child is
able to walk, usually about 3 to 7 years of age. The child develops a waddling,
wide-based gait and uses the Gowers’ maneuver to rise from the floor.
■ Positioning of the child after surgery for scoliosis is an important nursing action.
The child must be turned using the logrolling technique.
■ Early mobilization is important in the care of the child who has had a spinal
fusion. Early mobilization prevents atelectasis, pneumonia, pulmonary emboli,
phlebitis, and skin breakdown.
■ Kyphosis is a nonpainful spinal curvature of the spine and is commonly
described as “hunchback.”
■ Lordosis is commonly described as “swayback,” an excessive backward cavity of
the spine.
■ Prevention of tetanus is the best defense; tetanus prophylaxis through
immunization is the key to preventing this condition.
■ Reliable prenatal diagnosis about OI is not currently available. Diagnosis is
based on the severity of clinical symptoms and the level of disability.
■ Research shows that an intake of calcium in school-age and adolescent girls
plays an important role in preventing the development of osteoporosis.
■ Casts, boots, splints, skin traction, skeletal traction, and distraction devices are
effective methods in treating musculoskeletal conditions in the child.
■ Complications can occur when a child is immobilized in a cast. The major
complication that can occur is compartment syndrome, which is caused by an
accumulation of fluid in the fascia.
■ Symptoms of compartment syndrome include pain, pallor, pulselessness,
paresthesia, and paralysis.
■ A nursing assessment of a child in a cast includes the 5 Ps: pain unrelieved by
narcotics, pulse present at the distal site, pallor, paresthesia, and paralysis.
■ Recognize that the main principle of traction is to reduce dislocations and
immobilize fractures in the child.
■ Distraction devices are usually used to lengthen a bone; the surgeon cuts
through a bone and places the distraction device.
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http://www.heart.org/HEARTORG/
Anderton, M. J., Hastie, G. R., Paton, R. W. (2018). The positive predictive value
of asymmetrical skin creases in the diagnosis of pathological developmental
dysplasia of the hip. Bone Joint J 100-B:675.
Aprato, A., Conti, A., Bertolo, F., & Masse, A. (2019). Slipped capital femoral
epiphysis: Current management strategies. Orthopedic Research and Reviews
11, 47–54. https://doi.org/10.2147/ORR.S166735
Collins, M. (2020). Pediatric neuromuscular disorders. Pediatric Clinicals of North
America 67(1):45–57. doi:10.1016/j.pcl.2019.09.002
Groarke, P. J., McLoughlin, L., Whitla, L., et al. (2017). Retrospective Multicenter
analysis of the accuracy of clinical examination by community physicians in
diagnosing developmental dysplasia of the hip. J Pediatr 181:163.
Hsu, J. R., Mir, H., Wally, M. K., Seymour, R. B., & Orthopaedic Trauma
Association Musculoskeletal Pain Task Force (2019). Clinical practice
guidelines for pain management in acute musculoskeletal injury. Journal of
Orthopaedic Trauma 33(5), e158-e182. 10.1097/BOT.0000000000001430
Marshall, N., Ward, E., Williams, C. (2018). The identification and appraisal of
assessment tools used to evaluate metatarsus adductus: a systematic review
of their measurement properties, Journal of Foot and Ankle Research,
10.1186/s13047-018-0268-z, 11, 1,
Martiniuk AL, Vujovich-Dunn C, Park M, et al. (2017) Plagiocephaly and
developmental delay: A systematic review. J Dev Behav Pediatr 38:67.
McCarthy, A., Kelly, M. (2019) Ahead of the curve: Pediatric scoliosis. The Journal
for Nurse Practitioners, 16(1): 34–40 Published online: September 23, 2019.
National Academy of Medicine (2017). Retrieved from https://nam.edu/
National Posture Institute. (2014). Public posture programs. Retrieved from
http://www.npionline.org/programs/public/index.html
National Institute of Arthritis and Musculoskeletal and Skin Diseases: Preventing
musculoskeletal sports injuries in youth: a guide for parents. https://www-
niams-nih-
gov.treadwell.idm.oclc.org/Health_Info/Sports_Injuries/child_sports_injuries.asp
(Accessed on August 28, 2017).
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musculoskeletal injuries in young athletes in United States. Transl Pediatr
6:160.
Pavone, V., Chisari, E., Vescio, A., Lucenti, L., Sessa, G., & Testa, G. (2018). The
etiology of idiopathic congenital talipes equinovarus: A systematic review.
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idiopathic congenital talipes equinovarus: a systematic review.
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osteomyelitis in pediatric patients: epidemiology and risk factors of a poor
outcome. The Journal of International Medical Research, 48(4),
300060520910889. https://doi.org/10.1177/0300060520910889
Ruggiero, K., & Ruggiero, M. (2020). Fast facts handbook for pediatric primary
care: A guide for nurse practitioners and physician assistants. New York:
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torticollis: Bridging the gap between research and clinical practice. Pediatrics
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Craniosynostosis. Pediatric Neurolology. 2019;99:7-15.

Davis Advantage
CHAPTER 22
Caring for the Child With an Integumentary Condition
CONCEPTS
Skin integrity
Thermoregulation
Trauma
Infection
KEY WORDS
comedones
anaerobic
cellulitis
septicemia
curettage
cryotherapy
tinea corporis
tinea pedis
tinea cruris
tinea capitis
tinea unguium (dermatophyte onychomycosis)
fomites
atopic
seborrheic
oliguria
vector
erythema migrans
lymphadenopathy
total burn surface area (TBSA)
rule of nines
Lund and Browder Chart
eschar
fasciotomy
LEARNING OBJECTIVES
■ Describe the anatomy and physiology and normal function of the skin.
■ Examine the diseases and symptoms related to various skin conditions.
■ Prioritize developmentally appropriate and holistic nursing care for skin and burn conditions.
■ Explore diagnostic and laboratory testing and medications for skin and burn conditions.
■ Develop teaching plans and discharge criteria for parents whose children have skin and burn conditions.
PICO(T) Questions
1. Is (I) severe acne (O) more common in (P) teenage girls than (C) teenage boys?
2. Does (I) application of aloe vera gel (O) speed healing of unblistered sunburned skin in (P) children younger than age
6?
INTRODUCTION
Normally the skin acts as a barrier, protecting the body from foreign organisms. On the other hand, the
skin also hosts a variety of bacterial flora, including the major pathogenic varieties of staphylococci and
streptococci. The pediatric population is at risk for skin breakdown, so maintenance of skin integrity is
critical for this age group. This chapter provides an overview of skin conditions that are common during
infancy, childhood, and adolescence. Various skin disorders common in the pediatric population are
described including bacterial, viral, and dermatophytosis skin infections. In addition, a description of
nursing assessment, documentation, prevention of altered tissue integrity and developmentally
appropriate and holistic nursing care of skin integrity is included in this chapter. Information about
diagnostic and laboratory testing and medications is provided. Teaching plans and discharge criteria for
parents whose children have various skin conditions are incorporated.

Emotional Effect of Integumentary Conditions
The child with an integumentary condition may experience increased emotional insecurity because of decreased self-
esteem and disturbances in self-image related to alterations in appearance from acne, scars, or burns. The nurse caring
for the child with a skin condition should focus on promoting positive self-esteem. The nurse understands that learning
and mastering tasks can increase confidence and should encourage the child to participate in activities that promote
learning, self-confidence, and acceptance. Activities and stimulation should be individualized to each child’s
developmental age and situation. The nurse should assess for signs of avoidance and social isolation. The nurse should
encourage the child to interact with others normally to encourage social and cognitive development.
It is important that the nurse cares for the integumentary condition and also attends to the child’s self-image. The nurse
should provide an environment of openness that fosters a sense of well-being to the child. The nurse should provide
education to the child about the disease process and treatment expectations in a nonjudgmental manner that fosters open
communication and trust. The nurse should encourage parental involvement to better ease the child’s discomfort and
acceptance of the disease process.
THE SKIN
The skin is the largest organ in the body and its main purpose is to protect the deeper tissues from injury
and from foreign matter invasion. The skin also protects the body from exposure to environmental, pest,
tactile, and chemical irritants that can disrupt the effectiveness of the skin as a protective barrier. Other
functions of the skin include synthesizing of vitamin D from ultraviolet light, aiding in water retention, and
ridding the body of toxins. The skin also helps regulate temperature and initiates the sensations of
touch, pain, heat, and cold in the body.
The skin has three layers: the epidermis, the dermis, and the subcutaneous fatty layer (Fig. 22-1).
These three layers provide the body with a barrier against external invaders. Each layer of the skin
contains specific properties. The epidermis is the outlet for the sweat glands, and the hair follicles
protrude through this layer. The dermis contains the nerves, muscles, connective tissue, sebaceous and
sweat glands, blood vessels, and lymph channels. The subcutaneous fatty layer separates the skin from
the underlying tissue. While all the accessory structures of the skin—the hair, nails, sebaceous glands,
exocrine glands, and apocrine glands—are present at birth, most are immature and cannot function to
their full potential until middle childhood.
FOCUS ON SAFETY
Infant Skin and Temperature
An infant’s skin is thin and contains very little subcutaneous fat. For this reason, temperature regulation becomes an
important issue because the infant tends to lose heat rapidly. Take care not to leave an infant uncovered and exposed for
a prolonged time. Because of their immature neurological system and large body surface area, infants have more
difficulty in regulating their body temperature.
FIGURE 22-1 The skin has three layers: the epidermis, the dermis, and the subcutaneous fatty layer.
Skin Lesions
A skin lesion is a circumscribed area of altered tissue (Venes, 2021). When assessing the skin for a
lesion, it is important to note the size, shape, color, and texture. The two main types of lesions are
primary and secondary. Primary lesions include macules, papules, patches, nodules, tumors, vesicles,
pustules, bullae, and wheals. Macules, papules, and nodules are found in children and adolescents with
acne. Vesicles and pustules are seen in the child with chickenpox and impetigo. Wheals are often seen
in the child with an allergic reaction. Secondary lesions are those that result from changes from the
primary lesions. They include crusts, scales, lichenification, scars, keloids, fissures, erosions, and ulcers
(Table 22-1).
Notably visible lichenification, or the thickening of the skin with hyperpigmentation, is often found on
children who have atopic dermatitis. Ulcers may be associated with cancer. Scars are the result of a
wound. Keloids, seen mainly in persons of color, result from hypertrophy of the scar tissue that extends
beyond the wound edges (Venes, 2021).
Wounds and Wound Healing

Typical wounds found in the child are a result of cuts, scrapes, and burns and can be secondary to
surgical intervention. When an injury has occurred, skin healing has three phases that often overlap.
The first stage, inflammation, reflects the skin’s initial healing response and lasts about 2 to 5 days. This
is a preparatory stage for repair. Under normal circumstances, the wound seals itself with blood
coagulation, followed by vasodilation that allows the leukocytes to ingest the bacteria and debris at the
site of the injury. In the second phase, proliferation, the blood flow is re-established to the site and
natural debridement occurs. In this phase, lasting 2 days to 3 weeks, the wound contracts and a fine
layer of epithelial cells cover the site of new collagen. Finally, during remodeling, the third phase,
collagen production allows for scar formation. This phase, lasting 3 weeks to 2 years, allows the
collagen to increase the tensile strength of the newly mended tissue. Scar strength is only 80% as
strong as the original tissue (Fig. 22-2).
TABLE 22-1
Common Skin Lesions and Associated Conditions
LESION NAME DESCRIPTION ASSOCIATED CONDITION (EXAMPLE)
PRIMARY LESIONS
Macules Flat, circumscribed area that has Freckles, flat moles, petechiae, measles, scarlet
color change: <1 cm in diameter fever
Papules Raised, circumscribed area: 1 cm Warts, moles, lichen planus, scabies

diameter
Patches Macule that is flat and nonpalpable, Port-wine stains, café-au-lait spots, capillary
irregular shape: 1 cm diameter hemangiomas
Nodules Raised, firm, circumscribed (deeper Lipomas, erythema nodosum

than a papule), 1–2 cm diameter
PRIMARY LESIONS
Tumors Raised and solid; may be clear, Lipomas, hemangiomas, neoplasms, benign
deep in the dermis, 2 cm in diameter tumors
Vesicles Raised, circumscribed, superficial, Varicella, herpes zoster (shingles)

filled with serous fluid, 1 cm in
diameter
Pustules Raised, superficial, like vesicle, but Impetigo, acne
fluid is purulent
Bullae Vesicle 1 cm in diameter Blister
Wheals Raised, irregular shape, cutaneous Urticaria, insect bites, allergic reaction
swelling, solid; diameter is variable
(usually transient)
SECONDARY LESIONS
Crusts Dried body fluid on the skin surface: Disease where the skin weeps: eczema,
serum, pus, or blood impetigo, seborrhea
Scales Raised cluster of keratinized cells, Seborrheic dermatitis, dry skin, skin flaking after
irregular, diameter is variable, can allergic reaction
be thick or thin, dry or oily
Lichenification Rough, thickened epidermal area Chronic dermatitis
often in the flexor surface of
extremity
Scars Fibrous tissue, thin or thick, Healing wound of any etiology

coloration may be lighter or darker
than surrounding skin
SECONDARY LESIONS
Keloids Fibrous tissue (scar) of irregular Postoperative wound healing (more common in
shape, raised and grown beyond the persons of color)
boundary of the original wound
Fissures Linear crack in the epidermis may be Athlete’s foot; cracks at the corner of the mouth
deeper; moist or dry or anus
Erosions Depressed, moist, loss of part of the After rupture of vesicle or bulla (e.g., varicella)
epidermis
Ulcers Concave, moist, loss of epidermis Ulceration: stasis, decubitus

and dermis
SKIN INFECTIONS
A number of bacterial, viral, or fungal invaders can affect the skin. While most of the skin conditions
resulting from these invaders respond quickly to treatment, others require extended healing time. The
specific pathogens that are responsible for the infection as well as the treatment and sequela of the
infection affect the healing response. Three specific pathogens are identified as the most frequent
causes of bacterial skin infections: Staphylococcus aureus, Streptococcus, and Pseudomonas. Viral
infections can be caused by any number of viruses, but those encountered most often include a
member of the poxvirus group, herpes simplex I or II, and the human papillomavirus. Fungal infections
are also caused by a wide variety of pathogens, the most common being Candida albicans.
PROCEDURE ■ The Child With Eczema (Impaired Skin Integrity

Related to Inflammatory Processes)
Measurable Short-Term Goal: The child will regain skin integrity as evidenced by decreased skin redness, pruritus, and
dryness.
Measurable Long-Term Goal: The child will not experience secondary infection.
NURSING INTERVENTIONS
1. Review family history for allergies or eczema.
RATIONALE: Assists with diagnosis of lesions because infantile eczema is often associated with familial tendencies.
2. Assess child’s skin lesions for location, size, color, type, drainage, signs of secondary infection, and any precipitating
factors the family can identify.
RATIONALE: Provides baseline data from which to evaluate improvement or worsening of the condition. Intense itching
and scratching may disrupt skin integrity further and lead to secondary infections.
3. Administer cool compresses or medications as ordered to relieve itching and treat secondary infection (specify drug,
dose, route, and times).
RATIONALE: Cold helps reduce irritation. Antihistamines and/or topical steroids may be prescribed to reduce
inflammation and pruritus, and antibiotics may be required for secondary infection.
4. Teach the family to promote skin hydration by bathing child in a lukewarm bath without harsh soaps and to apply
emollient lotions liberally to damp skin.
RATIONALE: Hot water and harsh soaps may exacerbate the skin irritation. Emollient lotions help trap moisture next to
the skin to reduce irritation and itching.
5. Teach the family to dress the child in light, soft, nonirritating clothing and to keep the child’s fingernails short, smooth,
and clean.
RATIONALE: Overheating and irritating fabrics may increase pruritus and inflammation. Nail care may help prevent
secondary infection from itching.
6. Assist the family to identify and remove potential irritants from the child’s environment, including harsh detergents,
perfumes, rough fabrics, and animal dander.
RATIONALE: A nonirritating environment helps decrease the likelihood of flare-ups of the condition.
FIGURE 22-2 Three phases of wound healing. A, Inflammation. B, Proliferation. C, Remodeling.
Overview of Common Skin Infections

Bacterial infections commonly cause impetigo and acne, while most viral infections cause inflammation
and vesiculation. Examples of the latter include the herpes simplex I virus and warts. Dermatophytosis,
commonly known is ringworm, is a fungal infection caused by a group of closely related fungi that invade
the stratum corneum, hair, and nails. These infections live on (not in) the skin. Scabies is an infection by
the Sarcoptes scabiei. Lesions are created as the female scabies mite burrows in the stratum corneum
of the epidermis, where she deposits her eggs and feces. An inflammatory response to the eggs and
feces under the skin causes intense pruritus. Lesions are characteristically located in intertriginous
areas: the interdigital surfaces, axillar-cubital area, popliteal folds, and inguinal region. Therefore, the
nursing assessment should include observation for discrete papules, burrows, or vesicles. Pediculosis
captitis (head lice) is an infestation of the scalp by Pediculus humanus capitis, a parasite in school-age
children. Itching is usually the only symptom.
Acne
Acne vulgaris is the most common bacterial skin disorder treated by physicians in adolescents (Fig. 22-
3). Although acne can occur during any age and could be a clinical manifestation of other conditions,
generally it begins in the teen years.

Acne During Adolescence
With the increase in the androgenic hormones during adolescence, there is an increase in the size of the sebaceous
glands, and consequently, more sebum secreted. With the increase in sebum secretion, the follicle (a small secretory sac)
enlarges, placing the person at risk for a keratin plug. These plugs result in the presence of a closed comedo that is called
a “whitehead.” At times, the comedo becomes inflamed and creates enough pressure to rupture. If a follicle is dilated
enough to reach the skin surface, a comedo may form what is often called a “blackhead.” Hyperpigmentation (increase in
color) in the area of insult will remain for weeks to months. If the area is aggravated by mechanical means, such as
scratching, squeezing, or harsh chemical cleansers, a scar may form. When inflammation deepens into the dermis, there
is a potential for scarring as well as walling off of infection in cysts. Often, adolescents who have excessive sebum have
more acne present because sebum is a growth medium for Propionibacterium acnes (P acnes).
SIGNS AND SYMPTOMS

Signs and symptoms of acne can be mild, moderate, or severe and progress in the following pattern:
■ Increased sebum production
■ Follicular hyperkeratinization
■ Propionibacterium acnes (P acnes) within the follicle
■ Inflammation with papules, pustules, nodules, or cysts
Signs and symptoms of mild acne include open comedones, closed comedones, and no
inflammatory lesions. An open comedo, often called a blackhead, has an open follicular orifice with
oxidized lipids, keratinocytes, and melanocytes. A closed comedo, which has a white head and pustule,
has a closed follicular orifice with sebum and keratinous substances.
Moderate acne will have a mix of noninflammatory comedones and inflammatory pustules and
papules, while severe acne will have an increased number of inflammatory papules, pustules, and
nodules with evidence of scarring. Severe acne is a significant progression of the signs and symptoms
listed.
DIAGNOSIS
A thorough skin assessment and a complete health history is the method of diagnosis for acne. The
nurse can prepare the teen for an assessment by making sure their face, scalp, chest, and back are
exposed and cleansed of all makeup and powders. Laboratory tests are ordered when an underlying
endocrine disorder is suspected.
FIGURE 22-3 Acne generally begins in the teen years.
What to Say
Assessing Acne in an Adolescent

Adolescents may suffer a psychological burden related to their acne. The nurse must realize that it is important to elicit
information from the adolescent about their feelings and relationships and the effect of acne on these areas of life. If
necessary, the nurse can refer the adolescent to the primary health-care provider for further support and intervention.
When assessing acne in an adolescent, the nurse asks specific questions that guide the acne treatment regimen:
“When did your acne begin?”
“What types of cleansing products, makeup, or moisturizers and hair care products are you currently using?”
“What medications are you taking, including over-the-counter and natural products?”
“Have you noticed certain foods, activities, or environmental factors that affect your acne?”
“Do you notice a change in your acne related to your menses?”
“What other dermatological problems have you had recently or in the past?”
“Does anyone tease you in person, in writing, on the Internet, or via text or phone conversations about your acne?”
“Can you tell me how you feel about having acne?”
PREVENTION
Acne can be prevented in some adolescents with care in skin cleansing along with decreasing
rubbing and picking of the existing comedones. Avoiding oil-based cleansing and moisturizing products
in the areas where acne breakouts commonly occur, such as the forehead and nose (T-zone), may also
be beneficial. Oil-based makeup does not resolve acne breakouts and may worsen them. Stress may
make acne worse in some adolescents at particularly taxing times.
Over-the-counter medications for acne typically have one or more of the following ingredients: salicylic
acid, benzoyl peroxide, sulfur, and alpha hydroxyl acids. Most adolescent acne improves with cleansing
and proper moisturizing with a water-soluble moisturizer.
Both nursing care and medical care play an important role in treating adolescent acne. The nurse must teach the
adolescent about proper treatment of the acne. Prior to any type of acne care, assist the adolescent in gently cleansing
the affected area. Be sure to assess the acne area including the face, chest, and back in good light. Post-treatment
measures include gently cleansing or using a cool cloth to soothe the immediate inflammatory effects of tissue disruption
and provide comfort.
Nursing care also includes teaching the adolescent about medications used in the treatment of acne including
antimicrobials (topical or oral antibiotics), retinoids, and/or hormonal therapy.
Antimicrobials include erythromycin (Ery-Tab) (topical or oral), clindamycin (Cleocin) (topical or oral), tetracycline
(Sumycin) (oral), minocycline (Minocin) (oral), and doxycycline (Vibramycin) (oral). Retinoids include tretinoin (Retin A)
(topical), tazarotene (Tazorac) (topical), and isotretinoin (Accutane) (oral).
Teaching and reinforcing proper skin care and medication management are essential for the
adolescent with acne. Acne treatment tends to be very drying and must not be covered with moisturizers
or makeup. Teaching the teen how to use the medication at bedtime may increase adherence to the
treatment regimen. Information about common medication for acne is found in Table 22-2.
Patient Education
Common Medications to Treat Acne:
TETRACYCLINE (SUMYCIN), MINOCYCLINE (MINOCIN), AND DOXYCYCLINE (VIBRAMYCIN)
Tetracycline (Sumycin), minocycline (Minocin), and doxycyline (Vibramycin) can all cause photosensitivity with prolonged
exposure to sunlight or tanning beds. Patients must be instructed regarding this risk along with education to avoid
pregnancy while taking any of these medications because they can cause permanent discoloration of the offspring’s teeth
if exposed in utero during the second half of pregnancy or in children younger than 8 years.
Isotretinoin (Accutane) has been shown to cause severe birth defects. Therefore, women must not take this medication
if there is any chance of becoming pregnant. Be sure to discuss this with all adolescents. Pregnancy tests must be
performed before treatment with this medication, monthly during treatment, and 1 month after the cessation of treatment.
Nurses must counsel women considering this treatment to use two forms of birth control.
Impetigo Contagiosa
Impetigo contagiosa is a bacterial staph or strep infection of the skin often found on and around the
mouth and nose of the child or elsewhere on the face (Fig. 22-4). It may also appear on the hands,
neck, trunk, buttocks, or extremities. Infants and children younger than age 5 are at greatest risk for
impetigo. It is generally caused by Staphylococcus aureus. On rare occasions, other bacteria may be
responsible for the skin infection, including methicillin-resistant Staphylococcus aureus (MRSA).
SIGNS AND SYMPTOMS
The lesions begin as a vesicle or pustule surrounded by edema (swelling) and erythema (redness).
Later these lesions erupt, leaving honey-colored exudate. This exudate becomes crusty in appearance
and sticky to the touch. The child may experience pruritus (itching) that is not usually painful. Over time,
impetigo clears, leaving no residual scarring in the absence of scratching or picking.
DIAGNOSIS
Impetigo is diagnosed through assessment and rarely requires lab testing. A diagnostic culture is
needed if the health-care provider is unsure of the exact diagnosis and is investigating a differential
diagnosis such as contact dermatitis or herpes virus.
PREVENTION
Impetigo is very contagious and passed by touch from the infected child to others. Good hand
washing and keeping a child at home for 24 hours after the induction of the antibiotic will decrease the
spread of impetigo in the child’s environment.
COLLABORATIVE CARE
Topical antibiotics such as mupirocin (Bactroban) may be used if the skin lesions are limited. Oral
antibiotics are given for widespread infections and may include amoxicillin/clavulanate (Augmentin),
dicloxacillin, or erythromycin (E.S.S.) Other common medications for impetigo include cephalexin
(Keflex) (oral) and clindamycin (Cleocin) (oral).
What to Say
Teaching About Impetigo
When the nurse is caring for the child with impetigo, it is important to teach the child and caregiver:
“Do not be embarrassed; this occurs quite commonly.”
“It is very important to wash your hands.”
“Try not to scratch the lesions.”
“Change pillowcases nightly until the lesions are no longer oozing or flaking.”
Methicillin-Resistant Staphylococcus Aureus (MRSA)

MRSA is a circular, anaerobic, gram-positive bacterium prevalent in the nose and skin of most
individuals. MRSA is resistant to treatment from beta-lactam antibiotics such as methicillin, also called
meticillin, amoxicillin (Amoxil), penicillin G (Bicillin L-A), and oxacillin (Bactocill). Hospital-acquired
MRSA may result in systemic infection, but community-acquired MRSA is usually limited to the skin and
soft tissue.
SIGNS AND SYMPTOMS

MRSA is most often a skin infection, and signs and symptoms can include vesicles, pustules, and
other bumps that are painful, red, leaking pus, and/or swollen. The lesion may resemble a spider bite.
Skin around a sore is warm or hot to the touch. Upon rupture, the exudate is white to yellow.
DIAGNOSIS
MRSA is diagnosed through clinical assessment. However, a culture is warranted if the lesion is one
of many, a recurrent lesion, or if the child has impaired immunity or has recently been released from the
hospital.
TABLE 22-2
Medications for Acne
NAME INDICATIONS ACTIONS THERAPEUTIC CONTRAINDICATIONS ADVERSE ROUTE NURSI
EFFECT AND PRECAUTIONS REACTIONS AND AND IMPLIC
SIDE EFFECTS DOSAGE
erythromycin Treatment of Inhibits Anti-infective Hypersensitivity, known Nausea/vomiting, Topical and Assess
(E-Mycin) acne protein alcohol intolerance rashes systemic Obtain
synthesis of culture
bacterial before d
ribosome Assess
in the c
clindamycin Treatment of Inhibits Anti-infective Hypersensitivity, Diarrhea, rashes, Topical and Assess
(Cleocin) skin infections: protein previous pseudomembranous systemic Obtain
acne synthesis of pseudomembranous colitis culture
bacterial colitis, severe liver before d
ribosome impairment Monitor
eliminat
Assess
in the c
tetracycline Treatment of Inhibits Anti-infective Hypersensitivity, known Nausea/vomiting, Systemic Assess
(Sumycin) various protein alcohol intolerance, diarrhea, infectio
infections: synthesis of pregnancy, lactation photosensitivity Obtain
acne bacterial culture
ribosome before d
Monitor
function
Assess
in the c
tretinoin Acne, acute By Antiacne, Hypersensitivity Oral: Dysrhythmia Systemic Assess
(Retin-A) promyelocytic stimulating antineoplastic, Topical: and topical sensitiv
leukemia, the retinoid Erythema, scaling, Oral: Assess
wrinkles transcription dryness, itching, capsule, Assess
process, it photosensitivity liquid filled: in the c
increases 10 mg
epidermal Topical
cell mitosis cream:
and 0.02%,
epidermal 0.025%,
cell turnover 0.05%, 0.1%
Topical
gel/jelly:
0.01%,
0.025%,
0.04%, 0.1%
Topical
solution:
0.05%
Usually used
once per day
before bed
adapalene Acne, Thought to Retinoid-like Hypersensitivity Erythema, scaling, Topical gel: Assess
(Differin) chloasma, normalize effect dryness, itching, 0.1% sensitiv
keratosis epithelial photosensitivity Solution Assess
cells 0.1% Assess
Usually used in the c
once per day
before bed
tazarotene Acne, Studies Retinoid Hypersensitivity, Topical: Safety not Assess
(Tazorac) psoriasis, suggest: pregnancy erythema, scaling, established sensitiv
wrinkles inhibits dryness, itching, in children Assess
growth of photosensitivity <12 years Assess
human old in the c
keratocyte
Topical
cream:
0.05%,
0.1%
Topical
gel/jelly:
0.05%, 0.1%
minocycline Treatment of inhibits Anti-infective Hypersensitivity, known Nausea/vomiting, Systemic Assess
(Minocin) various growth of alcohol intolerance, diarrhea, infectio
infections: human pregnancy, lactation photosensitivity Obtain
acne keratocyte culture
before d
Observ
skin pig
Monitor
function
Assess
in the c
doxycycline Treatment of Inhibits Anti-infective Hypersensitivity, known Nausea/vomiting, Systemic Assess
(Vibramycin) various protein alcohol intolerance, diarrhea, infectio
infections: synthesis of pregnancy, lactation photosensitivity Obtain
acne bacterial culture
Treatment of ribosome before d
anthrax Monitor
function
Assess
in the c
isotretinoin Acne Reduces Antiacne, Hypersensitivity, Dermatologic: Systemic Obtain
(Accutane) sebaceous retinoid pregnancy cheilitis, dry skin, Safety and two test
gland size itching. effectiveness followed
and inhibits Endocrine in children during t
sebaceous metabolic: serum <12 years comple
gland triglycerides raised not and 1 m
activity Hepatic: established discont
hepatotoxicity 1 mg/kg/day therapy
Psychiatric: ORALLY in 2 Assess
aggressive divided psychos
behavior, doses ideation
depression, violent behavio
behavior Monitor
by obta
weekly
interval
Registe
Program
www.ip
Assess
in the c
Source: Data from Vallerand, A. H., & Sanoski, C. A. (2021). Davis’s drug guide for nurses (17th ed.). Philadelphia, PA: F.A.
Davis.
FIGURE 22-4 Impetigo is a highly contagious bacterial infection.
PREVENTION
MRSA is contagious and is passed skin-to-skin and from inanimate surfaces to the skin. Because
MRSA can live longer on hard surfaces than soft surfaces, it is important to teach parents to clean
surfaces. Children should be taught good hand washing and personal hygienic practices. Athletes
should shower immediately after events and avoid sharing personal items. Schools, day cares, and
athletic facilities should cleanse the environment regularly with a good bactericidal spray or wash. In the
home setting, regular unscented bleach is very effective in killing bacteria and viruses on hard surfaces.
COLLABORATIVE CARE
The first line of treatment for MRSA is the administration of an oral antibiotic and/or a topical antibiotic
cream:
■ Vancomycin (Vancocin) (IV)
■ Clindamycin (Cleocin) (IV/IM/PO), dicloxacillin (PO)
■ Mupirocin (Bactroban (topical)
What to Say
Teaching About MRSA
When the nurse is caring for the child with MRSA, it is important to teach the child and caregiver:
“This is a common skin infection.”
“It is very important to wash your hands.”
“Try not to scratch the lesions.”
“Keep the area covered until it scabs over.”
“Use the medication as prescribed for the entire duration prescribed.”
Cellulitis
Cellulitis is a bacterial infection that occurs when bacteria, most commonly streptococcus and
staphylococcus, enter through a crack or break in the skin. Animal bites can cause cellulitis. Bacteria
can also enter through areas of dry, flaky, or swollen skin.
SIGNS AND SYMPTOMS
With cellulitis, skin may be:
■ Red to purplish-red
■ Swollen or indurated
■ Warm or hot to touch
■ Tender or painful to touch
DIAGNOSIS
A complete history and physical is the usual method of diagnosis. Lab tests, radiological testing, or
surgical biopsy is used only in the presence of severe infection. Complete blood counts and blood
cultures are ordered to rule out septicemia (infection of the blood) if symptoms warrant.
PREVENTION
To help prevent cellulitis, tell the caregiver about these simple care measures when the child has a
skin wound:
■ Wash the child’s wound daily with soap and water.
■ Apply an over-the-counter antibiotic cream or ointment.
■ Watch for signs of infection such as redness, pain, and drainage.
COLLABORATIVE CARE
Nursing Care
Management may vary depending on the location of the cellulitis and the total surface area of the
induration as well as the age of the child. Most cases of cellulitis are handled in the outpatient arena.
Cellulitis that manifests on the face and neck, genitals, or over a joint is more worrisome as it may cause
systemic infection. Orbital cellulitis carries a high risk of morbidity and is treated aggressively with
hospitalization for IV antibiotics (Fig. 22-5). Nursing care of a patient with cellulitis includes marking the
circumference of the reddened area with a marker to distinguish if the rash is improving or worsening
with treatment.
If a child has a severe case of cellulitis, hospitalization and IV antibiotics may be necessary. In
addition, steroids to decrease inflammation such as prednisolone (Pediapred) may be ordered but are
not routine. Another nursing intervention for symptom control is the administration of an anti-
inflammatory medication such as ibuprofen (Children’s Advil) or acetaminophen (Children’s Tylenol).
FIGURE 22-5 Child who has orbital cellulitis.
PROCEDURE ■ Bleach Solution
A bleach solution can be easily prepared by mixing 1 tablespoon of bleach for every 1 quart of water. A bucket and cloth
or spray bottle can be used. Always make sure that you mix this solution in a well-ventilated area. Bleach water solution
loses its antibacterial effects within 24 hours, so it needs to be made on the day it is to be used.
Medical Care
Medications are important in the management of cellulitis, and these medications are often
prescribed:
■ Penicillin G (Bicillin) IM
■ Amoxicillin (Amoxil)
■ Ceftriaxone (Rocephin)
■ Cephalexin (Keflex)
■ Clindamycin (Cleocin)
If MRSA is considered (based on history or suspect abscess), these medications are used:
■ Vancomycin (Vancocin) (IV)
■ Clindamycin (Cleocin) (IV/IM/PO)
■ Dicloxacillin (PO)
FOCUS ON SAFETY
Group A Streptococcus
Group A streptococcus can cause necrotizing fasciitis (flesh-eating bacteria). Be alert to the following clinical
manifestations of necrotizing fasciitis: severe pain, bruising, crepitus, or bullae filled with bluish/purple-colored fluid over
the induration.
Optimizing Outcomes
Family Adherence
The best outcome for a child with cellulitis who is receiving an antibiotic is for the family to be adherent and administer the
entire medication as prescribed. If the family has a history of nonadherence to a medical plan, or if the child cannot take
the medication as prescribed, the nurse must notify the health-care provider immediately. The health-care provider may
then choose to order a single dose of IM penicillin G (Bicillin L-A) or a 3-day regimen of ceftriaxone (Rocephin) instead of
the oral medication. Using a topical anesthetic such as EMLA (lidocaine/prilocaine) at the injection site at least an hour
before the injection helps decrease the pain.
Viral Infections
Molluscum Contagiosum
Molluscum contagiosum is a skin infection caused by a poxvirus, common in the pediatric population. It
is caused by molluscum contagiosum virus (MCV) and is transmitted mainly by direct contact with
infected skin, which can be sexual, nonsexual, or autoinoculation. Clinically, Molluscum presents as firm
rounded papules, pink or skin-colored, with a shiny and umbilicated surface. The duration of the lesions
is variable, but in most cases, they are self-limited in a period of 6 to 9 months (Meza-Romero,
Navarrete-Dechent, & Downey, 2019). Transmission is commonly through direct contact, skin-to-skin
contact, or with contaminated objects.
SIGNS AND SYMPTOMS

Signs and symptoms of molluscum contagiosum include small flesh- or pink-colored papules (pearl-
like) that are no larger than 2 to 6 mm in diameter. The central depression of the papule may have an
exudative plug. Groups of papules range from a few to several hundred. In children, the papules are
found predominately on the trunk and face. Papules are never seen on the palms or soles in any age
group.
DIAGNOSIS
The condition is diagnosed by assessing the skin for lesion typology. A family history may reveal that
the virus has recently affected other family members.
PREVENTION
A child who has molluscum contagiosum should use the bathtub alone rather than bathe communally
with siblings. The tub must be disinfected after a bath, and the child’s towels should not be shared.
Special covering of the lesions is not required for normal activities of daily living because the child and
family may already have or have had the viral infection.
COLLABORATIVE CARE
Nursing Care
The nurse communicates to the family that no specific diagnostic testing or intervention is required for
mild cases because they resolve on their own. If medications are prescribed, proper instruction in
medication name, dose, interval, and potential adverse effects are discussed.
Medical Care
Generally, molluscum contagiosum will self-resolve. In more severe cases, medical treatment may
require the daily use of topical tretinoin (Retin A) to irritate the skin and in turn stimulate the immune
system to respond to this viral condition. If this is unsuccessful, the health-care provider may choose
curettage (cutting away) or cryotherapy (freezing each lesion with liquid nitrogen). Complications from
these treatments may include scarring. A secondary infection would require treatment with topical or oral
antibiotics.
The nurse instructs the family in good hand hygiene, redirecting the child from picking at the lesion to
prevent autoinoculation, and allowing scabbing to fall off naturally.
Human Papillomavirus
Human papillomavirus infections (warts) are common among children. The human papillomavirus
causes warts by invading the epithelial cells in the skin. The wart is transmitted by direct skin-to-skin or
mucous membrane contact and from hard surface areas such as plantar warts from gymnasium floors.
The usual incubation period is 2 to 6 months, but in some cases there is a latency period. Three types of
warts occur in children: common warts (verruca vulgaris), plantar warts (verruca plantaris), and flat warts
(verruca plana).
SIGNS AND SYMPTOMS
Common warts can appear anywhere on the body and appear:
■ Rough (cauliflower appearance)
■ Raised or flat
■ Flesh-colored
At times, there will be a central black dot. They may appear alone or in clusters (Fig. 22-6).
Tinea Capitis, Tinea Corporis, Tinea Cruris, and Tinea Pedis

Tinea capitis, tinea corporis, tinea cruris, and tinea pedis (dermatophytosis) are fungal infections that
affect the skin, scalp, or nails (Fig. 22-7). Children of all ages can be affected. This infection may spread
from person-to-person or from animal (especially cats) to person. These infections may also be spread
by contact with inanimate objects such as clothing, furniture, or bed linen of another infected person.
Some children may be colonized but remain asymptomatic.
The major clinical subtypes of dermatophyte infections are:
FIGURE 22-6 Warts are a cutaneous elevation of the skin.

FIGURE 22-7 Obtaining a fungal culture.
■ Tinea corporis – Infection of body surfaces other than the feet, groin, face, scalp hair, or beard hair
characterized by a round to oval lesion with maculopapular border with central clearing and often with
scaling, except the scalp, groin, hands, and feet; seen in children and adolescents; sometimes
referred to by the common term ringworm even though no “worm” is involved.
■ Tinea pedis – Infection of the foot, also known as “athlete’s foot,” characterized by red, scaly, pruritic
skin that may develop weeping and involves the kinesthetic webbed areas of the toes and feet. This
infection can occur in children and adolescents.
■ Tinea cruris – Infection of the groin, commonly known as “jock itch,” characterized by red, scaly skin
that involves the inner thighs, inguinal creases, or perineal area (rare before adolescence).
■ Tinea capitis – Infection of scalp hair characterized by scaly, pruritic patches that can be associated
with breakage of the hair and is usually seen in prepubertal children between ages 1 and 10.
■ Tinea unguium (dermatophyte onychomycosis) – Infection of the nail.
SIGNS AND SYMPTOMS
Other signs and symptoms of these infections include:
■ Pruritic rash with round, scaly, pink to red lesions, often with central clearing, creating a circular lesion
■ On the head, hair loss may occur in the area of the rash
The nurse must remember that attempting to remove the oral thrush can cause the lining of the oral
mucosa to bleed.
DIAGNOSIS
The diagnosis of tinea is made by visual inspection using a Wood’s lamp that discloses yellowish-gold
fluorescent coloration.
PREVENTION
Have family pets checked at the veterinarian if they experience areas of fur loss, excessive itching, or
self-grooming. Encourage good hand washing. Have children and adolescents in sports activities bathe
as soon as they are home from practice or games to remove fungal spores that may be on the skin. Do
not share fomites (objects that can carry infection) like bath and hand towels, combs and brushes, hats,
helmets, and intimate apparel.
COLLABORATIVE CARE
Nursing Care
The nurse must stress that everyone in the family needs to be treated and that it is essential not to
share hairbrushes or bath towels. Specifically, with tinea capitis, the affected area of hair growth may
take 6 to 12 months to grow or may not grow back at all. The nurse can provide emotional support and
suggest hairstyles to help conceal tinea capitis.
Medical Care
Topical or systemic antifungal drugs are often effective therapies. Most superficial cutaneous
dermatophyte infections can be managed with topical therapy with agents such as azoles, allylamines,
butenafine, ciclopirox, and tolnaftate (Table 22-3). Nystatin, an effective treatment for Candida
infections, is not effective for dermatophytes (Goldstein & Goldstein, 2019). Oral treatment with agents
such as terbinafine, itraconazole, fluconazole, and griseofulvin is used for extensive or refractory
cutaneous infections, and patients should not be treated with oral ketoconazole because of risk for
severe liver injury, adrenal insufficiency, and drug interactions (Goldstein & Goldstein, 2019).
TABLE 22-3
Topical Treatments
CLASSIFICATION NAMES PRECAUTIONS
Anesthetics benzocaine (Americaine) Allergy
lidocaine and prilocaine (EMLA) Do not use over wounds
Do not use over large areas: avoid the eyes
Antibacterial bacitracin and polymyxin B (AK-Poly-Bac) Allergy
neomycin (Myciguent) Existing infection (for prevention of infection)
mupirocin (Bactroban) Antibiotic resistance
Use for only minor cuts/scrapes/burns
Antifungal clotrimazole (Lotrimin) Cautious use in nail and scalp infections
ketoconazole (Nizoral) miconazole (Aloe Vesta)
nystatin (Mycostatin)
Anti-itch diphenhydramine (Benadryl) Allergy
Photosensitivity
Emollients White petrolatum jelly Allergy
Mineral oil Choose fragrance-free products
Lanolin
Glycerin
Steroids Varying strengths Allergy
Strongest group I: betamethasone (Diprolene) Repeated use in the same area of the skin will
Group II: dexamethasone (Decadron) cause thinning of the skin and may inhibit the
Group III: triamcinolone 0.5% (Kenalog) skin’s ability to fight infection
Group IV: fluocinolone (Lidex) The lowest strength on the thin skin of the face
Group V: hydrocortisone 0.2% (A-Hydrocort) and genitalia is used
Group VI: desonide (Tridesilon) Avoid the eye area: places the patient at risk for
Group VII: hydrocortisone 1% (A-Hydrocort) glaucoma or cataract formation
Source:Vallerand, A. H., & Sanoski, C. A. (2021). Davis’s drug guide for nurses (17th ed.). Philadelphia, PA: F.A. Davis.
The child is checked periodically throughout treatment to be sure a proper response is noted. The
nurse must stress the importance of completing the recommended treatment even after the lesions
appear to be cleared. For treatment of tinea pedis, education should include wearing light-weight dry
socks, well-ventilated shoes, and adequate cleaning of shower areas to prevent spread of the infection.
HYPERSENSITIVE SKIN REACTIONS

Eczema and Dermatitis
The terms “dermatitis” and “eczema” are frequently used interchangeably. When the term “eczema” is
used alone, it usually refers to atopic dermatitis (atopic eczema). “Eczematous” also connotes some
scaling, crusting, or serous oozing as opposed to mere erythema. The term “dermatitis” is typically used
to describe several different skin disorders. Specific types of eczematous dermatitis are more common
in some age groups. As an example, atopic dermatitis is far more common in children than in adults.
There are three common classifications of dermatitis in children: atopic, contact, and seborrheic.
Atopic Dermatitis
Atopic dermatitis is often described as “the itch that scratches” with pruritis as a classic clinical
characteristic. This chronic skin condition has three distinct phases (acute, subacute, and chronic) with
no known etiology (Weston & Howe, 2019). This condition has a genetic basis and is the most common
type of eczema. Atopic dermatitis tends to begin early in life in those with a predisposition to allergies.
Characteristically, rashes occur on the head, face (especially the cheeks), neck, elbow and knee
creases, and ankles in infants (Fig. 22-8). In the older child, the rash presents in the folds of the arms
and legs and occasionally on the eyelids and neck.
This condition is found in children with allergies and/or a family history of allergies, asthma, and
rhinitis. Approximately 50% of persons with atopic dermatitis present in the first year of life and an
additional 30% in the years between ages 1 and 5 (Weston & Howe, 2019). Although the etiology may
be genetic, the child may also have immunological impairment. It is also possible for the etiology to be
environmental in nature (e.g., pollution, indoor allergens such as cigarette smoke, or infections).
SIGNS AND SYMPTOMS
The child with atopic dermatitis has a red, raised rash that is pruritic and may cause some discomfort
or pain.
DIAGNOSIS
A complete family history and visual assessment of the child reveals the common signs of this
condition. Blood tests reveal an increase in circulating IgE antibodies.
FIGURE 22-8 Atopic dermatitis.

PREVENTION
The priority preventive measure is stopping a secondary infection, which can be accomplished with
good skin care and close monitoring. When a child has atopic dermatitis, prevention of secondary
infection is very important and requires adhering to good hygiene processes, following prescribed
treatment protocols, and maintaining skin hydration.
NURSING CARE
Close and frequent monitoring and assessment of the rash is an important nursing care measure.
Warm, not hot, bathing water will decrease irritation. Encourage the adolescent to keep the water a bit
cooler, avoid excessive scrubbing with exfoliating scrubs and cloths, and pat dry. Moisturizing
immediately after bathing with emollients, such as Cetaphil Moisturizing Cream® or Eucerin®, locks in
moisture and decreases dry, flaky, or itchy skin (National Eczema Organization, 2019).
Nurses need to reinforce gentle cleansing and the use of tepid to slightly warm water for bathing as
well as use of appropriate emollients. Encourage patients to practice itch-scratch avoidance and to keep
fingernails trimmed short with no sharp edges. Teach parents the signs and symptoms of secondary
infection including a fever remaining above 101.5°F (38.6°C) or evidence of red, painful, pus-filled
lesions.
Contact Dermatitis
Contact dermatitis can occur after contact with an allergen or skin irritant. In children, the irritant agents
that cause this type of skin sensitivity are often soaps or detergents with fragrances or dyes. For infants,
the diaper area is especially prone. Diaper dermatitis is one form of irritant contact dermatitis and can be
caused by prolonged exposure to urine and feces. It is characterized by an erythematous, confluent
maculopapular rash that is prominent on convex surfaces and in the folds. Children playing outdoors
may encounter plant life that can cause contact dermatitis, such as poison oak, ivy, or sumac.
SIGNS AND SYMPTOMS
Signs and symptoms of contact dermatitis include:
■ Irritated, inflamed, and pruritic rash within 48 hours of contact with the offending agent
■ Vesicles and bullae may be present in the area
■ Urticaria (hives) when there is contact with an allergen
■ Vesicles that may weep serous fluid
DIAGNOSIS
A complete history of both indoor and outdoor exposures for a child presenting with a rash helps
determine diagnosis. If a differential diagnosis is required because of atypical lesions, a biopsy may be
performed. Vesicular lesions that present in children may also include varicella and impetigo. These
etiologies are ruled out before a diagnosis of contact dermatitis is considered.
Patch Testing
If the offending agent is not easily determined, an allergist may be an appropriate referral to determine if allergic contact
dermatitis is the diagnosis. One method of determining an allergy is by completing patch testing. The allergist prepares
the proper concentration of allergens in a paraffin base and places this on the child’s skin, usually the back, holding it in
place with hypoallergenic tape (Fig. 22-9).
FIGURE 22-9 Child receiving allergy patch testing.
PREVENTION
Children entering weedy or wooded areas should wear long sleeves, long pants, and socks to prevent
contact with poisonous plants. Strict avoidance of known allergens in the home, including soaps and
fragrances, will decrease the incidence of allergic contact dermatitis. Prevention of irritant contact
dermatitis is avoidance of known substances that have resulted in rash and, for infants, frequent diaper
changes.
NURSING CARE
Nursing care of diaper dermatitis is aimed at allowing the area to heal in an environment of minimal
moisture. This can be accomplished by frequent diaper changes, allowing the area to air dry, and the
use of barrier ointments that include white petrolatum or zinc oxide.
Seborrheic Dermatitis
Seborrheic dermatitis (Fig. 22-10) is a self-limiting eruption consisting of erythematous plaques with
greasy-looking, yellowish scales distributed on areas rich in sebaceous glands such as the scalp, the
external ear, the center of the face, and the intertriginous areas (Weston & Howe, 2019). While
seborrheic dermatitis can occur in infants, children, and adolescents, it most commonly occurs in infants
between the ages of 3 weeks and 12 months. The prevalence of SD peaks at the age of three months
(about 70%) and decreases steadily in the following months to about 7% of children still affected by age
2 (Weston & Howe, 2019).
SIGNS AND SYMPTOMS
Signs and symptoms of seborrheic dermatitis include:
■ Red to pink patches
■ Loose yellow, greasy scales
The rash usually appears on the face, the cheek bones, and the nasolabial folds as well as behind the
ears. It can also be found on the scalp, in the eyebrows, and on the upper chest and upper back.
DIAGNOSIS
The child who is diagnosed with seborrheic dermatitis has the defined rash. The nurse understands
that the particular look of the rash differentiates it from other conditions such as lupus, rosacea, and
atopic or contact dermatitis.
PREVENTION
If a child has had seborrheic dermatitis in the past and it clears, it can be prevented by preemptive
treatment. Daily or at least three times a week, an antiseborrheic shampoo can be used to cleanse the
area of skin that is prone to breakout.
FIGURE 22-10 Seborrheic dermatitis (cradle cap).
COLLABORATIVE CARE
Nursing Care
The initial treatment of scalp seborrheic dermatitis includes education, reassurance, and conservative
measures (emollients and frequent shampooing) to soften and remove the scales. Some
nonpharmacologic interventions include massaging baby oil or olive oil into the baby’s scalp to gently
loosen and remove the scales.
Medical Care
For more severe cases of seborrheic dermatitis, a health-care provider may order topical
corticosteroids. If conservative measures fail, we suggest either topical low-potency corticosteroids or
ketoconazole 2% shampoo or cream with the addition of an antifungal cream if the scales appear fungal
in nature (Weston & Howe, 2019). It is important to educate parents that this skin condition (even with
treatment) can recur several times before resolving.
FOCUS ON SAFETY
EpiPen®
The EpiPen Jr.® autoinjector is used for children experiencing a life-threatening reaction. An injection of 0.15 mg of
epinephrine (Adrenalin) is used for children up to 33 lb (15 kg), and an injection of 0.3 mg is used for older children and
adults. If a severe allergic reaction occurs, the medication is administered by IM injection immediately. Be sure to check
the expiration date on the EpiPen® or EpiPen Jr.®
The nurse communicates to the child and family that it is important to know the offending allergen and
that it can be introduced into the system through ingestion, inhalation, or coming into direct contact.
Reinforcing the signs and symptoms of the allergic response as well as emergency treatment is
essential information for the child and family.
INFESTATIONS
Pediculosis Capitis
Pediculosis capitis, head lice, is a common childhood condition that can be passed among friends and
family. Approximately 6 to 12 million school-aged children are infested yearly. There are three kinds of
lice: scalp (pediculosis capitis), body (pediculosis corporis), and pubic area (pediculosis pubis). The lice
pierce the skin and suck blood. The bites can cause severe itching and can predispose the child to a
secondary infection.
Signs and Symptoms

Signs and symptoms of pediculosis include:
■ Live lice
■ Tend to live near the nape of the neck and behind the ears
■ Louse eggs (nits)
■ Can be found anywhere along the shaft of the hair; the older the nits are, the more distal
■ Pearlescent teardrop in shape, initially laid at the base of the hair shaft
■ Fluoresce blue under a Wood’s lamp
Diagnosis
For lice, the clinical presentation and identification of the louse and/or its eggs is important. Persistent
itching of the head is the classic sign.
Prevention
To prevent lice, all children must avoid the use of one another’s combs, barrettes, hats, and headbands.
Children who are involved in sports may pick up lice in batting helmets and other protective headgear
that is shared. These fomites can easily carry lice from child to child.
In the home or school setting, children with active lice need treatment and the environment should be
treated as well. All associated persons affected by lice are also treated.
Collaborative Care
NURSING CARE
The nurse educates the family about over-the-counter lice treatments that may be helpful in the care
of lice. The nurse can explain to the child and family that anyone can get lice if in close proximity to
others who happen to have it. Lice are common in school-age children, and there is no need for
embarrassment. Guide the parents to resolution through treatment.
MEDICAL CARE
Over-the-counter lice treatments may be helpful. Types of pediculicide treatments include pyrethroids,
such as permethrin (Nix) and malathion (Ovide), and antiparasitics, including benzyl alcohol (Ulesfia),
lindane (Kwell), spinosad (Natroba), and ivermectin (Stromectol). Ivermectin is used orally in hard-to-
manage cases of head lice. Malathion (Ovide) is recommended for children older than 2, and benzyl
alcohol is not recommended for children younger than 6 months. Permethrin (Nix) is not recommended
for infants under 2 months of age, and spinosad has not been proven safe in children younger than age
4.
What to Say
Pediculosis
When parents inquire about lice, the nurse:
• Asks family members if there is a recent history of another family member with infestation.
• Asks the school nurse or day-care provider about recent lice infestation in that setting.
• Communicates that a “nit check” of each individual will help the family members determine who needs treatment.
• Reminds family members and friends that they may acquire lice from the affected child.
The nurse instructs the family to wash the hair according to the product’s instructions. If a child is unable
to tolerate these shampoos, former remedies including the use of asphyxiants like petrolatum and food
oils (e.g., olive oil) can be used. Once the shampoo is rinsed from the hair, remove nits by backcombing
with a fine-tooth comb while the hair is still wet (nits are easier to remove when the hair is damp).
The nurse stresses to the caregiver to implement house-cleaning (e.g., dust, vacuum, and scrub);
wash clothing and bedding; and wipe off hats, helmets, and toys. If a soft or cloth toy like a stuffed
animal is not washable, it must be bagged in a sealed plastic bag and away from family members’
rooms for 14 days. Launder all bed linens in hot water. Pillows are washed if possible or thrown away if
used by the child to avoid reinfestation. Antilice sprays can be used for furniture and other
environmental objects that are not disposable, but the most important cleaning step is vacuuming. Hair
care items can be boiled (hot water above 140°F) or soaked in antilice shampoo and never shared.
The nurse instructs the family member to remove nits from eyelashes by applying petrolatum jelly to
the eyelashes twice a day for 8 days. The family member can check the school’s antilice policy; children
must remain home from school until lice-free. The child may be required to be checked by the school
nurse or day-care provider before returning. Tell the family member that the child should be rechecked
for infestation in 7 to 10 days, sooner if they are scratching incessantly or the itching is interfering with
sleep.
Patient Education
Pediculosis
TOPIC: The nurse will discuss how to prevent the spread of pediculosis
• Assess for lice using good lighting and examining the child’s head to identify both live lice (very small and brown or
black) and nits.
• Separate sections of the hair, paying particularly attention to the area behind the ears and the nape of the neck.
• Teach the family member that this dandruff-like appearance cannot be easily removed by combing because of the sticky
adherence of the nit.
• Wet-combing hair moistened with water and food oil (e.g., olive oil) is very effective and safe in small children and may
preclude the need for a medicated shampoo. Parents can use a nit comb to carefully comb the hair in its entirety while
removing live lice and nits and disposing of them in a sealed plastic bag.
Scabies
Scabies results from a mite infestation with Sarcoptes scabiei. Children with a weakened immune
system are at increased risk. Scabies is transmitted by close personal contact with an infected person
and is more common in persons who live in crowded conditions or share a bed. The scabies mite
burrows under the epidermis layer of the skin, laying eggs and fecal matter that causes irritation and
severe itching. The burrows appear as small black lines under the skin on physical examination.
Scabies mite cannot survive for more than 3 days away from the skin.
Mite infestation is highly transferable, and although children of all ages are affected, it is most
commonly seen in children younger than 2. The classic clinical feature of scabies is pruritus. It is often
severe and usually worse at night. Pruritus results from a delayed hypersensitivity reaction to the mite,
mite feces, and mite eggs (Goldstein & Goldstein, 2019).
Typical cutaneous findings are multiple small, erythematous papules, often excoriated (Fig. 22-11).
Burrows may be visible as 2 to 15 mm, thin, gray, red, or brown, serpiginous lines (Goldstein &
Goldstein, 2019). Burrows are a characteristic finding but often are not visible due to excoriation or
secondary infection. Miniature wheals, vesicles, pustules, and, rarely, bullae also may be present.
Signs and Symptoms

Signs and symptoms of mite infestation may include:
■ Sides and webs of the fingers
■ Flexor aspects of the wrists
■ Extensor aspects of the elbows
■ Anterior and posterior axillary folds
■ Periareolar skin (especially in women)
■ Periumbilical skin
■ Waist
■ Male genitalia (scrotum, penile shaft, and glans)
■ Extensor surface of the knees
■ Lower buttocks and adjacent thighs
■ Lateral and posterior aspects of the feet (Goldstein & Goldstein, 2019)
NURSING INSIGHT
Mite Infestation
In this condition, the female arachnid mite burrows into the outer layer of the epidermis and lays her eggs, leaving a trail
of debris and feces (scybala). The larvae hatch in approximately 2 to 5 days and proceed to the surface of the skin. This
cycle repeats every 7 to 14 days. The original mite dies in the burrow after 4 to 5 weeks. The scabies rash is red-streaked
and appears linear from the burrowing. The mites, eggs, and their excrement can cause intense itching, especially at
night. There are also signs of papules that are a result of inflammation secondary to infestation.
FIGURE 22-11 Image of a mite.
Assessment Tools
Checking for Scabies
In assessing for scabies, it is essential to check all pruritic areas for the primary burrows and secondary inflammatory
papules (raised, circumscribed lesions). A skin scraping may be viewed under the microscope for evidence of the mite,
eggs, or feces. As an alternate assessment tool, the nurse can use clear adhesive tape (wrapping or packing tape), apply
to the area of the linear rash, press firmly, and then lift away. Place the adhesive tape on a slide and evaluate under
microscopy.
Prevention
Do not share a bed, clothing, or intimate touch with a person who has scabies. Children should avoid
sleeping in the same bed as a parent or sibling with scabies. Even if only one member of the family has
scabies, the entire family is treated.
Nursing Care
The nurse teaches the family how to use the medication after a bath and what to look for in the case of
minor skin irritation. Furthermore, the nurse reminds the parents that a dishwasher with no other
contents can be used to clean washable toys and hair items. Treating clothing, bedding, towels, and
cloth toys by washing them in hot water and then placing them in the dryer is necessary to kill scabies.
Permethrin 5% cream (Elimite) is approved for infants over 2 months of age.
BITES AND STINGS

Insects
The most common insect bite comes from the mosquito. Spider and tick bites are also prevalent among
children. The stings experienced most frequently are from bees, wasps, and hornets, and in some parts
of the United States, scorpions. Other insects are also likely to bite, such as some types of flies, fleas,
and fire ants.
Signs and Symptoms

Mosquito bite:
■ Red, edematous papule
■ Pruritic
■ Burning pain
Spider bite (e.g., widows, false black widows, and brown recluse):
■ Red, edematous papule, wheal, or pustule, often solitary
■ Pruritic
■ Pain: mild to severe
■ Local necrosis and systemic symptoms (rare) Tick bite:
■ Small reddish area that may be raised
■ Sometimes pruritic
■ Tick may still be attached
■ Systemic symptoms associated with related diseases, including Rocky Mountain spotted fever and
Lyme disease
Bee, wasp, or hornet sting:
■ Red, edematous papule
■ Pain at the time of the sting
■ If the reaction is systemic:
■ Generalized urticaria (hives)
■ Flushing
■ Angioedema with wheezing (rare)
NURSING INSIGHT
Brown Recluse and Black Widow Spider Bites
The bite of the brown recluse spider begins with itching, pain, and erythema. The venomous sting advances into a purple
lesion that signals the beginning of necrosis. The site becomes red with blisters, develops a white ring, and is surrounded
by irregular erythematous. The black widow spider’s bite leaves a stinging sensation at the time of the bite along with two
fang bite marks, edema, petechiae, and erythema. The neurotoxin is usually self-limiting but can result in a more severe
anaphylactic reaction. A systemic reaction from the neurotoxic venom can occur in 1 to 3 hours, with symptoms peaking
in 3 hours and then diminishing in 72 hours. A systemic reaction includes muscle rigidity of the abdomen and torso,
muscle cramps near the bite, malaise, sweating, dizziness, restlessness, insomnia, nausea and vomiting, hypertension,
arrhythmias, and oliguria (low urine output).
Diagnosis
Diagnosis of insect bites and stings is based on the child’s history and physical findings.
Prevention
To protect against insect bites and stings when spending time outdoors, the nurse can stress that
children and adolescents should wear light-colored clothing with minimal patterns, wear minimal
perfumes or colognes, and cover the skin whenever possible. Mosquitoes bite more in the dusk and
darkness; protecting the child with bug repellent after sundown will decrease the incidence of bites. Do
not play in areas of dead foliage where spiders like to nest. Children should not play in live, blooming
foliage to avoid bee stings. Playing in wooded areas is OK, but doing a thorough tick inspection upon re-
entering the home is absolutely necessary (CDC, 2019).
Nursing Care
All bites must be cleansed gently with soap and water and patted dry. Monitor bites for signs and
symptoms of infection from the vector (e.g., insect or arachnid) and from secondary infection caused by
scratching the bite site.
Specific care measures for mosquito bites and therefore mosquito-borne illnesses are the use of bug
repellent sprays applied sparingly to the child’s clothing to help decrease bites and therefore lower the
risk for contracting West Nile virus, a significant mosquito-borne illness in the United States today. DEET
is effective against mosquitoes, biting flies, chiggers, fleas, and ticks. DEET, a common ingredient in
most bug repellents, has been in use for over 70 years and is considered the “gold standard” of insect
repellents (CDC, 2020). Two new repellents are oil of lemon eucalyptus or PMD (Repel) and picaridin
(KBR 3023) (Cutter Advanced Insect Repellent), easily found in local stores that carry brand-name bug
repellent sprays (CDC, 2019).
The first step is to remove all ticks immediately and properly. The nurse must remember to tell parents
to remove a tick, grasping it firmly with fine-point tweezers where the mouth part is attached. Pulling
gently is important to avoid squeezing of the tick’s body and leaving parts of the insect in the child’s
body. The nurse explains to the parents to save the intact tick in a sealable bag in the freezer with the
date of the bite recorded (in case the tick needs to be tested for disease). Stingers from bees, wasps,
and hornets are removed immediately; they will come out in one piece with a single tug or scrape. When
the stinger is injected, the venom is already in the skin; however, the stinger can cause more irritation
and pain and possibly a deep “foreign body” reaction if not removed immediately. After removal of any
vector, cleanse the area with soap and water and pat dry.
Lyme Disease
Lyme disease, a tick-borne infection caused by an inflammatory response to the spirochete Borrelia
burgdorferi, is the most common vector-borne disease in the United States. Exposure to Lyme disease
can occur in any outdoor setting where ticks are endemic. The tick bite is often found on the head and
neck, back, arms, or legs. Animals such as dogs and cats can also have the disease. Lyme disease
occurs year-round, with the highest incidence of infection in the summer. Children between 5 and 14
years of age are at highest risk because of outdoor activities. Infection does not induce immunity. It
takes 48 hours after contact with a human to introduce the spirochete into the feeding site where the tick
has buried its head. Any rash that appears before 48 hours is an allergic reaction or infection, not Lyme
disease. The infection is not contagious from person to person.
Signs and Symptoms

Lyme disease presents in three stages:
Early localized disease (3–30 days after bite)
■ Red macule at the bite site
■ Bulls-eye rash with a central macule and surrounding clear area, then an expanding rash (5–50 cm in
circumference)
■ Possible systemic symptoms
■ Fatigue, headache, arthralgia (joint pain), neck pain, fever, and myalgia (muscle pain) (listed in order
of prevalence)
Early disseminated disease (2 weeks after bite until chronic symptoms develop)
■ Expands as a red, roundish, flat, nonpruritic, and nonvesicular (erythema migrans) rash; this is the
most common manifestation of this stage
■ Fatigue, headache, arthralgia (joint pain), and fever become more common
■ Possible cranial nerve palsy, especially facial nerve palsy (bilateral facial nerve palsy is
pathognomonic for Lyme [characteristic for specific disease])
■ Meningitis (1% of affected children)
■ Carditis (less than 1% of affected children)
■ 90% will have positive serological conversion in this stage
Late disease (weeks to months after the initial bite)
■ Arthritis, lasting up to many years but not considered chronic

■ Singular joint at a time, migrates from joint to joint, typically larger joints and primarily the knee(s)
■ Swollen and tender, rarely erythematous
■ Can bear weight but is uncomfortable
Diagnosis
Diagnosis is determined by physical and history; incidence of tick bite may or may not be reported. Labs
can confirm Lyme disease. Lab testing is not appropriate in the child who presents with erythema
migrans and lives in or has just visited an area where Lyme disease is endemic. That child should be
treated presumptively for Lyme disease.
Labs
Immunoassay
Lab testing is performed to determine if Lyme disease is present. The enzyme-linked immunosorbent assay (ELISA) is
performed with follow-up of positive results with the Western blot for confirmation (CDC, 2020). The ELISA method may
provide a false-positive result because of cross-reactive antibodies to other spirochetal infections. Seroconversion takes
at least 6 weeks in Lyme disease, so the child is treated symptomatically while waiting for lab confirmation. The child will
have specific IgM antibodies that will appear first at 3 to 4 weeks, peak at 6 to 8 weeks, and then decline. The IgG
antibodies appear at 6 to 8 weeks.
Prevention
Avoiding play in wooded areas or using precautions in such environments will decrease the incidence of
Lyme disease. Children can dress in long sleeves and long pants when in wooded areas; DEET spray is
used when age-appropriate. At the end of the day of play (preferably within 2 hours), a shower or bath
should be taken, followed by a tick check from scalp to toes. Clothing and other worn items are put in
the clothes washer to avoid live ticks from roaming into the home. Pets can be combed and have tick
collars or skin treatments as an added protection.
Collaborative Care
NURSING CARE
During the history and physical, the nurse asks the family member if there has been an occurrence of
a tick bite.
MEDICAL CARE
A 2-week course of oral antibiotics is given if infection is suspected. Amoxicillin (Amoxil) or cefuroxime
(Ceftin) are the most often used antibiotics in children 8 or younger; however, the American Academy of
Pediatrics recommends the use of Doxycycline (Vibramycin) or Tetracycline (Sumycin) in children less
than 8 years of age for up to 21 days of treatment. Otherwise, use of these antibiotics is reserved for
children over 8 years of age due to the risk of staining teeth enamel. If recurrent arthritis, central nervous
system complications, or carditis occurs, treatment lasts for 4 weeks with IV ceftriaxone (Rocephin),
cefotaxime (Claforan), or penicillin G (Bicillin L-A).
Teaching methods of tick bite prevention is invaluable. If the child is treated for Lyme disease, whether
presumptively or because of positive lab tests, the nurse reinforces the proper use of antibiotics,
including compliance. Furthermore, the nurse reminds the family of follow-up appointments with the
Rocky Mountain Spotted Fever

Rocky Mountain spotted fever (RMSF) is a multisystem disease that can be mild, moderate, or severe.
The onset can be either gradual or sudden. The greatest risk of mortality is to the child younger than 4
or who presents late in the illness or without the characteristic rash (CDC, 2019). Some ticks, such as
the American dog tick and the Rocky Mountain wood tick, harbor the organism Rickettsia rickettsii that
can be transmitted to the human host after a tick bite.
RMSF is one of the spotted fever rickettsioses with the highest incidence in the contiguous states of
North Carolina, Oklahoma, Arkansas, Tennessee, and Missouri (CDC, 2019). It typically begins with a
fever and headache, followed a few days later by the development of a rash. The rash is generally
made up of small spots of bleeding and starts on the wrists and ankles. The death rate overall for RMSF
is 23% if untreated and less than 5% if treatment ensues early in the disease process (CDC, 2019). The
peak pediatric age for RMSF is 5 to 9 years of age; however, the majority of those affected are ages 50
to 60. Those at highest risk include males, Native Americans, and persons living in wooded areas (CDC,
2019). The incubation period lasts 2 to 14 days after the bite of an infected tick; most people will be
symptomatic on days 5 to 7.
Signs and Symptoms

Signs and symptoms of RMSF include:
■ At onset, fever, headache (severe), malaise, myalgias (muscle pain), arthralgia (joint pain), and
nausea with or without vomiting
■ Severe abdominal pain that mimics appendicitis pain (greater than 60% of children)
■ Edema
■ Rash
■ Develops between days 3 and 5 of the disease (10% to 20% of patients will not have a rash)
■ Begins on the wrists and ankles and spreads centrally and out to the palms and soles
■ Macular/papular but may become petechial
■ No urticaria (hives)
■ Nonpruritic
■ Difficult to visualize in darker-skinned individuals
Diagnosis
Diagnosis of RMSF is based on the classic triad of presenting symptoms, which include rash, fever, and
history of a tick bite. Often symptoms are vague and particularly difficult to diagnose if the child or
parents do not recall a tick bite. The nurse asks questions about the child’s history: outdoor play, playing
with animals, and appearance of a singular macule/papule that may have been the original tick bite site.
A nonspecific rash with fever and a poor history will lead to laboratory testing.
Prevention
Instruct parents children to avoid playing in wooded areas or to use precautions when in this type of
environment; children can dress in long sleeves and long pants when in wooded areas. DEET spray can
be used when age-appropriate. At the end of the day of play (preferably within 2 hours), the child should
take a shower or bath, followed by a tick check from scalp to toes. Clothing and other worn items are
placed in the clothes washer right away to keep live ticks from entering the home. Pets should be
combed and given tick prevention collars or treatments for added protection.
Labs
Complete Blood Count and Comprehensive Metabolic Panel
The nurse can expect a positive immunofluorescence assay (IFA) and elevations in white blood cell (WBC) count,
thrombocytopenia (low platelets), and hyponatremia (a decreased concentration of sodium in the blood). This sodium
imbalance is responsible for the edema seen in children. There may also be elevated liver enzymes. The child’s WBCs
will likely remain low in the early stage and rise to slightly abnormal in later stages.
WBCs: 5,000 to 10,000/mm3; Later stage: 10,000 to 12,000/mm3
Platelets: 150,000 to 400,000/mm3; Thrombocytopenia less than 150,000/mm3
Na: 136 to 145 mEq/L; Hyponatremia 136 mEq/L
Bilirubin (total): 0.3 to 1.0 mg/dL; Hyperbilirubinemia 1.0 mg/dL
Collaborative Care
NURSING CARE
The nurse communicates to the family that treatment will begin based on clinical symptoms and
epidemiology. Teaching about the medication regimen will assist the family in adherence. Teaching
about the typical course of the illness and expectations for return to wellness and full functioning will
alleviate child and family fears.
MEDICAL CARE
Doxycycline is the treatment of choice for RMSF and all rickettsial infections for children of all ages
(CDC, 2020). If treated in the first 5 days with doxycycline, people with RMSF typically recover. Those
treated after day 5 may experience a more severe illness requiring hospitalization or intensive care unit.
If left untreated, long-term sequelae can include damage to blood vessels throughout the body leading
to organ and tissue damage. Supportive therapy for other symptoms resulting from RMSF may include
antipyretics, anti-inflammatory medication, and IV fluids.
Time for recovery must be allowed after RMSF. Usually, a child can return to school, but time for rest
must be allowed during and after the school day. The family may need to work with the school system to
allow for limited hours and the ability to complete work at home. Sports and other activities can be
resumed as the child begins to tolerate normal activity levels. Monitoring the child’s stamina even more
closely is warranted if they were very ill and/or had prolonged hospitalization.
Cat Scratch Disease

Cat scratch disease (CSD) is a self-limiting illness lasting 6 to 12 weeks that begins with a scratch or
bite from a cat (CDC, 2020). Approximately 40% of domestic cats are reservoirs for the bacillus
Rochalimaea henselae, which causes the disease response in humans.
Signs and Symptoms

Signs and symptoms of CSD include:
■ Tender lymphadenopathy (swollen lymph nodes) of the head, neck, and/or upper limbs
■ General malaise and low-grade fever
■ Headache
■ Papule at site of original bite or scratch
Symptoms manifest 3 to 10 days after injury and take between 6 and 12 weeks to resolve.
Diagnosis
A history of a cat scratch and the physical findings are used to diagnose CSD. If there is concern about
a differential diagnosis, laboratory studies may be ordered.
Prevention
To prevent CSD, parents should discourage rough play with cats and kittens. If a cat bite or scratch does
occur, wash the wound immediately in warm soapy water. Do not let the cat or child lick open wounds.
Keep wounds covered if the child cannot protect the cuts from the animal.
Nursing Care
Communication to the family includes prevention techniques and the antibiotic regimen that has been
prescribed. Other treatments and care are not typically indicated, but good hand hygiene and wound
management are indicated.
Encourage the parents to monitor the scratch site for changes that might indicate worsening infection.
Increased redness, swelling, pain, and fever (temperature greater than 101.5°F [38.6°C]) warrant a
return to the health-care provider.
BURNS
The skin is the largest organ in the body. Its epidermal layer protects the body from infection, regulates
body temperature, prevents fluid losses, helps with sensory function, manufactures vitamin D, and plays
a role in body image determination. The dermal layer provides elasticity and durability to the skin. A burn
injury interrupts each of these normal processes. Some children are at higher risk for burns because of
their environment, their behavior, and their age. Burns are a result of either thermal, radiation, chemical,
or electrical insult.
Child Development and Burn Injuries

Because children develop in a predictable time frame, they are at risk for certain types of burn injuries at
certain ages and developmental stages. Infant growth involves increasing gross motor and fine motor
development. The infant is able to do things one day that they could not do the day before. In addition,
the infant is becoming mobile, which increases the risk for danger. Typically burn injuries seen in infants
are:
■ A scald from reaching for items, like coffee, tea, or hot oil from deep fat fryers
■ A scald from being placed in a bathtub, basin, or pan of water hotter than 120°F (48.9°C) (National
Fire Protection Association [NFPA], 2020)
■ A radiation burn from touching hot objects like a wood stove
■ An electrical cord burn to the mouth from chewing on electrical cord that was plugged into the wall
■ A flame and/or inhalation burn from a house fire
Toddler growth involves separating from the parents and finding independence. The infant freely
explores the environment and observes parental behavior, copying it without knowing dangerous
consequences. Typical burn injuries seen in toddlers are:
■ A scald burn from pulling down hot items from tall surfaces
■ A scald burn from attempting to turn on the bathtub faucet
■ A flame burn from attempting to ignite a match or lighter
■ A flame and/or an inhalation burn from a house fire
■ A radiation burn from touching hot appliances like curling irons
■ An electrical cord burn to the mouth from chewing an electrical cord that was plugged into the wall
Preschool child growth involves increased mobility and independence. The preschooler becomes
inventive and uses magical thinking in daily activities. Typically burn injuries in preschoolers are:
■ A scald burn may happen when running into the kitchen and getting in the way while a parent is
cooking
■ A radiation burn from touching hot appliances like a stove burner
■ An electrical burn from playing with an electrical cord that had a frayed wire
■ A radiation burn from touching hot appliances like a clothing iron
■ A flame burn from trying to ignite a lighter or a match
■ A flame and/or an inhalation burn from a house fire
School-age children and adolescents have more freedom and access to adult items. This age group
may use their independence to cook, light candles, and investigate situations without thinking about the
danger. Typical burn injuries in school-aged children and adolescents include:
■ A scald burn from cooking in the microwave, stove, or oven
■ A flame burn from trying to ignite a lighter or a match
■ A chemical burn from experimentation with chemical agents
■ An electrical burn from climbing trees where electrical power lines of 14,000 volts or more are passing
through the tree
FOCUS ON SAFETY
Burn Prevention
The nurse is instrumental in helping to prevent burn injuries in children of all ages. Prevention of burn injuries is included
when discussing anticipatory guidance during the well-child visit. School nurses can teach burn prevention as part of
health education during National Burn Awareness Week (CDC, 2019) in February and National Fire Prevention Week in
October (NFPA, 2020).
Education for parents includes a discussion about smoke detectors installed in every sleeping room, outside each
separate sleeping area, and on every level of the home, including the basement. For the best protection, the alarms
should be interconnected using wireless battery-operated smoke detectors. Batteries on smoke detectors should be
checked monthly by pushing the test button and changed at least once per year (NFPA, 2020). Water heaters are set no
higher than 120°F (48.9°C) and should deliver shower or bath water at no higher than 100°F (37.8°C). Pot handles on
the stove are turned in so they cannot be knocked or grabbed by curious children, and appliance cords are kept away
from the edges of counters. Hot foods and liquids are also kept away from the edges of the table or counter-tops.
Cigarettes, lighters, matches, and lit candles are kept out of reach of small children.
Burn Centers
Burn centers treat both adult and pediatric patients. Patients with burn injuries are referred to a verified burn center based
on these criteria for transfer from the American Burn Association (ABA, 2019):
• Partial-thickness burns of greater than 10% of the total body surface area
• Burns that involve the face, hands, feet, genitalia, perineum, or major joints
• Electrical burns, including lightning injury
• Chemical burns
• Inhalation injury
• Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect
mortality
• Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of
morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient’s condition may be
stabilized initially in a trauma center before transfer to a burn center. Physician judgment will be necessary in such
situations and should be in concert with the regional medical control plan and triage protocols.
• Burned children in hospitals without qualified personnel or equipment for the care of children
• Burn injury in patients who will require special social, emotional, or rehabilitative intervention
Burn Severity
Three factors—type of burn, depth of burn, and size and extent of the burn—determine the burn
severity.
Type of Burn
There are four major types of burn injury: thermal, radiation, chemical, and electrical. The classifications
are described as follows.
■ Thermal burns are the most common type of burn in childhood and occur as a result of contact with a
flame, flash, or scald.
■ Flame burns occur from the ignition of combustible materials and contact with fire, fireworks,
candles, and campfires.
■ Flash burns are caused by explosions, especially with combustible fuels like gasoline, kerosene,
charcoal lighter, fireworks, or hairspray.
■ Scald burns occur when hot liquid is spilled on a child (e.g., oil, grease, coffee, hot tea, or soup),
from hot tap water in sinks and bathtubs, or from steam.
■ Contact burns are caused by exposure to a hot object like an oven, hot iron, radiator, hot light bulb,
or other heating device.
■ Radiation burns occur when the skin of the child comes in contact with radiofrequency or ionizing
agents. The most common radiation burn injury is sunburn. However, cancer patients undergoing
radiation therapy can also suffer a radiation burn. Another form of radiation burn is exposure to
radioactive material as with a nuclear plant meltdown.
■ Chemical burns occur when the skin comes in contact with a chemical agent that is corrosive to the
skin. Acids like sulfuric acid and muriatic acid are caustic to the skin. Alkaline agents like lye, lime,
ammonia, and household cleaning agents are also caustic to the skin and cause injury.
■ Electrical burns occur when electricity passes through or around the body as it seeks the fastest path
of least resistance to the ground. Household current of 110 volts can cause a full-thickness burn injury
to the corner of the mouth. Electrical lines that carry electricity throughout towns and cities typically
carry 14,800 volts. High-tension wires can carry as much as 150,000 volts. Lightning can have
between 10 and 100 million volts.
Depth of Burn
Depth of burn injury is another factor that is assessed (Fig. 22-12). Depth of injury used to be classified
by degree (first, second, third, and fourth). These terms are no longer used in burn care. Burn depth is
classified as:
■ Superficial Thickness: presents with erythema (reddened) and pain for 2 to 3 days (e.g., a sunburn).
These burns involve an intact epidermis without blisters.
■ Superficial Partial Thickness: presents with erythema and blister formation. The blisters may burst and
weep. It generally has a moist appearance to it. It bleeds easily and is very painful. The heat of the
burn injury has damaged the epidermis and the outer portion of the dermis. Most of the time, scarring
will occur and these burns heal spontaneously within 3 weeks.
■ Deep Partial Thickness: presents with a white or pale color to the injured tissue. There are generally
huge blisters, which burst, and the pale dermis is visible. This type of burn is extremely painful. If it
does not become infected, it will heal within 3 to 9 weeks. Scarring will occur with this type of burn
because it will take longer than 2 weeks to heal. Sometimes excision and grafting are performed to aid
the healing process and diminish the severity of scarring.
■ Full Thickness: destroys the epidermis and dermis, and eschar is visible. A deep full-thickness burn
may also damage the nerves, bones, and muscles.
FIGURE 22-12 Classification of burns. A, Partial thickness (superficial). B, Partial thickness (deep). C,
Full thickness.
Size or Extent of a Burn

The size of the burn is determined using a chart that calculates the total burn surface area (TBSA)
(percentage of body surface area that has been affected by a burn injury). The rule of nines (Fig. 22-
13A) chart is used for adolescents. It uses one set of numbers for calculating the percentage for each
body part. It is not recommended in infants and growing children. The Lund and Browder Chart (Fig.
22-13B) is used in pediatric burn care. It allows for the estimation of TBSA, size, and percent of burn
injury that takes growth and development into account (Saffle & the Evidence-Based Guidelines Group,
American Burn Association [ABA], 2001).
A Team Approach for Burns
The care of a burned child requires interactions with the interprofessional team. During hospitalization, the nurse provides
essential nursing care and acts as the advocate for the child and family. The nurse also coordinates care of other health-
care professionals such as a physical therapist who helps the child maintain or regain physical function. An occupational
therapist helps the child adapt to activities of daily living and also makes splints for treatment. A dietitian plans appropriate
nutrition for immediate and long-term nutritional needs. As the child becomes more able to return to activities including
school, the case manager, social worker, or nurse helps bridge any information gap between agencies. Long-term
therapy, with rehospitalization and scar revisions, is another reason for an integrative team approach in which health-care
professionals provide optimal care for the entire family.
Optimizing Outcomes
Best Outcomes of Burn Care
The best outcome for a burned child will result from holistic nursing interventions from the following
categories:
• Burn assessment
• Fluid resuscitation
• Prevention of infection
• Prevention of sepsis
• Prevention of pneumonia
• Pain management
• Maintaining circulation
• Promotion of good nutrition
• Pruritus management
• Psychological issues
• The rehabilitation phase
• Education/discharge instructions
NURSING INSIGHT
Awareness of Abuse or Neglect
Remember to assess the burn injury for the possibility of neglect or physical abuse. Be alert for the following:
• The burn injury does not fit the story of what occurred.
• The developmental stage of the child does not fit the burn injury.
• The parent or guardian tells different versions of the injury to different members of the health-care team.
• There was a delay in seeking treatment.
It is extremely important to document the nursing assessment and the parents’ account of the burn. Use quotations and
document who made the statement. It is important to document the date and time of the injury as well as the date and
time of the initial access to the health-care facility.
FIGURE 22-13 A, Rule of nines.
FIGURE 22-13—cont’d B, Lund and Browder chart. C, Hand method.
Fluid Resuscitation
Children with about 10% of TBSA burn will likely require IV fluid resuscitation. Children who suffer burns
greater than 15% TBSA are at risk for developing hypovolemic and cellular shock. Children require more
fluid per kilogram than adults and average 5.8 mL/kg/% burn of fluid resuscitation. The Parkland formula
recommends 4 mL/kg/% burn/day and is acceptable for burn injury of 14% TBSA and less (Box 22-1).
Whether using the Parkland formula or the increased fluid formula of 5.8 mL/kg/% TBSA, the formula is
administered in the same way. The first 50% of the formula is administered at the time of the burn in the
first 8 hours. The remaining 50% is administered over the next 16 hours. In all cases, the formula that is
used is a guideline. The child’s urine output determines how well they are tolerating resuscitation; 0.5 to
1 mL/kg/hr of urine output is the goal during the resuscitative phase (Jaindl, Oberleitner, Endler, et al.,
2016).
Infection prevention for a child with a burn is critical in achieving wound closure. Burn wound infections
originate from the patient because of the bacteria that is already found on the patient’s body or as a
nosocomial infection transmitted by others. Burn wound infections can be a serious complication that
increases morbidity and mortality in the burned child. Factors that have an influence in the morbidity and
mortality of a child with a burn wound infection or sepsis are major burn injuries (typically greater than
30% TBSA), a significant full-thickness injury, prolonged open wounds, and delayed initial burn care.
Dressing change to wounds is performed once or twice daily. Maintaining aseptic technique during the
dressing changes is essential. With patients who have burn injuries greater than 80%, two nurses
perform the dressing change. Dressing changes to the face of an intubated child always require two
nurses. During the dressing change, if there is a break in sterile technique, the nurse informs the other
nurse of the break and regloves to maintain asepsis. If there are signs of infection, the frequency of the
dressing changes or the topical agent is adjusted by the health-care provider. When the dressing
change is complete, the physical therapist performs range of motion exercises and applies splints.
Wound cultures are also done once or twice per week to monitor for infection as well as monitor the type
of bacteria that may be growing on the skin.
BOX 22-1
Algorithm for Initial Assessment of a Burn Injury in the Hospital

PRIMARY SURVEY
• Circulation, Airway, Breathing
• Intubation, ventilation, vascular access, fluid resuscitation
SECONDARY SURVEY
• Head-to-toe examination
• History
BURN SPECIFIC
• Stop the burning process
ESTIMATE SIZE OF BURN
• Lund & Browder Chat
• Palm = 0.5% TBSA
ESTIMATE DEPTH OF BURN
• Examination of wounds
• Estimation of full thickness, deep partial thickness, superficial partial thickness
BEGIN FLUID RESUSCITATION
• Calculate total volume of fluids
• Administer per the protocol that was used
DETERMINE PRESENCE OF INHALATION INJURY
• Intubate if inflation injury is present
DETERMINE PRESENCE OF CIRCUMFERENTIAL BURN

• Escharotomy to be performed, if present
EVALUATION OF ANATOMY AREA
• Face, hands, genitalia
• Provide treatment
EVALUATION FOR SPECIAL INJURIES
• Electrical, abrasive, drugs, cold, chemical
• Provide treatment
DETERMINE WHETHER INJURY IS ABUSIVE OR NEGLECTFUL
• Notify proper authorities
TREAT WOUNDS
• Surgical debridement & dressing changes
• Hydrotherapy & dressing changes
Source: Adapted from Avci, V., & Kocak, O. F. (2018). Treatment algorithm in 960 pediatric burn cases: A review of etiology
and epidemiology. Pakistan journal of medical sciences, 34(5), 1185–1190.
NURSING INSIGHT
Infection Control Surveillance
Infection control surveillance has led to systematic collection of data to monitor infection rates, trend data, and evaluate
the current treatment methods. Infection control protocols include surveillance cultures from the patient, cohort patient
care teams, strict enforcement of patient and health-care professional hygiene, hand sanitizer units, patient isolation, and
monitoring antibiotic use as well as the antibiotic resistance/susceptibility patterns.
Prevention of wound infection requires assessment of the wound with each dressing change, looking for changes in
wound color, character, odor, and amount of wound drainage. Factors that help prevent morbidity and mortality are early
wound closure, topical antibiotics, prophylactic antibiotics, and advances in infection control. Strict aseptic technique is
essential during a dressing change. A debriding dressing is chosen if necrotic tissue is seen during the dressing change.
A protective, moist dressing is preferable if the wound is clean. Treatment of a wound infection may involve changing the
topical agent or the frequency of the dressing changes.
Pain Management
Pain is a significant issue in the care of the child with a burn because wound debridement hurts. The
nurse administers IV pain medication 20 to 30 minutes before a dressing change using IV narcotics
such as morphine sulfate (MS-Contin). Nonnarcotic pain control methods are also important. Diversional
activities such as music, television, and visualization may assist with pain control. Involving child life
services during the dressing change can be beneficial. Children as young as 3 can participate in the
dressing change by removing the dressing with supervision from the nurse or child life therapist. By
participating in the dressing change, the child is given control over this painful procedure and may better
be able to cope.
FOCUS ON SAFETY
Proper Equipment Needed
When a child is intubated, it is important to ensure that emergency intubation equipment is nearby. Resuscitation bag
appropriate for the size of the child and suction equipment must be assembled at the bedside and ready to be used in
case of an emergency. Several of the correct size of suction catheters should also be at the bedside. An endotracheal
tube of the same size and one that is one size smaller are placed near the head of the bed, and the tube size needs to
be documented in the medical record. When an intubated child is being transported, a resuscitation bag and suction
equipment, including catheters and a cardiorespiratory monitor, must accompany the child.
Maintaining Circulation
Nursing interventions for burn care ensures that circulation to the injured extremity is assessed and
maintained. Decompression of circulation pressure on the tissue includes a fasciotomy and assessment
of the muscle compartments. Compartment pressures are measured; pressures greater than 30 mm Hg
in the tissue or pressures that are greater than 10 to 20 mm Hg of the diastolic pressure indicate
increased compartment pressure and require emergency surgery. In many cases, muscle damage is so
severe that the extremity cannot be saved, resulting in amputation of the extremity. Entry and exit sites
are the most common sites for severe circulation impairment and eventual amputation. Traditional pre-
and postoperative nursing care measures are employed.
NURSING INSIGHT
Eschar, Escharotomy, and Fasciotomy
Eschar has a waxy, white, gray, black, bright red, dry, and leathery appearance. There is a lack of pain while the eschar is
intact and a prolonged capillary refill time. If the capillary refill time is impaired or the injury is circumferential (perimeter of
the wound), an escharotomy (a surgical incision through the necrotic skin) is performed within the first 24 to 48 hours.
This surgery allows the eschar to expand and allows the underlying blood vessels, nerves, ligaments, tendons, and bones
to receive oxygenation. A skin graft is also performed; a full- or split-thickness grafting depends on wound condition,
location, thickness, size, and aesthetic concerns.
A deep full-thickness burn that is circumferential may require a fasciotomy (a surgical incision through the fascia)
performed within the first 24 to 48 hours after the burn (Venes, 2021). This surgery allows the underlying blood vessels,
nerves, ligaments, tendons, and bones to receive oxygenation. In severe burns, an amputation (removal of a limb or body
part, as a result of the burn injury and a lack of adequate circulation to the extremity or body part) may be performed
(Venes, 2021).
Promotion of Good Nutrition

Balanced nutrition is essential during burn recovery because a balanced diet is necessary for wound
healing. Patients are weighed at twice a week. Patients not tolerating an oral diet must receive total
parenteral and enteral nutrition. Advancement to enteral feedings and eventually oral feedings happen
as the child recovers and can tolerate the diet. As soon as the patient is able, they are encouraged to sit
in a chair, get out of bed, and walk, which may stimulate the appetite.
Topical doxepin (Sinequan) is a tricyclic medication with potent histamine receptor-blocking abilities—
about 50 times more potent than hydroxyzine and 800 more times potent than diphenhydramine
(Benadryl). Local anesthetics such as lidocaine are used to diminish nerve impulses by blocking sodium
channels on neuronal cell membranes. Colloidal oatmeal has been shown to reduce pruritus because it
forms an occlusive barrier on the skin and maintains optimal levels of hydration in the skin. Compression
garments have been used for scar maturation for many years. Compression therapy can also be an
effective treatment for burn pruritus. The mechanism of this is not clear, but it may be associated with a
reduction in inflammatory cells and a decrease in histamine release.
Nursing Care for Minor Burns

Minor burns are usually treated in a clinic or outpatient setting. An interprofessional team collaborates in
providing care to these patients. In a clinic or outpatient setting, the nurse uses the concept of the six
“Cs” to manage minor burns:
■ Clothing: Remove any clothing that is hot or has been in contact with the offending chemical, if it is a
new burn.
■ Cooling: Burns need to be cooled immediately with cool (54°F) (12.2°C) saline-soaked gauze or any
available clean cloth soaked in cool water, if it is a new burn. Caution: Do not use ice!
■ Cleaning: Wash wound with mild soap and rinse well with water with each dressing change.
■ Chemoprophylaxis: Bacitracin (BAK-tracin) may be used topically to prevent infection. Other types of
anti-infective agents are used in moderate and major burns. A tetanus booster (Td) is also
administered if not administered within the previous 5 years.
■ Covering: Cover the burn with gauze to prevent infection, to decrease pain, and to absorb drainage. A
moist wound heals much better than an open wound.
■ Comfort: Give acetaminophen (Children’s Tylenol) or ibuprofen (Children’s Advil) to decrease the pain.
Premedication for dressing changes is done 45 minutes before the dressing change to achieve
maximum benefit from the pain medication. Pain medications are scheduled regularly to decrease
pain in the child who has sleep, play, or mood alterations.
Patient Education
Home Care Teaching for the Burned Child
TOPIC: The nurse will teach the family how to care for the burned child.
ESSENTIAL INFORMATION: When the child is discharged home, the parents will assume care of the burned child, so
the nurse instructs parents on these measures:
• Bathing
• Skin care measures
• Massages with a nonperfumed moisturizer
• Wound dressing changes
• Knowledge about the signs and symptoms of infection
• Information about when to call the doctor or nurse practitioner
• Application of pressure garments
• Application of splints
• Importance of physical therapy
• Importance of occupational therapy
• Nutritional diet that contains high protein and calories
• Frequent follow-up appointments
• Attendance at a parent support group
• Attendance at a victim support group (if necessary)
• Participation in a school re-entry program
HYPOTHERMIA
Hypothermia is secondary to cold air exposure, wet clothes, and immersion in water. Hypothermia is
also present in victims of burns, when large amounts of skin are no longer present, or the child no
longer has the capacity to hold heat. Mild hypothermia is a condition in which the child’s core body
temperature falls below 93.2°F (34°C). Hypothermia is a life-threatening emergency. The body loses
heat in one of five ways: radiation, conduction, convection, evaporation, and respiration (Table 22-4).
Different developmental stages predispose the child to different types of exposure. Infants and young
children are at higher risk because of their immature thermoregulatory system, thinner skin, and lack of
subcutaneous fat. Older children are at high risk for hypothermia because they may lack the cognitive
ability to evaluate risky situations. Adolescents are at risk for hypothermia because of risk-taking
behaviors such as participating in outdoor activities without proper clothing and potentially ingesting
alcohol or other illicit drugs. In children of any age, trauma, brain disorder, or severe sepsis can also
cause hypothermia because these conditions interfere with the thermoregulation system.
Signs and Symptoms

Signs and symptoms of hypothermia are dependent on its stage. During stage one, these include:
■ Temperature between 93.2°F and 96.8°F (34°C–36°C)
■ Shivering and piloerection (goose flesh)
■ Vasoconstriction
■ Increased metabolism
■ Shallow breathing, fatigue, nausea, and visual disturbances
■ Poor fine motor coordination
■ Local reaction: burning and numbness of extremities, pallor (pale/blue-gray) to erythema (redness)
Stage two symptoms include:
■ Temperature between 86°F and 93°F (30°C–34°C)
■ Violent shivering, pallor, and distal cyanosis
■ Poor gross motor coordination; stumbling
■ Confused but awake and alert
■ Local reaction: insensate (no feeling) and skin may blister from frostbite
■ Mild to moderate frostbite can resolve in rewarming with little to no sequelae (pathological conditions)
TABLE 22-4
Types of Heat Loss
Radiation Heat loss from the head and areas with less subcutaneous fat and thin skin
(e.g., prematurity of the newborn)
This is the most rapid method of heat loss and accounts for at least 50% of heat
loss
Conduction The transfer of heat away from the body by direct contact with a cooler surface
(e.g., wet clothing or immersion)
Convection The transfer of heat away from the body by the movement of air over the skin
surface (e.g., wind and drafts)
Evaporation The transfer of heat away from the body (e.g., skin moisture turned to vapor as it
is dried by the movement of air)
Respiration Expiration of heat from the lungs (e.g., cold and windy weather)
During stage three, the individual will experience:

■ Temperature less than 86°F (less than 30°C)
■ Stops shivering
■ Reduced consciousness moving to stupor
■ Paradoxical behavior (unusual); undressing
■ Metabolism slows to 1/2 of normal
■ Bradycardia and tachyarrhythmias
■ Respirations slow
■ Central nervous system stops
■ Multiple organ failure
■ Death (Avci & Kocak, 2018)
Diagnosis
A diagnosis of hypothermia in children is based on body temperature and relevant behaviors. With no
etiology of prolonged exposure to the cold, the child will need differential diagnostics to determine if the
etiology is neurological or metabolic.
Prevention
Emphasize to parents the need to protect the child from all bodies of water, especially in the cooler
temperatures, to avoid both the incidence of accidental drowning and immersion hypothermia.
Appropriate cold weather clothing is vital to keeping warm. Covering the head will help the child stay
warm; covering the ears, hands, and feet helps reduce the chance of frostbite. Warm socks under
waterproof footwear as well as mittens work well for children who are out of doors for short periods of
time in the cold weather.
Nursing Care
The nurse initiates emergency medical care by calling the emergency response team and conducting a
complete assessment of airway, breathing, and circulation. Cardiopulmonary resuscitation is initiated if
the child’s condition warrants. The nurse must record core body temperature. Rectal temperatures are
most accurate and are used during the rewarming process. However, if peritoneal lavage with warm
fluids is used, the rectal temperature may not be reliable, and a central venous monitor will be more
accurate.
Important nursing care measures include removing all cold and wet clothing, wrapping the child in
warmed blankets, and administering warmed oxygen and warmed IV fluids to promote cardiac output.
Vital signs and urine output are also monitored during the rewarming process. Electrocardiograms are
used to give essential information about the heart, both rate and rhythm. The nurse must remember that
ventricular or atrial dysrhythmias are possible in hypothermia. After these critical measures are
implemented, the nurse raises the child’s body temperature by using a forced air warming system (e.g.,
the Bair Hugger®). This type of system uses convection to heat the trunk area first.
CASE STUDY
Hypothermia
Eight-year-old Sam and his friends are planning to ice fish on a small farm pond about 100 yards from his backyard. Sam
and his friends are cutting a small hole in the ice about 10 feet from the shore of the pond when a cracking sound sends
Sam’s friends running to shore. Sam has always been braver, and he continues his work to open an ice hole. In a little
while, Sam’s friends return to see his progress. As his friends watch from shore, they see Sam fall into the water near the
edge of the pond.
Sam’s friends run to the house to tell Sam’s mother. She calls 911, then runs down to the pond and pulls him out. Her
cold, limp son lies on the ground while she waits for the emergency medical team to arrive. While she waits, she
remembers that it is best to remove any wet clothing and begins to frantically undress Sam. She then covers him in the
blankets that the friends have brought down to the pond. When the medical team arrives, they find him not breathing and
unresponsive. Sam has no signs of respirations or heartbeat, and his body temperature is very cold. The team begins
circulation, airway, and breathing, and Sam is transported to the local emergency room.
1. What are the priority nursing actions that you will perform when Sam enters your emergency department?
2. Sam’s heart monitor shows asystole, and his rectal temperature is 71.6°F (22°C). What is the status of Sam’s condition?
3. Is external rewarming the most effective method of rewarming after severe hypothermia?
See Suggested Answers to Case Studies on DavisPlus.
FROSTBITE
Frostbite in children is an injury that results from prolonged exposure (more than an hour) to severe cold
and usually affects the outer extremities (ears, cheeks, nose, hands, and feet). Crystal formations occur
in the tissue and blood cells, which result in dehydration of the cells and ischemic damage.
Signs and Symptoms

Signs and symptoms of frostbite depend on severity:
■ Mild to moderate
■ Reddened, cool to touch skin
■ Tingling or numbness
■ Mild swelling
■ Pain upon rewarming
■ Severe
■ Pale, waxy, cool skin; feels “wooden”
■ Numbness, insensate (no feeling) that may not improve immediately with rewarming
■ Blisters
■ Extensive swelling
■ Blackened, necrotic (dead or dying) tissue; damage may extend down through the skin to the
muscle and bone if severe or prolonged exposure
Diagnosis
Frostbite can be identified by the hard, pale, and cold quality of skin that has been exposed to the cold.
The extent of the injury is determined upon rewarming.
Prevention
Monitoring children closely so they do not leave the house in inclement weather without adequate
protection is essential information to pass along to parents. Appropriate cold weather clothing is vital to
keeping warm. Covering the head will help the child stay warm; covering the ears, hands, and feet helps
reduce the chance of frostbite. Warm socks under waterproof footwear as well as mittens work well for
children who are outdoors for short periods of time in the cold weather.
Nursing Care
Treatment for frostbite is much like core hypothermia treatment. Place the child in a warm area, remove
all wet and cold clothing, and replace with warm, nonrestrictive clothing. Remove watches and rings if
present. Add warm blankets around the child and use the Bair Hugger® if available.
Do not rub, massage, or soak the frostbitten area. Massage causes the crystals that have formed in
the capillaries to break through the skin, causing damage in the area. After rewarming is complete, the
affected extremity is wrapped in a soft cloth or gauze, and the child can be encouraged to rest. If no
subsequent problems arise, the child can remove the soft cloth and return to indoor activities. If parents
suspect continued problems, the health-care practitioner should be notified.
SUMMARY POINTS
■ Children are at a higher risk for certain skin conditions based on their large body surface area and still maturing immune
system.
■ A skin lesion is a circumscribed area of altered tissue. When assessing the skin for a lesion, it is important to note the
size, shape, color, and texture.
■ Typical wounds found in the child are a result of cuts, scrapes, and burns and can be secondary to surgical intervention.
■ A number of invaders can affect the skin, and these can be bacterial, viral, or fungal in nature. While most of the skin
conditions resulting from these invaders respond quickly to treatment, others require an extended time for healing.
Methicillin-resistant Staphylococcus aureus (MRSA) is a contagious bacterium that is resistant to treatment from beta-
lactam antibiotics.
■ Contact, atopic, and seborrheic dermatitis is an inflammatory rash on the skin marked by itching and redness that occur
because of numerous conditions.
■ Cutaneous skin reactions are a manifestation of an allergic response. The offending allergen can be introduced into the
system in a variety of ways such as ingestion, inhalation, or coming into direct contact.
■ Infestations in children include pediculosis and scabies mites.
■ The most common insect bite comes from the mosquito. Spider and tick bites are also prevalent among children. The
stings experienced most frequently are from bees, wasps, and hornets. Animal and human bites as well as diseases
from these bites are common.
■ Children are at risk for certain types of burn injuries at certain ages and developmental stages.
■ Three factors—type of burn, depth of burn, and size and extent of burn—determine the severity.
■ The best outcomes for a burned child include holistic nursing interventions from the following categories: burn
assessment and fluid resuscitation and prevention of infection, sepsis, and pneumonia. Pain management, maintaining
circulation, promotion of good nutrition, pruritus management, psychosocial issues, the rehabilitation phase, and
education/discharge instructions are also important care measures.
■ Injuries associated with burns include inhalation of toxic gases and injuries from chemical burns and electrical burns.
■ Minor burns are usually treated in a clinic or outpatient setting. An interprofessional team collaborates in providing care
to these patients.
■ Hypothermia is a life-threatening emergency, and the body loses heat in one of five ways: radiation, conduction,
convection, evaporation, and respiration.
■ Frostbite in children is an injury that results from prolonged exposure (more than an hour) to severe cold and usually
affects the outer extremities (ears, cheeks, nose, hands, and feet).
REFERENCES
American Burn Association. (2019). Burn incidence and treatment in the United States: 2019 fact sheet. Retrieved from
http://www.ameriburn.org/resources_factsheet.php
Avci, V., & Kocak, O. F. (2018). Treatment algorithm in 960 pediatric burn cases: A review of etiology and epidemiology.
Pakistan Journal of medical sciences, 34(5), 1185–1190. doi:10.12669/pjms.345.15101
Centers for Disease Control and Prevention (CDC). (May 2019). Guideline for disinfection and sanitization and sterilization in
health care facilities, 2008. Retrieved from https://www.cdc.gov/infectioncontrol/guidelines/disinfection/
Centers for Disease Control and Prevention (CDC). (2019). Dog bite.
Centers for Disease Control and Prevention (CDC). (2019). Head lice. Retrieved from
https://www.cdc.gov/parasites/lice/head/epi.html
Centers for Disease Control and Prevention (CDC). (2019). Scabies. Retrieved from
https://www.cdc.gov/parasites/scabies/index.html
Centers for Disease Control and Prevention (CDC). (2019). Cat scratch disease. Retrieved from
https://www.cdc.gov/bartonella/cat-scratch/
Centers for Disease Control and Prevention (CDC). (2019). National Burn Awareness Week.
Centers for Disease Control and Prevention (CDC). (2020). Rocky Mountain spotted fever. Retrieved from
https://www.cdc.gov/rmsf/index.html
Centers for Disease Control and Prevention (CDC). (2020). Preventing tick bites. Retrieved from
https://www.cdc.gov/lyme/index.html
Goldstein G., & Goldstein, O. (2019). Scabies Management. Retrieved from https://www.uptodate.com/contents/scabies-
management?search=scabies&source=search_result&selectedTitle=2~93&usage_type=default&display_rank=2
Meza-Romero, R., Navarrete-Dechent, C., & Downey, C. (2019). Molluscum contagiosum: An update and review of new
perspectives in etiology, diagnosis, and treatment. Clinical, Cosmetic and Investigational Dermatology, 12, 373–381.
doi:10.2147/CCID.S187224
National Fire Protection Association. (2020). Educational Messages Advisory Committee.
Vallerand, A. H., & Sanoski, C. A. (2021). Davis’s drug guide for nurses (17th ed.). Philadelphia: F.A. Davis.
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dermatitis-eczema?
search=cradle%20cap&source=search_result&selectedTitle=4~12&usage_type=default&display_rank=4

CHAPTER 23
Caring for the Child With a Genitourinary Condition
CONCEPTS
Urinary elimination
KEY WORDS
nephron
pyelonephritis
hydronephrosis
hyperkalemia
renal biopsy
hemofiltration hemodialysis (HD)
peritoneal dialysis (PD)
arteriovenous (AV) fistula
vulvovaginitis
primary amenorrhea
secondary amenorrhea
hypospadias
epispadias
testicular torsion
orchiectomy
LEARNING OBJECTIVES
LEARNING OBJECTIVES
■ Describe the anatomy and physiology of the genitourinary (GU) system.

■ Examine common pediatric conditions of the GU system.
■ Prioritize developmentally appropriate and holistic nursing care measures when caring for the child with conditions of the
GU system.
■ Explore diagnostic testing, laboratory testing, and medications used for common conditions of the GU system.
■ Develop patient and family discharge teaching plans that work in a family-centered care framework to prepare discharge
criteria for families caring for children with common GU conditions.
PICO(T) Questions
1. Is there a (O) higher incidence of (I) enuresis in (P) children where one or both parents also had enuresis?
2. Does (I) the use of moist cleansing wipes after urination (O) lower the rate of urinary tract infections (P) in adolescent
girls (C) compared with the use of toilet paper?
INTRODUCTION
This chapter provides a short review of the anatomy and physiology of the GU system, as well as fluid
and electrolyte balance, followed by a discussion of a variety of renal and reproductive problems. The
discussion includes an examination of the various GU conditions, including developmentally appropriate
and holistic nursing care. Information about diagnostic and laboratory testing and medications is given.
Teaching plans and discharge criteria for parents whose children have various GU conditions are
incorporated.
GU conditions vary from hereditary anomalies to infectious diseases and sometimes traumatic
injuries. These types of conditions occur in both genders throughout childhood, ranging from the
newborn period through adolescence. Nurses must have the requisite knowledge about the GU system
and knowledge about the factors that affect its functions so they can provide safe and competent
nursing care.
ANATOMY AND PHYSIOLOGY REVIEW OF THE KIDNEYS

The kidney is divided into an outer cortex and inner medulla (Fig. 23-1). The outer cortex is composed of
the glomeruli and convoluted tubules of the nephron and blood vessels. The medulla is composed of the
renal pyramid. Kidneys receive their blood supply through a single renal artery that comes from each
side of the aorta, one to each kidney. The renal artery further subdivides into segmental arteries that
feed each kidney.
The glomerulus is a tuft of capillaries in a thin-walled capsule termed Bowman’s capsule. Blood flows
into the glomerulus through the afferent arteriole and leaves through the efferent arteriole. Fluid and
blood particles are filtered through capillary membranes into a fluid-filled space in Bowman’s capsule.
The filtered blood is called filtrate.
FIGURE 23-1 Anatomy of the kidney.
The tubular components of the nephron are divided into four parts. The first part is a coiled portion
termed the proximal convoluted tubule that drains Bowman’s capsule. The second part is a thin loop
termed the loop of Henle, and the third part is the distal convoluted tubule. The fourth and final part is
the collecting tubule, which joins several tubules together to collect filtrate.
Considerations With Kidney Impairment

For normal renal function, there must be unimpaired renal blood flow through the kidneys, as well as unimpaired
movement of urine from the renal pelvis down through the ureters and to the bladder. Impairment of either function can
lead to common disorders of the GU system. Other GU conditions, such as hypospadias and renal and bladder disorders,
predispose the child to alterations in elimination. Disturbances in elimination and surgical repair of the GU system can
have a negative effect on growth and development.
The nurse should educate the family and the child about surgical repair and other treatments as appropriate to avoid
disturbances in growth and development. If the child is having alterations with elimination because of the GU condition,
the nurse should encourage coping and acceptance of the disease process. Problems with the “private parts” can be
embarrassing and emotional for the child. The nurse should provide appropriate psychosocial and emotional support to
the parents and the child. The nurse should explore for feelings of guilt or blame and refer to a counselor if needed.
Functions of the kidney include removal of waste products, filtering the blood, maintaining fluid and
electrolyte balance (e.g., sodium, potassium, calcium, and phosphorus), maintaining acid-base balance,
and releasing hormones:
■ Renin: blood pressure regulation
■ Calcitriol: vitamin D activation for healthy bones
■ Erythropoietin: red blood cell production
Monitoring kidney function includes:
■ Glomerular filtration rate (GFR)
■ Amount of blood filtered by the glomeruli
■ 125 mL/minute
■ Creatinine clearance (reflects GFR)
■ 85 to 135 mL/min
■ Creatinine
■ 0.5 to 1.5 mg/dL
■ BUN
■ 10 to 30 mg/dL
■ Urine specific gravity
■ UA (no protein, blood)
FLUID AND ELECTROLYTE BALANCE

Children are at a greater risk for fluid and electrolyte imbalance than adults because they have a
proportionately greater amount of body water, require more fluid intake, and subsequently excrete more
fluid. Fluid balance implies that the liquid in the body is regulated in such a way as to maintain
homeostasis (a state of equilibrium). The body’s intake and output of fluid in a 24-hour period is
approximately the same. A fluid deficit occurs when fluids are lost by diaphoresis, vomiting, diarrhea, or
hemorrhage. A fluid overload occurs from conditions that create impaired fluid excretion, such as kidney
disease or congestive heart failure. Fluid overload also can occur because of excessive administration
of intravenous fluids (Venes, 2021). Fluid balance is measured by daily discrepancies in body weight
and by monitoring fluid intake and output.
Assessment Tools
Calculation of Daily Maintenance Fluid Requirements for Intake and Output
To determine fluid maintenance for intake use:
Body surface area for children greater than 22 lb (10 kg): 1,500 to 2,000 mL/m2 per day. OR
Child’s Weight Daily Maintenance Fluid Requirement
0–10 kg (0–22 lb) 100 mL/kg of body weight
11–20 kg (24.2–44 lb) 1,000 mL + 50 mL/kg for each kg >10
>20 kg (>44 lb) 1,500 mL + 20 mL/kg for each kg >20
To determine fluid maintenance for output use: Infant: 2 to 3 ml/kg per hour Toddler/Preschooler: 2 mL/kg per hour
School-age: 1 to 2 mL/kg per hour Adolescent: 0.5 to 1 mL/kg per hour
Risk for Fluid and Electrolyte Imbalance

Children are at a greater risk than adults for fluid and electrolyte imbalance because children have:
■ A greater body surface area
■ A higher percentage of total body water (the volume of total body water decreases with increasing
age)
■ A greater potential for fluid loss via the gastrointestinal tract and skin
■ An increased incidence of fever, upper respiratory infections, and gastroenteritis
■ A greater metabolic rate
■ Immature kidneys that are inefficient at excreting waste products
■ Kidneys that have a decreased ability to concentrate urine
■ Increased risk for developing hypernatremia based on their inability to verbalize thirst
The body is continually losing water in urine and stool and by evaporation from the skin and lungs. If
the child is not taking in enough fluids to make up for the amount lost, they can become dehydrated.
Dehydration occurs when the amount of fluid leaving the body exceeds the amount of fluid entering the
body.
Types of Dehydration
Depending on the cause of the fluid loss, a child will lose water and electrolytes. Dehydration is
classified as isotonic, hypotonic, or hypertonic.
■ Isotonic dehydration occurs when electrolyte and water deficits are present in balanced proportions
(sodium and water are lost in equal amounts). Serum sodium remains in normal limits (130–150
mEq/L). This is the most common type of dehydration. Hypovolemic shock is the greatest concern.
■ Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit. Serum sodium
concentration is less than 130 mEq/L. Physical signs are more severe with smaller fluid losses.
■ Hypertonic dehydration is the most dangerous type and occurs when water loss exceeds electrolyte
loss. Sodium serum concentration is greater than 150 mEq/L. Seizures are likely to occur.
NURSING INSIGHT
Fluid Deficit and Excess
Nurses should be aware of the signs and symptoms of fluid deficit and excess so they can take appropriate action. This
information appears in Table 23-1.
Pathophysiology of Dehydration
In the early phases of dehydration, fluids with some electrolytes are lost from the extracellular fluid. If the
fluid loss continues, loss of the intracellular fluid can occur. Hypovolemic shock occurs when there is an
insufficient amount of fluid in the circulatory system and can be fatal (Fig. 23-2).
TABLE 23-1
Fluid Deficit and Excess
FLUID DEFICIT (TO DETERMINE NORMAL VALUES USE CALCULATION OF DAILY MAINTENANCE FLUID
REQUIREMENTS)
CAUSES SIGNS AND SYMPTOMS NURSING CARE MEASURES
Diminished fluid intake Dry skin Determine underlying cause
Diaphoresis Dry mucous membranes Replace fluids
Vomiting Poor skin turgor Replace electrolytes
Diarrhea Thirst Oral hydration
Scaphoid abdomen
Nasogastric suction Poor perfusion IV hydration
Fever Decreased urinary output Measure intake and output
Hemorrhage Weight loss Monitor vital signs
General fluid deficit Fatigue Monitor laboratory values (electrolytes)
Tachycardia Nursing care measures listed
Tachypnea
Decreased blood
pressure
High urine specific gravity
High hematocrit
FLUID EXCESS (TO DETERMINE NORMAL VALUES USE CALCULATION OF DAILY MAINTENANCE FLUID
REQUIREMENTS)
CAUSES SIGNS AND NURSING CARE
Excessive oral intake Pulmonary edema (crackles) Determine underlying cause
Hypotonic fluid overload Weight gain (fluid retention) Decrease fluid intake
Kidney disease Lethargy Administer diuretics
All causes Decreased level of consciousness Monitor vital signs
Slow, bounding pulse Monitor laboratory values (electrolytes)
Low urine specific gravity Nursing care measures listed
Decreased hematocrit
The main electrolytes are sodium (the primary electrolyte of the extracellular fluid) and potassium (the
primary electrolyte of the intracellular fluid). These electrolytes keep the body in balance by maintaining
muscle contraction, heart rhythm, and brain function. Normal values for sodium are 130 to 150 mEq/L,
and potassium values are 3.5 to 5.5 mEq/L. An imbalance in one or both of these electrolytes can cause
illness in children. Calcium imbalance can also pose problems for children. The normal value for calcium
is 8.8 to 10.8 mEq/L.
FIGURE 23-2 Pathophysiology of dehydration.
NURSING INSIGHT
Electrolyte Imbalance
Nurses should be aware of the signs and symptoms of an electrolyte imbalance so they can take appropriate action. This
information appears in Table 23-2.
Nursing care for fluid and electrolyte imbalances centers on recognizing the underlying causes of
dehydration and electrolyte imbalance, then replacing water loss and electrolytes. Another nursing care
measure is education. Explain to parents the signs and symptoms of dehydration and the importance of
offering clear liquids.

Assessing Peripheral IV Infiltration
Peripheral IV (PIV) infiltration occurs when the IV catheter moves out of the vein and the administered fluid then enters the
surrounding tissue. This can be exhibited by redness around the site; swelling, puffy, or hard skin around the site;
blanching (lighter skin around the IV site); pain or tenderness around the site; or cool skin temperature around or distal to
the IV site.
Assessing the PIV site every 4 hours is a critical nursing action. Use the Pediatric PIV Infiltration scale to watch for PIV
infiltration:
Grade 0
• No symptoms
• Flushes with ease
Grade 1
• Localized swelling (1%–10%)
• Flushes with difficulty
• Pain at the site
Grade 2
• Slight swelling at the site (up to 1/4 of the extremity above or below site, or 25%–50% of the extremity above or below
site)
• Presence of redness
Grade 3
• Moderate swelling at the site (1/4 to 1/2 of the extremity above or below site, or 25%–50% of the extremity above or
below site)
• Skin cool to touch
• Blanching
• Diminished pulse below site
Grade 4
• Severe swelling at the site (more than 1/2 of the extremity above or below site, or more than 50% of the extremity above
or below site)
• Infiltration of blood products, irritants, and/or vesicants (any amount of swelling)
• Skin cool to touch
• Skin breakdown/necrosis
• Blistering
• Diminished or absent pulse
• Pain at site
• Capillary refill greater than 4 seconds
Source: (Binay Yaz et al, 2018)
If PIV infiltration occurs, stop the infusion immediately. Helpful nursing measures are elevating the extremity, applying
warm packs, and using a compression dressing. For more advanced infiltrations, Bacitracin (Baciguent) is applied
topically, and the site is covered with a dressing. Call the health-care provider for medical orders in severe situations.
Reassess the site frequently, and accurately document the site as well as nursing care measures.
COMMON DISORDERS OF THE URINARY SYSTEM

In addition to a physical assessment and history, a urinalysis provides data for assessment of common
disorders of the urinary system. Table 23-3 presents normal urinalysis data.

An acquired infection of the urinary system caused by a bacterium, virus, or fungus is referred to as a
urinary tract infection (UTI). Most often, UTIs are ascending and start distally at the urethral area,
causing urethritis or cystitis. If they start in the upper tract, they cause ureteritis and pyelitis, or
pyelonephritis. The probability of an ascending UTI depends on the virulence of the organism and the
status of health and immunity of the child. The most common organism noted with UTI is Escherichia
coli.
TABLE 23-2
Electrolyte Imbalance
SODIUM (Na+) DEFICIT (HYPONATREMIA; SERUM SODIUM CONCENTRATION <130 mEq/L)
Decreased sodium intake Dehydration Determine underlying cause
Excessive sweating Nausea Determine underlying cause
Fever Weakness Administer IV fluids with the appropriate amount
of sodium added
Malnutrition Lethargy Monitor laboratory values (electrolytes)
Malnutrition Lethargy Determine underlying cause
Vomiting Abdominal cramping Determine underlying cause
Diarrhea Dizziness Measure output and calculate fl uid requirements
Nasogastric suction Weak pulse Contact health-care provider for specific orders
Diabetic ketoacidosis Decreased blood pressure Contact health-care provider for specific orders
Kidney disease Hematuria, tea or red-colored urine
SODIUM (Na+) EXCESS (HYPERNATREMIA; SERUM SODIUM CONCENTRATION ≥ 145 mEq/L)

Excessive salt Oliguria Determine underlying cause
intake
Fever Nausea Monitor neurological status
High insensible water loss Vomiting Monitor laboratory values (electrolytes)
Diabetes insipidus Muscle twitching Administer desmopressin (DDAVP) per
Hyperglycemia Lethargy healthcare provider order
Kidney disease Vomiting Contact health-care provider for specific orders
Encephalopathy Contact health-care provider for specific orders
Overload of fl uid in the lungs
POTASSIUM (K+) DEFICIT (HYPOKALEMIA; SERUM POTASSIUM CONCENTRATION ≤3.5 mEq/L)
Diuresis Muscle weakness Determine underlying cause
Starvation Muscle cramping and stiffness Monitor vital signs
IV fl uid without potassium added Hypotension Offer high-potassium foods
Diarrhea Hyporefl exia Administer oral potassium supplements (assess
Vomiting Cardiac arrhythmias (tachycardia or for adequate output before administration)
Nasogastric suction bradycardia) Administer IV potassium based on health-care
Administration of diuretics or Fatigue provider’s order
corticosteroids Drowsiness Obtain electrocardiogram (ECG) (for IV
Burns that are healing Apnea potassium bolus)
Metabolic alkalosis Cyanosis Monitor laboratory values (electrolytes)
Nausea Evaluate acid-base status
Vomiting Contact health-care provider for specific orders
Diarrhea
POTASSIUM (K+) EXCESS (HYPERKALEMIA; SERUM POTASSIUM CONCENTRATION ≥5.5 mEq/L)
Increased intake of potassium Muscle twitching Determine underlying cause
Severe dehydration Muscle weakness Monitor vital signs
Rapid administration of IV potassium Flaccid paralysis Obtain ECG
chloride Hyperrefl exia Administer IV fl uids as ordered
Potassium-sparing diuretics Oliguria Administer IV insulin to facilitate potassium
Burns Apnea (respiratory arrest) moving into cells (if ordered)
Kidney disease (failure) Bradycardia Monitor laboratory values (electrolytes)
Adrenal insuffi ciency Ventricular fi brillation (cardiac Evaluate acid-base status
(Addison’s disease) arrest) Begin cardiopulmonary resuscitation
Metabolic acidosis Rapid breathing Contact health-care provider for specific orders
Confusion
Lethargy
Severe metabolic acidosis that can
lead to shock or death
CALCIUM (Ca2+) DEFICIT (HYPOCALCEMIA; SERUM CALCIUM CONCENTRATION <8.8 mEq/L)

Inadequate dietary intake Tetany Determine underlying cause
Vitamin Ddeficiency Convulsions Administer oral calcium supplement as
Feeding cow’s milk to infants Neuromuscular irritability prescribed
Adrenal insufficiency Tiredness Administer IV calcium slowly and monitor IV site
Weakness for irritation
Dizziness Monitor laboratory values (electrolytes)
Nausea
Vomiting
Diarrhea
Loss of appetite
Stomachache
Joint aches and pains
CALCIUM (Ca2+) EXCESS (HYPERCALCEMIA; SERUM CALCIUM CONCENTRATION >10.8 mEq/L)

Excessive vitamin D intake Weakness Determine underlying cause
Acidosis Fatigue Obtain ECG
Immobilization (prolonged periods of Constipation Monitor laboratory values (electrolytes)
time) Anorexia Contact health-care provider for specific orders
Increased bone catabolism Nausea Contact health-care provider for specific orders
Hyperthyroidism Vomiting Contact health-care provider for specific orders
Kidney disease Thirst
Bradycardia (cardiac arrest)
Gender, age, race, renal tissue, poor hygiene, constipation, nutritional status, and adaptive and
resistant qualities of the causative agents as well as structural abnormalities, catheterization, urinary
tract instrumentation, and sexual activity all contribute to the incidence and etiology of this disease.
Constipation results in incomplete bladder emptying.
Newborns, particularly premature and low-birth-weight infants, have a higher incidence of UTIs. In
girls, UTIs peak during infancy and during toilet training, and uncircumcised boys have a greater risk of
contracting UTIs
Risk Factors for UTIs

The most significant risk factor for UTI is the presence of a urinary tract abnormality that causes urinary
stasis, obstruction, reflux, or dysfunctional voiding, as in vesicoureteral reflux (VUR) (Williams, Hodson,
& Craig, 2019). Pyelonephritis (an infection in the renal pelvis) also contributes to UTI and causes
renal scarring with repeated infections. Alterations that interfere with elimination (such as constipation)
create a risk for UTIs. Conditions associated with chronic perineal irritation such as poor hygiene, nylon
or spandex undergarments, masturbation, pinworms, diaper rash, sexual activity, sexual abuse,
prolonged baths, or bubble baths can cause UTIs. Other important associations to consider in UTIs
include difficulty with toilet-training, neurogenic bladder, and/or a history of abnormal voiding patterns.
TABLE 23-3
Normal Urinalysis
URINALYSIS NORMAL VALUES
Appearance Clear
Color Amber yellow
Odor Aromatic
pH 4.6–8.0 (average 6.0)
Osmolarity 50–1,400 mOsm/L
Protein None or up to 8 mg/dL 50–80 mg/24 hr (at rest) <250 mg/24 hr (exercise)
Specific gravity Adult: 1.005–1.030 (usually 1.010–1.025)
Newborn: 1.001–1.020
Leukocyte esterase Negative
Nitrites Negative
Ketones Negative
Crystals Negative
Casts None present
Glucose Brand new specimen: negative 24-hour specimen: 50–300 mg/day or 0.3–1.7
mmol/day (SI units)
White blood cells (WBCs) <5/hpf
WBC casts Negative
Red blood cells (RBCs) <5/hpf
RBC casts None
Signs and Symptoms

Unique developmental related signs and symptoms accompany UTIs. In the neonate, signs and
symptoms include:
■ Jaundice
■ Hypothermia
■ Vomiting or diarrhea
■ Cyanosis
■ Lethargy
■ Sepsis
In the infant, signs and symptoms include:
■ Poor feeding
■ Fever (especially related to pyelonephritis)
■ Malodor
■ Dribbling urine
■ Abdominal pain/colic irritability
■ Malaise
■ Poor weight gain
In the toddler and preschooler, signs and symptoms include:
■ Abdominal pain
■ Flank pain
■ Fever (especially related to pyelonephritis)
■ Malodor
■ Altered voiding pattern
■ Diaper rash
■ Enuresis
■ Malaise
In school-age and adolescent children, signs and symptoms include:
■ Enuresis
■ Malodor
■ Classic dysuria with frequency, urgency, and discomfort
■ Fever/chills (especially related to pyelonephritis)
■ Abdominal pain
■ Flank pain
■ Malaise
Malodor is often noticed by parents with children 1 to 3 years of age with a UTI. However, the malodor
in this case is not correlated strongly with a diagnosis of UTI (AAP, 2020). The ammonia odor of urine is
attributed to normal flora breaking down urea.
NURSING INSIGHT
UTIs in Adolescents
Adolescents can hide the true nature for seeking health care. With the adolescent, it is important in the review of systems
to check for the classic symptoms of UTI within the context of the GU system. Symptoms may include “dysuria, urgency,
frequency, discharge, and bleeding” (Williams, Hodson, & Craig, 2019).
Diagnosis
An accurate diagnosis determines the treatment and is based on the urine culture and sensitivities.
Diagnosis of a UTI includes obtaining a urinary culture that confirms the pathogen and the exact type of
bacteria present in the urine. Suprapubic aspiration (SPA) or catheterization with 50,000/mL bacterial
growth can also indicate a UTI. In infants and children ages 2 to 24 months, researchers found SPA
more invasive and painful and the results similar to, but not as effective as, urinary catheterization.
When a child is intensely ill, however, a catheterization or SPA is the choice in all age groups to detect
UTIs (AAP, 2020).
URINALYSIS
A urinalysis that is normal does not rule out the presence of a UTI. Therefore, any possible UTI
requires culture and sensitivity (CDC, 2019). A complete blood count (CBC) with differential, a test for
blood urea nitrogen (BUN), creatinine, and a C-reactive protein is done for the child less than 1 year of
age who appears sick or whose symptoms and signs suggest pyelonephritis. Fever is the most
commonly presenting symptom in a child less than 2 years of age with a UTI. To localize the actual
infection, imaging studies are delayed for 3 to 6 weeks after an infection for follow-up. If, however,
obstruction is suspected, imaging studies are done immediately.
Diagnostic Tools
Determining Problems With the Urinary Tract
• The AAP recommends that children less than 2 years of age with a first occurrence of UTI should have ultrasonography
in the acute phase and cystography or renal cortical scan (Arlen, Kirsch, Leong, Cooper, 2017). The renal ultrasound
depicts the ureters but does not discern if there is an infection.
• A voiding cystourethrogram (VCUG) depicts urethral and bladder anatomy and is appropriate usually 2 to 6 weeks
following an infection (AAP, 2020). Health-care providers should remember that children who are from a disadvantaged
background and who may not have a consistent primary health-care provider may have already had a UTI or febrile
infection that was not followed up on. An IV pyelogram assists with identifying the size, shape, and position of the
urinary system as well as elimination function by noting length of time for passage of contrast material through the
kidneys.
• Nuclear cystography visualizes the bladder and is good for detecting VUR.
• Nuclear cortical scanning detects tubular damage and scarring.
• A nitrite test is used to assess if urinary gram-negative bacteria (particularly E coli, Klebsiella, and Proteus) are present.
Prevention
Box 23-1 outlines UTI risk factors. UTI parents need to teach children to void frequently, wash hands
after elimination, wear loose-fitting clothes, and teach girls to wipe from front to back. Cotton underwear
for both genders is preferable because it decreases moisture by allowing more aeration than nylon
underwear. Finally, constipation, if it is an issue, needs to be prevented. Parents can talk with their
health-care provider about best treatment and practices to prevent constipation. Tell parents it is also
important for the child to drink plenty of water for their age to prevent dehydration and enhance the
immune system’s infection-fighting abilities.
BOX 23-1
Urinary Tract Infection Risk Factors

• Lack of circumcision in male infants
• Male infants in the first 6 to 8 postnatal months
• Lack of breastfeeding in first 6 postnatal months
• Constipation
• Dysfunctional voiding pattern
• Recent history of antibiotics
• Urinary tract infection in the past 6 months
• Indwelling catheters or intermittent catheterization
• Family history of recurrent urinary tract infection
• Recent sexual intercourse
• Use of a diaphragm for birth control or spermicidal agents
Source: Adapted from Shaikh N, Hoberman A, Hum SW, et al. (2018). Development and Validation of a Calculator for
Estimating the Probability of Urinary Tract Infection in Young Febrile Children. JAMA Pediatrics; 172:550.
Collaborative Care
NURSING CARE
The goal of nursing care is to collaborate with the patient, family, and other health-care providers
along the continuum of care to diagnose and treat UTIs. With every diagnostic test and medication
ordered, the nurse provides developmentally appropriate education for the entire family.
Obtain a history that identifies risk factors, signs and symptoms, medications, and nutritional and fluid
intake and output parameters. A nursing assessment is done of the external genitalia, noting irritation,
pinworms, sexual abuse, or trauma. Also, for girls, inspect the perineal area for redness, edema,
discharge, labial adhesions, and vaginitis. In males that are not circumcised, “dribbling, threadlike
stream, and urethral ballooning” is assessed. Other assessments include vital signs, growth and
development, pain, tenderness, a mass in the flank area, or fecal impaction. Notice odors associated
with the urine and record intake and output.
Typically, patients who require IV fluids or IV antibiotics, neonates, and infants identified as high risk
are admitted to the hospital. All infants younger than 1 month with suspected UTI, even if not febrile, are
admitted. There may be other reasons for admission based on the health-care provider and/or family’s
collaborative decision (Arlen, Kirsch, Leong, Cooper, 2017).
MEDICAL CARE
The AAP recommends parenteral antibiotics for children with toxic symptoms, dehydration, vomiting,
or noncompliance. IV antibiotics are usually given for 14 days to toxic children or those with
pyelonephritis. Oral antibiotics for 2 to 4 days for uncomplicated cases are thought by some sources to
be as effective as 7 to 10 days of oral treatment. Table 23-4 lists the most common urinary tract anti-
infective agents, side effects, and related nursing interventions.
Patient Education
Broad-Spectrum Antibiotics
Emphasize the importance and rationale for taking all antibiotics for the entire designated time, along with adequate
intake of fluids. For children on low-dose antibiotics prophylactically, medication taken at night allows the drug more time
to eliminate the infection in the bladder.
Teach the family signs of infection depending on the age of the child, including the importance of hand
washing, which is the most important measure for reducing infection. Assist parents in understanding
the relationship of fecal soiling and constipation as an increased cause of infection. Constipation
prevention or intervention includes collaboration with the health-care provider regarding increased
dietary and fluid intake as well as administering stool softeners and laxatives and teaching the child to
establish normal bowel habits. If appropriate, reinforce the risk factors related to contracting UTIs.
TABLE 23-4
Common Urinary Tract Anti-infective Agents, Side Effects, and Related Nursing Interventions
ANTI-INFECTIVE SIDE EFFECTS NURSING INTERVENTION
cefotaxime (Claforan) Mild diarrhea, mild abdominal Monitor fluid intake.
cramping
ampicillin (Principen) Nausea, vomiting, diarrhea, rash Hold medication and notify health-care provider if
rash or diarrhea develops.
With prolonged therapy monitor renal, hepatic,
and hematology lab work.
gentamicin (Gentamicin Pediatric) Serious side effects are ototoxicity Monitor urinalysis.
and nephrotoxicity. Know that the therapeutic peak is 5–10 mcg/mL
and the trough is 2 mcg/mL.
The family needs to notify the health-care
provider if balance, hearing, urinary, or vision
problems occur even after drug is completed.
ceftriaxone (Rocephin) Serious side effects are antibiotic- Assess bowel pattern or pain.
associated colitis manifested as Monitor intake and output.
severe abdominal pain, tenderness,
fever, and diarrhea that is severe
and watery.
cefixime (Suprax) Serious side effects are Stevens- Monitor BUN and serum creatinine.
Johnson syndrome, nephrotoxicity, Monitor intake and output.
blood dyscrasias, and Teach parents how to recognize signs of
superinfections. superinfection (e.g., furry tongue, perineal
itching).
Tell parents to give this medication with
yogurt/buttermilk to decrease superinfections by
maintaining intestinal flora.
cephalexin (Keflex) Serious side effects are antibiotic- Monitor intake and output for nephrotoxicity.
associated colitis, superinfections, Assess bowel activity and stool consistency and
nephrotoxicity with preexisting renal increasing gastrointestinal effects.
disease, angioedema, Take this medication with food or milk if mild
bronchospasm, and anaphylaxis, gastrointestinal upset occurs.
especially if allergies to penicillin or Assess mucous membranes and tongue for
cephalosporins. white patches.
sulfamethoxazole-trimethoprim Serious side effects are fatalities This medication is contraindicated in children
(Bactrim) secondary to Stevens-Johnson younger than 2 months of age; kernicterus may
syndrome, toxic epidermal result if used with newborns.
necrolysis, fulminant hepatic Monitor intake and output.
necrosis, and other blood dyscrasias Assess skin for pallor, purpura, and rash or overt
such as agranulocytosis and aplastic signs of bleeding or swelling.
anemia. Monitor hematology, liver, and renal function lab
results.
The family needs to report new symptoms (e.g.,
bruising, fever, sore throat, or other skin
reactions).
nitrofurantoin (Macrobid) Serious side effects are Stevens- Monitor for peripheral neuropathy (e.g.,
Johnson syndrome, liver toxicity, numbness and/or tingling of extremities).
peripheral neuropathy, and Monitor for liver toxicity signs and symptoms.
impairment of pulmonary function. Monitor respiratory system and chest pain,
cough, or difficulty with respirations.
ciprofloxacin (Cipro) This medication has several IV Monitor intake and output.
incompatibilities so be sure to check Ensure that fluid intake is maintained.
with the pharmacist. Use caution regarding sun exposure affecting
Serious side effects are eyes and skin.
superinfection, nephrotoxicity, If the child wears contact lenses, remove them if
cardiac arrest, cerebral thrombosis, taking ophthalmic solution or ointment.
and arthropathy that may occur in
children younger than 18 years.
Vesicoureteral Reflux
Normally, urine should flow downward from the kidneys through the ureters into the bladder and urethra.
In VUR, the urine backflows from the bladder to the ureters and sometimes back to the kidneys. The
disorder occurs at the vesicoureteral junction, which normally creates a one-way valve for the urine to
enter the bladder without being refluxed back into the ureters or kidneys. VUR is as a common cause of
children with UTI and is most frequently diagnosed between ages 2 and 3. VUR is more common in
girls, Caucasians, and those who have a family history of this condition. It causes UTI in infants and
children and is commonly diagnosed after the first or second UTI episode.
With primary VUR, a child is born with a valvular defect at the ureter and bladder junction because of
insufficient fetal growth of the ureter. The resultant valvular defect allows urine to backflow from the
bladder to the ureters. As a child grows and the ureters lengthen, this type of VUR may resolve
spontaneously.
In secondary VUR, an obstruction from an abnormal tissue fold within the urethra may cause urine to
flow backward to the ureters. It is more often bilateral in this case (NKF, 2020; Williams, Hodson, Craig,
2019). When urine refluxes backwards into the kidneys, it can cause hydronephrosis (distension of the
kidney) and risk for pyelonephritis (kidney infection, as opposed to bladder infection).
Gradations of VUR are provided in the International Reflux Grading System, with a range from Grade
I to Grade V (Fig. 23-3). These gradations were created based on the appearance of the renal pelvis
and calyces on VCUG (radiography of the bladder and urethra by use of a radiopaque contrast
medium).
Signs and Symptoms

The most common presentation for VUR is recurrent UTI. Flank pain, abdominal pain, and enuresis may
coexist, although developmentally, toddlers are seldom capable of describing these symptoms. The
major risk of VUR is the development of acute pyelonephritis because of the backflow of urine toward
the kidney. Even one episode of febrile acute pyelonephritis can cause renal damage in children (AAP,
2020).
Children may also have these signs and symptoms:
■ Fever
■ UTI symptoms
The risks of persistent VUR, especially in children younger than 2 years old, are significant because it
is the most common cause of UTI and renal scarring. Children with UTI who are younger than 2 years of
age may more easily develop sepsis and become gravely ill.
FIGURE 23-3 Gradations of VUR are found in the International Reflux Grading System ranging from
Grade I to Grade V.
Diagnosis
Diagnosis of VUR is most consistently based on the VCUG radiograph which identifies the bladder,
urethra, and ureters during micturition. Radiographic contrast material is observed as it refluxes back
into the ureters and kidneys from the bladder. Renal ultrasound, nuclear scan, or IV pyelography (IVP)
are ancillary tests that also may be ordered.
Diagnostic Tools
VCUG Results According to the International Reflux Classification
• Grade I: Urine backs up into the ureter only.
• Grade II: Urine backs up into the ureter, renal pelvis, and collecting system without dilation.
• Grade III: Reflux into the collecting system with mild dilation, slight ureteral tortuosity, and no or slight blunting of the
fornices.
• Grade IV: Moderate dilation of the renal pelvis and calyces with complete obliteration of the sharp angle of the fornices
(Arlen, Kirsch, Leong, Cooper, 2017; Williams, Hodson, Craig, 2019).
Prevention
VUR may be genetic and physiological. Prevention centers on preventing UTI and pyelonephritis when
children have VUR.
Optimizing Outcomes
Children With VUR and UTI

A thorough nursing assessment promotes the best outcome for a child with VUR and UTI. Because infants and small
children cannot express urinary discomfort easily, nurses can observe for discomfort during voiding or straining to void,
dribbling of urine, and starting and stopping of the stream. Fever of unknown origin and irritability may be suspicious for
UTI in nonverbal children especially. Nurses must take extreme care to obtain a reliable clean-catch urine specimen
through assisting older children in the collection of the sample and through proper handling of a bagged specimen in
younger children.
MEDICAL CARE
The treatment plan varies based on the grade of the actual reflux. In Grades I and II, the mildest types
of reflux, the VUR may resolve spontaneously as the child grows up (in 85% of the cases), and grade III
VUR may resolve spontaneously in only 50% of children (Williams, Hodson, & Craig, 2019). In children
with more severe grades of reflux, such as Grades IV and V, surgical intervention may be required, and
the child needs to be seen by a pediatric urologist and pediatric nephrologist.
Many children with VUR are treated with prophylactic antibiotics, such as a daily low dose of an
antibiotic. Children on medication are followed by urine culture periodically (every 2 or 3 months).
Prophylactic antibiotics are often recommended until the child has been free of infection for a long time.
However, other researchers disagree and say it may not be necessary for children with VUR to take
urinary antibiotic prophylaxis for VUR because it may lead to antibiotic resistance and may not be
necessary in many cases for long-term treatment (Selekman, Shapiro, Boscardin et al, 2018).
SURGICAL CARE
Surgical management ranges from abdominal surgery to less invasive endoscopic surgery.
Candidates for surgery include children with recurrent breakthrough pyelonephritis, renal inflammation,
fever, and reflux that have not improved within 1 year of diagnosis. Several surgical approaches are
available, usually involving the ureter, but a new outpatient surgical technique using Deflux is also used.
Deflux is composed of complex sugars that form a gel that is inserted into the ureter to stop urine from
refluxing back into the ureters (Williams et al, 2019). Nurses caring for the postsurgical patient must be
vigilant in monitoring intake and output as well as maintaining the patient’s pain control.
Nurses play a vital role in educating the parents and family members about signs and symptoms of UTI
and the importance of medication in this chronic disorder. Pyelonephritis secondary to VUR causes
renal scarring and damage, so early identification and treatment of UTIs are important.
Other causes of proteinuria include protein in the urine that occurs after fever or hardy exercise. When
the patient’s temperature subsides or the patient has not exercised heavily for 48 hours, the proteinuria
subsides as well. In this case, it is wise to obtain a urine sample potentially associated with exercise and
compare it to one produced after 48 hours without heavy exercise (Williams, Hodson & Craig, 2019).
Signs and Symptoms

The dipstick must show 1+ (30 mg/dL) or higher level of proteinuria to be considered significant. False-
positive readings for proteinuria are possible with highly concentrated urine, with specific gravity greater
than 1.015, and in this case, the proteinuria must be 2+ or higher to be considered significant.
Proteinuria may also be noted in infected urine, often along with leukocytes, hematuria, and positive
nitrates (NKF, 2020).
Note potential signs of renal disease:
■ Periorbital (around the eye orbit) edema
■ Peripheral edema
■ CVA tenderness
■ Bladder distension
■ Renal masses
Diagnosis
Proteinuria is found on dipstick in about 10% of all children ages 8 to 15 (AAP, 2020). The child needs to
void at bedtime and not again until the morning the specimen is obtained. Obtain serial first-voided (the
first urine of the morning) specimens for urinalysis at least three times over a 2-week span if orthostatic
proteinuria is suspected. It is advisable to send urine for culture and sensitivity to rule out a UTI. Any
urinalysis containing proteinuria, especially higher than 1+, along with possible hematuria, white blood
cells, casts, crystals, and bacteria, is more suspicious for urological or renal disease. Additional renal
serum tests that should be ordered include BUN and creatinine. A 12- or 24-hour urine test for
creatinine (a chemical waste product of muscle metabolism) and protein may suggest pathology.
Further diagnostic testing may include renal ultrasound, VCUG, and testing for antistreptolysin titer
(ASO) to rule out poststreptococcal glomerulonephritis. Referral to a urologist or nephrologist is
necessary when proteinuria is persistent, of a high level, or is associated with other urinary
abnormalities.
Prevention
Proteinuria can sometimes be prevented by avoiding extreme exercise and minimizing fever
occurrences.
Collaborative Care
NURSING CARE
In the clinic setting, the nurse instructs the parent or child on how to obtain a first-voided morning
specimen to test for orthostatic or postural proteinuria. Make certain the parent understands whether the
specimen is to be returned to the clinic or to a laboratory. Nurses can perform an accurate urine dipstick
test by obtaining proper quantities of urine to dip the sticks into and then waiting the appropriate amount
of time to test each specimen (Fig. 23-4).
In the clinic, the nurse also assesses weight, blood pressure, pulse, and growth, which may be
impaired with renal disease, and performs an abdominal examination to assess for renal masses and
extended bladder.
If the child requires further testing in the inpatient or outpatient settings, the nurse is instrumental in
educating parents about what each test entails. Educational handouts can help patients understand
urinary disorders and how various urological tests are performed. In this case, the nurse’s role is largely
that of an educator. Nurses also ensure that patients receive the proper follow-up after proteinuria is
discovered, which may include return visits to the clinic and the establishment of appointments with a
pediatric urologist or nephrologist.
FIGURE 23-4 Nurses can perform an accurate dipstick test.
Hematuria
It is especially important for children with gross hematuria to undergo a significant urological work-up.
Conversely, gross hematuria in children is more serious as it may be indicative of a more serious
disorder (such as IgA nephropathy, hypercalciuria with or without calculi, poststreptococcal
glomerulonephritis, or renal trauma).
Signs and Symptoms

The main sign of hematuria is blood in the urine; it can be either microscopic (only seen on dipstick or
laboratory analysis) or macroscopic (visible to the eye).
Diagnosis
The color of the urine may be significant; tea-colored or brownish urine often signifies a urological
disorder. Pink or red urine with or without blood clots, but without protein, usually originates in the lower
urinary tract. If higher than 1+ hematuria is present on dipstick, then it is necessary to obtain a
microscopic urinalysis to check for red blood cells (RBCs). Pseudohematuria is a condition that shows a
false-positive dipstick but no RBCs on microscopic lab examination.
Urinalysis that reveals hematuria along with casts and proteinuria is highly suspicious for renal
disease. UTI may show hematuria along with mild proteinuria but without casts. Significant proteinuria
and presence of casts often signify the risk of more severe renal disease. Urine culture is suggested to
rule out UTI in cases of hematuria, and a complete blood and platelet count are needed early. Further
diagnostic work-up may first include renal ultrasound, and if necessary, IVP (a dye study that cannot be
done if the child is allergic to the IVP dye or shellfish), cystoscopy (scope into bladder), and VCUG.
Referral to a pediatric urologist or nephrologist is necessary in cases of hematuria suggesting the
potential for renal disease.
Prevention
Preventable types of hematuria are associated with UTIs and to some extent with renal calculi. Use the
same techniques as those to prevent UTIs. Renal calculi, which occur in children, may sometimes be
prevented by decreasing intake of certain foods, depending on the type of renal stone identified.
Collaborative Care
NURSING CARE
If the child cannot voluntarily provide a urine specimen, be sure to use the appropriate bagging
technique to obtain the specimen. A clean-catch specimen may be needed. Obtain a urine specimen by
collecting urine from a bag that fits over the perineum in females or over the penis in males. The skin
must be dry for the bags to adhere, and it is ideal to cleanse the perineum in girls or penis in boys
before placing the plastic collecting bag. The bag must be removed as soon as the child voids to avoid
fecal contamination. Transfer the urine to a sterile collection container using universal precautions and
send it to the laboratory immediately. The nurse is also responsible for accurately testing the urine with a
dipstick, ensuring an adequate sample, and allowing the proper time limits for testing.
Depending on the cause of the hematuria, the nurse is called on to educate the child and parent about
necessary laboratory and procedural tests, in addition to giving an understandable explanation of the
cause of the hematuria. In the case of UTI, the nurse educates the family in the proper techniques of
collecting a urine specimen.
Glomerulonephritis
Glomerular disease (glomerulonephritis) can be a result of primary kidney disease or secondary
multisystem diseases that damage the glomerulus. Both primary and secondary diseases are
accompanied with histological evidence that captures the glomerular damage and resultant clinical
manifestations and needed treatment. Glomerulonephritis, or nephritis, as it is also known, can be
divided into acute, intermittent, or chronic type. Furthermore, nephritis is also classified according to
primary and secondary types. Primary glomerulonephritis occurs when the glomerulus is the structure
that is impaired in some way. Secondary glomerulonephritis implies that renal issues are secondary to
systemic diseases such as Henoch-Schönlein purpura, systemic lupus erythematosus, and drug
hypersensitivity reactions. Figure 23-5 shows glomerular filtration and tubular reabsorption.
Acute Glomerulonephritis
Inflammation of the glomeruli (tubules of the kidney) is called glomerulonephritis. Interference with the
glomeruli filtering waste products from the blood gives rise to acute and chronic clinical manifestations. If
the inflammation follows the course of an infection, it is called postinfectious glomerulonephritis. If it can
be directly attributed to the streptococcus organisms, it is called poststreptococcal glomerulonephritis.
FIGURE 23-5 The nephron showing glomerular filtration and tubular reabsorption.
NURSING INSIGHT
Poststreptococcal Glomerulonephritis
Although uncommon, it is possible for children to develop an acute glomerulonephritis within 2 weeks following an acute
Group A beta-hemolytic streptococcal infection, even if it was successfully treated with antibiotics. Antigen-antibody
complexes with the streptococcal bacteria form and are then deposited in the glomeruli, causing damage. Infections that
were missed or not cultured may cause patients to develop this sequelae. Consider not only Group A beta-hemolytic
streptococcal pharyngitis but also other potential sources of this bacteria, such as impetigo.
SIGNS AND SYMPTOMS

Signs and symptoms of glomerulonephritis include:
■ Gross hematuria, either tea- or red-colored urine
■ Edema, which may be seen in the periorbital region (around the eye orbits)
■ Hypertension and headache
■ With severe disease, ascites because of fluid shifting
DIAGNOSIS
If the child has not had a diagnosed streptococcal infection in the previous two weeks, the health-care
provider will order a serum ASO titer that will indicate exposure to the bacteria. Serum complement (C3)
is another blood test that may be positive. Urine microscopic hematuria may still be noted up to 1 year
after this disease resolves. Laboratory tests such as BUN and creatinine are used to assess renal
function. If children do not fully recover, they may develop nephrotic syndrome (NS) and require a renal
biopsy.
PREVENTION
Preventive measures focus on preventing infections with the streptococcus organisms. Teach families
standard prevention measures such as hand washing, cleaning the perineal area, and keeping the child
home when they are ill or show signs of acute infection.
COLLABORATIVE CARE
Nursing Care
Nurses should closely monitor children for hypertension as this can be a side effect of
glomerulonephritis. In addition, urine output should be closely monitored.
Children who develop significant oliguria, gross hematuria, and hypertension are hospitalized
because of the risk of associated acute renal failure (ARF). The child’s renal status is carefully
monitored to make certain there is no severe renal dysfunction. Dietary restrictions such as sodium,
potassium, and fluid intake are necessary. In most cases, the disorder begins to resolve within 2 or 3
weeks.
Medical Care
The most common etiology of glomerulonephritis is from an untreated strep infection (usually staph
pharyngitis or impetigo). The etiology must be determined and infectious sources such as streptococcus
treated with appropriate antibiotics. Children with acute poststreptococcal glomerulonephritis require
antibiotic therapy if an infection is still found. Fluid imbalances require monitoring of fluid intake and
output. Supportive treatment with diuretic medications and antihypertensive drugs may also be
necessary. Children with severe glomerulonephritis may require PD or HD. Plasma exchange may be
instituted in severe cases to decrease the amount of circulating immunoglobulins that are damaging the
kidney, and corticosteroids may be used in the acute stage of the disease. When hypertension is
present, it is generally related to fluid overload. Loop diuretics such as furosemide (Lasix) may be given
to reduce the circulating intravascular fluid volume.
Advise patients and families to take the antibiotic treatments until fully completed to avoid resistant
organism development and recurrence of infection.
CASE STUDY
Poststreptococcal Glomerulonephritis
Sara is a 4-year-old girl who is taken to the pediatric emergency department with edematous eyelids and swollen
abdomen. Sara’s mother reports that along with her daughter’s swollen eyelids, her daughter has a decreased appetite
and has been very fatigued for the past several days. Sara’s vital signs are normal except for her blood pressure, which is
140/90. The systems review and physical exam are negative except for lesions on her ankles and a “doughy” or “dense”
feeling to her abdomen, which is slightly firm to touch. The ankle lesions are circular and crusted with sticky yellow
drainage, which Sara scratches during the exam. Sara’s mother reports that her daughter is allergic to amoxicillin (Amoxil)
and develops a rash.
1. What does the nurse suspect is the cause of Sara’s signs and symptoms?
2. What other questions does the nurse ask Sara’s mother?
3. What other laboratory tests are anticipated?
4. What are two other laboratory tests that would confirm a diagnosis of poststreptococcal glomerulonephritis?
5. What type of diet will be ordered for Sara?
6. What antibiotic could be given to Sara because she is allergic to amoxicillin?
7. What patient teaching would the nurse provide to the mother before Sara goes home?
SIGNS AND SYMPTOMS

Signs and symptoms of acute glomerulonephritis include:
■ Decrease in the urine output
■ Tea-colored urine
■ Headaches
■ Increased abdominal girth
■ Swelling of the labia or scrotum
■ Hematuria, microscopic or macroscopic
■ Proteinuria
■ Abnormal BUN and creatinine
DIAGNOSIS
Diagnosing chronic glomerulonephritis includes the use of diagnostic laboratory tests including a
urinalysis (showing proteinuria and hematuria), blood chemistry, BUN, serum creatinine, and pH.
PROCEDURE ■ Collecting a Urine Specimen

PURPOSE
The purpose of collecting a urine specimen is to screen for early signs of disease (Fig. 23-6).
EQUIPMENT
• Packaged urine culture set (usually contains three antiseptic towelettes and a sterile urine collection plastic container)
STEPS
1. Wipe (or have the child wipe) the labia or penis with the three provided iodine or antiseptic solution towelettes. In
occasional situations, it is considered appropriate to use just soap and water to wash these areas. The customary
procedure is to wipe the areas 3 times. In males, wipe the urethral tip 3 times in a circular fashion, once with each
wipe. In a female, holding the labia open to expose the urethra, wipe the right side, top to bottom, and discard the
wipe. Then repeat this on the left side, discarding the wipe. Wipe top to bottom over the central area where the
urethral meatus is and discard that wipe.
RATIONALE: Cleansing removes normal flora that may contaminate a urine culture and make it impossible to tell which
organisms are pathogens.
FIGURE 23-6 The nurse collects specimens in a bag that fits over the perineum in females or over the
penis in males.
2. Ask the child to begin to urinate into the toilet, bedpan, or urinal, and then stop urinating.
RATIONALE: This action flushes away urine in the distal urethra, which may be contaminated with normal flora from
the skin.
3. Position the sterile urine container so that it catches the “midstream” urine, which needs to be about 3 to 4 ounces of
urine.
4. Remove the container and cap it, taking care not to contaminate the inner container with your gloved hands.
RATIONALE: Removing the container keeps the specimen sterile.
5. Allow the child to finish voiding into the toilet, bedpan, or urinal.
Do not keep a urine culture at room temperature any longer than 10 minutes. If the specimen cannot be sent to the
laboratory immediately, it is necessary to refrigerate it in a plastic specimen bag to prevent the overgrowth of organisms
that interfere with the interpretation of the culture and sensitivity to specific antibiotics. The specimen is plated on a
nutrient medium, and bacteria that are present are allowed to grow and then are counted. Usually, different antibiotic discs
are placed on the inoculated medium to show which ones decrease the colony counts (sensitivity).
COLLABORATIVE CARE
Nursing Care
Nursing care also depends on the degree of renal insufficiency or failure. Dietary management may
include restriction of salt and fluid along with instituting low-potassium foods. Careful monitoring of urine
output, along with weight and abdominal girth, is necessary.
Chronic glomerulonephritis is a serious disease that may manifest in hypertension, NS, and renal
failure, so children are vigilantly monitored for electrolyte and fluid imbalances as well as for
deteriorating renal function. Proper diet may require instruction from a dietitian. Educate families on the
delicate balance of fluid and salt in this disease as well as on the potential complications that can occur
if the disease is not properly managed. Children may require emotional support and counseling to live
with this chronic condition because their energy levels may be severely decreased. Tell parents that
activity levels may be restricted at certain points of development.
Hemolytic Uremic Syndrome

Hemolytic uremic syndrome (HUS) is the most common cause of ARF in children. HUS is most
commonly associated with children ingesting beef contaminated with E coli, although other organisms,
such as shigella, coxsackievirus, adenovirus, salmonella, ECHO virus, pneumococci, and rickettsia have
been implicated. This potentially lethal outcome is most commonly seen in young children between 6
months and 3 years of age but can occur in all age groups (Williams, Hodson & Craig, 2019).
FOCUS ON SAFETY
E coli O157:H7
Undercooked ground beef has been one of the primary sources of E coli O157:H7 that can cause HUS. Meat should be
cooked until it reaches a temperature of 160°F (71.1°C) and is no longer pink. E coli outbreaks have occurred in fast-
food and other restaurants and have been found in unpasteurized cider, milk, juice, alfalfa sprouts, strawberries, and
most recently, raw spinach.
It is believed that an endotoxin is produced from the dangerous bacteria in the gastrointestinal tract
and results in inflammation causing capillary wall destruction. This occurs also within the glomerular
arterioles, and as the endothelium of the glomerulus becomes more edematous, platelets aggregate at
the site of injury. A clot then forms that impedes renal circulation. This stimulates increased rennin
production, which results in hypertension. These platelets are damaged, and this results in
thrombocytopenia or a drop in the platelet count to less than 100,000/uL for a period of 1 to 2 weeks.
The overall effect damages the glomerular blood vessels, resulting in a lesser GFR, lowered urine
output, ARF, and hypertension. The clotting and inflammatory process may also affect the respiratory
system and any other body system.
FOCUS ON SAFETY
At-risk Populations
Young children and older adults are at-risk populations for developing HUS from E coli O 157:H7, so it is prudent to
investigate whether any person with diarrheal illness has eaten contaminated food. Stool culture tests for E coli O
157:H7 are available at most clinics and are ordered by a health-care provider if there is a suspicion of contaminated
food (Fig. 23-7).
Signs and Symptoms

Classically, HUS includes a triad of symptoms: thrombocytopenia, anemia, and ARF.
Other signs and symptoms include:
■ Gastroenteritis (inflammation of the intestines as a result of infection) with abdominal pain, vomiting,
and bloody diarrhea
■ Potential upper respiratory infection
■ Hematuria
■ Proteinuria
■ Pallor
■ Lethargy
■ Irritability
■ Decreasing urine output
■ Hepatosplenomegaly
■ Dehydration
■ Possible seizures
■ Consciousness alteration
■ Anemia with high reticulocyte count
■ Thrombocytopenia
Diagnosis
HUS has an average annual incidence rate of 0.5 cases per 100,000 children (Raina et al, 2019).
Diarrhea-associated HUS was identified in 38 (81%) cases, of which the median age was 29 months,
79% were <5 years of age with the majority being girls (Kent et al, 2019). In HUS, laboratory
abnormalities show an elevation in BUN and creatinine levels. Hyperkalemia (elevated potassium level)
also may occur because of decreased urinary excretion. Serum glucose levels may drop because of
increased metabolic needs but may also rise if the pancreas is affected, and some children require
insulin. Other affected electrolytes include calcium, which decreases, and phosphorus, which rises. The
reticulocyte count rises, which refers to immature RBCs being produced from the bone marrow as a
response to the hemolytic anemia to try to improve oxygenation (Raina et al, 2019).
Collaborative Care
NURSING CARE
The child suffering from HUS is ill enough to be in intensive care and require dialysis. Monitor the
child’s level of consciousness, signs of increased intracranial pressure, congestive heart failure,
bleeding, and hypertension. Fluid intake and output is measured every 4 hours and up to every hour if
the child is critically ill. Daily weights are essential, and the nurse needs to assess electrolyte balances
(sodium, potassium, chloride, and bicarbonate) as well as arterial blood gas measurements. The BUN
and creatinine are important to measure to determine if renal status is worsening, and the child may be
at risk of needing dialysis. The lungs should be assessed for signs of congestive heart failure such as
rales. Assess for peripheral and periorbital edema because these are indicators of worsening renal and
cardiac status.
FIGURE 23-7 The role of E. coli in HUS.
Monitor the child’s vital signs frequently for hypertension and tachycardia. It is recommended that
children with HUS have electrocardiographic monitoring to assess for possible changes such as
widened QRS complexes, heart block, and peaked T waves caused by hyperkalemia.
Patient Education
Preventing HUS
The nurse should educate parents about what to look out for in terms of signs and symptoms of HUS when a child is
taking medications that may cause HUS. In addition, parents and caregivers can help prevent childhood HUS due to E.
coli 0157:H7 by:
• Avoiding unclean swimming areas
• Avoiding unpasteurized milk, juice, and cider
• Cleaning utensils and food surfaces often
• Cooking meat to an internal temperature of at least 160°F (21°C)
• Defrosting meat in the microwave or refrigerator
• Keeping children out of pools if they have had diarrhea
• Keeping raw foods separate from cooked foods
• Washing hands before eating
• Washing hands well after using the restroom and changing diapers
Assessment Tools
Hemolytic Uremic Syndrome (HUS)
Be observant for the risks related to HUS:
• Signs of bleeding associated with thrombocytopenia, petechiae, epistaxis (nosebleed), prolonged bleeding at
venipuncture sites, and ecchymosis
• Signs of increased intracranial pressure, including change in level of consciousness and risk of seizure
• Abdominal symptoms are the primary presenting complaints for children and occur in the form of diffuse abdominal pain,
intussusception (telescoping of the bowel), nausea and vomiting, diarrhea, and fever. These abdominal symptoms may
present up to 1 week after exposure to the E coli O 157:H7 toxin.
MEDICAL CARE
Antibiotics are contraindicated in treating HUS because they may worsen the situation.
Teach patients and families to properly cook all ground beef products to an internal temperature of
160°F (71.1°C). Ensure a restaurant also properly cooks the meat at the noted temperature. It is
recommended that people should order ground beef that is well-done and no longer pink or red in color.
Educate patients and families about epidemic outbreaks that have occurred with a variety of produce
types, including apple cider and spinach. Produce should be carefully selected and washed, although
this may still not entirely eliminate the risk of infection.
Nephrotic Syndrome
Nephrotic syndrome (NS) is a disorder allowing for increased permeability of the glomerular filtration
barrier leading to excessive protein excreted into the urine. It appears that the glomerular membrane
may become more permeable, thus allowing more protein to be excreted. It may result from allergic,
infectious, vascular, malignant, autoimmune, or idiopathic (unknown) reasons. It occurs 15 times more
often in children than adults, with peak incidence from ages 2 to 6 years of age (Yu-Hin Chan et al,
2019).
NS is classically characterized by four clinical features: proteinuria, hypoalbuminemia, hyperlipidemia,
and edema. When these large proteins are excreted in the urine, water follows, which leads to the
classic symptom of proteinuria. The largest protein, albumin is depleted, leading to hypoalbuminemia.
Loss of this fluid activates the renin-angiotensin-aldosterone system (RAAS) leading to increased
sodium and fluid retention resulting in increased edema. In addition to activation of the RAAS system,
the decrease in oncotic pressure (or the pressure keeping fluid inside the semipermeable cell
membrane) leads to a fluid shift causing fluid to “leak” out of cells. This causes periorbital edema. Loss
of protein (through urine) also activates a compensatory mechanism in the liver, leading to
hyperlipidemia.
Signs and Symptoms

Signs and symptoms of NS include:
■ Edema, especially periorbital and dependent (e.g., feet and ankles)
Sudden weight gain (from the edema)
■ Decreased urine production
■ Possible ascites with respiratory compromise because of enlarged abdomen
■ Hypertension
■ Anorexia
■ Diarrhea
■ Vomiting
■ Growth failure and muscle wasting if prolonged illness
Diagnosis
Urinalysis may show protein levels of 2+ or greater, hyaline or granular casts, microhematuria, and high
specific gravity. Cholesterol levels may be elevated, and serum albumin levels may be low. A kidney
biopsy may be required.
Prevention
Based on the cause of nephritic syndrome, prevention can be promoted through regular visits to a
Collaborative Care
NURSING CARE
Hospitalization may be needed if the disease is severe. Fluid and electrolyte balance, weight, and
degree of edema are monitored. Be aware of the disease manifestations and the need for possible
kidney biopsy.
MEDICAL CARE
The primary medication used is prednisone, given in higher doses initially to induce remission and
then tapered down to handle the inflammation, potentially over several months (Yu-Hin Chan et al,
2019). Diuretics and albumin replacement may be used early in the disease process. Salt may be
restricted.
Teach parents the need to monitor daily weights every morning in addition to daily urine dips to identify
the signs of potential relapse. A sudden increase in weight gain from fluid retention or a proteinuria are
indications of a relapse of NS.
STRUCTURAL DEFECTS OF THE URINARY SYSTEM

Although theoretically the urinary tract system is composed of two ureters, one bladder, and one urethra
that appears independent of the kidneys, the two systems are intertwined. Abnormalities with the urinary
tract system ultimately affect the other systems. The abnormalities may be anatomical, infectious,
cellular, inflammatory, functional, or maturational.
Bladder exstrophy is a urinary tract system structural abnormality that can damage the kidney.
Another example is a kidney disease, hydronephrosis, an accumulation of urine in the renal pelvis that
results from an obstruction. These structural defects also compromise kidney function, resulting in
hypertension, metabolic acidosis, inability to concentrate urine, urinary stasis and infection, and chronic
renal failure.
Obstructive uropathy refers to structural or functional abnormalities that also result in retrograde flow
of urine back into the renal pelvis. The most common of these obstructive uropathies is ureteropelvic
junction obstruction (an obstruction or stenosis of the ureteropelvic valve between the renal pelvis and
ureters). The outcome of untreated obstructive uropathy is chronic renal failure caused by damage to
the renal parenchyma from hydronephrosis.
Hydronephrosis means swollen urinary tract. Hydronephrosis can be acute or chronic and it can occur
antenatally (before birth) or postnatally. In children, hydroureter implies a ureter that is dilated.
Hydronephrosis is often associated with VUR (Arlen, Kirsch, Leong, & Cooper, 2017). In children,
especially newborns, the physical examination may be abnormal when hydronephrosis is present. An
abdominal mass may be palpated from an enlarged kidney due to hydronephrosis.
A child with external ear abnormalities or low-set ears (below an imaginary line drawn from the eye to
the side of the head) may also have congenital kidney problems. Also, a single umbilical artery may be
associated with congenital anomalies (abnormalities) of the kidney and urinary tract. If a child has
hydronephrosis, it is important to determine the underlying cause to discover how best to treat this
condition.
Exstrophy of the Bladder

Bladder exstrophy is a congenital defect in which the abdominal and anterior bladder walls do not fuse
during fetal development. The birth prevalence of classic bladder exstrophy has been estimated to be
between 1 in 10,000 and 1 in 50,000 livebirths (O’Kelly, Keefe, Herschorn, & Lorenzo, 2018). As a
result, the anterior surface of the bladder is open on the abdominal wall. Exstrophy comes from the
Greek meaning “turn inside out.” The tissue that usually covers the bladder does not form correctly and
is separated so the bladder is fully exposed.
Signs and Symptoms

The visualization that the bladder is open on the abdominal wall is the main determinant of this
condition.
Diagnosis
Ultrasound is used to diagnose exstrophy of the bladder.
Prevention
Prevention is promoted through good prenatal care and prenatal nutrition. Early detection of exstrophy
of the bladder in utero can assist the family to deliver at a neonatal intensive care unit that is capable of
proper care measures needed for the infant’s overall health and promotion of a good health outcome.
Collaborative Care
NURSING CARE
An important nursing consideration in caring for a child with bladder exstrophy is to cover the exposed
organ with saline-soaked gauze. Additional nursing care measures for exstrophy include vital signs
monitoring, fluid and electrolyte balance, infection prevention, nutrition maintenance, psychological care,
and pre- and postsurgical care.
SURGICAL CARE
Surgery is necessary within the first 24 to 48 hours of the infant’s life in this rare disorder. The surgical
procedure puts the bladder back into the abdomen, the separated pelvic bones are brought together,
and the abdominal skin is closed. The bladder may need to be augmented to improve its size, and
urinary diversion is sometimes required. Associated abnormalities may require correction with
subsequent surgeries.
The nurse teaches the family to provide care for their infant including incisional care post-operatively. If
the infant is discharged prior to reconstructive surgery, instruct parents to change diapers frequently and
cover the defect with plastic wrap to decrease the risk of infection and ulceration. The nurse must teach
the family the signs and symptoms of UTIs and when to seek care. The nurse must educate and support
the family regarding realistic long-term outcomes of both functional and cosmetic results depending on
the exact components of the infant’s GU defects.
FUNCTIONAL DISORDERS OF THE URINARY TRACT

Dysfunctional Elimination Syndrome
Dysfunctional elimination syndrome (DES), also called voiding dysfunction, is an abnormal but common
pediatric elimination pattern associated with bladder and bowel withholding and incontinence. DES
refers to the inability to efficiently empty the bladder, and this may be associated with UTI, constipation,
incontinence, and other issues.
There are different types of enuresis. Primary nocturnal enuresis (PNE) is bedwetting during the night.
Primary enuresis occurs when children have never been able to gain urinary control. Secondary
enuresis occurs after a child has achieved dryness for 6 to 12 months. A small percentage of primary
enuresis has a pathophysiological cause, but most cases are functional. Besides genetics and
developmental delay, some children with enuresis may have small bladder capacity; difficulty with
arousing during the night to void; low levels of antidiuretic hormone (ADH), which keeps people from
voiding at night; stress; and other family disruptions such as a new baby at home, school phobias, or
parental divorce.
NURSING INSIGHT
Functional Voiding Disorders
Enuresis may carry a genetic etiology. If one or both parents have suffered from enuresis, there is a higher likelihood their
offspring may suffer too. Chromosomal studies show a genetic predisposition for enuresis. Fifty percent of children with
enuresis have one parent who suffered from it. Developmental delays in other areas, such as speech, motor, and growth,
may accompany enuresis issues.
Signs and Symptoms

Signs and symptoms of enuresis include:
■ Patterns of urinary urgency, crossed legs, jiggling behaviors, holding genitals
■ Foul-smelling urine odor
■ Behavior problems, developmental delays, or possible ADHD
■ Encopresis (involuntary loss of stool after normal time of control)
■ Diabetes mellitus (polyuria, polydipsia, polyphagia, weight gain or loss)
■ Obstructive sleep apnea
■ Psychological stress
■ Signs of sexual abuse
Diagnosis
Diagnosis is based on patient history and physical examination to rule out other medical conditions as
the cause of enuresis.
Prevention
Enuresis is sometimes genetic, making prevention associated with awareness of familial incidence. In
other cases, enuresis may be related to a variety of conditions, some of which can be prevented by
medications or counseling.
Collaborative Care
NURSING CARE
It is important to determine whether the child has primary or secondary enuresis. Enuresis is not
considered abnormal until it is outside the range of 5 to 6 years of age. Nurses need to counsel parents
on this fact and make them aware of developmental norms for toileting. Patient education can include
these measures:
■ Bed alarms are very popular with a higher success rate than medications; a bell or buzzer is triggered
when the child begins to void. Eventually, the child usually learns to wake, but it may take up to 12
weeks of treatment.
■ Not every child with enuresis has psychological problems, but there is an increased incidence of
psychological issues in secondary enuresis, including parental divorce, school trauma, hospitalization,
and sexual abuse. Acupressure or massage therapy can be useful in some cases of psychological-
induced enuresis.
■ Motivational therapy uses rewards, such as a star chart where the child receives a star for dry nights
or days. Children are taught to become more sensitive to body cues for voiding. Rewards can be
associated with achieving a certain number of dry nights.
MEDICAL CARE
In extreme cases of enuresis, the child may be given medication to control the bladder. Many children
are embarrassed by this problem, and school functions, camp, and sleepovers become problematic.
Some parents use medication only as needed for these special occasions. The most commonly
prescribed medication to treat enuresis is desmopressin (DDAVP), a synthetic analogue of ADH. This
oral medication lowers nocturnal urinary production. DDAVP is available in 0.2 mg tablets given in
dosages of 0.2 mg to 0.6 mg per night. It is not to be used under age 6, and there is a risk of
hyponatremia (low sodium), which can be dangerous, even causing seizures. A prior form of DDAVP,
the nasal form, has been withdrawn from the market because of high risk of hyponatremia and seizures.
Children who are hypertensive or who have risk of fluid or electrolyte imbalance (e.g., children with
cystic fibrosis) should not use DDAVP oral tablets.
MEDICATION: Imipramine (Tofranil)

(im-ip-pra-mean)
Indications: Depression, enuresis, bulimia, attention deficit disorder in children, obsessive-compulsive disorder, panic
disorder
Actions: Tricyclic antidepressant known to increase the effect of norepinephrine and serotonin in the body. It also
possesses anticholinergic side effects.
• Cardiovascular disease
• Seizure disorder
• Children younger than age 6
• Concomitant use of MAO inhibitors, such as Nardil and Parnate; cannot take Tofranil within 2 weeks of taking an MAO
inhibitor drug
• Recent myocardial infarction
• Nervousness, anxiety, emotional instability
• Fainting, convulsions
• Constipation, nausea, vomiting
• Fatigue, sleep disorders
• Dry mouth
• Gynecomastia
• Confusion, hallucinations
• High or low blood pressure
• Tremor, numbness
1. Risk of potential suicidal ideation during initiation of upward titration of this medication, especially in children and
adolescents.
2. Toxic and possibly fatal drug interactions can occur with concomitant use of MAO inhibitors (e.g., Nardil, Parnate),
SSRI drugs (e.g., Prozac, Paxil), and clonidine (antihypertensive drug also used for ADHD).
3. Blood pressure and heart rate should be assessed before treatment, and an initial electrocardiogram (ECG) should be
taken. Serial ECGs may be needed with dose adjustments to monitor for prolonged PR and QT intervals and flattened
T waves.
4. Nurses must assess patients for mood alterations, hallucinations, confusion, and laboratory abnormalities (leukocytes,
blood glucose, and renal and hepatic status).
5. There is a significant risk of agitation, arrhythmias, hallucinations, fever, dyspnea, seizures, and vomiting in acute
overdose. Treatment consists of gastric lavage, use of charcoal, and a stimulant cathartic. Additional supportive
measures are heart monitoring, respiratory status monitoring, and possibly use of antiarrhythmic and anticonvulsant
agents (AAP, 2020).
Oxybutynin chloride is used for immediate release or extended release. This anticholinergic drug is used to defer
incontinence. It is not used for children under 5 years of age. It is effective for daytime enuresis. The dose is 5 mg orally
once daily. If needed, the health-care provider increases the dose as tolerated in 5 mg increments up to a maximum of 20
mg per day. Side effects include mouth dryness, urinary retention, and constipation.
RENAL TRAUMA
In the emergency department, the nurse is prepared for all situations, and GU system traumas account
for approximately 10% of all injuries. A GU system trauma includes the scrotum, penis, urethra, ureters,
bladder, and kidneys. For those patients with trauma to the abdomen, there are about 10% to 15% GU
injuries that are concurrent.
Kidney trauma is present in about 8% to 10% of abdominal trauma situations. History of injury relates
to blunt and penetrating abdominal injury. Blunt trauma examples are injuries from sports, violence,
motor vehicle injuries, and falls from high places. Kidney injury occurs more often from blunt trauma.
Blunt abdominal trauma often is not the only damage that occurs because there may be multisystem
injuries, but kidneys are known for rupturing from blunt trauma. Penetrating trauma examples are often
caused by animal bites, gunshot wounds, or stabbings. Death with renal trauma is secondary to
hemorrhage or multisystem damage. Children must be observed for covert symptoms of hemorrhage
because they can compensate and not show hypovolemia until in great distress. Also, it is important to
recognize that children’s kidneys are more anterior and mobile (greater amount of space in the
abdomen) as well as greater in size compared with the child’s body and often are less protected by
adipose tissue.
Signs and Symptoms

With critical injuries involving renal trauma, children show the following signs and symptoms:
■ Grey-Turner sign (ecchymosis localized in the flank area and flank tenderness) Palpable mass
■ Hematuria
NURSING INSIGHT
Hematuria
While hematuria is rarely seen, it is often considered the cardinal marker of renal injury. The presence of any degree of
hematuria is regarded as a potential indication of underlying renal injury or anomaly. Hematuria out of proportion to the
mechanisms of injury should suggest a congenital anomaly or neoplasm.
Diagnosis
Understanding the actual injury mechanisms assists in diagnosing the extent of the renal injury.
Diagnosis of renal trauma is confirmed by history and clinical findings as well as diagnostic studies that
may include focused abdominal sonography for trauma, computerized tomography, and diagnostic
peritoneal lavage (Yu-Hin Chan et al, 2019).
Prevention
Prevention of morbidity and mortality is gained through proper emergency care in situations including
car accidents and athletic injuries.
Collaborative Care
Nursing Care
Because renal trauma is a critical injury, advanced trauma life-support guidelines are followed. The goal
of nursing care is prevention of renal morbidity and mortality. Kidney injuries are assessed with grades I
through V. Blunt trauma, such as bruising without any urinary extravasation (grades I, II, and III), is
treated conservatively. Treatment includes bedrest, analgesia, and prophylactic antibiotics. Grades IV
and V renal trauma require referral to the urologist.
Nursing care centers on recognizing a renal injury and its potential urgency. The nurse gathers a
detailed history of the problem. Sometimes a lengthy admission process is not possible because of the
impending surgery. Performing a nursing assessment including vital signs, growth and development,
nutritional and immunization status, and a thorough physical examination is essential. The nurse gains
crucial information such as the precipitating event, allergies, medications, general state of health, and
previous hospitalizations or surgeries. Also, the nurse gathers information including possible previous
renal disease, increased blood pressure, or the presence of only one kidney, which presents its own
special needs.
Surgical Care
Surgery may be required if abdominal exploration is needed. Prepare both the child and family for the
surgery and immediate postoperative care. Essential abbreviated information is communicated because
the family may not understand the full situation. Serious injury to the urinary system often requires
astute observation in the critical care unit. Nursing care is tailored to the identified problems in order of
importance, and the nurse must develop a care plan that deals with the multifaceted problems.
After surgery, the child is placed on bedrest for initial observation and remains on bedrest for 3 days
after internal bleeding has subsided. The nurse must monitor vital signs; urinary, respiratory, cardiac,
and gastrointestinal status; and the surgical incision. Priority actions also include monitoring intake and
output, measuring weight and abdominal girth, administering IV fluids, and managing pain. Report signs
of inadequate renal perfusion (hypotension) and acidosis and observe for edema, oliguria, or anuria.
Collaborative care that includes psychological support is also important. Psychosocial care of the
family includes encouraging the parents to remain at the bedside, relaying appropriate developmental
information, and minimizing stressors experienced by the child. Remind the family to avoid discussions
at the bedside that may upset the child. Respect and support the family’s decisions about medical care
but advocate through the proper channels for the child if the best interest of the child is in question.
Notify a hospital chaplain for spiritual care if the family desires.
Inform the family to follow health-care provider instructions and keep clinic appointments. Educate the
family on potential complications that may occur years later such as hypertension or proteinuria. The
American Academy of Pediatrics, American Academy of Family Physicians, and the Medical Society of
Sports Medicine recommend avoiding heavy contact sports or collisions.
RENAL FAILURE
Acute Kidney Injury
Acute renal failure in children is now referenced as acute kidney injury (AKI), which is characterized by
the acute failure of the kidneys to maintain adequate electrolyte, acid-base, and fluid homeostasis along
with a reduction in GFR (American Academy of Pediatrics, 2020). AKI is a life-threatening syndrome in
which there is a sudden decreased capacity of the kidneys to eliminate waste products, resulting in an
inability to maintain fluid and electrolyte or acid-base balance (Shaikh, Hoberman, Hum, et al, 2018).
Acute kidney injury has a significant morbidity and mortality for critically ill pediatric patients, especially if
children have suffered a multisystem organ failure.
Hypotonic fluids used in excess can cause hyponatremia and anemia, which affect the central
nervous and cardiac systems (Shaikh et al, 2018). If there is an overload of potassium (hyperkalemia) or
inadequate ability of the kidneys to excrete potassium, life-threatening hyperkalemia may cause cellular
damage and increased neuromuscular excitability and possibly lead to cardiac arrhythmias. With AKI,
hydrogen ion excretion and bicarbonate reabsorption by the kidneys are insufficient. The resultant
acidosis promotes further hyperkalemia resulting from the movement of intracellular potassium into the
extracellular space as the body attempts to accommodate the higher hydrogen ion concentration.
Respiratory compensation for an underlying metabolic acidosis may cause low carbon dioxide pressure
resulting from tachypnea or Kussmaul’s respiration. Failure of renal phosphate excretion with AKI can
lead to hyperphosphatemia, and inversely hypocalcemia, sometimes causing tremors and seizures.
Diagnosis
Determining if the cause of the AKI is prerenal, intrarenal, or postrenal requires a very careful history,
analysis of symptoms, and physical examination. A medical history helps to determine previous
infections such as acute glomerulonephritis or neurogenic bladder. Genetic problems, such as a
horseshoe-shaped kidney or only one kidney, may be uncovered.
Diagnostic Tools
Renal Biopsy
Renal biopsy is ordered by the health-care provider if the cause of the AKI cannot be ascertained. Contraindications to
percutaneous renal biopsy include sepsis, uncontrolled high blood pressure, infection, hemorrhagic diathesis,
parenchymal malignancy, or infection. After the biopsy, bleeding is the most frequent problem but is rarely a critical issue
that would require operative strategies. In conjunction with a biopsy, renal ultrasound has advantages, such as pinpointing
obstructive uropathy and helping identify fluid collecting in perirenal spaces, which assists in differentiating cysts and
masses that are solid and can illustrate the actual flow of blood with use of the Doppler.
Labs
Complete Blood Count and Urinalysis

A CBC helps identify evidence of renal anemia and gives information about platelets and red and white blood cells that
provides clues of infection and types of anemia (Tables 23-5 and 23-6). If the values are outside normal ranges, then
more lab investigation is important (e.g., understanding if erythropoietin therapy is needed or if there are other causes
such as infection, hyperparathyroidism, or deficiencies in vitamins such as B12 and folic acid) (Raina et al, 2019).
It is also important for the nurse to review urinalysis, serum BUN, serum creatinine, creatinine clearance, BUN-to-
creatinine ratio, and biomarkers.
The nursing responsibilities for care of the patient with AKI are multiple and require significant patience with a child
who has a changing level of consciousness and irritability. It is important to monitor laboratory results and identify
hemodilution from overload of fluids.
An inaccurate weight recorded in the patient’s electronic record can cause life-threatening harm for the patient. It is
critical that when delegating to nonlicensed health-care providers, such as nursing assistants, the nurse carefully
monitors that the weight measures are being done properly and that the body mass index is plotted. Be sure to obtain
accurate weight on the same scale, at the same time of day, and with the patient wearing the same clothing (infants are
weighed naked and older children often only have on their underwear). The weights are ordered once a day, before
feedings, and every 12 hours for critically ill children.
Collaboration with the health-care team is critical to ensure AKI complications are reduced or prevented, depending on
whether the etiology is prerenal, intrarenal, or postrenal. Early recognition with a good nursing assessment assists with a
medical diagnosis. Appropriate nursing intervention aids in preventing AKI progression to parenchymal damage and
increasing renal failure (Tables 23-7 and 23-8). The complications of AKI are variable, depending on the underlying
etiology.
Table 23-5
Common Urinalysis Findings of Acute Kidney Injury
URINALYSIS FINDINGS INTERPRETATION
Urinary Sediment Intrinsic kidney failure
Color “Dirty” brown: intrinsic renal failure Reddish brown: acute glomerulonephritis Bilious
tinge: mixed hepatic and renal failure
Proteinuria Glomerulonephritis Interstitial nephritis Toxic and infectious causes
Casts Red blood cell (RBC) casts Glomerulonephritis or vasculitis White blood cell (WBC)
casts Interstitial nephritis Granular casts: glomerulonephritis Uric acid crystals: tumor
lysis syndrome Calcium oxylate crystals: ethylene glycols
Ingestion acetaminophen (Tylenol) crystals: acetaminophen (Tylenol)
The long-term outcome for AKI relates to the etiology. Referral to a nephrologist as well as renal
replacement therapy may prevent further complications from AKI (Nash, Przech, Wald, & O’Reilly,
2017). The family of a child with AKI is cared for holistically; close physical observations of nutrition,
intake and output, and vital signs are necessary to prevent future chronic renal failure.
Chronic Kidney Disease

The term chronic kidney disease (CKD) has replaced the previous term of chronic renal failure or
chronic renal insufficiency but excludes children younger than 2 whose quick response to treatment
cannot be estimated alone by the GFR (Table 23-9). For children older than 2, the GFR may
progressively deteriorate through four separate stages, and the rate varies from patient to patient.
TABLE 23-6
Common Causes of Acute Kidney Injury
PRERENAL INTRINSIC RENAL POSTRENAL
Dehydration Glomerulonephritis Posterior urethral valves
Hemorrhage Postinfectious/Poststreptococcal Ureteropelvic junction obstruction
Sepsis Lupus erythematosus Ureterovesicular junction obstruction
Hypoalbuminemia (severe) Henoch-Schönlein purpura Ureterocele
Cardiac failure Anti-glomerular basement Tumor
membrane Urolithiasis
Hemolytic uremic syndrome Hemorrhagic cystitis
Acute tubular necrosis Neurogenic bladder
Cortical necrosis
Renal vein thrombosis
Rhabdomyolysis
Acute interstitial cystitis
Tumor infi ltration
Tumor lysis syndrome
TABLE 23-7
Complications of Acute Kidney Injury
METABOLIC CARDIOVASCULAR GASTROINTESTINAL NEUROLOGICAL HEMATOLOGICAL INFECTION OTHE
Hyperkalemia Pulmonary edema Nausea Neuromuscular Anemia Pneumonia Hiccup
Metabolicacidosis Arrhythmias Vomiting irritability Bleeding Septicemia Increa
Hyponatremia Pericarditis Malnutrition Asterixis (fl apping Urinary tract parath
Hypocalcemia Pericardial effusion Gastrointestinal tremor) infection hormo
Hyperphosphatemia Pulmonary embolism hemorrhage Seizures Low to
Hypermagnesemia Hypertension Mental status triiodo
Hyperuricemia Myocardial infarction change Low th
Norma
thyrox
TABLE 23-8
Medications Used to Treat Complications of Acute Kidney Injury
MEDICATION ACTION/INDICATION NURSING IMPLICATIONS
Hyperkalemia Exchanges sodium for potassium May require up to 4 hours to take effect. Monitor
• Kayexalate Counteracts potassium-induced for ECG changes. IV infiltration may result in
• calcium gluconate 10% increased myocardial irritability tissue necrosis. Give by inhalation.
• albuterol Shifts potassium to the cells
Metabolic Acidosis Helps correct metabolic acidosis by Do not mix with calcium. Complications include
• sodium bicarbonate or sodium exchanging hydrogen for potassium fluid overload, hypertension, and tetany.
citrate
Hypocalcemia Used in the presence of tetany; Administer slowly to prevent bradycardia. Monitor
• calcium gluconate 10% provides ionized calcium to restore for ECG changes.
nervous tissue function to control
serum phosphorus
Malignant Relaxes smooth muscle in Administer by continuous IV infusion; fall in blood
Hypertension (B/P >95% for age) peripheral arterioles pressure is seen within 10–20 min.
• sodium nitroprusside, nitroglycerin
TABLE 23-9
Four Stages of Chronic Kidney Disease According to Glomerular Filtration Rate (GFR)
PERCENTAGE OF REDUCTION STAGE OF RENAL FAILURE GLOMERULAR FILTRATION RATE AS
OF GFR APPLIED TO CHILDREN AGE 2 AND OLDER*
35%-55% of normal 1. Reduced renal reserve ≥90
25%-35% of normal 2. Renal insufficiency 60.89
20%-25% of normal 3. Renal failure 30.59
Less than 20% of normal 4. End-stage renal disease (ESRD) 15.29*
*If GFR <15, dialysis is needed

A Developmental Perspective of CKD
Developmentally, the etiology of CKD in children is age-related and dependent on the organs affected. For children
younger than 2 years, obstructive uropathy or renal hypodysplasia is the common underlying problem. For children
between 2 and 5 years of age, neonatal vascular accidents, renal hypodysplasia, and obstructive uropathy are factors.
For older children and adolescents, glomerulonephritis, lupus nephritis, or reflux nephropathy are the underlying
etiologies. Genetic considerations include polycystic kidney disease, congenital nephritic syndrome, and sickle cell
disease. For some, the course of the disease may eventually be fatal unless RRT and dialysis are initiated and
sometimes followed by kidney transplantation (de Galasso, Picca, Guzzo, 2019).
Children with renal disease beginning in infancy and those with a congenital etiology are at risk for
growth failure and for progression to end-stage renal disease (ESRD). Genetic counseling is promoted
in family planning in these situations. It is also important for early detection of CKD for the following
reasons:
■ Timely surgical intervention, so early in-utero surgery can occur
■ Knowledge that each disorder requires different treatments and has varying prognoses
■ Information about genetic counseling because early diagnosis and treatment for siblings can be
initiated if a hereditary or metabolic disease is discovered
■ Attention to the timing and donor selection for renal transplantation
Signs and Symptoms

Table 23-10 outlines the pathophysiology that underlies the signs and symptoms of CKD. The most
common pathophysiological findings at the time of diagnosis are related to (1) fluid and electrolyte/acid-
base abnormalities, (2) metabolic abnormalities, (3) hormone alteration, (4) uremia, and (5) growth
restriction. Additional conditions diagnosed secondary to severe uremia include congestive heart failure,
pericarditis, uremic pleuritis, encephalopathy, and gastrointestinal bleeding. Actual signs and symptoms
of CKD are:
■ Failure to thrive or anorexia
■ Nausea
■ Vomiting
■ Lethargy
■ Headaches
■ Reduced urine output
■ Polyuria and polydipsia
■ Bedwetting
What to Say
Gathering Information From Parents
The nurse asks the parents if the child has any of the following symptoms:
• Malaise
• Poor appetite
• Vomiting
• Bone pain
• Headache
• Polyuria
The nurse also asks the parents if the child has had any of the following signs and symptoms in the past:
• Perinatal complications
• Oligohydramnios
• Recurrent UTIs
• Enuresis
In addition, the nurse asks the parent:
• “Is there any family history of renal disease?”
• “Is there any family history of hearing impairment?”
Diagnosis
Physical examination findings of CKD have correlations with underlying pathophysiological mechanisms
with all major body systems including skeletal, cardiopulmonary, neurological, endocrine, reproductive,
hematological, gastrointestinal, integumentary, immunological, HEENT, and the abdomen (Table 23-11).
TABLE 23-10
Pathophysiology of Chronic Kidney Disease
SIGNS AND SYMPTOMS MECHANISM
Accumulation of nitrogenous waste products Decrease in glomerular filtration rate
Acidosis Decreased ammonia synthesis
Impaired bicarbonate reabsorption
Decreased net acid excretion
Sodium retention Excessive renin production Oliguria
Sodium wasting Solute dieresis
Tubular damage
Urinary concentrating defect Solute dieresis
Tubular damage
Hyperkalemia Decrease in glomerular filtration rate
Metabolic acidosis
Excessive potassium intake
Hyporeninemic hypoaldosteronism
Renal osteodystrophy Impaired renal production of 1, 25-dihydroxycholecalciferol
Hyperphosphatemia
Hypocalcemia
Secondary hyperparathyroidism
Growth retardation Inadequate caloric intake
Renal osteodystrophy
Metabolic acidosis
Anemia
Growth hormone resistance
Anemia Decreased erythropoietin production
Iron deficiency
Folate deficiency
Vitamin B12 deficiency
Decreased erythrocyte survival
Bleeding tendency Defective platelet function
Infection Defective granulocyte function
Impaired cellular immune functions
Indwelling dialysis catheters
Neurological symptoms (fatigue, poor Uremic factors
concentration, headache, drowsiness, memory Aluminum toxicity
loss, seizures, peripheral neuropathy Hypertension
Gastrointestinal symptoms (feeding intolerance, Gastroesophageal reflux Decreased gastrointestinal motility
abdominal pain)
Hypertension Volume overload
Excessive renin production
Hyperlipidemia Decreased plasma lipoprotein lipase activity
Pericarditis, cardiomyopathy Uremic factor(s)
Hypertension
Fluid overload
Glucose intolerance Tissue insulin resistance
Source: Used with permission from Sreedharan, R., & Avner, E. (2011). In R. M. Kliegman, B. M. D. Stanton, St. J. W. Geme,
N. F. Schor, & R. E. Behrman, Nelson’s textbook of pediatrics (19th ed.). Philadelphia, PA: Elsevier Saunders.
Common urinalysis findings associated with CKD include a urinary sediment; color ranging from dirty
brown, reddish brown, to bilious tinge; proteinuria; and casts.
Labs
CKD Laboratory Findings
Laboratory findings are reflected in elevated BUN and serum creatinine along with hyperkalemia, hyponatremia,
acidosis, hypocalcemia, hypophosphatemia, and elevated uric acid. A CBC is essential along with serum cholesterol and
triglyceride levels, which are often increased.
Diagnosis is also based on fluid, electrolyte, and acid-base abnormalities including identifying
potassium (usually high), degree of fluid volume overload, and sodium imbalance. Diagnosis of
metabolic abnormalities is made through calcium and phosphate serum elevations and increased
parathyroid hormone (PTH), which promotes phosphate and calcium excretion. Assessment of active
vitamin D is necessary because there is a vitamin D deficiency, which reduces the absorption of calcium
in the gut and causes skeletal problems secondary to PTH.
CKD diagnostic tests that are frequently ordered by the health-care provider to assess for the fluid,
electrolyte, and acid-base abnormalities; metabolic abnormalities; hormone alterations; uremia; and
growth restriction include chest radiographs, bone films, renal ultrasounds, and ECGs if the child is
hyperkalemic (NKF, 2019).
TABLE 23-11
Physical Examination Findings Correlated With Underlying Pathophysiological Mechanisms for Chronic Kidney
Disease
ORGAN SYSTEM PHYSICAL FINDINGS CORRELATION WITH
PATHOPHYSIOLOGICAL MECHANISMS
Skeletal Osteitis fibrosa (bone inflammation with fibrous Bone resorption associated with
degeneration) hyperparathyroidism, vitamin D deficiency, and
Bone demineralization (principally subperiosteal demineralization
loss of cortical bone in the fibers, lateral ends of Lowered calcium and raised phosphate levels
the clavicles, and lamina dura of the teeth)
Spontaneous fractures, bone pain; osteomalacia
(rickets or rachitic changes) with end-stage renal
failure
Edema
Absent patella
Cardiopulmonary Hypertension, pericarditis with fever, chest pain, Extracellular volume expansion as cause of
pericardial friction rub, pulmonary edema, hypertension
Kussmaul’s respiration Hypersecretion of renin also associated with
Flow murmur hypertension
Gallop Fluid overload associated with pulmonary edema
Rub and acidosis leading to Kussmaul’s respiration
Neurological Encephalopathy (fatigue, loss of attention, Uremic toxins associated with end-stage renal
difficulty problem solving) disease
Peripheral neuropathy (pain and burning in the
legs and feet, loss of vibration sense and deep
tendon reflexes)
Loss of motor coordination, twitching,
fasciculations, stupor, and coma with advanced
uremia
Hypotonia
Irritability
Endocrine and Retarded growth in children (short stature) Decreased growth hormone
Reproductive Osteomalacia Elevated parathyroid hormone
High incidence of goiter Decreased thyroid hormone
Sexual dysfunction: menorrhagia, amenorrhea, Elevated hormones: luteinizing hormone (LH),
infertility, and decreased libido in women; follicle-stimulating hormone, prolactin, and LH-
decreased testosterone levels, infertility, and releasing hormone; decreased testosterone,
decreased libido in men estrogen, and progesterone
Hematological Anemia, usually normochromic, normocytic; Reduced erythropoietin secretion associated with
platelet disorders with prolonged bleeding times loss of renal mass, leading to reduced red cell
(increase in bleeding gums) production in the bone marrow; uremic toxins
associated with shortened red cell survival
Gastrointestinal Anorexia, nausea, vomiting Retention of urea, metabolic acids, and other
Mouth ulcers, stomatitis, bad breath (uremic metabolic waste products, including
fetor), hiccups, peptic ulcers, gastrointestinal methylguanidine
bleeding, and pancreatitis associated with end-
stage renal failure
Integumentary Abnormal pigmentation and pruritus Retention of urochrome, contributing to sallow,
yellow color
High plasma calcium levels associated with
pruritus
Immunological Increased risk of infection that can cause death; Suppression of cell-mediated immunity
decreased response to vaccination Reduction in number and function of
lymphocytes
Diminished phagocytosis
HEENT Retinal changes Uremic toxins
Preauricular pits
Hearing deficit
Abdomen Palpable kidneys
Suprapubic mass
Prevention
Malnutrition of the pregnant woman has correlation with renal disease for herself as well as for the
unborn child. Hence, good prenatal care is of the utmost importance. After birth, it is also important to
plot the child’s growth on a standardized growth chart because growth delays alert a health-care
provider to potential renal problems.
With the emphasis now on prevention and early assessment to spot CKD, prognosis has improved.
Future experience with biomarkers such as interleukin-18, neutrophil gelatinase-associated lipocalin,
and kidney injury molecule 1 may allow for prevention by determining earlier if kidney disease is
present. Intervening quickly can prevent further renal damage.
Collaborative Care
NURSING CARE
A through nursing assessment includes correlating the pathophysiology with the affected organ
systems. The goals of nursing care for a patient with CKD are mutually established by the health-care
provider and family. Collaboration with the health-care team is essential so that the quality of the child’s
life is extended as long as possible as the renal capacity diminishes affecting all organ systems.
It is important to provide the best possible nutrition. Nutrition has the greatest effect on renal recovery
(AAP, 2020). Given the many changes that occur with CKD, normal nutrition is challenged. Collaborate
with a dietitian who helps with meal planning to counteract growth restriction.
Pastoral care may be needed because this chronic disease takes its toll on the entire family as ESRD
occurs. Also, the nurse can discuss renal transplant with the family.
MEDICAL CARE
Once the diagnosis is made from a well-taken history and laboratory results are completed,
medications are ordered (Table 23-12).
RENAL REPLACEMENT THERAPY

Renal replacement therapy (RRT) is the treatment option for ESRD and is also used for AKI. For the
child with CKD, discussion with the family often starts when the child is in Stage 4 of the disease. RRT
for children is a momentous decision for the family while they await a possible donor kidney. There are
three methods of RRT:
TABLE 23-12
Medications Commonly Used for Children With Chronic Kidney Disease
MEDICATION ACTION OR INDICATION NURSING CONSIDERATIONS
Vitamin and mineral supplement Add vitamins and minerals missing from Only prescribed vitamins should be used;
(Nephrocaps) heavily restricted diet over-the-counter brands may contain
elements that are harmful.
Phosphate-binding agents: calcium Reduce absorption of phosphorus from Ensure that phosphate-binding agent is
carbonate (Tums), calcium acetate the intestines aluminum-free.
(PhosLo), or sevelamer hydrochloride
(Renagel)
calcitriol (Rocaltrol) Replace the calcitriol that kidneys are no Monitor serum calcium level. Ensure that
longer producing to keep calcium calcium supplement is provided.
balance normal
epoetin alfa (Epogen, Procrit) Stimulates bone marrow to produce red Given by IV or subcutaneous injection.
blood cells, treats anemia caused by Monitor blood pressure because
CRF hypertension is an adverse effect.
Monitor hematocrit and serum ferritin
level according to facility guidelines.
Iron supplementation Treat iron deficiency when epoetin alfa May be administered orally or IV during
(Epogen) is prescribed hemodialysis.
Growth hormone (GH) Used to stimulate growth in children with Record accurate height measurements at
CRF regular intervals.
Antihypertensive agents: Angiotensin- Used with proteinuric kidney disease Monitor renal function and electrolyte
converting enzyme (ACE) inhibitor because it slows the progression to balance.
(enalapril, lisinopril) Loop diuretics ESRD
Used when volume overload is present
1. Hemofiltration, also known as continuous RRT (CRRT)

2. Peritoneal dialysis (PD)
3. Hemodialysis (HD)
Hemofiltration
In the pediatric setting, hemofiltration, or CRRT, is a broad category that results in removing water by
filtration through an extracorporeal system.
Collaborative Care
NURSING CARE
Prior to hemofiltration or CRRT, the goals of care include stabilizing fluid balance and assessing BUN,
creatinine, glucose, and partial thromboplastin time (PTT) before initiating the procedure. Once
hemofiltration, or CRRT, commences, vital signs are monitored along with fluid balance every 30
minutes. The ultrafiltration rate is assessed every hour with replacement fluid set by the nephrologist.
The patency of all the circuits is carefully checked, including looking for clots. Analysis of PTT and
clotting studies are monitored every 1 to 3 hours.
Hemodialysis or Peritoneal Dialysis

The choice of dialysis, hemodialysis (HD) or peritoneal dialysis (PD) depends on the medical
diagnosis, age, and symptoms that indicate the timing of starting RRT. Dialysis may be done through the
peritoneal wall (PD) or through cleansing the blood by using a dialysis machine (HD). It is important to
note that while dialysis is usually reserved for children in ESRD as a result of chronic renal failure, it may
also be needed in ARF if BUN and creatinine levels elevate.
Peritoneal Dialysis
The process of PD uses the peritoneal membrane (abdominal lining) to filter blood and purify it. A
dialysis solution composed of dextrose sugar and other minerals in water is inserted into the child’s
abdomen through an abdominal catheter. Through an osmotic process, the dialysis solution draws
toxins, excess water, and waste chemicals from the blood into the dialysis solution. From there, it is
drained through an abdominal tube out of the abdomen. The amount of time the dialysis solution is in
the abdomen is termed the dwell time, and the entire process of filling and emptying the abdomen is
termed an exchange. Box 23-2 outlines the advantages and disadvantages of PD in children with
ESRD.
PD and Adolescents
Adolescents may lack adherence to the PD protocol. Based on their age, body image, and self-esteem,
they may be affected by the appearance of an external catheter. It is important to suggest professional
counseling to help adolescents adapt to PD.
SIGNS AND SYMPTOMS
Signs and symptoms of PD complications include:
■ Potential peritonitis
■ Catheter dysfunction and obstruction
■ Pain
■ Pulmonary complications
DIAGNOSIS
Prior to PD, AKI or CKD is diagnosed.
BOX 23-2
Advantages and Disadvantages of Peritoneal Dialysis in Children With

End-Stage Renal Disease
ADVANTAGES
• Ability to perform dialysis treatment at home
• Easier than HD, especially in infants
• Ability to live a greater distance from medical center
• Freedom to attend school and after-school activities
• Less restrictive diet
• Less expensive than HD
• Promotes independence (adolescents)
DISADVANTAGES
• Catheter malfunction
• Catheter-related infections (peritonitis and at the site)
• Impaired appetite (because of full peritoneal cavity)
• Negative body image
• Caregiver burnout
Source: Sreedharan & Avner (2011). Chronic kidney disease. In R. M. Kliegman, B. M. D. Stanton, St. J. W. Geme, N. F.
Schor, & R. E. Behrman, Nelson’s textbook of pediatrics. (19th ed.). Philadelphia, PA: Elsevier Saunders
PREVENTION
The nurse who assesses the patient carefully regarding intake and output, lab work, and vital signs
and ascertains that these findings are within normal limits helps reduce complications by determining if it
is safe to start the PD. Also, once the cycle is completed, the nurse who discerns carefully that the
dialysate return is clear or quickly reports if it is cloudy, helps prevent peritonitis or PD complications.
COLLABORATIVE CARE
Nursing Care
Nursing care is directed at preventing or identifying PD complications. The riskiest problem with PD is
the chance of peritonitis, an infection of the abdominal peritoneum. This is extremely serious and
requires urgent antibiotic therapy, hospitalization, and follow-up with the child’s nephrologist. To prevent
infection, monitor the abdominal catheter sites for signs of infection or malfunctioning equipment and
make certain that the returning dialysate solution remains clear if in the hospital setting. Usually,
Staphylococcus aureus is the source of peritoneal infection, and cephalosporins and vancomycin
hydrochloride (vancomycin hydrochloride injection) are frequently used for treatment. Yet today,
because of vancomycin-resistant bacteria, vancomycin hydrochloride injection is not used as frequently.
Monitor for pain during PD, which may be present even though the patient may not complain. If the
pain is caused by inflow of the dialysis infusion, decrease the rate or infuse smaller volumes of the
dialysate. Pain can also occur from the catheter being in a pocket instead of the peritoneal area, and
distention can occur. This may indicate a need for the nurse to insert a new catheter. Pain also can
occur once the cavity of the abdomen is emptied completely, so arranging for a small amount of residual
fluid by decreasing the outflow time to less than 5 to 10 minutes reduces this pain.
When the cycle is completed, disconnect the tubing aseptically, cap the access, and use a sterile
dressing to cover the site. The patient is then placed on a scale and weighed to judge the adequacy of
fluid removal and to assess if kidney function has improved.
Assist parents and older children in learning about PD and preventing complications. Parents can
learn how to monitor for infection if the PD is given at home. If the dialysate return is cloudy, it indicates
a potential infection or problem. Parents must notify the health-care provider immediately.
Peritoneal Dialysis
The nurse, family, and child work together with the health-care provider with regard to the PD and to determine when a
new catheter needs to be inserted. The family also works closely with the dietician to learn about a renal diet that
promotes health. The family has a working relationship with the surgeon who placed the catheter, and that surgeon is
available when it is removed. When the catheter is removed, sterile technique is used and the tip of the catheter is sent
into the lab for a culture, according to institutional policy.
Hemodialysis
To prevent accumulation of unwanted fluid and toxins, HD removes unwanted products by
extracorporeal circulation through a dialyzer (Fig. 23-8). In adolescents and children in the United States
with ESRD, HD is preferred. Extra water, extra salt, and toxic waste products are removed while the
blood pressure and electrolytes, such as potassium, calcium, sodium, and bicarbonate, are kept in
balance.
Permanent and temporary vascular access means are available. Permanent vascular access is
offered through an arteriovenous (AV) fistula, AV graft, and dual lumen catheters with Dacron cuffs.
Access through the permanent port ideally occurs after a waiting period of 2 to 6 weeks, which allows
the AV fistula to become stronger.
The preferred type of vascular access is the AV fistula. In the AV fistula type, a surgeon connects an
artery directly to a vein, commonly in the forearm and around the wrist. A bruit is a noise heard on
auscultation that can best be detected over an AV fistula to make certain it is patent. The bruit is heard
best at the incision. Also, a thrill can be palpated. Palpating and listening for the bruits are important to
discern if thrombosis or stenosis has occurred as a complication.
The AV graft is reserved for children with small veins that do not properly form a fistula over time. It
requires a synthetic tube such as polytetrafluoroethylene to be implanted under the skin of the forearm.
In comparison to the AV fistula, AV grafts have a higher pressure within the arterial venous connection,
making them less compliant.
Many children must be hemodialyzed three times a week at an outpatient dialysis center. It is possible
to arrange for home HD if families meet the criteria of having running water and a parent and/or
caretaker who is able to understand how to do HD (CDC, 2019). Because each treatment lasts 3 to 4
hours, it is disruptive to the child’s time, although it is possible for the child to read, write, complete
homework, play video games, and watch television during this process. HD can be done in the hospital
or in the home setting and is administered at night, over a longer duration, which assists in removing
waste with fewer potential adverse effects such as hypotension.
FIGURE 23-8 The hemodialysis process.
KIDNEY TRANSPLANT
Children with progressive renal disease leading toward ESRD are referred for a kidney transplant
evaluation. Causes of ESRD may include:
■ Polycystic kidney disease
■ Inherited disease in which the kidneys overgrow with cysts that destroy good nephrons
■ Tubular disorders: renal tubular acidosis, Fanconi’s syndrome
■ Urinary tract abnormalities: reflux nephropathy, posterior ureteral valves, neurogenic bladder
■ Obstructive disorders: renal calculi, retroperitoneal fibrosis, prostatic hypertrophy
■ Autoimmune disorders: Goodpasture’s disease, Wegener’s disease, systemic lupus erythematosus,
IgA nephropathy
■ Primary glomerular disorders with NS
■ Renal vasculitis diseases: polyarteritis nodosa, Henoch-Schönlein purpura
■ Rare causes: hemolytic-uremic syndrome, thrombotic thrombocytopenic purpura, nephrotoxic agents,
renal cell carcinoma, renal aplasia, scleroderma, amyloidosis, tubulointer, stitial nephritis
The child and their family are evaluated to help provide the best transplant outcome. Children with
ESRD become transplant candidates if a transplant could improve quality of life and if the child can
withstand the significant surgical risks of transplantation. The child must not be significantly
immunocompromised prior to transplant. If the results of the evaluation are positive, then the child is
placed on the national waiting list. The United Network for Organ Sharing (UNOS) has data identifying
all patients who are waiting for a transplant and maintains a computer network to link all organ donation
centers and transplant centers.
Children may receive renal transplants either from unrelated donors who have died or from living
donors. The living donors may be relatives, close friends, or parents who have ideal tissue matches.
Over 50% of children who have a transplant receive from a living donor.
Prevention
To prevent rejection, children who receive renal transplants are on long-term immunosuppressive and
steroid medications. Medications include such drugs as FK506, Prograf, cyclosporine, and steroids.
Blood levels are monitored for medication adjustment of dosage as needed. These drugs increase the
child’s risk for infection and can cause Cushing’s syndrome by affecting glucocorticoids. Steroids can
also raise serum glucose level, giving the potential for development of diabetes mellitus. In addition,
steroids affect bone mineralization and strength, which can cause impairments in a growing child.
Growth hormone has been used to counteract this problem.
Collaborative Care
Nursing Care
Any transplant recipient needs a thorough nursing assessment related to possible infection, imbalance
of fluid and electrolytes, and rejection. Children who receive transplants remain on protein-restricted
diets to avoid overloading the kidneys and help the child maintain proper nutrition. Be sure to assess
growth and development and provide developmentally appropriate activities. Collaborate with social
workers, child life therapists, pastoral care, psychiatrists, counselors, financial assistance experts,
educators, and other health-care providers to ensure the best outcome for the child.
Signs and Symptoms of Kidney Transplant Rejection

Signs of kidney transplant rejection in children include hypertension, decreased urinary output, fever, weight gain,
tenderness over donated kidney, edema, graft site pain, and increasing BUN and creatinine levels. Educate parents about:
• Follow-up care
• Immunizations
• Immunosuppressive therapy
• Dietary compliance and avoiding undercooked food
• Activities and play
• Medications
• Schooling
• Wearing masks in crowded public places and not being in contact with ill people
• Good oral care and dental visits
• Adolescents transitioning to self-management
REPRODUCTIVE DISORDERS AFFECTING GIRLS

Vulvovaginitis
There are various etiologies of vulvovaginitis (inflammation of the vulva and vagina) in prepubertal
girls. Candidiasis, a yeast organism, is the most common source of this disorder. Vulvitis (vulvar
inflammation) may be isolated or occur with vaginitis, which is vaginal inflammation. The prepubertal girl
is sensitive to lack of estrogen, lack of protective hair, and lack of labial fat pads as well as the influence
of poor hygiene and proximity of the anus to the vulva. Clothing, soaps, and other chemicals may be
irritating to vulvar skin. Tight jeans, ballet leotards, nylon tights, underwear, and bathing suits may all
contribute to maceration and vulvar infection, especially if the weather is warm and there is associated
sweating. It is common for young girls to void with their legs together, which increases the risk of urine
refluxing into the vagina. Candidiasis is often associated with bubble baths in young girls, and this may
also lead to UTI.
Nonspecific vulvovaginitis without a clear etiology represents most cases in prepubertal girls. Fecal
organisms may cause vulvovaginitis because of poor hygiene and possibly wiping back to front after
voiding. Candida, bacteroides, and some other streptococcal species have also been noted. Gram-
negative Escherichia coli organisms have been cultured from girls with vulvovaginitis, and these may be
fecal in origin. Normal flora including lactobacilli, diphtheroids, and Staphylococcus epidermidis have
been noted on vaginal cultures of vulvovaginitis.
The presence of sexually transmitted infections such as those caused by Neisseria gonorrhea,
Chlamydia trachomatis, Trichomonas, herpes simplex, and human papillomavirus may indicate sexual
contact, either voluntary or because of sexual assault (CDC, 2019).
Signs and Symptoms

■ Vulvar itching
■ Discharge can vary from glutinous gray-white to purulent, blood-tinged, foul-smelling, and brown,
green, or thick white curds
Diagnosis
Diagnosis is based on patient history, clinical findings, and pH testing of vaginal secretions.
Pseudohyphae (branching yeast organisms) may be found on microscopy where the pH is less than 4.5.
Also, under the microscope, clue cells (large epithelial cells with bacteria) may indicate bacterial
vaginosis, and trichomonads may indicate trichomonads infections. Other organisms may be found on
Pap smears in adolescents (Candida or trichomonads).
Prevention
Instruct the parents and children to avoid predisposing factors for vaginitis. Use of antibiotics is
sometimes associated with Candida vaginitis.
Collaborative Care
NURSING CARE
Instruct young girls to wipe from the front to the back after voiding to avoid contaminating the
perineum with stool. Educate patients in complementary care measures.
Patient Education
Vaginal Candidiasis
Educating patients and families regarding prevention of vaginal candidiasis includes:
1. Wearing cotton underwear to allow better ventilation
2. Avoiding wearing wet clothing, such as bathing suits, for long periods
3. Avoiding bubble baths as well as perfumes or powder near the vaginal area
4. In menstruating females, avoiding use of scented sanitary pads or tampons
5. Avoiding excessive sugars and simple carbohydrates in the diet
6. Eating yogurt because the natural lactobacilli maintain normal bacterial balance
MEDICAL CARE
Medical management of vaginal candidiasis in prepubertal girls is best accomplished with over-the-
counter antifungal remedies such as miconazole (Monistat) and clotrimazole (Gyne-Lotrimin) creams
applied topically, avoiding internal insertion until the adolescent years.
Labial Adhesions
Labial adhesions are most common in girls from 3 months to 6 years old. This disorder is defined as the
fusion of the labia minora because of inflammation, infection, trauma, and estrogen deficit.
Signs and Symptoms

■ A thin film that develops over the labia, from the posterior aspect to the anterior aspect
■ The vaginal introitus and urethral meatus are not visible
■ Dysuria
■ Urinary incontinence
Diagnosis
Diagnosis is based on signs and symptoms, along with common associated problems such as dysuria
and incontinence if urine is trapped or dribbling after voiding in toilet-trained girls.
MEDICATION: Antifungal Agents

Miconazole (Monistat-Derm), Nystatin (Mycostatin), and clotrimazole (Mycelex) are antifungal agents used topically in the
vaginal area. Based on the health-care provider order, one of these medications is applied topically to the external vagina
once or twice daily in children. It can be applied also through a vaginal applicator in adolescents.
Prevention
Monitor for complications of UTI caused by obstruction of urine flow.
Collaborative Care
NURSING CARE
Conduct a thorough nursing assessment of the newborn and infant during health-care visits. Be sure
to report abnormal findings to the health-care provider. Assess for dysuria and incontinence. Ask the
parent about signs and symptoms of UTIs.
MEDICAL CARE
Treatment with hormone cream such as Premarin cream 0.625 mg bid for 10 to 14 days is the
standard treatment.
SURGICAL CARE
Surgery for lysis of adhesions may be performed as determined by the health-care provider.
Communicate to the family that the condition may have spontaneous resolution over time or with
treatment.
Amenorrhea
Amenorrhea refers to the absence of menses. Primary amenorrhea occurs by age 14 if there has been
no growth or development of secondary sexual characteristics (e.g., pubic hair, axillary hair, and
breasts). Primary amenorrhea also is defined as no menses by age 16 if there are secondary sexual
characteristics already. Secondary amenorrhea refers to a female who was previously menstruating
and has had no menses for at least 6 months.
Amenorrhea has several possible causes: congenital abnormalities or absence of the uterus, fallopian
tubes, or ovaries; deficiency of gonadotropin-releasing hormone from the pituitary; chromosomal
disorders such as Turner’s syndrome; lactation; menopause (premature or normal); hypothyroidism or
hyperthyroidism; chemotherapy; polycystic ovarian syndrome (PCOS); diabetes mellitus; stress;
excessive exercise, weight loss, anorexia, or bulimia; and pregnancy. Pregnancy must always be
considered as a cause of secondary amenorrhea, even if the patient denies sexual contact. In addition,
certain medications can cause amenorrhea, including birth control pills and medroxypro-gesterone
acetate (Depo Provera), which is given as a contraceptive injection.
Signs and Symptoms

Primary amenorrhea is characterized by delayed puberty based on the Tanner stages of sexual
characteristic development.
■ Delayed puberty
■ The Tanner stages of sexual characteristic development show delay
Secondary amenorrhea may include:
■ Signs and symptoms of pregnancy
■ Mastalgia (breast tenderness) or breast enlargement
■ Urinary frequency
■ Enlarged uterus
■ Chadwick’s sign
NURSING INSIGHT
Other Underlying Conditions
• Hypothyroidism as evidenced by fatigue, hoarseness, constipation, and an enlarged thyroid gland
• Hyperthyroidism as evidenced by oily skin and hair, diaphoresis, tachycardia, diarrhea, and a goiter (enlarged thyroid
gland)
• PCOS as evidenced by hirsutism (excessive facial and body hair) and obesity
• Corpus luteum cysts that cause intermittent pain in the lower abdominal quadrant
• Other cysts that can grow and rupture, causing significant lower abdominal quadrant pain as well as peritoneal signs of
rebound, guarding, and rigidity
Diagnosis
In the absence of menses, a number of laboratory tests and other diagnostic tests are often necessary
in the evaluation of amenorrhea.
Diagnostic Tools
Determining Reason for Amenorrhea
• Genetic testing may be required to determine disorders such as Turner’s syndrome.
• Pelvic ultrasound or transvaginal (ultrasound wand in the vaginal canal) is used to test for pregnancy, ovarian cysts, and
other gynecological abnormalities. Patients normally are required to drink four 8-ounce glasses of water 1 hour before a
pelvic ultrasound to elevate the bladder to view the pelvic organs.
Prevention
It is important to educate adolescent girls and boys about how pregnancy occurs and various birth
control methods.
Collaborative Care
NURSING CARE
Evaluate the patient with amenorrhea for signs and symptoms of pregnancy including weight gain,
unprotected coitus, fatigue, nausea and vomiting, and mastalgia. A urinary human chorionic
gonadotropin (HCG) test is given, and the patient is informed that it may turn positive within days after a
missed menses. In cases of possibly false negative urine pregnancy tests, it is necessary to administer
the serum HCG test to determine pregnancy status. If a parent is present with a girl who may be
pregnant, the nurse should attempt to have the parent wait outside to speak confidentially to the
adolescent girl by suggesting that, at this age, it is common to interview young women alone. Invite the
parent or guardian back at the conclusion of the discussion. This sometimes allows the opportunity for a
young woman to discuss the possibility of pregnancy or her concerns about contraception and sexually
transmitted diseases.
Assist the patient in constructing a calendar depicting her abnormal menstrual pattern. Young girls often
need to be educated about variations in menstrual cycles and why it is essential that they keep track of
their cycle days, intervals, and duration. Girls who have eating disorders such as anorexia nervosa or
bulimia may incur secondary amenorrhea because of weight loss and associated alterations in
estrogen. When body fat significantly decreases, amenorrhea or oligomenorrhea (infrequent menses)
may occur. Young girls who exercise heavily (e.g., gymnasts or distance runners) may develop
menstrual disorders as well as young girls with eating disorders. In the circumstance of adolescent
females, those with primary amenorrhea may have family members who have experienced the same
issue.
REPRODUCTIVE DISORDERS AFFECTING BOYS

Varicocele
Varicoceles are defined as abnormal dilations in the testicular veins, normally unilateral and affecting the
left testicle. Most varicoceles arise after age 9, and 16% of adolescents and 20% of adult males have
varicoceles. The etiology of this disorder remains unknown, but it is now considered the most common
cause of male infertility that is correctable.
Signs and Symptoms

Signs and symptoms of a varicocele include:
■ “Bag of worms” appearance
■ Thickened spermatic cord
■ Distended veins while standing
■ Decrease in varicocele when laying supine
■ Testes often smaller
■ Pain or heaviness in scrotum
Diagnosis
Doppler ultrasonography helps to definitively determine the presence of varicocele. Semen analysis may
also be done in older males.
Prevention
Prevention is important to prevent later infertility. The nurse recommends that the patient see the
urologist about potential surgical treatment.
Collaborative Care
NURSING CARE
Because this condition affects the genital area, emotional support is needed for the patient and family
of males contemplating surgical procedures. For the older child, testicular self-exam is taught. Athletic
supporters may help with the heaviness sensation.
SURGICAL CARE
Surgical ligation (binding or tying) of the spermatic veins is the curative approach to preserve fertility.
Nursing care centers on caring for the postsurgical patient. Standard postoperative measures are
implemented through overall assessment and assessment of the surgical area, vital signs, bleeding,
pain, respiratory status, intake and output, level of consciousness, nausea and vomiting, and fluid and
electrolyte balance.
Immediate home care includes low-level activities and rest. Teach parents signs and symptoms of
infection and how to assess for pain. Loose-fitting diapers are recommended. Prevent the child from
using riding toys during play. Instruct the parents to call the health-care provider with concerns or
questions.
Cryptorchidism
Cryptorchidism is defined as absent, undescended, or ectopic testicles. This is the most common male
congenital anomaly, noted in 2% to 4% of all newborn males. It may result from hormonal, anatomical,
or chromosomal variations. Prematurity increases the risk of cryptorchidism. Intersex conditions such as
congenital adrenal hyperplasia may be associated. In 80% of the cases, the testicles are palpable but
undescended, and the scrotal sac is empty as well as potentially flat or small. This condition must be
distinguished from retractile testes, which are descended testicles that rise into the groin area but can
be pushed down into the scrotum. Retractile testes are very common in young males (Verkauskas,
Malcius, Dasevicius, & Hadziselimovic, 2019).
The major risk associated with cryptorchidism is testicular cancer, which remains a lifetime risk even if
the child has surgical repair. There is also risk of decreased fertility, testicular torsion, and increased
trauma. If the testis does not descend permanently by age 6 months, surgical intervention is needed. All
patients with a history of cryptorchidism must be vigilant with testicular self-exam and have annual
testicular exams by a health-care provider.
Signs and Symptoms

Signs and symptoms of cryptorchidism include the following:
■ A retractile testis has descended but retracts with exam and physical stimulation.
■ An ectopic testis is outside the normal pathway (e.g., in the groin, abdominal wall, or perineum).
■ After 1 year of age, it is uncommon for the testes to spontaneously descend.
■ Affected testicle is unilateral in most cases (up to 85% of the time) (Verkauskas, Malcius, Dasevicius,
& Hadziselimovic, 2019).
Diagnosis
Diagnosis is based on patient history, physical examination findings, and imaging tests.
Prevention
Be aware that the risk of infertility may be decreased with surgical treatment although the risk of
testicular cancer remains high throughout life.
Collaborative Care
NURSING CARE
Gentle compression of the inguinal canals should reveal a palpable nodule in undescended testicles
(Fig. 23-9). Counsel the parents of the child about the surgery and the benefits of surgery for infertility.
Be prepared to counsel parents about the emotional upset of increased lifelong risk of testicular cancer.
SURGICAL CARE
The child will receive general anesthesia and sometimes a caudal block prior to surgery. The surgical
repair is called an orchiopexy and is usually done between ages 6 and 12 months. This surgery is
minimally invasive and may involve a laparoscope to locate and pull down the undescended testicle into
the scrotal sac, anchoring it there.
Similar education/discharge instructions apply to the patient who has undergone an orchiopexy as do
patients with varicocele.
NURSING INSIGHT
Hydrocele
A hydrocele is a collection of fluid in the scrotal sac, related to a patent processus vaginalis, which is the channel that
gives fluid the ability to move from abdomen to groin. Peritoneal abdominal fluid can pass into this patent canal, enlarging
the scrotal sack. This canal is patent in the majority of all newborns at birth, and in the first month of life, the incidence
decreases and again decreases by the age of 18 to 24 months. While this condition can rarely occur in females, primarily
in intersex conditions, it is common enough in males that it must be repaired if it has not resolved by 1 year. If a hernia is
found with it, earlier surgical repair is necessary.
FIGURE 23-9 An undescended testis is palpable in various areas and needs to be surgically corrected.
Hypospadias and Epispadias

Hypospadias and epispadias are possibly genetic congenital conditions that imply an abnormal
positioning of the urethral meatus in boys. In hypospadias, the meatus is inferior to its usual position. In
epispadias, the meatus is superior to its usual position, and a surgical correction with possible penile
urethral lengthening may be necessary. Hypospadias may cause chordee, which is a bending of the
penis that may later present problems with intercourse. Young males with hypospadias may not be able
to urinate standing, and there may be associated cryptorchidism. Patients need to be referred early to
pediatric urologists for surgical repair.
Signs and Symptoms

Signs and symptoms of hypospadias include:
■ Opening of the urethra below the tip on the bottom side of the penis
■ Incomplete foreskin
■ Curvature of the penis during erection
■ Abnormal position of the scrotum in relation to the penis
Signs and symptoms of epispadias are:
■ Opening of the urethra above the tip of the penis
■ Curvature of the penis
■ Urinary incontinence
Diagnosis
Diagnosis is based on patient history, physical examination findings, radiography, and ultrasound.
Prevention
Nurses must be aware of potential voiding dysfunction and chordee issues.
Collaborative Care
NURSING CARE
The etiology of hypospadias is uncertain. Nurses can assist the families with coping and counseling
parents about the child’s need for surgery.
SURGICAL CARE
Surgery is usually performed during the second 6 months of the boy’s life and before toilet training.
Circumcision cannot be done until after this procedure because the foreskin may be used in the surgical
repair. Potential surgical complications may include urethral fistula (an opening that allows urine to leak
to the surface), stenosis, return of the meatus to its original site postsurgically, and strictures at the site
of the anastomosis.
Teach parents to watch for evidence of UTI (e.g., fever; cloudy, foul urine; and hematuria). These
pediatric patients also often suffer acute pain related to bladder spasm, incisional pain, and pain related
to infection. Oxybutynin chloride (Ditropan) is an anticholinergic medicine that may relieve bladder
spasm.
Testicular Torsion
Testicular torsion is considered an emergency, and surgical intervention must occur within a 4- to 8-
hour time frame from the onset of symptoms or the patient risks the need for orchiectomy (testes
resection). Loss of one testis through orchiectomy has been documented to decrease sperm counts
and reduce fertility. This emergency condition is most common in growing males between the ages of 10
and 19; it is also possible to have an intermittent torsion that can self-resolve or progress to a full
testicular torsion. Testicular torsion is the cause of 16 to 27% of scrotal pain, so this needs to be ruled
out in the presence of acute scrotal pain (Verkauskas, Malcius, Dasevicius, & Hadziselimovic, 2019).
Signs and Symptoms

Neonates:
■ Scrotum appears dusky colored:
■ Solid mass is palpated:
■ Scrotal edema prevents transillumination (inspecting the testis by passing a light through the scrotum):
■ Minimal or no pain from testicular motion:
Older males:
■ Severe and persistent pain that may begin gradually:
■ Trauma and physical exertion may promote the development of torsion:
■ Pain may be severe enough to awaken patients at night and prevent ambulation:
■ Fever, anorexia, nausea, and vomiting
Diagnosis
Diagnosis is based on patient history, physical examination findings, and Doppler ultrasonography.
Assessment Tools
Doppler Ultrasonography
Doppler ultrasonography is the preferred diagnostic test, and it is ordered immediately if torsion is suspected. In testicular
torsion, the testicle may be enlarged and may reveal decreased or absent blood flow. The Doppler test can also
differentiate between ischemia and inflammation, such as that seen in orchitis (inflammation of a testis) and epididymitis
(inflammation of the epididymis) often associated with gonorrhea. In the case of possible false-negative results on
Doppler ultrasound, a technetium scintigraphy test shows definitive testicular torsion. Urinalysis is normal in most of the
cases of testicular torsion.
Collaborative Care
NURSING CARE
Offer support to the patient and family about this emergency because it may be frightening. Prior to
surgery, complete a through nursing assessment and history. Be sure to ask about allergies. Obtain
medical orders including pain medication. Vital signs are necessary, and the patient is NPO. A surgery
consent form must be signed by the parents or guardian and witnessed by the nurse. Keep the patient
calm by using distraction techniques.
SURGICAL CARE
Manual detorsion (surgery for torsion of a testicle) by the urologist is done with sedation and local
anesthesia to provide immediate mitigation of pain. Surgery is performed within 4 to 8 hours, and an
orchiectomy may be required if the testicle becomes necrotic and cannot be salvaged. However, if the
surgeon is able to save or detorse the testicle, it will be sutured into the scrotum so that it is no longer
able to twist. The other testicle is also stabilized in this same way to prevent recurrence of the torsion.
This latter procedure is called orchiopexy.
Phimosis
This condition refers to a situation in which the foreskin is so tight that it cannot be retracted over the
glans penis. It can be acquired from infection or inflammation underneath the foreskin, or it can be
congenital. There are two types of phimosis. Primary or physiological phimosis occurs in the first 6 years
of life when the glans has not totally separated from the epithelium. Secondary or pathological phimosis
occurs when the foreskin cannot be retracted although it was previously retracted.
Signs and Symptoms

Signs and symptoms of phimosis include:
■ Possible infection or inflammation of the penis
■ Presence of paraphimosis
■ Dysuria
■ Pain
■ Abnormal, intermittent urine stream
■ Inability to retract foreskin
■ Pinpoint opening of foreskin
Collaborative Care
NURSING CARE
Nursing care centers on promoting gentle cleansing of the penis and gentle stretching of the foreskin
but only to the point of resistance. Counsel parents that a tight foreskin in uncircumcised males is
normal and most often resolves by the age of 6. Circumcision is then suggested unless symptoms do
not resolve.
MEDICAL CARE
In this condition, the health-care provider may suggest the use of low-dose topical steroid cream to
promote successful retraction.
SURGICAL CARE
Circumcision may be indicated for an unresolved condition, infection, or urinary obstruction.
Postoperative orders include assessment, pain management, fluids as tolerated, and discharge when
the patient is stable.
If the child has had surgery, teach the parents about the importance of assessing the surgical site, signs
and symptoms of infection, hydration, loose-fitting clothing, and follow-up appointments.
SUMMARY POINTS
■ It is essential for pediatric nurses to understand the pathophysiology of the renal system, renal disorders, AKI, and CKD.
■ Assessment of the GU system is a priority nursing action when caring for the child with a fluid and/or electrolyte
imbalance. The astute nurse recognizes fluid deficit and excess as well as electrolyte imbalance and then provides the
proper care.
■ UTI is a very common infection in infants, children, and adolescents. In infants and young children, it may be difficult to
determine the usual signs and symptoms of UTI.
■ Vesicoureteral reflux (VUR) is a backflow of urine caused by anatomical abnormalities, and there is risk for the
development of acute pyelonephritis.
■ The most common etiologies for gross hematuria include hypercalciuria with or without stones, hypertension, and
glomerulonephritis. Asymptomatic microhematuria has no identifiable cause in the majority of patients.
■ Glomerular disease can be caused by primary kidney disease or secondary multisystem diseases that cause damage to
the glomerulus.
■ Hemolytic uremic syndrome (HUS) is considered the most common cause of ARF in children. HUS is most commonly
associated with children ingesting beef contaminated with Escherichia coli O 157:H7.
■ Abnormalities of the urinary tract system ultimately affect the kidneys. The abnormalities may be anatomical, infectious,
cellular, inflammatory, functional, or maturational.
■ The most common causes of renal trauma are motor vehicle accidents.
■ Collaboration with the health-care team is critical so that AKI complications are reduced or prevented depending on
whether the etiology is prerenal, intrarenal, or postrenal.
■ The goals of nursing care for a patient with chronic renal disease are mutually established with the patient and family.
Collaboration with the health-care team is essential so that the quality of life can be extended as long as possible
because the renal capacity diminishes and affects all organ systems.
■ Renal replacement therapy (RRT) has three modalities: CCRT, PD, and HD. Each of these modalities has its
advantages and disadvantages.
■ Nutrition is one of the most important interventions for positive outcomes in renal disease.
■ Children in need of a renal transplant are placed on a waiting list and are registered with the United Network for Organ
Sharing (UNOS), which keeps a computer network to link all organ donation centers and transplant centers.
■ Enuresis can be primary or secondary. Culture influences how enuresis is evaluated and treated. Nurses can be very
helpful in providing education for non-medicinal therapies for enuresis, including integrative therapies.
■ Assess DES in children by identifying issues, asking the child when they have voided and asking the child if it is possible
to hold back voiding if no bathrooms are available. Potential emotional and social problems may result related to shame
and embarrassment.
■ Genital and reproductive disorders in girls include amenorrhea, labial adhesions, Candida and vulvovaginitis,
nonspecific vulvovaginitis, and ambiguous genitalia.
■ Genital and reproductive disorders in boys include varicocele, hypospadias, epispadias, hydrocele, testicular torsion,
cryptorchidism, gynecomastia, and ambiguous genitalia.
REFERENCES
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https://www.aappublications.org/news/2020/01/17/focus011720
Arlen, A. M., Kirsch, A. J., Leong, T., & Cooper, C. S. (2017). Validation of the ureteral diameter ratio for predicting early
spontaneous resolution of primary vesicoureteral reflux. J Pediatr Urolology 13:383.e1.
Binay Yaz, Ş., Bilsin, E., Özalp Gerçeker, G., Kahraman, A., & Bal-Yılmaz, H. (2019). Comparison of the effectiveness of two
different methods of decreasing pain during phlebotomy in children: A randomized controlled trial. Journal of
PeriAnesthesia Nursing 34. 10.1016/j.jopan.2018.11.010.
Centers for Disease Control and Prevention (CDC). (2019). Retrieved from http://www.cdc.gov/diabetes/projects/kidney/htm
de Galasso, L., Picca, S., & Guzzo, I. (2019). Dialysis modalities for the management of pediatric acute kidney injury. Pediatr
Nephrology.
Kent, A., Makwana, A., Sheppard, C. L., Collins, S., Fry, N. K., Heath, P. T., Ramsey, M., & Ladhani, S. N. (2019). Invasive
pneumococcal disease in UK children <1 year of age in the post13 valent pneumococcal conjugate vaccine era: What are
the risks now? Clinical Infectious Diseases 69(1): 84–90. https://doi.org/10.1093/cid/ciy842
Nash, Przech, Wald, & O’Reilly (2017). Systematic review and meta-analysis of renal replacement therapy modalities for
acute kidney injury in the intensive care unit. J Crit Care. 41:138–44.
National Kidney Foundation. (2020). Retrieved from https://www.kidney.org
National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) (2020). Retrieved from
http://kidney.niddk.nih.gov/
O’Kelly, F., Keefe, D., Herschorn, S., & Lorenzo, A. J. (2018). Contemporary issues relating to transitional care in bladder
exstrophy. Canadian Urological Association Journal [Journal de l’Association des urologues du Canada] 12(4 Suppl 1),
S15–S23. https://doi.org/10.5489/cuaj.5313
Pasin, L., Boraso, S., & Tiberio, I. (2019). Early initiation of renal replacement therapy in critically ill patients: A meta-analysis
of randomized clinical trials. BMC Anesthesiol 19: 62.
Raina, R., Grewal, M. K., Radhakrishnan, Y., Tatineni, V., DeCoy, M., Burke, L. L., & Bagga, A. (2019). Optimal management
of atypical hemolytic uremic disease: Challenges and solutions. International Journal of Nephrology and Renovascular
Disease 12: 183–204. https://doi.org/10.2147/IJNRD.S215370
Selekman, R. E., Shapiro, D. J., Boscardin, J., et al. (2018). Uropathogen resistance and antibiotic prophylaxis: A meta-
analysis. Pediatrics 142.
Shaikh, N., Hoberman, A., Hum, S. W., et al. (2018). Development and validation of a calculator for estimating the probability
of urinary tract infection in young febrile children. JAMA Pediatrics 172:550.
Sinha, R., Sethi, S. K., Bunchman, T., et al. (2018). Prolonged intermittent renal replacement therapy in children. Pediatr
Nephrology 33:1283.
Taber’s Online Medical Dictionary. (2019). Retrieved from
http://www.tabers.com/tabersonline/ub/view/Tabers/144109/40/urine
Vallerand, A. H., & Sanoski, C. A. (2021). Davis’s drug guide for nurses (17th ed.). Philadelphia: F.A. Davis.
Venes, D. J. (2021). Taber’s cyclopedic medical dictionary (24th ed.). Philadelphia: F.A. Davis.
Verkauskas, G., Malcius, D., Dasevicius, D., & Hadziselimovic, F. (2019). Histopathology of unilateral cryptorchidism.
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https://doi.org/10.1016/j.kint.2019.09.033

CHAPTER 24
Caring for the Child With a Hematological

Condition
CONCEPTS
Hematology
Bleeding
Clotting
KEY WORDS
valine
glutamine
asplenic
thrombocytopenia
purpura
pancytopenia
neutropenia
autologous transplant
allogeneic transplant
syngeneic transplant
plasmapheresis
LEARNING OBJECTIVES
■ Describe the physiology of the hematological system.
■ Examine common conditions of the hematological system that occur in children.
■ Prioritize developmentally appropriate and holistic nursing care measures for common
pediatric conditions of the hematological system.
■ Explore diagnostic and laboratory testing and medications for common pediatric conditions
of the hematological system.
■ Develop teaching plans and discharge criteria for parents whose children have common
hematological conditions.
PICO(T) Questions
1. Do (P) children with acute idiopathic thrombocytopenia purpura (ITP) whose condition
resolves without treatment have (O) a lower rate of (I) recurrence compared with (C)
children with acute ITP who receive treatment?
2. What (I) nonpharmacological pain management strategies do (P) patients with sickle cell
disease state are (O) most effective for moderate pain?
INTRODUCTION
A hematological disorder in a child can have various causes including injury,
nutritional deficit, genetic disorder, infection, congenital problem, or any number
of blood-related conditions. This chapter will review the anatomy, physiology, and
developmental aspects of common hematological conditions. The discussion
includes an examination of various pediatric hematologic conditions including
developmentally appropriate and holistic nursing care. Diagnostic and lab testing
as well as medications will be reviewed. Teaching plans and discharge criteria for
children who have various hematological conditions are incorporated. In addition,
blood transfusion therapy, bone marrow transplant, apheresis, and thrombosis
are reviewed.
HEMATOLOGICAL SYSTEM
Blood is composed of two parts: the fluid portion called plasma and the cellular
portion. The solutes in the plasma include albumin, electrolytes, proteins, clotting
factors, fibrinogen, globulins, and circulating antibodies. The cellular portion
consists of the formed elements (red blood cells [RBCs], white blood cells
[WBCs], and platelets).
The primary function of the RBCs (erythrocytes) is to transport hemoglobin
(HGB) that carries oxygen from the lungs to the tissues. The life span of a
normal RBC is approximately 120 days. Leukocytes (WBCs) are mobile units of
the body’s protective system. Most leukocytes migrate to areas of serious
inflammation and provide a rapid defense against any foreign agent. WBCs are
also important in immune system mediation.
Megakaryocytes are cells that give rise to platelets. Platelets are small
fragments of megakaryocytes. Platelets, the smallest of all formed blood
elements, are not really cells because they do not possess a cellular structure.
The primary function of platelets is hemostasis and vascular repair after injury to
a vessel wall. Platelets aggregate to form a plug. Their life span is approximately
7 to 10 days. Almost one-third of all circulatory platelets can normally be found in
the spleen. In normal circumstances, platelets are removed by the liver and
spleen in 10 days if not utilized in a clotting (Fig. 24-1).

Managing Fatigue
The nurse understands that the child with a hematological condition such as iron deficiency
may experience greater amounts of fatigue than a healthy child. It is important to provide
activities that are developmentally stimulating and that conserve energy. Nutritional therapy
can help to replace electrolytes and calories that are required for healthy activity. The nurse
should provide education about health promotion to the patient and families to avoid
reoccurrences of the disease process.
COMMON HEMATOLOGICAL CONDITIONS

Several common hematological conditions can occur in children. Some of these
are acute in nature and with proper care can be easily managed. Others can be
life-threatening or cause a chronic illness that can permanently affect the lifestyle
of the child and family. It is essential that the nurse understand the necessary
assessment, nursing care measures, medications, laboratory tests, and
important teaching aspects associated with these conditions (Table 24-1 and 24-
2).
Anemia
One of the most common hematological conditions of infancy and childhood is
anemia (a decrease in the number of RBCs, or a reduction in RBC mass or
blood HGB concentration) (Box 24-1). The reduction in circulating RBCs
decreases the oxygen-carrying capacity of the blood. For the majority of patients,
anemia is not a disease but rather a symptom of other diseases. As a review:
■ Hematocrit (HCT) is the fractional volume of a whole blood sample occupied
by RBCs, expressed as a percentage. As an example, the normal HCT in a
child age 6 to 12 years is approximately 40%.:
■ Hemoglobin (HGB) is a measure of the concentration of the RBC pigment HGB
in whole blood, expressed as grams per 100 mL (dL) of whole blood. The
normal value for HGB in a child age 6 to 12 years is approximately 13.5 g/dL
(135 g/L) (AAP, 2018).:
Normal ranges for HGB and HCT vary substantially with age, race, and sex
(see Table 24-3). The threshold for defining anemia is HCT or HGB at or below
the 2.5th percentile for age, race, and sex.
Anemia can result from:
■ Decreased production of RBCs, such as in bone marrow failure and
myelodysplastic syndromes:
■ Increased destruction of RBCs, such as in sickle cell anemia or hereditary
spherocytosis:
■ Acute or chronic blood loss:
FIGURE 24-1 A & P of the circulatory system.
TABLE 24-1
Assessment of the Child With a Hematological Disease
SYSTEM REVIEW OF SYMPTOMS PHYSICAL EXAM (SIGNS:
(SYMPTOMS: SUBJECTIVE, OBJECTIVE, CURRENT)
HISTORICAL, OR CURRENT)
• General • Fatigue, malaise, weakness, • Ruddy face, hands, and
lethargy, exercise intolerance, feet; sweating; severe and
history of bleeding disorder, sudden pain in bones,
transfusions or need for joints, back pain, and
medications to control clotting, chills with G6PPD
exposure to toxins. Fever, chills,
and infections if WBCs are deficient
• Skin, Nails, Hair • Jaundice, pallor, rubor stated by • Jaundice, pallor, or rubor
patient or family (may not be noted by the provider on
evident on exam), history of exam. Spooning of nails is
bruising or petechiae indicative of iron-
deficiency anemia.
Multiple bruises and
different stages of healing,
pruritus (caused by mast
cell activation), petechiae,
superficial ecchymoses,
purpura, and unusually
heavy menstrual flow
• Head • Headache, dizziness, or vertigo • Abnormal facial bone
structure (thalassemia)
• Eyes • Visual disturbances (polycythemia) • Pale outer canthus, scleral
icterus (jaundice), retinal
hemorrhage
• Ears • No specific problems with • No specific problems with
hematology hematology
• Nose • History of epistaxis • Epistaxis, gingival
bleeding, bullous
hemorrhage on the buccal
mucosa
• Mouth and Throat • Pale mucous membranes, increased • Pale mucous membranes,
bleeding of gums with or without easy bleeding of gums,
brushing red painful tongue,
smooth glossy tongue
(atrophic glossitis), mouth
erosions
• Neck • No specific problems with • No specific problems with
• Breast • No specific problems with • No specific problems with
• Respiratory/Thorax Lungs • Exertional dyspnea, coughing up • No specific problems with
blood (hemoptysis), tachypnea hematology
• Cardiovascular • Palpitations, history of central vein • Transient heart murmur,
thrombosis, nocturia, glossitis cardiomegaly, iron
overload on T2 MRI
exam, tachycardia, pedal
edema
• Peripheral Vascular • Coldness, numbness, pain in legs • Cool, delayed cap refill, full
(DVT) bounding pulse, unilateral
swelling of calf (DVT),
brown discoloration of
skin (venous stasis)
• Gastrointestinal • GI distress (polycythemia), GI • Positive guaiac testing,
disorders that may cause poor hepatomegaly, atrophic
absorption of iron or vitamins, blood gastritis, and
in stool, pica, glossitis, dysphagia, splenomegaly, black tarry
weight loss, malabsorption, and stools in newborn
diarrhea with steatorrhea,
gallstones (sickle cell)
• Urinary • Blood in urine • Reduced GFR and uremia
in cases of anemia of
renal failure
• Genitalia • Increased bleeding with menses • No specific problems with
hematology
• Neurologic • Coordination problems, headaches, • Intracranial hemorrhage
irritability, light-headedness,
restless leg syndrome, impaired
psychomotor or mental
development, may contribute to
ADHD and decreased cognitive
function in adolescents. Paranoid
ideation, dementia, hallucinations,
and distorted senses, paresthesias
to spastic ataxia, somnolence,
memory impairment
• Hematologic • History of hematological disorders, • Noticeable bleeding
need for or current use of iron or anywhere on exam,
other supplements, family history of unexplained hemorrhage
bleeding disorder or bleeding from IV sites
after trauma or sepsis
• Endocrine • No specific problems with • No specific problems with
• Musculoskeletal • Pain in joints and bones. Delayed • Abnormal skeletal
growth pattern structure
TABLE 24-2
Medications
MEDICATION/SUPPLEMENT DOSAGE/ROUTE/TIMING ACTION COMMENTS
NAME
• Aspirin (Bayer Aspirin, • ½-1 baby aspirin/day or • Antiplatelet • Effects can last
Bufferin) QOD as long as 1
week
• Coagulation factors • Dosing is variable • Used as a • Usually replaced
according to disease and replacement in in IV infusion
coagulation studies coagulopathies therapy unit
when the factor
deficiency is
known and
replaceable
• warfarin (Coumadin, • Dosing is individualized • Anticoagulants • Oral dosing
Jantoven, Warfilone) 1–10 mg/day in adjusted • Given in
or variable doses conditions with
high risk for
thrombi
(thrombocytosis,
Factor V Leiden,
or polycythemias)
• desmopressin (DDAVP) • Dosing sub Q – 0.3 • Hormones • Monitor serum
mcg/kg 30 minutes prior • Used for von sodium
to procedure Willebrand’s
disease, helps to
promote
replacement of
vWF
• desferrioxamine (Desferal) • 50 mg/kg/dose every 6 • Antidotes • Given IM, IV, or
hours or 90 mg/kg/dose • Given with subcutaneous
every 8 hours, not to thalassemia and
exceed 1 g/dose or 6 other diseases
g/day requiring
hypertransfusions
as an iron
chelation agent
• erythropoietin (Epogen, • Dosing is individualized. • Antianemics • Given
EPO, Erythropoietin, 25–300 units/kg 3–7 • Given for anemias subcutaneously
Procrit) times per week. of all types or IV
especially for
anemia of renal
disease
• heparin (Calcilean, • Dosing individualized and • Anticoagulants • Patient is
Calciparine, Hepalean, adjusted with a PTT • Given in hospitalized.
Heparin Leo, Hep-Lock, between 60 and 85 conditions with Carefully
Hep-Lock U/P) seconds. Loading dose high risk for determine
75 units/kg for 10 thrombi appropriate
minutes then reduce to (thrombocytosis, concentration
28 units/kg/hr Factor V Leiden, because there
maintenance or polycythemias) are different
formulations
• hydoxyurea (Droxia, Hydrea, • 15 mg/kg/day daily • Antineoplastics • Increase dose
Mylocel) • Given for sickle by 5 mg/kg/day
cell anemia to every 12 weeks
increase to a maximum
concentration of dose of 35
hemoglobin F, mg/kg/day.
which has Reduce dosage
protective alternating with
properties erythropoietin
against
hemoglobin S
• enoxaparin (Lovenox) • Dosing (prophylaxis) 0.75 • Given in • Can be given as
mg/kg/dose every 12 conditions with outpatient, and
hours for infants high risk for family is
• Children: 0.5 mg/kg/dose thrombi instructed to
every 12 hours (thrombocytosis, give
• Treatment: Infants: 1.5 Factor V Leiden, subcutaneously.
mg/kg/dose every 12 or polycythemias) Transition from
hours heparin dosing
• Children: 1 mg/kg/dose to Lovenox—
every 12 hours draw antifactor
Xa 4 hours after
dosing
Source: Ruggiero & Ruggiero (2020).

It is important to identify the cause of anemia so that the treatment plan can be
tailored to the child’s specific needs.
Signs and Symptoms

Anemia may be insidious, and the child may be asymptomatic because of
compensatory mechanisms. The child with mild anemia may be asymptomatic
and not diagnosed until blood work is obtained. Initial signs of anemia vary but
may include:
■ Fatigue:
■ Shortness of breath:
■ Headache
■ Difficulty concentrating
■ Dizziness
■ Pale skin
The child with moderate to severe anemia will have overt signs and symptoms:
■ Irritability
■ Fatigue
■ Delayed motor development
■ Tachycardia
■ Decreased activity level
■ Pale skin
BOX 24-1
Common Causes of Iron-Deficiency Anemia

DECREASED IRON SUPPLY
Inadequate iron supply at birth Nutrition
• Deficient iron intake
• Excessive milk
• Limited solid foods
• Poor eating habits, vegetarian diet, increased fast foods
INCREASED IRON DEMANDS
Growth
• Low birth weight, twins, or multiple births
• Prematurity/infants
• Adolescents
• Pregnancy
• Cyanotic congenital heart diseases (e.g., tetralogy of Fallot)
BLOOD LOSS
Acute
Chronic
Parasite infection
GI tract (the most common site)
INABILITY TO FORM HEMOGLOBIN
Lack of vitamin B (e.g., pernicious anemia)
Folic acid deficiency
IMPAIRED ABSORPTION
Presence of iron inhibitors
• Phytates, phosphates, or oxalates
• Gastric alkalinity
• Malabsorption syndrome (e.g., celiac disease, severe prolonged diarrhea,
postgastrectomy, inflammatory bowel disease)
■ Listlessness
■ Systolic heart murmur
■ Hepatomegaly, congestive heart failure
FOCUS ON SAFETY
Screening Guidelines
Newborns usually take the iron they need during the last trimester of fetal development.
Therefore, if a newborn was full-term and the mother has no history of iron-deficiency
anemia (IDA), the infant will likely have enough iron stores for the first 4 to 6 months of life.
Conversely, risk factors for IDA include premature infants or a mother with IDA during her
pregnancy. HGB and HCT are first evaluated beginning at 9 and 12 months of age and again
during early childhood (between 1 and 5 years of age). Additional preventive screening
includes checking children in late childhood (between 5 and 12 years of age) and again in
adolescence (between 14 and 20 years of age). The growing and developing brain can be
greatly affected by low iron levels, which will decrease oxygen transport to the brain, leading
to negative sequelae, including poor performance on standardized tests or overall school
performance. The nurse should be aware that if a child struggles in school, IDA is an organic
cause for this, and labs will likely be evaluated for IDA.
Patient Education
Iron Supplementation for Breastfed Babies
The American Academy of Pediatrics (APA, 2020) recommends that infants who only receive
breast milk (exclusively breastfeed) will need a supplement of iron each day at a dose of 1
milligram of iron for each kilogram of body weight, starting at 4 months of age. The nurse
should educate families that iron can stain the baby’s teeth, so it should be administered with
a dropper.
When infants receive both breast milk and formula, their need for supplemental iron will
depend on how much breast milk and how much formula they consume. Parents should talk
to their infant’s health-care provider about whether their infant is getting enough iron.
If an infant receives only iron-fortified infant formula (during the time before complementary
foods are given), then additional iron supplementation is not necessary. At about 6 months of
age, an infant’s iron needs can be met through the introduction of iron-rich foods, iron-fortified
cereals, or iron supplement drops.
Diagnosis
A complete blood count (CBC) and reticulocyte count are obtained to evaluate
the HGB and HCT. Anemia exists when the HGB content is less than required to
meet the oxygen demands of the body.
Labs
Hemoglobin
Normal hemoglobin (HGB) (g/dL) lab values for children are:
• Newborn: 12.7–18.6 g/dL
• 2 Months: 9.0–14.0 g/dL
• 2 Years: 10.5–12.7 g/dL
• 6–12 Years: 11.2–14.8 g/dL
• 12–18 Years: 10.7–15.7 g/dL
HCT is the percent of whole blood that is composed of RBCs. The HCT measures both the
number and size of the RBCs and is approximately three times greater than the HGB value.
The HCT indirectly measures the HGB. The average HCT value in children lies between
35% and 45%.
A child’s CBC measures the formed elements in the blood, including RBCs, WBCs, and
platelets, providing valuable information with regard to illnesses and disease processes that
may be occurring. In addition to the quantitative analysis, the blood cells of the CBC can also
be evaluated for shape, size, and color.
Prevention
Anemia caused by clinical conditions such as sickle cell disease (SCD),
hereditary spherocytosis, beta-thalassemia, and RBC disorders often do not
respond to traditional preventive measures. Anemia caused by iron deficiency
and poor nutrition may be prevented by following screening guidelines and
encouraging a well-balanced diet. Additionally, preventing exposure to lead-
containing items such as paint, gasoline, and other household hazards may
prevent the development of anemia.
Labs
Blood Values According to Age
Be knowledgeable about the age-specific laboratory value norms for the child. Based on the
child’s age, there may be variations in expected ranges (Tables 24-3, 24-4, and 24-5).
Generic adult values should not be translated for pediatric patients.
TABLE 24-3
Laboratory Blood Values According to Age
AGE/BLOOD NEWBORN 2 2 YEARS 6–12 12–18 COMMENTS
COMPONENT MONTHS YEARS YEARS
Red blood 4.1–5.74 2.7–4.9 3.9–5.03 4.93–5.3 3.7–5.5 Measure of bone
cells (RBCs) marrow function
Hemoglobin 12.7–18.6 9.0–14.0 10.5–12.7 11.2–14.8 10.7–15.7 Amount of
(HGB) (g/dL) hemoglobin/dL of whole
blood
Hematocrit 37.4–56.1 28.0–42.0 31.7–37.7 34.0–43.9 33.0–46.2 Percentage of packed
(HCT) (%) RBC to whole blood,
approximately 3 times
the Hgb content
White blood 6.8–14.3 5.0–19.5 5.3–11.5 4.5–10.1 4.4–10.2 Differential count is
cells (WBCs) more important than the
total number of WBCs
Platelets (x 164–586 164–586 206–459 189–403 175–345 Platelets contribute to
103/mm3 blood clotting
[mcL])
TABLE 24-4
Normal White Blood Cell Differential Count According to Age
AGE/WHITE FUNCTION NEWBORN 2 MONTHS 2 YEARS 6–12 12–18
BLOOD CELL YEARS YEARS
COMPONENT
Neutrophils Phagocytosis 19–49 15–35 13–33 32–54 34–64
(%)
Eosinophils Allergic 0–4 0–3 0–3 0–3 0–3
(%) reactions
Basophils (%) Inflammatory 0–1 0–1 0 0–1 0–1
reactions
Lymphocytes Humoral 38–46 42–72 46–76 27–57 25–45
(%) (B cells immunity (B
and T cells) cell) and
cellular
immunity (T
cell)
Monocytes (%) Phagocytosis 0–9 0–6 0–5 0–5 0–5
(macrophages) and antigen
processing
TABLE 24-5
Red Cell Laboratory Values for Children
TEST REFERENCE RANGE COMMENTS
Mean corpuscular volume 79–95 µm3 Average size of a single RBC,
(MCV) expressed as cubic microns (μm3)
Mean corpuscular 25–33 pg/cell Average weight of the Hgb within a
hemoglobin (MCH) RBC, expressed in picograms (pg)
Mean cell hemoglobin 31%–37% Hgb [g]/dL RBC Average concentration of Hgb in each
concentration (MCHC) RBC
Reticulocyte count 0.5%–1.5% Measure of the production of mature
Peripheral smear Size, shape, and structure RBCs by the bone marrow
of the RBCs as well as an Can indicate variations in size and
estimate of the amount of shape of RBCs, microcytic,
Hgb in the RBCs macrocytic, or normocytic
Source: Modified from Ruggiero & Ruggiero (2020).
Labs
Complete Blood Count, Reticulocyte, and Peripheral Smear Lab Values for Children
When evaluating the presence of anemia, initial laboratory tests include CBC and a
reticulocyte count. The CBC includes HGB, HCT, RBC indices, platelet count, WBC count
with a differential, and a peripheral smear to examine the morphology of the RBCs. For the
patient with suspected anemia, the peripheral blood smear is imperative to confirm the
appropriate diagnosis.
Evaluating a CBC
Blood Elements Increase Decrease
RBC (HGB/HCT) Polycythemia Anemia
WBC Leukocytosis Leukopenia
Platelets Thrombocytosis Thrombocytopenia
Collaborative Care
NURSING CARE
Nursing care for a child with anemia varies based on the etiology. The nurse is
responsible for administering and monitoring blood transfusions and other
prescribed pharmacological treatments.
MEDICAL CARE
Treatment for anemia varies based on the etiology. To effectively replenish the
RBCs, the underlying cause must be identified.
Important home care instructions from the nurse are necessary for children with
anemia to prevent complications that may occur. The caretaker must be able to
identify signs and symptoms of anemia in the home setting such as pallor,
fatigue, dizziness, and lethargy. Additional teaching must be completed on how
to administer iron supplements, if necessary, for the child’s treatment plan. The
child with anemia may also need to have laboratory tests and medical exams
periodically to evaluate the status of the anemia.
Iron-Deficiency Anemia
The most prevalent nutritional disorder worldwide is iron-deficiency anemia.
According to the World Health Organization, approximately 30% of the
population is affected with iron-deficiency anemia. Iron-deficiency anemia is
defined as a microcytic, hypochromic anemia caused by an inadequate supply of
iron (Ro, Toth, Snyder, & Kemper, 2020). Iron is essential for the production of
HGB. When iron stores are inadequate, the production of HGB is diminished. As
a result of the decrease in HGB, there is a decreased oxygen-carrying capacity
of the blood.
Iron-deficiency anemia is more common in infants who are premature and
those ages 6 to 12 months. The most common cause of anemia in young infants
is physiologic anemia, which occurs at approximately 6 to 9 weeks of age.
Compared with term infants, preterm infants are born with lower HCT and HGB,
have shorter RBC life span, and have impaired erythropoietin production due to
immature liver function. In addition, the fetus takes what iron stores it needs for
the first 6 months of life in the third trimester of pregnancy.
Premature infants are at a high risk for physiological anemia because of their
decreased fetal iron supply. Other causes of anemia in children vary based upon
age at presentation, sex, race, and ethnicity (Table 24-6). For example, anemia
detected at 3 to 6 months of age suggests a hemoglobinopathy while toddlers,
older children, and adolescents tend to have acquired causes of anemia.
Screening for iron-deficiency anemia is recommended in all children at 9 to 12
months of age.
Pica, or eating items of non-nutritive value such as starch, clay, ice, or paper,
may also be associated with iron-deficiency anemia. Iron deficiency, alone or
with anemia, may result in impairment of cognitive skills that may not be
reversible.
Diagnosis
Diagnosis of iron-deficiency anemia is based on lab tests that are frequently
performed including those that quantify or describe HGB, iron concentration, and
morphological changes in the RBC.
Prevention
Prevention is the key to avoiding iron-deficiency anemia. Parents should ensure
that their children eat iron-rich foods such as beans, meat, fortified cereals, eggs,
and green leafy vegetables.
TABLE 24-6
Pediatric Hematology Ranges by Age
TEST AGE RANGE UNITS
Red Cell Count 0–1 month 3.90-5.90 millions/mm3
1–2 months 3.10-5.30
2–3 months 2.70-4.50
3–6 months 3.10-5.10
6 months-1 year 3.90-5.50
Hematocrit 0-1 month 42-65 %
1-2 months 33-55
2-3 months 28-41
3-6 months 29-41
6 months-1 year 31-41
Hemoglobin 0-1 month 13.4-19.9 gm/dL
1-2 months 10.7-17.1
2-3 months 9.0-14.1
3-6 months 9.5-14.1
6 months-1 year 11.3-14.1
MCH 0-1 month 31-37 pg
1-3 months 27-36
3-6 months 25-35
MCHC 0-6 months 28-36 g/dL RBC
MCV 0-1 month 88-123 femtoliters
1-3 months 91-112
3-6 months 74-108
White Cell Count 0-1 month 9,000-30,000 mm3
1-3 months 5,000-19,500
3 months-1 year 6,000-17,500
1-2 years 6,000-17,000
2-4 years 5,500-15,500
Differential (manual) 0-1 month 1,000-20,000 mm3
Neutrophils 1-3 months 1,000-9,000
3-6 months 1,000-8,500
6 months-5 years 1,500-8,500
5-18 years 1,700-7,500
Lymphocytes 0-1 month 2,000-11,000 mm3
1-3 months 2,500-16,500
3-6 months 4,000-13,500
6 months-1 year 4,000-10,500
1-2 years 3,000-9,500
2-5 years 2,000-8,000
5-18 years 1,250-7,000
18+ years 875-3,300
Monocytes 0-1 month 540-1,800 mm3
1-3 months 350-1,365
3-12 months 300-875
1-2 years 300-850
2-5 years 275-775
5-18 years 28-825
18+ years 130-860
Eosinophils 0-1 month 270-900 mm3
1-3 months 150-585
1-2 years 180-510
2-5 years 165-465
5-18 years 40-650
18+ years 40-390
Basophils 0-1 month 0-400 mm3
1 month-5 years 0-140
5-18 years 7-140
18+ years 10-136
Collaborative Care
NURSING CARE
Stress to parents the importance of an iron-rich diet in avoiding iron-deficiency
anemia. If oral iron supplements are prescribed, the nurse will teach parents how
to properly administer them to the child.
MEDICAL CARE
Early identification and recognition of iron-deficiency anemia is essential. Many
instances of iron-deficiency anemia can be avoided with the appropriate food
selections. The dietitian provides nutritional counseling and assists with obtaining
recommended iron-fortified formula and cereal.
Oral iron supplements may be prescribed if dietary treatment is not successful.
The recommended dosage of elemental iron is 3 mg/kg per day based on body
weight in one or two divided doses. The severity of the anemia dictates the
monitoring frequency of laboratory testing and follow-up with the health-care
provider. Several days after initiating iron replacement therapy, the reticulocyte
count will rise, which is an indicator of RBC production.
Iron supplementation should not be given with milk as this inhibits iron
absorption. For patients who cannot tolerate oral iron supplementation, iron
infusions are available (iron sucrose or iron gluconate infusions).
Patient Education
Preventing Iron-Deficiency Anemia
TOPIC: Tell parents to prevent iron-deficient anemia:
• “Feed your infant breast milk or commercial infant formula recommended for the first 12
months of life.”
• “Are you aware of community resources such as WIC to provide assistance with formula and
iron-fortified foods?”
• “Be sure to use iron-fortified cereal from 6 to 12 months of age.”
• “Do not feed your infant cow’s milk before 12 months of age because it does not contain iron
and essential nutrients. After 12 months of age, limit the amount of cow’s milk to 18 to 24
ounces per day.”
• “Offering solids before giving the bottle helps prevent iron deficiency.”
• “Tell adolescents on a vegetarian diet or weight reduction diet to understand proper dietary
alternatives. Red meats, beans, whole grains, nuts, and iron-fortified cereals are good
sources of iron.”
Educating parents on the proper administration of oral iron is a vital nursing
responsibility. The iron supplement needs to be taken between meals because
absorption is improved in an acidic environment. Administering this medication
with a glass of orange juice may also enhance absorption. Iron supplements
should not be taken with tea or dairy products because they may adversely affect
the absorption process. Inform parents that liquid iron preparations may stain
teeth, so it is important to administer the medication with a dropper or drink it
through a straw. Encourage the child to rinse the mouth after taking this liquid
medication.
■ Inform parents that iron can be constipating, and it is necessary to increase the
fiber and water intake to prevent this possible complication.:
■ Inform parents that possible side effects of iron therapy include gastric upset,
nausea, vomiting, and constipation. Black, tarry stools are a common finding
and are normal for children taking iron supplements.:
Sickle Cell Disease

One of the most common genetic hematological conditions present in children is
SCD. This disorder is transmitted via an autosomal recessive pattern of
inheritance. Both parents of the child must have the sickle cell gene for the child
to have SCD. In this SCD, the globin chain in normal HGB A (HBA) is partially or
completely replaced by HGB S (HBS). HBS has a substitution of the amino acid
valine for glutamine, which is more sensitive to the changes in the oxygen
concentration in the blood. An important point to understand when caring for a
patient with SCD is that an oxygenated erythrocyte cannot sickle. When a patient
has a decrease in oxygen levels, these abnormal HGBs clump together within
the cell and change the shape from donut-like to a sickled shape (Fig. 24-2).
Once RBCs sickle, they are more fragile and easily destroyed. The surfaces of
these sickled cells are also sticky and adhere to the blood vessel walls. Once an
erythrocyte sickles, it cannot revert back to a “normal”-shaped erythrocyte;
hence, clinical symptomatology results. However, keeping a child with sickle cell
crisis well oxygenated will help prevent further sickling. Research shows that
hyper-oxygenating erythrocytes (i.e., hyperbaric chambers) can have a rebound
effect, so adequate oxygenation is ideal. If the RBCs cannot circulate through the
vascular system and there are occlusions, hypoxemia may result that could lead
to ischemia, infarcts, and possible tissue death. The average life span of a
sickled RBC is approximately 8 to 21 days. As a result of the shortened life span
of the RBCs, children with SCD have an increased amount of hemolysis as
evidenced by their chronic anemia. This puts a significant burden on the spleen
(the filtration system of dead RBCs), and for this reason children with SCD are
considered functionally asplenic (or “without” a spleen) (Tanabe, Spratling,
Grissom, & Peyton, 2019).
FIGURE 24-2 In sickle cell disease, the shape of the cell changes from a donut
shape to a sickled shape.
Complications
Complications related to occlusion of blood vessels can include priapism (painful
and continuous erection of the penis). In addition, due to the shortened RBC life
of children with SCD, RBCs are constantly being filtered out by the spleen;
therefore, children with SCD are considered functionally asplenic (without a
spleen). Other, more severe complications include splenic sequestration, acute
chest syndrome, and a cerebrovascular accident (CVA). These conditions are
medical emergencies and treatment must be obtained immediately to prevent
permanent disability or a life-threatening event.
Patient Education
Genetic Risk of SCD
Consistent with the genetic pattern of inheritance, HGB genes come from both parents. If one
parent has SCD and the other parent does not, the child has only the sickle cell trait. If one
parent has SCD and the other has sickle cell trait, there is a 50% probability (1 out of 2) that
the child will have either the SCD or the sickle cell trait. When both parents have sickle cell
trait, they have a 25% probability (1 out of 4) of having a child with SCD or who will become a
carrier of the disease (Fig. 24-3).
Children affected by this condition are usually of African American or Mediterranean
descent. Although rare, this genetic disorder may be seen in other populations, including
individuals with Caribbean, Asian, Central or South American, or East Indian ancestry.
Patients with sickle cell trait have the heterozygous form of the disease. They usually are
asymptomatic because they possess one sickle and one normal gene. The child with the trait
may be affected only in certain situations such as high altitudes, periods of extreme stress
such as dehydration, and females later in life during pregnancy. Children with SCD have the
homozygous form of the disorder, indicating that both genes are abnormal.
Signs and Symptoms

Because SCD is a blood disorder, all organs of the body may be affected. The
symptom that is most evident in a child with sickle cell anemia is the result of the
vaso-occlusion of the blood vessels from the sickled RBCs and hemolysis, which
causes pain. The pain can be found anywhere in the body. Infants less than 6
months of age are often asymptomatic. Other symptoms seen in children with
SCD can include:
■ Weakness
■ Pallor
■ Fatigue
■ Tissue hypoxia
■ Jaundice as a result of RBC hemolysis
FIGURE 24-3 Pattern of inheritance of sickle cell disease.
Resulting conditions include:

■ Chronic hemolytic anemia
■ Increased susceptibility to infections
■ Hand-foot syndrome (dactylitis)
■ Enuresis and nocturia
■ Stroke
■ Avascular necrosis of the shoulder or hip
■ Acute chest syndrome (severe pneumonia)
■ Priapism
■ Cholelithiasis
■ Leg ulcers
■ Delayed physical growth and sexual maturation
Diagnosis
Newborn screening is a standard in all 50 states. However, recognize that all
parents may not be aware of their newborn screening results. In addition,
children born outside the United States may not have received any screening
tests at birth.
The newborn screening serves only as a screening tool and not a definitive
diagnosis. Toddlers and preschool children who visit the health-care provider
with nonspecific symptoms and are anemic undergo a thorough history and
physical. If the etiology of the anemia is undetermined, a screening for SCD is
indicated.
Diagnostic Tools
Further Testing for Infants Suspected of Having Sickle Cell Disease
When SCD is suspected, infants will require further testing, such as an isoelectric focusing
(IEF), high-performance liquid chromatography (HPLC), or an HGB electrophoresis. Further
more specific blood testing such as an HGB electrophoresis can be used to identify SCD
versus sickle cell trait in a child. In addition, laboratory tests including a CBC and reticulocyte
count are necessary.
As reported by the CDC (2020), children with SCD have a longer life
expectancy than they did in the past. The mortality rate of infants and young
children with SCD who have access to comprehensive care has decreased
dramatically compared with that of adults, in large part because of the decrease
in sepsis from early use of prophylactic antibiotics and immunizations (such as
the Haemophilus Influenzae B (HIB) and pneumococcal vaccines).
In addition to better preventive care, research has identified additional factors
that contribute to an increase of quality of life and life expectancy for children
who have SCD. In a cohort of children in Belgium with SCD who were treated
with either hydroxyurea, hematopoietic stem cell transplantation (HSCT), or
observation, the estimated 15-year survival rates were 99%, 94%, and 95%,
respectively (CDC, 2020). Survival was greater in children who received
hydroxyurea primarily due to fewer deaths from acute chest syndrome and
infection.
Prevention
SCD is a genetically transmitted disease that may affect every organ of the body.
Raising awareness is paramount in preventing the transmission of this chronic,
lifelong disease. Genetic counseling and follow-up of genetic screening at birth
may assist parents in being aware of susceptibility and proper care of a child with
SCD. Family members who are carriers of the sickle cell trait should take
necessary precautions when planning pregnancies and participating in high-risk
behaviors such as becoming dehydrated with excessive physical activity, high
altitudes, and/or the need for anesthetics or surgical procedures.
Collaborative Care
NURSING CARE
The nurse provides supportive and specific care based on the type of crisis
present. Nursing care focuses on rest, hydration, pain control, and adequate
oxygenation.
When providing nursing care to patients with sickle cell crisis, attempts are
made to coordinate nursing care to allow adequate rest periods and to minimize
unnecessary interruptions. Nursing care includes administering and monitoring
adequate hydration (oral or IV).
Another essential nursing care measure is monitoring respiratory status and
oxygenation of sickle cell patients. The child with sickle cell crisis may be at risk
for an acute pulmonary event that may be a result of the disease itself or the use
of opiates. A complete respiratory assessment includes signs and symptoms of
respiratory distress, including auscultation of lung sounds to detect decreased
and abnormal breath sounds, respiratory effort and quality, continuous
monitoring of oxygen saturations, color and perfusion, and any necessary
laboratory or radiographic studies. If abnormal findings are present, the nurse
immediately informs the health-care provider so treatment can begin. For
example, if the patient’s oxygen saturation is consistently less than 90% on room
air, supplemental oxygen is indicated. Pneumonia and pulmonary infarcts occur
more often in this patient population.
Sickle cell patients with numerous complications may benefit from a bone
marrow transplant. However, this treatment is not without risks, and most
patients are not able to find a compatible donor match.
MEDICAL CARE
Treatment for SCD is the early identification and treatment of hypoxic
episodes. Hydration is essential. The fluid requirement recommendations are 1.5
times above the child’s normal calculated requirements. Adequate hydration
promotes dilution and diminishes the possibility of hypoxic episodes. In addition
to hydration, pain management is essential to adequately treat a painful vaso-
occlusive crisis.
At home, the initial management consists of oral pain medication consisting of
acetaminophen (Children’s Tylenol), ibuprofen (Children’s Advil), or
acetaminophen with codeine (Children’s Tylenol-Codeine) for mild to moderate
pain. If the child continues to have pain, hospitalization may be required. For the
hospitalized child with vaso-occlusive crisis, opioids such as immediate and
sustained release morphine (Duramorph), oxycodone (OxyContin),
hydromorphone (Dilaudid), or methadone (Methadose) may be administered
around the clock. Morphine (Duramorph) is often considered the drug of choice.
It may be administered by patient-controlled analgesia (PCA). Meperidine
(Demerol) is sometimes avoided because of the possible central nervous system
toxicity. PCA is an appropriate method of pain management for children who are
able to manage their own pain relief. Another medication that may be used for
painful crises and does not have the common side effects of the opiate drugs is
ketorolac (Toradol). Ketorolac (Toradol) is a parenteral anti-inflammatory drug
that has been found to be effective in reducing pain associated with a vaso-
occlusive crisis. The recommended duration of ketorolac (Toradol) should not
exceed 5 days because of the increased risk of gastritis and gastrointestinal (GI)
bleeding.
MEDICATION: Toradol (Ketorolac)

(tor-ah-dal) (Kee-toe-role-ak)
Indications: Short-term (less than 5 days) management of moderate to severe pain, including
postoperative pain
Actions: Inhibits prostaglandin synthesis by decreasing activity of the enzyme
cyclooxygenase, which results in a decrease of prostaglandin precursors
Therapeutic Effects: Pain relief
Route and Dosage:
MANUFACTURER’S RECOMMENDATIONS:
Single dose treatment:
IM: 1 mg/kg as a single dose
MAXIMUM DOSE: 30 mg
IV: 0.5 mg/kg as a single dose
MAXIMUM DOSE: 15 mg
MULTIPLE-DOSE TREATMENT:
IM OR IV: 0.5 mg/kg every 6 hours. Do not exceed 5 days of treatment.
ORAL DOSE:
INITIAL DOSE: 20 mg
MAINTENANCE DOSE: 10 mg every 4 to 6 hours
MAXIMUM DOSE: 40 mg/day
(Dosage information retrieved from http//www.drugs.com, 2013)
CONTRAINDICATED IN: Hypersensitivity to Toradol, acetylsalicylic acid (Children’s Aspirin), or
other nonsteroidal anti-inflammatory drugs (NSAIDs); patients with peptic ulcer disease or
anyone with bleeding tendencies
Adverse Reactions and Side Effects: Dizziness, headache, rash, diarrhea, GI pain,
bleeding, prolonged bleeding times, anaphylaxis, hypersensitivity reactions
1. Instruct the patient and parents on medication administration.
2. Do not exceed 5 days of total use.
3. May cause drowsiness and impair ability to perform activities requiring mental alertness.
FOCUS ON SAFETY
When a Child Is Asplenic
A child with a temperature greater than 101.5°F (38.6°C) requires immediate medical
attention because most children with SCD are functionally asplenic. When a child is
asplenic, they do not have the ability to filter certain encapsulated bacteria. This allows the
bacteria to multiply within the bloodstream, causing a low-grade bacterial infection or serious
sepsis. Children with SCD generally are asplenic by the age of 3 to 5 years. The major cause
of death in children with SCD who are younger than 5 is overwhelming infection because of
Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis. If a
child with SCD has a fever, immediate treatment involves blood cultures and the
implementation of parenteral broad-spectrum antibiotics. Children with SCD often receive
prophylactic oral penicillin at home to prevent overwhelming sepsis. The nurse knows that
this critical information is necessary for parents to ensure the child receives the
pneumococcal and H influenzae type b vaccine and other routine vaccinations.
Children and families affected by SCD must learn to cope with a lifelong chronic
illness. Families must be knowledgeable of the signs and symptoms of sickle cell
crisis so they can report them to their primary health-care provider. The
community-based nurse can educate the family about the goals of ongoing care
including the prevention of complications associated with infections, hypoxemia,
and vaso-occlusive crisis. Ensure that parents understand that strenuous
activities may precipitate dehydration resulting in hypoxia; these activities should
be avoided. Parents should also be knowledgeable about possible complications
such as management of pain and fever, splenic sequestration, priapism, acute
chest syndrome, and stroke. All of these complications could result in permanent
disability or death.
Teach parents how to avoid a sickle cell crisis by providing rest and adequate
hydration. Patients with SCD are on prophylactic penicillin to prevent
overwhelming sepsis and supplemental folic acid to assist with RBC production.
Adherence to these medications is critical in preventing complications associated
with this disease. In addition to scheduled medications, all required
immunizations should be administered per AAP guidelines. Parents must be
aware that preventable illnesses have the potential to be life-threatening for a
patient who is asplenic.
In the event a patient experiences a mild sickle cell crisis at home, instruct
them to stop what they are doing, rest, drink fluids, and take the prescribed pain
medication. If improvement is not observed, notify the physician and anticipate
the need for the patient to see a health-care provider or to go to the nearest
emergency facility for additional treatment.
Thalassemia
The word “thalassemia” originates from the Greek word “thalassa” meaning “the
sea” because the first cases identified were in children of Mediterranean
descent. Thalassemia is an inherited autosomal recessive condition that results
in a deficiency of the alpha or beta globin protein needed for the production of
HGB. Beta-thalassemia is the most common inherited genetic disorder in the
world. There are three forms of beta-thalassemia:
■ Thalassemia minor (or thalassemia trait) is asymptomatic or with mild
microcytic anemia.
■ Thalassemia intermedia is similar in signs and symptoms to splenomegaly
(enlarged spleen) with severe anemia.:
■ Thalassemia major is the most severe form, also known as Cooley’s anemia.:
In addition to beta-thalassemia, alpha-thalassemia occurs when the alpha-
chain is affected. These patients are sometimes mistakenly diagnosed with iron-
deficiency anemia. The severity of alpha-thalassemia is based on the number of
alpha genes affected. If the patient has 1 or 2 missing alpha genes, they are
most likely asymptomatic or have a mild anemia. A patient missing 3 alpha
genes is classified as having HGB H disease, which is characterized by an
excess of beta-chains, resulting from minimal production of alpha-chains in the
bone marrow and resulting development of HGB H.
Signs and Symptoms

Children with beta-thalassemia who are symptomatic have:
■ An enlarged liver and spleen:
■ Mild jaundice:
■ Growth retardation:
■ Moderate to severe anemia:
■ Increased risk of infections secondary to splenomegaly or splenectomy:
Children with beta-thalassemia experience diminished erythropoiesis (less
production of RBCs), in which the body attempts to increase RBC production to
compensate for the anemia. When the HGB level declines and severe anemia is
present, bones that normally do not produce RBCs take on this function. As a
result, bony deformities such as frontal bossing or maxillary prominence may
result from the excess cell production. These children also have an increased
susceptibility to infection secondary to loss of spleen function.
Diagnosis
A thorough history and physical examination are necessary for diagnosis.
Frequently performed laboratory tests include those that quantify or describe
HGB such as a CBC with red cell indices. Laboratory studies often reveal
decreased HGB and HCT, hypochromia, microcytosis, low mean corpuscular
volume (MCV), and increased reticulocyte count.
Prevention
Thalassemia is a chronic, lifelong illness that requires adherence to all special
aspects of care to ensure optimal quality of life. Most patients with beta-
thalassemia will require blood transfusion therapy for life or a bone marrow
transplant, which is curative. Patients receiving chronic transfusion therapy may
experience iron overload requiring chelation therapy to prevent additional
complications such as multiorgan failure. Thalassemia is transmitted genetically,
so genetic counseling is strongly recommended to prevent disease transmission.
Nursing Care
Children with beta-thalassemia are dependent on transfusions to maintain their
HGB to improve the quality of their life. The blood transfusions prevent
extramedullary hematopoiesis, promote growth and development, and reduce
infections. The goal of nursing care for children with beta-thalassemia major
(Cooley’s anemia) is to prevent hypoxia by providing blood transfusion therapy
usually every 3 to 4 weeks for the child’s lifetime.
Children with beta-thalassemia may experience numerous complications
related to their disease and/or to the treatment of their disease. As a result of
chronic transfusion therapy, these children are at high risk for developing
hemosiderosis. Hemosiderosis is the accumulation of iron in the organs of the
body.
Children with beta-thalassemia (Cooley’s anemia) may be cured with a bone
marrow transplant. Finding a suitable match may pose a challenge because of
the limited donors available. Younger children often fare significantly better than
older children who are treated with bone marrow transplant, primarily because
their organs have not sustained substantial damage from the chronic transfusion
therapy that may have caused iron overload.
FOCUS ON SAFETY
Accumulation of Iron (Hemosiderosis)
As a result of the chronic blood transfusion therapy, in which each unit contains
approximately 200 mg of iron, iron may accumulate in the body. The body does not have a
mechanism to remove the iron. Excess iron is stored in the tissues and organs
(hemosiderosis). Hemosiderosis must be treated to prevent toxic levels of iron in the body
and possible death. Iron may be removed from the body by using drugs called chelating
agents that bind with the iron and allow for excretion through the urine and stool. Chelating
agents include deferasirox (Exjade) and deferoxamine B (Desferal). The patient’s clinical
condition often determines which chelating agent will produce the best outcome. Other
factors that influence chelating selection include the route of administration, cost, and
severity of iron overload. Several chelating agents are available for prevention and treatment
of iron overload.
Patients at risk for hemosiderosis are evaluated for long-term complications.
Complications that may occur are a result of iron deposits that may damage vital organs
causing hearing loss, diabetes, organ failure, and ultimately, death.
Patients with this chronic hematological disorder require supportive care and
teaching by the nurse. The nurse addresses the importance of blood transfusion
therapy and chelation to ensure adherence with the treatment regimen to
promote quality of life. Teach the family the appropriate technique for
administration of the chelation therapy. Other teaching aspects include
meticulous hand washing because these children are often asplenic, which
increases their susceptibility to infection. Be sure to alert parents to seek medical
attention if the child develops a temperature of 101.5°F (38.6°C). If the child has
a fever, inform the parents that antibiotic prophylaxis may be indicated. Also,
instruct the family on the importance of genetic counseling and referrals to
community resources for support.
Hemophilia
The most common group of hereditary bleeding disorders, hemophilia is caused
by a deficiency or absence of factor VIII (hemophilia A) or factory IX (hemophilia
B) and plasma proteins required for normal blood clotting. This group of bleeding
disorders is inherited sex-linked recessive (Ruggiero & Ruggiero, 2020). The
mother is the carrier of the X-linked deficiency, and the sons are those affected
with the disorder (Rajendran & Bansal, 2019).
In children with hemophilia, the coagulation process cannot be completed, so
bleeding is prolonged. A common misconception is that bleeding is faster in
these patients, but this is not the case. The prolonged bleeding is what causes
the clinical manifestations to be evident. The child with a greater degree of factor
deficiency experiences more bleeding episodes than the child with mild
deficiency. Hemophilia A is classified as mild, moderate, or severe based on the
degree of deficiency present.
Signs and Symptoms
Often a child with hemophilia is diagnosed after presenting with bleeding or there
is a known family history of bleeding disorders. Common presenting signs and
symptoms include the following:
■ Bruising:
■ Excessive bleeding (circumcision, tooth loss):
■ Oozing after a circumcision:
■ Intracranial hemorrhage in the neonate as a result of childbirth:
■ Soft tissue bleeding:
■ Swelling or stiffness of joints, especially the knees:
■ Decreased range of motion of extremities:
■ Painful joints (Rajendran & Bansal, 2019):
Most children are free of symptoms until they crawl or walk. In infancy, a
bleeding disorder may be discovered at the time of circumcision. In older
children, excessive bleeding may occur with a tooth extraction or tooth loss. For
the child with hemophilia who experiences frequent bleeds in the joints, long-
term consequences may include mobility limitations, bony changes, and crippling
deformities.
Children with bleeding disorders often experience hemarthrosis (a bloody
effusion within a joint) and soft tissue bleeding (Rajendran & Bansal, 2019).
Children who have hemarthrosis often seek medical attention after a minor injury
in which there is swelling or pain in the affected joint.
Diagnosis
For the child who experiences moderate to severe bleeding from minor
procedures or bleeding into large joints, diagnostic testing is warranted. Common
diagnostic tests may include a prothrombin time (PT) and a partial
thromboplastin time (PTT). The most important test is the direct assay of plasma
factor activity level for hemophilia A and B (Chaturvedi, 2018). Based on the type
of factor deficiency and the percentage of factor level in the plasma, the
diagnosis and the type and the classification of hemophilia are confirmed.
Prevention
Hemophilia is a genetically transmitted condition; therefore, the primary strategy
for prevention is genetic counseling to decrease the possible transmission of this
blood disorder. Patients with hemophilia require education on how to determine if
a bleed is present and methods to treat and prevent further episodes. Strategies
to prevent bleeding episodes are essential. Patient must be instructed to avoid
aspirin and aspirin-containing products, IM injections, and avoidance of activities
that may cause injuries. Safety precautions at home must be reinforced to the
family. Patients are taught to use safety equipment such as helmets, car seats,
and seat belts to protect the child. In addition, use of common household items
such as bunk beds, ladders, and play toys such as skateboards, trampolines,
and other high-risk items should be avoided. Patients that require factor
supplementation are instructed on how to properly administer factor products at
home safely to prevent injury.
An Interdisciplinary Approach for Hemophilia
A collaborative interdisciplinary approach is essential in the care of children with hemophilia.
The school nurse and others, including coaches, day-care providers, or team leaders who
interface with the child, must be aware of the condition and taught about emergency care if
needed. Parents must be notified by whoever is working with the child so proper care can be
sought.
The nurse initiates prompt treatment of bleeding episodes. The identification of the deficient
factor is imperative to administer the proper replacement factors. The number one nursing
priority for all patients with bleeding disorders is always patient safety, prevention of additional
complications, and promoting wellness and quality of life.
FOCUS ON SAFETY
Hemophilia
The majority of patients with hemophilia can be safely managed at home by informed and
educated family members. Depending on the severity of the bleed, such as a bleed into a
joint, a head injury, or internal trauma, patients may require close observation and inpatient
hospitalization.
MEDICAL CARE
Recombinant factor products are the main treatment of hemophilia patients
(Rajendran & Bansal, 2019). These manufactured clotting factors are genetically
engineered, thus reducing the transmission of various infectious diseases. After
years of receiving replacement factor products, some children may develop
inhibitors to the specific coagulation proteins. The development of inhibitors
poses a unique treatment challenge to manage these patients. Changes or
additions to the treatment regimen may be necessary to provide adequate
replacement factors.
For children with severe hemophilia, prophylactic doses of recombinant factor
products may be administered in the home setting by caretakers to prevent
bleeding episodes. The nurse instructs family members how to administer these
factor products by IV access. Older, mature children may assume the
responsibility of self-administering factor products at home after instruction has
been completed. One of the most important steps toward independence for
adolescents with hemophilia is learning how to self-administer medications.
Proper administration of factor products at home improves the quality of life,
decreases hospitalizations, reduces missed days in school, and prevents long-
term complications for children with this chronic illness. Administration of
replacement factor products:
1. Prepare the setting: Gather supplies, wash hands, and have the environment
ready for medication administration
2. Medication preparation: Mix the factor concentrate with sterile water per
instructions
3. Set up: Draw contents of the reconstituted drug into a syringe to be ready to
administer IV
4. Prepare the child for treatment to be given
5. IV access: Insert a butterfly needle into a vein so you can infuse factor
medication
6. Injection: Infuse the factor concentrate to treat bleeding episode or to
administer as prescribed for preventive measures
7. Dispose of sharps and syringe in appropriate containers
Von Willebrand’s Disease

One of the most common inherited bleeding disorders is von Willebrand’s
disease (vWD); this condition plays a role in the early phase of hemostasis by
enhancing platelet aggregation adhesion (Rajendran & Bansal, 2019). This vWF
factor acts as a “platelet plug.” This disorder is transmitted via an autosomal
dominant pattern of inheritance, affecting males and females equally. This
disease is characterized by a deficiency of von Willebrand factor (vWF) and has
variable clinical manifestations, including prolonged bleeding associated with
surgery, nose bleeds, minor injuries, and menorrhagia.
Patient Education
The Child With Hemophilia
HOW TO: Teach the Family How to Care for the Child With Hemophilia
Because there is no known cure for hemophilia, the interdisciplinary health-care team
members, including physicians, nurses, rehabilitative services, social workers, child life
specialists, and school personnel, are instrumental in teaching the family about how to care
for their child with hemophilia.
Recommendations for families are to seek health care at a facility with a comprehensive
hemophilia care center. If the treatment regimen is followed, these children can live long and
productive lives. It is essential that the health-care team members teach the family about the
prevention of bleeding to avoid complications. If a bleeding episode occurs, the family is
instructed on the proper interventions to take. In the instance that the child has a soft tissue
injury or bleeding into a joint, before seeking medical attention the family initiates supportive
measures (i.e., application of pressure to bleeding site, ice, elevation, and rest) (Rajendran &
Bansal, 2019). Other family teaching tips include:
• Instruct families on the signs and symptoms that require prompt medical attention. Most
importantly, any trauma to the head or a change in the level of consciousness is a medical
emergency.
• Teach families about the factor replacement products, including how to obtain the product.
Often parents are instructed on how to administer prophylactic doses of factor replacement
at home.
• Ensure families are aware that safety is of utmost importance. Injury prevention is reviewed
at all stages of development because risk factors change based on the child’s development
and age. Contact sports are highly discouraged. The child is fitted for a safety helmet to
prevent head injury when bike riding.
• Explore with families any home environmental factors that may pose a safety risk (e.g.,
mobility issues, bunk beds, and stairs).
• Inform families that, for children who have experienced bleeding into the joints, physical
therapy may be necessary to preserve and maintain functional status. The physical therapist
is a key member in the collaboration with the family to provide comprehensive care.
• Ensure children wear a medical alert bracelet in case a medical emergency occurs outside
the home when their caretaker or parent is not present.
• Review with families the purpose of genetic counseling and why it is recommended.
• Collaborate with other health-care professionals such as a nurse case manager or social
worker who can assist with insurance issues, help obtain medications and supplies, locate
rehabilitation services, coordinate home nursing care, and assist with other concerns. The
social worker is also available for emotional and psychosocial support.
• Relay that resources are available at comprehensive hemophilia centers and also online by
the National Hemophilia Foundation at www.hemophilia.org.
Signs and Symptoms

When there is a deficiency of vWF, signs and symptoms of prolonged bleeding
times may include:
■ Epistaxis:
■ Menorrhagia:
■ Bleeding from the oral cavity:
■ Easy bruising:
■ Excessive bleeding following minor surgery or dental extraction:
Diagnosis
Often, children are diagnosed with vWD when excessive bleeding is present with
a simple tooth loss or a minor procedure such as circumcision. A comprehensive
family history is essential. The family history reveals similar bleeding
manifestations in other family members because vWD is an inherited bleeding
disorder. A complete physical examination is essential to detect clinical
abnormalities for bleeding tendencies such as multiple sites of bruising. For a
child who is experiencing moderate to severe bleeding, a thorough diagnostic
evaluation is warranted. The nurse obtains blood samples for PT, PTT,
fibrinogen, thrombin time, platelet function assay, CBC, vWF, and vWF antigen.
Prevention
vWD is a genetically transmitted blood disorder; therefore, the primary strategy
for prevention is genetic counseling to reduce the transmission of the disease.
The teaching priority for patients with vWD is directed on controlling and
preventing bleeding episodes. Patients are instructed on how to administer
desmopressin (DDAVP), which is administered at home intranasally. Tell the
family to contact the health-care provider if the patient has symptoms of an upper
respiratory infection such as a runny nose or congestion; this may decrease the
effectiveness of the intranasal DDAVP. Teaching about DDAVP also includes a
reduction in fluid intake to prevent overhydration and possible hyponatremia.
DDAVP therapy is most effective for patients with mild bleeding episodes. Teach
parents to alert the health-care provider if bleeding episodes are not controlled or
the patient has complaints of headaches.
Collaborative Care
NURSING CARE
For the child identified with an inherited bleeding disorder such as hemophilia
or vWD, the health-care provider recommends a medical alert bracelet be worn
to alert health-care personnel and others about the child’s condition.
MEDICAL CARE
Treatment for this disorder includes the administration of DDAVP, a synthetic
analog of the antidiuretic hormone vasopressin. This hormone increases the
plasma vWF and factor VIII after the administration by releasing vWF from its
endothelial cell storage to produce an immediate increase in the plasma levels.
This medication improves platelet function and shortens the bleeding time. This
treatment method may be effective in correcting the bleeding defect of vWD. In
addition to the primary function of DDAVP, there may be secondary stabilization
of additional factor VIII. Other treatment modalities of vWD include the IV
administration of Humate-P and/or the administration of cryoprecipitate or fresh
frozen plasma (AAP, 2018).
Nursing care includes instructing parents about common sites of bleeding such
as the nose, gums, and internal bleeding. Even the smallest nosebleed (Fig. 24-
4) can be upsetting to a child and parent. Education can also be focused on
controlling the bleeding by applying pressure, applying ice, and seeking medical
attention. Educate adolescent females on what constitutes excessively heavy
menses. The nurse’s teaching also includes tips to avoid an embarrassing
moment during periods of heavy menstrual flow, such as wearing two maxi pads
and not wearing light-colored pants or skirts. Small children can be instructed to
avoid nose picking, vigorous nose blowing, and strenuous activity that may
cause a nosebleed. Teach children to sneeze with their mouth open and gently
blow the nose if needed. Avoid the use of acetylsalicylic acid (children’s aspirin)
or NSAIDs, which may promote bleeding episodes. Children prone to epistaxis
can use cool mist humidification as a preventive measure. Gentle flossing and
usage of a soft bristle toothbrush are encouraged.
Immune thrombocytopenia (ITP) is the most frequently occurring
thrombocytopenia of childhood. Although there is no known cause of ITP and no
cure, the prognosis for a child with ITP is very good. Usually, the child’s body
stops making the antibodies that are attacking the platelets and the disorder
resolves on its own. The characteristic features include thrombocytopenia (an
abnormal decrease in the number of blood platelets) and purpura (discoloration
caused by a hemorrhage beneath the skin).
ITP is a disorder of increased platelet destruction caused by antiplatelet
antibodies. These antiplatelet antibodies attach to the child’s own platelets, and
the body’s immune system eliminates the platelets through the spleen, which has
identified these antiplatelet antibodies as foreign. Since 90% of cases of pediatric
ITP resolve without any intervention, these patients are followed by a pediatric
hematologist. If after one year the ITP persists, treatment involves a
splenectomy.
FIGURE 24-4 When a nosebleed occurs, the nurse can provide simple first aid
measures that may assist in stopping the bleeding.
ITP is classified by duration, lasting a few months to a year, or chronic lasting

longer than a year. The more common type of ITP is often of shorter duration.
Newly diagnosed ITP is characterized by a normal platelet count within 6
months of diagnosis with no evidence of relapse. Approximately two-thirds of
children diagnosed with acute ITP achieve complete remission.
Chronic ITP is most common in adults. However, a small percentage of
children have this chronic condition. Chronic ITP is defined as the persistence of
thrombocytopenia (usually less than 150,000) that lasts longer than 12 months
(Bruno et al, 2018). In some chronic ITP cases, there seems to be a strong
correlation with the development of systemic erythematosus lupus.
Signs and Symptoms

The clinical presentation of ITP is generally a previously healthy child who may
have had a recent viral infection and the following symptoms:
■ Petechiae:
■ Bruising:
■ Mucocutaneous bleeding:
■ Epistaxis:
■ Menorrhagia:
■ Internal bleeding such as intracranial hemorrhage (rare occurrence):
Diagnosis
A thorough history and physical examination are essential. Most of these
patients appear healthy, with the exception of bruising and bleeding. ITP is a
diagnosis made by exclusion because there are no tests that confirm the
diagnosis.
Newly diagnosed ITP is often benign, self-limiting, and often occurs in children
younger than 10 years of age after an upper respiratory infection; after childhood
diseases such as measles, rubella, mumps, and chickenpox; and it may also
occur after an infection with parvovirus B19 (Rajendran & Bansal, 2019).
What to Say
Diagnosing Idiopathic (Immune) Thrombocytopenia Purpura
Communicate to the family about how ITP is diagnosed. It is essential that the nurse tell the
family that there are no definitive tests to establish the diagnosis. Explain that other disorders
such as lupus, leukemia, and lymphoma must be ruled out (Rajendran & Bansal, 2019).
Numerous tests are required to confirm the diagnosis of ITP, including CBC and peripheral
smear examination, coagulation analysis, and possible bone marrow aspirate if steroid
therapy is implemented. A bone marrow aspirate may be performed to rule out an underlying
malignancy. The CBC often shows isolated and usually severe thrombocytopenia, usually a
platelet count of less than 20,000 (normal platelet count is 150,000 to 400,000). The
peripheral smear is often normal with the exception of thrombocytopenia with normal-size to
large platelets.
NURSING INSIGHT
Accurately Diagnosing ITP
The child who appears in the emergency department with ITP may be erroneously identified
as a child who is a victim of abuse. ITP and child abuse may be easily confused. An accurate
history and physical and evaluation of CBC will assist the health-care team in determining the
actual cause of the observed bruising or bleeding.
Collaborative Care
NURSING CARE
The majority of patients with acute ITP may have spontaneous resolution of
the disorder with no treatment. The treatment for ITP among pediatric
hematologists is not consistent, although recommendations from the American
Society of Hematology have been established. General guidelines recommend
that children who have a platelet count greater than 20,000 and are
asymptomatic do not require treatment, and platelet counts are monitored. Small
toddlers and active children with bruising and petechiae with platelet counts less
than 20,000 are treated aggressively to avoid the most serious complication of a
life-threatening intracranial bleed. Unless severe life-threatening bleeding is
present, transfusion of platelets is not recommended to treat acute ITP because
the antibodies attach to the infused platelets and destroy the new platelets in a
similar fashion as the destruction of the patient’s own platelets.
MEDICAL CARE
Treatment strategies for thrombocytopenia may include steroid administration,
intravenous immune gamma globulin (IVIG) administration, or anti-D antibody
(WinRho® SDF) administration. Children with exceptionally low platelet counts
and acute bleeding require inpatient hospitalization with close observation
because of the potential of a rare complication of a cerebrovascular bleed. These
children may also receive a 2- to 3-day course of IVIG intravenously. The
mechanism of action of IVIG is to prevent antibody attachment to the platelets,
thereby preventing platelet destruction in the spleen. A vast majority of patients
who receive IVIG experience a substantial rise in platelet count within 48 hours.
Inpatient care may include bedrest, monitoring of vital signs and adverse
reactions during the administration of IVIG, and daily blood counts.
The Administration of IV Anti-D Antibody

The newest treatment modality for acute ITP patients with an Rh(D)-positive blood type is the
administration of IV anti-D antibody. The mechanism of action of anti-D antibody is to bind to
the RBCs, which are selectively destroyed in the spleen instead of platelets. The anti-D
antibody coats the Rh(D)-positive RBCs with antibody, only for Rh(D)-positive patients. The
anti-D-coated cells saturate the capacity of the spleen receptors, and the platelets are spared.
A common side effect of anti-D antibody is a transient hemolytic anemia that often resolves as
the IgG disperses. It is important that the nurse communicate to the family the other possible
side effects of anti-D antibody (e.g., fever, chills, or headache after infusion). A paramount
nursing action is close observation and monitoring of the child’s vital signs.
SURGICAL CARE
In selected children for whom medical treatment has failed and there have
been acute life-threatening bleeding episodes, a treatment modality may include
a splenectomy. These patients must be older than 5 years of age and have low
platelet counts that affect their activities of daily living. However, advancements
in medical treatment for ITP have diminished the need for the major surgical
procedure of a splenectomy. Postoperative nursing care measures include:
■ Monitoring vital signs as per institution policy for postoperative care until the
child’s condition is stabilized:
■ Administering IV fluids, pain medications, and antibiotics if ordered:
■ Assessing the surgical site for the signs and symptoms of bleeding or infection:
■ Monitoring intake and output:
Teach the family that the most important information related to this condition is
the child’s safety. Advise parents to restrict activities such as contact sports and
high-risk activities such as bicycle riding, roller skating, and riding motor
scooters. Parents must be instructed on how to manage a bleeding episode in
the home, most commonly minor cuts, scrapes, and nosebleeds. Instruct parents
to apply pressure to the injury site. If the bleeding is from the nose, the nurse can
instruct the caretaker to have the child lean down and forward, pinch the bridge
of the nose, and if possible, apply ice. For severe bleeding that does not stop
with manual pressure, the caregiver must seek medical attention.
Other important teaching strategies include avoiding the use of acetylsalicylic
acid (children’s aspirin) or other aspirin-containing products, injections, the use of
straight-edge razors, the use of tampons, or inserting a thermometer or
suppository into the rectum. Instruct caregivers to report signs or symptoms of
bleeding immediately and to provide a safe environment to prevent trauma such
as using a nail file as opposed to clippers for nail grooming. It is essential that
the nurse recommends to parents of a child with chronic ITP that a medical alert
bracelet be worn (Fig. 24-5).
FOCUS ON SAFETY
Intracranial Bleeding
Ensure that caretakers are knowledgeable about identifying the most serious complication of
ITP—an intracranial bleed. Parents must report any changes in level of consciousness or
behavior, severe headaches, vision changes, ataxia, slurred speech, complaints of
weakness or numbness, and severe vomiting not associated with nausea.
CASE STUDY
Kelly is a 4-year-old child who has just had a respiratory infection last week. When she woke
up this morning to go to day care, she had bruises and petechiae. She did not have a fever.
The parents immediately phoned the pediatrician and were told to bring the child to the
emergency department. Her physical examination was unremarkable except for her bruising,
petechiae, and a platelet count of 6,000. All of Kelly’s other labs were within normal limits. She
was admitted to the hematology oncology unit.
1. What is the goal of Kelly’s treatment?

2. What treatment would you expect the health-care provider to recommend for Kelly?
Disseminated intravascular coagulation (DIC) is a hematological illness that is
secondary to an underlying disease. Some disease states in which children may
develop DIC include sepsis (usually gram-negative bacteria), hypoxemia, major
trauma with severe tissue injury, malignancy, thrombotic thrombocytopenic
purpura, hemolytic uremic syndrome, extensive burns, and severe viral infections
(Chaturvedi, 2018).
Children with DIC display an abnormal coagulation process characterized by
excessive stimulation of normal coagulation that results in microthrombi. These
microthrombi are released, and as a result more coagulation factors and
platelets are consumed and produced. This process causes the destruction of
platelets and coagulation factors, resulting in hemorrhaging and thrombosis.
When this clinical diagnosis of DIC is evident, there is accompanying decreased
platelet count, increased prothrombin, decreased fibrinogen, and a buildup of
fibrin degradation products that may develop into DIC and tissue ischemia.
FIGURE 24-5 Any child who has immune thrombocytopenia purpura (ITP)
should wear a medical alert bracelet.
Signs and Symptoms

Signs and symptoms of DIC may include:
■ Excessive bleeding from orifices or from other locations because of minor
procedures:
■ Hematomas:
■ Petechiae or purpura:
■ Hypotension:
A resulting condition includes:
■ Progression to multiorgan failure caused by infarctions and ischemia:
Diagnosis
There is no single test that confirms the diagnosis of DIC. The diagnosis is based
on the combination of the child’s clinical condition and laboratory tests pertinent
to coagulopathies. Children with DIC often demonstrate suspicious findings that
include thrombocytopenia, prolonged PT, prolonged PTT, decreased fibrinogen,
and increased D-dimer.
Prevention
DIC is often a complication of other disease processes; therefore, the most
important aspect of prevention is to identify the underlying cause and treat
appropriately. Important nursing responsibilities include early identification of risk
factors that predispose patients to develop DIC, recognizing clinical signs and
symptoms of DIC, and communicating findings with the health-care provider for
prompt interventions.
Collaborative Care
NURSING CARE
When caring for a child with DIC, the nurse’s primary intervention is to assess
the child and provide supportive care for the symptomatology. Monitor for signs
of hemorrhage, bleeding, petechiae, cutaneous oozing, dyspnea, lethargy, pallor,
increased heart rate, decreased blood pressure, headache, dizziness, muscle
weakness, and restlessness. Monitor for internal bleeding by checking both the
urine and stool for occult blood. If the child is bleeding, it is important not to
disturb clots, use pressure, apply ice to control bleeding, and measure blood
loss. The nurse also obtains necessary laboratory tests and administers
supportive treatments such as blood and factor products per physician’s orders
(Bruno et al, 2020).
What to Say
When a child is critically ill and has the diagnosis of DIC, parents are informed of the plan of
care and course of treatment. In the intensive care unit, the nurse orients families to the unit
procedures, equipment, and treatments. The possibility of excessive bleeding from multiple
sites may occur and could be upsetting to family members. The nurse communicates to
families about the occurrence of excessive bleeding to help decrease anxiety. Identifying
areas of knowledge deficits and ensuring consistent caregivers during this time of crisis are
important nursing interventions. Provide families with honest answers in clear and concise
terms.
MEDICAL CARE
Children with DIC are critically ill and may require management in the intensive
care unit. The administration of blood and factor products is often necessary.
Prognosis for DIC has improved significantly over the last two decades because
of advances in supportive care such as improved antibiotics, antifibrinolytic
therapy, and improvement in transfusion therapy.
Because DIC is not a primary disease, parents should understand the
importance of treating infections and the triggers that were identified to cause
this coagulation disorder. Preventing complications of the primary illness will play
a key role in preventing the development of DIC.
Aplastic Anemia
Aplastic anemia is a rare illness but one of the most serious hematological
conditions that generally afflicts adolescents and young adults. This condition,
characterized by pancytopenia (a reduction in all cellular elements of the blood,
WBCs, platelets, and RBCs), is caused by bone marrow hematopoiesis failure
(Chaturvedi et al, 2018). The clinical course may be acute and may progress to
severe bone marrow suppression with the possibility of rapid deterioration
leading to death. The condition could also have an insidious onset and chronic
course. Classification can range from moderate aplastic anemia to very severe
aplastic anemia.
Aplastic anemia is hereditary (a congenital disorder) or an acquired illness.
Hereditary aplastic anemia (a congenital disorder) is relatively rare, but it can
occur with diseases such as Fanconi’s anemia. Fanconi’s anemia is inherited as
an autosomal recessive trait. Fanconi’s anemia accounts for 25% to 30% of all
cases of childhood aplastic anemia (Bruno et al, 2020). Children with congenital
aplastic anemia have chromosomal breakages and structural abnormalities that
increase the incidence of various malignancies such as leukemia.
The majority of aplastic anemia cases are considered to be acquired and the
specific cause is never determined (Box 24-2). Other forms of aplastic anemia
are considered secondary to etiological agents that are usually associated with
various environmental factors and physical conditions.
Signs and Symptoms

The presenting signs and symptoms of a child with aplastic anemia vary by
severity of bone marrow suppression:
■ Pancytopenia
■ Bleeding
■ Bruising
■ Fatigue
■ Pallor
BOX 24-2
Causative Factors of Acquired Aplastic Anemia

• High-dose radiation
• Autoimmune disorders
• Pregnancy
• Infectious processes
• Hepatitis
• Epstein-Barr virus
• HIV
• Cytomegalovirus (CMV) infection
• Infectious mononucleosis
• Nonpharmacological agents
• Benzene
• Lindane (insecticide)
• Kerosene
• Heavy metals
• Pharmacological agents
• Chemotherapy
• Chloramphenicol
• Selected antiepileptics (carbamazepine)
• Sulfonamides
• Penicillamine
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Antithyroid drugs
• Psychotropics (e.g., clozapine)
• Certain cardiovascular drugs
• Penicillamine
• Antithyroid drugs
• Certain cardiovascular drugs
The child’s symptoms are related to the degree of pancytopenia. Anemia,

pallor, dizziness, and fatigue may be present because of a decreased RBC
count. Increased bleeding and bruising, petechiae, and epistaxis may be
attributed to a low platelet count. Increased susceptibility to infections and oral
ulcerations that do not respond well to antibiotics are related to a low WBC
count. The most common presenting symptom is bleeding, usually from the
nose, mouth, and GI tract. The nurse is aware that the child with aplastic anemia
characteristically does not have the clinical finding of hepatosplenomegaly or
lymphadenopathy. The child with this clinical finding is usually diagnosed with
leukemia.
Diagnosis
To confirm the diagnosis of aplastic anemia and to rule out other hematopoietic
diseases, a bone marrow aspirate and biopsy are performed. The results of the
bone marrow aspiration generally reveal a fatty marrow with few developing
blood cells. Children who are suspected to have aplastic anemia require a
thorough history and physical and laboratory tests, including a CBC with
differential. The findings of the CBC usually are consistent with all cell lines
depressed.
Prevention
For patients with inherited aplastic anemia, genetic counseling is recommended
to prevent transmission. For patients who have acquired aplastic anemia, if the
causative is identified, exposure to or use of the product (such as a medication)
is avoided.
Nursing Care
Nursing care for children with aplastic anemia varies based on the severity of
illness and determination of causative factors. If the causative factor of the
aplastic anemia has been identified, immediate removal of the agent is
necessary. Some patients may respond to medical treatment and support. In
these cases, HSCT may not be warranted. If there is no identified cause of the
severe aplastic anemia and a suitable stem cell donor is identified, the treatment
of choice is HSCT. For best outcomes and long-term survival, every effort must
be made to proceed to transplant as soon as possible. Following the stem cell
transplant, nursing care consists of supportive care, immunosuppressive therapy,
or the administration of hematopoietic growth factors. All patients diagnosed with
aplastic anemia are extremely susceptible to infectious agents. These patients
may not exhibit the “classic signs of infection.”
Another treatment modality includes the administration of hematopoietic
growth factors. These growth factors are copies of substances that occur
naturally in the body and attempt to stimulate the bone. Sometimes combinations
of these growth factors are used to treat aplastic anemia.
FOCUS ON SAFETY
Antithymocyte Globulin (ATG)
Children with aplastic anemia who receive ATG require specific nursing care related to the
administration of this medication. Although rare, a severe anaphylactic reaction may occur
(e.g., hypotension, tachycardia, shortness of breath, or chest pain). Because there is a
potential risk for anaphylaxis, an ATG test dose is often administered to determine the
potential for an adverse reaction to this medication. The child may have no adverse reaction
to the test dose but still have a reaction to ATG. If the child has been identified as being
“allergic” to ATG, administration of this medication can still take place after a desensitization
process or administration of premedications such as antihistamine and steroids.
Because of variations in severity of aplastic anemia, the nurse’s teaching plan
correlates with the child’s clinical condition. Provide reassurance and support to
families, including basic explanations of the disease process and recommended
treatment plan. It is important for the nurse to review the child’s prescribed drugs
and discuss possible adverse reactions. Children can continue a normal lifestyle
with some restrictions. The nurse communicates to the family that monitoring the
child’s CBC is imperative, so changes in condition from mild to moderate aplastic
anemia are noted. Children and their families must be aware of signs and
symptoms of pancytopenia. Patients with moderate to severe aplastic anemia
are encouraged to schedule regular rest periods, avoid contacts with crowds,
and avoid sources of infections (e.g., sick contacts, soil, standing water). Injury
prevention may include using a soft toothbrush for oral hygiene, ensuring a safe
play environment, and avoiding the use of tampons for adolescent girls. Stress
the importance of meticulous oral hygiene and diligent hand washing. For
additional education materials and resources for family teaching, refer families to
the Aplastic Anemia and MDS International Foundation at www.aamds.org.
Neutropenia
Neutropenia occurs when an absolute neutrophil count (ANC) is less than
1,000/mcL in infants younger than 1 year of age and 1,500/mcL for those older
than 1 year of age. The ANC is the total number of WBCs multiplied by the
percentage of neutrophils (segs and bands).
The National Cancer Institute neutropenia grading system classifies slight
neutropenia as grade 1 with ANC of less than 2,000, minimal neutropenia as
grade 2 with ANC of less than 1,500, and moderate neutropenia as grade 3 with
ANC less than 1,000 (AAP, 2018). The most severe neutropenia is grade 4 with
an ANC of less than 500. When caring for children with neutropenia, the nursing
plan of care is based on the severity of neutropenia present.
Signs and Symptoms

Signs and symptoms of neutropenia include:
■ Fever
■ Lymphadenopathy
■ Organomegaly
■ Pallor
■ Bruising
■ Petechiae
Infection
Observe the child for any underlying infection, especially the mouth, skin, ears, and perianal
area. A fever may be the only clinical sign that an infection is present. Often the child with
neutropenia may not have the classic signs of an underlying infection, so the nurse must pay
close attention to the subtle signs that may be present. The reason these children do not
display the classic signs and symptoms is that they do not possess the cells (i.e., neutrophils)
to evoke such a response, such as redness, swelling, or pus.
Diagnosis
The child diagnosed with neutropenia requires a meticulous history and physical
examination. The child’s height and weight are plotted on the growth chart to
evaluate for any underlying genetic illness or deviations from the norm. The
child’s laboratory work-up is based on the findings from the history and physical.
In most cases a CBC with differential and a peripheral smear will be performed.
An important area to focus on is the ANC as opposed to the total WBC count.
Prevention
For patients with congenital neutropenia who are considering pregnancy, genetic
counseling is recommended. For patients with neutropenia as a result of an
illness such as a blood cancer, prevention is focused on treating the underlying
disease and close monitoring of blood counts. Patients receiving
immunosuppressive therapy should be aware of when the nadir (time of lowest
blood counts) occurs related to treatment, and neutropenic precautions are
observed.
Collaborative Care
NURSING CARE
In children with congenital neutropenia, the nursing plan of care is based on
the degree of neutropenia and physical findings. In patients with acquired
neutropenia, the etiology must be evaluated. One of the most important aspects
of nursing care for neutropenic patients includes monitoring for infections by
checking for fever, evaluating ANC, and performing physical exams. In the event
an infection is suspected, treatment of a documented infection in the neutropenic
patient is dependent on the organism that is isolated. Empiric therapy, usually
with a broad-spectrum antibiotic, is usually implemented during the period of time
in which culture results are pending. Once culture results are obtained, antibiotic
therapy is evaluated for sensitivities and adjusted accordingly.
MEDICAL CARE
Treatment may range from supportive measures to the administration of
colony-stimulating factors, and in most severe cases to bone marrow transplant if
necessary. The administration of granulocyte colony-stimulating factor (GCSF)
such as Neupogen stimulates the bone marrow to produce more neutrophils
(Venes, 2021).
Instruct parents of a child who has had an exposure to chickenpox (i.e., any
type of varicella illness) to immediately contact a health-care provider.
Administering the varicella-zoster vaccine may be helpful to the neutropenic child
who might be exposed to an outbreak of chickenpox.
Granulocyte colony-stimulating factors (GCSF) are powerful regulators of
blood cell proliferation that stimulate the bone marrow to produce granulocytes
and stem cells releasing them into the bloodstream. Growth factors are given to
prevent profound neutropenia and decrease susceptibility to life-threatening
infections. In the home setting, this medication is given by subcutaneous
injection once daily by the child’s caregiver. Possible side effects include fever,
bone pain, headache, and local reaction at the injection site.
The child who has neutropenia, whether congenital or acquired, needs specific
teaching on management. Families are instructed on when and how to
appropriately wash their hands. Hands are washed with soap and water for at
least 10 to 15 seconds using a circular motion. Friction (rubbing) is the most
important aspect of hand washing because it assists in removing germs from the
hands.
Teach parents how to appropriately check the child’s temperature. Remind
them to never check a temperature rectally because this route may cause a tear
in the rectal mucosa, promoting an entrance for bacteria. Parents need to seek
medical attention if the child develops a temperature of 101.5°F (38.6°C). Instruct
caregivers to keep the neutropenic child away from anyone who is sick or has
recently received live vaccines.
Teaching the family about meticulous oral hygiene is also important. To
prevent bacteria in the mouth, the child can use a soft toothbrush and rinse well
after brushing. Good skin care is essential to prevent infections or breaks in the
skin.
Patient Education
The Neutropenic Child
Families and children with neutropenia are taught the following measures to reduce the
incidence of infection:
• Know when routine visits are scheduled.
• Know the signs and symptoms of infections, such as fever (greater than 101.5°F [38.6°C]).
• Know that acetylsalicylic acid (aspirin) or NSAIDs are not given to children with low counts.
• Avoid large crowds or anyone who may be sick with a cold, flu, etc.
• Keep the child’s body clean by bathing every day and brush teeth after meals and before
bedtime.
• Avoid hot tubs.
• Always be sure to wash the child’s hands before eating or touching the face, eyes, nose,
and mouth.
• Avoid constipation and straining to have a bowel movement by drinking 2 quarts of fluids
each day, such as water, and use a stool softener.
• Avoid putting anything in the child’s rectum, including thermometers and suppositories.
• Avoid exposure to fresh flowers or live plants.
• Avoid exposure to stool droppings from pets and cleaning bird cages or cat litter boxes.
• Do not share bath towels or drinking glasses with others, including family members.
• Avoid eating the following items:
- Raw milk or milk products or any milk product that has not been pasteurized, including
cheese and yogurt made from unpasteurized milk
- Raw or uncooked meat, fish, chicken, eggs, or tofu
- Foods that contain mold (e.g., blue cheese)
- Raw honey (honey that has not been pasteurized)
- Uncooked fresh fruit or vegetables that are not well cleaned
- Outdated foods or foods left at room temperature for more than 2 hours
• Tell adolescents not to use tampons, vaginal suppositories, or douche.
• Tell adolescents to avoid manicures, pedicures, acrylic nails, or nail tips.
• Tell adolescents to use an electric shaver instead of a disposable blade razor.
BLOOD TRANSFUSION THERAPY

Because of recent advances in health care and more children living with chronic
illnesses, blood transfusion therapy may be required as part of the nursing care
plan. Illnesses such as hematological, oncological, and other chronic conditions
often necessitate the use of blood products. Nurses must be knowledgeable
about blood transfusion products and specific indications for each blood product
(Table 24-7). Administration of blood may vary based on institution policy and
procedures and the actual product being administered.
TABLE 24-7
Transfusion Products
TRANSFUSION INDICATIONS NURSING ACTIONS
PRODUCT
Red Blood Cells Hemoglobin <8 grams on a stable Observe for clinical signs and
patient with a chronic anemia. symptoms of anemia:
Hypovolemia caused by acute blood • Fatigue
loss. • Syncope
Evidence of impending heart failure • Pallor
secondary to severe anemia. • Tachycardia
Patients on hypertransfusion regimen • Diaphoretic
for SCD and history of: • Shortness of breath
• Cerebrovascular accident • Inability to perform activities of daily
• Splenic sequestration living
• Acute chest syndrome Don appropriate personal protective
• Recurrent priapism equipment (PPE) for all blood product
• Preoperative preparation for surgery transfusions.
with general anesthesia Monitor vital signs per hospital policy
• Hypoxia and procedure.
Children requiring increased oxygen- Monitor hemoglobin and hematocrit.
carrying capacity (i.e., complex During blood product infusions,
congenital heart, intracardiac observe for adverse reactions.
shunting, severe pulmonary disease Blood can be stored only in a
—ARDS): designated blood refrigerator.
• Shock states (decrease B.P., Generally 10-15 mL/kg of packed red
increased peripheral blood cells are transfused (Khilnani,
vasoconstriction pallor, cyanosis, 2005).
diaphoretic, clamminess, mottled
skin, increased oxygen requirement,
decreased urinary output)
• Cardiac failure
• Respiratory failure requiring
significant ventilatory support
• Postoperative anemia
Autologous For general scheduled surgical Verify with parents that self-donation
Blood (self- procedures in which there are clinical has occurred.
donated blood indications that a blood transfusion Patient identification and
product) may be necessary during the administration process is the same as
intraoperative or postoperative period, for all other blood products.
the patient may elect to self-donate.
Check with blood bank facilities for
time criteria for this type of donation.
For general surgical procedures, the
recommended hemoglobin is 10
grams or greater and for orthopedic
surgery the recommendation is
hemoglobin of 11.5 or greater.
Whole Blood or Hypovolemia caused by acute blood Same nursing actions applicable to
Packed Red loss nonresponsive to crystalloids red blood cell infusions.
Blood Cells • HCT<35%
(PRBC) • Hypovolemia caused by acute In major trauma situations, patient
Reconstituted massive blood loss (i.e., major may be transfused with O negative
With Fresh trauma) blood, the universal donor.
Frozen Plasma • History of blood loss at delivery or Use blood warmer and rapid infuser if
(FFP) large amount of blood drawn for lab available.
studies (10% blood volume)
• Cardiac patients HCT <40% (e.g.,
structural heart disease, cyanosis,
or congestive heart failure)
• Drop in HGB to below 10 grams
intraoperatively
• Exchange transfusion
Platelets Platelet count <20,000 Know normal platelet count (150,000
Active bleeding with symptoms of DIC to 400,000).
or other significant coagulopathies Obtain CBC.
Platelet count <50,000 with planned Assess bruising, petechiae, and
invasive procedure (i.e., surgical bleeding.
procedure, central line insertion, does
not include drawing blood, IM
injection, or IV catheter insertion)
Prevention or treatment of bleeding
caused by thrombocytopenia
(secondary to chemotherapy,
radiation, or bone marrow failure)
Treatment of patients with severe
thrombocytopenia secondary to
increased platelet destruction or
immune thrombocytopenia associated
with complication of severe trauma
Massive transfusion with platelet
dilution
Fresh Frozen Replacement for deficiency of factors Notify blood bank to thaw FFP;
Plasma (FFP) II, V, VII, IX, X, XII; protein C or product must be used within 6 hours
protein S of thawing.
Bleeding, invasive procedure, or Don appropriate PPE for all blood
surgery with documented plasma product transfusions.
clotting protein deficiency (e.g., liver Monitor vital signs per hospital policy
failure, DIC, or septic shock) and procedure.
Prolonged PT and/or PTT without Monitor coagulation studies.
bleeding During FFP infusions, observe for
Significant intraoperative bleeding adverse reactions.
(>10% blood volume/hr) in excess of
normally anticipated blood loss that is
at high risk of clotting-factor deficiency
Massive transfusion
Therapeutic plasma exchanges
Warfarin anticoagulant overdose
Cryoprecipitate Fibrinogen levels below 150 mg/dL Assess for signs and symptoms of
(CRYO) with active bleeding bleeding.
Bleeding or prophylaxis in von Don appropriate PPE for all blood
Willebrand’s disease or in factor VIII product transfusions.
(hemophilia A) deficiency Monitor vital signs per hospital policy
unresponsive to or unsuitable for and procedure.
DDAVP or factor VII concentrates Monitor coagulation studies.
Replacement therapy, bleeding, or During cryoprecipitate infusions,
invasive procedure in patients with observe for adverse reactions.
factor XIII deficiency
Patients with active intraoperative
hemorrhage in excess of normally
anticipated blood loss who are at risk
of clotting factor deficiency
Granulocytes Bacterial or fungal sepsis (proven or Type and crossmatch required for all
(white blood cell strongly suspected) unresponsive to WBC transfusions.
transfusion) antimicrobial therapy Premedications may be ordered, such
Infection (proven or strongly as antihistamines or acetaminophen.
suspected) unresponsive to
antimicrobial therapy
Factor VII Treatment of factor VII deficiency Assess for signs and symptoms of
Treatment of factor VIII inhibitors bleeding.
Treatment of factor IX inhibitors Don appropriate PPE for all blood
Idiopathic uncontrolled bleeding products, even recombinant.
Monitor coagulation studies.
If undiluted, dilute vial with indicated
amount of sterile water and
administer IV as per manufacturer’s
guidelines.
Factor VIII Hemophilia A (factor VIII deficiency) Assess for signs and symptoms of
Concentrate Patients with factor VIII inhibitors bleeding.
Patients with von Willebrand’s Don appropriate PPE for all blood
disease products.
Check product to see if refrigeration is
necessary.
Record expiration date and lot
number of product.
Factor IX Treatment of hemophilia B Assess for signs and symptoms of
Concentrate Hemophilia A with factor VIII inhibitors bleeding.
(prothrombin Patients with congenital deficiency of Don appropriate PPE for all blood
complex) prothrombin, factor VII, and factor X products.
number of product.
Intravenous Congenital or acquired antibody Don appropriate PPE for all IVIG
Immunoglobulin deficiency infusions.
(IVIG) Immunological disorders such as Monitor vital signs per hospital policy
idiopathic thrombocytopenia (ITP), and procedure.
Kawasaki’s disease Start infusion slowly and increase
rate/titrate per physician orders.
Post-transplant patients used During IVIG infusion, observe for
prophylactically, newborns with adverse reactions such as fever,
severe bacterial infections chills, and headache.
Product is obtained from pharmacy.
number of product.
Blood Product Administration

Most blood transfusions are delivered in the hospital. The first responsibility of
the nurse administering a blood transfusion to a child is to review the plan of care
with the family and explain in detail the indications and process of a blood
transfusion. The ordering health-care provider must obtain signed consent from
the parent or guardian to administer blood to the child.
FOCUS ON SAFETY
Blood Transfusion Safety Measures
During the collection of a blood sample for crossmatch, a blood bracelet with the specific
identifying numbers is placed on the child’s extremity, and the nurse uses two patient
identifiers. This safety measure is to ensure that the child receives the correct blood product
cross-matched specifically for their blood type to prevent a fatality.
Optimizing Outcomes
Type and Screen and Type and Crossmatch

The best outcome exists for the child when the nurse understands the difference between the
type and screen and type and crossmatch. TYPE AND SCREEN
• Obtain a type and screen in anticipation that a child may need a blood transfusion
• Use the proper ABO group and Rh(D) type
TYPE AND CROSSMATCH
• Obtain a type and crossmatch if almost certain the child will require blood.
• Use the proper ABO/Rh(D)-compatible donor red cells.
• Know that the type and crossmatch are good for 72 hours.
FOCUS ON SAFETY
Understanding the Administration Process
Blood is administered to the child after verifying that the correct blood product is available
and that the child’s clinical condition is stable (i.e., vital signs within parameters to safely
administer blood). The nurse completes the preassessment process for blood administration.
The nurse is aware that there are several clinical conditions that may delay the
administration of a blood product:
• Fever greater than 101°F (38.3°C)
• Lack of IV access
• Child is unable to be closely monitored by nursing staff
• Complex medication regimen with drugs with potential for anaphylaxis
When the child is clear to receive blood products, the nurse must understand the
administration process:
PRETRANSFUSION
• Do not call for the blood product until it is needed.
• Obtain a set of pretransfusion vital signs to ensure patient is clinically stable.
• Verify the health-care provider’s orders, including the appropriate product and volume to be
infused. Check with institution policies and procedures. The transfusion must be started
within 30 minutes after the blood has left the blood bank.
• The maximum time for the infusion is 4 hours. Transfusion needs to start immediately
because of the risk of bacterial contamination and cell lysis. Most blood banks do not
accept blood back after 30 minutes.
• Follow institutional policy for obtaining, verifying, and transporting blood products obtained
from the blood bank.
• Complete appropriate forms and ensure accurate patient identification.
• Indicate product type and check for any special orders such as cytomegalovirus safe or
irradiated.
• Always check to see if any premedications were ordered before administration.
• Use personal protective equipment. Be sure to wear goggles and gloves.
• All blood products must be checked at the patient’s bedside by two appropriate health-care
providers and using two patient identifiers as per the institution’s policy.
Remember, the two patient identifiers must match the number on the blood product and
the wrist band.
INITIATION OF THE TRANSFUSION
• Obtain baseline vital signs.
• Start the infusion slowly for the first 15 minutes.
• Designate a nurse to remain with the patient for the first 15 minutes of transfusion in the
event of an adverse reaction.
DURING THE TRANSFUSION
• Do not infuse any other solutions simultaneously with blood through the same IV line. The
only exception to this is normal saline.
• Never add any medications to blood.
• Monitor vital signs per the institution’s policy and procedures.
• All identification information that is attached to the blood product must remain attached until
the transfusion is completed.
• Monitor for signs and symptoms of adverse reactions such as a change in vital signs;
additionally, continue to monitor for any shortness of breath, trouble breathing, flushing,
urticaria or feelings of impending doom, or other signs and symptoms of an adverse or
analphylactic reaction.
• Immediately stop the infusion if any signs or symptoms of adverse or anaphylactic reaction
are suspected.
POST-TRANSFUSION
• Save the transfusion bag for at least 1 hour after the transfusion has ended.
• The blood slip must be completely filled out with the institution’s required information.
• The child’s medical record must include the transfusion order, the type of blood product, the
donor unit number, date and time of transfusion, pre– and post–vital signs, the volume
infused, required signatures, and if applicable any transfusion adverse events (AAP, 2018).
• Place the chart copy and blood bank copy of the blood slip in an appropriate area to be
kept on file as per policy and procedure.
Safe administration of blood products must be observed for all transfusions,

even in an emergency situation. Initially, verification of the health-care provider’s
orders and awareness of the indication for the blood transfusion are necessary.
Always use the two patient identifiers per institution guidelines. The use of a
second witness and “double check” at the bedside is an additional safety
measure to ensure safe administration of blood.
Collaborative Care
Nursing Care
An important nursing care measure includes monitoring the child’s temperature
to recognize febrile reactions early and prevent progression. If the child is having
a febrile response, the nurse stops the transfusion, monitors vital signs, and
notifies the health-care provider.
Medical Care
With the increased use of leukocyte-depleted blood products, the prevalence of
this type of reaction has diminished. Premedication with acetaminophen
(Children’s Tylenol) sometimes can prevent this type of adverse reaction.
Allergic Reaction
Another type of nonhemolytic reaction is an allergic reaction. This occurs during
a transfusion in which the child has had a previous exposure to a particular
allergen in the blood product. The exposure to this allergen stimulates an
antibody response, and an allergic transfusion reaction becomes evident. An
allergic reaction may occur on the second or subsequent transfusions.
Signs and Symptoms

The patient may experience rash, hives, pruritus, swelling of the lips, wheezing,
and anxiety.
Collaborative Care
NURSING CARE
If the nurse suspects an allergic reaction, stop the transfusion, monitor vital
signs, and notify the health-care provider.
MEDICAL CARE
In most cases, the administration of an antihistamine such as
diphenhydramine (Benadryl) resolves an allergic response. A histamine blocker
such as ranitidine (Zantac) may be administered to aid in symptom relief. In
severe allergic reactions, the child may require the administration of steroids
such as hydrocortisone (Solu-Cortef) and possibly adrenaline (Epinephrine). For
future transfusions for this child, prophylaxis care may be required with
diphenhydramine (Benadryl) and hydrocortisone (Solu-Cortef).
BONE MARROW TRANSPLANTATION

Hematopoietic stem cell transplant (HSCT) is the treatment for some types of
oncological illnesses and hematological diseases. There are several types of
hematological diseases in which HSCT may be a treatment option. For instance,
a child newly diagnosed with severe aplastic anemia who has a human leukocyte
antigen-matched (HLA-matched) sibling donor may proceed immediately to
transplant as curative treatment. Children with other hematological disorders who
have severe sequelae, including SCD with multiple complications such as CVAs
and acute chest syndrome, may also be candidates to undergo an HSCT.
Children who require chronic transfusion therapy may have the indications for
HSCT such as beta-thalassemia and Diamond-Blackfan anemia. Some genetic
and autoimmune diseases are now being treated with HSCT.
In these conditions, a large volume of actual bone marrow is harvested and
bone marrow transplantation (BMT) is performed. The preparative BMT regimen
consists of the administration of “near lethal” doses of chemotherapy and/or
radiation to ablate the diseased bone marrow. This preparative regimen results in
severe myelosuppression and places the child at grave risk for infection.
After the preparative regimen, the bone marrow is surgically obtained and then
infused through a central line. Day “0” of the transplant process is the day that
the patient receives the infusion of the stem cells. Following the infusion of the
stem cells, waiting begins for engraftment (when the donated cells start to grow
and make new blood cells). This treatment is not without potential risks, including
death. This type of therapy may have lifelong consequences for the patient and
their family, such as chronic immunosuppression, multiorgan failure, graft
rejection, graft versus host disease, and long-term late effects.
There are three types of HSCT:
■ In an autologous transplant, the ill child is their own donor of stem cells.
These donor stem cells are obtained by harvesting the child’s cells through
peripheral access or directly from the bone marrow cavity. This method is not
used in hematological diseases because hematological illnesses originate in
the bone marrow.:
■ In an allogeneic transplant, the recipient’s HLAs are matched to a compatible
donor, usually a sibling. The sibling must be tested by a thorough genetic
investigation to determine if they are a carrier of the same hematological
illness as the patient or is a compatible match before the transplant can occur.
In other cases, the allogeneic donor is an unrelated donor but is someone who
has been identified from the National Marrow Donor Program. Umbilical cord
blood stem cell transplant is another allogeneic type of transplant. These rich
stem cells are obtained from the childbirth process immediately after delivery
of the infant. The ability to obtain stem cells in this manner is a viable
alternative that recently became available.:
■ In a syngeneic transplant, the donor of the bone marrow is an identical
sibling.:
■ Indications for HSCT include::
■ Severe aplastic anemia
■ Beta-thalassemia
■ Sickle cell disease
■ Fanconi’s anemia
■ Kostmann’s disease
■ Diamond-Blackfan anemia
The child with a hematological illness who receives an HSCT must be
prepared to live with potential complications. The majority of these children
receive the HSCT from an unrelated donor. This carries a greater risk of long-
term complications such as acute and chronic graft versus host disease. Other
complications that may occur can be a result of the preparative regimen from the
chemotherapy or radiation. Additional complications may result from infections,
immunosuppression, organ dysfunction, and psychosocial effect.
APHERESIS
Some children with hematological diseases may require apheresis as part of
their treatment plan. The name of the apheresis procedure is identified according
to a specific blood component that is extracted. This process usually takes place
in the hospital setting with specially trained staff. In most institutions, children
must weigh more than 11 lbs. (5 kg).
The process of apheresis is the selective removal of a specific blood
component from a donor or child while retransfusing the remaining components.
The ultimate goal in using apheresis therapy is to deplete or collect a circulating
cell or substance. Blood is removed from the child, pumped through a special
cell separator in the apheresis machine that removes the specific desired
component by centrifugal force, and then is returned to the patient. The
mechanics of the apheresis machine are comparable to those of a dialysis
machine and require two large-bore lines, one line to draw from and another to
return the blood. There are three types of apheresis.
Plasmapheresis
Plasmapheresis is removal of plasma containing harmful components such as
circulating complexes, antibodies (IgM, IgG), cholesterol, and toxins. Plasma
alone is depleted from the child’s blood and replaced by donor plasma or a
plasma substitute that is reinfused along with the child’s own RBCs, WBCs, and
platelets (AAP, 2018).
Erythrocytapheresis (Red Cell Exchange)

In erythrocytapheresis (red cell exchange), RBCs are removed from the patient’s
blood and replaced by leukocyte-depleted donor RBCs that are reinfused to the
patient along with the patient’s own plasma, WBCs, and platelets. Sickle cell
anemia with acute chest syndrome, CVA, or severe priapism may require red cell
exchange.
Leukapheresis (Stem Cell Collection or Leukodepletion)

The purpose of stem cell collection is to harvest an adequate amount of stem
cells/mononuclear cells as noted by a countable marker on the white cell called a
CD34 antigen. Based on the disease or reason for collecting, there may be
multiple sessions to collect sufficient targeted cells. These mononuclear cells
(monocytes) are involved in the body’s immune responses. The collected stem
cells are processed by the blood service and are cryopreserved in liquid nitrogen
for future use. These stem cells are reinfused at a later specific date after the
preparative regimen has ablated the bone marrow. Patients with solid tumors are
the usual candidates to have their own stem cells removed, treated, and
reinfused. Another procedure that may be used to remove excess WBCs is
leukodepletion. Leukodepletion is primarily used for patients with high WBC
counts such as patients newly diagnosed with acute or chronic leukemia or at
risk for acute tumor lysis syndrome. Complications may develop during the
apheresis process.
SUMMARY POINTS
■ Blood is composed of two parts, the fluid portion called plasma and the cellular portion. The
solutes include albumin, electrolytes, proteins, clotting factors, fibrinogen, globulins, and
circulating antibodies. The cellular portion consists of the formed elements: RBCs, WBCs,
and platelets.
■ Several common hematological conditions occur in children. Some of these conditions can
be acute in nature and with proper care can be easily managed. However, others can be life-
threatening or cause a chronic illness that can permanently affect the lifestyle of the child
and family.
■ The nurse can stress to the parents that the primary goal regarding iron-deficiency anemia is
prevention. Nursing care consists of nutritional counseling, assistance with obtaining
recommended iron-fortified formula or cereal, and the administration of oral iron
supplements.
■ Children and families affected by SCD must learn to cope with this lifelong chronic illness.
The community-based nurse can educate the family about the goals of ongoing care,
including the prevention of complications associated with infections, hypoxemia, and vaso-
occlusive crisis.
■ Because there is no known cure for hemophilia, the interdisciplinary health-care team
members including physicians, nurses, rehabilitative services, social workers, child life
specialists, and school personnel are instrumental in teaching the family about how to care
for their child with hemophilia.
■ Aplastic anemia is rare but one of the most serious hematological conditions that generally
afflicts adolescents and young adults. This clinical syndrome is characterized by
pancytopenia (a reduction in all cellular elements of the blood) caused by bone marrow
hematopoiesis failure.
■ Neutropenia can be congenital or acquired. All patients will need specific teaching on home
management, including infection prevention measures such as the importance of hand
washing.
■ The first responsibility of the nurse who is administering a blood transfusion to a child is to
review the plan of care with the family, explain in detail the indications and process of a
blood transfusion, and then obtain blood consent from the appropriate individual.
■ During every transfusion, the importance of strict observance to the institutional policy
regarding the administration of blood products cannot be stressed enough. In addition, the
accuracy of patient verification is an important nursing action that prevents this type of acute
hemolytic transfusion reaction.
■ A possible hematological complication for patients with chronic illness includes the
development of a thrombosis. A thrombosis is an abnormal formation of blood constituents
within the vascular system.
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F.A. Davis.
Van Leeuwen, A. M., Poelhuis-Leth, D. J., & Bladh, M. L. (2021). Davis’s comprehensive
handbook of laboratory and diagnostic tests (9th ed.). Philadelphia: F.A. Davis.
Venes, D. (Ed.). (2021). Tabers cyclopedic medical dictionary (24th ed.). Philadelphia: F.A. Davis.
Women, Infants, and Children. (2020). Retrieved from http://www.fns.usda.gov/wic/women-
infants-and-children-wic

Advantage
CHAPTER 25
Caring for the Child With a Cognitive

or Psychosocial Impairment
CONCEPTS
Addiction
Cognition
Development
Abuse
Behavior
Stress
Suicide
KEY WORDS
developmental disabilities
culture
ethnicity
diversity
separation anxiety disorder
panic disorder
agoraphobia
specific phobia
social anxiety disorder
generalized anxiety disorder
post-traumatic stress disorder (PTSD)
major depression
dysthymic disorder
bipolar disorder
tics
substance abuse
substance dependence
teratogenic effects
LEARNING OBJECTIVES

■ Discuss vulnerability and resilience, culture, diversity, health disparities, and
barriers to access to child and adolescent mental health.
■ Examine the conditions related to various cognitive and psychological
conditions.
■ Explore the risk factors that contribute to various cognitive and psychological
conditions.
■ Prioritize developmentally appropriate and holistic nursing care for various
psychological and cognitive conditions.
have various psychological and cognitive conditions.
PICO(T) Questions
chapter.
1. Do (P) children with learning differences have a (O) higher incidence of (I)
depression than (C) children without learning disorders?
2. Is there a (O) screening tool that most accurately identifies (P) children
suffering with (I) anxiety disorders?
INTRODUCTION
This chapter provides a review of the developmental aspects of
various psychological and cognitive conditions. The discussion
includes an examination of the various psychological and cognitive
conditions and developmentally appropriate and holistic nursing
care. Information about diagnostic and laboratory testing and
medications is given. Teaching plans and discharge criteria for
parents whose children have various psychological and cognitive
conditions are incorporated.
Understanding the normal neurological, cognitive, and emotional
development of children is important in determining whether a
pediatric patient functions at the appropriate developmental level.
For example, anxiety in infants and young children may suddenly
arise as a fear of strangers or in response to separation from
caregivers. This typically occurs between 7 to 12 months and peaks
between 9 to 18 months but decreases for most children by age 2
1/2. Also, a child may have an inherent anxious temperament and
may be inhibited when encountering new situations, people, or
objects and may respond to these with fear and withdrawal.
Likewise, nurses note that normal behaviors for young children (e.g.,
imaginary friends, concrete thinking, etc.) are interpreted differently
when displayed in adults (as signs of schizophrenia). The nurse
should have a thorough understanding of developmental milestones,
including language development, sensory perception, emotion
regulation, motor skills, attention, and memory.
The child with a pervasive developmental disorder (PDD) such as
autism is characterized by developmental deficits in language and
communication, social reciprocity, and patterns of interests and
behaviors. Children diagnosed with autistic disorders have a greater
percentage of delayed attainment of all developmental milestones.
Children with cognitive conditions rely heavily on caregivers to get
basic needs met. Research has identified that regression of growth
and development may occur in children with these cognitive
disorders known as regressive autism. Losses of language and
communication skills, and changes in social engagement and
responsiveness, have been exhibited in children diagnosed with
regressive autism. Causes of developmental losses are
hypothesized but primarily unknown. Prior to developmental losses,
children may display subtle changes in development such as
abnormal head circumference. Increasing awareness and knowledge
about regressive developmental disorders will allow for better
identification of these children.
Nurses should become knowledgeable of various psychosocial
and cognitive conditions and their effects on normal growth and
development. Developmental disabilities are known to occur with
children affected with fragile X syndrome (FXS), Down’s syndrome
(DS), fetal alcohol spectrum disorder (FASD), learning and cognitive
disorders, and autism spectrum disorder (ASD). Early identification
of children affected with psychosocial and cognitive conditions is
essential to prevent further loss and or regression of growth and
developmental milestones. The nurse should assess for behavioral
abnormalities and delays in achievement of developmental
milestones; this is often done through developmental screening
tools. The nurse should promote attainment of growth and
development while being attentive to known deficits. The nursing
plan of care should be individualized to the child’s specific abilities
and needs. The nurse should teach parents the normal stages of
growth and development and methods to promote achievement of
milestones as well as prevention strategies for regression.
Collaboration with occupational, physical, and speech therapists
should be considered based on the needs of the child. The nurse
should educate the family on ways to help the child develop
independence based on their own personal abilities (Ruggiero &
Ruggiero, 2020).
Optimizing Outcomes
Understanding Resilience in the Face of Vulnerability

It is important to keep in mind that pediatric behavioral and mental health
disorders are not isolated to the brain or neurologic development. For example,
recent research in pediatric mental health disorders links these issues to other
medical conditions. Research by Cowan, Dinan, and Cryan et al (2019)
describe the microbiota-gut-brain axis and its associations with
neurodevelopmental outcomes. This review is an excellent primer to better
understand how individual differences in cognition or emotional and behavioral
health might be influenced by our microbiota. The brain might be most
susceptible to these effects when still developing.
CULTURE, DIVERSITY, AND HEALTH

DISPARITIES
Culture and diversity have a significant influence on children’s and
families’ cognitive and psychosocial health. Culture, considered an
external and acquired phenomenon, is the complex set of beliefs and
attributes passed on within a group. What is considered mental
illness in one culture may be considered normal by another.
Ethnicity refers to groups of people who share similar cultural
characteristics (i.e., common language, religion, food, and beliefs
about health). Race is used to describe categories of people, mostly
based on physical characteristics (e.g., skin color and shape of
nose). Diversity refers to the fundamental differences between
cultures. The nurse must be able to recognize the place of cultural
values, beliefs, and customs for each family, as well as to respect
the definitions brought forth from each diverse culture. With the ever-
growing virtual world, the physical world has opened exponentially,
creating numerous situations that test the nurse’s knowledge of and
openness toward others.
Health disparities, including socioeconomic, racial, and ethnic
inequalities that predispose children to a disadvantage in terms of
health outcomes, deserve attention from the nursing profession. For
example, children from lower-income families are more likely to
develop mental illness and yet are less likely to receive timely
diagnosis or treatment. The nurse should recognize that parents may
focus only on their children’s basic health-care needs (e.g., vaccines
and treatment for ear infection) and may not attend to their children’s
cognitive and psychosocial health needs. It is important that the
nurse do a thorough assessment of all health-care needs, including
cognitive and psychosocial well-being.
Given the magnitude of mental health disparities in children and
adolescents, nurses at all levels of practice, along with other health-
care providers, must become better prepared to implement
strategies designed to reduce health-care disparities. Nurses are
well positioned to take a leadership role in the movement toward
abating and eliminating health-care disparities through awareness
and advocacy.
BARRIERS TO CHILD AND ADOLESCENT

MENTAL HEALTH
Families face a number of barriers that can prevent diagnosis and
treatment of children’s cognitive and psychosocial health. A brief
overview is provided here to help the nurse gain an understanding of
the issues so they can intervene to minimize these barriers. Though
efforts to educate the public are increasing, the stigma of mental
illness continues to prevent children and their families from
accessing mental health service. The health-care community and the
public have long been skeptical about whether young children
experience clinically significant mental health disorders such as
depression or anxiety. The nurse must understand that this type of
thinking causes issues for children, adolescents, and their families
such as:
1. Not getting screened on a timely basis for disordered behaviors
and emotional difficulties that may be attenuated or resolved with
early intervention
2. Having a sense of shame for the family if a child or adolescent is
eventually diagnosed with a mental health problem that might
have been prevented
3. Inability to receive adequate mental health or psychosocial
treatment when indicated because of lack of resources
One barrier that relates not only to mental health concerns but to
health in general is that of health-care illiteracy. Even well-educated
people may be “illiterate” when coping with mental illness and related
health care.
MENTAL ILLNESS IN CHILDREN

Children and adolescents are not immune to mental and emotional
illnesses. Mental illness in young people may be confusing and
frightening for children and families. The disorders can be
devastating, particularly if they are not detected and treated.
Anxiety
While children commonly experience transient anxiety at various
developmental points, clinically significant anxiety must be
recognized as a problem outside of normal development. It is
important to distinguish between developmentally expected anxiety,
anxious temperament, and symptoms of a disorder. The following
diagnostic categories related to anxiety disorders have been
identified in the Diagnostic and Statistical Manual of Mental
Disorders (DSM-V): separation anxiety disorder, panic disorder,
agoraphobia, specific phobia, social anxiety disorder, generalized
anxiety disorder, substance-induced anxiety disorder, and post-
traumatic stress disorder (PTSD) (American Psychiatric Association
[APA], 2013).
Signs and Symptoms

Criteria common to all anxiety disorders in childhood are as follows:
■ Anxiety that does not abate or gets worse over time (persistent)
■ Anxiety that pervades more than one aspect of the child’s life
■ Significant distress or avoidance of feared situations
■ Impaired functioning or development in response to the anxiety
Diagnosis
As with any emotional or psychiatric difficulty, a complete physical,
psychosocial, and family history helps reveal genetic, biological, and
familial contributors to anxiety. Differentiation between the categories
of anxiety disorders is related to the type of fear exhibited by the
child.
In separation anxiety disorder, children experience
overwhelming fear of becoming separated from or losing a caregiver
(Fig. 25-1).
Panic disorder usually begins in adolescence but may start
earlier. Symptoms of a panic attack might include:
■ Palpitations Sweating
■ Shaking
■ Nausea
■ Dizziness
■ Fear of dying
■ Tingling sensations
■ Chills or hot flushes
Agoraphobia refers to the fear of and avoidance of certain places
or situations (e.g., fear of leaving home) or being in open or crowded
places. Specific phobia refers to unrelenting fear of certain objects
or situations (e.g., spiders, storms, snakes, or water). These may be
difficult to evaluate because, at each developmental stage, children
and adolescents have various expected fears. Children with social
anxiety disorder avoid social situations. In generalized anxiety
disorder, children experience excessive worry about everything,
including peer relationships, social acceptance, and pleasing others.
Post-traumatic stress disorder (PTSD) occurs in response to a
perceived or actual threat to one’s life or safety. There is a clear
precipitant, and a reaction is generally understandable. The
response may persist for weeks, months, or years and is
accompanied by panic symptoms.
Anxiety often presents in the form of somatic complaints like
stomach aches and restlessness (American Academy of Child &
Adolescent Psychiatry [AACAP], 2020a). The pediatric nurse can
recognize anxiety problems when a child persistently presents with
symptoms that do not have a recognizable physical cause.
FIGURE 25-1 This child is displaying signs of separation anxiety.
Prevention
A nurse may undertake measures to help prevent anxiety disorders
and to lessen the effect of existing disorders. Simply paying attention
to any signs of anxiety is the first step in recognizing clinically
significant symptoms. Children and adolescents are more likely to
respond to someone who takes the time to listen and care.
Children are exposed to countless scary images, whether in the
form of games, movies, television, or actual events in the news. It is
important for the nurse to understand this influence and help parents
think about ways to protect children from the influx of information that
might be overwhelming.
Collaborative Care
NURSING CARE
There are several evidence-based therapies provided by qualified
advanced practice clinicians. The pediatric nurse is aware of some of
these therapies to assist parents in finding a referral. The American
Academy of Pediatrics (2019) published a list of resources for
parents of children with anxiety (Box 25-1).
The nurse can provide health teaching for families related to healthy
coping and communication. Additional teaching interventions may
involve teaching relaxation and deep breathing as well as problem-
solving techniques.
Patient Education
Mindful Breathing
Mindfulness means paying attention in the present moment. Paying attention to
one’s breathing may be a way of coping with anxiety (Fig. 25-2). The teaching
works best before an anxiety episode. The nurse teaches slow breathing by
telling the child to:
• Consciously direct your attention to your breathing.
• Breathe in slowly, paying attention as the air enters nose and mouth and fills
your lungs.
• Breathe out slowly, paying attention as the air leaves your body.
• Allow your mind to follow the breath in and out.
• Imagine yourself in a rubber raft riding the gentle waves of your breath.
Post-traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is an anxiety disorder that
occurs in response to a real or perceived trauma or threat to one’s
life or safety. Children of all ages may be involved in traumatic
situations related to human (e.g., abuse, violence, war, etc.) or
environmental (e.g., natural disasters, automobile accidents, etc.)
causes. While some may exhibit little or no negative immediate or
long-term consequences of the trauma, or are easily comforted and
can move on, others are vulnerable to PTSD.
Signs and Symptoms

After a trauma, a child or adolescent with PTSD exhibits symptoms
within each of the following sets of reactions:
■ Re-experiencing the trauma through flashbacks, nightmares, or
physical sensations
■ Avoiding reminders of anything or any place that triggers
memories
■ Physiological symptoms of anxious arousal (e.g., insomnia, startle
response, or sense of panic) (APA, 2013)
BOX 25-1
Resources for Parents and Children Coping

With Anxiety
BOOKS FOR PARENTS
• Worried No More: Help and Hope for Anxious Children by Aureen P. Wagner
• Treating Childhood and Adolescent Anxiety: A Guide for Caregivers by Eli
Lebowitz and Haim Omer
• What to Do When You Worry Too Much: A Kid’s Guide to Overcoming Anxiety
by Dawn Huebner
• Freeing Your Child From Anxiety by Tamar E. Chansky, PhD
• CBT Toolbox for Children and Adolescents by Lisa Phifer
• Helping Your Anxious Child: A Step by Step Guide for Parents by Ronald
Rapee and Ann Wignall
• The Huge Bag of Worries by Virginia Ironside
BOOKS FOR CHILDREN AND ADOLESCENTS
• When My Worries Get Too Big! A Relaxation Book for Children Who Live With
… by Kari Dunn Buron
• Wilma Jean the Worry Machine by Julia Cook
• Outsmarting Worry: An Older Kids’ Guide to Managing Anxiety by Dawn
Huebner
• Hey Warrior! By Karen Young
• David and the Worry Beast by Anne Marie Guanci
• Wemberley Worried by Kevin Henkes
• Anxiety Sucks! A Teen Survival Guide by Natasha Daniels
FIGURE 25-2 The nurse teaches the child how to reduce anxiety
with slow breathing.
Diagnosis
Diagnosis is based on the exhibited symptoms within the sets of
reactions. There are clear developmental differences across
childhood and adolescence that must be accounted for in making a
definitive diagnosis (Gillies et al, 2016).
Prevention
Preventing traumatic experiences from causing emotional and
physical damage is an important aspect of this condition. Possible
preventive factors might include:
■ Promoting resilience in at-risk families and children (prior to
traumatic events)
■ Promoting resilience in general by teaching safety measures for
potential risk factors (e.g., environmental disasters, “stranger-
danger,” etc.)
■ Early research on pharmacological measures to prevent PTSD has
been promising
■ Creating and implementing programs that ensure safety
Nursing Care
Many children who endure post-traumatic distress may not be
brought into a mental health-care facility for clinical intervention.
Some seriously traumatized children enter treatment through the
court system after experiencing abuse or serious loss within the
family of origin. The nurse may come in contact with these children
in primary care, school, or other settings.
In the community, the nurse is instrumental in educating parents
about the symptoms and helping the family and child by making
referrals for appropriate services. The nurse can reinforce the
importance of providing a secure home base for the child, one that
includes the family’s or caregiver’s willingness to be available to and
comfort the child without judgement.
As with each of the anxiety disorders, awareness of the resources
available for treatment of PTSD is important. Mental health
professionals equipped to help the young person process and cope
with the sequelae of trauma can provide various types of cognitive
behavior therapy with or without medication intervention.
Pharmacological intervention for treatment of PTSD in children and
adolescents has been limited. In a review of extant studies, selective
serotonin reuptake inhibitors (SSRIs) are often used as first-line
treatment of PTSD in children and adolescents. More compelling
evidence was found about supporting specific treatment of
symptoms as they arise (i.e., antiadrenergic agents for hyperarousal,
alpha agonists for sympathetic symptoms, and alpha-1 agonists or
antipsychotics for intrusive thoughts).
MEDICATION: Selective Serotonin Reuptake

Inhibitors (SSRIs) and PTSD
Children may be prescribed SSRIs for a variety of mental health issues
including depression but also for the management of anxiety and in decreasing
the avoidant behaviors and intrusive thoughts engendered by PTSD. In fact,
SSRIs are considered first-line therapy for PTSD, in view of treatment guideline
recommendations and the results of numerous clinical trials. Sertraline and
paroxetine are the only antidepressants approved by the FDA for the treatment
of PTSD and are the most extensively studied SSRIs for this indication. All
other agents are used in an off-label fashion. In addition to sertraline and
paroxetine, the SSRI fluoxetine has been recommended as first-line treatment
(off label) for patients with PTSD (Gillies, 2016).
The nurse can teach the family that psychotherapy and
psychopharmacotherapy together may be most helpful for children
suffering with PTSD. It is important to help parents and families
understand the immediate and ongoing effect that a traumatic event
may have in the young person’s life.
MOOD DISORDERS
Pediatric mood disorders may take the form of major depression
(serious, time-limited depression), dysthymic disorder (longer-term,
less-intense depression), or bipolar disorder (BPD) (consisting of
mood swings between depression and mania). These disorders are
sometimes more difficult to diagnose in children and adolescents
than in adults because of developmental phases and the lack of
language and cognitive skills to describe symptoms and
experiences.
Depression
Depression may be situational or related to environmental factors
combined with genetic and biological factors. Adolescent major
depressive disorder (MDD) is a significant health problem,
associated with substantial morbidity, cost, and mortality. Depression
is a major risk factor for suicide, which is now the second leading
cause of death in young people. Up to 20% of adolescents will
experience MDD before adulthood, and while a substantial
proportion will improve with standard-of-care treatments
(psychotherapy and medication), roughly one-third will not (Strawn &
Croarkin, 2020).
Signs and Symptoms
Five key features must be present and persistent for most days
during a period of 2 weeks for the diagnosis of an MDD in children
and adolescents. This list of symptoms is compiled based on several
diagnostic classification publications to reflect a developmentally
sensitive criterion (APA, 2019).
■ Persistent sad or irritable mood—reported feeling sad or empty or
observed by others (e.g., appears tearful). This mood is different
from the child’s baseline emotional and behavioral state and is
unrelated to events that may cause temporary distress or sadness
(e.g., getting a time-out).
■ Loss of interest in activities once enjoyed (anhedonia)—reported
by child or observed by others.
■ Significant change in appetite or body weight—difficulty sleeping or
oversleeping.
■ Fatigue or loss of energy.
■ Feelings of worthlessness or excessive/inappropriate guilt.
■ Decreased ability to think or concentrate or to make decisions; an
example is a drop in grades and/or school performance.
■ Recurrent thoughts of death or suicide with or without a suicide
plan, and in younger children, consistent engagement in activities
or play that involve themes of death and suicide.
Diagnosis
Diagnosis is based on the exhibited depressive symptoms.
Nursing Care
The most important aspect of helping a depressed child is to ensure
safety. It is recommended that any nurse working with a child who is
depressed understand how to deal with the potential suicide ideation
or intent.
Because depression often goes unrecognized in children or
adolescents, the nurse is instrumental in determining the presence of
signs and symptoms. Pediatric and school nurses are in a position to
observe changes in a child’s behavior and demeanor as well as
grades. Developing a trusting relationship with a child and asking
about feelings or thoughts may provide evidence of underlying
depression and provide the child with a first step in feeling better.
Nurses can talk with the parent(s) or caregiver(s) of a child about
suspected depression and suggest referral to a counselor, pastor,
chaplain, or spiritual director for evaluation and treatment.
Bipolar Disorder
Bipolar disorder (BPD), also known as manic depression, is a mood
disorder that is evidenced by significant mood swings (from
depression to mania) (APA, 2013).
Signs and Symptoms

Because BPD is a combination of major depression and mania, the
nurse must be aware of symptoms associated with BPD. Both manic
and depressive symptoms are described in Table 25-1 (Danese,
2020).
Suicide
Suicide represents a devastating consequence resulting from any
number of psychiatric difficulties. This is a serious public health
problem that affects children and adolescents. Glenn et al (2020)
reiterate an alarming statistic: Suicide is now the second leading
cause of death among 10- to 24-year-olds according to Centers for
Disease Control and World Health Organization data (Centers for
Disease Control and Prevention [CDC], 2017). The most common
methods used in suicides of children and adolescents include firearm
(46%), suffocation (37%), and poisoning (8%), although research
has been unable to link owning a firearm to an increased risk of
suicide by firearm (Glenn et al, 2020). Many more children and
adolescents survive suicide attempts than actually die from such
attempts. A nationwide survey performed by the CDC found that
15% of the youth in grades 9 to 12 in public and private schools in
the United States reported seriously considering suicide, 11%
reported creating a plan, and 7% reporting trying to take their own
life in the preceding 12 months. Each year, approximately 149,000
youth between the ages of 10 and 24 receive medical care for self-
inflicted injuries at emergency departments across the United States
(CDC, 2020).
Optimizing Outcomes
Screening for Suicidal Ideation

Dwyer, Stringaris, Brent, and Bloch (2020) highlight a problem that,
unfortunately, is related to high rates of suicide in young people. Approximately
20% of adolescents will experience an episode of MDD. Of those, about a third
will not improve with standard psychotherapy or pharmacological treatments.
Adolescents whose depression is untreated (or unsuccessfully treated) tend to
do poorly in school, experience interpersonal difficulties, and are at elevated risk
for substance abuse and suicide (Strawn and Croarkin, 2020). Unfortunately for
nurses caring for this population, once adolescents have failed to respond to a
second-line treatment, there is no rigorous evidence base on which further
treatment options have been developed. As nurses caring for adolescents with
depression, it is critical that they be screened for suicidal ideations. Various
screening tools are available on the CDC Web site (CDC.gov).
TABLE 25-1
Common Symptoms of Bipolar Disorder
MANIA DEPRESSION
Overly happy, irritable, silly, and elated Persistent sad or irritable mood
Worried, feeling empty
Overly inflated self-esteem; grandiosity Loss of interest in activities once
Increased energy, feels jumpy or “wired” enjoyed
Decreased need for sleep—able to go Change in eating and sleeping habits
with very little or no sleep for days Physical agitation or slowing
without tiring Loss of energy
Increased talking—talks too much, too Feelings of worthlessness or
fast; changes topics too quickly; cannot inappropriate guilt
be interrupted Difficulty concentrating
Distractibility—attention moves Recurrent thoughts of death or suicide
constantly from one thing to the next
Hypersexuality—increased sexual
thoughts, feelings, or behaviors; use of
explicit sexual language
Increased goal-directed activity or
physical agitation
Disregard of risk—excessive
involvement in risky behaviors or
activities
Impulsive behavior, such as spending
sprees
Source: Danese, A. (2020). Annual Research Review: Rethinking childhood

trauma – new research directions for measurement, study design and analytical
strategies, Journal of Child Psychology and Psychiatry, 61, 236–250.
Signs and Symptoms

Red flags for suicide potential include any of the following in the child
or adolescent:
■ Symptoms of depression or other mental illnesses
■ Withdrawal from friendships
■ Expression of hopelessness
■ Isolative behavior
■ Personality changes
■ Decline in schoolwork
■ Giving away personal possessions that were once prized
■ Preoccupation with death in writing or playing
■ Refers to dying or no longer being around
■ Access to a method of suicide (e.g., medications or weapons)
What to Say
When a Patient Expresses Suicidal Ideation
If the nurse is concerned that a child or adolescent might be suicidal, the nurse
must ask the child about suicidal thoughts or behaviors. This information may
help to save the child’s life.
• “Have you thought about doing something to hurt yourself or take your life?”
• “Do you ever wish you were not alive?”
• “What would you do if you were to hurt yourself?”
Prevention
The school nurse is in a position to recognize children or
adolescents who might be suicidal. The nurse must ask about
suicide ideation. The nurse can discern: Does the child have a plan?
Is that plan possible (i.e., is the means to self-harm accessible)? Has
the child attempted suicide before? Foremost, if any of these factors
are present, the nurse must refer the child (and family) to a mental
health professional who can assess the level of risk. The child or
adolescent may need immediate hospitalization to remain safe.
The school nurse can identify school-based programs that target
students who are at risk for dropping out of school and assist the
child or adolescent to remain involved in school. Cognitive-
behavioral techniques may be used with a suicidal child or
adolescent by conducting exercises, activities, and discussions that
assist them to connect their thoughts with their behaviors.
Nursing Care
The nurse is supportive of the child or adolescent and supportive of
the medication regime. Pharmacological treatments include
medications to treat the underlying psychiatric difficulty (Table 25-2).
In 2004, the U.S. Food and Drug Administration issued a “black
box” warning that SSRIs may increase the risk of suicide in children
and adolescents. Subsequent studies have weighed the benefits of
antidepressants versus the potential risks but have not generated a
great deal of clarity. Additional studies related that the increased
incidence of suicide ideation and attempt was not universal, nor was
it related only to those diagnosed with depression but also in children
taking SSRIs for other disorders. The evidence is controversial
because other studies have shown antidepressants to be very
effective in decreasing suicide risk by effectively dealing with the
underlying causes.
TABLE 25-2
Pharmacological Treatments for Psychological Difficulties
CATEGORY MEDICATIONS USES
Antianxiety Beta blockers Anxiety
propanolol (Inderal) Alpha blockers
clonidine (Catapres)
Antidepressants Selective serotonin uptake inhibitors Depression
(SSRIs) Anxiety
fluoxetine (Prozac) OCD
sertraline (Zoloft) Elective mutism
paroxetine (Paxil)
citalopram (Celexa)
escitalopram (Lexapro)
fluvoxamine (Luvox)
Tricyclics Enuresis
imipramine (Tofranil) Autism
clomipramine (Anafranil)
Other
bupropion (Wellbutrin)
venlafaxine
Mood Stabilizer lithium carbonate Bipolar disorder
(Lithobid, Lithane, or Eskalith) Mania
ODD
ADHD
Anticonvulsants valproate (Depakote) Bipolar disorder
Mania
Antipsychotics Traditional Autism
haloperidol (Haldol) Psychosis
Atypical Tourette’s
risperidone (Risperdal) syndrome
Behavioral
problems related to
other psychiatric
disorders
(conduct disorder,
ADHD, MR)
olanzapine (Zyprexa)
quetiapine (Seroquel)
ziprasidone (Geodon)
aripiprazole (Abilify)
Stimulants methylphenidate (Ritalin and Concerta) ADHD
dextroamphetamine
(Dexedrine and Adderall)
Nonstimulants atomoxetine (Strattera) ADHD
Source: Van Leeuwen, A., Poelhuis-Leth, D., & Bladh, M. (2021). Davis’s
comprehensive handbook of laboratory and diagnostic tests with nursing
implications (9th ed). Philadelphia, PA: F.A. Davis.
Several factors have been proposed to explain the occurrence of
suicidal ideation in children treated with these medications: (1) The
prescription may be an inadequate dose, and therefore the
depression is not treated. (2) An energizing phenomenon, which
describes a situation in which the depressive symptoms related to
energy decrease before the mood symptoms, may occur, thus
making it more possible for the depressed individual to have the
energy to attempt suicide. (3) The emergence of an activation
syndrome may be related to a toxic reaction to the medication. (4)
Motor restlessness related to akathisia (motor restlessness that may
appear as a side effect of antipsychotic medication) may occur. (5) A
shift from depression to mania in a not-yet-diagnosed bipolar child
may occur. (6) Idiosyncratic reactions (perhaps related to gene-drug
reactions) may occur.
Instruct the family on protective measures for the child. They must
remove all potentially self or other harmful objects from the home,
including guns and other weapons. Rid cupboards of poisons, lock
medicines away, and provide close, constant supervision. Assist the
family in identifying strengths and resources available (e.g., crisis or
suicide hot lines, counseling, and inpatient treatment facilities).
Schizophrenia
Schizophrenia is a serious chronic mental health disorder that is
thought to be the result of abnormalities in neurodevelopmental
processes that occur early (i.e., prenatal, infancy, and early
childhood) as well as later (i.e., late childhood and adolescence) in
life. The disorder typically begins in late adolescence or early
adulthood, but it is possible for children as young as 5 or 6 to exhibit
signs (AACAP, 2020b).
Signs and Symptoms

Schizophrenia has the following signs and symptoms:
■ Hallucinations (hearing voices, seeing things, or experiencing
strange sensations)
■ Delusions (false beliefs, e.g., beliefs that the radio is sending
special messages)
■ Disorganized speech and behavior
■ Decreased or “flattening” of affect (visible expression of mood),
speech, and motivation (APA, 2013)
Diagnosis
A diagnosis of schizophrenia is based on a mental health interview
that includes a comprehensive developmental and family history.
Nursing Care
Early treatment for schizophrenia usually involves pharmacological
agents (e.g., atypical antipsychotics), adolescent and family
psychoeducation, and psychotherapy aimed at increasing level of
functioning. To obtain the best outcome, the adolescent and family
should always stay in treatment. Acute treatment for active
psychosis (e.g., hallucinations, delusions, fearfulness, and acting
out) consists of maintaining the safety of the child and others. It is
frightening to lose sight of reality. Families of children with
schizophrenia, like those with any chronic difficult illness, may need
ongoing support. There are organizations that offer support and
advocacy for families of the mentally ill. One such organization is the
National Alliance on Mental Illness (NAMI; www.nami.org), which
provides parents and families with important information.
Patient education involves reminding the child and family about the
importance of taking the medications as well as informing them of
the related side effects. Reinforce ongoing psychotherapy and
support.
COMMON PEDIATRIC MENTAL HEALTH

DISORDERS
Reactive Attachment Disorder
Reactive attachment disorder (RAD) is a relatively rare condition
characterized by significant difficulties in forming emotional
attachments with others (AACAP, 2020d). Children with RAD have
generally experienced early life trauma or loss, making it difficult for
them to form meaningful and vital connections. Attachment
difficulties can be recognized as early as infancy and definitely by
the age of 5 (AACAP, 2020d).
Infants develop attachments during their earliest months and years
of life. John Bowlby (1909–1990) studied the effect of maternal
deprivation on childhood development. Mary Ainsworth (1913–1999)
studied forms of attachment, identifying traits that described an
infant’s security in relationship to its mother. In establishing reliable
attachments to their earliest caregivers, infants are afforded the
framework for future trusting relationships. These attachments create
situations within which the child can safely test out physical and
emotional boundaries, as well as a context within which to develop
the ability to regulate emotions.
Children who have not been afforded consistent and nurturing
presence early in their lives become either anxiously attached or
detached in relation to others. Infants and children diagnosed with
attachment disorders have usually endured neglect and/or
maltreatment or have experienced severe trauma. Vulnerable
children are those within the foster care and international and
domestic adoption system who have previously been abandoned or
abused. These are the children who have most clearly experienced
disrupted early attachment. Infants with mothers with significant
postpartum depression or mental illness may not have had the
opportunity to bond and attach healthily.
Signs and Symptoms
Signs and symptoms of RAD may include:
■ Marked disturbance in ability to relate socially, manifesting as:
■ Emotional withdrawal or inhibition
■ Inability to seek or accept warmth from others
■ Inability to show or respond to affection
■ Marked disinhibition
■ Indiscriminate willingness to seek comfort even from strangers
■ Excessive trust of strangers
■ Infants with serious insecure attachment may exhibit severe
feeding difficulties not related to a physiological cause
Diagnosis
The pediatric nurse can aid in the diagnostic process by parental
report and observing how the child interacts around parents and
strangers.
Prevention
As with many of the childhood and adolescent disorders that are
related to early trauma, prevention lies in educating parents and
caretakers and providing them with mental health services prior to
becoming parents. Adoptive parents should be aware of the
difficulties that may have been experienced by their children prior to
adoption. While it is not always possible to avoid attachment
difficulties, nurses can help parents and caregivers cope with the
sequelae.
Nursing Care
Because attachment disorders in infants and children result from the
lack of opportunity to experience a caring relationship, this
opportunity is offered as a first step in treatment. Developing trust
through meeting the child’s basic needs or responding to cries or
tantrums or listlessness with patience and consistency is
exceptionally important. A child with RAD has no true concept about
which basic needs will be met. RAD is a rare but serious condition.
Families who present with a child with symptoms should be referred
for psychotherapy (AACAP, 2020d).
Parents of children with RAD need a great deal of support. They
should be educated about attachment and bonding and about how to
deal with a child who has difficulty making interpersonal connections.
These parents often benefit from involvement in a support group with
other families of children with RAD.
Attention-Deficit/Hyperactivity Disorder
Attention-deficit/hyperactivity disorder (ADHD) is familiar to parents,
schoolteachers, and others who know the child. Many of us are
familiar with the commonly portrayed images of the overactive,
talkative child “bouncing off the walls” and always in trouble. ADHD
is one of the most publicized and prevalent psychiatric conditions of
childhood. A child can have attention-deficit disorder with or without
hyperactivity. The category of ADHD without hyperactivity typically
has symptoms of distractibility. While ADHD without hyperactivity
garners much less attention than ADHD with hyperactivity, it can
cause just as much difficulty in the life of the child and the family.
The CDC has indicated that 9.5% of the children in the United
States have been diagnosed with ADHD. That represents a
significant increase over the 3% to 7% reported in the DSM-V.
Parent-reported ADHD (or the percent of parents who report their
child has ADHD) increased at an even greater rate of 22% (CDC,
2020a). As with other psychiatric disorders, particularly ASD, it is yet
unclear if the increase in numbers is a result of better case-finding,
increased public awareness, or actual increase in the disorder.
Signs and Symptoms

Signs and symptoms of ADHD include:
■ Inattention
■ Often fails to give close attention to details or makes careless
mistakes in schoolwork, work, or other activities
■ Often has difficulty sustaining attention in tasks or play activities
■ Often does not seem to listen when spoken to directly
■ Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (not due to
oppositional behavior or failure to understand instructions)
■ Often has difficulty organizing tasks and activities
■ Often avoids, dislikes, or is reluctant to engage in tasks that
require sustained mental effort (such as schoolwork or
homework)
■ Often loses things necessary for tasks or activities (e.g., toys,
school assignments, pencils, books, or tools)
■ Is often easily distracted by extraneous stimuli
■ Is often forgetful in daily activities
■ Six (or more) of the following symptoms of hyperactivity-impulsivity
have persisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level:
■ Hyperactivity
■ Often fidgets with hands or feet or squirms in seat
■ Often leaves seat in classroom or in other situations in which
remaining seated is expected
■ Often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, may be limited to
subjective feelings of restlessness)
■ Is often “on the go” or often acts as if “driven by a motor”
■ Often talks excessively
■ Impulsivity
■ Often blurts out answers before questions have been completed
■ Often has difficulty awaiting turn
■ Often interrupts or intrudes on others (e.g., butts into
conversations or games)
Although ADHD is most often diagnosed in early school-age
children, symptoms can be seen in much younger children. Children
with these symptoms often have difficulty with school performance
as well as social and peer interaction. While poor school
performance is usually the driving factor in seeking help for children
with these symptoms, difficulty with peer groups and family
relationships are just as evident. Many children with ADHD also have
comorbid conditions such as depression, anxiety, oppositional
defiant disorder (ODD), and learning disabilities.
Diagnosis
Evaluations for ADHD are conducted by advanced practice nurses,
physicians, and other health-care providers. Health-care providers
use the guidelines in the American Psychiatric Association’s
Diagnostic and Statistical Manual, Fifth Edition (DSM-V), to help
diagnose ADHD. This diagnostic standard helps ensure that people
are appropriately diagnosed and treated for ADHD.
Based on the types of symptoms, three kinds (presentations) of
ADHD can occur (CDC, 2020):
■ Combined Presentation: if enough symptoms of both criteria
inattention and hyperactivity-impulsivity were present for the past 6
months
■ Predominantly Inattentive Presentation: if enough symptoms of
inattention, but not hyperactivity-impulsivity, were present for the
past 6 months
■ Predominantly Hyperactive-Impulsive Presentation: if enough
symptoms of hyperactivity-impulsivity, but not inattention, were
present for the past 6 months
Because symptoms can change over time, the presentation may
change over time as well.
When the criteria are met, the final diagnosis requires evidence of
the child’s behavior in a variety of settings, such as classroom,
during homework, or playtime. Evidence is obtained by asking
parents, teachers, and other caregivers to complete rating scales
about behavior. Additional information needed includes the age at
onset of symptoms, duration of symptoms, and degree of impaired
functioning.
Nursing Care
ADHD is evaluated by using a variety of scales that ask the
caregiver or teacher to rate the child’s behavior (e.g., behavior
occurs extremely often, often, sometimes, rarely, or never). A school
nurse is trained to perform observations of the child while in class to
assist in the information gathering. These scales in combination with
a clinical family interview provide the examiner with valuable
information to determine a diagnosis. A thorough clinical interview
with the child is also important in determining the appropriate
diagnosis and treatment.
The most effective treatment for ADHD is a combination of
pharmacological and psychosocial interventions. Using both
modalities allows for the control or abatement of symptomatic
behavior by the medication while at the same time working on
changing maladaptive behavior patterns through therapy with the
child and family. When recommending psychosocial intervention,
clinicians must keep in mind the developmental level of the child and
family. Also, from a developmental psychopathology perspective, it is
important to inform the family that early intervention works best and
that the child and family may have periods of adaptive and
maladaptive behavior.
The nurse can educate the family in techniques for helping the child
focus and maintain appropriate behaviors. Education about
pharmacological interventions is also important.
MEDICATION: ADHD
Stimulants are the most commonly used medication for this condition, including
Ritalin and other forms of methylphenidate, amphetamine salts (Adderall), and
atomoxetine (Strattera), a nonstimulant medication. Methylphenidate also is
prescribed in a transdermal patch form for children 6 years and older. This
patch was designed for children who cannot swallow tablets or capsules.
When providing psychosocial care, the nurse recognizes that

children often respond to therapeutic approaches that include
behavioral therapy, rewards (sticker charts), and positive versus
negative reinforcement (used as often as possible when child
demonstrates acceptable behavior). School nurses are in a position
of supporting teachers and other staff in the use of behavioral charts.
Pediatric nurses in the community can offer support to parents and
families in ongoing use of behavior modification.
Some families may resist medications. Other families may put their
entire faith into medications, but not complete other parts of the
treatment plan. It is important for the nurse to help the family make
use of all the treatment options available to them and participate
actively with their health-care providers in developing a plan for their
child.
Oppositional Defiant Disorder and Conduct Disorder

Antisocial behaviors can often evolve or further develop into clinical
disorders, most often ODD and conduct disorder (CD).
ODD and CD have multifactorial and complex etiologies. Studies
have identified a number of biological and psychosocial factors that
may be associated with the development of CD and ODD in children
and adolescents.
Signs and Symptoms

ODD has these signs and symptoms:
■ Frequent temper tantrums
■ Excessive arguing with adults Often questioning rules
■ Active defiance and refusal to comply with adult requests and rules
■ Deliberate attempts to annoy or upset people
■ Blaming others for their mistakes or misbehavior
■ Often being touchy or easily annoyed by others
■ Frequent anger and resentment
■ Mean and hateful talking when upset
■ Spiteful attitude and revenge seeking
Conduct disorder has the following signs and symptoms:
■ Breaking rules without obvious reason
■ Cruel or aggressive behavior toward people or animals (e.g.,
bullying, fighting, using dangerous weapons, forcing sexual
activity, and stealing)
■ Failure to attend school (truancy beginning before age 13)
■ Heavy drinking and/or heavy illicit drug use
■ Intentionally setting fires
■ Lying to get a favor or avoiding things they have to do
■ Vandalizing or destroying property
Diagnosis
Diagnosis is accomplished using the behavioral criteria presented. It
is important to note that many children who meet the criteria for ODD
or CD often have comorbid mental health problems and may also
function poorly in interpersonal relationships with peers and
caregivers (AACAP, 2020b).
Prevention
Early assessment of these conditions is important. Multimethod and
multi-informant assessment approaches include self-report scales,
child interview, parent interview, physical assessment, observation of
child-parent interaction, and thorough family assessment (e.g.,
history of exposure to violence in the family and community).
When working with children and adolescents who exhibit ODD or
CD, it is important for the nurse to be aware of and manage personal
feelings that may be aroused by the patient and family. The nurse
can educate the family about the family-based prevention and
intervention programs.
Nursing Care
Children with ODD or CD may be prescribed medications from a
number of categories, such as stimulants for ADHD symptoms,
antipsychotics for behavior regulation, mood stabilizers for regulation
of high and low mood presentations, and antianxiety agents.
Nurses who work with families that have children with ODD or CD
must be mindful of the stress that these disorders have on the whole
family. It may be exhausting for parents to cope with the defiant
behaviors. Spending time with the misbehaved child may put siblings
at risk of harm. Respite care (short-term care) can give the family a
“rest” from the child who has the disorder. Encouraging family
members to learn coping skills and take care of personal needs as
well as the child’s may help them find balance in daily living.
Nursing care for these conditions also includes educating the family
about medications. It is important that the child and family
understand the action, potential side effects, and additional
information about prescribed medications. In addition, the nurse
should educate families about community resources available for
respite and the importance of psychotherapy.
Tics are sudden, painless, non-rhythmic behaviors that are either
motor (related to movement) or vocal and that appear out of context
—for example, grimacing in class. They are fairly common in
childhood; tics are generally temporary conditions that resolve on
their own. For some children, however, the tics persist over time,
becoming more complex and severe. These tics can affect a
person’s capability to function.
Examples of simple motor tics:
■ Eye blinking
■ Facial grimacing
Examples of complex motor tics:
■ Hand gestures
■ Jumping
Examples of simple vocal tics:
■ Throat clearing
■ Grunting
Examples of complex vocal tics:
■ Meaningless changes in volume and pitch of speech
■ Echolalia (repeating last heard sounds or words) (APA, 2013)
MALTREATMENT OF CHILDREN
Child maltreatment includes abuse and neglect of a child less than
18 years of age by anyone who is in a caregiver or custodial role
(e.g., a parent, foster caregiver, clergy, coach, or teacher). The most
common forms of abuse are physical, sexual, emotional abuse, and
neglect (CDC, 2020a). Child physical abuse may result in injury
inflicted by beating, pushing, kicking, pinching, burning, or choking.
Physical abuse includes traumatic brain injury, which manifests as
symptoms related to head trauma as a result of forceful shaking of
the infant or young child.
Child sexual abuse involves any sexually related act, usually
between a child and an adult (related or not) that can include
fondling, forced or assented oral sex or intercourse, sodomy,
exposing children to adult sexual behavior (e.g., showing
pornography to children), and exploiting through child pornography
or prostitution.
Child emotional abuse includes any behavior, attitude, or failure to
act that disrupts children’s socioemotional development and mental
health. Some examples include shaming or humiliating (ascribing
derogatory labels to the child, e.g., “you are worthless”) and
intimidating (threatening and frightening).
Child neglect involves failure to provide emotional and physical
care as well as opportunity for education. Neglect is most common
but also the most difficult to identify.
Other types of abuse include Munchausen-by-proxy syndrome in
which a person, usually the mother, deliberately makes the child sick
often to elicit feelings of empathy and compassion for the mother.
The profile of a person with Munchausen-by-proxy syndrome is often
the child’s primary caregiver and has some type of general
knowledge about the medical system.
Statistics gathered by the U.S. Department of Health and Human
Services track the incidence of child maltreatment and give a
breakdown of the incidence of the various types of maltreatment.
Child abuse and neglect are common. At least one in seven children
have experienced child abuse and/or neglect in the past year, and
this is likely an underestimate. In 2018, nearly 1,770 children died of
abuse and neglect in the United States. Children living in poverty
experience more abuse and neglect. Rates of child abuse and
neglect are five times higher for children in families with low
socioeconomic status compared with children in families with higher
socioeconomic status (CDC, 2020).
Patient Education
Tools to Prevent Child Abuse and Neglect
Child abuse and neglect are preventable. Everyone benefits when children
have safe, stable, nurturing relationships and environments. CDC has
developed a technical package, Preventing Child Abuse & Neglect: A Technical
Package for Policy, Norm, and Programmatic Activities, to help communities
take advantage of the best available evidence to prevent child abuse and
neglect. The toolkit includes strategies and approaches proven to affect
individual behaviors, as well as family, community, and societal factors, that
influence risk and protective factors for child abuse and neglect. They are
intended to work in combination in a multilevel, multisector effort to prevent
violence.
Labs
Ruling Out Bleeding Disorders
If child abuse/neglect is suspected, the health-care provider may need to
rule out organic causes of the injury. Labs are often a piece of the puzzle and
provide forensic as well as diagnostic information. For example, when child
abuse is suspected and bruises are present, clotting studies to evaluate for
abnormal bleeding and bruising should be routine. However, if there is pattern
bruising, coagulation studies may not be necessary. A detailed work-up by a
hematologist may be required if there is a family or patient history of a
bleeding disorder or abnormal results from a screening test. However, a
clotting disorder does not rule out the possibility of abuse (Botash, 2020).
Signs and Symptoms

The signs and symptoms of abuse are multifaceted and appear in
Table 25-3.
TABLE 25-3
Physical, Sexual, Emotional Abuse, Neglect, and Munchausen-by-Proxy
TYPE OF ABUSE TACTICS OF ABUSE POSSIBLE SIGNS AND
SYMPTOMS IN THE CHILD
Physical: Bodily injury Beating, hitting, Suspicious bruises, welts, or
caused by intentional or slapping, poisoning, burns
unintentional physical kicking, pinching, biting, Unexplained fractures or
aggression shoving, choking, dislocations
pulling hair, burning New and healing or healed
Excessive corporal lacerations or abrasions
punishment Wariness of adults or caregivers
Shaken baby syndrome Fearful of going home
Munchausen-by-proxy Acting out with aggression
Retinal hemorrhages
CNS injury
Prolonged or recurrent illnesses
or injuries that cannot be
explained
Sexual: Sexual acts Penetration, incest, Inappropriate or precocious
involving an adult and a rape, oral sex, sodomy, interest in or knowledge of
child fondling sexuality Poor peer
Violations of bodily relationships
privacy Sudden changes in behavior
Exposing children to (regressive, acting out, sexual
adult sexuality behavior, enuresis, recurrent
Commercial exploitation urinary tract infections, redness
Sexual exploitation and swelling of genitalia)
(prostitution or Running away from home or
pornography) substance abuse
Rapidly declining school
performance
Suicide attempts
Emotional: Attitude, Intimidation, belittling, Apathy, depression
behavior, or failure to shaming, lack of Hostility
act that interferes with a affection and warmth, Difficulty concentrating
child’s mental health or habitual blaming,
social development ignoring or rejection,
extreme punishment,
exposure to violence,
child exploitation, child
abduction
Neglect: Pattern of Physical, educational, Clothing unsuited to the weather
failing to meet basic emotional Poor hygiene
needs Hunger
Lack of supervision
Sources: American Psychiatric Association (2013); Diagnostic and statistical

manual of mental disorders (DSM-V). American Psychiatric Pub; American
Academy of Child & Adolescent Psychiatry (AACAP) (2020a). Anxiety disorder
resource center.
It is also important to note that PTSD in children or the adolescent
can be maltreatment when undetected or not caught early in the
presentation of such symptoms.
Diagnosis
Diagnosis of physical, sexual, or emotional abuse or neglect may
take time, and a thorough family history, physical examination, and
developmental assessment are necessary for diagnosis. It may be
necessary to x-ray various areas of the body in addition to obtaining
serum chemistry lab tests to determine any infection, drug induction,
or toxicity.
FOCUS ON SAFETY
Risk Factors for Maltreatment
If a nurse can identify risk factors related to the maltreatment, the harm to
children may be prevented. Children who are at risk for maltreatment include:
• Children with disabilities
• Children of very young parents
• Children of young single mothers who live in poverty
• Parents who suffer from mental or chronic physical illness
• Parents who have:
- extremely stringent ideas of discipline may use harsh punishment
- excessive stress
- marital conflict
• Parental substance abuse
• Intergenerational history of abuse
Nursing Care
The nurse is instrumental in the care of children who have
experienced any type of abuse. Nursing can use primary and
secondary preventive strategies that include the following:
■ Teach parents about ways to discipline the child that do not involve
physical or verbal aggression.
■ Educate parents about using birth control to decrease unintended
pregnancies.
■ Instruct mothers about the use of alcohol or drugs during
pregnancy and the effect it has on the growing baby.
■ Discourage new parents from substance use.
■ Improve the availability of and access to health care across the
spectrum of the family’s life.
■ Educate children and adolescents about the body and personal
boundaries.
■ Advocate for political initiatives to help avoid and ultimately stop
child abuse.
Professionals who report child abuse are not revealed to the family
in question unless the caller chooses to disclose this information.
While all reports are taken seriously, not all reports result in the
removal of the child from the home. Every report is investigated, but
action may or may not be taken depending on the assessment
(AACAP, 2020). It is also important to note that the nurse is required
to report any suspicion of child abuse or neglect.
■ Provide parents with information regarding normal stages of
growth and development.
■ Provide family education about what to expect from parenthood.
■ Instruct parents on how to cope with some of the difficult times
related to raising a child.
■ Help parents develop resources for support, such as babysitters,
family members, and community resources.
Reporting Cases of Child Abuse

To report suspected child abuse, the nurse can call the local enforcement
agency and/or follow the clinical setting’s guidelines for reporting abuse. All U.S.
states have mandatory reporting guidelines for professionally licensed health-
care workers/providers. It can be a difficult experience to report child abuse
because of possible consequences to the child, family, and professional. It is
important to remember that all allegations of child abuse must first be
investigated before being confirmed. After documented confirmation, the child
will be placed in a safe environment free of abuse.
National Hotline in USA: 1-800-4-A-CHILD or 1-800-422-4453
For more information consult the link:
http://www.helpguide.org/mental/child_abuse_physical_emotional_sexual_ne
glect.htm#online
SUBSTANCE USE AND ABUSE

Substance abuse refers to the repeated use of illicit substances
(drugs or alcohol or inhalants) despite the negative consequences.
Substance dependence, or addiction, refers to the physiological
and/or emotional reliance on that substance with tolerance and
withdrawal symptoms noted (AACAP, 2020c).
Optimizing Outcomes
Teen Substance Use and Risk
The AAP recommends screening for substance use in children starting at age 9.
Alcohol, cannabis, and tobacco are the substances most commonly used by
adolescents (AAP, 2015). According to data from the CDC:
• By 12th grade, about two-thirds of students have tried alcohol.
• About half of 9th through 12th grade students reported ever having used
marijuana.
• About 4 in 10 9th through 12th grade students reported having tried cigarettes.
• Among 12th graders, close to 2 in 10 reported using prescription medicine
without a prescription.
Although it is illegal for people under 21 years of age to drink alcohol, these
findings show that people from 12 to 20 years of age consume about one-tenth
of all alcohol consumed in the United States (CDC, 2020). Substance use
among preteens and teens can:
• Affect growth and development, particularly brain development
• Increase the risk of other dangerous behaviors, such as risky driving and
unprotected sex
• Contribute to the development of health problems in adulthood, including sleep
disorders, high blood pressure, and heart disease
• Lead to substance abuse
Children and adolescents may abuse any of the same substances

abused by adults. The major factors determining which substances
are used are availability and cost. Some of the more common
substances of abuse for children and adolescents include alcohol,
tobacco, marijuana, cocaine, ecstasy, methamphetamine, other
forms of stimulants, prescription medications (e.g., the child’s own
prescription or medications stolen from a family member), and
inhalants (e.g., glue, gasoline, and Wite-Out®). The earlier teens
start using substances, the greater their chances of continuing to use
substances and developing substance use problems later in life.
When teens begin drinking at an early age, they increase the chance
of becoming addicted to or continuing to abuse substances later in
life (CDC, 2020).
Signs and Symptoms

The American Academy of Child & Adolescent Psychiatry published
a list online of some of the warning signs that a young person might
be abusing alcohol or drugs:
■ Physical: Fatigue, repeated health complaints, red and glazed
eyes, and a lasting cough
■ Emotional: Personality change, sudden mood changes, irritability,
irresponsible behavior, low self-esteem, poor judgement,
depression, and a general lack of interest
■ Family: Starting arguments, breaking rules, or withdrawing from
the family
■ School: Decreased interest, negative attitude, drop in grades,
many absences, truancy, and discipline problems
■ Social problems: New friends who are less interested in standard
home and school activities, problems with the law, and changes to
less conventional styles of dress and music
Diagnosis
Diagnosis of substance use and abuse is based on the physical,
emotional, and social factors exhibited by the child. A thorough
family history is essential along with information about the child’s
physical and emotional health.
Prevention
Parents can help prevent substance abuse in their families. This
does require an investment of time and energy into their children’s
and adolescent’s lives. Parents can:
■ Communicate their concerns about substance use
■ Clearly state what the expectations are for behavior
■ Get acquainted with the friends of the children and adolescents
■ Have full knowledge of the location of the children
■ Establish rules that are developmentally appropriate for the age of
the child
Parents concerned about their children’s mental health should
seek treatment because untreated psychiatric disorders can increase
the risk of substance abuse.
Nursing Care
Initial nursing care involves the use of screening tools to assess drug
and alcohol use in children. The nurse is in an ideal position to
identify adolescents at risk for substance abuse, especially if there is
a strong family and genetic history of abuse. Two tools that can be
used in the identification of substance abuse are the CRAFFT
(Knight et al, 2002) and the CAGE (Ewing, 1984). Both these tools
use simple acronyms to assist in the evaluation of drinking or drug
use (Table 25-4).
The CRAFFT is recommended by the American Academy of
Pediatrics’ Committee on Substance Abuse for use as a screening
tool with adolescents. It consists of a series of six questions
developed to screen adolescents for high-risk alcohol and substance
use disorders simultaneously. This short, effective screening tool is
meant to assess whether a longer conversation about the context of
use, frequency, and other risks and consequences of alcohol and
other drug use is warranted.
Screening using the CRAFFT begins by asking the adolescent to
“Please answer these next questions honestly”; telling them “Your
answers will be kept confidential”; and then asking three opening
questions.
■ Be alert to early signs of substance use (e.g., smelling alcohol or
cigarette smoke).
■ Observe for changes in mood or odd behavior when the
adolescent returns home (AACAP, 2020).
The nurse can help the child and family find community resources
that may help conquer the substance abuse problem. The most
promising appears to be a family-based, family-supported approach.
EATING DISORDERS
Eating disorders that are mostly apparent in adolescence are
classified into four categories by the APA that include anorexia
nervosa (purging or withholding), bulimia nervosa (binging and
purging), binge eating disorder (binging without purging), and eating
disorder not otherwise specified.
Eating disorders most often affect females, but adolescent males
are also known to suffer from these illnesses.
FOCUS ON SAFETY
Eating Disorder Risk Factors
• Family genetics
• Rigidity, ritualism in home
• Stressful life event
• Hormonal and physiological changes associated with puberty
• “Picky” eater in childhood
• Participation in sports that focus on the pursuit of thinness (APA, 2013)
TABLE 25-4
The CRAFFT and CAGE Tools Use Simple Acronyms to Assist in the
Evaluation of Drinking or Drug Use
EVALUATING THE CHILD FOR SUBSTANCE ABUSE: TWO COMMON WAYS
OF EVALUATING FOR SUBSTANCE ABUSE ARE CRAFFT AND CAGE.
CRAFFT CAGE
Have you ever ridden in a Car driven by Have you ever felt like Cutting down on
someone (including yourself) who was your drinking?
high or had been using alcohol or
drugs?
Do you ever use alcohol or drugs to Have people made you Angry by talking
Relax, feel better about yourself, or fit about your drinking?
in?
Do you ever use alcohol or drugs while Have you ever felt Guilty about your
you are by yourself Alone? drinking?
Do you ever Forget things you did while Do you ever need a drink first thing in
using alcohol or drugs? the morning to have enough Energy or
to feel ready for the day?
Do your Family or Friends ever tell you
that you should cut down on your
drinking or drug use?
Have you ever gotten into Trouble while
you were using alcohol or drugs?
Scoring: 2 or more positive items Scoring: 2 or more positive answers =
indicate the need for further an alcohol problem.
assessment.
Note: This tool is used with individuals
16 and older
Source: Reprinted from Center for Adolescents Substance Abuse Research at

Children’s Hospital, Boston.
Source: Ewing, J. A. (1984). Detecting alcoholism: The CAGE questionnaire.
Journal of the American Medical Association, 252(14), 1905–1907.
Signs and Symptoms

■ Inordinate concern and gross distortion of body image and body
weight
■ Preoccupation with food
■ Hide behaviors related to food and caloric intake from others
■ Depression
■ Anxiety
■ Family discord; conflict avoidance
■ Weight loss up to 85% of ideal body weight
■ Consuming caloric intake but then purging by vomiting
■ Vigorous physical activity
■ Amenorrhea
■ Weakness
■ Fatigue (APA, 2013) (AACAP, 2020).
Anorexia Nervosa
Anorexia nervosa can become a life-threatening problem or cause
death because of severe weight loss that can result in electrolyte
imbalance and hemodynamic instability.
Assessment Tools
Eating Disorders
The nurse can also use astute assessment skills to help diagnose the child or
adolescent suspected of an eating disorder. The nurse needs to determine:
• Perception of issue, shape, and weight
• Eating habits
• Mental status
• Cognitive distortions: “My life is over if I gain 5 pounds”
• Participation in rigorous physical regimen
• Vitals: blood pressure, pulse, and temperature will be low
• Lanugo
• Jaundice
• Cool extremities with poor skin turgor
• Dental erosion, if purging
• Peripheral edema
Labs
Abnormal Lab Results Associated With Eating Disorders
• Hypokalemia
• Hyponatremia
• Anemia
• Leukopenia
• Increased liver enzyme levels
• Elevated bilirubin level
• Decreased levels of follicle-stimulating hormone (Van Leeuwen, Poelhuis-
Leth, & Bladh, 2021)
Diagnostic Tools
Electrocardiogram changes such as prolongation of the QT interval,

bradycardia, and ventricular tachycardia with a risk of sudden death must also
be evaluated (Ruggiero & Ruggiero, 2020).
Prevention
The nurse is in the best position to identify early cases of eating
disorders and refer for preventive individual and family treatment.
The nurse must remember that the assessment needs to be
conducted within a growth and developmental perspective and that
intervention is considered within a family-based approach.
Nursing Care
Mental health nursing care measures are essential in the treatment
of a child or adolescent diagnosed with an eating disorder. The nurse
can employ these measures if the child is admitted to a mental
health-care facility or teach the parents these care measures to use
in the home environment. Such measures include:
■ Providing a highly structured environment
■ Involving the patient in decision making and participation in the
plan of care
■ Assisting the patient in setting realistic weight goals
■ Promoting cognitive reframing: assist patient in changing the
negative perception to a positive one
■ Monitoring patient’s weight, vitals, intake and output, caloric intake,
and exercise
There are no drugs that are specifically for eating disorders;
however, there are medications that treat the core symptoms of
eating disorders. For example, SSRIs have been useful in reducing
obsessive compulsive behaviors and craving for carbohydrates.
When making referrals for treatment, it is important to consider the
skill level of the treatment clinician, and often a team approach with
expertise in this area of health and mental health works best. It is
important to instruct families that treatment for eating disorders can
take a long time and that family members will be involved in the
recovery.
SLEEP DISORDERS
Adequate sleep is essential to good health. Sleep difficulties are
relatively common in children and adolescents. The APA estimates
that between 20% and 25% of children and adolescents suffer from
one of the nearly 80 sleep disorders that affect children and
adolescents. These disorders cause varying degrees of symptoms
and distress, but all are important to recognize and ameliorate. Sleep
can be viewed as a part of normal growth and development because
some sleep problems are considered normal and subside as the
child grows.
There is a reciprocal relationship between sleep disorders and
other psychiatric disorders. In other words, many psychiatric
disorders cause difficulties with sleep (e.g., depression, anxiety,
ADHD, etc.), and conversely, a child whose sleep is impaired is more
susceptible to stress-induced disorders. For example, research by
Odgers and Jensen (2020) addresses the question of whether digital
technologies, including cell phones and social media, are
responsible for rising rates of adolescent depression. The concern is
related to the connection between digital technologies and
adolescent mental health, fueled in part by widely reported findings
that screen time is correlated with sleep disturbances, suicidal
behavior, and symptoms of depression in young people (Twenge et
al, 2017). Research is aiming to better screen for adolescents at risk
for depression online and develop online treatment options along
with recommendations for supporting adolescent mental health in the
digital age and minimizing economic inequities in the effects of digital
technologies. This research will ultimately require collaboration
between tech industries and social media platforms with health-care
providers and researchers.
A good nursing assessment is essential in identifying sleep
problems in children and in differentiating between
physiological/psychological disorders versus developmental or
behavioral issues (e.g., poor sleep hygiene, long daytime naps,
caffeine consumption, etc.).
Signs and Symptoms

■ Difficulty falling asleep at night
■ Difficulty returning to sleep after waking up during the night
■ Waking up frequently during the night
■ Light sleep; not deep sleep
■ Sleepiness and low energy during the day
■ Daytime irritability
■ Snoring or periods of sleep apnea
Diagnosis
A child who presents with sleep difficulties must receive a thorough
physical examination to rule out physiological causes. It is important
to assess sleep patterns as well as quality of sleep. Sleep disorders
are considered based on a positive answer by the parent or
caregiver to one or more of these questions:
■ Is it hard for your child to fall asleep?
■ Is it hard for your child to stay asleep through the night?
■ Does your child wake up feeling tired?
■ Is your child sleepy during the day?
Common causes of sleep problems in children include:
■ Nightmares
■ Prolonged use of electronic devices
■ Sleep terrors
■ Sleepwalking
■ Episodes of insomnia
■ Irregular sleep routine
■ Caffeine intake
■ Sleep apnea
■ Restless leg syndrome
Prevention
The nurse must listen carefully to the parents’ concerns about the
child’s sleeping issues. It is important to discover this problem early
and understand the causes of sleep disturbances as well as
implement prevention and intervention strategies. Early identification
and intervention are important in preventing significant emotional,
developmental, and physical difficulties. The nurse educates parents
about healthy sleep hygiene, management of respiratory disorders,
pediatric depression, anxiety, and developmental and mental health
diagnoses to prevent ongoing difficulties.
Nursing Care
The nurse can help the family by providing support while listening
without passing judgement and providing information on healthy
sleep habits. The American Academy of Sleep Medicine has
developed a Web site for teachers (K–12) to help them better
understand sleep in their students. The guidelines listed in Box 25-2
are also helpful for the nurse and the family.
BOX 25-2
Top 10 Healthy Sleep Habits for Children and

Teens
1. Only use your bed for sleeping.
2. Avoid drinking caffeine in the afternoon and at night.
3. Avoid taking naps in the late afternoon or in the evening.
4. Avoid large meals right before bedtime.
5. Dim household lights at night and let in plenty of sunlight in the morning.
6. Create a healthy sleep environment in your bedroom with:
a. Dim lighting
b. A comfortable temperature
c. Soothing sounds
d. No TV or computer
7. Turn off all of these items at least 30 minutes before your bedtime:
a. Computer
b. TV
c. Movies and videos
d. Video games
e. Cell phone or other popular technological devices
8. Develop a bedtime routine that helps you relax by:
a. Eating a healthy snack or light dessert
b. Brushing your teeth
c. Taking a warm bath or shower
d. Reading
e. Listening to relaxing music
9. Go to bed at or near the same time every night, even on weekends.
10. Discuss any ongoing sleep problems with your parent or doctor. Source:
The American Academy of Sleep Medicine (2020).
Encourage the family to continue with follow-up care with the health-
care provider and help them locate community resources such as a
support group.
CASE STUDY
Sleeping Issues
Paul is 4 years old, and according to his mother, he has had sleeping difficulties
since he was a baby. He voices many fears, makes demands, and sometimes
has tantrums at bedtime. He says he is afraid of the dark even though he has a
nightlight in his room. Paul complains of being hungry as soon as he lies down
in bed. Unless his mother stays in the room with Paul until he falls asleep, he
does not stop crying and often becomes upset for no apparent reason. Paul
takes an afternoon nap until 5 p.m. Now that the family is expecting a new baby,
they wish to have Paul’s sleeping difficulties under control. He has a bedtime of
8 p.m., but he does not get to sleep until 11 p.m. or midnight unless he has not
napped during the day.
1. Name the priority nursing diagnosis related to this situation.

2. Discuss the importance of parental education and specific sleep hygiene
techniques that the nurse can teach.
LEARNING DISABILITIES, COGNITIVE

IMPAIRMENTS, AND DEVELOPMENTAL
DISABILITIES
Learning Disabilities and Cognitive Impairment
In 2018–19, 7.1 million students ages 3–21 received special
education services under the Individuals with Disabilities Education
Act (IDEA), representing 14% of all public school students. Among
students receiving special education services, 33% had specific
learning disabilities (NCES, 2020). The nurse understands that a
child may manifest challenges in more than one specific learning
area, including math, reading, and organizing skills. Early learning
challenges are influenced by emotional and social competencies,
auditory processing and language skills (e.g., memory and ability to
retrieve), perceptual motor skills, motor planning (e.g., sequencing
and visual memory), visual/spatial processing skills, and ability to
modulate sensory information. The ability to learn involves many of
these skills working together. Increased information about learning
issues may help identify this condition early and initiate preventive
interventions. Learning disabilities are very common. There are
several learning disabilities including, but not limited to:
■ Reading Disorder (Dyslexia)—significantly impaired ability to read;
words or letters may be “mixed up” or distorted, making it
impossible to recognize what others see.
■ Arithmetic Disorder (Dyscalculia)—significant inability to
understand or recognize numbers or functions of numbers, or copy
them correctly, or follow sequences.
■ Writing Disorder (Dysgraphia)—difficulties forming letters or writing
within a prescribed space.
■ Language Disorder (delays in or lack of ability to understand or
express verbal communication).
Signs and Symptoms

Signs and symptoms of learning disabilities commonly seen in
children include:
■ Academic achievement significantly less than would be expected
for their age, education, and level of intelligence
■ Significant interference with academic performance or activities
that require reading, math, or writing skills (APA, 2013)
The nurse understands that a multidimensional approach is used
to assess early learning patterns. The recommended areas for
assessment include functional, emotional, and developmental
capacities, auditory processing and language, visuospatial
capacities, and regulatory-sensory processing patterns.
Diagnosis
Diagnosis is made through comprehensive assessments involving
interviews and observation. Definitive testing is recommended before
a learning disorder or challenge is diagnosed.
Prevention
Early assessment of learning challenges should be conducted before
a child is fully immersed in an academic environment so that
intervention can begin as soon as possible. Early identification and
treatment give the child the greatest potential for a good outcome.
Nursing Care
The nurse communicates to the family that the child’s strengths are
incorporated as part of assessment, early prevention, and
intervention. The nurse can fully inform the parents about their
child’s rights and entitlements in the public-school sector. Often,
children who enter public education with a learning challenge or
disability will have an individualized education plan (IEP) that is
revised every few months.
The nurse can teach the parents about how to capitalize on their
child’s strengths. School nurses are particularly useful in providing
education and support to children and their families.
Developmental Disabilities
Developmental disability is a term that encompasses a number of
serious disorders affecting the child’s mental and/or physical
developmental processes. The developmental disorders that will be
discussed in this section are DS, FXS, and intellectual disabilities
(formerly mental retardation). Each of these is evidenced by global
delays in developmental functioning. There is wide variability in the
classification of developmental disabilities. In addition to the three
mentioned in this section, others include but are not limited to ASD,
fetal alcohol syndrome disorders, and ADHD (CDC, 2020c). Each of
these additional diagnoses will be discussed individually in this
chapter. Developmental disabilities may co-occur with a variety of
physical conditions such as seizures, sensory impairments, speech
and language problems, and cerebral palsy. The incidence of
developmental disabilities has increased significantly from 1997 to
2008 (CDC, 2020c). Whether this is related to better screening and
diagnosis, greater public awareness, or actual increased incidence is
unclear. Continued screening is essential.
A number of conditions may be responsible for these disorders.
Genetic conditions that cause developmental disabilities, such as
FXS or DS, result when abnormal genes are inherited from parents
or from errors in genetic combinations. Metabolic conditions such as
phenylketonuria (PKU) can lead to developmental disabilities if not
recognized and treated early. Pregnancy-related problems include
alcohol ingestion or viral infection such as rubella. In addition,
trauma or asphyxia during the birth process can lead to inadequate
oxygen availability and may also cause developmental disabilities.
Prevention
Promoting good prenatal care will aid in preventing some of the
developmental disabilities. The nurse communicates to families that
the most preventable forms of developmental disabilities are related
to prenatal nutrition and abstinence from alcohol (CDC, 2020a).
Genetic counseling may also be helpful, particularly in families where
the parents are older or where there is a history of FXS.
Nursing Care
Nursing assessment of children with developmental disabilities
includes information from the mother’s prenatal history, birth history,
and child’s developmental progress. Each of these assessment
categories provides the nurse and family with valuable information.
The nurse understands that there is not one portrait of a
developmentally disabled child and knows that each child with a
disability has unique needs.
An important aspect of nursing care is ongoing communication
with the family about the child’s specific disability, treatment
measures, and medications. Another focus of nursing care is helping
the family build life skills for the child based on the degree of
disability. The goal is for the child or adolescent to develop the
greatest level of functioning and skills possible to maintain daily
living. The nurse can encourage the family to use physical therapy,
speech and language therapy, and special educational opportunities.
The nurse can teach the family about community resources such as
the Special Olympics or schools for therapeutic horseback riding
instruction. Group activities can build both motor and learning skills
as well as provide socialization.
The nurse can also support the family in collaborating with the
public school system. The schoolteacher, nurse, and parents work
together to develop an IEP. This plan addresses the child’s unique
needs and provides the services to meet the needs of each child.
Fragile X Syndrome
Fragile X syndrome (FXS), the most common cause of
developmental and intellectual disabilities in children (CDC, 2020d),
is a genetic disorder in which the protein necessary for normal brain
development is not manufactured. It may be hard to discern infants
who have FXS from infants who have other disorders based on
physical characteristics alone. Identification is based on awareness
of the potential signs and symptoms as well as family genetic history.
It is imperative to make early identification of the disorder and begin
early intervention with the child and family to begin to create the best
opportunity to maximize positive outcomes for the child and family.
The nurse has an important role in helping to identify the disorder
and then providing education and support and connecting families
with appropriate special education and health services.
SIGNS AND SYMPTOMS
Fragile X syndrome has the following signs and symptoms:
■ Physical features: Large head; elongated face; prominent ears,
chin, and forehead
■ Developmental delays: Not reaching milestones in line with
children in the same age group
■ Learning disabilities: Difficulty learning new skills; poor intellectual
development
■ Social/behavioral difficulties: Poor communication, self-abuse, no
eye contact, difficulty paying attention (CDC, 2020d)
DIAGNOSIS
Diagnosis is made through DNA testing to find changes in the
fragile X mental retardation (FMR1) gene. DNA testing is generally
not done unless there is a known family history of the disorder or
physical symptoms are present.
NURSING CARE
While FXS has no known cure, the nurse can help the family
access and use early intervention services. Families need
encouragement to take advantage of health-care and social services
available. They also need information about growth and
development and anticipatory guidance to raise the child according
to their developmental level.
The nurse can provide the family with information related to FXS
and the potential sequelae. If medications are prescribed, particularly
to deal with the behavioral symptoms, the nurse can provide
valuable medication education and support.
Down’s syndrome
Down’s syndrome (DS) is the most common and readily identifiable
chromosomal abnormality associated with developmental disabilities
(National Dissemination Center for Children and Youth with
Disabilities [NICHCY], 2010). New terminology identifies the child as
having an intellectual disability. During cell development, the fetus
receives 47 chromosomes instead of the normal 46. The extra
chromosome changes the development of the body and the brain.
SIGNS AND SYMPTOMS
Common signs and symptoms of DS at birth include:
■ Poor muscle tone
■ Slanting eyes with folds of skin at the inner corners (epicanthal
folds)
■ Hyperflexibility
■ Short, broad hands with a single crease across the palms of one or
both hands
■ Broad feet with increased space between the first and second toes
■ Flat bridge of the nose
■ Short, low-set ears
■ Short neck with extra folds of skin
■ Small head
■ Small oral cavity and airway
■ Short, high-pitched cries in infancy
NURSING INSIGHT
Health-Related Issues With Down’s syndrome
In addition to a distinct physical appearance, children with DS frequently have
health-related issues that may include:
• Heart defects (specifically, VSDs are the most common CHD for children with
DS)
• Decreased immune function
• Gastrointestinal anomalies
• Visual and hearing difficulties
• Speech difficulties (often due to protruding tongue)
• Laryngomalacia (most common cause of inspiratory stridor often due to a
“floppy” of softened larynx or upper airway)
• Hypothyroidism
Sleep apnea is also noted in children who have DS. The nurse should
assess the child’s sleep patterns and ask the caregiver if the child snores and
has pauses in breathing during sleep. If they show these symptoms, further
evaluation must begin with sleep studies that include electroencephalography.
DIAGNOSIS
The diagnosis of DS is usually made from a chromosomal blood
test shortly after birth. In addition, just as intelligence varies in the
normal population, individuals in the DS population show a wide
variation in cognitive abilities, behavior, and developmental progress.
NURSING CARE
Nursing care of a child with DS is similar to that of any
developmental disorder. The nurse must be sensitive to the needs of
parents who have learned the newborn has the disorder. Helping
parents cope and providing them with resources is an important
nursing intervention.
Early intervention with children who have DS has become much
more sophisticated. Early intervention services provide the best
possible individualized care to children with DS so these individuals
can make the most of personal capabilities. Nursing care is geared
to the special physical, developmental, and emotional needs of each
child. The nurse can coordinate programs designed to help children
with DS. These programs offer speech therapy, cognitive and social
skills, self-help skills, and occupational and physical therapies that
may improve gross and fine motor development. The nurse is also in
a good position to help families cope emotionally with living with a
child with this disability.
The nurse can educate parents and families about the resources
available for children with DS, as they will likely need assistance
throughout their lives. In addition to ongoing therapies, these
resources could include help with education, employment, and
independent living. A variety of organizations offer resources to help
educate and empower people living with DS and their families,
including the National Down Syndrome Society and the National
Association for Down Syndrome. Other resources include the
following:
■ Brighter Tomorrows is a resource for parents who have received a
diagnosis of DS either prenatally or at birth. Get answers to
common questions, learn more about the condition, and
experience stories of other parents touched by DS.
■ Down Syndrome Pregnancy provides information and support to
expectant parents preparing for the birth of a baby who has DS.
■ The International Mosaic Down Syndrome Association offers
support and resources to families of and people who have mosaic
DS.
Raising Public Awareness
The nurse has a responsibility to raise public awareness and acceptance about
children who have DS. Children with DS can be included in mainstream
educational curriculum and society. The parent, nurse, school personnel, and
other individuals in the community can develop an IEP. The nurse can help the
child with DS throughout the life span as the child grows into adulthood.
Through improved public acceptance and increased community resources,
more opportunities for persons with disabilities to live and work independently
in the community are possible.
Intellectual Disabilities
Intellectual disability may present across the spectrum from minimal
impairment to severe impairment. There are a number of potential
causes of intellectual disability. In addition to those mentioned
earlier, PKU and the use of alcohol or drugs during pregnancy, other
difficulties during pregnancy and birth (e.g., prematurity, low birth
weight, lack of oxygenation, environmental toxins, illnesses, and
malnutrition), or after birth (e.g., whooping cough, chickenpox,
measles, Haemophilus influenzae, or exposure to environmental
toxins) can contribute. Poverty may increase these risk factors.
SIGNS AND SYMPTOMS
Table 25-5 provides the classifications of intellectual disabilities.
DIAGNOSIS
Diagnosis of intellectual disabilities is based on determination of
intellectual (i.e., IQ, reasoning, learning, and problem solving) and
adaptive functioning (National Center for Educational Statistics,
2020). The diagnosis also considers delays in reaching
developmental milestones or inability to perform developmental
tasks. The official diagnosis of intellectual disability is performed by a
qualified health-care provider or a collaborative team of clinicians.
These clinicians assess developmental progress at various stages of
development and perform intelligence and achievement testing. With
a confirmed diagnosis of developmental disabilities, the nurse can
assess the level of functioning of the child and the family and
determine their current level of need. The nurse can communicate to
parents that using standardized tests can further suggest a
diagnosis.
PREVENTION
Preventive measures that address education of parents prior to
and during pregnancy may help prevent intellectual disabilities. As
with all developmental disabilities, recognition of and amelioration of
environmental and maternal health risk factors decrease the
possibility of intellectual disability. In addition, promoting health and
safety measures for the infant, toddler, and young child (e.g.,
nutrition, safety awareness, lead prevention, child safety seats, etc.)
is essential.
NURSING CARE
Nursing care of the children with developmental disabilities
includes information gained from the mother such as prenatal
history, birth history, and child’s developmental progress. Each of
these assessment categories provides the nurse and family with
valuable information.
TABLE 25-5
Classifications of Intellectual Disability
• Mild Intellectual Disability IQ between 55 and 69; the person is generally
able to live independently; by far the largest
group of developmentally disabled children
• Moderate Intellectual Disability IQ between 40 and 54; the person is able to
function semi-independently
• Severe Intellectual Disability IQ between 25 and 39; the person generally
requires institutionalization or very close
monitoring
• Profound Intellectual Disability IQ below 25; the person requires total care
There is no single portrait of a developmentally disabled child.

Some mildly disabled children may not have an obvious difference
from other children. The nurse knows that each child with a type of
disability has unique needs.
An important aspect of nursing care is ongoing communication
with the family about the child’s specific disability, treatment
measures, and medications. The nurse communicates to families
that the most preventable forms of developmental disabilities are
related to prenatal nutrition and abstinence from alcohol. Tell families
that genetic counseling may also be helpful, particularly in families in
which the parents are older or when there is history of FXS.
Promoting good prenatal care, encouraging parents to have their
children immunized, and enforcing safe practices when bike-riding or
playing may help prevent developmental disabilities.
Another focus of nursing care is helping the family find educational
resource tools directed toward building life skills for the child based
on the degree of disability. The goal is for the child or adolescent to
develop the greatest level of functioning and skills possible to
maintain daily living. The nurse can encourage the family to use
physical, speech, and language therapy. The nurse can teach the
family about community resources such as the Special Olympics or
schools for therapeutic horseback riding instruction. Group activities
can build both motor and learning skills as well as provide
socialization.
Autism Spectrum Disorders

Autism, or ASD, refers to a broad range of conditions characterized
by challenges with social skills, repetitive behaviors, speech, and
nonverbal communication. According to the CDC, autism affects an
estimated 1 in 54 children in the United States (CDC, 2020). The
DSM-V defines ASD as a continuum of disorders that involve
limitations in social relatedness, verbal and nonverbal
communication, and the range of interests and behaviors (APA,
2020).
We know that autism is not one disorder but made up of many
subtypes, most influenced by a combination of genetic and
environmental factors. Because autism is a spectrum disorder, each
person with autism has a distinct set of strengths and challenges.
The ways in which people who have autism learn, think, and
problem-solve can range from highly skilled to severely challenged.
Children with ASD may require a range of support in their daily lives
(Fig. 25-3).
Autism is often accompanied by sensory sensitivities and medical
issues such as gastrointestinal (GI) disorders, seizures, or sleep
disorders, as well as mental health challenges such as anxiety,
depression, and attention issues.
FOCUS ON SAFETY
Defining Autism Spectrum Disorders
In 2013, the American Psychiatric Association merged four distinct autism
diagnoses into one umbrella diagnosis of ASD. They included autistic disorder,
childhood disintegrative disorder, PDD-not otherwise specified (PDD-NOS),
and Asperger syndrome.
FIGURE 25-3 It is important for the pediatric nurse to remember that
while having a sibling with autism or any other disability is a
challenge to a child, it is not an insurmountable obstacle. Most
children handle the challenge effectively, developing advanced
coping skills, and many of them respond with love, grace, and humor
far beyond their years as is the case of Sami (age 6) and her brother
Jaxson (10 years old, living with autism).
SIGNS AND SYMPTOMS
Those with ASD have these signs and symptoms:
■ Persistent qualitative impairment in social reciprocity (i.e., unable
to engage in socially appropriate communication).
■ Impaired communication (using no language, or using deviant
speech with errors in tone, prosody, pitch, grammar, or pragmatics
[taking turns]).
■ Restrictive or repetitive behaviors, interests, or activities.
The reported number of children who have ASD has increased
since the early 1990s. The estimated incidence in 2004 was 1 in 166
children. The most recent data from the CDC (2020e) indicated an
increase in prevalence by 2008 to 1 in 88 children. Whether this
reflects a true increase in prevalence or an increase in reporting
remains a matter of speculation. Barriers to understanding the
potential increase in prevalence include the difficulty of
retrospectively ascertaining rates from decades ago, changes in
diagnostic criteria (e.g., the concept of autism is now viewed as a
spectrum of disorders), heightened public awareness of autism, and
increased media coverage of affected children and families (CDC,
2020e).
DIAGNOSIS
Autism spectrum disorders can be first diagnosed in infancy or
childhood. Symptoms typically appear by age three (CDC, 2020e).
While there is currently no cure for autism, research shows that early
intervention improves patient outcomes; therefore, early recognition
and initiation of interventions (most often cognitive behavioral
therapy) is the key to improved outcomes.
Pediatric primary care nurses and other health-care workers
should be familiar with the signs and symptoms of autism. Based on
this awareness, a thorough developmental history is conducted that
can lead to an early diagnosis. Recent speculation on a relationship
between vaccinations and autism has been disproved (CDC, 2020).
Optimizing Outcomes
Vaccine Safety: Examine the Evidence
Scientists constantly study the safety and effectiveness of vaccines. Because
vaccines are designed to be given routinely during well-child visits, they must be
extraordinarily safe. Safety testing begins as soon as a new vaccine is
contemplated, continues until it is approved by the FDA, and is monitored
indefinitely after licensure. The American Academy of Pediatrics (AAP) works
closely with the CDC to make recommendations for vaccine use.
Over the past decade, questions have been raised regarding a relationship
between autism and vaccines. Along with general safety concerns, parents
have wondered about too many vaccines overwhelming the immune system;
the measles, mumps, rubella combination vaccine (MMR); and the preservative
thimerosal, which was never present in MMR but was present in several
vaccines used in the 1990s. It has since been removed from all routinely used
childhood vaccines with the exception of flu (Pivetti, 2020). Research has been
conducted on all these concerns, and the studies continue to support the safety
and efficacy of vaccination to prevent serious disease (Pivetti, 2020).
Patient Education
Understanding Autism Spectrum Disorder
The CDC has developed an initiative entitled “Learn the Signs. Act Early” that
has a three-pronged approach to improving detection and care of children with
ASD and other developmental disorders (CDC, 2020). The program focuses on
health education, early screening and intervention, and research and
evaluation. The CDC offers education related to helping parents understand
and track early developmental milestones, encouraging them to act early if they
have questions or concerns about their child’s progress. The campaign
partners with systems from state, territorial, and national efforts to broaden
collaborative efforts to help parents and professionals. The research and
evaluation component of the program strives to continually develop resources
and tools for early identification and referral.
The CDC developed the following guidelines (CDC, 2020), employing the
acronym A.L.A.R.M. to highlight important information the nurse can use in
helping families with autistic children.
Autism is prevalent:
• 1 out of 6 children is diagnosed with a developmental disorder and/or
behavioral problem.
• 1 in 88 children is diagnosed with an ASD. Developmental disorders have
subtle signs and may be easily missed.
Listen to patients:
• Early signs of autism are often present before 18 months.
• Parents usually do have concerns that something is wrong.
• Parents generally do give accurate and quality information.
• When parents do not spontaneously raise concern, ask if they have any
concerns.
Act early:
• Know the subtle differences between typical and atypical development.
• Learn to recognize red flags.
• Improve the quality of life for children and their families through early and
appropriate intervention.
Refer:
• To the Web for sources related to early intervention of autism or a local school
program.
• To an autism specialist, or team of specialists, immediately for a definitive
diagnosis.
• To audiology to rule out a hearing impairment.
• To local community resources for help and family support.
Monitor:
• Schedule a follow-up appointment to discuss concerns more thoroughly.
• Look for other features known to be associated with autism.
• Educate parents and provide them with up-to-date information.
• Advocate for families with local early intervention programs, schools, respite
care agencies, and insurance companies.
• Continue surveillance and watch for additional or late signs of autism and/or
other developmental disorders.
NURSING CARE
Nurses who work in primary care settings can provide care for
children with autism. Awareness of the need for early intervention is
important because of the substantial cortical plasticity (the ability of
tissues to grow during early brain development). There are many
successful nonmedical treatments for children with autism. One of
the most important interventions involves early language
development. Poor functional communication skills also contribute
significantly to the problematic behaviors that some autistic children
display (e.g., poor frustration tolerance and aggression toward self or
others). Equally important are interventions that address social
competence. The nurse can teach parents that social skills training
and acquisition groups provide the child with an opportunity to learn
and practice appropriate social behavior and relationships (Botash,
2020).
The nurse can assist the child and family in coping with this
disorder. Children with ASD respond best to structure and
predictability. Learning and social interactions are approached
systematically and gradually, allowing the child to develop comfort
with the concepts. As with the schizophrenic child, it is important to
stay aware of the child’s physical boundaries and reluctance to be
touched by others.
Parents can be taught the A.L.A.R.M. acronym as a means of
understanding ASD and its treatment.
Fetal Alcohol Spectrum Disorder

The teratogenic effects (causing abnormal development of the
embryo) of alcohol have long been recognized. Warnings against
drinking while pregnant are carried on all alcoholic beverages. Still,
FASD is a common disorder with a range of physical and
neurodevelopmental problems that are known to be completely
preventable. The CDC estimates the occurrence of FASD at 40,000
babies/year (CDC, 2020b). FASD results from maternal consumption
of alcohol during pregnancy. Data show that alcohol intake at any
time of pregnancy is harmful.
FASD describes a continuum of alcohol-related disorders that
includes fetal alcohol syndrome (FAS), alcohol-related
neurodevelopmental disorder (ARND), alcohol-related birth defects
(ARBD), and fetal alcohol effects (FAE) (AACAP, 2020b).
SIGNS AND SYMPTOMS
Nurses working in the nursery or in the neonatal intensive care
unit may be able to identify the physiological features of FASD. Other
symptoms become apparent as the child’s development progresses.
■ FAS:
■ Abnormal facial features (i.e., epicanthal folds, flat mid-face,
short nose, short eye openings, thin upper lip, underdeveloped
jaw, and groove in upper lip)
■ Growth problems
■ Hyperactive behavior
■ Learning and attention difficulties
■ Poor motor skills
■ Developmental delays or disabilities
■ ARND:
■ Intellectual disabilities
■ Behavioral problems
■ Learning problems
■ Poor attention
■ Poor judgement
■ Poor impulse control
■ ARBD:
■ Physiological problems (heart, kidneys, orthopedic, and/or
hearing)
DIAGNOSIS
Early diagnosis is important, but often very difficult without
definitive evidence of maternal alcohol ingestion. A diagnosis of
FASD requires a comprehensive history, including information on
maternal consumption of alcohol during pregnancy. Physical
characteristics at birth can alert the nurse that the infant needs
further testing for this syndrome.
PREVENTION
The nurse can communicate to families that FASD and ARND are
100% preventable, and as such, it is important to develop prevention
programs to reduce the rates of these disorders. Nurses can provide
information to families about the effects of alcohol on the fetus.
School nurses especially can facilitate early education regarding
alcohol consumption during pregnancy. Because there are no
guidelines about safe consumption rates for pregnant women, the
public must know that the safe amount is no alcohol intake during
pregnancy. In addition, nurses can help identify cases of FASD and
connect families with appropriate services.
NURSING CARE
While there is no cure for FASD, nurses must understand that
early intervention and referral can help the child and family achieve
optimal function. Involving the child in early education such as the
birth-to-three services as an infant and in special education as a
preschooler can teach adaptive skills they will use throughout life.
Help parents or caregivers work with their child and adapt to their
limitations and strengths.
Women of childbearing age should be informed that FAS can be
prevented by abstaining from alcohol ingestion during pregnancy.
Parents with a child who has FAS must be taught how to cope with
behaviors and given resources to help them deal with their
limitations.
SUMMARY POINTS
■ Vulnerability is defined as a predispositional factor or set of factors that make

a disordered state possible. Resilience is a dynamic developmental process
reflecting evidence of positive adaptation despite significant life adversity.
■ Research indicates that racial and ethnic minorities are disproportionately
affected by health-care disparities. Barriers such as mistrust, fear, and
discrimination stand in the way of optimal mental health outcomes in
ethnically diverse families.
■ Though public education has significantly increased, the stigma of mental
illness remains a major barrier to accessing mental health services for
children and their families.
■ Mental illness in children includes conditions such as anxiety, depression,
PTSD, suicide, BPD, schizophrenia, and ASD.
■ The most effective treatment for ADHD is a combination of pharmacological
and nonpharmacological interventions. Using both modalities allows for the
control or abatement of symptomatic behavior.
■ Child maltreatment is considered to be any action or failure to act by a person
that endangers a child’s physical or emotional health and development. A
person is abusive if the person fails to nurture the child, physically injures the
child, or relates sexually to the child.
■ The nurse is in an ideal position to identify adolescents at risk for substance
abuse, especially if there is a strong family and genetic history of abuse.
These patients should be referred for treatment as early as possible.
Treatment might involve family psychoeducation regarding substance abuse.
■ Anorexia nervosa can become a life-threatening problem or cause death
because of severe weight loss that can result in electrolyte imbalance and
hemodynamic instability.
■ A number of factors can cause developmental disabilities: genetic conditions,
such as DS or FXS; metabolic conditions such as PKU; or pregnancy-related
problems, including alcohol ingestion or viral infections such as rubella.
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Davis Advantage
CHAPTER 26
Caring for the Child With Cancer
CONCEPTS
Cellular regulation
Cancer
Nursing
Development
KEY WORDS
anaplasia
staging
intrathecally
petechiae
multiagent chemotherapy
leukocoria
malnutrition
extravasation
mucositis
LEARNING OBJECTIVES

■ Examine common childhood cancers.
■ Describe the anatomy and physiology related to the pattern of tumor
progression.
childhood cancers.
■ Explore diagnostic and laboratory testing, and medications for common
childhood cancers.
■ Explore the negative and long-term effects of chemotherapy for children with
common childhood cancers.
■ Examine the medical emergencies that occur in children with common
childhood cancers.
■ Develop teaching plans and discharge criteria, including the psychological
effect for parents whose children have common cancers.
PICO(T) Question
chapter.
1. Is there (O) a difference in the (I) rate of recurrence of non-Hodgkin’s
lymphoma in (P) children age 10 or younger (C) compared with children older
than 10?
2. What (I) nursing interventions are shown to be (O) most beneficial in
assisting (P) parents at the time they first learn of their child being diagnosed
with cancer?
INTRODUCTION
The challenges of caring for a child with cancer are tremendous. The
family is dealing with many emotions including significant
uncertainty, fear, anger, and worry that their child will not be cured.
Pediatric oncology nurses are well positioned to help the family cope
and care for them through this most difficult and challenging time.
This can be done through providing patient- and family-centered
care. Pediatric oncology nurses integrate information about the
treatment modalities with observations of how the patient and family
are responding to treatment and whether additional education and
supports are needed.
Much of a pediatric oncology nurse’s practice is grounded in
standards of care and professional performance defined by the
Association of Pediatric Hospital Oncology Nursing (APHON).
Pediatric oncology nurses provide care across the care continuum
from prevention, early detection, ongoing physical and psychosocial
care, and long-term survival. These standards of care also define
activities associated with each step of the nursing process—a
process that includes assessing the patient, identifying problems
requiring nursing intervention, specifying expected outcomes,
planning and implementing a nursing plan of care, and evaluating
the child’s progress (AACO, 2020). With the patient as the central
focus, the ultimate goal is to re-establish a level of optimal wellness
as defined by the patient and family. The nursing process is dynamic
and considers all dimensions of care; therefore, the plan of care is
continually adjusted in response to changes in the patient’s condition
and treatment plan.
This chapter examines common childhood cancers, including
developmentally appropriate and holistic nursing care of the child
with cancer, anatomy and physiology related to the pattern of tumor
progression, and common diagnostic tests, interventions, and new
therapies for a child with cancer. Teaching plans and discharge
criteria are incorporated, including the psychological effect for
parents whose children have common childhood cancers.
EPIDEMIOLOGY
Approximately 13,500 cases of childhood cancers are diagnosed in
the U.S. each year, causing about 1,500 deaths annually among
children ages 0 to 14 (AACO, 2020). Leukemia is by far the most
common childhood cancer, representing about 33% of cases; brain
tumors represent about 25%; lymphomas represent about 8%.
Cancers that are unique to children include neuroblastoma (7% of
cases), Wilms’ tumor (5% of cases), rhabdomyosarcoma (3 to 4% of
cases), and retinoblastoma (3% of cases) (AACO, 2020).
Thanks to better therapies, more than 80% of U.S. childhood
cancer patients now become long-term survivors. As more children
survive childhood cancers, late-effects clinics have emerged to
manage the long-term sequalae from treatment of pediatric cancers
including infertility, secondary cancers, and psychosocial issues. In
2018, the National Cancer Institute estimated that 420,000 adult
survivors of childhood cancer live in the United States, along with
many more around the world.
Because of the severe consequences and complexity of treatment,
children with cancer are best treated in centers with expertise in
childhood cancers. Treatment depends on the type of cancer and
stage. Common treatments include chemotherapy, surgery, radiation
therapy, and stem cell transplantation. Immunotherapy, a newer type
of treatment that helps the person’s own immune system attack the
cancer, may be helpful for certain childhood cancers. Different types
of immunotherapy include monoclonal antibodies, oncolytic virus
therapy, cancer vaccines, chimeric antigen receptor T-cell therapy
(CAR T therapy), and bispecific T-cell engagers.
The effect of a cancer diagnosis and the intensity of the treatment
are overwhelming to the child and family. Maintaining a sense of
normalcy for the child is difficult, especially given the need for
frequent hospitalizations, outpatient visits, and potentially painful
procedures.
PHYSIOLOGY OF CANCER
Cancer occurs when cells grow and divide (out of normal cell growth
and division) and allows for the spread of abnormal cells
(anaplasia). Anaplastic cells resist normal growth controls. This
abnormal cellular growth is also known as a neoplasm and is caused
by one or a combination of three factors: (1) external or
environmental stimuli, (2) viruses that can alter the immune system
and let the cancer grow, and (3) chromosomal and gene
abnormalities.
Pattern of Tumor Progression
A tumor originates as a single, transformed cell somewhere in the
body. That cell must undergo a long process of growth and
development before it forms a tumor. The cell experiences countless
divisions to form a mass that may be made up of a billion cells at the
time of diagnosis. Tumor cells are under very stringent constraints as
they grow. Each of the newly created cells must have a steady
supply of nutrients to keep growing. While the tumor may not be
directly next to a capillary, it may be close enough so that oxygen
and nutrients can diffuse through tissue to tumor cells. If the tumor
receives a continuous supply of nutrients and blood, it grows and
invades surrounding tissue. Once a tumor grows past its critical
phase, it induces growth of new blood vessels into the tumor mass. It
can then grow much more rapidly and become a clinically detectable
tumor. If a tumor does not receive adequate blood supply and
nutrients, it can die. A tumor lacking a sufficient blood supply can
also remain dormant for years and not grow beyond a certain size
(Fig. 26-1).
Normal cells divide in an orderly fashion through mitosis, or cell
division, and have a control mechanism that stops division when it is
complete. In addition, normal cells have the function of apoptosis, or
programmed cell death, which eliminates precancerous or cancerous
cells. Sometimes a “successful” cancer cell manages to escape
apoptosis and continues to divide and replicate unchecked without
stopping. These cancer cells have no control mechanism and take
most of the nutrition from normal cells.
FIGURE 26-1 Typical cell.
An oncogene is a gene found in a virus that has the ability to

encourage a cell to become malignant (Venes, 2021). A tumor is a
mass of abnormally growing cells that is either benign (not
cancerous), with slow and limited noninvasive growth, or malignant
(cancerous), a progressively virulent growth. Cancerous growths are
divided further into solid tumors (e.g., a brain tumor) and systemic
cancers, such as leukemia. In children, many common malignancies
arise from primitive embryonic tissue in which there is a strong
environmental link related to the development of cancer.
Staging describes the severity of the patient’s cancer. It is the
process of classifying tumors in relation to the degree of
differentiation, possibility of responding to therapy, and prognosis
(Venes, 2021).
■ Stage 0 indicates early cancer that is present only in the layer of
cells in which it began.
■ Stage I, Stage II, and Stage III indicate more extensive disease,
greater tumor size, and/or spread of the cancer to nearby lymph
nodes or adjacent organs.
■ Stage IV indicates that the cancer has spread to another organ(s).
PREVENTION OF COMMON CHILDHOOD

CANCER
While prevention is not always possible with pediatric cancer, early
detection is key in achieving a better prognosis and positive
outcome. Today, health-care providers order x-rays and computed
tomography (CT) scans more sparingly than in the past because
limiting children’s exposure to radiation may lower the risk of
developing cancer. The cause of cancer is still unknown, but
genetics, environmental factors, and viruses may play a part in the
development of childhood cancer. The typical warning signs of
cancer may or may not apply to the type of cancers children acquire.
However, a basic understanding of early warning signs is important.
The American Cancer Society uses the word C-A-U-T-I-O-N to help
recognize the seven early signs of cancer:
■ Change in bowel or bladder habits
■ A sore that does not heal
■ Unusual bleeding or discharge
■ Thickening or lump in the breast, testicles, or elsewhere
■ Indigestion or difficulty swallowing
■ Obvious change in the size, color, shape, or thickness of a wart,
mole, or mouth sore
■ Nagging cough or hoarseness
Other symptoms may also indicate the existence of some types of
cancer:
■ Persistent headaches
■ Unexplained loss of weight or loss of appetite
■ Chronic pain in bones or any other areas of the body
■ Persistent fatigue, nausea, or vomiting
■ Persistent low-grade fever, either constant or intermittent
■ Repeated infection
COMMON CHILDHOOD CANCERS

Leukemia
The term leukemia refers to the cancers of the blood-forming cells or
hematopoiesis. There are two types of blood-forming cells: myeloid
and lymphoid. Myeloid cells (Fig. 26-2) differentiate and form into red
blood cells (RBCs), monocytes, granulocytes, and platelets.
Lymphoid cells differentiate and form into B cells and T cells. In
leukemia, normal hematopoiesis (production and development of
blood cells) is altered. Immature blood cells multiply at the expense
of normal blood cells. These immature blood cells also have a
growth advantage over normal cellular elements because of their
increased rate of proliferation (cell growth), a decreased rate of
spontaneous apoptosis (cell death), or both. The immature cells are
known as blast cells.
Normal bone marrow elements are replaced by large amounts of
these immature lymphocytes (blast cells), which causes a “crowding
out” of normal RBCs, platelets, and white blood cells (WBCs). This
results in pancytopenia, an abnormally low level of all blood cells
produced by the bone marrow, including low levels of RBCs, WBCs,
and platelets. Leukemia can develop at any point during the stages
of normal lymphoid or myeloid differentiation in the bone marrow and
can spread to the blood, lymph nodes, spleen, liver, central nervous
system (CNS), or other organs in the body.
Classification of leukemia is based on the predominant cell line
affected and the level of cellular differentiation. The terms myeloid
and lymphoid denote the cell line involved. Both myeloid and
lymphoid cell lines can proliferate into acute or chronic forms of
leukemia. The three major classifications of childhood leukemia are
acute lymphocytic leukemia (ALL), acute myelogenous leukemia
(AML), and chronic lymphocytic leukemia. Acute leukemia is a
rapidly progressing disease that affects mostly immature,
undifferentiated cells that are not able to perform their normal
functions. Acute myelogenous leukemia affects all three types of
blood cells, but the cells maintain some of their normal function, and
chronic lymphocytic leukemia is a less rapidly progressing disease
allowing the production of mature, more differentiated cells. Chronic
lymphocytic leukemia is rarely reported in children.
Another type of leukemia, juvenile myelomonocytic leukemia, is
rare and affects only 1% to 2% of children diagnosed with leukemia.
It mostly affects children younger than age 4 and is very difficult to
treat. A disease related to leukemia is myelodysplastic leukemia
(MDS). In MDS, the child’s bone marrow does not produce enough
WBCs, RBCs, and platelets. MDS ranges from mild to severe
(Dupuis et al, 2016).
FIGURE 26-2 Myeloid cells differentiate and form into red blood
cells, monocytes, granulocytes, and platelets.
Acute Lymphocytic Leukemia

Acute lymphocytic leukemia (ALL) is the most common type of
cancer in children. ALL accounts for 75% to 80% of all childhood
leukemia cases and approximately one-third of all childhood
cancers. It most often occurs in children ages 3 to 5 and affects
slightly more boys than girls during infancy. About 3,000 people
younger than age 20 are diagnosed with ALL each year in the United
States (ACS, 2019).
With ALL, the leukemic cells are usually acquired rather than
inherited. However, there is an increased risk among children with
certain genetic disorders, such as Down’s syndrome. A variety of
factors may predispose children to developing leukemia (Table 26-1).
The current 5-year survival rate for children with ALL has greatly
improved over time and is now 91%. For children diagnosed with
acute leukemia, those who remain free from the disease after 5
years are generally considered “cured” because it is rare for acute
leukemia to recur later (ACS, 2019).
SIGNS AND SYMPTOMS
The presenting symptoms of ALL vary widely depending on the
degree of infiltration of the bone marrow and other organs by
leukemic cells. Most cases have an acute onset, but in some cases
symptoms appear slowly.
■ Fever in approximately 50% of the cases
■ Fatigue and lethargy
■ Enlarged lymph nodes (often “matted” and supraclavicular)
■ Abdominal distension (usually due to enlarged spleen)
■ Pallor caused by associated anemia
■ Anorexia
■ Bone or joint pain in about one-third of cases, especially among
younger children
■ Limping or refusal to walk
Less common symptoms include headache, vomiting, difficulty
breathing, and low urine output. Bleeding under the skin, in the
mouth, or sometimes in the eyes may be present. Petechiae can
also be noted. Hepatomegaly may also be present.
TABLE 26-1
Factors Predisposing to Childhood Leukemia
GENETIC CONDITIONS ENVIRONMENTAL FACTORS
Down’s syndrome Ionizing radiation
Fanconi’s syndrome Drugs
Bloom’s syndrome Alkylating agents
Shwachman’s syndrome Nitrosourea
Klinefelter’s syndrome Epipodophyllotoxin
Turner’s syndrome Benzene exposure
Neurofibromatosis Advanced maternal age
Li-Fraumeni syndrome Severe combined immune deficiency
DIAGNOSIS
A complete blood count and other blood tests are done to evaluate
the WBC count, platelets, and liver and kidney function. A bone
marrow aspirate is required to diagnose ALL. A finding of more than
25% abnormal lymphoblast cells (Fig. 26-3) in the bone marrow is
diagnostic. Other samples in the bone marrow are sent for further
testing and will show chromosomal changes that better identify the
specifics of the leukemia. The child’s WBC count and age at
diagnosis are the most important prognostic signs in ALL. The best
prognosis is associated with a WBC count less than 5,000/mm3 and
an age of 2 to 9 years. The worst prognosis is associated with an
initial WBC count of 50,000/mm3 and an age older than 10 years.
Infants younger than 1 year of age at the time of diagnosis also have
a very poor prognosis.
Lumbar puncture is performed to assess for the presence of CNS
disease and staging of leukemia (Fig. 26-4). A chest radiograph is
obtained to detect a mediastinal mass. Laboratory findings show
liver or kidney involvement.
Diagnostic Tools
Lumbar Puncture (LP)
LP, also known as a “spinal tap,” is the introduction of a needle into the
subarachnoid space of the lumbar spinal cord. The needle is inserted with a
stylet into the interspace between the third and fourth lumbar vertebrae under
strict sterile technique. This test is usually done to remove a sample of
cerebrospinal fluid (CSF) to test it for infection. For cancer patients, this
procedure is also used to introduce chemotherapeutic agents into the CSF
space. This is known as giving chemotherapy intrathecally (through the theca
of the spinal cord into the subarachnoid space). Because some medications
cannot cross the blood-brain barrier easily, physicians have obtained better
results by introducing chemotherapeutic agents into the CSF space to kill
cancer cells so they cannot “hide” behind the blood-brain barrier.
COLLABORATIVE CARE
Nursing Care
Without effective therapy and nursing care, ALL is fatal. Leukemia
is treated with chemotherapy and includes three phases: remission-
induction, consolidation, and maintenance. In the remission-
induction phase, the tumor burden is reduced to an undetectable
level. Ninety-five percent of children with ALL achieve remission
during induction, which usually lasts 4 weeks (Bosshard et al, 2018).
Once remission is achieved, most children relapse within a few
months if treatment is stopped.
FIGURE 26-3 Dark-stained lymphoblast cells seen in acute

lymphocytic leukemia (ALL), the most common type of childhood
leukemia.
FIGURE 26-4 Lumbar puncture.
Medical Care
Chemotherapy agents used for remission-induction are vincristine
(Oncovorin), L-asparaginase (Elspar), and prednisone (Deltasone) or
dexamethasone (Decadron). Children who have a worse prognosis
are also given an anthracycline drug (a chemotherapy drug that is
known to affect and damage the heart, such as doxorubicin
[Adriamycin]). Children with ALL also receive CNS prophylaxis. The
prophylactic chemotherapy agent is injected intrathecally into the
CSF space during an LP. Once the child is stable, the chemotherapy
can be given in an outpatient setting.
The goal of the second phase, consolidation, is to destroy any
residual leukemic cells. This phase starts immediately after
remission is achieved and lasts about 6 months. Chemotherapy in
this phase is frequently administered in high doses. Children are not
usually hospitalized for this phase unless a complication arises. This
phase may also require radiation.
The third phase, maintenance, controls the leukemia. It can last for
2 to 3 years after diagnosis. Today, remission can be induced in 95%
of cases (Bosshard et al, 2018). Bone marrow transplant is the
treatment option for children who have a second relapse after
remission. This treatment involves giving the child high doses of
chemotherapy and/or radiation to eradicate disease or cancer and
then rescuing the patient with a source of stem cells that allows for
recovery of healthy bone marrow.
There are two basic types of bone marrow transplants: autologous
and allogeneic. In an autologous transplant, the patient’s own
peripheral blood or bone marrow is given back. An allogeneic
transplant can be from a matched sibling, a relative, or an unrelated
donor accessed through the National Marrow Donor Program.
BIOLOGICAL THERAPY (AND OTHER TARGETED THERAPIES)
In recent years, biotherapy, also known as biologic response
modifiers (BRMs), biologic therapies, and targeted therapy, has
emerged as a treatment modality using immunologic mechanisms to
eradicate tumor cells. Biotherapy agents include a wide range of
products such as vaccines, blood and blood components,
allergenics, somatic cells, gene therapy, tissues, and recombinant
therapeutic proteins. For example, there are vaccines to help prevent
cancers as well as those designed to treat cancer. For example, the
HPV vaccine can prevent certain types of cancer caused by HPV.
Biologic therapies interact with the child’s immune system to
enhance the response to cancer. Common side effects of biotherapy
include flu-like syndrome (characterized by fever, chills, rigors,
myalgias, headache, and fatigue). During and after administration,
the nurse observes the patient for tachycardia, hypotension, fever,
chills, anaphylaxis, and signs of a local reaction. In addition, the
nurse should establish the patient’s baseline (with vital signs) Nurses
should also teach the patient and family about potential side effects
that might occur at home, including any pain discomfort, symptom
management, and signs and symptoms of anaphylaxis.
Parents are made aware of the importance of these children
avoiding falls and “being careful” during play. Tell parents to monitor
for signs of red dots called petechiae that are described as small (1
to 2 mm), red or purple spots on the body caused by broken
capillaries that do not blanch or fade when pressed by the finger.
With a low WBC count, tell parents to keep the child away from
people who are ill and avoid crowded places, such as shopping
malls.
Acute Myelogenous Leukemia

Acute myelogenous leukemia (AML) is the second most common
type of leukemia seen in children. The principal defect in AML
appears to be an arrest in the differentiation pathway of myeloid
progenitors or precursors rather than abnormal growth kinetics. The
molecular mechanism that leads to a block in differentiation is mostly
unknown. AML can affect all three types of blood cells (Fig. 26-5).
Accordingly, a standard classification system called the French-
American-British system is used to differentiate AML into eight main
types.
SIGNS AND SYMPTOMS

Children with AML may present with vague symptoms resembling
the flu. Because blast cells replace the normal blood cells in the
bone marrow, children with AML often present with abnormal blood
counts. An inadequate number of RBCs may result in anemia,
decreasing oxygen delivery to the blood cells and tissue. Pallor,
fatigue, headache, or dizziness may result.
■ As a result of a decreased number of platelets, thrombocytopenia,
petechiae, easy bruising, nosebleeds, or bleeding gums may be
present.
■ Fever and infection may be present as a result of decreased
WBCs.
■ Bone pain and arthralgias are less common complaints in
childhood.
■ Massive hepatosplenomegaly is uncommon except in infants with
AML.
■ Patients with AML present with signs and symptoms that
infrequently occur with ALL, including subcutaneous nodules or
“blueberry muffin” lesions, infiltration of the gingiva, signs and
laboratory findings of disseminated intravascular coagulation, and
discrete masses known as chloromas or granulocytic sarcomas
that may occur in the absence of apparent bone marrow
involvement (Bosshard et al, 2018).
FIGURE 26-5 Acute myelogenous leukemia cells (AML).
Diagnosis
AML diagnosis requires bone marrow aspiration and analysis. The
biopsy typically reveals a hypercellular marrow consisting of a
pattern of cells with features that permit a subclassification of
disease (ACS, 2020). The diagnosis is typically made when there
are more than 25% malignant myeloid blast cells.
COLLABORATIVE CARE
Nursing Care
Once diagnosis is made, treatment begins promptly, especially to
control any copresenting symptomatology. Cancer treatments
usually involve multiagent chemotherapy, meaning more than one
type of chemotherapy. Treatment outcomes have improved
significantly since the first effective therapies were introduced in the
1970s. The 5-year survival rate has increased from less than 5% in
1970 to 43% today as a result of treatment intensification, the
incorporation of hematopoietic stem cell transplant into primary
therapy, and enhanced supportive care (Boston Children’s Hospital,
2019). Aggressive multiagent chemotherapy is successful in
inducing remission in about 80% of patients. Up to 10% of patients
die of either infection or bleeding before a remission can be
achieved. More individualized therapies and better supportive care
have pushed the survival rate of AML 3 years after diagnosis to 71%
reported by St. Jude Children’s Research Hospital (2019).
Medical Care
Induction treatment includes the combination of cytarabine (Ara-C)
and daunorubicin (Daunomycin). Other commonly used pediatric
induction therapy regimens use cytarabine (Ara-C) and
anthracyclines in combination with other agents such as etoposide
(VP-16) and/or thioguanine (6-TG).
Parents of children who are discharged after receiving
chemotherapy should be alert to signs and symptoms of infection,
such as fever and fatigue, and should monitor for bruising if blood
counts are low. The children usually receive a specific number of
days of treatment and are not discharged until their blood count
levels are safe and at a level determined to be an adequate return to
baseline values.
Chronic Myelogenous Leukemia

Chronic myelogenous leukemia (CML) is a clonal disorder of the
hematopoietic tissue (formation of blood cells) that accounts for 2%
to 3% of all cases of childhood leukemia; about 99% of the cases are
characterized by an alteration in the Philadelphia chromosome
(Houshmand et al, 2019). This disease has been associated with
exposure to ionizing radiation, but very few children have a history of
such exposure.
SIGNS AND SYMPTOMS

The presenting signs and symptoms of CML are nonspecific but
include:
■ Fever
■ Fatigue
■ Weight loss
■ Anorexia
CML is also characterized clinically by an initial chronic phase in
which the malignant clone (cancerous alteration) produces an
elevated leukocyte (WBC) count with increased numbers of
immature granulocytes. In addition to leukocytosis, the blood counts
may reveal mild anemia and thrombocytosis (increased number of
platelets). The spleen is often greatly enlarged, resulting in pain in
the left upper quadrant of the abdomen.
The chronic phase typically ends 3 to 4 years after onset when the
CML moves into an accelerated or “blast crisis” phase. At this point,
the blood counts rise dramatically and cannot be controlled with
drugs. Additional manifestations may occur, including hyperuricemia
and neurological symptoms, which are related to increased blood
viscosity with decreased CNS perfusion.
DIAGNOSIS
A diagnosis is suggested by increased numbers of myeloid cells
with differentiation to mature forms in the peripheral blood smear and
bone marrow. Cytogenetic studies yield the presence of the
characteristic Philadelphia chromosome.
COLLABORATIVE CARE
Nursing Care
The optimum therapy is allogenic bone marrow or stem cell
transplantation from a matched sibling, which is curative in up to
80% of children (Houshmand et al, 2019). Therefore, the main
nursing care revolves around post–bone marrow or transplant
interventions.
Medical Care
Treatment of the signs and symptoms in the chronic phase can be
controlled with hydroxyurea (Droxia, Hydrea), which gradually
returns the leukocyte count to normal. This treatment is not definitive
and does not eliminate the abnormal clone or prevent the
progression of the disease. Therapy with interferon-a can produce a
hematological remission in up to 70% of patients and cytogenetic
remission in about 20% of patients (NCI, 2018). Combination
chemotherapy is based on health-care provider order and has been
successful in the treatment of children with this disease.
As with ALL, parents must be made aware of the importance of
these children avoiding falls and being careful during play. Tell
parents to monitor for petechiae on the skin that do not blanch or
fade when you press your finger on them. With a low WBC count,
the parents should keep the child away from people who are sick
and avoid crowded places, like shopping malls.
Solid Tumors
Solid tumors in children differ significantly from those in adults. Some
solid tumors that affect children never or very rarely develop in
adults, including neuroblastoma, Wilms’ tumor, rhabdomyosarcoma,
and osteosarcoma. The most common types of solid tumors found in
children are discussed here. Solid tumors are named for the type of
cells of which they are composed:
■ Sarcoma is a cancer arising from connective or supporting tissues
(e.g., bone or muscle).
■ Carcinoma is cancer arising from the body’s glandular cells and
epithelial cells.
■ Lymphomas are cancers of the lymphoid organs, such as the
lymph nodes, spleen, and thymus, that produce and store
infection-fighting cells. These cells also occur in almost all tissues
of the body; therefore, lymphomas may develop in a wide variety
of organs.
Brain Tumors
Tumors of the brain or of the CNS are the second most common
cancer in children after leukemia. Brain tumors in children differ
greatly from those seen in adults. Virtually all childhood brain tumors
are primary tumors, meaning that they originate in the brain. In
contrast, with adults, brain tumors are primarily metastatic,
originating from another site and then spreading to the brain.
Brain tumors are divided into two types: supratentorial and
infratentorial. Supratentorial tumors occur in the anterior two-thirds of
the brain above the tentorium (dura matter located between the
cerebrum and cerebellum, supporting the occipital lobes), primarily in
the cerebrum. Infratentorial tumors are located in the posterior third
of the brain, primarily in the cerebellum and brainstem and below the
tentorium. The mortality rate among children and adolescents with
brain tumors approaches 45% (Boston Children’s Hospital, 2019).
SIGNS AND SYMPTOMS
Clinical manifestations of patients with brain tumors depend on the
tumor location, tumor type, and the age of the child.
■ Classic signs and symptoms are related to the tumor obstructing
CSF drainage paths, leading to increased intracranial pressure
(ICP).
■ Because their cranial sutures are open, infants may exhibit
lethargy, irritability, and macrocephaly. They may also have a
raised or tense fontanelle.
■ Projectile vomiting is often seen in the morning with little warning,
or a headache may be noted.
In young children, the diagnosis of a brain tumor may be delayed
because the symptoms are often similar to those of a typical
gastrointestinal illness. Subtle changes in personality, mentation,
and/or speech may precede the classic signs and symptoms of brain
tumors. Brainstem tumors are associated with cranial nerve
abnormalities such as hemiparesis—a weakness on one side of the
body—or a spastic gait. Older children may fall or stumble.
DIAGNOSIS
Any child who displays signs of increased ICP or other
neurological signs, such as ataxia, visual disturbances (if able to
ascertain), or hemiparesis, needs to be referred for a complete
neurological exam. The diagnostic work-up may include magnetic
resonance imaging (MRI) or a CT scan. CT takes less time (5 to 10
minutes) and may be more appropriate if the child is able to lie still
without sedation. An endocrine work-up may be required for tumors
that occur in the pituitary area.
COLLABORATIVE CARE
Nursing Care
The main focus of a physical assessment of a child with a brain
tumor is the neurological exam. A patient’s baseline assessment is
important to detect any subtle changes. This exam includes vital
signs; pupil size, equality, and response to light; level of
consciousness (LOC); strength and equality of grip of hands; and
movement of the legs. Head circumference and the assessment of
the anterior fontanelle are extremely important in assessing an
infant’s ICP. Parents may first notice behavioral changes. The nurse
performs frequent neurological exams to determine early changes in
a child’s condition. Detecting subtle changes in the neurological
exam can be of great value in managing a child’s condition and
eventual prognosis. It is important for the nurse to remember that the
neurological exam can change rapidly. Timely responses to
neurological changes are of vital importance for the child with a brain
tumor.
Good communication with the care delivery team is vital. Parents
and the child need good emotional support and accurate information.
Nurses are the pivotal coordinators of the care in this difficult
situation. The nurse demonstrates a positive attitude and is
reassuring to parents during difficult treatments to build a trusting
relationship with the family.
What to Say
When a Child Is Diagnosed With a Brain Tumor
A 4-year-old child has just been diagnosed with a brain tumor. The pediatric
nurse knows that the family is most likely in a state of shock. The family or the
child does not understand the exact nature or future implications of a brain
tumor. While caring for the child, the nurse treats them as normally as possible.
It is acceptable to communicate with the child and family while the child plays.
It is also important that the nurse support the parents or caregivers and allows
them time to “absorb” the diagnosis. What would the pediatric nurse say to the
family?
• “It is important for you to verbalize and express your feelings.”
• “You may find it helpful to talk with others who have had the same experience
as you. I have contact information for a support group. Would you like me to
make a call for you?”
• “I know this is a very difficult time for you. Let’s take this one day at a time and
make your child’s daily routine as normal as possible.”
Other nursing care measures include continued neurological

assessments, airway and fluid maintenance, prevention of infection,
pain management, adequate nutrition, and promotion of normal
growth and development.
Medical Care
Treatment may include surgical resection, radiation therapy,
chemotherapy, or a combination of these, though in the last decade
chemotherapy has emerged as the standard care in the treatment of
certain pediatric brain tumors, especially for children younger than 3.
Several rounds of high-dose chemotherapy with stem cell rescue are
now being offered for metastatic medulloblastoma, as well as for
some other incurable brain tumors. The current 5-year survival rate
for medulloblastoma is 85% (St. Jude Children’s Research Hospital,
2019).
The goal of radiation therapy is to destroy the tumor while sparing
normal tissue in the developing brain. Early use of radiation is done
sparingly because of the desire to preserve intellectual growth and
decrease the possibility of growth impairment. When radiation is
used, the dose is usually high and the toxicity (poison level) can be
severe. Radiation therapy to large areas of the brain can sometimes
cause changes in brain function (Venes, 2021).
Surgical Care
The extent of surgical resection (cutting out) of the tumor
correlates with the prognosis. Radical resections are particularly
important in children younger than 2 years of age because cranial
radiation can be deferred in these patients. Because many of the
brain tumors infiltrate into surrounding normal brain tissue, complete
resection is not often possible.
Optimizing Outcomes
Postoperative Care
Postoperative nursing care for children with surgical resection of tumors should
include observation of pupils. Dilated, unequal, or sluggish pupils should require
immediate attention as this is an indicator of increased ICP.
After resection, postoperative care includes monitoring vital signs, performing
an ongoing neurological assessment, administering IV steroids such as
dexamethasone (Decadron) to prevent edema within the brain, assessing the
surgical site, and helping the child regain self-care skills and maintain age-
appropriate development. Anticonvulsants are indicated for the child with a
supratentorial tumor because seizures are possible. Two of the most common
anticonvulsant drugs used in the pediatric population are fosphenytoin
(Cerebyx) and phenytoin (Dilantin). The nurse should ensure the child’s comfort
and alleviate pain as well as offer support to the family.
Patient Education
Education for CNS Involvement
It is important in discharge planning that parents are taught to monitor for
headaches, blurred vision, pressure, confusion, or an altered LOC when taking
their child home. Nurses should also teach parents to monitor for fever and
check the incision site for signs of infection.
Neuroblastoma
Neuroblastoma is the third most common pediatric cancer after
leukemia and brain tumors (Boston Children’s Hospital, 2020).
Neuroblastoma is a tumor of nerve tissue that develops in infants
and children from the tissues that form the sympathetic nervous
system. The nervous system controls body functions like heart rate
and blood pressure, digestion, and levels of certain hormones. Most
commonly it develops in the abdomen within the tissues of the
adrenal gland, but it may also be found in other areas like the brain,
pelvis, mediastinum, and sympathetic ganglia. It can spread to the
lymph nodes, liver, bones, and bone marrow.
Neuroblastoma accounts for about 8% of all childhood cancers
(Pappo & Dirksen, 2019). Neuroblastoma is the most common
diagnosed neoplasm in infants. The median age at diagnosis is 2
years. Ninety percent of all cases are diagnosed in children younger
than 5 years. It can occasionally be seen in teenagers and young
adults (BCH, 2019). The incidence is slightly higher in boys than in
girls, and in Caucasian, non-Hispanic children. In the United States
there are about 800 new cases of neuroblastoma diagnosed per
year (Pappo & Dirksen, 2019).
SIGNS AND SYMPTOMS
Children with neuroblastoma present with a wide variety of initial
symptoms depending on the primary site of the tumor.
■ Most commonly, the tumor is detected by palpation. On palpation
the nurse notes that neuroblastoma crosses the midline. The
tumor is noted as a hard, painless mass in the neck or abdomen.
■ Masses of the thorax can be seen on radiographs and are usually
an incidental finding on a film done to rule out pneumonia.
■ If large enough, the tumor can produce edema of the lower
extremities related to vascular compression.
Unfortunately, at the time of diagnosis, 75% of patients with
neuroblastoma have a tumor that has already spread, or
metastasized, to another site (Pappo & Dirksen, 2019). Nearly one-
half of the patients have widespread metastasis to the bone that
causes bone pain. The bones of the skull and orbit are also
frequently affected, so swelling and bruising around the eyes are
common. The current 5-year survival rate for neuroblastoma is 75%
(St. Jude Children’s Research
Hospital, 2019).
DIAGNOSIS
Imaging studies, such as MRI and CT scan, may indicate the
presence of a mass. A clear diagnosis of neuroblastoma can be
made only by biopsy. Bone marrow aspiration may also be
performed. Laboratory studies may be ordered because 95% of
neuroblastomas secrete catecholamines. These are secreted in the
urine, so vanillylmandelic acid and homovanillic acid tests are used
to measure the level of catecholamines or catecholamine
metabolites (breakdown products) in the urine.
COLLABORATIVE CARE
Nursing Care
During the treatment phase, a complete nursing assessment is
vital to ensure that the child does not have an infection and their
condition remains stable. Place emphasis on the child’s comfort,
including pain relief measures. Supporting the child and the family
during the diagnosis and treatment phase is most important.
Encourage both the child and caregivers to share their feelings about
the disease process and related treatments. Providing accurate
information and education for the family is also important.
Medical Care
Treatment for neuroblastoma is determined by the stage of the
disease and the age of the child. Initially, surgical resection is
performed and followed by chemotherapy. In advanced stages of the
disease, a complete surgical resection is sometimes not possible,
and chemotherapy is initiated. Neuroblastoma is radiosensitive, but
radiation alone is not curative. Radiation is used for tumor control in
conjunction with chemotherapy and autologous or allogeneic bone
marrow transplant.
Parents are taught to monitor the incision site for signs of infection
and watch the child for fever. It is best to keep children away from
large crowds and ill people during the treatment phase. Teach
parents about comfort measures, too.
Wilms’ Tumor
Wilms’ tumor (nephroblastoma) is a tumor that originates in one or
both kidneys. It is named after the German doctor, Max Wilms, who
first described it in 1899. The actual cause of Wilms’ tumor is
unknown. Ninety percent of all kidney tumors are Wilms’ tumors, and
it is the fourth most common cancer in children. The average age at
diagnosis is between 2 and 5 years (Caldwell, Wilcox, Cost, 2017).
The disease occasionally affects older children, and girls and boys
are equally affected. About 9 out of 10 children with Wilms’ tumor are
cured. A great deal of progress has been made in treating this
disease with surgery, radiation, and chemotherapy (American
Cancer Society, 2020). The present 5-year survival rate is 90% (St.
Jude Children’s Research Hospital, 2019).
SIGNS AND SYMPTOMS
The tumor is usually discovered on a routine physical exam or is
felt or seen by a family member during bathing or routine care.
Unlike neuroblastoma, the mass frequently presents on one side and
seldom crosses the midline.
■ Children with Wilms’ tumor present with an abdominal mass that is
usually painless.
■ Hematuria, hypertension, and pain occur infrequently.
■ Other symptoms may be aniridia (absence of the iris, the colored
part of the eye), hemihypertrophy (an increased size of one-half of
the body), or urinary defects such as cryptorchidism and
hypospadias.
DIAGNOSIS
A child presenting with an abdominal mass needs a timely
diagnostic work-up. The nurse explains to the parents that ongoing
laboratory and diagnostic testing include urine and electrolyte
analysis and a complete blood count, and a renal or abdominal
ultrasound, CT scan, or MRI of the abdomen are done. If metastasis
is suspected, a chest x-ray exam is ordered.
COLLABORATIVE CARE
Nursing Care
Nursing care for Wilms’ tumor consists of a thorough health and
history and nursing assessment. Foods high in calories and protein
are important. If a child is unable to eat enough to meet basic caloric
requirements for growth and development, dietary supplements,
allowing the child food choices, and ensuring that food textures
facilitate eating might help. Enteral or parental feeding may be
provided if necessary.
Palpation of the Abdomen in a Child With Wilms’ Tumor

Once a child has been diagnosed with Wilms’ tumor, never palpate the
abdomen or allow anyone else to do so. Palpating this kind of encapsulated
tumor can cause it to rupture or lead to further metastasis. Be sure to place a
warning sign on the child’s hospital room door that says, “No abdominal
palpation.”
Medical Care
Medical treatment includes both chemotherapy and postradiation
care. The most common chemotherapy drugs used for Wilms’ tumor
are actinomycin D (Dactinomycin) and vincristine (Oncovorin). For
tumors in more advanced stages, those with unfavorable histology,
or those that recur after treatment, the following drugs are used:
doxorubicin (Adriamycin), cyclophosphamide (Cytoxan), etoposide,
irinotecan, and/or carboplatin (American Cancer Society, 2020).
Surgical Care
A surgical removal of the mass, which usually involves taking the
entire kidney, and biopsy are performed. After surgical resection for
a Wilms’ tumor, postoperative care is similar to care for children
undergoing other abdominal surgeries. A critical postoperative
assessment of the remaining kidney is necessary to ensure its
function. Typical postoperative care measures are done. To track
kidney function, closely monitor urine output for amount, color,
clarity, presence of clots, pain, and laboratory values.
CASE STUDY
Wilms’ Tumor
A mother brings her 3-year-old to the pediatrician’s office. She states that while
giving her daughter a bath, she noticed a lump on the girl’s abdomen. The
mother says the child shows no abnormal behavior. She is sleeping and playing
normally. However, the mother does state her daughter is a picky eater but
assumes that is normal for a preschooler. The mother is concerned about a
“hernia or something.” On physical examination by the pediatrician, a small
mass in the abdominal cavity is discovered. The pediatrician sends the child for
an abdominal CT scan. The CT confirms there is a mass on the left kidney. It is
classified as a stage II Wilms’ tumor.
1. What is the course of treatment for this child?

2. What information does the parent need to know about nutrition?
Teach parents to monitor the incision site for signs of infection as
well as the child for a fever. Parents need to be aware of the child’s
nutritional intake and bowel movements. Stress the importance of
follow-up appointments and clinic visits.
Rhabdomyosarcoma
Rhabdomyosarcoma is the most common pediatric soft-tissue
sarcoma and accounts for 5% to 8% of all childhood cancers (Pappo
& Dirksen, 2019). It arises from mesenchymal cells that are normally
committed to skeletal muscle formation but can also arise from
smooth muscle cells. There are two main types of
rhabdomyosarcoma: embryonal rhabdomyosarcoma and alveolar
rhabdomyosarcoma, along with some less common types. These
tumors occur at virtually any anatomical site but are most often found
in the head and neck, genitourinary tract, extremities, and trunk.
Rhabdomyosarcoma occurs with an increased frequency of patients
with neurofibromatosis (Pappo & Dirksen, 2019). Overall, two-thirds
of children diagnosed with rhabdomyosarcoma will become long-
term survivors. The current 5-year survival rate for
rhabdomyosarcoma is 65% (St. Jude Children’s Research Hospital,
2019). Children with distant metastatic disease at diagnosis have a
poor prognosis, with only 30% surviving 5 years. It is most common
in children less than 10 years of age but can occur in teens and
adults. It is slightly more common in boys than girls (American
Cancer Society, 2019).
DIAGNOSIS
Definitive diagnosis is established by biopsy. Investigating a lesion
may help with diagnosis. Paratesticular lesions may be ignored for a
long time by an adolescent. A lesion in an extremity may be
mistaken for a hematoma or hemangioma. Physical examination
also includes attention to the lymph nodes. Radiographic studies
include x-ray exams, CT scan, and MRI.
COLLABORATIVE CARE
Nursing Care
Nursing care is based on which treatment options are prescribed.
If surgical resection is done, monitoring of the surgical site is vital. If
chemotherapy is the treatment, standard nursing care of the patient
receiving chemotherapy is indicated.
Medical Care
Medical care is based on the primary tumor and disease stage.
Patients with complete surgical resected tumors have the best
prognosis. Unfortunately, most rhabdomyosarcomas are not
completely resectable. Chemotherapy is the standard treatment.
Parents are taught about the importance of monitoring the surgical
site and watching the child for a fever. Stress the importance of
follow-up care and clinic visits. As with any child with cancer, remind
parents to keep the child away from crowded areas and ill people.
The child can resume normal activity depending on the treatment
protocol and how they feel. Parents can be taught about quiet
activities that integrate normal developmental socialization.
Retinoblastoma
Retinoblastoma is a malignant tumor that arises from the retina at
the back of the eye during fetal life or early childhood. A
retinoblastoma can grow rapidly or slowly. It may produce multiple
tumors that can affect one or both eyes. It is sometimes recognized
at birth. Retinoblastoma can often be seen by looking at a young
person’s eyes or by observing a photograph taken of the individual.
There is no racial or gender predominance, but there is a familial
predisposition in about one-third of patients. Overall, 60% of cases
are unilateral and nonhereditary. Bilateral involvement is found in
42% of those presenting when younger than 1 year of age and is
even less common at older ages. Close to 95% of retinoblastomas
are cured (Pappo & Dirksen, 2019).
SIGNS AND SYMPTOMS
Usually retinoblastoma is detected by the caregiver, who notices a
whitish glow in the pupil known as leukocoria (cat’s eye reflex). This
is seen instead of the red eye reflex typically seen in photographs
and is the most common manifestation of this tumor. Other signs
include:
■ Strabismus
■ Red, painful eyes
■ Blindness (late sign)
Less common evidence of the tumor includes:
■ Visual impairment
■ Abnormal appearance of the eye that consists of a change in color
of the iris, pupils of unequal size, or increased pressure inside the
eye
DIAGNOSIS
Retinoblastoma is usually diagnosed via an examination under
anesthesia using an ophthalmoscope. Orbital ultrasound and CT or
MRI may be used to evaluate the extent of intraocular disease and
extraocular spread.
COLLABORATIVE CARE
Nursing Care
An important nursing care measure before surgery includes
showing parents a photograph of another child who had this
procedure. Parents can then understand that the child’s facial
appearance will be nearly normal. It is also important to inform
parents that after surgery the eyelid is usually closed, and the child
will wear a patch over the operative eye. It is important to keep the
operative site clean and dry. Postoperative medical orders may
include eye socket irrigation and the application of an antibiotic
ointment. Traditional postoperative measures such as airway and
fluid maintenance, vital signs, pain management, and nutrition are
also important.
Medical Care
Treatment for this tumor depends on the size and location of the
tumor (or tumors), with the primary goal of curing disease and the
secondary goal of preserving vision.
The child is usually discharged in 3 to 4 days after the surgery.
The nurse teaches parents about care of the eye socket by showing
them gentle irrigation of the area with the prescribed solution, then
applying a thin coating of the prescribed antibiotic ointment. Eye
gauze pads are applied until the wound has completely healed.
Enforce good hand washing for the entire family. After about 3
weeks, the child is fitted for a prosthetic eye. Through the entire
process, the nurse offers support to the child and family and
encourages follow-up care.
Bone Tumors
Malignant bone tumors account for approximately 5% of all
childhood cancers. The two most common bone tumors are
osteogenic sarcoma and Ewing’s sarcoma (Misaghi et al, 2018).
Osteosarcoma
Osteogenic sarcoma, or osteosarcoma, is a bone tumor that usually
occurs in the metaphysis (the growing portion of a bone) (Fig. 26-6).
The long bones are more frequently affected than the flat bones
such as the pelvis or skull. The leg is the most common site, with the
femur (upper leg) the most commonly affected bone, followed by the
tibia (lower leg) and the humerus (upper arm). The high-risk period
of developing osteosarcoma is during adolescent growth spurts.
Often a traumatic event leads to the discovery of osteosarcoma as a
secondary finding. Osteosarcoma can also occur as a complication
of treatment for another tumor, especially at a site of prior radiation
for a tumor such as retinoblastoma. These secondary radiation-
associated osteosarcomas can occur 7 to 15 years after successful
treatment of the primary tumor.
The cause of osteosarcoma is unknown. Certain genetic or
acquired conditions may predispose children to the development of
osteosarcoma. Children with hereditary retinoblastoma have a
significantly increased risk of developing osteosarcoma. The annual
incidence of osteosarcoma in the United States is 5.6 cases per
million children younger than 15 years of age (Misaghi et al, 2018).
Presently, using modern therapy, the 5-year, event-free survival rate
is 65% to 70% with an overall survival rate of 70% to 80%. Patients
with nonmetastatic extremity osteosarcoma are cured with current
multiagent treatment protocols 75% of the time (Patel et al, 2020).
SIGNS AND SYMPTOMS
Pain and swelling are the most common presenting symptoms.
The pain increases with activity and weight bearing and may cause
the child to limp. It is common for a child to have a dull, aching pain
for several months before diagnosis. Palpation at the site of the
disease often reveals tenderness, swelling, warmth, and erythema.
FIGURE 26-6 Osteosarcoma.
DIAGNOSIS
An x-ray film may show a sunburst pattern on the affected bone.
An accompanying chest x-ray exam is performed to check for
metastasis. A MRI of the entire bone is performed to evaluate the
extent of the tumor. A nuclear medicine scan or bone scan may also
be done to determine the extent of involvement in the bone (St.
Jude’s Research Hospital, 2018). Nuclear tracer isotopes, such as
techne-tium-99m or thallium-201, which are radioactive materials,
show an increased uptake of radioactive material in the areas of the
primary tumor as well as any area of metastasis. The most common
site of distant metastatic spread of osteosarcoma is to the lung.
Certain laboratory tests, such as elevated blood serum levels of
serum alkaline phosphatase or lactic acid dehydrogenase, can help
diagnose osteosarcoma. Although the diagnosis of osteosarcoma
may be strongly suspected after diagnostic studies, only a biopsy
with microscopic examination provides final confirmation of
osteosarcoma.
COLLABORATIVE CARE
Nursing Care
For the child with osteosarcoma, monitoring and treating pain is
important. Use age-appropriated pain scales to assess pain. To
decrease the child’s pain, use both pharmacological and
nonpharmacological measures. Promote function and mobility and
monitor the surgical site for redness, warmth, and signs of infection.
Medical Care
Children with osteosarcoma receive chemotherapy first to shrink
the size of the tumor. Then, the primary treatment goal is total
eradication of the tumor.
Surgical Care
Surgical resection of the affected bone is often performed after
chemotherapy. Nursing care for the child postoperatively includes
monitoring vital signs, performing ongoing nursing assessments,
providing adequate pain control, and monitoring for signs and
symptoms of infection. Emotional support of the child and family after
surgical resection is another key aspect to help the child accept an
altered body image.
Tell parents it is important to monitor mobility function and pain
after surgery. The overall goal is to prevent further amputation. While
the child and family may want to preserve the limb, sometimes
amputation with later prosthesis is a better choice when function of
the limb is impaired or pain becomes uncontrollable. The child can
resume normal activity depending on the treatment protocol and how
they feel. Parents can be taught about quiet activities that integrate
normal developmental socialization.
Ewing’s Sarcoma
Ewing’s sarcoma involves the bone as well as soft tissue. It tends to
appear in the middle of bones, most often the femur, pelvis, ribs,
upper arms, and thigh (Fig. 26-7). Ewing’s sarcoma is a highly
malignant bone tumor with a histological appearance that differs
from that of osteosarcoma. It is more often seen in young males than
in females. Ewing’s sarcoma commonly affects patients between 10
and 20 years of age. Annually between 300 and 400 cases are
diagnosed in the United States each year. It is extremely rare among
African American children and in Asian Americans. Patients with
small, nonmetastatic, distally located extremity tumors have the best
prognosis. The 5-year survival rate is up to 85% after treatment with
chemotherapy, surgery, and/or radiation (Shanbhag & Ambinder,
2018).
FIGURE 26-7 Ewing’s sarcoma.
SIGNS AND SYMPTOMS

Clinical symptoms of Ewing’s sarcoma are similar to those of
osteosarcoma.
■ Pain and swelling at the site of the tumor are the usual presenting
symptoms (Memorial Sloan Kettering Cancer Center, 2019).
■ The bone pain or swelling may be attributed to a sports injury, and
caregivers may delay seeking care.
■ When the tumor is present in the chest wall (Askin’s tumor), the
child may present with respiratory distress.
■ The child with paraspinal or vertebrospinal tumors may present
with symptoms of spinal cord compression.
■ There may be systemic manifestations such as fever or weight
loss.
DIAGNOSIS
Diagnosis of Ewing’s sarcoma is made via biopsy of the bone
lesion. A complete staging procedure must be performed. A CT
scan, MRI, or radionuclide bone scan is helpful in determining the
primary site. Location of the primary tumor is important, especially
with pelvic and sacral lesions, because those tumors cannot be
removed. Ten to thirty percent of patients have metastatic disease at
the time of diagnosis (Patel et al, 2020). The lung, other bones, and
the bone marrow are the most common sites of metastasis.
Widespread metastasis to other bones and the bone marrow may
have a poor prognosis
COLLABORATIVE CARE
Nursing Care
Nursing care measures include assessment of unusual swelling
and dilated surface blood vessels. Notice that the child may walk
with a limp or have weakness on the affected side. Palpate the area
and note any firm or nontender enlargements. The primary nursing
diagnosis is impaired mobility.
Medical Care
Multiagent chemotherapy is important because it can rapidly
shrink the tumor and prevent new tumors from forming. Various
chemotherapy treatment plans may be used depending on institution
and established health-care provider protocol. Any time
chemotherapeutic agents are administered, nurses should be aware
of the type of personal protective equipment (PPE) required.
Depending on the site of tumor involvement, radiation therapy may
also be used (Memorial Sloan Kettering Cancer Center, 2019). When
radiation treatment is performed, it is associated with the risk of
radiation-induced secondary tumors, especially osteosarcoma, as
well as failure of bone growth in skeletally immature patients.
Surgical Care
Surgical resection is preferred if possible. Postoperative care
includes monitoring for signs and symptoms of infection, such as
fever, redness, and warmth at the surgical site. Monitor drainage
from the surgical site.
Discharge instructions include educating the parents about the
signs and symptoms of infection such as fever, redness, and warmth
at the surgical site. The child can resume normal activity depending
on the treatment protocol and how they feel. Parents can be taught
about quiet activities that integrate normal developmental
socialization.
Lymphomas
Lymphoma refers to a group of varied cancers that develop in the
WBCs in the lymphatic system. This group of organs and tissues
found throughout the body are part of the immune system and help
to form new blood cells. These include the lymph nodes, small
organs composed of lymphoid tissue at various parts of the body that
are connected by lymphatic vessels; the spleen; the bone marrow;
and the thymus gland just below the neck that produces one type of
lymphocyte called the T cell. A lymphoma is a malignancy that arises
from the lymphatic system.
Hodgkin’s Disease
Hodgkin’s disease (HD) consists of two types of lymphomas in
children: Hodgkin’s lymphoma (HL) and non-Hodgkin’s lymphoma
(NHL). Hodgkin’s disease was first described in 1832 by the English
physician Thomas Hodgkin. HL tends to involve the lymph nodes
near the surface of the body while NHL typically affects the tissues,
particularly those of the bowel, the region adjacent to the appendix,
and the upper midsection of the chest.
In the United States, HD accounts for about 5% of childhood
malignancies. Hodgkin’s disease is rare in children younger than 5
years. There are three main age groups affected by HD:
■ Childhood form (younger than 14 years of age)
■ Young adult form (15 to 34 years of age)
■ Older adult form (55 to 74 years of age)
There is a male predominance in patients younger than 10 years
of age, with an equal gender distribution in adolescence. People with
a pre-existing immunodeficiency, either congenital or acquired, have
an increased risk of developing HD. The role of the Epstein–Barr
virus is being studied in relation to HD. The Reed-Sternberg cell, a
large cell with multiple or multilobulated nuclei, is considered the
hallmark of HD, although similar cells are seen in mononucleosis.
Hodgkins disease has a much better survival rate than non-
Hodgkins. With intensive treatment, currently the long-term survival
rate for children with limited stage (stage I or II) lymphoblastic
lymphoma is higher than 90%. The long-term survival rate for more
advanced (stage III or IV) lymphoblastic lymphomas is generally
higher than 80% (American Cancer Society, 2020).
HODGKIN’S LYMPHOMA
Signs and Symptoms
The onset of HL is not commonly acute in nature. The child may
have symptoms for a long time before telling anyone or seeking
care. A few patients may have no presenting symptoms early in the
disease other than swollen lymph nodes. The disease is usually
localized when patients present at the time of diagnosis.
■ Painless, firm, cervical, or supraclavicular lymphadenopathy is the
most common presenting sign.
■ Inguinal or axillary sites are uncommon areas of presentation of
lymphadenopathy; in addition, lymph nodes filled with cancer cells
tend to be matted, nonmoveable, and painless because they are
filled with cancer cells.
■ An anterior mediastinal mass is often present and can rapidly
disappear with therapy.
■ Systemic symptoms considered important in staging are
unexplained fever, fever that comes and goes, weight loss, or
drenching night sweats.
■ Less common symptoms are lethargy, anorexia, itching all over the
body, coughing, chest pain, breathing problems caused by swollen
lymph nodes in the chest, excessive sweating, a full feeling, pain,
and flushed skin.
Diagnosis
The only way to confirm HL is with a biopsy or removal of the
enlarged lymph node. After biopsy confirms HL, several tests and
scans are performed to determine the extent of spread: chest x-ray
exam, CT scan, lymphangiogram to show abnormal nodes, MRI,
bone scan, bone marrow biopsy, and blood tests.
Collaborative Care
NURSING CARE
Nursing care for HL focuses on a thorough nursing assessment
that includes monitoring the patient for fever and for painless lymph
nodes in the neck, groin, or armpit area. Coughing or difficulty
breathing, chronic fatigue, and possible chest pain are noted. Pain,
swelling, or a feeling of fullness in the abdomen is assessed. It is
also important for the nurse to manage pain, provide comfort
measures, and provide support to the child and the family. Obtain lab
tests as ordered and prepare the child for imaging studies. Teaching
the family about chemotherapy is necessary if this is the prescribed
treatment regimen.
MEDICAL CARE
Treatment for HL may include chemotherapy and/or radiation
therapy, depending on the clinical stage at the time of diagnosis (Fig.
26-8). Pharmacological interventions are often prescribed to manage
the patient’s pain.
With a low WBC count, tell parents to keep the child away from
people who are ill and avoid crowded places such as shopping
malls. Teach the parents about comfort measures for the child.
Stress the importance of follow-up appointments and clinic visits.
The child can resume normal activity depending on the treatment
protocol and how they feel. Parents can be taught about quiet
activities that integrate normal developmental socialization.
NON-HODGKIN’S LYMPHOMA
Malignant lymphoma is a cancer of lymphoid tissue or lymphatic
system. NHL is different from HL in that it has no single focal origin
(the malignant cells are rarely localized). NHL has a rapid onset and
presents with widespread involvement. NHL results from malignant
clonal proliferation of lymphocytes of T or B or indeterminate cell
origin. Four different types of NHL are defined by how the cells look
under the microscope:
■ B-cell non-Hodgkin’s lymphoma (Burkitt’s and Burkitt’s-like
lymphoma) and Burkitt’s leukemia
■ Diffuse large B-cell lymphoma
■ Lymphoblastic lymphoma (a malignancy of T cells)
■ Anaplastic large cell lymphoma
Two other types of lymphoma that occur in children:
lymphoproliferative disease associated with a weakened immune
system and rare non-Hodgkin’s lymphomas that more commonly
affect adults (Shanbhag & Ambinder, 2018).
FIGURE 26-8 A child receiving chemotherapy.
Among children younger than 15 years of age, 60% of lymphomas

are NHL. NHL is seen from infancy through adolescence, with a
peak between the ages of 7 and 11. Boys are affected more often
than girls. The cause is unknown, although viral, genetic,
immunological, and environmental factors have been implicated.
Current 5-year survival rate for children with NHL is 80% (St. Jude
Children’s Research Hospital, 2019).
Signs and Symptoms
The presenting symptom of NHL is usually pain or swelling
depending on the initial site of involvement and the extent of disease
spread. The most frequent sites of involvement are the abdomen,
chest, and the head or neck region.
These lymphomas grow rapidly, and most children present with
advanced-stage disease. Spread into the CNS may result in
weakness of the facial muscles. Spread to the bone marrow may be
associated with pale skin or bruising.
Diagnosis
Prompt tissue diagnosis and staging are important because of the
rapid growth of lymphomas. Elevated levels of serum lactic
dehydrogenase (greater than 500 units/L) correlate with tumor mass
and are useful in deciding on therapy intensity. Other laboratory
findings vary with the site or organs involved. A CT scan or MRI of
the chest, the abdomen, or both may assist in determining disease
extent.
Collaborative Care
NURSING CARE
When handling equipment or material that has contained
chemotherapy drugs, discard it in a designated container that is
properly labeled (Fig. 26-9). Chemotherapy drugs are considered
hazardous waste material.
MEDICAL CARE
Aggressive, multiagent chemotherapy is started as soon as
possible once the diagnosis is made and tumor staging is complete.
Intrathecal chemotherapy is given for CNS prophylaxis.
FIGURE 26-9 Chemotherapy waste receptacle.
Discharge instructions and education for NHL include monitoring
the child for pain, infection, fever, and enlarged lymph nodes. Tell
parents to watch for difficulty breathing and teach them about
comfort measures. Stress the importance of follow-up appointments
and clinic visits.
Liver Cancer
In the United States, primary malignant liver tumors are the 10th
most frequent pediatric malignancy (St. Jude Children’s Research
Hospital, 2020). However, many other kinds of cancers can spread
or metastasize to the liver. The two primary types of liver cancer are
hepatoblastoma and hepatocellular carcinoma.
Signs and Symptoms

It is not uncommon for these symptoms to be present for months
before diagnosis.
■ The first sign of liver cancer is a mass in the abdomen discovered
by a family member or physician during a routine exam. It is
usually located in the upper right side of the abdomen.
■ Other symptoms the child might experience are a vague feeling of
abdominal fullness, pain, vomiting, diarrhea, fever, abnormal
weight loss, jaundice (yellow appearance of skin or sclera), or
general itching.
■ Occasionally, the liver may produce hormones that cause platelets
to increase and the child has a very high platelet count.
Diagnosis
X-ray, ultrasound, CT scan, and MRI are used to diagnose liver
cancer. These tests enable the physician to determine the severity
and metastasis. The most common areas of metastasis are to other
parts of the liver, the lungs, lymph nodes in the abdomen, and rarely,
to the brain or bones. Biopsy of the liver cells confirms the diagnosis.
Medical Care
Chemotherapy is used first to shrink the size of the tumor. The best
chance of curing liver cancer is surgical removal of the tumor. More
than three-fourths of the liver can be removed without any problems
because the liver can regenerate. Hepatoblastoma responds well to
chemotherapy, but hepatocellular carcinoma does not respond well
to any known chemotherapy.
Instruct parents that it is important to follow up with all laboratory
tests ordered by the health-care provider. Parents must monitor the
child for any pain and discomfort, as well as be taught
nonpharmacological comfort measures. Stress the importance of
follow-up appointments and clinic visits.
HOLISTIC NURSING CARE OF THE CHILD WITH

CANCER
Tailored holistic nursing care of the child with cancer is important to
their survival and overall well-being. After diagnosis and staging as
well as during ongoing treatment, a thorough nursing assessment is
crucial to maintain realistic optimal health and prevent complications.
The nurse assesses for signs and symptoms of infection and
bleeding. Additionally, the nurse monitors skin integrity (including
mucous membranes), heart, kidney, bowel, lungs, musculoskeletal,
and sensory function. Assessing the child’s nutritional and pain
status and evaluating the child’s ability to meet normal growth and
developmental milestones are also important.
There are several areas of nursing care for the child with cancer:
maintaining nutrition, preventing infection, administering
chemotherapy, addressing radiation side effects, understanding the
use of surgery, managing pain, offering psychosocial support,
managing negative and long-term effects of cancer treatments, and
preventing medical emergencies. Understanding the psychological
effect of pediatric cancer is also an important element of nursing
care.

The child with cancer experiences alterations or lags in growth and
development because of altered nutrition, fatigue, pain, social
isolation, and complications from the disease process requiring
frequent hospital admissions. Nursing care for the child with cancer
includes interventions to minimize the effects of the disease process
on the child’s growth and development.
Good nutrition is essential to maintain normal growth and
development. The child with cancer may experience insufficient
nutrition because of the inability to ingest enough calories to meet
the demands of the body and the disease process. The nurse should
encourage the child to eat small, frequent, high-calorie meals to
meet the body’s increased metabolic needs. The nurse should
promote good oral hygiene to prevent complications of
pharmacological therapies. Enteral and parenteral nutrition should
be implemented when needed. A nutritionist should be used to
identify appropriate resources for the child.
Normal activity supports self-esteem and self-knowledge, so the
nurse should encourage play while allowing adequate periods of rest
because the child with cancer may fatigue easily. Quiet activities
should be encouraged when the child has low levels of energy. The
nurse should frequently assess the child’s pain and implement
appropriate pain relief measures to encourage activity and play.
Peer contact and schoolwork promote cognitive and social growth
and development, so the nurse should encourage the child to attend
school or see/interact with peer (even remotely via online platforms)
to avoid social isolation. The nurse should work closely with teachers
and child life workers to identify schoolwork needs and support re-
entry to school when appropriate.

Survivors of Childhood Cancer
Two-thirds of children who do survive cancer face at least one chronic health
condition, and one-quarter of survivors face a late-effect from treatment that is
classified as severe or life-threatening (AACO, 2020). Late-effects of treatment
can include heart damage, secondary cancers, lung damage, infertility,
cognitive impairment, growth deficits, hearing loss, and more. Children are
being treated for cancer at a time of life characterized by rapid growth and
development. As such, their bodies and brains are at risk for significant late-
effects including both physical and cognitive disabilities, chronic health
conditions, and even subsequent battles with additional cancer. Therefore, it is
imperative that all survivors of childhood cancer receive ongoing monitoring
and continued physical and psychosocial care throughout their adult lives.
• Childhood cancer survivors should have their growth and development
monitored closely; if CNS involvement was part of their cancer treatment,
then regular neurocognitive testing should occur.
• Prepubertal girls should be closely monitored for signs of early onset puberty.
• Patients who have evidence of impaired fertility should be referred to a
specialist for ongoing assessment.
• Neck, spine, or brain radiotherapy may warrant ongoing thyroid function
observation.
• Follow-up appointments are important.
• Give patients written summaries about their diagnosis, treatment, and
possible late treatment side effects.
• A multidisciplinary team approach is important in the ongoing care of the
patient.
Nutrition
Good nutrition is essential for the child with cancer to promote
realistic optimal health and to maintain normal growth and
development (Fig. 26-10). For the child with cancer, the demands of
the illness and subsequent treatment can cause certain challenges,
including elevated nutritional needs because of the disease and the
effect of treatment. At the same time, all children already have higher
nutritional needs compared with adults for their normal growth and
development.
Parents frequently have anxiety about proper nutrition because the
child’s desire to eat and drink may fluctuate throughout treatment.
Some children are able to eat enough food to have strength and
energy to enjoy a normal level of activity; others are not. Poor
nutrition can lead to tiredness or irritability, greater susceptibility to
infections, and reduction of growth and developmental patterns.
FIGURE 26-10 Good nutrition is essential for the growing child to

maintain normal growth and development.
The side effects of cancer therapy (nausea and vomiting, mouth

sores, diarrhea, or constipation) can also make achieving adequate
nutrition a challenge. Chemotherapy and radiation may interfere with
the ability to chew and swallow. The child’s sense of taste may
change and their appetite may be poor.
A healthy immune system is a critical foundation of treatment.
Proper immune function is possible only if the child obtains enough
fluid intake and a high-calorie, well-balanced diet emphasizing
proteins, fatty acids, vitamins, and minerals. The nurse should offer
suggestions to maintain good nutrition (Box 26-1). Encourage a diet
that includes foods from all four food groups.
The nurse tries simple care measures first, such as offering small,
frequent feedings, allowing the child food choices, choosing
appealing food textures, and providing the child adequate time to
eat. If the patient is unable to maintain good nutritional status, the
nurse considers enteral tube feedings. If the gastrointestinal tract is
not functioning well, total parenteral nutrition (TPN) via the IV route
may be the only option. Communicate to the child and their parents
that tube feedings or TPN may be temporary and that they may be
able to eat independently again.
The Role of a Dietitian
Since most children with cancer are at risk for malnutrition, consultation with
the dietitian is essential to achieve the child’s best nutritional outcome. In
addition, research has shown that malnutrition has been proposed to increase
infection rates and reduce survival in pediatric cancer patients (BCH, 2019). If a
child is unable to eat or meet basic caloric requirements for growth and
development, the dietitian can recommend protein shakes and nutritional
supplements. The dietitian teaches the child and family what foods would be
best tolerated for certain conditions, like oral ulcerations or difficulty in
swallowing.
Infection
A priority nursing action is preventing infection. It is essential that the
nurse monitor for systemic and localized signs of infection every 2 to
4 hours (take the child’s temperature every 4 hours). Report a single
temperature greater than 101.2°F (38.5°C) in a 24-hour period or
100.4°F (38.0°C) three times in a 24-hour period.
The nurse provides meticulous skin care and maintains good hand
washing. Instruct visitors to wash hands on entering and leaving the
patient’s room. Universal precautions and designated isolation
precautions are instituted. Monitor and report laboratory values as
ordered, such as absolute granulocyte count, WBC count, complete
blood count with differential, serum protein, serum albumin, and
cultures. Encourage rest by providing a quiet environment. It is
important to teach the child and parents about the principles of
prophylactic antibiotics and about the signs and symptoms of
infection to promote the best possible health for the child.
BOX 26-1
Suggestions for Nutrition

NAUSEA/VOMITING
• Offer plain, bland foods, such as cereal, canned or fresh fruit, rice, pasta,
toast, mashed potatoes, soup, crackers, or plain meat.
• Avoid spicy, heavy, or fatty foods.
• If food smells bother the child, choose cold or room-temperature foods; use a
cup with a lid.
• Do not offer solid food and liquid at the same time because this can induce
nausea by making the child feel too full; give liquids 30 to 60 minutes after
solid food.
DIARRHEA
• Offer plenty of liquids.
• Try bananas, rice, applesauce, toast, or tea.
• Decrease the fiber in the diet.
CONSTIPATION
• Provide extra liquids; offer beverages that contain caffeine, like coffee, tea,
and cola.
• Increase fiber in the diet.
• Encourage the child to increase activity level.
POOR APPETITE
• Offer small amounts of food four or more times a day.
• Offer liquids between meals.
• Make every bite count by offering “power-packed foods.”
• Start with small portions and gradually increase them.
• Allow the child to have foods and beverages that they especially like.
SORE THROAT AND MOUTH
• Offer soft foods such as pudding, gelatin, macaroni and cheese, applesauce,
bananas, ice cream, Italian ice, and popsicles.
• Avoid acidic foods like oranges and tomatoes, spicy foods, or foods that
require a lot of chewing.
• Encourage good oral hygiene.
HEARTBURN OR REFLUX
• Do not give the child high-fat, spicy foods, caffeine, citrus juices, cinnamon,
peppermint, or pepper.
• Keep the child upright for at least 1 hour after eating.
DIFFICULTY CHEWING OR SWALLOWING/DRY MOUTH
• Give the child soft, moist foods.
• Encourage sips of liquids while eating.
• Avoid hard foods that require a lot of chewing.
• Cut the food into small pieces.
• Use extra butter, sauces, or gravies.
• Offer hard candy.
BELCHING, INTESTINAL GAS, OR CRAMPS
• Avoid gas-forming foods such as cabbage, broccoli, cauliflower, cucumbers,
beans, and carbonated beverages.
• Encourage the child to eat or drink slowly.
• Do not allow the child to chew gum.
Chemotherapy
Chemotherapy is the primary treatment modality for many pediatric
cancers. The nurse administers chemotherapy using a variety of
drugs to destroy or kill rapidly dividing cancer cells. The goal of
chemotherapy is to reduce the primary size of the tumor by
destroying cancer cells and to prevent those cells from spreading, or
metastasizing. Before administering chemotherapy, the nurse
reviews the patient’s medical record and interviews the patient and
family to determine past experience with chemotherapy, level of
tolerance, and antiemetics used. During the interview, the nurse
explains the current treatment plan, discusses each agent, reviews
potential side effects, and completes a medication reconciliation
process. The medication reconciliation process includes a review of
medications taken or discontinued since the last visit. Asking the
patient and family about medications reinforces an understanding of
the treatment plan or if the symptom management plan should be
adjusted. Because many chemotherapeutic agents are highly toxic,
the National Institute of Occupational Safety and Health has
developed standards to protect health-care workers when handling
or administering chemotherapy and caring for patients who have
received chemotherapy.
In addition to using PPE to administer chemotherapy, the nurse
should also be aware the administration of chemotherapy should be
through a central line (i.e., PICC line, Double or Triple Lumen
Broviac, or Port-a-Cath). In addition to chemotherapy (e.g.,
doxorubicin, daunorubicin, mitomycin C, vincristine, vinblastine, VP-
16, and dacarbazine), other common medications that cause
extravasation include TPN, hyperosmolar fluids, and Dilantin.
Chemotherapy destroys these rapidly dividing and mutating
cancer cells by interfering with cell division (Table 26-2). A variety of
venous access devices are available to administer chemotherapy
(Table 26-3).
TABLE 26-2
Chemotherapeutic Agents and Common Cancer Drugs
AGENT INDICATIONS ROUTE SIDE EFFECTS
asparaginase (Elspar, Acute lymphocytic IM and IV Seizures,
Kidrolase) leukemia (ALL) hyperglycemia
Classification: Nausea and
Antineoplastic vomiting, rashes,
Pharmacological coagulation
action: Enzyme abnormalities,
hepatotoxic,
pancreatitis,
anaphylaxis (have
emergency
medications
available)
bleomycin Hodgkin’s disease IM, IV, and SQ Pulmonary fibrosis
(Blenoxane) (HD), Pneumonitis,
Classification: osteosarcoma, hypotension,
Antineoplastic testicular nausea and
Pharmacological: embryonal cell vomiting, anorexia,
Antitumor antibiotics carcinoma hyperpigmentation,
rashes.
Anaphylaxis: fever,
chills
carboplatin Brain tumors, soft IV Ototoxicity, nausea
(Paraplatin, Paraplatin tissue sarcoma, and vomiting,
AQ) osteosarcoma, constipation,
Classification: retinoblastoma, diarrhea, stomatitis,
Antineoplastic neuroblastoma renal and liver
Pharmacological: toxicity,
Alkylating agent hypocalcemia,
hypokalemia,
hyponatremia,
hypomagnesemia,
anaphylactic-like
reactions
Corticosteroid ALL, non- PO, IV, and IT Immunosuppression
(Dexamethasone, Hodgkin’s Weight gain,
Decadron, lymphoma (NHL), hypertension,
Hydrocortisone, HD, cerebral anorexia, nausea
Prednisone) edema and vomiting, acne,
delayed wound
Classification: healing, hirsutism,
Corticosteroid petechiae,
Pharmacological: osteoporosis,
Systemic growth delay
corticosteroids, anti- Cushingoid
inflammatory appearance
cyclophosphamide NHL, HD, ALL, PO and IV Myelosuppression
(Cytoxan, Neosar, neuroblastoma, Nausea, vomiting,
Procytox) Wilms’ tumor, bone anorexia, diarrhea,
Classification: and soft tissue pulmonary and
Antineoplastic, sarcoma, myocardial fibrosis,
immunosuppressant retinoblastoma hemorrhagic
Pharmacological: cystitis, leukopenia,
Alkylating agent hematuria, alopecia,
sterility, SIADH,
may cause second
neoplasm
daunorubicin ALL, AML, IV Blistering,
(Daunomycin, osteosarcoma, soft myelosuppression.
Cerubidine) tissue sarcoma Cardiotoxic:
Classification: arrhythmias, acute
Antineoplastic cardiac myopathy-
Pharmacological: delayed, nausea
Anthracyclines and vomiting,
stomatitis,
potentiation of
radiation, alopecia,
rash,
hyperpigmentation
of nails
doxorubicin ALL, AML, IV Blistering, nausea
(Adriamycin, Adria, Osteosarcoma, soft and vomiting,
DOX, Rubex) tissue sarcoma, stomatitis,
Classification: neuroblastoma esophagitis,
Antineoplastic diarrhea, red urine,
Pharmacological: anemia,
Anthracyclines hypersensitivity
reaction, sterility.
Cardiotoxic:
arrhythmias, acute
cardiomyopathy—
delayed,
potentiation of
radiation,
hyperpigmentation
of nails, seizures,
hypertension,
edema, cough,
shortness of breath,
rash, thrombotic
events
epoetin/erythropoietin Anemia IV and SQ Pulmonary edema,
(Epogen, EPO, CHF, MI,
Procrit) hypotension,
Classification: nausea and
Biological response vomiting,
modifier anaphylaxis
Pharmacological:
Hormone
etoposide (VP-16, AML, ALL, NHL, IV Excessive
VePesid) HD, bone and soft leukocytosis, pain,
Classification: tissue sarcoma, and redness at
Antineoplastic Wilms’ tumor, brain subcutaneous site
Pharmacological: tumor,
Podophyllotoxin neuroblastoma,
derivative retinoblastoma
filgrastim (GCSF— Recovery drug for IV and SQ Medullary bone pain
granulocyte colony- neutropenia
stimulating factor)
(Neupogen)
Classification: Colony-
stimulating factor
Pharmacological:
Hematopoietic
progenitor mobilizer
fluorouracil (5-FU, Brain tumors, germ IV Myelosuppression,
Adrucil) cell tumors, nausea and
Classification: osteosarcoma, soft vomiting (mild),
Antineoplastic tissue sarcoma, mucositis (severe),
Pharmacological: NHL, ALL hyperpigmentation
Antimetabolite of nails, nail loss,
dermatitis,
phototoxicity,
myelosuppression,
nausea and
vomiting, diarrhea,
neurotoxicity
(encephalopathy,
hallucinations),
hepatotoxicity,
hemorrhagic
cystitis, alopecia,
sterility, may cause
second neoplasm
ifosfamide (Ifex) Stops methotrexate IV Allergic reactions:
Classification: from harming the rash, urticaria,
Antineoplastic cells when given in wheezing
Pharmacological: high doses
Alkylating agent
leucovorin Recovery drug to IV and PO Dose dependent on
(Citrovorum factor, prevent methotrexate level
folinic acid, hemorrhagic Given 24 hours after
Wellcovorin) cystitis from first methotrexate
Classification: Antidote ifosfamide and level has begun
(for methotrexate), cyclophosphamide
vitamins
Pharmacological: Folic
acid analog
mesna (Mesnex, Prevention of IV, PO, IM, and Dizziness,
Uromitexan) ifosfamide-induced IT drowsiness,
Classification: Antidote hemorrhagic headache, anorexia,
Pharmacological: cystitis diarrhea, nausea
Ifosfamide detoxifying and vomiting,
agent unpleasant taste,
flushing, flu-like
symptoms
methotrexate (MTX, ALL, IV Myelosuppression,
Amethopterin) osteosarcoma, nausea and
Classification: NHL vomiting, stomatitis,
Antineoplastic alopecia,
Immunosuppressant hepatotoxicity,
Pharmacological: neurotoxicity,
Antimetabolite photosensitivity,
rash, pulmonary
fibrosis, aplastic
anemia
ondansetron (Zofran) Prevention of IV and PO Headache, diarrhea,
Classification: nausea and constipation, dry
Antiemetic vomiting mouth,
Pharmacological: 5- associated with extrapyramidal
HT3 antagonist chemotherapy reactions
PEG-L-asparaginase ALL, HD IM and IV Seizures,
(pegaspargase) pancreatitis, lip
(Oncaspar) edema, headache,
Classification: nausea and
Antineoplastic vomiting, diarrhea,
Pharmacological: DIC, hemolytic
Enzymes anemia,
pancytopenia, chills,
night sweats
vincristine Wilms’ tumor, IV Altered LOC,
(Oncovorin, Vincasar Ewing’s sarcoma, blistering, peripheral
PFS) brain tumor neuropathy,
Classification: alopecia,
Antineoplastic constipation,
Pharmacological: Vinca SIADH, seizure,
alkaloids nausea and
vomiting
Note: IV, intravenous; IM, intramuscular; SQ, subcutaneous; PO, by mouth; IT,
intrathecal. Source:Vallerand & Sanoski (2021).
Negative Effects of Chemotherapy

Chemotherapy is toxic to the body because it kills not only cancer
cells but healthy cells as well. The exact extent and long-term
consequences of chemotherapy-induced damage in pediatric
cancers are unknown. Research has found that cisplatin treatment,
which is the common chemotherapeutic agent used to treat
osteosarcoma, can potentially double the mutational burden in
osteosarcoma. The nurse must recognize and provide proper
nursing care to promote the best health for the child during their
treatment.
Chemotherapy drugs must be handled carefully to avoid
extravasation, which is leaking of vesicants that can cause tissue
damage surrounding the IV or central line insertion site; blistering,
blanching, or excoriation may lead to ulceration and deep skin
sloughing. In rare cases, vesicants can cause cellulitis that turns into
a more severe infection. It is important to handle chemotherapy
agents safely. The nurse infusing these agents is specially trained
and certified in the administration of chemotherapy agents. Flushing
the line properly and ensuring a good blood flow can help prevent
extravasation.
Patient Education
How To: Teach the Family How to Recognize Signs and Symptoms of Infection
The family needs to understand that any of these signs and symptoms, or a
combination of them, must be reported to the physician immediately:
• Fever
• Decrease in temperature
• Runny nose (or other respiratory illness)
• Sore throat
• Childhood disease such as chickenpox
• Lethargy
• Pale or ashen color
• Chills
• Diaphoresis
• Poor appetite
• Poor fluid intake
• Nausea, vomiting, or diarrhea
• Decreased urination
• Foul smelling urine or pain or burning upon urination
Essential Information:
The rectal mucosa is very vascular and an area of potential injury or a source
of infection. Never take a rectal temperature or administer any rectal
suppository or an enema.
TABLE 26-3
Venous Access Devices
NAME DESCRIPTION ADVANTAGE NURSING CARE
Central implanted A saucer-shaped Decreased risk of Cleanse skin with
ports, such as plastic device with a infection. warm water and
Infuse-A-Port, self-sealing Placed under the soap prior to use.
Mediport, Port-A- injection port that skin, reducing the Administer topical
Cath, or Norport can be accessed chance of anesthetic such as
from the top or side. becoming EMLA (lidocaine
Requires placement dislodged or pulled and prilocaine)
in operating room. out. before accessing
Limited noticeability the port.
(small bump under Use a Huber
the skin). needle to access
Patency is the port.
maintained by Observe child
administering during medication
heparin after administration for
access. dislodgment of
Little maintenance needle.
or care; child can When treatment is
participate in complete, the port
regular activities. must be surgically
removed.
Central Groshong A silicone, flexible Easy for self- Weekly irrigation
catheter and clear catheter; administered with normal saline.
at the proximal end, medications and Parents can learn
there is a closed-tip fluids. catheter care (site
two-way valve. No heparin must be kept clean
Requires placement required. and dry).
in operating room. No clamping Teaching points
needed because of include: (1)
two-way valve. strenuous activity
Minimal backflow. and water sports
Decreases are restricted and
possibility of air (2) overall safety
embolism. because the
catheter protrudes
from body and may
be pulled out.
Offer support based
on body image
disturbance.
Central tunneled An open-ended Easy for self- Daily heparin
catheter such as silicone, flexible, administered flushes.
Broviac or Hickman radiopaque medications and Parents can learn
catheter. Requires fluids. catheter care (site
placement in Decreases risk of must be kept clean
operating room. infection. and dry).
When not in use,
must be clamped.
Teaching points
include: (1)
strenuous activity
and water sports
are restricted and
(2) general safety
precautions
because the
catheter protrudes
from body and may
be pulled out.
Peripherally Catheter made of Does not require Flushed with saline
inserted central Silastic or placement in using 5- to 10-mL
catheters polyurethane operating room. syringe.
material. Pediatric nurse Not suitable for
Single or double practitioners can rapid fluid
lumen available. insert the line using replacement (small-
Inserted into a small-lumen lumen needle).
antecubital fossa needle. Sometimes can be
passing through the Decreases risk of difficult to remove
cephalic or basilic infection. because of
vein entering the resistance.
superior vena cava.
Radiation
Radiation therapy uses ionizing radiation to break apart the bonds
within a cell, causing it to die. This treatment has evolved over the
years with respect to children. Today, with the use of CT and
magnetic resonance imaging scans, it is possible to deliver radiation
therapy more precisely to very specific, targeted areas. External
beam radiation accounts for the majority of radiation treatments in
children. The amount of radiation used is determined by the patient’s
age, tumor site, tumor size, tumor radiosensitivity, coexisting
disease, and the use of other treatment modalities. The lowest
effective dose of radiation is calculated and then delivered over a 3-
to 6-week period. Treatment lasts just a few minutes. It is important
for the child to remain still during treatment. Sometimes it may be
necessary to sedate the child (AACO, 2020). Radiation is used with
some hesitancy in children younger than 3 years of age because it
can cause severe damage to healthy cells and restrict growth and
fertility in the future. Nursing care includes measures that address
the side effects of radiation.
Radiation Side Effects

• Nausea
• Alopecia
• Fatigue and malaise
• Low WBC
• Skin desquamation
• Mucous membrane inflammation and irritation
Surgery
The child may have cancer-related medical conditions before
surgery; therefore, the nurse understands that care measures are
tailored to the child’s pre- and postoperative nursing diagnoses.
Before the development of chemotherapy and radiation, surgery was
the principal treatment of children with solid tumors. Now surgery is
used as an adjunct to both chemotherapy and radiation. Tumors are
usually treated with chemotherapy and radiation first to reduce the
size before surgical resection. The use of surgery varies widely
depending on the child’s diagnosis. Surgery is also an important role
in the diagnosis of a tumor via biopsy. The biopsy sample may be
obtained through a fine-needle aspiration or an open biopsy
procedure.
Pain Control
Controlling the child’s pain is an essential nursing intervention. Pain
associated with cancer can be acute or chronic. Four common types
of pain found in children with cancer are tumor-related pain,
impingement of tumor on nervous tissue, treatment-related pain, and
post-LP headaches. Postoperative pain is also a concern after tumor
resection, biopsy, amputation, or central line placement. The most
effective pain management strategies reported by children with
cancer are use of effective pain medications combined with
adequate rest and sleep, massage, heat, distraction, and social
support.
Assessing Pain
It is imperative to use the appropriate pain assessment tool. The
FLACC score for infants and young children, the Faces scale, and
the numbers scale are used when children are asked to rate their
pain.
Medications
■ Pain management: To manage the pain of cancer, the health-care
provider may start by ordering acetaminophen (Children’s Tylenol)
and progress to a nonsteroidal anti-inflammatory such as naproxen
or ibuprofen (Advil or Motrin) for children older than 6 months of
age. Nonsteroidal anti-inflammatory agents are contraindicated in
children with renal insufficiency or low platelet count.
■ If these pain medications are insufficient, opioids may be
administered orally, IV, IM, or by a patient-controlled anesthesia
device. Some are even available in a transcutaneous patch.
Opioids for moderate pain are codeine (codeine sulfate or Tylenol
with codeine). The opioid drug of choice is morphine (Duramorph)
because of its extensive clinical usage and current published data.
It is globally available and has controlled-release varieties. Doses
are titrated for maximal effectiveness. Fentanyl (Duragesic) is a
quick-acting opioid narcotic available in a transdermal patch.
Hydromorphone hydrochloride (Dilaudid) is another opioid that is
used to control pain. Methadone hydrochloride (Methadone) is
being explored as a drug for use in the pediatric population and
may offer an alternative to opioids.
■ Procedural pain may require the additional use of benzodiazepines
for sedation in addition to the pain medication. This class of drugs
has a fast-acting sedative effect that offers a “dissociative effect” in
which the child experiences an out-of-body-like experience that is
effective for minor procedural sedation. Propofol (Diprivan) is an
anesthetic agent used to reduce children’s anxiety. It can be
administered in intermittent bolus doses to provide adequate
sedation during painful procedures such as an LP.
FOCUS ON SAFETY
Ketamine Hydrochloride (Ketamine HCl) and Propofol (Diprivan)
Ketamine hydrochloride (Ketamine HCl) and propofol (Diprivan) are only to be
given by a medical provider with proper training in the use of anesthetic
agents. It is given in a controlled environment with adequate resuscitation
equipment available if needed. Nurses do not give either of these two agents.
Psychosocial Support
Psychosocial support is an essential part of holistic nursing care.
Encourage 24-hour stay with parents and other family members or
friends. Involve a child life specialist who can use therapeutic play or
encourage arts and crafts. Video games, computers, handheld
devices, or other technological equipment can be helpful when
offering psychosocial support. Encourage visits to the playroom (if
appropriate for the child’s condition) while the child is in the hospital.
Being present or simply listening can be powerful in the care of
children with cancer. The nurse can also provide the family with
community resources, reliable internet sources, and information
about support groups and local educational events (Fig. 26-11).
FOCUS ON SAFETY
Ataxia
Children with ataxia may have difficulty walking and are at risk for falling.
Ataxia can be a result of the therapy or disease process. It may also be a
result of certain medications. Be sure to evaluate the child’s ability to walk
safely. Evaluate the child’s fall risk using the Humpty Dumpty Scale (Fig. 26-
12) or other tools devised to assess the child’s fall risk. Some children may
need to use walkers or simply the assistance of an adult to walk. It is important
to involve physical therapy to optimize the child’s strength.
Nausea and Vomiting

Nausea and vomiting are major negative effects of chemotherapy,
and the nurse understands that the nausea may persist for weeks.
Acute nausea begins 2 to 3 hours after chemotherapy starts, peaks
at 4 to 10 hours, and lasts for 12 to 24 hours. Delayed nausea
begins 1 to 5 days after chemotherapy, peaks at 48 to 72 hours, and
is less severe than acute nausea. Anticipatory nausea is
psychological, and the nurse understands that it is important to
medicate the child if they complain about nausea.
FIGURE 26-11 Many communities and health systems sponsor

pediatric cancer awareness events.
It is also important for the nurse to be knowledgeable about

medications (antiemetics) that can prevent or lessen nausea and
vomiting in children (Fig. 26-13).
MEDICATION: Ondansetron (Zofran)
(on-dan-se-tron)
Classification: Antiemetic
Indications: Prevention of nausea and vomiting associated with chemotherapy
or radiation therapy
Action: Blocks the effects of serotonin receptor sites
Contraindications: Hypersensitivity
Adverse Reactions and Side Effects: CNS: headache, dizziness, drowsiness,
fatigue, weakness. GI: constipation, diarrhea, abdominal pain, dry mouth,
increased liver enzymes. Neuro: extrapyramidal reactions
Route and Dosage:
PO (ADULTS AND CHILDREN GREATER THAN 11 YR)
PREVENTION OF CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING: 8 mg 30
min prior to chemotherapy and repeated 8 hr later
PO (CHILDREN 4 TO 11 YR)
PREVENTION OF CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING: 4 mg 30
min prior to chemotherapy and repeated 4 and 8 hr later
IV (CHILDREN 6 MO TO 18 YR)
PREVENTION OF CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING: 0.15
mg/kg 15 to 30 min prior to chemotherapy and repeated 4 and 8 hr later
Assess patient for nausea, vomiting, abdominal distension, and bowel sounds
prior to and following administration.
Alopecia
Hair loss (alopecia) is another negative effect associated with cancer
treatment (Fig. 26-14). Not all children undergoing chemotherapy
lose their hair. When it does occur, it may be devastating to the child
and the family. Providing a wig or a hat and helping the child present
a positive body image and peer acceptance are crucial. There are
agencies that assist with providing the child with a wig.
What to Say
When a Child Asks “Will My Hair Grow Back?”
Children who start chemotherapy often have many questions, especially about
whether their hair will grow back. Children worry about their appearance to an
extent that depends on their age. The nurse explains that the hair will probably
start to fall out 10 days to 2 weeks after chemotherapy begins and that it may
fall out in sections. The nurse can assure the child that once the chemotherapy
has been completed, their hair will grow back. Try to make this experience as
positive as possible by emphasizing there are wigs available as well as head
wraps and “cool” hats and caps to cover the child’s head. Encourage the child
to speak with others their age who have been through this experience. It is
important for the nurse to emphasize the fact that just because their hair falls
out, it does not change the person the child is inside. The child is the same
person, who just looks a little different for a little while. The nurse can make this
a special event by arranging for a first “cool hat” purchase before the child
leaves the hospital.
FIGURE 26-12 Humpty Dumpty Fall Risk Scale.
FIGURE 26-13 It is important for the nurse to be knowledgeable of
medications (antiemetics) that can prevent or lessen nausea and
vomiting in children receiving chemotherapy.
FIGURE 26-14 Alopecia is a negative effect associated with cancer

treatment that can cause the child to feel self-conscious.
Mucositis
Mucositis is a diffuse inflammation of the mucosa of the mouth, a
change in the integrity of the mucous membranes characterized by
soreness, redness, and swelling. Lesions on the mucous
membranes allow bacteria to attach themselves to the affected areas
and are a source of localized and systemic infection. Mucositis is
caused by chemotherapy and radiation to the head and neck. It is
essential to keep the oral cavity clean by rinsing the mouth with a
solution (e.g., chlorhexidine oral [Peridex], sodium bicarbonate swish
and spit, Nystatin swish and swallow, a “magic mouthwash”
consisting of milk of magnesia and Carafate, or others [variable by
institution]).
Assessment Tools
Oral Assessment
It is important to inspect the oral cavity for problems related to cancer
treatment:
• Voice or cry (normal, deep, or raspy-harsh)
• Ability to swallow (normal, pain, difficult to swallow)
• Lips (smooth, pink, moist, dry, cracked, ulcers, or bleeding)
• Tongue (midline, pink, moist, reddened, patches, film, blisters, or swollen)
• Saliva (normal, excessive, thick or strands, absent or decreased)
• Mucous membranes (pink, moist, red, coated, patches, ulcers, bleeding)
• Gingiva (pink, firm, edema with or without redness, bleeding)
• Teeth (clean, plaque, debris, condition)
Diarrhea and Constipation

Diarrhea may occur with chemotherapy. Assess the rectal mucosa to
prevent infection. Gently cleaning the skin around the anus with a
soft cloth and warm water is important. Apply a barrier cream (such
as Desitin®) and allow the irritated skin to be exposed to open air as
much as possible. Have the child drink plenty of clear fluids (based
on 24-hour intake) and eat small amounts of soft, bland, low-fiber
foods such as bananas, rice, noodles, white bread, or skinned
chicken. Avoiding greasy, fatty, spicy, or fried foods, raw vegetables
and fruits, and whole-grain breads (cereals, nuts, and popcorn) can
help. It is also important to discourage gas-forming foods (beans,
cabbage, and carbonated beverages) and limit beverages with
caffeine. Communicate to parents that they can contact the health-
care provider about an over-the-counter medication for diarrhea such
as loperamide (Imodium) or a prescription medication like
diphenoxylate (Lomotil).
If the child becomes constipated, suggest foods high in fiber (fruits
and vegetables) and stress the importance of fluid intake. Normal
activity and playing, if approved by the health-care provider, can
help. Instruct parents to ask their health-care provider for
medications that will help with the constipation. The health-care
provider may prescribe docusate sodium (Colace) or bisacodyl
(Dulcolax).
Anemia
Anemia can also be acquired during chemotherapy. Bone marrow
suppression, nutritional deficiencies, and blood loss may all lead to
anemia below 8 g/dL. While the cancerous cells are being killed,
sometimes healthy cells such as RBCs are also killed.
Some signs of anemia are severe fatigue, headache, irritability, or
tachycardia. For children with mild anemia, the nurse can provide
supportive care guidelines for improving the anemia through diet or
vitamin supplementation. Children with moderate to severe anemia
may need an RBC transfusion to restore blood volume. For anemia
as a result of concomitantly administered chemotherapy, administer
hematopoietic growth factors such as epoetin alpha (Epogen) that
may prove beneficial in decreasing the need for blood transfusions.
Thrombocytopenia
Like RBCs, platelets can also be destroyed. Platelets are important
for the clotting of the blood. Thrombocytopenia is a decreased
number of platelets (less than 100,000 mcL). Thrombocytopenia
develops as a result of increased destruction, decreased production,
or loss of platelets. A platelet transfusion may be given if platelet
counts drop to less than 50,000 mcL, if the patient has spontaneous
bleeding, or if an invasive procedure is scheduled.
Neutropenia
Neutropenic children have few WBCs and often do not show signs of
infection, such as swelling, redness, or drainage. The only sign may
be fever. A fever in an oncology patient is 101.2°F (38.5°C) in a 24-
hour period or 100.4°F (38.0°C) three times in a 24-hour period.
Take only axillary or oral temperature.
Labs
Lab Values for Neutropenia
• A severe neutropenic patient has an absolute neutrophil count (ANC) less
than 500/mm3.
• An ANC greater than or equal to 500 to 1,000/mm3 is considered moderately
neutropenic.
• ANC greater than or equal to 1,000 to <1,500/mm3 is considered mildly
neutropenic.
• When a child undergoing chemotherapy develops a fever, it is considered an
emergency.
Diagnostic Tools
Calculating the Absolute Neutrophil Count (ANC)

Formula: (WBC × 10) × (Bands + Neutrophils)
Example: WBC = 8.8, Neutrophils = 82, Bands = 5
ANC = (8.8 × 10) × (82 + 5)
ANC = (88) × (87)
ANC = 7,656
Optimizing Outcomes
Neutropenic Precautions
IMPORTANT GUIDELINES TO TEACH PATIENTS AND FAMILIES:
• Notify your health-care provider if the child exhibits any of the following:
- Oral or axillary temperature is ≥38.5°C (101.3°F) or is 38°C (100.4° F) two
times within 24 hours
- Oral lesions
- Erythema at central venous access site
- Open skin lesions
- Perirectal laceration or irritation
- Cough
- Rhinorrhea
- Tachypnea
- Complaints of ear or throat pain
- Diarrhea
- Lethargy
• In addition, teach parents and families to perform meticulous hand washing.
• Do not take rectal temperatures or give suppositories (due to significant risk
of perforation).
• Avoid crowds and people who are sick.
• Do not share utensils with others.
• Do not let the child provide direct care to pets (e.g., the child should not
change kitty litter).
• Do not keep reptiles or birds as pets.
• The child and siblings should not receive live-virus vaccines.
• Avoid exposure to mold
Two sets of blood cultures are required for the neutropenic patient before the
start of antibiotics. Broad spectrum antibiotics are started empirically and
immediately following obtaining blood culture specimens. These are determined
by the health-care provider, such as ceftazidime (Fortaz), ampicillin (Unasyn),
gentamycin (Garamycin), or Vancomycin Hydrochloride (Vancomycin
Hydrochloride Injection) that treat both gram-positive and gram-negative
bacteria. These are started as soon as possible, no later than 1 hour after
admission. More specific antibiotics are administered once culture and
sensitivities are identified from the blood cultures. Monitor vital signs closely
when administering antibiotics because of the release of endotoxin that may
occur. Left unchecked, this condition may lead to septic shock. Filgrastim
(Neupogen) is an injection also used in a neutropenic patient to increase the
production of neutrophils. Neutrophils, a subtype of WBCs that make up
approximately 70% of WBCs, are important in maintaining the body’s ability to
fight infection.
Long-Term Effects of Cancer Treatments

Now that children with cancer are surviving longer, researchers are
just beginning to understand the long-term effects of cancer
treatments. Children undergoing cancer treatments are assessed for
acute effects at the time but also need follow-up care in adulthood to
assess for potential long-term effects. A child who has been in
remission for 5 years or who has been off cancer therapy for 2 years
is considered a long-term survivor.
High-tone hearing loss may be a side effect of cisplatin (Platinol).
Other chemotherapeutic agents can cause loss of speech,
impairment in depth perception, and increased response time, which
can be a problem for the adolescent who wishes to drive. Lung
problems can be caused by scarring of lung tissue or a reduction in
lung elasticity during breathing. Shortness of breath and a reduced
capacity to exercise can significantly affect the child. Kidney
problems include bleeding, damage to the tubules that affects
electrolyte exchange and salt balance, and protein wasting.
Musculoskeletal defects involving the bones or soft tissue and teeth
have been reported. Functional and/or mobility deficits may persist if
an amputation was performed. Hormonal abnormalities that are often
treatable may also exist. Cancer treatment can sometimes produce
sterility. Hearing, skin problems, and cardiac dysfunction are some of
the side effects that children may deal with later in life.
Children who had radiation to the brain may show growth
retardation, cognitive impairment, and/or learning disabilities.
Damage to the hypothalamus may cause an irreversible disorder
called diabetes insipidus. A type of nerve damage called peripheral
neuropathy can lead to decreased reflexes and weakness. The
thyroid gland is also sensitive to radiation and may pose problems
later in life.
MEDICAL EMERGENCIES
Because of an altered state of health, a child with cancer is prone to
conditions that may constitute a medical emergency including
accidents, infections, allergic reactions, and common childhood
diseases. If one or more of these conditions is negatively affecting
the child, the pediatric nurse must act quickly and notify the
physician or oncologist caring for the child to prevent a life-
threatening condition or further complications.
Hemorrhagic Cystitis
When caring for an oncology patient who is undergoing
chemotherapy, using certain chemotherapy agents such as
cyclophosphamide (Cytoxan) or ifosfamide (Ifex) can cause
hemorrhagic cystitis (bloody or painful urination). This is a medical
emergency that requires immediate medical attention. In addition,
radiation may also cause hemorrhagic cystitis.
Signs and Symptoms

Signs and symptoms in this condition can range from mild dysuria
(painful urination) with urinary frequency to severe hemorrhage
significant enough to damage the epithelial lining of the bladder.
Patients also have leukocytes, erythrocytes, and clots in the urine.
Diagnosis is based on the noted signs and symptoms.
Prevention
The best way to treat hemorrhagic cystitis is to prevent it with
adequate hydration before and during the administration of
chemotherapy.
Nursing Care
Be sure to test the urine for blood, pH, and specific gravity. The
specific gravity should be 1.012 or below. If it is not, a bolus of IV
fluid is required. If the urine is positive for blood, send an immediate
urinalysis sample to the lab and notify the physician immediately.
Monitoring of intake and output is vital as well as a daily blood urea
nitrogen (BUN) and creatinine. Mesna (Mesnex, Uromitexan) is a
drug given to prevent hemorrhagic cystitis by helping to protect the
lining of the bladder.
NURSING INSIGHT
Identifying Possible Cystitis
Look for signs of dysuria or hematuria, which may indicate possible cystitis,
especially hemorrhagic cystitis that will warrant a full work-up and prompt
medical attention.
Tumor Lysis Syndrome

Tumor lysis syndrome is a life-threatening condition that may
develop in children with cancer. Tumors with high growth rates, large
volume, or those that are widely disseminated as in Burkitt’s
lymphoma, lymphoblastic lymphoma, T cell, and ALL are associated
with this disorder. Tumor lysis syndrome may result from cell death
related to a chemotherapy agent or the malignancy itself. It is most
likely to occur during the first one to two rounds of chemotherapy,
when a large number of tumor cells lyse at once, causing all of the
intracellular components (like potassium [K+], DNA [made of uric
acids], and phosphates) to move extracellularly. This leads to
hyperkalemia, hyperuricemia, hyperphosphatemia, and
hypocalcemia (a result of the phosphates binding to calcium,
rendering it inactive).
Signs and Symptoms

Children develop lethargy, nausea and vomiting, oliguria, flank pain,
pruritus, tetany, and altered LOC. Renal failure can also occur.
Diagnosis
After the cell dies, there is a rapid (12 to 72 hours after treatment
starts) release of intracellular contents (metabolites) that leads to
hyperuricemia, hypocalcemia, hyperphosphatemia, and
hyperkalemia. An astute nursing assessment and immediate
laboratory results can help diagnose this condition.
Prevention
It is important to keep the urine alkalinized and maintain a low-
phosphate diet.
Nursing Care
Administration of allopurinol (Aloprim) to reduce uric acid formation
and promote excretion of by-products of purine metabolism is
essential. Maintaining adequate hydration is also paramount.
Monitoring electrolytes such as calcium, magnesium, phosphorus,
and potassium as well as kidney function with measurements such
as BUN and creatinine is very important. Sometimes dialysis or
exchange transfusions are necessary to decrease the metabolic
consequence that causes an even more severe effect on the child.
Septic Shock
The patient who is neutropenic and has a fever is at great risk for
septic shock. Septic shock happens in a child who is undergoing or
has just finished chemotherapy and/or radiation. The level of the
WBCs that fight infection and invading organisms is extremely low
(neutropenia).
Signs and Symptoms

It is important to remember that this septic shock response can occur
immediately or up to 48 to 72 hours after fever onset and symptom
development. Signs can include confusion, fever, increased
respirations (tachypnea), decreased urinary output, and cold,
clammy skin. The patient becomes pale, and the heart rate
increases in an attempt to compensate, and then suddenly the
patient’s blood pressure plummets (late sign). Laboratory studies
reveal acidosis and sometimes renal failure (Venes, 2021). Pediatric
patients compensate for shock by increasing the heart rate. When
that is no longer effective, the blood pressure falls rapidly.
Diagnosis
Vigilant monitoring of signs and symptoms by the nurse who is giving
antibiotics to a neutropenic patient is crucial in diagnosing this
condition.
Prevention
When the child is admitted to the hospital with a fever, they are given
an antibiotic regimen to cover both gram-positive and gram-negative
bacteria within a 1-hour window of arriving on the inpatient unit. As
the antibiotic destroys the cell wall of the bacteria, endotoxin is
released from the cell wall. This endotoxin starts a cascade and
overwhelms the compromised body’s ability to deal with the
endotoxin.
Nursing Care
An ongoing nursing assessment is essential because, by the time
the blood pressure drops, the situation is critical. For a child who is
neutropenic, admitted for a fever, and on antibiotics, the nurse must
take vital signs every 10 to 15 minutes during the antibiotic
administration to recognize signs of septic shock. Recognizing the
other signs is also crucial. Remember that a drop in blood pressure
is a late sign. Be ready to administer large amounts (1-L bags) of an
isotonic fluid such as normal saline (20 mL/kg) rapidly to prevent
circulatory collapse and possibly death. Be sure to check peripheral
pulses and capillary refill to monitor perfusion (whether the blood is
reaching the extremities). In an emergency, remember the
cardiopulmonary resuscitation (CABs) and other emergent care
measures:
Circulation
Airway
Breathing
Fluid resuscitation
Evaluation of etiology (complete blood count, electrolytes,
disseminated intravascular coagulation panel, blood cultures,
and liver and renal functions)
Blood products
Antibiotics
Vasopressors
PROCEDURE ■ Checking Urine Specific
Gravity (Fig. 26-15)
PURPOSE
The purpose of checking the specific gravity of urine is to measure the
concentration of the particles in the urine (Box 26-2).
EQUIPMENT
• Refractometer
• 3- or 5-mL syringe (needleless)
STEPS
1. Have the child urinate into a urine collection receptacle.
RATIONALE: Collecting the urine in a nonsterile container is necessary to
conduct the specific gravity test.
2. Using a 3- or 5-mL syringe, draw up 0.5 mL of urine into the syringe.
3. Place the syringe into a universal precaution container.
RATIONALE: Promotes a safe environment.
4. Take the urine specimen to the testing area.
RATIONALE: A specific testing area promotes a safe environment.
5. Open the refractometer.
6. Place 1 drop of urine in the center of the square opening.
7. Close the lid.
8. Look through the focused eyepiece to see the horizontal line clearly.
RATIONALE: Ensures accurate measurement of specific gravity.
9. Note where the blue horizontal line crosses the markings (see picture).
RATIONALE: The blue horizontal line that crosses the markings is the
specific gravity reading.
FIGURE 26-15 Urine specific gravity.
CLINICAL ALERT
If the institution does not have a refractometer, it is acceptable to use a urine
dipstick, with the realization that this is not as detailed. The specific gravity
markings on a urine dipstick are in increments of 0.005. On a refractometer, the
markings are in increments of 0.001.
TEACH PARENTS
The nurse can teach the parents about the purpose of a specific gravity
measurement.
DOCUMENTATION
Specific gravity done at 1300 h. Specific gravity 1.010. —M. Godshall, RN
BOX 26-2
Checking Urine Specific Gravity

SPECIFIC GRAVITY
• Check urine specific gravity for patients receiving Cytoxan, ifosfamide,
cisplatin, high-dose carboplatin, or high-dose methotrexate.
• Specific gravity must be 1.012 or below before the start of chemotherapy and
then for at least 24 hours after its completion.
• If at any time the specific gravity rises above 1.012, the patient should receive
a fluid bolus (extra fluid). DO NOT turn off the main IV. The bolus is in addition
to the main IV fluids.
• If giving more than two or three fluid boluses, notify the oncologist on call.
URINE pH
• Monitor when the patient is receiving methotrexate.
• Urine pH must be higher than 7.0 before starting methotrexate and must be
maintained at that level until the methotrexate serum blood level is <0.1
mg/dL.
• Before receiving high-dose methotrexate, patients are hydrated with IV fluids
of D5 1/4 with 40 mEq/L of NaHCO3. The NaHCO3 is needed to keep the
urine alkalinized.
Other Emergencies
■ Superior vena cava syndrome—obstruction or thrombus in the
superior vena cava
■ Superior mediastinum syndrome—tracheal compression
■ Pericardial effusion—fluid in the pericardial cavity, between the
visceral and the parietal pericardium, and may produce symptoms
of cardiac tamponade such as difficulty in breathing (Venes, 2021)
■ Pleural effusion—fluid in the thoracic cavity between the visceral
and parietal pleura, which may be seen on a chest radiograph if
the fluid exceeds 300 mL (Venes, 2021)
■ Abdominal emergencies—esophagitis, gastric hemorrhage,
perirectal abscess, hemorrhagic pancreatitis, massive acute
hepatomegaly, bowel obstruction
■ Neurological conditions—stroke, seizure, spinal cord compression
■ Shock—hypovolemic, cardiogenic, distributive
■ Hyperleukocytosis—WBC count greater than 100,000/mm3
THE PSYCHOLOGICAL EFFECT OF PEDIATRIC

CANCER
The psychological effect that cancer has on the entire family is
enormous. The feelings of shock, denial, confusion, and fear strike
everyone. Families may feel someone or something is to blame for
their child’s illness. The feeling of having absolutely no control over
any part of the situation adds to the stress. Emotions of any kind
during this situation are normal because everyone reacts differently.
Sometimes one of the best sources of support for the parents is
other parents who have also had a child with cancer. Encourage
families to develop support systems whether they are family, friends,
or others in the community or who share similar experiences.
Many parents maintain a bedside vigil, which is understandable
because they want to be there for their child. Because this can be
very wearing and tiring (Fig. 26-16), the nurse can communicate to
the parents that it is important that they get adequate rest and
nutrition to avoid becoming sick themselves.
Depending on the child’s age and level of understanding, it is
important for the parents and health-care team to be honest with the
child. A multidisciplinary approach is necessary, and the goal of the
team is to communicate enough information so that the child can
make sense of the situation without becoming overwhelmed.
Information must be tailored to each child’s developmental stage.
The nurse must keep the lines of communication open.
Families may ask questions such as, “Why did this happen?” “Why
does my child suffer?” “What did I do wrong?” These are normal
feelings for families when a child is diagnosed with cancer. It is
important to offer spiritual support when the child and family are
ready. The child may feel a sense of spirituality through the nurse.
The nurse can ask the hospital chaplain or faith community nurse to
visit on a regular basis, use prayer or meditation if requested, or read
from a spiritual or inspirational text. Be sure to allow the child and
family quiet time during the day to be alone and meditate if they
choose.
Help the child and family express their feelings. Being present and
giving reassurance that they are not being punished is important.
Through the nurse’s care, the child will know that they are loved.
Many parents tell the nurse how they were touched deeply knowing
that the nurse really cared for their child (Fig. 26-17).
What to Say
Siblings of an Ill Child
While children with cancer are undergoing many stressful events, a pediatric
nurse must not forget about the sibling(s) of the children with cancer. Visiting a
sick sibling is stressful for both the ill child and the sibling. The nurse can help
make the sibling’s day special by telling them a story or giving them a sticker or
a coloring book and crayons. Encourage the ill child to color a picture for their
sibling and hang it in the room. A sincere demeanor and common pleasantries,
such as saying hello or calling the sibling by name, can make the visit special
and less stressful.
FIGURE 26-16 Many parents maintain a bedside vigil to support

their child during treatment for cancer.
FIGURE 26-17 Through the nurse’s care the child will know that
they are loved.
SUMMARY POINTS
■ Cancer is a group of diseases causing out-of-control growth and spread of
abnormal cells known as anaplasia (loss of the normal pattern of growth of
cells).
■ In children, many common malignancies arise from primitive embryonic tissue
in which there has been a strong environmental link related to the
development of cancer.
■ Acute leukemia is a rapidly progressing disease that affects mostly immature,
undifferentiated cells. Chronic leukemia is a less rapidly progressing disease
allowing for the production of mature, more differentiated cells.
■ The most common types of solid tumors in children include brain tumors,
neuroblastoma, rhabdomyosarcoma, retinoblastoma, and nephroblastoma
(Wilms’ tumor).
■ The two most common bone tumors are osteogenic sarcoma and Ewing’s
sarcoma.
■ Lymphoma is a malignancy that arises from the lymphatic system. Two types
of lymphomas are seen in children: Hodgkin’s disease (HD) and non-
Hodgkin’s lymphoma (NHL).
■ Liver and extragonadal germ cell cancer are other types of cancer seen in
children.
■ Nursing care for a child with cancer includes maintaining nutrition, preventing
infection, administering chemotherapy, addressing radiation side effects,
understanding the use of surgery and related nursing diagnoses, controlling
pain, offering psychosocial support, managing negative and long-term effects
of cancer treatments, and preventing medical emergencies.
■ Understanding the psychological effect of pediatric cancer is also an important
element of care.
REFERENCES
American Cancer Society. (2020). How is neuroblastoma staged? Retrieved from
http://www.cancer.org/cancer/neuroblastoma/detailedguide/neuroblastoma-
staging
American Cancer Society. (2019a). Wilms’ tumor. Retrieved from
https://www.cancer.org/cancer/wilms-tumor/treating/chemotherapy.html
American Cancer Society. (2019b). Rhabdomyosarcoma. Retrieved from
http://www.cancer.org/cancer/rhabdomyosarcoma/detailedguide/rhabdomyosar
coma-what-is-rhabdomyosarcoma.
American Childhood Cancer Organization (AACO). (2020). Statistics on Childhood
Cancer. Retrieved from https://www.acco.org/us-childhood-cancer-statistics/.
Bosshard, R., O’Reilly, K., Ralston, S., Chadda, S., Cork, D. (2018). Systematic
reviews of economic burden and health-related quality of life in patients with
acute myeloid leukemia. Cancer Treat. Rev. 69: 224–232. doi:
10.1016/j.ctrv.2018.07.005
Boston Children’s Hospital. (2019). Neuroblastoma treatment and diagnosis in
children. Retrieved from
http://www.danafarberbostonchildrens.org/conditions/solidtumors/neuroblastom
a.
Burkit and Burkit Lymphoma. (2020). Retrieved from
https://www.cancer.org/cancer/childhood-non-hodgkin-lymphoma/detection-
diagnosis-staging/survival-rates.html
Caldwell, B. T., Wilcox, D. T., & Cost, N. G. (2017). Current management for
pediatric urologic oncology. Advanced Pediatrics;64(1):191–223.
Children’s Hospital of Philadelphia (CHOP). (2019). Pediatric leukemias: Diagnosis
and treatment. Retrieved from http://www.chop.edu/service/oncology/cancers-
explained/leukemia-diagnosis-and-treatment.html
Children’s Oncology Group. (2020). Philadelphia Chromosome Positive ALL.
Retrieved from http://www.childrensoncologygroup.org/index.php/patients-and-
families
Dupuis, L. L., Lu, X., Mitchell, H. R., Sung, L., Devidas, M., Mattano, L. A., Jr., et
al. (2016) Anxiety, pain, and nausea during the treatment of standard-risk
childhood acute lymphoblastic leukemia: A prospective, longitudinal study from
the Children’s Oncology Group. Cancer122(7):1116–25.
Houshmand, M., Simonetti, G., Circosta, P. et al. (2019). Chronic myeloid leukemia
stem cells. Leukemia 33: 1543–1556. https://doi.org/10.1038/s41375-019-
0490-0
Misaghi, A., Goldin, A., Awad, M., & Kulidjian, A. A. (2018). Osteosarcoma: A
comprehensive review. SICOT-J 4(12). doi:10.1051/sicotj/2017028
Memorial Sloan Kettering Cancer Center. (2019). Pediatric cancer care: Ewing’s
sarcoma. Retrieved from http://www.mskcc.org/pediatrics/childhood/ewing-
sarcoma
Patel, S., Lupo, M., A., & Nembhard, N. (2020). Cancer riskby attained age among
children with birth defects in Arkansas, Cancer Epidemiology 68:101796. ISSN
1877-7821. https://doi.org/10.1016/j.canep.2020.101796.
(http://www.sciencedirect.com/science/article/pii/S1877782120301302)
Pappo, A., & Dirksen, U. (2019). Current management of neuroblastoma and
future direction. Critical Review of Oncology Hematology 138:38–a43
Shanbhag, S., & Ambinder, R. F. (2018). Hodgkin lymphoma: A review and update
on recent progress. CA: A Cancer Journal for Clinicians 68(2), 116–132.
doi:10.3322/caac.21438
St. Jude Children’s Research Hospital. (2019). Five-year cancer survival rates:
1962 vs. present. Retrieved from http://www.stjude.org/stjude/v/index.jsp?
vgnextoid=5b25e64c5b470110VgnVCM1000001e0215acRCRD

Davis Advantage
CHAPTER 27
Caring for the Child With a Chronic

Condition, Disability, or End-of-
Life Care
CONCEPTS
Comfort
Empathy
Family
Chronic illness
Grief and loss
Nursing roles
KEY WORDS
chronic condition
developmental disabilities
Denver Developmental Screening Test (DDST)
diagnostic tool
technology-dependent
regression
patient-centered medical home model (PCMH)
caregiver burden
chronic sorrow
palliative care
hospice care
end-of-life care
pathological grief
bereavement team
burnout
compassion fatigue syndrome
moral distress
LEARNING OBJECTIVES

■ Describe chronic conditions and key terms related to chronic conditions.
■ Describe common disabilities that affect children by body system.
■ Describe the process of end-of-life care for a child.
■ Prioritize developmentally appropriate and holistic nursing care for various
chronic conditions.
■ Explore the effect of chronic illnesses and disabilities on the child and family.
■ Develop teaching plans and discharge criteria for the family of the child with a
chronic condition or disability.
■ Develop an understanding of how to support the family’s coping methods in
end-of-life care.
PICO(T) Questions
chapter.
1. Do (P) siblings of children with chronic conditions demonstrate (O) a higher
incidence of (I) behavioral issues than (C) sibling of children without chronic
conditions?
2. What (I) nursing interventions are beneficial in (O) helping relieve caregiver
burden in (P) parents of children with chronic conditions?
INTRODUCTION
A chronic condition is a health situation that persists over time,
usually longer than 3 months, or one in which recovery progresses
slowly. Chronic diseases are defined broadly as conditions that last 1
year or more and require ongoing medical attention, limit activities of
daily living, or both (Andes et al, 2019). This physical, psychological,
or cognitive impairment places limitations on the child’s daily
activities and requires ongoing care. The condition may require that
the child and family rely on assistance from other caregivers in the
hospital or community settings to carry out the activities of daily
living. A chronic condition can be a congenital defect, a problem that
occurs during fetal development, or can be acquired sometime
during the child’s life as a result of an illness, accident, or injury.
PREVALENCE OF CHRONIC CONDITIONS

According to the World Health Organization, young people today will
live less healthy lives than their parents, in part because of higher
rates and earlier onset of chronic diseases (Mayer-Davis et al,
2017). Current evidence in the United States suggests that chronic
disease among young people is a growing problem; however,
prevalence of chronic diseases in this population is generally
understudied (Raghupathi & Raghupathi, 2018). It is estimated that
1% to 3% of American children have hypertension, and stroke is
among the top 10 causes of childhood death (CDC, 2020). One in
five U.S. children has obesity, and the prevalence of type 2 diabetes
is projected to quadruple on a national level from 22,820 in 2010 to
84,131 in 2050 among people younger than 20 years (Andes et al,
2019). The consequences of a childhood diagnosis with certain
chronic conditions are serious; for example, one of five U.S.
adolescents is prediabetic. Engaging in healthy behaviors early
greatly reduces the risk for illness and death due to chronic diseases
(Box 27-1).
Developmental disabilities begin anytime during the
developmental period and usually last throughout a person’s lifetime.
Most developmental disabilities begin before a baby is born, but
some can happen after birth because of injury, infection, or other
factors. Developmental disabilities are conditions resulting from an
impairment in physical, learning, language, or behavior areas. These
conditions begin during the developmental period, may affect day-to-
day functioning, and usually last throughout a person’s lifetime
(CDC, 2020).
Most developmental disabilities are thought to be caused by a
complex mix of factors. These include genetics; parental health and
behaviors (such as smoking and drinking) during pregnancy;
complications during birth; infections the mother might have during
pregnancy or the baby might have very early in life; and exposure of
the mother or child to high levels of environmental toxins, such as
lead (CDC, 2020).
The following are some examples of what we know about specific
developmental disabilities (CDC, 2020):
■ At least 25% of hearing loss among babies is due to maternal
infections during pregnancy, such as cytomegalovirus (CMV)
infection; complications after birth; and head trauma.
■ Some of the most common known causes of intellectual disability
include fetal alcohol syndrome; genetic and chromosomal
conditions, such as Down’s syndrome and fragile X syndrome; and
certain infections during pregnancy.
■ Children who have a sibling with autism are at a higher risk of also
having autism spectrum disorder.
■ Low birthweight, premature birth, multiple birth, and infections
during pregnancy are associated with an increased risk for many
developmental disabilities.
■ Untreated newborn jaundice (high levels of bilirubin in the blood
during the first few days after birth) can cause a type of brain
damage known as kernicterus. Children with kernicterus are more
likely to have cerebral palsy, hearing and vision problems, and
problems with their teeth. Early detection and treatment of
newborn jaundice can prevent kernicterus.
About one in six children in the U.S. have one or more
developmental disabilities or other developmental delays (CDC,
2020). It is important for early screening and detection of any
developmental disabilities or delays as early intervention (ages 0–3
years of age) has shown to improve outcomes.
BOX 27-1
Examples of Chronic Conditions in Children by

Body System
Neurologic: Cerebral palsy, a seizure disorder, or post-infant meningitis
sequela
Cardiac: Congenital heart disease, defects, or acquired heart disease
Pulmonary: Cystic fibrosis, bronchopulmonary dysplasia, asthma, airway
stenosis, tracheomalacia, or restrictive lung diseases
Musculoskeletal: Muscular dystrophy, skeletal malformations, spinal
muscular atrophy, mitochondrial disease, central congenital hypoventilation
syndrome, spinal cord injury, or post-severe brain injury
Gastrointestinal: Kidneys (renal failure), acquired or chronic liver
dysfunction (biliary atresia, cirrhosis), or intestine (short bowel syndrome)
Integumentary: Eczema, dermatitis, or conditions such as Lyme disease
that can cause chronic arthritis
Psychological: Depression, bipolar disorder, autism spectrum disorders,
attention deficit disorder, attention-deficit hyperactivity disorder
Cognitive: Down’s syndrome, developmental or learning disabilities
Conditions such as diabetes, cancer, and HIV are considered chronic. The
condition may also have been acquired through an acute medical condition
such as an infection or from a trauma such as near-drowning, motor vehicle
crash, traumatic brain injury, or abusive head trauma.
Labs
Monitoring Preventive Care
Lab tests are often used in the pediatric setting to monitor preventive care.
For example, a blood lead test is the best available way to measure exposure
to lead. Several laboratory analytical methods can detect lead in blood. The
nurse should be familiar with the various lab tests in pediatric primary care.
Whatever the reason for the chronic condition, the child and family
must manage its health consequences throughout the child’s life.
The effect of and adaptation to the condition depend on its severity,
the age at which the insult occurred, the overall effect on the growth
and developmental aspects, and the child’s and family’s responses
to the condition (Fig. 27-1).
Diagnostic Tools
Denver Developmental Screening Tool
Screening tools such as the Denver Developmental Screening Tool are
important for a nurse to utilize in the primary care setting. The Denver
Developmental Screening Test (DDST) is a widely used assessment for
examining children 0–6 years of age as to their developmental progress.
FIGURE 27-1 Some children who have a chronic condition require
an adaptive device to help with mobility.
CHRONIC CONDITIONS AND TECHNOLOGY

In the United States today, the increase in chronic conditions may be
partially attributed to technological life-saving and life-sustaining
measures or technological devices that can now diagnose and treat
diseases that previously were either undiagnosed or untreatable. For
example, the use of a refined diagnostic tool such as a 4D
ultrasound has enabled health-care providers to find developmental
problems while the infant is still in the mother’s womb. Once the
condition is diagnosed, health-care professionals can begin to
develop a plan of care. The child who is born prematurely benefits
from medical technology, such as a ventilator, that enables the infant
to live. While technology has many benefits and has enabled some
children to live, it can also cause them to be dependent on
technology for survival. Technology-dependent means the child is
reliant on some type of medical device to compensate for the loss of
normal use of a vital body function.
The Technology Related Assistance for Individuals With Disabilities Act
In 1988, Congress passed the Technology Related Assistance for Individuals
with Disabilities Act (P.L. 103–218). This act was reauthorized in 1994, and in
1998 Congress enacted the Assistive Technology Act (P.L. 105–394),
commonly known as the “Tech Act.” The Tech Act program is administered by
the National Institute on Disability and Rehabilitation Research and the Office
of Special Education and Rehabilitative Services of the U.S. Department of
Education. Its main goal is to examine barriers for children and adults who
need to access and obtain assistive technology (AT). Assistive technology can
enable individuals to participate in and contribute more fully to activities of their
family, school, and community. Assistive technology devices are used to
increase, maintain, or improve functional capabilities of individuals with
disabilities. This includes ventilators for technology-dependent individuals.
Today, funding authorized by the Tech Act supports three programs: (1) AT,
state grant programs in 56 states and territories; (2) the Protection and
Advocacy for Assistive Technology program in 56 states and territories; and (3)
four national technical assistance programs. Thirty-two of the state-assistive
technology programs operate federal/state partnership alternative financing
programs as described in President Bush’s New Freedom Initiative. The Tech
Act programs have been a major force in helping children and adults with
disabilities live more productively and independently (Mayer-Davis et al, 2017).
EFFECT OF A CHRONIC CONDITION

A chronic condition affects the family and child differently depending
on the age at diagnosis. It can create a threat of the unknown, loss
of control, and can have long-term effects yet to be discovered.
Depending on the degree of illness, the child may require frequent
hospitalizations or clinic visits, which can create stress because
normal home routines are disrupted. In addition, more demands are
placed on the caregivers, who must balance time between the sick
child in the hospital and other responsibilities such as caring for
other children and maintaining employment. An overwhelming lack of
control can cause stress and may lead some parents to become
controlling, overpowering, over-protective, and unable to function in
a healthy manner. The family experiences social, financial, physical,
and psychological strain as a result of the chronically ill child. The
child also has to learn to cope with the condition including related
medical experiences and unfamiliar people and places. The child
can feel overwhelmed and unable to deal with the situation
depending on age, coping mechanisms, and situation.

The child with a chronic condition is faced with many challenges in daily life,
often with wide-ranging effects on health and well-being. They are more likely
to experience frequent doctor and hospital visits, may feel different than other
children, and may have limited activity because of the nature of the chronic
condition or adaptive devices needed. As a result of these challenges, children
with a chronic condition may also experience other cognitive, behavioral, or
emotional problems such as developmental delays, anxiety, and depression.
The nurse caring for the child with a chronic condition must foster healthy
growth and development by promoting independence as a vital component.
The nurse should encourage the parents to prevent the child from becoming
dependent on them for activities of daily living. The child should be allowed to
make choices and participate in self-care activities to increase the sense of
control and independence. Keeping the child involved with peers is important to
foster bonds and social interaction. Friends can help create a sense of
belonging and provide a means for coping.
The nurse should educate the child and family about healthy coping
mechanisms such as listening, gaining knowledge about the disease process,
and emphasizing the child’s strengths. Care should be provided to the family
caring for a child with a chronic illness. Parents may experience increased
financial strain from missing days of work or having to stay home to be a
caretaker to the child with a chronic illness. In addition, caretaker strain from
the emotional and/or physical strain of caring for a child with a chronic illness
should also be considered.
The child with a chronic condition or disability may experience negative
physical growth (growth failure) and developmental aspects. General growth
failure means that the child grows more slowly and that the height and weight
are in a lower percentile on the growth charts than for children of the same age.
It may result from the condition itself or from related treatments and
medications. Conditions such as cystic fibrosis or end-stage renal disease may
significantly alter the growth process.
The pathophysiology of the condition may also affect the child’s growth. For
example, if the child has a severe hypoxia problem, the tissues may simply not
receive the needed oxygen required to promote normal growth. Treatment
measures associated with chemotherapeutic agents may hinder growth or
damage usual organ functioning.
The child with altered growth may be delayed developmentally. The child
may achieve developmental milestones much later than peers or not at all. The
nurse must be aware that the parents may positively or negatively affect the
child’s development. For example, a parent, teacher, or guardian who is fearful
of consequences of a child’s condition may unduly restrict a child’s opportunity
for interaction and subsequently hinder development (e.g., parents of a child
with autism do not allow them to play with peers). Conversely, some parents
can embrace the child’s condition and help the child attain the most realistic
potential. The child’s personality, temperament, and motivation may help or
hinder developmental attainment.
An important nursing care measure related to growth is carefully plotting their
growth using charts from the National Center for Health Statistics (NCHS).
When a child is unable to take adequate nutrition by mouth, an alternate
feeding method is used to maintain and promote growth in the child. The type
of feeding method selected depends on the child’s medical condition.
The nurse can encourage parents to maintain realistic developmental
milestones. Helping the child interact with children of their own age (when
possible) and creating a social network consisting of family, friends, and others
in the community can help maintain development. Finding appropriate social
activities also positively affects the child’s development.
Effect of a Chronic Condition on the Infant

In infancy, the developmental task is to achieve an emotional
attachment or a bond with the primary caregiver. A prolonged
hospital stay for the infant in the neonatal intensive care unit
requiring extensive medical care affects the natural formation of the
parent-child bond.
NURSING CARE
Priority nursing interventions for the infant or child with a chronic
condition include rocking, holding, comforting, and using a soothing
voice. It is also important to provide visual and auditory stimulation
when one-on-one interaction is not possible. Brightly colored
mobiles, calming music, and low lighting also provide stimulation.
Group nursing care measures to minimize interruptions of nap and
sleep time because rest is important in the recovery and healing
process. The crib or patient’s room is maintained as a safe place
where no invasive procedures are performed. Drawing blood,
starting IVs, and other invasive procedures are done in a designated
treatment room. Anesthetic or analgesics are provided to minimize
any pain and discomfort. The nurse encourages parents to hold the
infant whenever possible, regardless of the amount of medical
equipment attached to the infant (Fig. 27-2). Siblings can visit and
participate in simple caretaking measures or create pictures to
display in the room to help them feel part of the chronically ill child’s
care.
CASE STUDY
An Infant With a Chronic Condition

Shelly developed HELLP syndrome at 23 weeks’ gestation with twins. This
condition, characterized by hemolysis, elevated liver enzymes, and low platelets
that signify pre-eclampsia, caused Shelly to experience premature labor. The
birth was further complicated when the first baby died from a heart defect and
the second baby experienced significant medical complications. The living infant
was placed on a ventilator and subsequently developed bronchopulmonary
dysplasia, a chronic lung condition.
After 3 months in the NICU, the infant was transferred to a rehabilitation
facility closer to home. As the days turned into months, the infant developed
other conditions such as sepsis and pneumonia; she also had one episode of
cardiopulmonary arrest. With the decline in health, nurses at the rehabilitation
faculty felt that the nursing care was no longer helpful and the child should be
allowed to die. As time progressed, the infant’s condition continued to
deteriorate, and during this time she received extreme care measures that
included oscillatory ventilation, numerous medications, and painfully invasive
procedures. The parents voiced that everything possible should still be done for
the infant. Later, the infant died at the rehabilitation facility at the age of 14
months.
1. The infant had several chronic conditions. How can the care given to the
infant be viewed by the nurse?
2. What are extreme care measures?
3. Does the nurse suffer?
4. What if the nurse’s beliefs about care differ from those beliefs of the
institution?
PROCEDURE ■ The Effect of Pain

Painful procedures can affect the infant’s long-term overall condition. These
hospitalized experiences often disrupt normal growth and developmental
milestones.
Effect of a Chronic Condition on the Toddler

The toddler’s main developmental task is initiating autonomy or self-
control, which is jeopardized by the effects of a chronic health
condition. The most frightening aspects of illness and hospitalization
for the toddler are pain, anxiety, and separation from parents.
The child’s chronic condition can hinder speech, gross motor
development, and fine motor development; appropriate speech,
physical, and/or occupational therapy is provided. Frequent or
repeated hospitalizations cause the toddler stress; however, the
toddler has a tremendous capacity to withstand this stress when the
relationship (attachment) to the parents or caregiver is maintained.
The nurse encourages parents to stay with the child by giving them
24-hour unlimited visitation and proper sleeping accommodations. If
a parent is unable to stay with the toddler, encourage them to
designate another family member, such as a grandparent, to remain
at the hospital. This measure provides both safety and security to the
toddler. The most common coping method employed by the
chronically ill toddler is regression. Tell the family that regression can
be expected and will subside in time after returning home.
FIGURE 27-2 It is important for parents to hold and care for their
chronically ill child.
NURSING INSIGHT
Regression
Regression is an abnormal return to an earlier reaction, characterized by
emotions or behaviors that are inappropriate for the current age and may
include the loss of recently acquired skills (Venes, 2021). Regression can be
both physical and emotional. For example, physical regression occurs when a
toddler refuses to continue bowel or bladder training. Regression can be
considered emotional when a child refuses to talk, withdraws, or becomes
easily irritated.
NURSING CARE
Priority nursing interventions for the toddler with a chronic
condition include maintaining the bond between the parents and
child, promoting realistic developmental skills, and not reacting
negatively to regression. Praise the child for all attempts at self-care.
The nurse also gives parents instructions about realistic methods of
discipline. Parents may be reluctant to enforce rules for the
chronically ill child based on feelings and concerns about the child’s
condition. In turn, the child may react emotionally (naughtily) to
inconsistent discipline patterns. Without consistent limitations, the
toddler may feel insecure and unable to complete developmental
tasks essential to the promotion of autonomy.
Pain management for the toddler includes administering
medication and providing other traditional nursing comfort measures
such as clean sheets, good hygiene measures, oral care, and skin
care. Because the toddler needs a set routine, the nurse encourages
parents to maintain the child’s normal home schedule as much as
possible. The nurse allows the child to express feelings through play,
artwork, and activities. Have the nurse communicate with the toddler
through a toy. For example, put a bandage on a stuffed doll before
putting one on the toddler to help allay feelings of fear.
Effect of a Chronic Condition on the Preschooler

The main developmental task of a preschooler is to create a sense
of initiative. A painful treatment, isolation, separation from a parent,
or loss of autonomy or mobility can be associated with chronic
illness, and the preschooler is likely to interpret this experience as
punishment for real or imagined wrongdoing. It is important to
reassure the preschooler that this is not the case and that they are
not being punished. Establishing a trusting relationship by explaining
procedures honestly before they occur is essential. The preschooler
with a chronic condition may react aggressively to the effect of
illness by throwing toys, biting, hitting, and other aggressive actions
that may shock the parent. The preschooler may also regress,
withdraw from others, wet the bed, have difficulty sleeping, or refuse
to cooperate. Reassure the parents that this reaction is expected
and temporary. The child also has nightmares that symbolize fears,
so encourage the child to verbalize dreams and feelings if they wake
up crying. Young children accept the meanings of words literally. If
death is associated with “going to sleep,” the child may fear going to
sleep.
NURSING CARE
Priority nursing interventions include providing the preschooler
with the opportunity to express fears and frustrations. At this age,
storytelling and reading books about the illness may help the child to
understand what is happening. The preschooler can express
concerns through play. The nurse can ask the child life specialist for
assistance with methods of play that will help the child express and
communicate feelings. The nurse shares with the parents that the
preschooler’s sense of security is derived from schedules and rules.
Parents are encouraged to maintain as normal a home schedule as
possible and enforce consistent and realistic limits. The nurse
teaches the parents that the child needs constant reassurance that
nothing they have done has caused the illness. Honesty is important
when explaining and preparing for procedures. The preschooler has
a limited concept of time, so it’s best to use general terms like after
lunch, after your nap, or at bedtime.
FOCUS ON SAFETY
Chronic illness takes a significant toll on children, but the psychological toll
can often go overlooked. Children with chronic illness are twice as likely to
have more emotional or behavioral challenges in comparison to healthy
children; therefore, the nurse should make sure to properly screen children
with chronic conditions for signs and symptoms of depression and especially
suicidal ideations (SIs) (CDC, 2020).
Effect of a Chronic Condition on the School-Aged Child

During the school-age period, the child’s main developmental task is
to achieve a certain degree of autonomy and independence and
strive to develop a sense of industry. Children in this age group take
pride in the ability to assume new responsibility. Peer relationships
become extremely important at this age. Separation from the peer
group is often a difficult consequence of a chronic condition. The
school-age child who experiences interrupted independence coupled
with little peer interaction may show anger by refusing to comply with
treatments. The school-age child can listen attentively but
sometimes does not completely comprehend all of the information.
They may be reluctant to ask questions or admit that they do not
know the answer. It is easy for the child to misinterpret medical
information. Remember that the school-age child has an increased
awareness about the significance of illness but may not understand
the lifelong consequences of the chronic condition.
NURSING CARE
Priority nursing interventions for the school-age child include pain
assessment and management. The nurse can use the FLACC pain
scale, the numeric pain scale, or the Wong-Baker FACES pain scale.
The nurse answers questions about treatment, procedures, and
medications honestly and at a level the school-age child can
understand. Play can be used as an outlet or a temporary escape
from the illness or as another way of communication about the
illness. Include peers or friends as appropriate during care or play
activities. The nurse teaches parents how to help the child attain
realistic independence by allowing them to play and/or socialize with
friends, attend school, choose activities, and enjoy private time. The
school-age child is aware of nonverbal cues and often understands
more information than parents and caregivers realize. For this
reason, it is important to encourage the child to maintain open and
honest dialogue with family and caregivers.
Child Life Specialist
Whenever a child is diagnosed with a chronic condition, it is important to
involve the child life specialist. Because the child with a chronic condition often
spends significant amounts of time in the hospital, the days can be long and
boring. The child life specialist is an expert in child development and
therapeutic play. They assist with diversion activities during procedures,
arrange for therapeutic play, or simply let the child take time to play (Fig. 27-3).
Effect of a Chronic Condition on the Adolescent

Adolescence is a time of increasing independence, autonomy, and
vulnerability. It is a time to ask, “Who am I?” and a time when self-
esteem is closely related with peer acceptance. To complicate
matters, during a chronic illness the adolescent may be placed on a
pediatric unit or on an adult floor. Neither situation seems to be the
right fit for this age group. Previously independent, the adolescent is
now faced with a chronic condition and may be required to accept
help from others. Dependence on caregivers and family for physical
care coupled with a lack of privacy can disturb the adolescent’s
sense of autonomy and ability to make decisions. Based on this loss
of independence, the adolescent may exhibit maladaptive coping
behaviors such as hostility, anger, aggression, and sometimes
noncompliance or refusal of treatment. Sometimes when presented
with frequent medications, tests, appointments, and other
procedures, the adolescent is easily overwhelmed and shows
regression in behavior. Besides worrying about the condition, self-
esteem, and identity, the adolescent may also show concern about
the burdens and strains the family may now face. It is imperative to
establish an open line of communication with the adolescent.
FIGURE 27-3 The child life specialist is called on to work with a child
who has been diagnosed with a chronic condition.
NURSING CARE
Priority nursing interventions for the adolescent with a chronic
condition include providing solitary time to help the adolescent regain
control and have personal space. It is important to give the
adolescent realistic choices to enhance control when possible.
Realistic choices include when to bathe, sleep, eat, and visit with
friends. The adolescent can be included in medical-related matters
when possible. Peers can be a strong source of support for the
adolescent, so peer interaction is important. The adolescent can be
encouraged to expand networks of social support through peer
groups and community programs when possible. A support group
may help normalize the adolescent’s crisis and give a new source of
strength and hope. Maintaining contact with peers via social media is
also important. Support groups are also available online.
Effect of a Chronic Condition on Siblings

Siblings of a child who has a chronic condition may experience
decreased self-esteem, less support from parents, mood swings,
lack of understanding about the condition, and a negative attitude
toward the ill sibling’s condition. The sibling often has feelings of
jealousy, embarrassment, resentment, loneliness, and isolation.
Siblings tend to feel isolated, act out in anger, feel guilty, and display
negative feelings and behaviors toward the ill child. If siblings are
close in age, the chronic condition means the loss of a playmate. A
young child, who has a vivid imagination, may believe they caused
the condition or fear that they might also get sick.
NURSING CARE
Promotion of family-centered care is the priority nursing
intervention for the child’s siblings. Instruct parents to maintain
familiar home routines as much as possible for other children. In
addition, the nurse helps the parents include the sibling in simple
care measures. Remind the parents that providing information about
the ill child may decrease stress reactions in the sibling. Encourage
sibling visitation and share age-appropriate information. If the sibling
is too young to participate in physician-family meetings, encourage
them to draw a picture to hang up in the patient room.
What to Say
When a Sibling Acts Out
How does the nurse handle “acting out” in the sibling? To achieve the best
outcome, give the sibling time to regain control and express feelings. To convey
genuine understanding the nurse might say, “You seem very angry today
(reflection). It is all right to be angry about your sister’s condition and about the
situation (validating the sibling’s feelings). It must be difficult for you to have
your sister in the hospital (empathizing and understanding).” The nurse can
then help the sibling find a positive outlet for the anger such as art therapy
(channeling). The nurse can encourage the sibling to tell an adult when the
anger returns (providing an outlet).
THE CHILD LIVING WITH A CHRONIC CONDITION

The percentage of U.S. children and adolescents with a chronic
health condition has increased. With the advancing technology and
demand for high-quality and low-cost health care, it is important to
make sure children have access to care. One way to address this is
through utilization of a medical home, also known as a family-
centered, patient-centered medical home model (PCMH). A
medical home is an approach to providing comprehensive primary
care that facilitates partnerships between patients, clinicians,
medical staff, and families (AAP, 2020). It is a medical practice
organized to produce higher quality care and improved cost
efficiency. In a medical home:
■ Patients have a relationship with a personal physician.
■ A practice-based care team takes collective responsibility for the
patient’s ongoing care.
■ The care team is responsible for providing and arranging all the
patient’s health-care needs.
■ Patients can expect care that is coordinated across care settings
and disciplines.
■ Quality is measured and improved as part of daily workflow.
■ Patients experience enhanced access and communication.
■ Practices move toward use of EHRs, registries, and other clinical
support systems.
The medical home provides a large majority of the care within the
practice, referring as appropriate, and working with other providers
on the health-care team both within and outside the practice.
Extensive evidence documents improvements in quality and
efficiency when patients have a usual source of care through a
primary care practice. The medical home design builds on that
relationship and research has shown that utilization of a medical
home best supports children with chronic conditions or disabilities.
For example, utilizing this model the nurse can provide care
coordination to help better coordinate the care a child with a chronic
condition receives. Research by Ruggiero and colleagues (2019)
has shown that providing care coordination to pediatric patients
improves outcomes of care. Similarly, gaps in care coordination can
result in treatment delays, breaks in communication, missed
appointments, medication discrepancies, and ultimately affect the
provision of quality care (Ruggiero, Pratt, & Antonelli, 2019).
Children living with a chronic condition may be affected by one or
more of the following:
■ Limitation(s) in motility appropriate for age and development
■ Disfigurement, deformity, or scarring
■ Dependence on technology
■ Dependence on assistive devices
■ Dependence on medication
■ Dependence on a special diet
■ Ongoing need for medical care, appointments, or treatments
■ Ongoing need for special services
■ Altered body image
■ Dependence on others for basic daily needs
■ Not being able to be or feel “normal”
■ Missed days at school
■ Not being able to participate in sports, social, or extracurricular
activities
■ Missing out on school functions such as football games and
dances
■ Lack of peer group or social support networks
NURSING INSIGHT
Caregiver Burden
A child living with a chronic condition requires day-to-day care and can become
a source of stress for parents and other caregivers. Caregiver burden is
described as consistent stress, pressure, and anxiety in providing day-to-day
care of a child with a chronic illness or disability while trying to maintain other
family functions and demands. While caring for a loved one can bring personal
fulfillment and satisfaction, it can also result in physical, psychological, and
financial burden for the caregivers. One of the greatest risks for caregivers is
becoming ill themselves. Caregivers have high rates of insomnia and
depression, don’t eat well, and are unable to exercise, take personal time, or
seek preventive health care. One in five caregivers describes their health as
fair or poor (Mayer-Davis et al, 2017). Financial burden becomes an issue as
many caregivers must adjust their work schedules, take leaves of absences, or
reduce work hours as a result of increased care responsibilities. Continuous
health care is expensive. Other costs related to housing, lifestyle modifications,
special equipment, and special services for the child are also expensive. Some
of these costs may not be reimbursed by private health-care insurance plans.
Nursing Care
The nurse must communicate to the family that overwhelming
feelings can be discussed with a health-care professional. Families
caring for children with chronic conditions should be reminded of
respite care. Respite care is short-term care offered to families living
with a child who has a chronic condition. The main goal of respite
care is to provide relief for family members of the burden and stress
of sustained care by giving them a break in the daily challenges of
caring for these children. Parents can also use respite care in
situations in which someone besides them, such as home care
nurses, can accompany the child to a doctor’s appointment. The
availability of respite care varies in every community and is not
always paid for by private insurance. Sometimes state agencies or
national programs can reimburse the family for respite care.
EMOTIONAL RESPONSES TO A CHRONIC

CONDITION
When a child is diagnosed with a chronic condition, the disruption of
family dynamics leads to emotional responses. Initially, the family
experiences shock and chaos, typically followed by feelings such as
anger, fear, disbelief, anxiety, and confusion. Emotional reactions
differ depending on the specific diagnosis and whether there is a
chance for the child to recover. The parental reaction to the
diagnosis of asthma will be different than the reaction to a diagnosis
of cancer. If a child has been ill for a long period, some parents may
express relief at finally having a diagnosis.
Children who do not focus on the positive aspects of the condition
blame themselves and others as well as display negativity and
irritability. Grieving parents may blame themselves or the other
parent for not having been able to prevent the condition, especially if
the condition is a congenital defect. In addition, parents may not be
able to bond with the child. Sometimes, as a defense mechanism, a
parent may be fearful of bonding with the child in case the child dies.
Nursing Care
The priority nursing intervention for the family’s emotional responses
to a chronic condition is communication, support, and understanding.
The nurse communicates to the family that the child can continue to
experience life as other children do, perhaps in moderation.
Important information is communicated about the necessary
treatment, procedures, medicine, and visits to the hospital or clinic.
The nurse supports the family to help them normalize daily activities
such as going to school and playing with friends. The nurse listens
carefully to understand the family’s concerns. Understanding is also
important as parents of a child diagnosed with a chronic condition
have been found to exhibit an initial grief reaction similar to that
experienced with bereavement. They report episodes of recurrent
sorrow, particularly at times of important transitions in the child’s life
that remind them that the child is not the same as other healthy
children. The period of episodic grieving interspersed with periods of
denial is called chronic sorrow. This lifelong sadness suggests
these parents never reach closure. Discuss the importance of the
parent’s continued involvement in the care of the child through these
recurrent sorrowful periods. Parents also need information about
community resources.
When talking about the child’s chronic condition with the family, the
nurse must be sure to use the child’s name and personalize the
discussion. It is important that the nurse avoid labeling the child by,
for example, saying “CF kids.” Instead, the nurse says, “Timmy will
need ongoing care for his cystic fibrosis.” This kind of communication
places the emphasis on the child and not on the condition. It is also
important to listen to the family so that home routines can be
continued during hospitalization.
The nurse assesses the language and nonverbal cues being used
by the child and family. The nurse also determines the locus of
control and where the decision-making process lies (with the parents
exclusively or if it involves a larger social unit of the family). Consider
the relevance of religious beliefs and spiritual practices, particularly
about death, the existence of an afterlife, and the belief in miracles.
Evaluate whether expressions of pain and related aspects are
allowable in the culture or looked at as signs of weakness.
Assessing how hope for future recovery is negotiated within the
family is also important.
ESTABLISHING A THERAPEUTIC RELATIONSHIP

The nurse understands the importance of establishing a therapeutic
relationship with the child and family who are living with a chronic
condition. This therapeutic relationship is vital when providing family-
centered care because the family has a tremendous amount of
responsibility in the care of the child. For the nurse to build a
successful therapeutic relationship with the family, the nurse must
first establish trust.
Optimizing Outcomes
Establishing Trust With the Family
The nurse takes the following actions when establishing trust:
• Consider the needs of the entire family; do not forget the siblings.
• Familiarize yourself with the child’s condition and know about the disease
process.
• Be open and honest.
• Show the family that the burden of care is understood. Burden of care includes
the combination of physical, psychological, social, and financial burdens the
family may face.
• Take time to listen to the child and to the caregiver.
• Include parents in the plan of care. Some parents like to participate in the
child’s care while the child is hospitalized. It is also important to maintain home
rituals as much as possible while the child is hospitalized.
• Treat each child as an individual. It is essential that the nurse does not label
the child according to the disease process.
• Allow the child to make decisions about the care when possible. Decision
making is especially important for the adolescent.
• Maintain confidentiality.
• Do not prematurely judge the parents. Some parents cannot stay with the child
in the hospital based on personal needs and responsibilities.
• Arrange for continuity of nursing care.
• Assess the family’s support systems and resources.
EDUCATION FOR THE CHILD WITH A CHRONIC

CONDITION/DISABILITY
Helping the family understand laws about educational services is
important. The Individuals with Disabilities Education Act (IDEA) is
the nation’s federal special education law that ensures public
schools provide for the educational needs of students with
disabilities. IDEA requires that schools provide special education
services to eligible students as outlined in a student’s individualized
education program (IEP). IDEA also provides specific requirements
to guarantee a free appropriate public education for students with
disabilities in the least restrictive environment. These are the
protected rights of every eligible child in all 50 states and U.S.
territories.
Patient Education
Federal Laws Governing Childhood Education
Remind patients and families that all children are entitled to a free education
and educational services. Free and appropriate public education (FAPE)
includes an individualized family service plan for families who have infants and
toddlers with disabilities.
In 1990, an amendment (PL101-476) was added to the Education for All
Handicapped Children Act (EHA) by adding components that included
renaming the EHA as Individuals with Disabilities Education Act (IDEA). The
amendment also replaced the phrase “handicapped child” with “child with a
disability.” This amendment provided transition services for a child by age 16
and extended eligibility to children with autism and traumatic brain injury. This
act also defined Assistive Technology Devices and Services for children with
disabilities. Additionally, it extended the Least Restrictive Environment clause.
Individuals with Disabilities Education Act (IDEA), PL 105-17 of 1997
ensures that all children with disabilities have “access to the general
curriculum” and that educators consider AT devices and services on the lEPs of
all students. Use of school-purchased devices (ATs) in a child’s home or other
setting is required if the child needs access to those devices to receive FAPE.
Every child with a disability must have a written IEP, and parents have the right
to question placement decisions and due process when settling differences.
This also includes orientation and mobility services to the list of related services
for children who are blind or who have visual impairments as well as for other
children who may also need instruction when traveling around their school or to
and from school.
The Rehabilitation Act, PL 93-112 of 1973, prohibits discrimination against
people with a disability. Section 504 specifies that each student who has a
disability be entitled to accommodations needed to attend school and
participate as fully as possible in school activities.
The Education for All Handicapped Children Act, PL 94-142 of 1975,
mandated that all children, even those with handicaps, be provided with public
education and related services.
CARING FOR THE CHILD RECEIVING END-OF-

LIFE CARE
Dying is the total cessation of life. Death is difficult to comprehend
and might seem mysterious, ambiguous, or confusing to the child
and family. The dying process is unique, and the exact time or date
of death is unpredictable. When the child enters the dying process,
the body begins to shut down physically as well as emotionally and
spiritually. This failure might happen slowly or rapidly depending on
the circumstance.
Patient Education
Do Not Resuscitate
The Do Not Resuscitate (DNR) request means withholding life-sustaining
treatment and requires that no attempt be made to revive a child who has
clinically died. Withholding life-sustaining medical treatment includes decisions
to withhold, withdraw, or limit medical treatment. Some medical ethicists feel
that there is no difference between withholding and withdrawing treatment if the
treatment is no longer beneficial to the child.
When making recommendations to withhold, withdraw, or limit medical
treatment, the benefits of treatment must be weighed against the burden of
continuing treatment for the child. A DNR order means that no lifesaving
measures will be initiated in the event of cardiac or respiratory arrest. This
decision also can mean removing medical equipment such as a ventilator or
monitor, dialysis machine, feeding tube used for artificial nutrition, and IV fluids
for hydration. Aggressive treatments such as chemotherapy or radiation
therapy are also terminated.
The child and family participating in the process of withdrawal of life-
sustaining therapy need consistency among health-care providers and the
delivery of consistent messages. All members of the interdisciplinary team
need to communicate effectively with each other so that families receive
ongoing and reliable information. It is imperative that the family be supported
when making this difficult decision for their child.
PERCEPTIONS OF DEATH
Perceptions of death vary across the age continuum. The nurse
prioritizes nursing actions and assists the child according to the
appropriate developmental level to help make the transition to death
fearless, peaceful, and painless. The causes of death among
children ages birth to 19 vary; deaths in infants include prematurity,
congenital defects, and infections. Death in toddlers and preschool-
age children commonly are the result of accidents and injuries. The
most frequent causes of death in school-age children are cancers
and unintentional injuries. The leading causes of death in
adolescents are accidents, homicide, suicide, and cancer.
Understanding of death is related to the level of cognitive
development. The infant’s perception of death is based on the
degree of discomfort and the reactions of the parent and others in
the environment. The nurse can ensure that the infant’s basic
physiological needs are met, such as providing non-nutritive sucking
or swaddling and holding the infant, and that they are able to build
trust with caregivers.
Toddlers have a more developed perception of death and can
sense by the way that the parents react that something is wrong.
The toddler is unable to distinguish fact from fantasy, which inhibits a
true comprehension of death. Death for the toddler may mean
separation from parents or disruption in routine. They see death as
reversible. The dying toddler responds to the possibility of death with
fear and sadness. It is important for the nurse to encourage parents
to stay with the child by giving 24-hour unlimited visitation and
ensuring their needs are met and comfort is maintained.
The preschool child seems to comprehend death more than can
be verbalized. The preschooler is able to see the body changing and
can understand that something is wrong. Fear of death may be
present as early as 3 years of age, and nurses can discuss death
simply and honestly in response to the child’s questions.
The school-age child often has a realistic understanding about the
seriousness of the condition, but the understanding of death is not
precise until they can understand the concept of time. Kübler-Ross
(1983) found that, after the age of 8 or 9, children understand the
permanence of death. The school-age child is aware of nonverbal
cues and often understands more of what is overheard than parents
and nurses realize. Attempts to shield the school-age child from
death can be perceived as distrust. The nurse must include children
of this age in discussions about their care, condition, treatment or
nontreatment, prognosis, and death. The school-aged child may
request graphic details about death (e.g., burial and decomposition).
The nurse evaluates for fears of abandonment, destruction, or body
mutilation. It is important to foster the child’s sense of control during
this difficult time.
The adolescent has the capacity to understand death at the adult
level but has difficulty accepting it as reality and often thinks that
death can be defied. The adolescent thinks that the body is
invincible, hence some of the risk-taking behaviors among this
group. Adolescence is a difficult time to deal with death because
establishing identity and independence is important. The adolescent
has a fear of becoming dependent on parents. The nurse can help
the family realize that even though the cognitive ability to understand
death is present, the emotional maturity to face death is absent. The
nurse and family include the adolescent in decision making. The
adolescent might wish to write a final poem or message as well as
say good-bye to friends. It is important to allow the adolescent to talk
about feelings and disappointments about goals and experiences
never to be attained. They may want to speak about unrealized
plans (e.g., going to college, getting married, etc.).
BEFORE THE CHILD DIES

The nurse completes the institution’s checklist to ensure that all of
the necessary policies and procedures are followed. The nurse can
contact the bereavement team before death so they are ready to
offer support when the death occurs. The nurse can also create a file
that includes community resources that the family may need after the
death to receive ongoing support.
A ledger may be created as a follow-up for acknowledging
important times in the child’s life (e.g., on the child’s birthday or
another special day). Later, the nurse can send a “thinking of you”
card to let the family know that the child is still remembered on these
occasions. The nurse can also make note of the child’s death date to
make a follow-up phone call that can allow parents to ask
unanswered questions or express feelings.
Assessment Tools
Recognition of Physical Signs of Impending Death
• Loss of sensation
• Loss of the body’s ability to maintain thermoregulation: skin may feel cool
• Skin color will be pale to eventually cyanotic (blue in color)
• Loss of bowel and bladder function
• Loss of awareness, consciousness, and slurring of speech
• Alteration in respiratory status
• Cheyne-Stokes respirations (a waxing and waning of respiration in the depth
of breathing with regular periods of apnea)
• Noisy chest or respirations with the accumulation of fluid in the lungs or in the
posterior pharynx
• Decreased, weak, or slow pulse rate
• Drop in blood pressure
• Confusion, delirium, or disorientation
• Weakness, fatigue
• Changes in pain perception
• Restlessness and agitation
• Alertness or alternation in sleep
• Decreased oral intake
• Seizures
Nursing Care
Once medical treatment is halted and the family has determined that
death is inevitable, the focus of nursing care is about allowing the
child to die. The nurse can shift from the curative technological
approach to providing care that enables the child to move toward
death by accessing their own inner resources. To help the child have
a peaceful death, comfort measures are essential to help create a
positive outcome at the time of the child’s death as well as later on
for the family. The nurse is aware of family needs and communicates
genuine feelings of kindness and sympathy to the family.
Optimizing Outcomes
Supportive Nursing Behaviors in End-of-Life Care

• Allow the parent to hold the child while life support is being discontinued.
• Provide a peaceful dignified scene at the bedside.
• Teach the family that the child can still hear you.
• Encourage the family to talk to the child.
• Use the team approach (Fig. 27-4).
• Encourage the family to ask questions.
• Validate the family’s caretaking decisions.
• Provide continuity of care.
• If the family is able, have them help care for the child.
NURSING INSIGHT
Offering Presence
The nurse responds sympathetically to the family at the time of the child’s
death. The death of a child is a sorrowful time for the family. One primary
intervention for the nurse is to be present. Presence includes a receptive,
nonverbal posture that signals to the family that the nurse is willing to sit quietly
and listen. Being present may reduce the family’s feelings of isolation. It is
important to remember that the family may not need the nurse to say profound
words. They may simply want the nurse’s support and willingness to remain in
the room.
The nurse can perform the following nursing actions to support the
dying process:
■ Promote good communication with the health-care team.
■ Manage pain and discomfort.
■ Create a peaceful and comfortable environment.
■ Assist the child to die with dignity.
■ Cease unnecessary treatments.
■ Allow the family to express their end-of-life care wishes.
Relationships are extremely important during the dying process,
and physical contact is a major source of comfort to both the child
and family. A simple touch from the nurse’s hand, gently stroking the
child’s head, or the placement of a favorite toy next to the child
shows the family that the nurse truly cares about the child. When a
nurse offers touch, the family members may lean in toward the nurse
and respond positively. The nurse must also be sensitive to a family
who is not comfortable with being touched and may respond with
stiffening or drawing back. In this situation, the nurse can quietly
remove the hand and perhaps take a step back. The nurse must also
have the insight to realize that this is not the time to share personal
stories about loss. It is important for the nurse to keep the focus on
the family.
It is important that the nurse give the family choices about what is
possible during the dying process. The nurse can ask the family
members if holding the child is desired. If death is imminent, the
nurse must be sure to tell the family that death could occur while
holding the child. Sometimes parents request to get into the bed with
the child. This behavior is acceptable during the death of a child.
The nurse assesses the situation and creates a peaceful
environment. Sometimes it is appropriate for the nurse to give the
family short periods to be alone with the child, or the family may want
a health-care professional in the room at all times. When the nurse
presents these choices, if the family does not respond, ask the family
again a few moments later because sometimes they cannot absorb
everything that is occurring.
FIGURE 27-4 The health-care team is of tremendous support to
parents and family of a chronically ill or dying child.
Palliative Care, Hospice Care, and End-of-Life Care

Care of the dying child includes holistic nursing interventions that
address the physical, emotional, and spiritual aspects of the child
and family. Care of the dying child is addressed in three ways—
palliative care, hospice care, and end-of-life care—which are both
similar and different from one another.
Palliative Care
With technological advances, nurses and other health-care
professionals are faced with decisions as to when to stop treatment
once it is initiated. Palliative care, sometimes called supportive
care, is a philosophy of care that seeks to prevent, relieve, reduce,
or soothe the symptoms produced by serious medical conditions or
their treatment and to maintain a patient’s quality of life.
Palliative care provides support and care for people, including
children, facing life-threatening illnesses. The care is focused on
enhancing the quality of life remaining by integrating physical,
psychological, social, and spiritual care as defined by the child and
family. An interdisciplinary team is aware of the child’s needs and
uses an approach and interventions that affirm life and neither
hasten nor postpone death. Palliative care measures can coexist
with curative measures. One goal of palliative care is to advocate for
the needs of the child and family so that they can continue to live
their lives with dignity and allow the child to die in a manner that is
meaningful. Applications of palliative care interventions will vary with
the setting and availability within that setting. Medical insurance
payments or reimbursements now support this quality of care in
some states.
Hospice Care
In 1967, Dr. Cicely Saunders established the first hospice, St.
Christopher’s Hospice in London. Hospice care is a form of health
care that provides palliative (comfort) care across a variety of
settings, based on the philosophy that dying is part of the normal life
cycle. Hospice promotes the concept of “living until you die.”
Hospice care uses a variety of services (medical equipment,
diagnostic procedures, and therapeutic interventions) provided by a
multidisciplinary group of health-care providers consisting of
physicians, nurses, and other personnel such as chaplains, health
aides, and bereavement counselors.
Optimizing Outcomes
A Hospice Approach to Nursing Care
With hospice, the focus of care is on improving the quality of remaining life—
that is, on palliative, not curative, measures. Additionally, it:
• Endorses family-centered care
• Meets the child’s physical, emotional, social, and spiritual needs
• Promotes effective symptom control and pain management
• Includes the interdisciplinary team
• Supports the family decision for home or hospital care
• Offers coordinated care
Once hospice care is initiated, the nurse can help the family determine the
best place for the child to spend the final days. Most children prefer to die at
home surrounded by family. The concept of children’s home hospice care is a
growing alternative to inpatient hospital care for the dying child. Holistic care
measures can be implemented easily in the home. The child who is cared for in
the home receives nursing care that includes visits, treatments, medications,
supplies, and equipment offered by the home care agency. At home, the child is
exposed to normal daily activities and surrounded by family members as death
draws near. When the child is at home, they may be able to continue to play
with other children and “feel normal” for as long as possible.
The nurse understands that remaining in the home environment may not
always be possible. Assuming care for a dying child can be an overwhelming
duty. Some parents simply have too much grief to care for the dying child and
other children along with household responsibilities. Hospice care also provides
respite care that allows family members to “take a break” or “time off to
reenergize before returning to the role of primary caregiver. In addition to the
actual care of the dying child, hospice care also offers professional support after
the death of the child.
End-of-Life Care
After it has been determined that the end of life is near (within about
6 months) for the child, care measures can be initiated to help the
child die peacefully and without pain. End-of-life care recognizes that
each child and family has unique needs at this time. End-of-life care
must be accessible to the child and the family in their desired setting
(the home, inpatient hospice, or intensive care unit). End-of-life
nursing care is meant to provide the best quality of life possible for
the child and family. It is a holistic approach to care that includes
physical, emotional, social, and spiritual interventions. Quality of life
can be enhanced by offering support to the bereaving child and
family, relieving distressing symptoms, and providing respite.
The home is usually the preferred site and can provide a peaceful,
supportive, and spiritual environment according to what the child and
family desire. Encourage the family to include familiar items in the
care of the child such as a favorite blanket, toy, picture, or other
items of importance to the child. During the dying process, changes
in care measures can be adjusted as needed, but drastic changes
during the final stage should be avoided.
NURSING CARE
End-of-life nursing care measures include managing discomfort
and pain in the dying child. This can be difficult because pain is a
subjective experience. Some children can clearly describe the pain
while others cannot. Dying children who are nonverbal have the
most difficulty in conveying pain (Table 27-1). The nurse can
communicate to the family the necessity of pain management.
TABLE 27-1
Holistic Care Measures to Support the Child Receiving End-of-Life Care
COMFORT EMOTIONAL SPIRITUAL ALTERNATIVE OR
MEASURES SUPPORT INTERVENTIONS COMPLEMENTARY
CARE
Manage pain Active listening Offer presence Use art therapy
Promote hygiene Show empathy Use meditation Discuss energy-
Provide oral care Use distraction Provide music based therapy
Use fresh linen and Encourage positive Encourage prayer (healing touch,
clothing coping Suggest spiritual therapeutic touch,
Reposition Encourage symbols Reiki)
Provide diet as verbalization of Promote relaxation
tolerated feelings Use guided imagery
Suggest physical Suggest Read from spiritual Discuss
therapy psychotherapy text or poetry acupuncture
Suggest Discuss support Allow for sacrament Discuss
occupational groups Contact the family’s aromatherapy
therapy Discuss topics religious or spiritual Discuss reasonable
Help the family about grief, loss, community activity
create new rituals isolation, fear, guilt, Discuss
when the old rituals and relationships God/Higher Power
no longer work Discuss concerns or Spiritual Source
because of the about life after the
progression of the child’s death that
disease relate to family,
friends, and others
GRIEVING
From the moment a family has been informed about the child’s fatal
condition, the family’s life changes direction and grieving begins (Fig.
27-5).
Grief begins at the moment of diagnosis and fluctuates with
remissions and exacerbations of the condition. It escalates at the
time of death (though it may be mixed with feelings of relief and guilt)
and continues at varying levels for years afterwards. Everyone
grieves differently. Bereaved parents often experience renewed and
intense grief on occasions that would have been significant
benchmarks in the life of the deceased child such as birthdays,
holidays, and anticipated graduation from high school.
Signs and Symptoms
Grief can be an emotional response as well as a physical response
to death. Somatic grief response can be described as:
■ Feelings of tightness in the throat or chest, sighing
■ Weakness or shortness of breath
■ Preoccupation with the image of the deceased (e.g., hearing or
seeing the person who died)
■ Inability to focus on anything other than the loved one who died
■ Emotionally distancing self from others
■ Feelings of guilt
■ Feeling responsible for the loved one’s death
■ Searching for what could have been done differently, thinking in
terms of “if I only had done …”
■ Hostile reactions that include feelings and expressions of anger
■ Inability to complete daily tasks
FIGURE 27-5 The hospital chaplain or another religious figure can

offer spiritual support to the child and their family.
What to Say
After the Death of a Child
After the child’s death, the family might ask the nurse questions such as, “What
did I do to deserve this?” “Did I do something wrong?” “Am I being punished?”
The nurse listens empathetically to the family and encourages them to “take it
one day and sometimes one moment at a time.” Help the family understand
that there may be “good days” and that inevitably there will be “bad days.” The
nurse can give the family hope that over time the emotional pain may dissipate
and that they can better understand the experience of their child’s death.
Grief Theories
It is important for the nurse to understand the grieving process from
well-known theories to provide proper care and support.
Kübler-Ross’s Stages of Grief

Elisabeth Kübler-Ross (1983) described five stages of grieving.
DENIAL AND ISOLATION
This stage includes feelings of numbness, disbelief, and shock.
Denial is a way of protecting the family and child from the emotional
pain that may be too severe to handle all at once. The numbness
helps the family and child by creating emotional distance from the
pain, thereby allowing continuation of daily responsibilities. The
nurse acknowledges feelings of numbness and reminds the family to
slow down, “take it easy,” pay attention to safety measures, and
retain healthy habits.
ANGER
Anger can be one of the most difficult stages. At this point, the
family and child have developed awareness about the reality of the
diagnosis. The feelings of anger, fear, and guilt can be an
overwhelming but a normal response to the impending death. Both
the family and child may become angry with God or a higher power
or experience a spiritual crisis. The nurse gives spiritual care by
sitting at the bedside or calling on a hospital chaplain or the family’s
personal clergy or spiritual leader to provide support. The nurse uses
prayer, meditation, reading from a spiritual text, or just being present
with the family. The nurse also encourages the family to find a
positive outlet for the emotions. Positive outlets can include talking
with other family members or friends, nurses, and families at the
hospital or expressing feelings in a support group. Physical exercise
is another positive way to release anger. Family members are
encouraged to write their feelings down in a journal or draw to
express emotions. The nurse helps the child to express anger
through therapeutic play or art therapy.
BARGAINING
It is common for the family members to ask, “What did I do to
make this happen?” It is normal for the family to try to bargain with
either self or with God in hopes that the child’s life will be spared.
The family may express guilt at times for disciplining the child on
occasion. The family may also feel punishment for personal life
circumstances. Specifically, a mother might wonder if she caused the
illness or injury during pregnancy. During this stage, it is natural for
the family to make vows of personal improvement if the child is
cured. It is important for the nurse to talk to the family about
bargaining and reinforce that the child’s illness is not anyone’s fault.
DEPRESSION
When the illness can no longer be denied or bargained away, the
family and child may begin to feel a profound sadness. The nurse
understands that sadness or depression is to be expected. There are
some warning signs that the nurse must be aware of that indicate
extra help is needed during this period of depression (e.g., insomnia
or excessive sleeping, nightmares, weight gain or weight loss, loss of
concentration that interferes with the ability to function normally,
overwhelming anger, and constant fear or worry about the physical
wellness of other family members). If the nurse assesses that any of
these signs are present, it is imperative to talk to the hospital social
worker, physician, or a professional counselor to obtain help.
ACCEPTANCE
Accepting a child’s illness and possible death means that the
family or child has made an emotional adjustment to the illness.
Although the family and child may still feel as if they are on an
emotional roller coaster, the difficulties will become more predictable
and manageable. At this phase, many family members find strength
and joy in everyday living. Family members begin looking for
meaning and a reason about why this happened to the child and
what effect this experience may have on the future. The nurse
remains present with the family and continues to offer support and
encouragement. The nurse provides community resources for the
family to help them continue in the grieving process.
Miles and Perry’s Stages of Grief

Miles and Perry (1985), two other well-known grief theorists, identify
three phases of parental grief.
PHASE 1
Phase 1 is a state of numbness and shock. The parents may
seem to be in a trance and display no emotion. Some parents may
try to comfort others yet show no emotion themselves.
PHASE 2
Phase 2 is a period of intense grief. The parents may cry. Some
parents express grief loudly with outbursts, while others cry quietly.
Other parents display inappropriate silliness or euphoria. It is a
mistake for the nurse to judge a parent as unaffected or uncaring
because of the type of emotional reactions at the time of death.
PHASE 3
Phase 3 is a period of reorganization. Initially the parents are in a
state of emotional shock and forget important information. Later
parents can remember verbatim the information that was given at the
time of the child’s death.
Epperson’s Theory of Grieving

It is important for the nurse to remember that no two families go
through the grieving process at the same time or at the same pace.
A family who experiences a sudden or catastrophic loss appears to
go through a slightly altered grief process. Epperson’s theory about
catastrophic grief may be helpful in the emergency department
setting. With the absolute loss of a child already evident, bargaining
is absent and depression is replaced with remorse. Epperson’s
theory of the grieving process includes six phases.
HIGH ANXIETY
High anxiety is described as a time of great stress, with many
physical manifestations of emotional upheaval. A nursing
assessment of the family member finds agitation, rapid respiration
and increased heart rate, irritability, muscular tension, and fainting
along with digestive or bowel changes that may result in nausea and
diarrhea. It is important to refer the family member to a health-care
provider.
DENIAL
Denial is a protective emotional reaction to postpone the
realization of the loss until sufficient psychological preparation has
been made. This phase must not be hurried, and a period of acute
denial is normal. However, the denial should not persist beyond the
viewing of the child’s body and after the family has departed the
hospital. If denial continues, the nurse needs to refer the family
member to a health-care provider or a professional counselor.
ANGER
Anger is a common emotional response and can be directed
inwardly, toward another family member, or toward others. Usually
the anger is a diffuse kind that lashes out at society or life in general,
with the feeling that the loss was somehow “allowed” to occur. Many
times, the anger may be an attempt to affix blame. The anger is
usually brief. During an assessment, if the nurse sees that the anger
persists, a complex underlying cause such as fear needs to be
addressed further by a mental health specialist.
REMORSE
Remorse includes feelings of both guilt and sorrow. The family
regrets that the accident or illness occurred and feels responsible
that it could not be prevented. The nurse understands that this is the
“if only …” stage. Nursing care includes giving the family repeated
reassurance that personal actions were reasonable. In situations of
true culpability, the responsible family member needs intensive
support and counseling to come to terms with personal liability.
GRIEF
Grief is an intense period of overwhelming sadness. The duration
and intensity of the grief depend on factors such as the medical
condition of the child, existing support systems, and culpability in the
disease or injury scenario. The nurse provides emotional support
and genuine caring during this phase.
RECONCILIATION
Reconciliation is described as the final phase to be experienced
and may be an end point to the acute family crisis. The nurse can tell
the family that reconciliation is a time when the family begins to
adapt to the existing circumstances and begins to move on with life.
COPING PATTERNS
Grief reactions can differ. Certain behaviors by the family directly
after a notification of illness or impending death tend to be
magnifications of their predominant stress-coping behaviors in times
of duress. In times of stress, the child and parents may revert
backwards to familiar ways of coping. It is important to note that if
there is too much damage to a familiar lifestyle or family structure,
the child or parents may become unable to cope.
Nursing Care
The nurse recognizes the exhibited coping patterns, discovering
ways to support the family directly or indirectly. The nurse listens,
sits silently, refers the family to a pastoral care person, offers spiritual
care such as prayer, or encourages journal writing or reading from a
spiritual text. If the nurse notices that the behavior is destructive to
self or others, it is necessary to call in a physician or a professional
counselor. The nurse does not alter the coping pattern completely
because alteration could strip the child and family completely of
protective buffers and leave them exposed to more pain than is
bearable.
Pathological Grief
On occasion, personal support systems do not adequately allow the
individual to cope, and the family members may experience
dysfunction or pathological grief. Intense grief feelings or a
dysfunctional personality may easily bring on pathological grief
(deviation from a healthy or normal grief), which can have
consequences such as violence, substance use, or poor decision
making.
Subtle changes may signify a problem. It is the intensity and
duration of these behaviors that are the deciding factors indicating
the need for professional help.
■ Absence of grief such as showing little or no emotion
■ Persistent blame or guilt
■ Anxiety
■ Aggressive and destructive outbursts
■ Depression and suicidal thoughts or actions
■ Unwillingness to speak about the deceased
■ Expressing only positive or only negative feelings about the
deceased
■ Prolonged dysfunction in school
■ Always assuming a caregiver role
■ Stealing or other illegal acts
■ Signs of addictive behavior (e.g., drugs, food, or certain activities)
SAYING GOOD-BYE
At the time of death, the parents of a dying child can be in extreme
grief, and saying good-bye to the child is an important process.
Nursing Care
Facilitating saying good-bye is important, and the process is not
rushed. It is paramount that, throughout the saying good-bye
process, the nurse calls the child by name, which helps parents and
family members feel that the nurse genuinely cares for the child.
Allow family members adequate time to be alone with the child after
death.
What to Say
Proper Communication
It is important to avoid platitudes such as “time heals all wounds,” “you wouldn’t
want them to live like that,” “you’re lucky; it could have been much worse,” or
“you can always have another child.” These phrases minimize the loss and
have little comforting effect. They may be upsetting to the family and make
them feel that somehow this child’s life has limited value. It is better to say
nothing if you do not know what to say. Some appropriate responses are:
“I’m sorry.”
“This must be terribly hard for you.”
“Is there anyone I can call for you?”
“Would you like me to stay with you for a while?”
During the good-bye, the nurse keeps the child covered up and as warm as
possible. The parents may want to assist in the immediate postmortem care as
a way of saying good-bye. Parents can give the child their last bath, comb the
hair, wash the face, or dress the child in a clean set of clothing. Allowing
parents to hold the child one more time as the final good-bye is said is an act of
compassion. Extended family members, friends, and others may come to say
good-bye as well. The nurse encourages parents and other visitors to talk
about memories of the child. Crying is common for the parents, family, friends,
and the nurse. If the nurse cannot keep personal emotional control, another
nurse offers relief.
The nurse’s role after the child’s death is to be supportive and allow the
family to dictate the “good-bye” timeline. If an extended time frame is needed to
say good-bye, the nurse contacts pastoral care services to coordinate a private
viewing time in the chapel. After the good-bye, it is important that the nurse
ensure that the parents and others have departed from the hospital before
transporting the child to the morgue.
When supporting the family at the end of a child’s life, the nurse:
■ Provides continuity of care
■ Allows the parent to hold the child while life support is being
discontinued
■ Provides a peaceful dignified experience
■ Teaches the family that the dying child “can still hear you” and “it is
all right to talk to them”
■ Uses the team approach with other health-care providers
■ Allows family members adequate time to be alone with the child
after death
■ Allows time after death for additional questions and concerns
■ Validates that everything possible was done for the child
■ Encourages the family to care for the child after death if they are
able (e.g., bathe and dress the body)

The sibling relationship is sometimes one of the most consistent and
ongoing relationships for a child. It can involve many feelings and
experiences, including disharmony. In a sibling relationship, the child
may experience love, caring, sharing, comforting, playing, jealousy,
envy, fighting, and blaming. To the child, the sibling is not only a
brother or sister but also many times a playmate, friend, or support
system. The child and sibling have learned and grown with each
other, and now the relationship is lost. A visit from the sibling(s) is
important.
When a child dies, the surviving sibling may be mistakenly
overlooked. Sometimes overlooking another child is unintentional as
the focus is placed on the child who died or on the parents.
Sometimes there is a perception that the sibling will “be all right.”
The child may have been sent away to a grandparent or neighbor
while the brother or sister was dying in the hospital.
Optimizing Outcomes
The Sibling
The nurse’s role in relation to the sibling consists of a variety of holistic nursing
interventions:
• Listen and help the sibling express their feelings.
• Show the family how to acknowledge the sibling’s presence during this difficult
time (initiate a simple conversation, turn on cartoons, offer a drink or snack, or
show the sibling how to touch the dying child).
• Explain the situation to the sibling and relate appropriate information in terms
understandable for the sibling’s age.
• Allow visitation during appropriate times.
• Help the sibling understand that they are not responsible for the sibling’s
death.
• Contact a child life specialist who can assist the sibling with art therapy.
• Encourage simple ways to be involved in the care such as making a final gift
for the sibling to keep at the bedside.
• Remind the family that the sibling is also experiencing a loss.
Patient Education
HOW TO: Teach the Family to Help the Sibling Say Good-Bye
• Teach the family that it is important that the sibling be included in the grieving
process and have the opportunity to say good-bye.
• Instruct families to allow the sibling to have short visits when possible.
• During visitation, encourage the family to have another support person with
the sibling such as a friend or grandparent.
• Tell the family that the sibling can write letters or draw pictures for the child as
a way of saying good-bye.
ESSENTIAL INFORMATION
Kübler-Ross (1983) says that the child who has been included in the death and
mourning process with the family is able to let go in a healthy way.
Sometimes the gathered items for the remembrance packet are refused by
the parents. If permission is granted, place them in an envelope or box. Some
parents are in such a state of shock they cannot accept the items but may ask
for them at a later date.
ORGAN TISSUE DONATION
A discussion soon after death about organ tissue donation, in many
states, is required by law. Organ tissue donation may be a sensitive
issue for the nurse and family. The bereavement team knows when it
is appropriate to approach the family. The bereavement team is a
group of trained professionals who provide information and help the
family consider the topic of organ tissue donation while maintaining
dignity and respect for the deceased child. In some circumstances,
the family may approach the nurse about organ tissue donation.
Sometimes, the physician provides information about organ tissue
donation.
Certain criteria must be met for the child to be an organ or tissue
donor. Depending on the type of illness, criteria may not be met for
organ tissue donation. Be aware of common questions that the
family may ask about organ tissue donation to help the family make
an informed decision. Sometimes after the organ tissue donation, the
family of the child gains comfort in knowing that the death of the child
enabled another child to live.
NURSING INSIGHT
Burnout, Compassion Fatigue Syndrome, and Moral Distress
Burnout, compassion fatigue syndrome, and moral distress are important
concepts.
• Burnout is a state of physical, emotional, and mental exhaustion caused by
long-term involvement in emotionally demanding situations. It emerges
gradually and is a result of emotional exhaustion and job stress.
• Compassion fatigue syndrome is characterized by a sense of helplessness,
confusion, and isolation from supporters and can have a more rapid onset
and resolution than burnout.
• Moral distress occurs when the nurse is unable to translate personal moral
choices into action. The nurse acts in a manner contrary to personal or
professional values which undermines integrity. During moral distress, the
nurse experiences feelings of frustration, anger, and anxiety.
It is important for the nurse to pay attention to personal needs and
recognize that certain actions can help relieve burnout, compassion
fatigue syndrome, and moral distress. Sharing grief with the child’s
family after death can help both the nurse and family deal with
feelings about the loss of the child. Most institutions have grief
counselors and support services available to the nurse. Debriefing
sessions with professional grief counselors after the child’s death
have proven to be helpful. Journal writing or art therapy is an avenue
many nurses explore. Ask for personal support as well as to be
supportive to other nurses. Consider organized support sessions
after the death of a child. These post-clinical debriefings may be
helpful for the nurse to talk with the physician or professional
counselor for reassurance that a change in the nursing care would
not have changed the outcome.
Another aspect is personal suffering that happens when the nurse
feels little control over the practice environment. Even though caring
for the dying child and family is a privilege that offers personal
rewards, the nurse must recognize that personal suffering is
possible. A good way to address the nurse’s suffering is to attend a
forum specifically for discussion, reflection, and shared
understandings about suffering. During the forum, the nurse can
express personal feelings, frustrations, and disappointments. The
nurse can also use strategies in the work setting such as journal
writing, art therapy, quiet time, a walk, prayer, or meditation that
acknowledge and allow the nurse to process the grief and loss.
Accept compassion and care from others. Self-care practices away
from the workplace such as exercise, leisure activities with friends
and family, and solitary time for reflection and renewal have great
value. The nurse needs to refresh their spirit. It is important for the
nurse to create healthy boundaries, setting proper limits for
compassion and self-sacrifice with the child and their family as well
as oneself.
SUMMARY POINTS
■ A chronic condition is a health situation that persists over time, usually longer
than 3 months, or one in which recovery progresses slowly.
■ The increase in chronic conditions may be partially attributed to technological
life-saving and life-sustaining measures or technological devices that can now
diagnose and treat diseases that previously were either undiagnosed or
untreatable.
■ Technology-dependent children are grouped according to the type of
equipment required.
■ A chronic condition affects the family and child differently depending on the
age at diagnosis.
■ A child living with a chronic condition requires day-to-day care and can
become a source of stress for parents and other caregivers.
■ The nurse understands the importance of establishing a therapeutic
relationship with the child and family who are living with a chronic condition.
■ The child with a chronic condition may experience negative physical growth
(growth failure) and developmental aspects.
■ When the child enters the dying process, the body begins to shut down
physically as well as emotionally and spiritually. This failure might happen
slowly or rapidly depending on the circumstance.
■ Perceptions of death vary across the age continuum. The nurse prioritizes
nursing actions and assists the child according to the appropriate
developmental level to help make the transition to death fearless, peaceful,
and painless.
■ The nurse recognizes physical signs of impending death. Knowing the normal
physical processes may help the family through the experience.
■ Once medical treatment is halted and the family has determined that death is
inevitable, the focus of nursing care is about allowing the child to die. The
nurse can shift from the curative technological approach to providing care that
enables the child to move toward death by accessing their own inner
resources.
■ Grief begins at the moment of diagnosis and fluctuates with remissions and
exacerbations of the condition.
■ The nurse encourages the family to include the sibling when saying good-bye.
After the child has died, give the sibling a chance to say good-bye, leave a
personal item, or be alone with the sibling if desired.
■ It is important to realize that the nurse can become depleted based on
constant demands from the dying child and family. When the demands of care
exceed personal energy, the nurse’s personal energy may be threatened.
REFERENCES
American Academy of Pediatrics. (2020). What is a medical home? Retrieved
from: https://www.aap.org/en-us/professional-resources/practice-
transformation/managing-patients/Pages/what-is-medical-home.aspx
Andes, L. J., Cheng, Y. J., Rolka, D. B., Gregg, E. W., & Imperatore, G. (2019).
Prevalence of prediabetes among adolescents and young adults in the United
States, 2005–2016. JAMA Pediatrics:e194498.
CDC response to Advisory Committee on Childhood Lead Poisoning Prevention
Recommendations in “Low Level Lead Exposure Harms Children: A Renewed
Call of Primary Prevention (2020).”
http://www.cdc.gov/nceh/lead/ACCLPP/activities.ht. Centers for Disease
Control and Prevention. (2020). Retrieved from
http://www.cdc.gov/ncbddd/developmentaldisabilities/index.html
Mayer Davis, E. J., Lawrence, J. M., Dabelea, D., Divers, J., Isom, S., & Dolan, L.
et al. (2017). SEARCH for Diabetes in Youth Study. Incidence trends of type 1
and type 2 diabetes among youths, 2002–2012. N Engl J Med;376(15):1419–
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Raghupathi, R. V. (2018). An empirical study of chronic diseases in the United
States: A visual analytics approach. Int J Environ Res Public Health 15(3):431.
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31389863.
F.A. Davis Company.

Davis Advantage
UNIT 7
Women’s Health
CHAPTER 28
Promoting the Safety of Women and

Families
CONCEPTS
Trauma
Family
Violence
KEY WORDS
intimate partner violence (IPV)

domestic violence (DV)
sexual coercion
economic abuse
honeymoon period
trauma-informed care (TIC)
mandatory reporting
sexual assault nurse examiner (SANE)
LEARNING OBJECTIVES

■ Define the term “intimate partner violence” and discuss the significance and
scope of the problem.
■ Describe the different types of intimate partner violence.
■ Identify a national health goal related to intimate partner violence and discuss
how nurses may be instrumental in helping the nation to achieve this goal.
■ Discuss characteristics of the three phases typically included in a cycle of
violence and describe how partners generally react during each phase.
■ Explain how to conduct intimate partner violence screening and assessments.
■ Describe the nurse’s role in planning and providing care for victims of intimate
partner violence.
PICO(T) Questions
chapter.
1. What (I) types of abuse are the (O) most lethal for (P) victims of intimate
partner violence (IPV)?
2. What are (P) the main reasons that victims of sexual assault (O) do not report
the incident (I)?
INTRODUCTION
This chapter focuses on various aspects of violence against women
and the nurse’s role in promoting safety for victims of violence.
Violence against women is a significant public health problem that
causes physical and emotional trauma for women, men, children, and
families and results in serious physical and mental health problems.
An important Healthy People 2030 national goal clearly
underscores the magnitude of intimate partner violence: Reduce
violence by current or former intimate partners (U.S. Department of
Health and Human Service, 2020). This includes physical and sexual
violence, psychological abuse, and stalking. Nurses can be
instrumental in helping the nation to achieve this goal by routinely
assessing women and their families to identify those at risk, assisting
with counseling or initiating referrals for professional care, and
maintaining contact to ensure that appropriate follow-up mechanisms
are in place (U.S. Department of Health and Human Services
[USDHHS], 2020).
DEFINITION, INCIDENCE, AND EFFECT ON

INDIVIDUALS AND SOCIETY
Intimate partner violence (IPV) is defined by the Centers for
Disease Control and Prevention as physical, sexual, or psychological
harm or social isolation perpetrated by a current or former partner
(adult or adolescent). IPV can occur in a vast degree of individuals
and relationships, affecting heterosexual, bisexual, homosexual,
transgendered, and other relationships as well as married spouses,
common-law spouses, civil union spouses, domestic partners,
boyfriends/girlfriends, dating partners, and ongoing sexual partners.
IPV can also occur among couples who do not engage in sexual
intimacy.
While some may use the term domestic violence (DV) to refer to
IPV, DV encompasses IPV as well as violence among other members
of a household, such as siblings, parents, grandparents, relatives,
and unrelated roommates. IPV is neither random nor haphazard and
occurs in all demographics and socioeconomic patient populations in
which one individual (abuser) exerts power and control over the other
(victim). The abuser’s actions are intended to instill fear and to
intimidate in efforts to control the victim.
IPV reaches across all strata of society and affects persons
regardless of economic status, ethnic background, educational level,
or religious status. World Health Organization data indicates that
about 35% of women worldwide have experienced some aspect of
IPV in their lifetime (World Health Organization, 2017). Statistically,
female victims are substantially more likely than male victims to be
killed by an intimate partner. Data has shown that 50% of homicides
of females are related to IPV with 1 in 10 of the victims reporting IPV
within 10 months preceding their death (Petrosky et al, 2017).
Health Outcomes
Victims of IPV experience a wide range of physical and mental health
problems. Physical outcomes can result from direct injuries. The
World Health Organization reports that 42% of women who
experience IPV suffer an injury as a consequence of this violence
(World Health Organization, 2017). Victims also experience adverse
health outcomes indirectly from chronic stress resulting in stress-
related disease such as cardiovascular disease and chronic pain.
Other negative health effects include adverse psychosocial and
mental health outcomes. Chronic mental health conditions related to
IPV include post-traumatic stress disorder (PTSD), anxiety disorders,
substance abuse, and suicide. PTSD is characterized by a cluster of
symptoms involving re-experiencing the previous trauma, avoidance,
and sustaining a state of hyperarousal. A multitude of physical
conditions such as chronic pain, neurological disorders resulting from
injuries, gastrointestinal disorders (e.g., irritable bowel syndrome),
sleeping difficulties, and migraine headaches often follow in the
aftermath of IPV. Table 28-1 lists some of the adverse health
implications of IPV.
TABLE 28-1
Adverse Effects of IPV
PHYSICAL EFFECTS MENTAL HEALTH EFFECTS
Injuries: Cuts, lacerations, bruises, Anxiety
fractures, strangulation Eating disorders
Headaches Antisocial behavior
Cardiovascular disease Suicidal behavior
Fibromyalgia Sleep disturbances
Irritable bowel syndrome/abdominal pain Flashbacks
Exacerbation of chronic illness Sleep disturbances
Sexually transmitted infections, including Depression
HIV/AIDS Post-traumatic stress disorder (PTSD)
Pelvic inflammatory disease Low self-esteem
Unintended pregnancy Fear of intimacy
Unsafe abortions Emotional detachment
Miscarriages Sexual dysfunction
Substance misuse
Source: Scannell, M. (2018b). Fast Facts About Forensic Nursing: What You Need
To Know. Springer Publishing Company; World Health Organization
(2017).Violence Against Women. Newsroom. Fact Sheets.
Risk Factors
History, environment, and other information can identify individuals
who have a greater likelihood of becoming involved in an IPV
relationship. Specific risk factors have been identified at the
individual, relationship, community, and societal levels that can affect
the risk of IPV (Table 28-2).
The abuser’s expressions of violent behavior in a IPV relationship
usually erupt early in the courtship and grow progressively worse.
Violence is used to handle conflicts, and the abuser exerts power to
elicit a pervasive feeling of powerlessness in those around them.
Male abusers frequently have a history of early and prolonged
exposure to family violence as children, adolescent delinquency, and
use of alcohol and other illicit substances in adolescents (Centers for
Disease Control and Prevention, 2018; World Health Organization,
2017). Risk factors for becoming a perpetrator of IPV appear in Table
28-3.
TYPES OF ABUSE
The violence in an IPV relationship often occurs in a cyclical fashion,
which can be unpredictable and typically increases in frequency and
intensity over time. An abuser may use many different types of
violence to maintain control in the relationship and victims may be
repeatedly subjected to more than one type of abuse. Physical abuse
is only one manifestation of IPV. The CDC recognizes four categories
of IPV: physical violence, sexual violence, threats of physical or
sexual violence, and psychological or emotional violence (Box 28-1).
Other types of abuse include social abuse and economic abuse.
Physical Violence
Physical abuse may include spitting; scratching; kicking; punching;
pushing; shoving; throwing; grabbing; biting; burning; choking;
shaking; slapping; strangling; using a weapon; and using restraints or
one’s body, size, or strength against another person. The abused
person may be seen in the health clinic, doctor’s office, or emergency
department with vague, chronic, nonspecific complaints, and often
there is a history of overuse of health services or unexplainable
injuries such as bruises and fractures. Nurses should be alert to the
patient’s chronic issues as possible symptoms of abuse. For
example, the person may seek treatment for headaches, anxiety,
stress, insomnia, or fatigue. The IPV victim’s appearance may vary.
They may be disheveled, dirty, and distressed or neat, well groomed,
and calm. Often, abused women are subjected to unnecessary
diagnostic testing to determine the cause of the chronic conditions.
Optimizing Outcomes
Recognizing Signs of IPV
By recognizing signs of IPV, nurses can be instrumental in helping to identify
women at risk or in danger. Certain behavioral clues may point to abuse. For
example, the intimate partner may refuse to leave the victim during the interview
and physical assessment or may answer all questions. The abuser may display
extreme attentiveness toward the victim and attempt to describe to the care
provider exactly how the injuries were sustained. The abuser may hover,
dominate, and control the information given. The abuser may refuse to allow the
victim to share private time with the health professional. The information about
the circumstances surrounding the injury may not match the actual injuries.
Frequently, victims suffer repeated injuries and delay medical treatment for
serious injuries. Nurses and other health-care providers should remember that
medical encounters can be extremely distressing and anxiety-producing for
individuals who are in abusive relationships.
Specifically, the nurse should remain alert to the following possible indicators
of IPV:
• Overuse of health services
• Vague, nonspecific complaints
• Repeated missed appointments
• Unexplained or untreated injuries
• Injuries/bruises in various stages of healing
• Significant delay between the injury and the presentation for care
• Injuries that do not match the patient’s description of how they were incurred
• Evidence or a history of several previous injuries
• Partner who refuses to leave the patient’s side or answers all questions for the
partner
• Nervous, ashamed, or evasive appearance
• Description of their partner as controlling or prone to anger
• Seems uncomfortable or anxious in the presence of their partner
• Stress-related or mental health illness; anxiety, depression, suicide attempts
• Exacerbation of chronic conditions such as asthma or migraines
• Gynecological problems, miscarriages, sexual dysfunction, vaginal discharge,
chronic pelvic pain
Source: Centers for Disease Control and Prevention, 2018; Crisis Prevention
Institute, 2021; M. J. Scannell & Normandin, 2018.
TABLE 28-2
Risk Factors for Experiencing IPV
INDIVIDUAL RELATIONSHIP COMMUNITY SOCIETY
• Low self-esteem • Marital conflict-fights, • Poverty and • Traditional
• Low income tension, and other associated gender norms
• Low academic struggles factors and gender
achievement/low • Difficulties • Low social inequality
verbal IQ communicating capital-lack of • Cultural norms
• Young age between partners institutions, that support
• Aggressive or • Jealousy, relationships, aggression
delinquent behavior as possessiveness, and and norms toward others
a youth negative emotion that shape a • Societal
• Heavy alcohol and within an intimate community's income
drug use relationship social inequality
• Having multiple interactions • Weak health,
• Depression and
suicide attempts partners or suspected • Poor educational,
• Anger and hostility by their partners of neighborhood economic,
infidelity support and and social
• Lack of nonviolent
cohesion policies/ laws
social problem-solving • Marital instability-
skills divorces or • Weak • Beliefs in
separations community family honor
• Antisocial personality
• Dominance and sanctions and sexual
traits and conduct
control of the against IPV purity
problems
relationship by one • High density • Ideologies of
• Poor behavioral
partner over the other of places that male sexual
control/impulsiveness
sell alcohol entitlement
• Traits associated with • Acceptance of
violence • Community • Weak legal
borderline personality
• Economic stress and norms that sanctions for
disorder
low access to paid privilege or sexual
• History of being ascribe higher
employment for violence
physically abusive status to men
women
• Having few friends and and lower
being isolated from • Unhealthy family
relationships and status to
other people women
interactions
• Unemployment
• Association with
• Emotional dependence
antisocial and
and insecurity
aggressive peers
• Belief in strict gender
• Parents with less than
roles (e.g., male
a high-school
dominance and
education
aggression in
relationships) • Having few friends and
being isolated from
• Desire for power and other people
control in relationships • Witnessing IPV
• Hostility toward between parents as a
women child
• Attitudes accepting or • History of experiencing
justifying IPV poor parenting as a
• Being a victim of child
physical, • History of experiencing
psychological abuse physical discipline as
or other forms of a child
maltreatment as a
child Unplanned
pregnancy
Sources: Centers for Disease Control and Prevention (2018); Violence Prevention.
World Health Organization (2017);Violence Against Women. Newsroom. Fact
Sheets.
NURSING INSIGHT
Recognizing Physical Patterns of IPV Injury
When caring for a victim of IPV, nurses must always complete a head-to-toe
assessment. Patients may be unaware of some injuries that the nurse may
detect. Physical injuries characteristically appear in a central pattern on the
face, chest, breasts, abdomen, and neck. The patient may complain of
abdominal pain upon palpation, chest pain related to rib trauma, or
musculoskeletal pain accompanied by redness and swelling. Bruises may be
noted on the posterior aspect of the arms, along with injuries suggestive of a
defensive-type posture that occur when someone holds their arm up to cover
their face. Other injuries may take on the form of the object that was used to do
the abuse, such as fingertips, bite marks, or a belt. The most common site for
genital injuries is the posterior fourchette, which often occurs when the patient
has experienced sexual abuse.
TABLE 28-3
Risk Factors for Committing Intimate Partner Violence
INDIVIDUAL FACTORS RELATIONSHIP FACTORS
Young age Marital confl ict—fi ghts, tension, and
Low self-esteem other struggles
Low income Marital instability—divorces or
Low academic achievement separations
Aggressive or delinquent behavior as a Dominance and control of the
youth relationship by one
Heavy alcohol and drug use partner over the other
Emotional dependence and insecurity Unhealthy family relationships and
Unemployment interactions
Depression Economic stress
Anger and hostility Community Factors
Antisocial personality traits Poverty and associated factors (e.g.,
Borderline personality traits overcrowding)
Prior history of being physically abusive Low social capital—lack of institutions,
Having few friends and being isolated relationships, and norms that shape a
from other people community's social interactions
Belief in strict gender roles (e.g., male Weak community sanctions against IPV
dominance and aggression in (e.g., unwillingness of neighbors to
relationships) intervene in situations where they
Desire for power and control in witness violence)
relationships Societal Factors
Perpetrating psychological aggression Traditional gender norms (e.g., women
Being a victim of physical or should stay at home, not enter
psychological abuse (consistently one of workforce, and be submissive; men
the support the family and make the
strongest predictors of perpetration) decisions)
History of experiencing poor parenting as
a child
History of experiencing physical
discipline as a child
Source: Centers for Disease Control and Prevention (CDC) (2010); Sexual assault
and STDs: 2010.
BOX 28-1
Categories of IPV
Physical abuse: The intentional use of physical force with the potential for
causing death, disability, injury, or harm. Direct acts include slapping, punching,
kicking, biting, strangulation, burns, attacking with weapons, throwing objects,
and depriving the partner of sleep. Indirect acts include abuse in which physical
effects can result such as subjecting the person to reckless driving or
withholding medical attention.
Sexual coercion: Includes the use of physical force to compel a person to
engage in a sexual act against their will, whether or not the act is completed;
attempted or completed sex act involving a person who is unable to understand
the nature or condition of the act, to decline participation, or to communicate
unwillingness to engage in the sexual act (e.g., owing to illness, disability, or the
influence of alcohol or other drugs or because of intimidation or pressure); and
abusive sexual contact. Other acts include forcing the person to engage in
sexual activities with others, pregnancy coercion, and subjecting the person to
sexually transmitted infections.
Threats: A type of abuse in which words, gestures, or weapons are used to
communicate the intent to cause death, disability, injury, or physical harm. These
can include threats to harm the partner, partner’s family, friends, pets, property,
and/or children (or threat to take the children away), as well as indirect acts and
threats to kill themselves.
Emotional abuse: Emotional abuse constitutes a range of various tactics,
name calling, threats of acts, coercive tactics, publicly humiliating partners,
convincing the partner they have mental health problems, and gaslighting.
Stalking, which refers to harassing or threatening behavior that an individual
engages in repeatedly (e.g., following a person, appearing at a person’s home
or place of business, making harassing phone calls, vandalizing a person’s
property) is frequently included among the types of IPV.
Isolation: Isolation includes cutting partner off from friends and family;
denying privacy; preventing them from leaving the house; denial of
communication from other people; preventing the person from learning the
language spoken in the country where they live; and controlling social media,
phone calls, and e-mails.
Economic abuse: Occurs when the perpetrator controls all money, prevents
the partner from working, or forces the partner to work excessively and takes the
earnings. Related types of abuse include interfering with the partner’s job or
ruining credit ratings so that the person is financially distressed.
Sources: Centers for Disease Control and Prevention (2018); Violence Prevention.
Scannell, M. J., & Normandin, P. A. (2018); Interpersonal violence. Fast Facts
About Forensic Nursing, 79–89; World Health Organization (2017); Violence
Against Women. Newsroom. Fact Sheets.
Strangulation has been identified as a red flag indicating escalating
violence and remains one of the most lethal forms of IPV for women.
Women who are strangled during IPV may or may not demonstrate
physical evidence of an injury to the neck. Visible evidence such as
red marks, scratches, scrapes, bruises, or rope burns may be
apparent in only a small percent of strangulation cases. Nurses
should be alert to patient complaints such as persistent throat pain,
voice changes, or difficulty swallowing, which may indicate neck
trauma sustained during an act of violence. Chin abrasions may be
present; as the victim lowers the chin in an instinctive effort to protect
the neck, the skin is scraped against the abuser’s hands. Victims of
strangulation attempts should be evaluated for possible damage
(e.g., fracture) to the hyoid bone, a small horseshoe-shaped bone in
the neck that supports the tongue. Although breathing difficulty may
initially appear mild, damage to the hyoid bone or other underlying
structures may result in fatal asphyxiation up to 36 or more hours
after the assault. Common areas to look for petechiae include the
sclera of the eyes, mouth, and tongue, which often occurs during
strangulation as pressure causes the bursting of these blood vessels
(Scannell et al, 2017).
Assessment Tools
Questions to Ask About Strangulation
Many of the available IPV screening tools do not include questions specific to
strangulation, and nurses need to be aware of including questions about
strangulation when screening for IPV. Anyone at risk for strangulation such as
patients with a history of IPV, sexual assault (SA), dating violence, human
trafficking, or stalking should be screened for possible occurrences of
strangulation. If someone discloses strangulation, nurses must document and
complete a thorough assessment on patients who have disclosed it. All
instances of strangulation should be documented thoroughly and accurately. In
some states, this action may constitute a homicide attempt. Assessment will
provide information about the severity of the assault and the need for a higher
level of health care. The nurse can ask the patient:
• Have you ever been strangled?
• What was the mechanism of strangulation?
• What was the duration of strangulation?
• Were you shaken?
• How many times were you strangled?
• Did you experience any loss of consciousness?
• Did you lose your bowels or notice any incontinence?
• Do you have a sore throat, change in voice, or new cough?
• Do you experience any difficulty breathing? (Scannell et al, 2017; Armstrong &
Strack, 2016)
Sexual Coercion
Sexual coercion occurs when the victim is coerced to carry out
sexual intercourse or other sexual activities (whether or not they are
completed) against their will. It may also include forced participation
in an early initiation of sexual activity, forced participation in sexual
activity viewed as humiliating or degrading, or forced participation in
sexual activities with others. Other aspects may include withholding
sex or the abuser having multiple sexual partners, which exposes the
victim to sexually transmitted infections including human
immunodeficiency virus (HIV) and AIDS. Contraception coercion
involves control over someone’s reproductive health. This includes
tampering with birth control, decreased condom use or otherwise
unprotected sexual intercourse, pressure to have or abort a
pregnancy, or forcing pregnancies to occur rapidly, one after one
another.
Psychological (Emotional) Violence

Psychological or emotional violence includes acts such as coercion,
making threats, and stalking. The abuser may verbally abuse the
victim with criticism, insults, put-downs, or name-calling. The
perpetrator may use facial expressions or gestures to intimidate and
instill fear. Other forms of emotional abuse include the perpetrator’s
use of threats of harm to children, family members, or pets. Not
uncommonly, abusers destroy the victim’s property, abuse their pets,
or display weapons to force the victim into submission. The abuser
may mislead children into viewing the victim as having “earned” the
abuse by causing the perpetrator to become angry—in this situation,
the children often blame the victim for the resulting violence. The
perpetrator frequently places the blame on the victim—denying fault
and instead claiming that any physical injury resulted from the victim’s
“clumsiness.” Often, the victim’s injuries are minimized and the
abuser creates excuses for the abusive behavior. The perpetrator
may also attempt to convince others that the victim is incompetent or
guilty of fabrication and not to be believed or taken seriously (Centers
for Disease Control and Prevention, 2018; Scannell et al, 2017).
Isolation
Isolation is a tactic used to limit the victim’s contact and time spent
with family and friends. For example, the abuser may require the
victim to obtain permission to leave the house. The victim may be
forbidden to seek outside employment or to attend school. The
perpetrator may conduct “odometer checks” on the victim’s car
milage to confirm that the victim has not left home, and in some
situations, the victim is required to provide a detailed account of any
time spent away from the abuser. With new technology available, the
abuser often uses GPS or cell phone tracking. The abuser may listen
to all the victim’s conversations with other people and read e-mails,
texts, and other messages. The abuser may also deny the victim
access to medical services.
Stalking is often a tactic used in IV relationships, in which the
abuser always tracks the victim and their whereabouts. According to
the CDC, 1 in 6 women and 1 in 17 men have experienced stalking in
their lifetimes (Centers for Disease Control and Prevention, 2021).
Stalking constitutes a serious threat and may result in severe
emotional distress, depression, and PTSD.
Acts of stalking may include:
■ Unwanted and/or constant phone calls
■ Unwanted and/or constant e-mails, instant messages, text
messages, voice messages, or social media messages
■ Contacting or posting about the victim on social networking sites
(Facebook, Twitter, etc.)
■ Approaching a victim or showing up unwanted at the victim’s home,
workplace, or school
■ Leaving strange or potentially threatening items for the victim to
find
■ Watching, following, or tracking a victim
■ Sneaking into the victim’s home or car and doing things to scare
the victim or let them know the perpetrator had been there
■ Damaging property
■ Sending gifts
■ Stealing things from the victim (Centers for Disease Control and
Prevention, 2021; National Center for Victims of Crime, n.d.)
Economic Abuse
Economic abuse may include the abuser controlling all aspects of
the victim’s finances, refusing to share money, forcing the victim to
account for any money spent, and forbidding the victim to work
outside of the home. For the perpetrator, these actions help to bring
about the victim’s emotional and financial dependency on the abuser.
The abuser may force the victim to miss work repeatedly, place
frequent telephone calls to the victim at the workplace, or show up at
the workplace unannounced to jeopardize the victim’s work ethic and
job security. In addition, the abuser may indirectly interfere with the
victim to cause stress at their place of employment. For example, the
abuser may prevent the victim from sleeping so they miss work or
cannot perform on the job. In other cases, the abuser may force the
victim to work several jobs and take their wages or destroy the
victim’s credit rating so they cannot get an apartment or loan.
PHASES OF ABUSE
Three phases of abuse have been identified: (1) tension building; (2)
acute violence/explosion; and (3) a tranquil, loving period of calm and
remorse, sometimes termed the honeymoon period. Although not
all abusive relationships follow this cycle, many victims can readily
recognize this pattern (Walker, 1979, 1984).
Tension-Building Phase
The first phase is characterized as a period of increasing tension.
During this time, the abuser demonstrates hostility and anger without
culminating into violent outbursts. The victim senses the escalating
behavior and attempts to placate the abuser. In many situations, the
victim’s behavior postpones rather than prevents the abuse. At some
point, the victim realizes that they cannot control the violent behavior
and withdraw to cope. This action only heightens the abuser’s anger.
They may also increase the use of alcohol and other substances
(Walker, 1979, 1984).
Acute Violence and Explosion Phase

In the second phase, the abuser discharges the pent-up tension. This
phase may be triggered by an internal response in the abuser or by
an external crisis. Over a period of hours or days, the abuser may
engage violent acts, such as biting, slapping, punching, stomping,
choking, pushing, burning, or mutilating. Most injuries are directed at
the face, neck, chest, breasts, buttocks, and abdomen; the hands
and forearms are often damaged as the victim attempts to protect
themself. The abuser often makes the victim feel that they have
angered the abuser and thus is responsible for the abuse. Frequently,
the victim minimizes the extent of injury and is reluctant to seek
medical care (Walker, 1979, 1984).
The Honeymoon Phase
During the third phase, the abuser feels remorse and apologizes
profusely. They promise that the abuse will never happen again and
may even believe that it will not. The abuser showers the victim with
love and kindness, lulling them into forgiveness and a desire to
continue the relationship. The victim desperately wants to believe the
abuser and is renewed in their hope that they really will change. This
phase provides the positive reinforcement for remaining in the
relationship. The victim denies the reality that the abuse will recur.
Unless there is some intervention at this point, this phase will end
and the cycle of violence will be repeated (Walker, 1979, 1984).
Victims’ Reactions to the Phases of Abuse

Victims react in various ways to each of the three phases of abuse.
During the first, or tension-building, phase, the victim uses denial as a
defense mechanism. If the relationship is not terminated at this point,
the abuse continues to escalate in frequency and violence, and the
phases of abuse will occur more frequently with less time between
the cycles. During the second (acute violence) phase, the victim can
no longer deny that the violence is occurring. Unfortunately, they are
unable to stop the violence, often due to fear of further provoking the
abuser. The victim may adapt various coping methods such as dutiful
obedience and cooperation, often conforming to the abuser’s wishes
in a desperate effort to reduce the violence. This behavior has been
called “learned helplessness.” The victim feels hopeless, powerless,
and depressed. They may have difficulty seeking help and may fear
lack of belief or assistance from others.
SPECIAL POPULATIONS
Pregnant Women
Pregnancy and IPV have an interrelated association: Unintended
pregnancy is often an outcome of an IPV relationship, and IVP often
increases during a pregnancy. IVP may also detrimentally affect the
health of a pregnancy and has been linked to traumatic
consequences including placental abruption, pelvic fractures, vaginal
bleeding, hypertension, miscarriage, preterm labor, increased risk for
cesarean section, anemia, kidney infections, inadequate weight gain,
and inadequate prenatal care utilization (Scannell, 2018a; USPSTF
et al, 2018). Fetal effects of IPV have been noted to include fetal
injury, preterm delivery, stillbirth, low birth weight, perinatal fetal
distress, intrauterine growth restriction, and hospitalizations
(Scannell, 2018a; USPSTF et al, 2018).
Older Populations
Elder abuse is defined as a single or repeated act, or lack of
appropriate actions, which causes harm, risk of harm, or distress to
an individual 60 years or older (Centers for Disease Control and
Prevention, 2020). The CDC estimates that 1 out of every 10 people
ages 60 and older who lives at home is a victim of abuse. Women 60
and older are at risk for IPV, which includes physical violence, sexual
violence, economic abuse, emotional abuse, and neglect (Box 28-2).
This population may not report abuse for fear of getting their family
member (husband or child) in trouble. Because these women grew
up and married during a time when IPV was often ignored, they may
have suffered many years of abuse and frequently have problems
with poor self-image and guilt. In addition, they may have health
problems that keep them dependent on their abusive partner, feel
committed to caring for their abusive and aging partners, and fear
being alone.
LGBTQI Communities
Individuals within the LGBTQI communities experience IVP at a rate
equal or higher than heterosexual individuals. Many individuals
experience many of the same types of abuse that heterosexual
partners do, but these populations may experience different acts of
violence. For example, the abuser may threaten to “out” the victim’s
sexuality or gender as a form of control. Many in the LGBTQI
community do not seek care for IPV because of limited resources and
other barriers to care. For example, a female who is a victim of IVP
relationship may need to seek services at a shelter, but her female
partner may go to the same shelter. A transgender woman may seek
shelter but be unable to access services because of gender (Calton
et al, 2016).
BOX 28-2
CDC Categories of Abuse/Neglect Toward

Elderly and Vulnerable Adults
Physical abuse: Occurs when an individual is injured, assaulted, or threatened
with a weapon or inappropriately restrained.
Sexual abuse or abusive sexual contact: Constitutes any sexual contact
against an individual’s will; includes acts in which the elderly person is unable to
understand the act or is unable to communicate. Abusive sexual contact
includes intentional touching of the genitalia, anus, groin, breast, mouth, inner
thigh, or buttocks.
Psychological (emotional) abuse: Occurs when an elder experiences
trauma after exposure to threatening acts or coercive tactics (e.g., humiliation,
embarrassment, controlling behavior, social isolation, trivializing needs, and
damaging or destroying property).
Neglect: Failure or refusal of a caregiver or other responsible person to
provide for an elder’s basic physical, emotional, or social needs, or failure to
protect an elder from harm.
Abandonment: The willful desertion of an elderly person by a caregiver or
other responsible person.
Financial abuse/exploitation: The unauthorized or improper use of an
elder’s resources for monetary or personal benefit, profit, or gain (e.g., forgery,
misuse or theft of money or possessions, improper use of guardianship or power
of attorney).
Source: Centers for Disease Control and Prevention (CDC) (2012). Understanding
intimate partner violence: Fact sheet.
Immigrant Communities
Individuals within immigrant communities often face varying forms of
IPV, but these populations are understudied. Cultural values within
some immigrant communities shape views, tolerance, and treatment
of IPV. Some may believe the husband has the right to abuse his wife
and the victim may be pressured by her own family to stay within the
marriage and submit to her husband. An abuser in this community
may prevent the victim from learning English, make threats about
deportation of the victim or their children, interfere with the person’s
employment, hide citizenship documents, or interfere with the
process of seeking legal citizenship (National Sexual Violence
Resource Center, 2018).
Adolescents
DV/IPV among adolescents is a serious public health problem that is
often overlooked, whether it occurs in a dating relationship, in the
home environment, or within another type of relationship. Homeless
youths, youths from families with DV, and youth who use substances
have a higher risk for experiencing DV. In a nationwide survey, 9.4%
of high school students report being hit, slapped, or physically hurt on
purpose by their boyfriend or girlfriend (National Domestic Violence
Hotline, 2019). Adolescent victims of IPV have several reasons for
failing to report the violence. Many do not want family or parents to
know and fear they may get in trouble for actions such as underage
drinking or breaking household rules. They may anticipate negative
parental responses and feel discomfort, embarrassment, shame, and
awkwardness in talking to family member about IPV (Gonzalez-
Guarda et al, 2016).
INTIMATE PARTNER VIOLENCE SCREENING,

DOCUMENTING, AND REPORTING
Screening for IPV
In 2000, the American Nurses Association (ANA) published a position
statement on violence against women. This important document
advocates universal screening, routine assessment, and
documentation of abuse for all victims in any health-care setting.
“Universal screening” means that all patients are assessed for IPV,
regardless of the presence or absence of any abuse indicators. The
majority of abused patients do not present with obvious signs and
often will not openly disclose a history of abuse. IPV patients are
more likely to disclose abuse and seek assistance if the environment
is safe and the health-care provider is someone they can trust.
Routine screening can facilitate early identification of IPV when signs
and symptoms may not be readily apparent. This can mean a timely
referral for appropriate services that may prevent further injury. If the
screening tool suggests that the patient may be at high risk for abuse,
a more detailed assessment should be performed.
A number of screening tools have been developed to assess for
IPV. Those with the highest levels of sensitivity and specificity are the
Woman Abuse Screening Tool/Woman Abuse Screening Tool-Short
Form (WAST/WAST-SF); the Hurt, Insult, Threaten, and Scream
(HITS); the Slapped, Threatened, and Throw (STaT); Humiliation,
Afraid, Rape, Kick (HARK); Modified Childhood Trauma
Questionnaire-Short Form (CTQ-SF); and the Ongoing Abuse
Screen/Ongoing Violence Assessment Tool (OAS/OVAT)
(Kottenstette & Stulberg, 2013). The Abuse Assessment Screen
(AAS) is a brief, easy-to-use validated tool that contains five simple
questions along with a body map to provide visual reference for
physical injury (Fig. 28-1). If the woman has disclosed IPV, the nurse
must document that a risk assessment was completed.
FIGURE 28-1 Abuse Assessment Screen. The National Health
Resource Center on Domestic Violence recommends that in the case
that screening is required, it be done in addition to a Universal
Education approach to violence prevention.
Trauma-Informed Care
All interviews a nurse conducts with a patient who has experienced
violence should be based in trauma-informed care principles.
Trauma-informed care (TIC) is a strength-based framework that
recognizes the effect of trauma on a patient’s physical and emotional
well-being. As a patient-centered approach to providing care, TIC
places patient central as the expert in making the health-care
decisions that are best for them. This framework fosters the
relationship with the patient based on respect, trust, and safety,
allowing them to feel empowered to report IPV and potentially leave
the relationship and pursue criminal justice.
TIC requires an empathetic and nonjudgmental approach on the
part of the nurse. Avoid attributing violence to risky behavior by the
victim, such as substance use, which often represents a coping
mechanism. During TIC, the nurse must watch for signs and
symptoms of distress and minimize retraumatization by giving breaks
or redirecting questions. The patient should be informed of what will
be happening in the examination process and be allowed time to
consider and process the information and prepare. Some patients
may have a difficult time with certain areas of the medical forensic
examination and may require additional time to prepare.
Essential components of TIC include the following:
■ Introduce yourself to the patient and explain the purpose of your
role.
■ Give patients a choice of where in the room to sit or stand.
■ Meet the person at eye level.
■ Ask permission before touching or interviewing the patient.
■ Interview the patient before they disrobe.
■ Explain all medical terms and procedures.
■ Offer frequent breaks and rest periods.
■ Monitor for signs of distress.
■ Provide extra time for the patient to process information and ask
questions (Jordan, 2019; Miller, 2018).
What to Say
Conducting the IPV Interview
All interviews should take place in a private place. Children over the age of 3
years should be gently removed from the room and cared for by a staff member
while the interview takes place. If language is a concern, a trained interpreter
should be available to facilitate communication. The victim’s partner, family
members, or friend should not be used as a translator.
After ensuring privacy, the nurse should maintain eye contact and begin with
a statement such as, “In this office, a part of our routine care is to ask about
IPV.” Then, proceed with open-ended questions such as, “How are things at
home? Do you feel safe at home? Do you feel safe in your community?” before
asking more direct questions such as, “Do you ever feel pressured to have
sex?”
If the patient hesitates to answer yes or no, offer the choice of “sometimes” as
a response. It is important not to pressure them to respond to the questions. If
injuries are present, it is important to acknowledge them and ask how they
occurred. If the patient’s responses do not seem to match the mechanism of the
injury, voice concern about the inconsistency, but don’t push for details. Always
promote trust and convey caring, and let the patient know that violence is wrong
and that no one deserves to be hurt. Demonstrating a nonjudgmental attitude
and creating trust is an essential strategy in facilitating the patient’s disclosure of
abuse, especially in a busy clinical setting. Gender-neutral language should also
be used to ensure sensitivity to patients, using terms such as “partner” and not
assume husband or boyfriend.
Once a patient discloses abuse, the nurse should facilitate an assessment to
determine urgent safety needs and to guide the plan of care. If the patient is in
immediate danger, an assessment for suicide and/or homicide may be indicated
as well.
Patients may not always use the word “abuse” when describing their intimate
relationships. It is important to be aware of words that suggest that abuse is
occurring. For example, the patient may confide that their partner “has a temper”
or “gets angry easily.” Care should be taken to avoid the use of stigmatizing
terms such as rape and instead use more neutral phrases such as forced to
have sex. Using the same terms expressed by the patient may enhance comfort
in confiding about the full extent of the abuse.
When IPV is identified, nurses and other health-care professionals
share the responsibility of offering referrals to confidential victim and
social support resources within the community. Referrals should be
made regardless of whether the woman chooses to report the abuse
to law enforcement. In the ideal situation, all health-care providers
should be a part of a coordinated community response to reduce DV,
a response in which shelters, hospitals, health-care providers, legal
advocates, and law enforcement work together to improve safety and
save lives.
Documenting IPV
Accurate documentation is essential, as it provides a record of the
abuse, facilitates communication among the various professionals
dealing with the case, and provides a record of previous episodes of
abuse. Documentation provides evidence of abuse escalation and
can be beneficial in helping the patient to recognize and acknowledge
the abuse. The patient’s general appearance and demeanor are
recorded, and additional subjective information, such as reported
threats and psychological abuse perpetrated by the abuser, is
documented as well. Findings from the physical examination are
carefully documented. It is important to remember that rape and SA
are legal terms that should not be used in medical records. Body
maps are useful in accurately pinpointing the areas of injury, including
the location, size, and age. Once the patient’s signed consent has
been obtained, photographs may be taken. Photographs provide an
excellent visual record of the injuries. Additional information including
the results of laboratory and diagnostic tests, radiography, and all
referrals (e.g., other health-care professionals, local shelters) are
recorded on the patient’s health record.
In the clinic, office, or hospital setting, nurses should carefully
document all injuries in great detail and use body maps to enhance
clarification. For example, terms such as strangulation should be
used in place of choked. By definition, strangulation is an assault with
malicious intent that causes harm to the victim, while choking occurs
when a foreign object has been lodged in the patient’s trachea or
esophagus. Treatment interventions and discharge information must
be clearly noted on the chart, along with a description of all referrals
and follow-up options that were provided to the patient. Nurses can
offer immediate contact with an IPV counselor either in person or by
phone, and referral to a mental health provider may also be
appropriate.
Nurses must ensure that an adequate referral system is in place for
victims of IPV. A number of resources are available to assist nurses
in providing appropriate, sensitive care in a timely manner and to act
against IPV perpetrators (Box 28-3). Establishing a professional
relationship with the local DV center empowers the nurse with a
variety of resources to better help the victim of abuse.
BOX 28-3
Safety Strategies and Resources for Victims of

IPV
Nurses can teach women to do the following:
• Remain aware of surroundings at all times.
• Identify trusted others who can check on your safety.
• Keep the car parked pointing out, the gas tank filled, and readily accessible
extra keys.
• Create and rehearse a safety plan with the children and teach them how to dial
911.
• Shop and bank at different places, especially if being stalked.
• Use different routes for driving to work or try to receive rides from different
persons.
• Obtain a protection order.
• Refrain from lunching alone.
• Cancel all joint credit card and bank accounts.
• Ask for workplace escorts to the car or public transportation.
• Determine whether an immediate danger exists; if so, go to a pre-established
safe place and call 911 (Davila et al, 2013).
HOTLINES
• National Domestic Violence Hotline 1-800-799-SAFE (7233)
• Rape Abuse & Incest National Network (RAINN) 1-800-656-HOPE (4673)
WEB SITES
• Futures Without Violence (formerly known as Family Violence Prevention
Fund) www.futureswithoutviolence.org
• National Coalition Against Domestic Violence www.ncadv.org
• National Network to End Domestic Violence www.nnedv.org
• National Resource Center on Domestic Violence www.nrcdv.org
• Office on Violence Against Women www.usdoj.gov/ovw
Key Documenting Elements

The nurse should document:
■ Description of the person who abused the patient
■ Date and time of incident or abusive situation
■ Patient’s account of what happened and all detail should be
included
■ Specific details about the abuse, using quotations to indicate when
the statements represent exactly what the patient said
■ Injuries should be documented with detailed descriptions and
measurements, and pictures should be taken if possible
■ Note patient’s coping and responses to the abuse
■ Type of injuries sustained or official reports
■ Note safety measures taken and safety assessment
■ Note referrals made for follow-up
■ Mandatory reporting and corresponding safety planning
Optimizing Outcomes
Photographing IPV Injuries

A minimum of three photographs should be taken of each injury: a full-body
photograph of the victim to establish identity, an injury photo taken a medium
distance from the body, and a close-up photo of each individual injury. All
photographs are clearly labeled with the patient’s name, date, time that they
were taken, and the photographer’s name. Ideally, a blue background, which
shows the depth and defines the clarity of an injury, is used. Additional
photographs can be taken at the follow-up visit (2 to 4 days) or at the local law
enforcement agency in cases where the incident has been reported to provide
additional documentation of the progression of the injuries (Scannell, 2018b).
Reporting IPV
Victims of abuse may be reluctant to report personal violence due to
fear, embarrassment, or the belief that the police cannot or will not do
anything to help. Victims often stay in an abusive relationship or fail to
report the abuse because of:
■ Fear for their own safety, safety of their children, or other family
members
■ Distrust of police, law enforcement, and legal system
■ Denial or disbelief that the abuse is occurring
■ Commitment and emotional attachment to or love for partner
■ Hope the behavior would change
■ Shame and embarrassment
■ Staying for the sake of the children
■ Depression and stress
■ Lack of faith in other people’s ability to help
■ Belief in the value of self-reliance and independence
■ Familial/community pressures
■ Fear of deportation of themselves or other family members
■ Lack of financial or economic resources (Crisis Prevention Institute,
2021; Slabbert, 2017)
FOCUS ON SAFETY
State Laws About IPV Reporting
Nurses must be familiar with laws on the mandatory reporting of IPV;
requirements vary from state to state. Certain states mandate that injuries
resulting from criminal conduct (which encompasses IPV) be reported. Also,
some states require medical personnel to report specific types of injuries (i.e.,
burns, firearms, stab or knife wounds, strangulation, and injuries resulting from
a deadly weapon) to law enforcement regardless of the victim’s statement. A
synopsis of current state statutes and reporting guidelines is available at:
https://evawintl.org/wp-
content/uploads/CompendiumofStateandUSTerritoryStatutesandPoliciesonDo
mesitceViolenceandHealth-Care.pdf
However, it must be pointed out that mandatory reporting violates the
framework on which the ethical codes of nursing are based. The ANA Code of
Ethics for Nurses, provision 3, states, “The nurse promotes, advocates for, and
strives to protect the health, safety, and rights of the patient” (ANA, 2015).
Mandatory reporting of IPV may place victims in danger and violates the
victim’s right to make personal choices. Furthermore, mandatory reporting laws
place the responsibility of the victim’s safety on health-care professionals, who,
in turn, must rely on law enforcement and the courts to provide safety for the
victim. This process may not necessarily be a desirable alternative, considering
that in many situations the abuser is incarcerated for only a brief period of time.
NURSING INTERVENTIONS
Education and Counseling
Education and counseling are an essential nursing role in IPV care.
The nurse should inquire about violence and family conflict, listen to
the woman’s story, and provide information and referrals. Nurses
should reassure their patients that they will provide help regardless of
whether they choose to remain in the relationship. Nurses must assist
victims of violence by informing them of available options and by
providing support in making decisions. Allowing the woman to break
the cycle of abuse restores her power and enables her to regain
control of her life.
Safety Cards to Facilitate IPV Screening and Education
Futures Without Violence (http://www.futureswithoutviolence.org) has developed
several small, easy-to-conceal, wallet-sized safety cards and brochures in
different languages. The safety cards provide information about unhealthy
relationships and include self-administered questions for IPV and reproductive
and sexual coercion along with safety planning strategies and tips on obtaining
help and other resources. Cards and brochures are available for LGBTQI
communities and for individuals of various racial and ethnic backgrounds.
Health-care providers can use the safety cards to facilitate IPV screening and
education; use of the cards provides a brief, evidence-based intervention that
can be reviewed with the patients (Futures Without Violence, 2019).
Leaving an IPV Relationship

Leaving an IPV relationship is a serious decision that often results in
escalating violence. Women typically have several reasons for
staying in this type of situation. Many women cannot leave for
financial reasons. Research has shown that homelessness for
women most commonly occurs after leaving an IPV relationship
(Slabbert, 2017). Enacting a safety plan when leaving takes
collaboration and expert level of care, given the increased risk for
violence. Nurses should never try to enact a safety plan on their own
without consultation and referrals to experts. Appropriate referrals
made in a timely manner help ensure the safest plan for anyone in an
IPV relationship who has express readiness to leave.
Optimizing Outcomes
The ABCDES of Trauma-Informed Care for the IPV victim

Nurses should remember the ABCDES of Caring to provide appropriate,
sensitive care for victims of IPV:
A—Reassuring the woman that she is not alone
B—Expressing the belief that violence directed against the woman is
unacceptable and not her fault
C—Confidentiality of the shared information will be maintained (explain the
mandatory reporting laws of the practice state, when applicable)
D—Documentation—Descriptive documentation includes quoted
statements, accurate descriptions of all injuries, and photographs (with
the woman’s written consent)
E—Education about the cycle of violence and community and national
resources
S—Safety—Always the most important component of the intervention,
especially because one of the most dangerous times for the victim is the
point at which she decides to leave her abuser
Treatment and Follow-Up

IPV centers offer services that frequently include a 24-hour hotline,
advocacy with community systems, and temporary shelter for victims
who cannot return home because of safety concerns for themselves
and their children. Advocacy with community systems includes
referral for services such as legal aid, housing, mental health,
substance abuse, and dental referral resources. In most situations,
IPV centers also assist victims in accessing local and state
government programs.
Nurses who deal with victims of IPV should also be familiar with the
local SA center. Women who have been sexually assaulted can
benefit from the specialized services (e.g., individualized counseling,
support groups) provided by these centers. Nurses can also advocate
for IPV awareness and assistance by placing information about local
resources in various public and private locations throughout the clinic
or office (e.g., waiting area, restroom, examination room) where
patients can have ready access to them. Many clinics distribute
business-size IPV cards that contain essential information such as
strategies for self-protection and protection of children and the
National Domestic Violence Hotline phone number. The business-
size card is particularly useful as it can be easily concealed.
Nurses must also recognize the victim’s need for legal information.
For those with access to a computer, the Web site WomensLaw.org
(http://www.womenslaw.org) contains an abundance of easy-to-
understand information for women living with or escaping IPV.
Resources include suggestions for obtaining restraining orders, court
forms, and other legal documents along with locations for various law
enforcement offices. Women who have no access to a computer may
receive assistance by dialing the toll-free phone number for the
National Domestic Violence Hotline (1-800-799-SAFE [7233]).
Excellent IPV resources are available for nurses and other health-
care professionals. The Minnesota Center Against Violence and
Abuse (http://www.mincava.umn.edu) offers educational resources for
training on violence of any type, including IPV, teen violence, and
dating violence.
Once a patient leaves the health-care setting, a lack of personal
contact does not mean that interventions cannot occur. McFarland
and colleagues (2004) used telephone interviews to conduct a
longitudinal study on abused women. After an initial personal contact
to ask about inclusion in the study and obtain informed consent,
researchers contacted the women with either six intervention and four
follow-up calls (experimental group) or four follow-up calls only
(control group). During the phone calls, the interviewers asked
women in the experimental group to answer yes or no to a series of
safety-promoting behaviors. These behaviors included such actions
as hiding money; hiding house and car keys; removing weapons from
the house; asking neighbors to call police if violence begins;
establishing a code with family and friends; and obtaining items such
as birth certificates, important phone numbers, identification cards,
and rent and utility receipts. The research findings indicated that
women in the intervention group (those who received six additional
phone calls) practiced more safety-promoting behaviors than did
those in the control group and that the required nursing time was
minimal. Such research findings are significant in supporting the
important role that nurses and other members of the health-care
team can have in helping victims of DV take control of their
environments and practice positive behaviors that can break the
cycle of abuse.
SEXUAL VIOLENCE
Sexual assault (SA) is a major public health problem in the United
States. SA is defined as “any type of sexual contact or behavior that
occurs without the explicit consent of the recipient, including but not
limited to rape, attempted rape, fondling, incest, molestation, sodomy,
and forcible intercourse” (United States Department of Justice, 2017).
Table 28-4 defines types of SA.
The effects of SA can have a long-lasting negative effect on the
victim’s health, including reproductive health issues, sexually
transmitted infections, pelvic inflammatory disease, transmission of
HIV, pregnancy, and infertility. Depending on the severity of force
used during the assault, victims can also experience minor to major
injuries resulting in disabilities, permanent scarring, and death
(Scannell, 2018b; Wong & Balemba, 2016). The mental health effect
is often prolonged and can manifest as depression, anxiety, PTSD,
and even suicide ideation and suicide attempts (Brooker & Tocque,
2016). Another significant effect of SA is the increase in substance
use and misuse of alcohol in the victim (Brooker & Tocque, 2016;
Lorenz & Ullman, 2016). Extensive research has demonstrated close
links between SA and future alcohol and illicit substance use, which
can have a direct effect on one’s future health and academic
performance (Lorenz & Ullman, 2016).
TABLE 28-4
Types of Sexual Assault Acts
TYPES OF SEXUAL ASSAULTS DEFINITION
Penetration assault (rape) “Includes unwanted vaginal, oral, or anal
insertion through use of physical force or
threats to bring physical harm toward or
against the victim.”
Drug facilitated assault “Includes unwanted vaginal, oral, or anal
insertion when the victim was unable to
consent because he or she was too
intoxicated (e.g., unconscious, or lack of
awareness) through voluntary or
involuntary use of alcohol or drugs.”
Unwanted sexual contact “Includes intentional touching, either
directly or through the clothing, of the
genitalia, anus, groin, breast, inner thigh,
or buttocks of any person without his or
her consent, or of a person who is
unable to consent. Unwanted sexual
contact also includes making a victim
touch the perpetrator.”
Noncontact unwanted sexual “Includes unwanted sexual attention that
experiences does not involve physical contact. Some
examples are verbal sexual harassment
(e.g., making sexual comments) or
unwanted exposure to pornography. This
occurs without a person’s consent and
sometimes, without the victim’s
knowledge.”
Source: Centers for Disease Control and Prevention (2018);Violence Prevention.

Victims of an SA may seek care at an emergency department or
specialty center and will require time-sensitive, compassionate,
coordinated care that addresses medical, psychological, and forensic
needs. The care of the SA survivor will be coordinated by a team of
specially trained registered nurses, often called a SANE nurse.
The Sexual Assault Nurse Examiner (SANE)
A sexual assault nurse examiner (SANE) is a registered nurse who has received
certification after specialized training and education in providing medical-
forensic examinations with evidence collection kits for victims of SA. SANE
nurses provide care within a trauma-informed framework that includes
immediate, compassionate, culturally sensitive, and comprehensive evaluation
and treatment. SANE nurses are trained to address victims’ medical,
psychological, legal, and forensic needs. Currently there are two certifications
from the International Association of Forensic Nurses: SANE-A specific for
adults and SANE-P specific for children (Scannell, 2018b). In most situations,
SANE programs provide 24/7 nursing care to SA survivors in emergency
departments, specialized clinics, and sometimes with sexual assault response
teams (SARTs) throughout the country (Scannell, 2018). If a victim discloses an
SA at a health-care setting, they may need to be referred to a hospital or center
that can provide specialty care.
What to Say
Before Examining a Victim of Sexual Assault
If an SA victim contacts her health-care provider prior to having a physical
examination, it is essential that the nurse offer the following suggestions:
• Report immediately to the medical care facility.
• Do not bathe or shower.
• If you have changed clothes, place all clothes from the assault in a paper bag
and bring it to the hospital.
• Do not brush your teeth or rinse out your mouth.
• Do not douche, urinate, or defecate.
- Do not clean your fingernails.
- Do not smoke, eat, or drink.
- Bring a change of clothes.
- Have a support person accompany you.
A major consideration of evidence collection in SA exams is preservation of
evidence for legal purposes. In some cases, the patient may not want to report
the assault or go through the legal system. Patients should have a clear
understanding of their options. Many patients will opt to be treated for their
injuries without going through the laborious process of evidence collection.
Nurses and other health-care professionals need to be mindful that patient-
centered care allows the patient to decide if evidence collection is a critical
component of their care given its sensitive and personal nature.
Assault History
The nurse must accurately document the specific details of the
assault, pre-assault activity (such as consensual kissing or substance
consumption), post-assault activity, and details about the assailant.
The health-care professional should begin by asking questions
regarding the date and time and location of the assault. Some victims
may be able to recall the specific date and time and others may only
be able to note an approximate date and time. The location where the
assault occurred should be described in detail and any identifying
landmarks should be noted, such as outdoors, grass area, rug, or
room in the house. This will help if there are foreign materials found
on the victim that can place them at specific locations.
A description of the type of assault should be given in detail.
Clarifying questions should be asked. For example, if a victim reports
a history of being touched “down there,” the nurse must ask clarifying
questions as to whether the assaulter touched the vagina or rectum
and whether penetration occurred. Nonpenetrative and nonsexual
acts should be documented if they occurred such as kissing, licking,
touching, and biting. Acts of penetration should document in terms of
oral, vaginal, or rectal. In addition, the penetrative item should be
noted, such as the assailant’s finger, tongue, penis, or object. The
victim should be asked if the assailant used any lubrication and
exactly what type. It should be noted if the assailant used a condom
and what happened to the condom at the end of the assault. If
ejaculation occurred, it should be documented where on the body it
occurred. The victim may not know if ejaculation occurred. The
health-care provider should document other possible transfer of
bodily fluids such as saliva and vaginal secretions and where they
occurred. The position of the victim and the assailant during the
assault should also be noted as this will indicate where injuries may
have occurred.
If a weapon was used, the nurse should document the type of
weapon and use as well as the degree and type of force. Document
whether the assailant used physical force such as holding the victim
down. Verbal threats should be described in direct quotes. Other
types of force can include intimidation, coercion, grooming, and
manipulation. Any physical or verbal resistance on part of the victim
should also be documented.
Document other injuries that occurred in the context of SA such as
hitting, punching, and strangulation. This information can help to
determine the severity of injury and guide the health-care provider in
examining and treating the patient. A description of pain and bleeding
should be documented as to where the victim is having pain.
Document acts of self-defense by the victim such as scratching or
trying to shield themselves from physical violence, as this information
can guide evidence collection.
The health-care provider should gather information about the
possibility of drug-facilitated assault. Many assaults occur in the
context of alcohol or other substances. In some cases, the victim may
have consumed alcohol or other substances consensually before the
assault occurred. In other cases, the victim may have experienced
memory loss, lapse of consciousness, or inability to defend herself
after being given a substance that made her incapacitated and
unable to consent.
Medical Treatment
Medical treatment of SA patients always begins with treating life-
threatening conditions such as strangulation. Depending on the injury,
treatment may include a complete trauma panel with x-rays and CT
scans. Many victims of SA may not be fully aware of the complete
acts that were committed against them.
Prophylactic Treatments
SEXUALLY TRANSMITTED INFECTIONS (STIs)
Patient should receive STI prophylaxis if they are within 5 days of
the assault. Any medications omitted in the acute phase should be
administered if there are no contraindications. Testing practices for
STIs vary. Some acute settings will treat the patient for all possible
STIs and then only test for STIs if there are current signs or
symptoms. All patients presenting for follow-up care with signs and
symptoms of an STI despite having received prophylaxis should be
tested. Unfortunately, some STIs such as syphilis have no
prophylactic treatment. The patient should receive testing around 6
weeks, 3 months, and 6 months post-assault, and patients should be
instructed on signs and symptoms of the STI. All medications should
be completed even if symptoms have resolved to prevent
reoccurrence and drug resistance. While being treated for an STI,
women should either refrain from sexual intercourse or use a condom
because transmission can still occur.
The human papillomavirus (HPV) is one of the most common STIs
worldwide, and the current recommendation is for women ages 9 to
26 to receive the HPV vaccine. Administering the HPV vaccine to
patients is an essential component of SA care. If a woman presents
for follow-up and has not received the HPV vaccine and has no
contraindications for vaccine administration, the vaccine should be
administered.
MEDICATION: Prophylactic STI Treatments
Recommended Treatment With
Infection/Condition 5 Days
Neisseria gonorrhoeae Ceftriaxone 500 mg IM as a single dose
Chlamydia trachomatis Azithromycin 1 g as a single dose or
doxycycline 100 mg twice once a day
for 7 days
Trichomoniasis Metronidazole 2 g orally in a single dose
Human Papillomavirus (HPV) Administer first dose of HPV vaccine
Recommended for females ages 9–26 series
Source: Scannell, 2020; St Cyr et al, 2020.
Hepatitis B vaccination status should be verified for all patients who

present for follow-up care. For patients who have not had the
hepatitis B vaccine series and whose assailant’s hepatitis status is
unknown, the CDC recommends a complete postexposure hepatitis
B vaccine series in the acute period. For patients who have not had
the hepatitis B vaccine and the assailant is known to be hepatitis B
positive, the CDC recommends that the patient receive both the
hepatitis B vaccine and hepatitis B immunoglobulin. Patients with
unsure status may need to have titers drawn to determine the correct
postexposure regimen.
HUMAN IMMUNODEFICIENCY VIRUS

Preventing HIV is a priority in patients who have been sexually
assaulted. Nonoccupational postexposure prophylaxis (n-PEP)
medication to prevent HIV is time-sensitive and is administered within
72 hours of an SA. N-PEP is a regimen of one or more antiviral
medications. N-PEP is prescribed for a course of 28 days depending
on the exposure risk. Patients receiving n-PEP should have had a
baseline liver-function test and blood counts. These patients will
require further risk assessment, medications, and blood monitoring.
N-PEP starter packs typically consist of 3 to 5 days of antiviral
medications given to patients who present in an emergency room.
Follow-up care is essential for patients who have been prescribed
this medication to monitor for abnormal laboratory tests and to
provide prescriptions for the remainder of the medication. Patients
who receive these medications should be counseled on their risk of
acquiring HIV and the importance of adherence. Those who present
outside the 72-hour window for n-PEP should be counseled on their
risk of HIV and tested. Whether patients receive n-PEP or not, they
should be counseled and tested for HIV at 6 weeks and 6 months
(Scannell, 2020; Scannell et al, 2018).
PREGNANCY TESTING AND PROPHYLAXIS

Women who present for follow-up care should be evaluated to
determine if they received pregnancy prophylaxis, also known as
emergency contraception (EC). EC is a standard of care for women
who have been sexually assaulted; however, it is not always
administered to patients. If the patient presents with 120 hours of the
assault prophylaxis and did not receive EC, it should be offered
unless contraindicated. EC comes in two forms: oral hormonal
methods (i.e., levonorgestrel and ulipristal acetate, and copper
intrauterine devices [IUDs]). Levonorgestrel, a progestin, is best
given within 2 days of the SA due to a decrease in efficacy over time.
Ulipristal acetate is not time-sensitive and can be given up to 120
hours after exposure and maintains its efficacy. However, the copper
IUD is the most effective method of EC and can be inserted up to 5
days after exposure and maintains high efficacy. If the women
presents for care more than 5 days after the assault and did not
receive EC, she should be counseled about the risk of pregnancy and
offered pregnancy testing at the time of the visit and 1 month post-SA
if she did not have a menstrual cycle. If patients did receive
pregnancy prophylaxis and have not had a menstrual cycle within 1
month, pregnancy testing is warranted.
Mental Health Care

SA can significantly affect the health and well-being of victims.
Victims may face both short- and long-term medical and mental
health disorders. These affect day-to-day function and can lead to
unhealthy behaviors. Victims who have sustained an SA have
significantly higher rates of PTSD. Often, these adverse
psychological outcomes are multifaceted and occur in conjunction
with one another, including PTSD as well as depression, anxiety,
suicidal ideation, and substance use and abuse.
Discharge Instructions
Discharge instructions are an essential component of post-assault
care. Given the risk for STDs, all women should be instructed on
signs and symptoms of STIs, and written instructions should be given
for reinforcement. The patient should be instructed on the signs and
symptoms to monitor and contact a health-care provider if they
experience these signs and symptoms. They may need to return for
further STD testing if symptoms develop. Support and information on
advocacy services should also be provided. If a woman must return
home to the person who assaulted her, it can affect her ability to seek
health care or continue with prescribed medications. If the perpetrator
is an acquaintance outside the patient’s home, she may be fearful of
further assaults.
Mandatory Reporting
In most states, health-care providers are not required to report an SA
to law enforcement. Cases where the patient is a minor, elder, or
protected disabled person warrant the health-care provider to file a
mandatory report. Some states may require the SANE to file a report
in certain circumstances, such as if a minor was present in the home
where the assault occurred. In other cases, strangulation may be
classified as an attempt at homicide, which in some states falls under
mandatory reporting. Nurses need to be aware of local reporting laws
so they can follow specific laws and regulations regarding mandatory
reporting.
SUMMARY POINTS
■ Intimate partner violence (IPV) is defined as physical, sexual, or psychological
harm or social isolation perpetrated by a current or former partner in an
intimate or dating relationship.
■ The abuser’s actions are intended to instill fear and to intimidate and control
the victim.
■ IPV reaches across all strata of society and affects persons regardless of
economic status, ethnic background, educational level, or religious status.
■ Women who are abused are more likely to be unemployed, suffer from health
problems, and receive public assistance than are women who are not victims
of abuse.
■ Routine screening can facilitate early identification of IPV when signs and
symptoms may not be readily apparent.
■ Accurate documentation of abuse is essential, and nurses must be
knowledgeable about IPV reporting guidelines for their practice state.
■ Nurses must assist victims of violence by informing them of available options
and by providing support in making decisions.
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Sheets. https://www.who.int/news-room/fact-sheets/detail/violence-against-
women

Davis Advantage
CHAPTER 29
Promoting Premenstrual,
Perimenopausal, and Menopausal
Health
CONCEPTS
Female reproduction
KEY WORDS
premenstrual syndrome
climacteric
menopause
premenopause
perimenopause
postmenopause
estrogen therapy (ET)
estrogen plus progestogen (EPT)
hormone therapy (HT)
local ET therapy
progestogen
systemic HT therapy
LEARNING OBJECTIVES

■ Identify diagnostic criteria for premenstrual syndrome.
■ Discuss the unique characteristics of symptoms that accompany premenstrual
syndrome.
■ Describe nonpharmacological and pharmacological approaches to care for
women who experience premenstrual syndrome.
■ Discuss the nurse’s role when caring for a patient with a premenstrual
disorder.
■ Identify physiological changes that occur during the menopausal period.
■ Identify self-care strategies to promote health during midlife and the later
years.
■ Recognize various risk factors for cardiovascular disease and osteoporosis.
■ Develop an educational program for perimenopausal women that focuses on
potential health threats and empowers women with strategies to optimize
physical and emotional well-being.
PICO(T) Questions
chapter.
1. Do (P) women with premenstrual syndrome (PMS) report (I) affective
symptoms as being (O) more troublesome (C) than physical symptoms?
2. What (I) nursing interventions do (P) women with premenstrual dysphoric
disorder (PMDD) report as being (O) most helpful?
3. Do (P) women who use complementary and alternative medicine (CAM)
approaches to treat menopausal or postmenopausal symptoms report (O) a
lower level of (I) anxiety related to menopausal health compared with (C)
women who do not?
INTRODUCTION
Hormonal changes throughout the life span guide women from
puberty and menarche to menopause and beyond. Nurses have a
central role in caring for women of all ages as they manage the
various health complaints that occur during each of these life stages.
In this chapter, we focus on evidence-based treatments and nursing
actions for women experiencing premenstrual syndrome (PMS),
premenstrual dysphoric disorder (PMDD), premenopause,
perimenopause, and postmenopause. Patient education can
demystify each of these phases and help women cope with the
related physical and emotional changes.
PREMENSTRUAL SYNDROME (PMS)

Premenstrual disorders affect many women during the reproductive
years. PMS, or premenstrual syndrome, is the presence of
behavioral, emotional, and physical symptoms that occur during the
second half, or luteal phase, of the menstrual cycle and cease at or
within a few days after the onset of menses. The timing of the
symptoms in relation to the menstrual cycle, rather than the
symptoms themselves, constitutes the unique element in this
disorder.
Phases of the Uterine (Endometrial) Cycle

Following menstruation (the “menstrual phase”), follicle-stimulating
hormone (FSH) stimulates the growth and development of the
ovarian graafian follicle, which secretes estrogen. The first phase of
the menstrual cycle is termed the follicular or proliferative phase; this
phase lasts from the end of menses through ovulation
(approximately days 7 to 14). When estrogen production reaches a
peak, the pituitary gland releases luteinizing hormone (LH), which
triggers ovulation. The “luteal phase” of the ovarian cycle begins at
ovulation and ends with the onset of menses. The corpus luteum
produces some estrogen but mainly produces progesterone. Eighty
percent of all the progesterone secreted during the entire menstrual
cycle is secreted during the first 8 days after ovulation. In the
absence of fertilization, the life span of the corpus luteum is 14 days.
Thus, the luteal phase of the uterine cycle is 14 days in length. As
the end of the luteal phase nears, low levels of FSH and LH cause
degeneration of the corpus luteum, which is associated with
declining levels of estrogen and progesterone. The decreased
hormonal levels trigger degeneration of the endometrium and the
onset of menses (the menstrual phase).
Prevalence and Economic Effect

Sources vary in estimates of the number of women who experience
symptoms of PMS. It has been estimated that more than 80% of
childbearing-age women experience various emotional and physical
changes during the premenstrual period. However, according to
experts, most patients who self-diagnose do not actually have PMS.
PMS symptoms significantly affect everyday function, with up to 15%
of women unable to attend school or work due to severity of
symptoms (Schoep et al, 2019). Of the women with premenstrual
symptoms, the American College of Gynecologists reports that
approximately 20% to 40% regard the emotional and physical
changes as difficult, although only 5% to 10% report a significant
degree of effect on their work or lifestyle.
Nevertheless, the disability associated with premenstrual disorders
is quite substantial. Women who suffer from PMS reportedly have
higher absenteeism from work and make more visits to ambulatory
health-care facilities than those who do not experience PMS.
Symptoms of PMS
The following five criteria constitute the major characteristics of PMS:
■ The woman’s symptoms occur in a cyclical pattern.
■ Symptoms occur 5 days prior to menstruation.
■ Symptoms end within 4 days after the start of menstruation.
■ Symptoms are not caused by any underlying physical or mental
condition.
■ Symptoms keep the individual from enjoying or doing some normal
activities (U.S. Department of Health and Human Services, 2018).
More than 100 physical and behavioral symptoms have been
reported by women during the premenstrual period; the most
common appear in Box 29-1. It is important to remember that to
meet the criteria for a premenstrual disorder, the symptoms must be
confined to the luteal phase of the menstrual cycle and resolve after
the onset of menstruation.
It has been noted that PMS symptoms commonly occur in
clusters, with some women reporting as many as 10 symptoms at
one time. Those who experience severe symptoms may be prone to
extremes of behavior, with an increased likelihood of accidents,
alcohol abuse, and suicide attempts. For others, PMS symptoms
may be described as annoying but mild.
BOX 29-1
Common Premenstrual Symptoms

Physical symptoms:
• Swollen or tender breasts
• Constipation or diarrhea
• Bloating or a gassy feeling
• Cramping
• Headache or backache
• Clumsiness
• Lower tolerance for noise or light
• Headache
• Aches and pains
• Swelling of the extremities
• Breast tenderness
• Weight gain
• Change in appetite
• Dizziness
• Nausea and/or vomiting
• Fatigue Emotional or mental symptoms of PMS include:
• Irritability or hostile behavior
• Mild psychological discomfort
• Feeling tired
• Sleep problems (sleeping too much or too little)
• Appetite changes or food cravings
• Trouble with concentration or memory
• Tension or anxiety
• Depression, feelings of sadness, or crying spells
• Mood swings
• Less interest in sex
• Confusion
• Poor concentration
• Social withdrawal
Source: Ferries-Rowe et al, 2020; U.S. Department of Health and Human

Services, 2018.
Optimizing Outcomes
Nonpharmacological Measures for Menstrual Migraines

During the late luteal and early follicular phases of the menstrual cycle,
estrogen levels sharply decline, triggering the onset of menses. In susceptible
women, the decrease in estrogen is probably related to the increase in migraine
headaches that often occurs premenstrually. Although pharmacological
interventions are usually required to treat migraine, the nurse can offer the
following suggestions that may serve as adjunct therapy:
• For nonpain symptoms, try ice or heat.
• The underground stems and root of black cohosh are used fresh or dried to
make tea, capsules, pills, or liquid extracts. Black cohosh is most often used to
help treat menopausal symptoms, and some women use it to help relieve
PMS symptoms.
• Dried ripe chasteberry is used to prepare liquid extracts or pills that some
women take to relieve PMS symptoms. CAUTION: Women taking hormonal
birth control or hormone therapy (HT) for menopause symptoms should not
take chasteberry.
• Evening primrose oil is taken from the plant’s seeds and put into capsules.
Some women report that the pill helps relieve PMS symptoms, but the
research results are mixed.
• Certain lifestyle changes may alleviate or prevent migraine headaches. Be
sure to get sufficient sleep and exercise and drink plenty of water. Avoid
caffeine, chocolate, and alcohol, and keep a diary of possible “triggers” for
your headaches (U.S. Department of Health and Human Services, 2018).
PREMENSTRUAL DYSPHORIC DISORDER

(PMDD)
Premenstrual dysphoric disorder (PMDD) is a diagnostic term for the
most severe form of PMS. It is estimated that nearly 5 million
American women have PMDD. PMDD pertains to women with PMS
who suffer from more severe and disabling emotional symptoms.
PMS and PMDD may be viewed as a spectrum of premenstrual
disorders that begins with mild emotional and/or physical symptoms
that are cyclical but not debilitating and proceeds through PMS to
PMDD. Women with PMDD most frequently report the following
symptoms: abdominal bloating, anxiety, tension, breast tenderness,
crying episodes, depression, fatigue and a lack of energy, irritability,
difficulty concentrating, appetite changes, thirst, and swelling of the
extremities.
Facilitating Appropriate Referrals
When evaluating a patient with PMS/PMDD symptoms, the nurse must always
take any report of suicidal thoughts or other indicators of extreme mood change
most seriously. The woman will need appropriate medications, close follow-up,
and referral to a qualified mental health professional. In the ideal situation,
mental examinations are timed to occur during both the luteal and follicular
phases of the menstrual cycle. If the patient experiences significant mood
symptoms (e.g., suicidal ideation) during both the luteal and follicular phases,
referral to a psychiatrist is indicated. Once she is stable, various interventions
such as lifestyle changes, dietary alterations, and conventional and
complementary care approaches can be initiated that will become an important
part of her long-term health promotion and maintenance.
Women who seek care for symptoms associated with

premenstrual disorders should be given a complete physical
examination and thorough clinical evaluation to rule out illness that
may be the source of the symptoms. A detailed health history is the
cornerstone in the accurate diagnosis of PMS/PMDD. Nurses should
inquire about risk factors such as emotional stress; poor nutritional
habits; side effects noted when taking combined hormonal
contraceptives (if indicated); increased intake of alcohol, salt, and
caffeine; tobacco use (women who smoke cigarettes are more than
twice as likely to have more severe symptoms); personal history of
depression; pre-eclampsia or eclampsia; and family history of PMS.
When taking the menstrual history, it is crucial to pay careful
attention to the cyclical timing of symptoms. For most women with
PMS, symptoms develop from 2 to 12 days prior to menstruation and
resolve within 24 hours following the onset of menses. Women who
have symptoms that primarily occur during the menstrual flow or
during the first 2 weeks of the menstrual cycle do not have PMS as
defined in the literature (Speroff & Fritz, 2011; Whyte & Peraud,
2009).
NURSING INSIGHT
Identifying Populations at Highest Risk for PMS
Although all age groups are affected, women in their late 20s to late 40s most
frequently report symptoms of premenstrual disorders. Symptoms often worsen
as the woman approaches the menopausal transition. Also, women with a body
mass index of 30 or above, those who have at least one child, those with a
personal or family history of major depression, and those with a history of
postpartum depression or an affective mood disorder are most often affected. It
is important to note that premenstrual disorders:
• Occur only in ovulatory women
• Occur only during the luteal phase of the menstrual cycle
• Resolve within 4 days following the onset of menses
The occurrence of premenstrual disorders is not dependent on the presence
of monthly menses. Interestingly, women who have had a hysterectomy without
bilateral salpingo-oophorectomy (removal of both ovaries) can still have cyclical
PMS symptoms (Nelson & Baldwin, 2011).
CAUSES OF PREMENSTRUAL DISORDERS

Clinical research has not yet determined the exact cause of
premenstrual disorders. Variations in the cyclical fluctuation of
estrogen and progesterone may account for symptoms in certain
individuals. However, the cause is believed to be multifactorial—that
is, a genetic predisposition and multiple biological, psychosocial, and
sociocultural factors most likely play a role in the development of
premenstrual disorders.
Although it was once believed that low levels of progesterone were
the primary cause of PMS, research has failed to find a significant
difference between PMS sufferers and non-PMS sufferers in levels
of various hormones, including progesterone, estradiol, FSH, LH,
prolactin, sex hormone-binding globulin (SHBG), and testosterone. It
has been proposed, however, that women with PMS may have a
greater biological vulnerability to the normal fluctuations in hormone
levels than do women without PMS. There appears to be a genetic
component to the development of PMS. Women who have a genetic
predisposition to the development of PMS are believed to have a
heightened sensitivity to various cyclical hormonal changes or a
varied response to naturally occurring neurotransmitters (e.g.,
serotonin). Interestingly, a genetic predisposition to PMS is also
known to be associated with a predisposition to other psychiatric
disorders (Biggs & Demuth, 2011; Gingnell, Comasco, Oreland,
Fredrikson, & Sundstrom-Poromaa, 2010; Nelson & Baldwin, 2011).
It has been demonstrated that levels of the gonadal steroids (i.e.,
androgens, estrogens, progestogens) are the same in patients with
and without PMS. However, the responses to fluctuating levels of the
hormones are different in women with PMS. Another area of
research has explored the role of the neurotransmitters serotonin
and gamma-aminobutyric acid (GABA) in the etiology of
premenstrual disorders. It has been suggested that a dysregulation
in serotonin in particular is linked to many of the psychological
symptoms in PMS, such as tension, irritability, and dysphoria (an
emotional state characterized by anxiety, depression, or unease)
(Gingnell et al, 2010; Nelson & Baldwin, 2011).
Optimizing Outcomes
Teaching Women About the Serotonin-Stress Relationship
Nurses can empower women with information about the normal workings of
their bodies and how certain lifestyle changes may promote an enhanced sense
of well-being and diminish PMS symptoms. For example, explaining the
relationship between cyclical estrogen fluctuation and changes in serotonin
levels may be beneficial in promoting an understanding about serotonin, one of
the natural brain chemicals that assists one in coping with life’s normal
stressors.
Other clinical investigations have focused on the renin-angiotensin-
aldosterone system. It has long been noted that many premenstrual symptoms,
such as bloating, breast swelling, and weight gain, are caused by fluid retention.
Estrogen increases the production of the serum globulin angiotensinogen (a
precursor for angiotensin), which leads to increased aldosterone and fluid
levels. Under normal circumstances, progesterone competes with aldosterone
and prevents excessive fluid retention. However, in the late luteal phase of the
menstrual cycle, declining progesterone levels give rise to an increase in the
effect of estrogen (Nelson & Baldwin, 2011; Whyte & Peraud, 2009).
Diagnostic Tools
Work-up for PMS/PMDD

In general, the diagnostic work-up for PMS/PMDD consists of four components:
1. A detailed history with a focus on the medical, psychosocial, psychosexual,
and substance abuse histories (the gynecological history must include the
timing of the symptoms and the regularity of the menstrual cycle)
2. A complete physical examination
3. Laboratory tests as appropriate to rule out other disorders such as
hypothyroidism
4. A record of the woman’s symptoms over a 2-to-3-month period
Labs
Necessity of Hormone Testing
Laboratory testing of the sex steroid hormonal levels is not necessary for
the diagnosis of PMS. Depending on the history and clinical findings,
appropriate serum testing may include a chemistry profile, a complete blood
cell count, or measurement of the thyroid-stimulating hormone level (Whyte &
Peraud, 2009).
Assessment Tools
Other Conditions That Mimic PMS
When interviewing patients with premenstrual disorder symptomatology, it is
essential to obtain a detailed history. Dysmenorrhea, hypothyroidism,
depressive disorders, pain disorders, and generalized anxiety disorders are
other conditions that may produce similar symptoms. Hypothyroidism, for
example, may be associated with fatigue, bloating, irritability, and depression.
Breast disease (breast tenderness) or anemia (fatigue) may be responsible for
other common symptoms. Various gynecological disorders such as polycystic
ovary syndrome or endometriosis may also cause symptoms that can be
confused with PMS.
Patient Education
Symptom Diary
One of the first steps in diagnosis and treating PMS is the need for accurate
account of symptoms to determine the cyclic pattern. Patients should be
instructed to complete a daily calendar and record their symptoms for each day
of the month. They should note the type of symptoms and whether they are
mild, moderate, or severe, as well as the effect symptoms have on their daily
activities. Patients will also need to have a precise record as well of their
menstrual cycle including the day they started menstruating and the day they
stopped menstruating. If patients are able to record their weight this will also be
helpful in establishing weight gain/bloating especially if it occurs with the
menstrual cycle.
Maintaining a prospective symptom diary for at least two to three consecutive
menstrual cycles is an essential element in the diagnostic work-up for
premenstrual disorders. Many medical disorders are exacerbated during the
luteal phase, so the symptom diary is instrumental in determining the severity
and the timing of the symptoms, which helps to guide treatments.
Several symptom inventories are available. The use of a standardized form
such as the Daily Record of Severity of Problems (DRSP) was designed to
diagnose PMDD. This tool has shown high test/retest reliability and is available
from the Madison Institute of Medicine. Other symptom diaries designed to
track premenstrual symptoms include the Calendar of Premenstrual
Experiences (COPE), the Penn Daily Symptom Report (DSR), the Prospective
Record of the Impact and Severity of Menstruation (PRISM), and the
Premenstrual Symptoms Screening Tool (PSST).
The nurse may teach the patient how to record her symptoms by taking
notes on a regular calendar each day as an alternative to using a symptom
inventory form. If the number of symptoms is excessive or overwhelming, the
patient may record only the three to five symptoms that are most profoundly
bothersome. Recording weight can also be helpful in establishing weight
gain/bloating if it occurs with the menstrual cycle. Under ideal circumstances,
the patient’s weight, basal body temperature, or home ovulation test results
should also be documented. The patient should also record use of therapies
such as yoga or medication as well as the outcome and level of relief achieved,
if any.
Daily symptom records are useful to heighten the patient’s awareness of her
symptoms, allow her to gain insights into her problem, and empower her to
become more involved in her diagnostic work-up and treatment plan. A
discussion of cyclical hormonal changes and PMS may increase the
understanding of premenstrual disorders and promote a greater sense of
control over the situation. If the woman is reluctant to track her daily symptoms,
her partner or a family member can be taught to assist with the data collection.
It is helpful to ask the patient to continue her charting after therapy has been
initiated so that she can identify which interventions improve her symptoms.
After the patient has been instructed in the use of a daily symptom diary, she
should return in 2 or 3 months for an evaluation of her symptom pattern.
Symptoms do not need to recur with equal intensity in each cycle. In fact, the
patient may experience different symptoms during different cycles. It is
important to recognize, however, that the diagnosis of PMS/PMDD hinges on
the timing of symptoms: They must peak in the luteal phase and disappear with
the onset of menses.
Diagnostic Criteria for PMS and PMDD

According to the American College of Obstetricians and
Gynecologists (ACOG), to meet the diagnostic criteria for PMS, at
least one of the following symptoms must be present during the
luteal phase of the menstrual cycle and resolve within 4 days of the
onset of menses.
Diagnostic criteria for PMDD defined by the APA includes four
major symptom categories and seven additional symptoms. To meet
the criteria, the woman must report that her symptoms interfere with
her usual activities; the symptoms must not represent an
exacerbation of another disorder; at least five symptoms must be
present for 1 to 2 weeks premenstrually, with relief by the fourth day
of menses; and the criteria must be confirmed by prospective daily
ratings for at least two cycles.
At least one of the PMDD major symptom categories must be
present:
■ Anger or irritability
■ Anxiety, edginess, nervousness
■ Depressed mood
■ Moodiness
At least five additional PMDD symptoms must be present:
■ Appetite changes or cravings
■ Decreased interest in usual activities
■ Difficulty concentrating
■ Fatigue
■ Feelings of being overwhelmed or out of control
■ Insomnia or hypersomnia
■ Physical symptoms (listed in the PMS diagnostic criteria)
Patient Care and Management of PMS Symptoms

Women with mild to moderate symptoms of PMS often respond well
to reassurance, emotional support, and simple health promotion
strategies. Education constitutes a central component in the care of
women with PMS. Nurses can teach women about self-help
modalities intended to reduce symptoms and enhance coping with
various discomforts.
Nonpharmacological therapies are often initiated during the initial
visit; patients can then implement them as they complete their daily
symptom charting and discuss helpful and unhelpful approaches at
the follow-up visit. The first step in treatment centers on validating
the woman’s experience and acknowledging that the symptoms are
real and have a physiological base. For many women, the simple act
of validation brings relief and opens the door to healing and quality of
life.
What to Say
Teaching Patients Strategies to Cope With PMS Symptoms
Nurses can suggest strategies to help women cope with specific PMS
symptoms. For example, a fitted support or sports bra may ease the discomfort
associated with breast tenderness. Abdominal pain and backache are often
relieved with the local application of heat; some women benefit from stretching
exercises, and NSAIDs are useful in reducing the production of pain-producing
prostaglandins. Others may be interested in exploring the possibility of using
extended cycle hormonal contraceptives to prevent ovulation. The nurse can
also encourage the patient to engage in relaxation techniques and, if available,
participate in a PMS support group to help reduce premenstrual tension and
anxiety. Support groups provide a forum for the sharing of feelings and
concerns and offer an opportunity for learning new strategies for self-care.
Physical Activity
Various lifestyle changes have been shown to improve PMS
symptoms, including physical activity, aerobic exercise, stress
reduction, and relaxation techniques such as yoga and meditation.
Nurses should encourage patients with PMS, as well as all women,
to regularly engage in physical activity such as brisk walking,
swimming, cycling, or other aerobic activity. Vigorous aerobic
exercise can lower stress and anxiety, as well as increase positive
mood and diminish certain physical symptoms of PMS (Ferries-
Rowe et al, 2020). The Physical Activity Guidelines for Americans
recommend that adults engage in at least 150 minutes per week of
moderate-intensity, or 75–150 minutes a week of vigorous-intensity,
aerobic physical activity or an equivalent combination of moderate-
and vigorous-intensity aerobic activity (U.S. Department of Health
and Human Service, 2018) (Box 29-2).
Nonpharmacological Treatments
For many women, various nonpharmacological approaches diminish
PMS symptoms. Trials of cognitive behavioral therapy, group
therapy, and relaxation therapy have demonstrated improvement in
physical and/or psychological symptoms of PMS, although few
studies have randomized patients. For some women, other
modalities such as massage, yoga, aromatherapy, biofeedback and
guided imagery, acupuncture, self-hypnosis, reflexology, chiropractic,
and bright-light therapy (used daily for 30 minutes) may have a
beneficial effect on PMS symptoms.
Acupuncture is an ancient alternative medicine methodology of
treating patients through the manipulation of thin, solid needles
inserted into various acupuncture points in the skin. According to
traditional Chinese medicine, stimulation of the acupuncture points
can correct imbalances in the flow of qi through channels known as
meridians (energy pathways). Research has shown benefits of
acupuncture in reducing mood-related symptoms of PMS and an
increase in the quality of life for women with PMS (Armour et al,
2018).
Dietary alterations may play a role in reducing certain
premenstrual disorder symptoms, although various clinical
investigations have not conclusively determined that modification of
specific substances, including caffeine, sugar, fat, soy, and complex
carbohydrates, ameliorates premenstrual symptoms. Drinking an
increased amount of water beginning around 7 to 10 days before
menstruation may help to decrease fluid retention. Nurses can
provide written information that lists foods to avoid (e.g., cola, coffee,
hot dogs, potato chips, canned goods) and foods to encourage (e.g.,
fruits, vegetables, milk, complex carbohydrates, high-fiber foods,
low-fat meals) to assist patients in making appropriate food choices
for a healthy lifestyle. Also, eating four to six smaller meals per day
(rather than three large meals) during the premenstrual period may
be beneficial in reducing symptoms of food cravings.
BOX 29-2
Examples of Moderate and Vigorous-Intensity

Exercises
MODERATE-INTENSITY ACTIVITIES
• Walking briskly (2.5 miles per hour or faster)
• Recreational swimming
• Bicycling slower than 10 miles per hour on level terrain
• Tennis (doubles)
• Active forms of yoga (for example, Vinyasa or power yoga)
• Ballroom or line dancing
• General yard work and home repair work
• Exercise classes like water aerobics
VIGOROUS-INTENSITY ACTIVITIES
• Jogging or running
• Swimming laps
• Tennis (singles)
• Vigorous dancing
• Bicycling faster than 10 miles per hour
• Jumping rope
• Heavy yard work (digging or shoveling, with heart rate increases)
• Hiking uphill or with a heavy backpack
• High-intensity interval training (HIIT)
• Exercise classes like vigorous step aerobics or kickboxing
Source: U.S. Department of Health and Human Service, 2018.

Nurses can encourage women with PMS symptoms related to
excessive fluid retention to reduce their sodium intake and consume
increased amounts of water during the days preceding the expected
menses. The water may serve as a natural diuretic and help reduce
edema. Foods that may promote a natural diuresis include peaches,
parsley, watermelon, asparagus, and cranberry juice.
Vitamins and minerals have also been prescribed to reduce PMS
symptoms. Pyridoxine (vitamin B6), which plays a role in the
biosynthesis of neurotransmitters, may be useful in diminishing
premenstrual breast pain and depression. Vitamin B6 can help
symptoms of moodiness, irritability, forgetfulness, bloating, and
anxiety. Supplementation with vitamin E (alpha-tocopherol) or
magnesium (especially in combination with vitamin B6) may be
beneficial in reducing certain PMS symptoms such as migraines
(U.S. Department of Health and Human Services, 2018), although
stronger evidence exists for the supplementation of calcium and
vitamin D. Calcium may be of benefit in reducing PMS symptoms
such as fatigue, cravings, and depression through its interaction with
estrogen and parathyroid hormone (U.S. Department of Health and
Human Services, 2018). High dietary intake of vitamin D may reduce
the risk of PMS by affecting calcium levels, cyclical sex steroid
hormone fluctuations, and/or neurotransmitter function (Bertone-
Johnson, Chocano-Bedoya, Zagarins, Micka, & Ronnenberg, 2011).
A list of the most common herbal supplements appears in Table 29-
1.
TABLE 29-1
Most Common Herbal Supplements
HERBS/BOTANICALS INDICATION CAUTION
Black cohosh The underground stems and Side effects, such as
roots of black cohosh are stomach upset, cramping,
used fresh or dried to make headache, rash, a feeling of
tea, capsules, pills, or liquid heaviness, vaginal spotting
extracts. Black cohosh or bleeding, and weight
found to help some women gain. Cases of liver failure
in relieving PMS symptoms. has occurred with anyone
who develops symptoms of
liver trouble, such as
abdominal swelling, dark
urine, or jaundice, while
taking black cohosh.
Chasteberry A low dose of chasteberry Side effects include
increases prolactin and gastrointestinal complaints,
progesterone levels and dizziness, and dry mouth.
decreases estrogen levels. Women who take
Dried ripe chasteberry is medications that affect
prepared as liquid extracts dopamine (e.g., certain
or pills to be taken orally antipsychotic medications
and relieve mostly breast and Parkinson’s disease
pain and tenderness medications). Interactions
associated with PMS. with taking hormonal birth
control or hormone therapy
for menopause symptoms
should not take chasteberry.
Evening primrose oil Recommended for relief of Side effects are temporary
PMS-related breast gastrointestinal symptoms
tenderness; however, to such as abdominal pain,
date, clinical trials of this fullness, or nausea.
omega-6 essential fatty Interactions occur with
acid–rich supplement have antiviral medication lopinar
failed to demonstrate and should be used with
statistically or clinically caution.
significant results.
Chamomile Recommend for symptom Side effects are uncommon
relief of pain, spasms, and and may include nausea,
anxiety effects. Shown dizziness, and allergic
effective when used in a reactions. Avoid taking
variety of forms such as tea, cyclosporine and chamomile
capsule, extract, and oil. as interactions can occur.
Source: Khalesi et al, 2019; U.S. Department of Health and Human Services,
2018; U. S. Department of Health and Human Services, 2021.
Patient Education
Counseling About Vitamin Supplements
When counseling about vitamin supplements for premenstrual disorders,
nurses must ensure that women understand the dangers of vitamin overdose.
Dosages of vitamin B6 must remain lower than 100 mg/day, as excessive
amounts may lead to peripheral neuropathy. Vitamin E supplements
recommendation is 200–400 IU per day and should never exceed 400 IU per
day (Ferries-Rowe et al, 2020). Higher amounts of vitamin E are associated
with a number of side effects, including diarrhea, flatulence, bloating,
weakness, headache, fatigue, abdominal pain, blurred vision, and an increased
risk of bleeding.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs are often used to help alleviate
symptoms of PMS. NSAIDs are an antiprostaglandin and help
reduce the production of prostaglandins, which are responsible for
many PMS symptoms, as well as provide pain relief. For treatment to
be effective they need to be taken as scheduled and not on an as-
needed PRN basis. The best effect occurs if the medications are
taken 1-2 days before the onset of menstruation and then on a
scheduled basis during the menstrual cycle. The first dose is often a
higher dose. For treatment with ibuprofen, the loading dose is 800
mg, then scheduled 400–800 mg every 8 hrs. For naproxen sodium,
the loading dose is 440 mg to 550 mg, then scheduled 220–550 mg
every 12 hours for the duration of the menstrual cycle (Ferries-Rowe
et al, 2020).
Oral Contraceptives
Oral contraceptives treat PMS symptoms by suppressing ovulation,
though most clinical trials have not demonstrated strong efficacy in
this approach. For some women, however, extended-cycle dosing of
continuous combined oral contraceptives, vaginal contraceptive
rings, and the patch creates shorter cycles. Regular administration of
Depo-Provera may provide symptom relief by suppressing ovulation
and reducing the number of withdrawal bleeding episodes and
associated symptoms (Nelson & Baldwin, 2011). The U.S. Food and
Drug Administration (FDA)–approved therapy for the treatment of
PMDD is the monophasic oral contraceptive with active pills that
contain ethinyl estradiol and drospirenone, a novel progestin.
Hormonal contraception is highly effective, with up to 80% of females
with PMS having a decrease in symptoms (Ferries-Rowe et al,
2020).
Antidepressants
Antidepressants are another pharmacological treatment that can
help resolve emotional symptoms as well as fatigue, food cravings,
and sleep problems. FDA-approved selective serotonin reuptake
inhibitors (SSRIs) for the treatment of PMDD include fluoxetine
(Prozac, Sarafem), sertraline (Zoloft), paroxetine (Paxil), and
escitalopram oxalate (Lexapro). Currently, these medications
constitute the mainstay of medical treatment. They have been
studied extensively for the treatment of PMDD symptoms, and
dosing may be administered on a continuous or intermittent
schedule. Luteal-phase dosing should be initiated about 14 days
before menses and continued until the onset of menstruation.
Other Medications
Other medications have been prescribed off-label for the treatment
of PMDD. Buspirone may be prescribed for women who are unable
to tolerate SSRIs but would benefit from psychotropic medication,
and the anxiolytic medication alprazolam has shown efficacy in the
treatment of PMDD. However, anxiolytic medications are habit-
forming and have the potential for abuse. Women with histories of
substance abuse are not appropriate candidates.
Spironolactone (Aldactone), a potassium-sparing diuretic, is a
nonhormonal medication that has been shown to be beneficial in the
treatment of PMS. Administered in a dosage of 25 mg two to four
times a day during the luteal phase, this agent reduces bloating,
weight fluctuations, and mastalgia and improves mood in many
patients. However, it should be noted that use in PMS management
is considered off-label (Nelson & Baldwin, 2011).
Two major pharmacological strategies are used to treat PMDD.
One targets the central nervous system processes that are believed
to contribute to premenstrual mood symptoms; the other approach
centers on eliminating the hormonal cyclicity by suppressing
ovulation. Pharmacological therapy is reserved for women who
qualify as having PMDD or severe manifestations of PMS.
THE CLIMACTERIC, PREMENOPAUSE,

MENOPAUSE, PERIMENOPAUSE, AND
POSTMENOPAUSE
The climacteric is a transitional time in a woman’s life marked by
declining ovarian function and decreased hormone production. The
climacteric begins at the onset of ovarian decline and ends with the
cessation of postmenopausal symptoms. Menopause refers to the
last menstrual period and can be dated with certainty when there has
been at least 1 whole year without menstruation.
The phases of menopause are termed premenopause,
perimenopause, menopause, and postmenopause. Premenopause
is the time up to the beginning of perimenopause, but the term is
also used to define the time up to the last menstrual period.
Perimenopause is the time preceding menopause, usually starting
between 2 and 8 years before menopause and lasting an average of
4 years (U.S. Department of Health and Human Services, 2019).
Menopause occurs around between ages 45 and 55. About half of
women have entered menopause by age 50 (Venes, 2021;
USDHHS, 2019). Postmenopause begins when ovarian estrogen
terminates, ovulation ceases, and menstrual periods have stopped
for 12 consecutive months. During postmenopause, estrogen is
produced solely by the adrenal glands. Women typically enter
postmenopause between the ages of 40 and 58; the average age is
51. Early menopause occurs between the ages of 40 and 45 in about
5% of women, often caused by preterm ovarian failure (Venes,
2021).
Symptoms of Menopause
Drastic changes in the body occur to prepare for and enter
menopause, resulting in a range of physical and emotional
symptoms. Many women have just a few mild symptoms, but others
have severe symptoms that interfere with activities of daily living.
Common symptoms of premenopause and menopause appear in
Table 29-2.
TABLE 29-2
Symptoms of Premenopause and Menopause
PREMENOPAUSE MENOPAUSE
Irregular menses Hot flushes
Hot flushes Night sweats
Vaginal dryness Vaginal dryness
Dyspareunia Discomfort during sex
Mood changes Difficulty sleeping
Low mood or anxiety
Reduced sex drive (libido)
Problems with memory and
concentration
Source: National Health Service, 2018.
Hormonal Changes
The age-related changes associated with menopause commence
with a decrease in the production of hormones. This can also occur
because of underlying pathological or medical conditions or
treatments, including oophorectomy, treatments with chemotherapy
or radiotherapy, or conditions such as Down’s syndrome or
Addison’s disease. Some behavioral and social conditions can result
in earlier menopause, such as smoking, low body weight, low
socioeconomic status, and malnutrition (Venes, 2021).
During the perimenopausal period, hormone levels are frequently
erratic, as highs and lows occur without the usual synchronicity. A
common hormonal pattern that occurs when ovulation becomes
unpredictable is an elevated estrogen level throughout the cycle with
low progesterone levels during the second half of the cycle, when
progesterone is normally at its peak. Some women develop very low
levels of estrogen as well. At this time, ovarian function declines and
the ovaries lose their ability to manufacture large amounts of sex
hormones. The physiological feedback loops among the ovaries, the
hypothalamus, and the pituitary glands also lose their synchronized
pattern. Progesterone undergoes the most dramatic drop during
menopause because its production depends on ovulation and the
development of the corpus luteum.
Menstrual Cycle Changes

Women rarely cease menstruation all at once and usually have
irregular menses during perimenopause. Most often, the menstrual
periods become progressively more irregular. The volume of blood
flow is variable and may be accompanied by midcycle spotting.
Changes in bleeding patterns largely result from a lack of ovulation.
The absence of ovulation interrupts the production of progesterone,
the hormone that stabilizes the endometrium, or uterine lining. Under
the influence of prolonged, continuous estrogen, the endometrium
continues to proliferate and may only be irregularly sloughed off.
When bleeding does occur, it may be heavier or more prolonged.
The endometrial lining may also develop irregular or thickened
areas; it may not slough off evenly or in its entirety, and these events
cause the menses to stop and start again. Women who are in the
perimenopausal period still ovulate at irregular times, and such
women need to be counseled on the risk of pregnancy during this
time.
Hot Flushes/Flashes, Night Sweats, and Sleep Disturbances

The terms “vasomotor symptoms,” “hot flash,” and “hot flush” are
often used to describe the same phenomenon, which is a hallmark of
menopause and one of its most common symptoms. The North
American Menopause Society (NAMS) defines vasomotor symptoms
as a global term that encompasses both hot flashes and night
sweats. A hot flush is a visible red flush of skin and perspiration. A
hot flash is a sudden warm sensation in the neck, head, and chest;
heat may be radiated from all parts of the body. During a hot flash,
skin temperatures rise as a result of peripheral vasodilation and
sweating begins primarily on the upper body. Most women describe
a sudden sweeping wave of heat sensation that spreads over the
body. An increase in the heart rate of about 7 to 15 beats per minute
occurs at approximately the same time as the peripheral vasodilation
and sweating. It may take up to 30 minutes or longer for skin
temperatures to return to normal. Hot flashes can occur infrequently
(e.g., monthly; weekly) or frequently (hourly), although there is
usually an individual pattern. A circadian rhythm has been observed,
with hot flash frequency peaking in the early evening hours—about 3
hours after the peak in core body temperature (NAMS, 2010b).
Night sweats are characterized by profuse perspiration and heat
radiating from the body during the night. The woman’s sleep may be
interrupted each night because her night-clothes and bed linens
become soaked with perspiration.
The cause of the alternating vasodilation and vasoconstriction
associated with hot flashes is not well understood, but it is known
that this symptom is related to hormonal changes that affect the
temperature-regulating centers in the hypothalamus. Low levels of
estrogen alone are not responsible. It is believed that the presence
of estrogen followed by its withdrawal triggers an imbalance in the
body’s temperature control center, which subsequently decreases
the core body temperature. The body then attempts to activate heat
centers to readjust the body’s thermostat. Other problems that may
be associated with vasomotor instability include dizziness,
numbness, or tingling in the fingers and toes and headaches.
Environmental and lifestyle factors such as being in a crowded or
warm room, consuming hot drinks, nitrates, alcohol or spicy foods,
and stress can precipitate or aggravate an episode of vasomotor
symptoms.
Vaginal Changes
Vaginal changes may accompany the perimenopausal period or may
not occur for several years after menopause. The mucous
membranes, previously supported by estrogen stimulation, become
thin, dry, and fragile. The vagina loses its rough texture and dark
pink coloration and becomes smooth and pale. The vagina also
shortens and narrows. Women may experience vaginal itching,
burning, bleeding, or soreness. The vagina lubricates more slowly
and produces less cervical mucus. As a result of these changes,
intercourse often becomes painful. Bleeding and/or pain may occur
following minimal trauma, such during a pelvic examination. Vulvar
changes may also make activities such as riding a bicycle
uncomfortable.
Alteration in the normal vaginal flora results in a decrease in the
normal protective mechanisms of the vagina. Declining estrogen
secretion is accompanied by a corresponding reduction in the
lactobacilli needed to maintain a healthy acidic vaginal environment.
With these changes in pH, normally harmless pathogens may
colonize the more alkaline vagina, potentially leading to infection.
When the vaginal mucosa becomes inflamed, the condition is termed
“atrophic vaginitis,” a condition characterized by burning, leukorrhea,
and malodorous yellow discharge (NAMS, 2021). Vaginal dryness
may increase frequency of urinating, which can be bothersome with
needing to void at inopportune times and at night. Vaginal dryness
has been found to be a common occurrence in menopause, but only
50% of women will report this symptom to their health-care provider
and only a fraction are using any form a treatment for vaginal
dryness (Venes, 2021; Waetjen et al, 2018).
Genitourinary Tract Changes

Menopause-induced changes in the genitourinary tract can produce
symptoms that include urinary urgency, increased frequency, stress
or urge incontinence, and recurrent urinary tract infections.
Vulvovaginal or urinary atrophic symptoms in postmenopausal
women can cause significant reductions in quality of life, avoidance
of sexual intercourse, and emotional distress. Approximately 50% of
menopausal women have some form of urinary incontinence
(Kołodyńska et al, 2019).
The most common types of urinary incontinence are “urge”
incontinence, “stress” incontinence, and “mixed” incontinence. Urge
incontinence is the sudden onset of urinary leakage caused by the
bladder contracting (e.g., from infection, bladder irritants, or bladder
spasms). Stress incontinence is the sudden onset of urinary leakage
caused by increased pressure on the bladder; it may occur with
coughing, sneezing, laughing, or running. Mixed incontinence is a
combination of stress and urge incontinence.
Biofeedback therapy has been used to assist the reeducation of
patients with pelvic floor spasms and results in significant
symptomatic improvement after several months of therapy.
Biofeedback uses a vaginal sensor that measures the level of
muscle activity generated by voluntary pelvic floor contraction. With
biofeedback, the patient is taught to voluntarily control the pelvic
muscles and bladder. With an electrode attached to the skin,
biofeedback machines measure the electrical signals elicited when
the pelvic muscles and urinary sphincter are contracted. Through the
visual cues from the graph shown on the monitor, patients can learn
to control these muscles voluntarily (Kołodyńska et al, 2019; National
Health Service, 2018; NAMS, 2021).
Vaginal cones or weights can also be used to strengthen the
vaginal muscles. The woman is instructed to insert the tampon-
shaped cone into the vagina while in a standing position, beginning
with the lightest weight. Once the cone has been inserted, the
patient should contract the levator ani muscles in an effort to keep
the cone in place for 15 to 20 minutes. As the muscles strengthen,
the patient then transitions, one at a time, to the next heaviest cone.
It is helpful to use the cone while doing pelvic floor exercises as well.
As the pelvic muscles strengthen, patients can use the cones while
engaging in the exercise (National Health Service, 2018; Tomed,
2021).
Some women choose to use a pessary, which is a device inserted
into the vagina to support the prolapsed bladder or uterus. This
device must be fitted by a health-care practitioner to ensure proper
size. Patients need to be instructed to wash their hands before use
and the pessary must be removed and cleaned regularly with soap
and water to reduce the risk of infection (Brigham and Women’s
Hospital, n.d.). Surgical intervention for a prolapsed bladder usually
involves an anterior repair (colporrhaphy). This procedure involves
shortening of the pelvic muscles to provide better support for the
bladder.
PROCEDURE ■ Teaching Patients to

Perform Pelvic Floor (Kegel) Exercises
To teach patients about pelvic floor exercises, the nurse may provide the
following information:
These exercises strengthen the pelvic floor and should help decrease your
urinary symptoms. To perform the pelvic floor exercise:
• First, contract the vaginal opening as if you are trying to stop the flow of urine;
if you are able to contract the muscles to stop the stream, you are using the
correct muscles. The abdomen and legs should remain relaxed.
• Now hold to a count of six (5–10 seconds).
• Relax to a count of 10, then repeat these steps 10 more times.
• Perform 5 to 10 sets of pelvic floor exercises each day with gradual increase
in the hold count to 15–20 seconds.
For patients who are unable to isolate the levator ani, electrical stimulation
and/or muscle biofeedback may be helpful (Kołodyńska et al, 2019). Electrical
stimulation during pelvic floor exercises expands and contracts the pelvic
muscles in a manner similar to the Kegels. This approach, conducted in the
health-care practitioner’s office, may be helpful for women who have difficulty
contracting the pelvic muscles voluntarily. It involves the use of a device that
delivers current to the pudendal nerve through a vaginally placed probe.
Urinary urgency and/or frequency combined with an involuntary

loss of urine are common signs of an overactive bladder.
Pharmacological management of incontinence is aimed at relaxing
the involuntary contractions that occur at the bladder. For overactive
bladder, medications frequently used include tolterodine (Detrol),
oxybutynin (Ditropan), and solifenacin (VESIcare) (National Health
Service, 2018). Common side effects associated with these
medications include dry mouth, nausea, dizziness, drowsiness, and
constipation. Low-dose vaginal estrogen creams, tablets, or rings
may also be prescribed to provide relief of urinary symptoms.
Skin and Hair Changes
Declining levels of estrogen affect many tissues throughout the body.
The skin and mucous membranes become dry. The fatty layer
beneath the skin tends to shrink, and this change is associated with
an overall decrease in elasticity and moisture. The skin feels rougher
to the touch, and the outer skin may be looser than the deeper
layers, which results in wrinkling. The skin produces less melanin,
and it can burn more easily. The increasing predominance of
androgens often causes a darker, thicker, more wiry hair to appear
on the symphysis pubis, underarm area, chest, lower abdomen, and
back. Some women experience an increase in facial hair, and the
hair on the head may become dry. Pubic and axillary hair often thins.
Genetically susceptible women may experience female pattern
(scalp) hair loss, a condition most likely related to the altered
estrogen-to-androgen ratio that accompanies menopause (NAMS,
2021).
Breast Changes
Glandular tissues in the breasts shrink during the menopausal
period. The breasts may lose their fullness, flatten, and drop. The
nipples may become smaller and flatter.
Long-Term Effects
Cardiovascular Disease
Menopause carries significant risks to the cardiovascular system
such as increases in blood pressure, lipid changes (increased low-
density lipoprotein cholesterol and apolipoprotein B), and
atherosclerosis. These changes can lead to coronary heart disease
(CHD), stroke, congestive heart failure (CHF), hypertension, and
other diseases of the heart and vascular system (American College
of Cardiology, 2020; NAMS, 2021; Rodriguez et al, 2021). Also
contributing to an increase in cardiovascular disease in menopause
is the increase in adipose tissue, increase in insulin resistance, and
behavioral changes such as decrease in physical activity (Rodriguez
et al, 2021). Before menopause, estrogen helps prevent CHD, heart
attack, and stroke. As women age, their risk of heart disease and
stroke begins to rise and keeps rising.
The nurse can recommend lifestyle changes to improve
cardiovascular health that include:
■ Exercise. Getting at least 30 minutes of physical activity on most
days of the week is one of the best ways to increase
cardiovascular fitness. Physical activity can help the bones, heart,
and mood. Exercise doesn’t have to be complicated. Brisk walking
and regular household chores are good for the health.
Recommend the following levels of physical activity for patients
who can safely exercise:
■ At least 2 hours and 30 minutes a week of moderate aerobic
physical activity or 1 hour and 15 minutes of vigorous aerobic
activity or some combination of the two
■ Exercises that build muscle strength on 2 days each week
■ Eat a healthy diet. Getting vitamins, minerals, and fiber also
reduces the risk for heart disease.
■ Quit smoking: Smoking has been associated with early CVD
events and doubles the risk of developing CVD by age 70. Nurses
can encourage women to avoid both cigarette smoking and
secondhand exposure to environmental tobacco smoke. When
discussing smoking cessation strategies, it may be useful to
identify and address barriers to smoking cessation such as a fear
of weight gain, fear of an inability to deal with negative mood and
anxiety, anticipated peer influence from other tobacco users, a lack
of support, a lack of interest, and a longstanding use of smoking as
a stress reliever (USDHHS, 2019).
Musculoskeletal Effects
Bone health is a serious concern for menopausal women as rapid
bone loss begins within 3 years of cessation of menstruation
(Karlamangla et al, 2018). In women who are recently menopausal,
excess bone loss commonly is caused by excessive osteoclast-
mediated resorption. In later postmenopausal years, suppressed
osteoblast activity and inadequate formation of bone may play a
major role in the progression of osteoporosis, providing an
opportunity for new therapeutic approaches such as stimulating bone
formation. Osteoporosis is one of the most common sequela and
occurs more often in women than men in part because of the
accelerated loss of bone that occurs after menopause.
Bone health promotion typically centers on methods to ensure
adequate intake of calcium. However, bone health maintenance and
prevention of fractures should encompass other strategies, such as
preventing the loss of calcium and other minerals from the bone,
maintaining the soft tissue components around the bone, and
promoting the efficiency of bone repair. Tooth loss and periodontal
disease represent other aspects of osteoporosis.
Nurses can recommend these strategies to improve bone health:
■ Maintain good posture.
■ Perform regular weight-bearing, strength/resistance, and stretching
exercises.
■ Eat a healthy diet that includes plenty of fruit, vegetables, and
sources of calcium, such as low-fat milk and yogurt.
■ Spend time in the sun, which triggers the production of bone-
strengthening vitamin D.
■ Stop smoking and limit alcohol.
■ Take calcium and/or vitamin D supplements.
■ Visit the dentist regularly.
While hormone replacement therapy can prevent osteoporosis,
this effect does not last when treatment ends (National Health
Service, 2018; NAMS, 2021).
PROMOTING COMFORT DURING THE

MENOPAUSAL TRANSITION
Complementary and Alternative Medicine
Complementary and alternative medicine (CAM) includes a broad
base of healing philosophies, approaches, and therapies that
conventional medicine has not commonly understood or used. In
general, a therapy is termed “complementary” when it is used in
addition to conventional treatment, and it is called “alternative” when
it is used instead of conventional treatment.
Many women use CAM approaches such as stress management,
guided imagery, biofeedback, massage therapy, yoga, chiropractic
care, acupuncture, and dietary supplements to relieve various
menopausal symptoms. Other non-medicinal interventions for the
relief of mild vasomotor symptoms include engaging in regular
exercise; consuming cool, refreshing foods such as cabbage,
cucumbers, and pineapple; minimizing the intake of alcohol, fatty
foods, sugar, and caffeine; avoiding “triggers” such as hot drinks,
alcohol, or spicy foods; and dressing in layers to keep cool. Wearing
clothing made of cotton, washable linen, or fabrics that wick
perspiration away from the skin and increase air movement can
increase comfort. Synthetic fabrics such as polyester should be
avoided, as they can trap body heat and trigger hot flashes. Nurses
can also counsel women to drink 8 to 10 glasses of water each day
and perform deep-breathing or paced-respiration exercises at the
beginning of a hot flash to diminish its effects (NAMS, 2021).
Daily aerobic exercise helps reduce the frequency and severity of
hot flashes by assisting in body-temperature regulation. Exercise is
also beneficial in reducing cardiovascular disease and osteoporosis
risk and helps to maintain normal glucose levels and weight. Midlife
women who engage in regular exercise report a higher quality of life,
and routine exercise can help to improve depression, muscular
soreness or stiffness, palpitations, memory, and sleep quality.
Alternative Medical Systems

Alternative medical systems include complete systems of theory and
practice that have evolved independent of and often prior to the
conventional biomedical approach. Many are traditional systems of
medicine practiced by individual cultures throughout the world.
Alternative Medical Systems, Mind-Body Medicine, Manipulative and
Body-Based Methods, and Energy Medicine are briefly described in
Box 29-3.
Biologically Based Treatments

This CAM category includes biologically based practices,
interventions, and products, many of which overlap with conventional
medicine’s use of dietary supplements. Botanical therapies are
complex mixtures of preparations made from the whole plant or plant
part, such as root, leaves, gum, resin, or essential oil. Most botanical
therapies are medicinal herbs. A medicinal herb is a plant or plant
part that produces and contains chemical substances that act on the
body (NAMS, 2021).
Herbal therapies intended for ingestion may be administered in a
variety of ways, such as:
■ Tea infusions (soft, aromatic parts of the plant are steeped, not
boiled, in water)
■ Tea decoctions (barks and roots, boiled in water)
■ Essential oils (highly concentrated)
■ Tinctures and fluid extracts (herbs macerated into water-alcohol
mixtures)
■ Dried standardized extract (these typically contain part of a plant
but can contain the whole plant; extracts are standardized to one
ingredient only)
■ Homeopathic preparations (extremely diluted) (NAMS, 2021)
The most studied of the botanicals for menopause-related
conditions are compounds often termed phytoestrogens (sometimes
called “dietary estrogens”). Phytoestrogens are a diverse group of
naturally occurring nonsteroidal plant compounds that have a
structural similarity with estradiol and are able to exert estrogenic
and/or antiestrogenic effects. There are three principal groups of
phytoestrogens: isoflavones, coumestants, and lignans. Herbal
compounds containing phytoestrogens are not FDA-regulated; there
is no proof of the efficacy, safety, or overall quality of the products.
Until such information becomes available, these remedies should be
considered to have the same issues as traditional menopausal HT.
To date there is no risk of isoflavones or phytoestrogens causing
endometrial or breast cancer; however, women with endometrial or
breast cancer should confer with their health-care provider before
taking as a therapeutic agent (NAMS 2021).
BOX 29-3
Alternative Medical Systems, Mind-Body

Medicine, Manipulative and Body-Based
Methods, and Energy Medicine
ALTERNATIVE MEDICAL SYSTEMS
TRADITIONAL CHINESE MEDICINE (TCM)
Traditional Chinese Medicine is a system of healing that dates back to 200 BC
in written form. TCM emphasizes the proper balance of two opposing and
inseparable forces: yin and yang. Yin represents the cold, slow, or passive
principle, and yang represents the hot, excited, or active principle. An
imbalance of these two forces is thought to lead to blockage in the flow of qi
(pronounced “chee” and meaning “vital energy”) and of blood along pathways
known as meridians. TCM consists of a group of techniques and methods,
including acupuncture, herbal medicine, oriental massage, and qi gong, to bring
the body back into harmony and balance (NAMS, 2010b).
AYURVEDA
Meaning “science of life,” Ayurveda is India’s traditional system of medicine.
Ayurvedic medicine is a comprehensive system of medicine that places equal
emphasis on body, mind, and spirit and strives to restore the innate harmony of
the individual. Some of the primary Ayurvedic treatments include diet, exercise,
meditation, herbs, massage, exposure to sunlight, and controlled breathing
(NAMS, 2010b).
HOMEOPATHIC MEDICINE
Homeopathy is an unconventional Western system that is based on the
principle that “like cures like” (i.e., large doses of a particular substance may
produce symptoms of an illness, very small doses will cure it). Very small doses
of specially prepared plant extracts and minerals are used to stimulate the
body’s defense mechanisms and healing processes to treat illness. The
homeopathic approach focuses on the links among an individual’s physical,
emotional, and mental symptoms (NAMS, 2010b).
NATUROPATHIC MEDICINE
In naturopathic medicine, disease is viewed as a manifestation of alterations in
the processes by which the body naturally heals itself, and emphasis is placed
on health restoration rather than on disease treatment. Practitioners of
naturopathic medicine employ a variety of healing practices, including diet and
clinical nutrition, homeopathy, acupuncture, herbal medicine, hydrotherapy,
spinal and soft-tissue manipulation, physical therapies involving electric
currents, ultrasound and light therapy, therapeutic counseling, and
pharmacology (NAMS, 2010b).
MIND-BODY MEDICINE
Mind-body medicine focuses on the interactions among the brain, mind, body,
and behavior and the powerful ways in which emotional, mental, social,
spiritual, and behavioral factors can directly affect health. Mind-body medicine
is an approach that respects and enhances each person’s capacity for self-
knowledge and self-care and emphasizes techniques that are grounded in this
approach. Hypnosis, dance, music and art therapy, prayer and mental healing,
relaxation and visual imagery, meditation, and yoga are typical techniques used
with this approach (NAMS, 2010b).
MANIPULATIVE AND BODY-BASED METHODS
These methods are based on manipulation and/or movement of structures and
systems of the body, including bones and joints, the soft tissues, and the
circulatory and lymphatic systems. While there is considerable variation in the
training and approaches of manipulative and body-based providers, they all
share certain principles, such as the belief that the human body is self-
regulating and has the ability to heal itself. Practitioners of manipulative and
body-based methods include osteopathic physicians (DOs), massage
therapists, and reflexologists (NAMS, 2010b).
ENERGY MEDICINE
Energy therapies focus on either energy fields originating within the body
(putative energy fields [biofields], which cannot be measured), or those from
other sources (veritable energy fields that involve the use of measurable
wavelengths and frequencies, also called “electromagnetic fields”). Examples of
putative energy medicine include qi gong, Reiki, intercessory prayer, and
therapeutic touch (NAMS, 2010b).
Isoflavones (e.g., red clover, soy) are the most widely used
phytoestrogens for menopause (NAMS, 2021). Isoflavones comprise
a class of organic compounds, often naturally occurring, related to
the isoflavonoids. Some isoflavones and isoflavone-rich foods
possess activity against cancer, including certain types of breast and
prostate cancers. Isoflavones are produced almost exclusively by
members of the bean family, and soybeans are the most common
source of isoflavones in human food. Soy and other isoflavone
supplements are regulated in the United States as dietary
supplements; their effectiveness has not been well-established, and
they are not monitored for purity, amount of active ingredient, or
health claims. Possible adverse effects associated with these
products include constipation, diarrhea, belching, bloating, nausea,
and insomnia.
Phytoestrogens interact with estrogen receptors in the body.
Foods that contain phytoestrogens include wild yams, cashews,
peanuts and almonds, dandelion greens, apples, cherries, alfalfa
sprouts, sage, black beans, and soy products (e.g., beans, flour,
milk, sauce). The use of soy-rich foods has also been investigated
as an alternative to HT for menopausal symptoms. According to the
Natural Standard database, there is good evidence for sage and soy
for menopause symptom management
(http://www.naturalstandard.com/). NAMS concedes that soy
products may have small benefits in the treatment of vasomotor
symptoms in the short term (12 weeks) but not for longer periods (6–
12 months). According to NAMS, there is strong evidence that soy is
nonbeneficial in the prevention of postmenopausal bone loss but
may be useful in maintaining cognitive function; however, additional
studies are needed (NAMS, 2021).
An important role for nurses centers on counseling women to
become informed about any herbal preparations they are
considering and consult with their health-care providers before using
any of them. Nurses should explain that before using any substance,
it is important to understand the mechanisms of action,
contraindications, and potential adverse effects. Herbs may be
beneficial in resolving physical symptoms as well as mood swings
and depression. To obtain current information about various dietary
supplements, health professionals and consumers may consult Web
sites such as those offered by the U.S. National Library of Medicine
and the National Institutes of Health
(http://www.nlm.nih.gov/medlineplus/dietarysupplements.html and
http://www.nlm.nih.gov/medlineplus/druginformation.html), and the
U.S.D.A. National Agricultural Library (http://nal.usda.gov/).
Nurses may also inform patients who wish to use soy, herbs, or
other dietary supplements about ConsumerLab
(http://www.consumerlab.com/), an independent company that tests
and provides objective reviews of many over-the-counter consumer
supplements; there is an annual subscription fee to access the
information.
Herbal teas composed of licorice, ginseng, sage, coptis, red
raspberry leaf, and Chinese rhubarb may provide some relief for hot
flashes. Dong quai and black cohosh have been used for various
menopausal discomforts. Dong quai, the most commonly prescribed
Chinese herbal medicine for “female problems,” purportedly
regulates and balances the menstrual cycle and is said to
“strengthen the uterus.” It is also purported to exert estrogenic
activity. However, dong quai has not been found to be useful in
reducing hot flashes and is not recommended for this symptom.
Also, dong quai can trigger heavy uterine bleeding and should never
be used in women who have fibroids, hemophilia, or other blood-
clotting problems; it is contraindicated for use with anticoagulants
(ACOG, 2014; NAMS, 2010b).
Black cohosh (Cimicifuga racemosa) may be helpful in the short-
term (less than 2 years) treatment of menopausal symptoms
including hot flashes, sleep disorders, anxiety, and depression.
There have been case reports of possible hepatotoxicity associated
with black cohosh, but no serious liver-related diseases were
observed or reported in trials. Both dong quai and black cohosh have
been investigated for effectiveness, with varying results. According
to the National Center for Complementary and Alternative Medicine
(NCCAM) (http://nccam.nih.gov/), there is very little high-quality
scientific evidence about the effectiveness and long-term safety of
CAM for menopausal symptoms.
St. John’s wort and valerian root have been used for mood
disturbances during menopause. The flower hypericum perforatum,
known as St. John’s wort, has been used for centuries to treat mild
to moderate depression. Side effects are similar to but much less
than those associated with standard antidepressant medications and
include fatigue, dry mouth, dizziness, and constipation. St. John’s
wort should not be used concomitantly with psychotropic
medications.
Valerian root (Valeriana officinalis) has traditionally been used as a
tranquilizer and soporific. Valerian improves subjective experiences
of sleep when taken nightly for 1 to 2 weeks. Although it has no
demonstrable toxicity, there have been reports of adverse reactions
and visual disturbances. Little is known about the actions, effects, or
potential interactions of valerian with other medications.
Some practitioners have recommended chasteberry and ginseng
for menopausal loss of libido. Chasteberry, or vitex, is also known as
chaste tree, Monk’s pepper, agnus castus, Indian spice, sage tree
hemp, and tree wild pepper. It has been used for vaginal dryness at
menopause and also for depression and to enhance libido in
menopausal women. Asian ginseng (Panax ginseng) is promoted as
an “adaptogen” that helps one cope with stress and boost immunity.
Ginseng is also reputed to be an aphrodisiac, although this claim has
not been substantiated by medical evidence. According to the
Natural Standard database, there is poor evidence for ginseng and
chasteberry for the treatment of menopausal symptoms but good
evidence for both sage and soy for menopause symptom
management.
Hormonal Therapies
Estrogen is the only pharmacological therapy that is government
approved in the United States and Canada for treating menopause-
related symptoms. Estrogen-containing drugs for menopausal use
are divided into two categories: estrogen therapy (ET) and combined
estrogen-progestogen therapy (EPT).
MEDICATION: NAMS Menopausal Hormone

Therapy Terminology Nurses should know the
correct terms to use for different types of HT:
• Estrogen therapy (ET) —unopposed estrogen prescribed for postmenopausal
women who have had a hysterectomy.
• Estrogen plus progestogen (EPT) —a combination of estrogen and
progestogen (either progesterone or progestin, synthetic forms of
progesterone). Although the available data suggest that the benefits of EPT
are almost exclusively the result of estrogen, progestogen reduces the risk of
endometrial adenocarcinoma in women with a uterus—and this risk is
significantly increased in women who use unopposed estrogen.
• Hormone therapy (HT) —encompasses both ET and EPT. The FDA refers to
EPT as HT.
• Local ET therapy—vaginal ET administration that does not result in clinically
significant systemic absorption.
• Progestogen—encompasses both progesterone and progestin.
• Systemic HT therapy—HT administration that results in absorption in the
blood high enough to provide clinically significant results.
Previously, the terms estrogen replacement therapy and hormone
replacement therapy were used. However, according to NAMS, the term
“replacement” is a misnomer because postmenopausal levels of HT provide
only a small fraction of the estrogen the ovaries once produced. The FDA
declared that the word “replacement” can no longer be used by marketers of
products available in the United States. The FDA uses ET to describe
unopposed ET and HT to describe EPT. NAMS, however, prefers using HT to
encompass all HT used for menopause and EPT to more clearly describe
combined therapy.
MENOPAUSAL HORMONE THERAPY: CONSIDERATIONS AND CHOICES

Owing to the findings from large-scale prospective clinical trials
such as the Women’s Health Initiative, which demonstrated that HT
is not without risks, the FDA and several professional organizations
recommend prescribing the lowest effective dose for the shortest
duration of time consistent with treatment goals for the individual
patient. Growing evidence indicates that the benefits and risks vary
with the type of estrogen and progestogen prescribed, as well as the
route of administration, timing of therapy, baseline risk of disease,
chronological age, age at menopause, cause of menopause, time
since menopause, and previous use of any hormone. A summary of
NAMS (2021) recommendations concerning HT for the treatment of
various menopausal symptoms is presented in Box 29-4.
Recommendations for duration of use differ between ET and EPT.
Because ET is associated with a more favorable safety profile, it is
generally considered for longer duration of therapy in the absence of
adverse effects and risk factors. Women who experience a
premature menopause are at an increased risk of osteoporosis and
possibly cardiovascular disease, and they frequently experience
more intense symptoms than do women who reach menopause at
the median age. Hence, HT is frequently advised for these young
women until the median age of menopause when treatment should
be reassessed.
BOX 29-4
Summary of NAMS 2021 Recommendations for

HT Use
Breast cancer: Diagnosis of breast cancer increases with EPT use longer than
3 to 5 years; women who start EPT shortly after menopause may have a
greater risk than women who start more than 5 years afterward. Because risk
for breast cancer does not appear to increase during an average of 7 years of
ET use, there is more flexibility in duration of ET treatment. ET use in breast
cancer survivors has not been proved to be safe and may be associated with
an increased risk of recurrence.
Cognitive aging and dementia: Available data do not adequately address
whether HT used soon after menopause increases or decreases the rate of
cognitive decline or later dementia risk. HT is not recommended at any age for
preventing or treating cognitive aging or dementia.
Coronary heart disease: HT is not recommended as a sole or primary
indication for coronary protection at any age; starting ET alone soon after
menopause may slow development of calcified atherosclerotic plaque and
lower CHD risk.
Diabetes mellitus: Inadequate evidence to recommend HT as the sole or
primary indication for preventing diabetes in perimenopausal or
postmenopausal women.
Endometrial cancer: Women with an intact uterus taking systemic ET
should take concomitant progestogen to counteract the risk of endometrial
cancer; HT is not recommended for women with a history of endometrial
cancer.
Mood and depression: Although HT might have a positive effect on mood
and behavior, HT is not an antidepressant and should not be considered as
such; evidence is insufficient to support HT use for the treatment of depression.
Osteoporosis: Extended HT is an option for women with decreased bone
mass; benefits decrease quickly once therapy has ended; standard-dose HT
reduces postmenopausal osteoporotic fractures, even in women without
osteoporosis, and low doses are effective in maintaining or improving BMD.
However, no HT product currently has government approval for the treatment of
osteoporosis.
Ovarian cancer: Data on HT and ovarian cancer conflict; the association
between ovarian cancer and HT beyond 5 years is rare.
Stroke: HT is not recommended for primary or secondary prevention of
stroke.
Vasomotor symptoms: Moderate to severe vasomotor symptoms (e.g., hot
flashes, night sweats) remain the primary indication for HT; also best treatment
for moderate to severe vulvar and vaginal atrophy; local vaginal ET is
recommended for treating urogenital atrophy alone; systemic or local ET can
relieve dyspareunia. The most effective treatment for menopausal vasomotor
symptoms and associated quality of life is ET or EPT.
Venous thromboembolism (VTE): Most likely an increased risk of VTE with
oral HT, especially in women with a history of VTE or factor V Leiden (a
hypercoagulability disorder).
Source: North American Menopause Society, 2021.
Today, clinicians have a wide variety of estrogen products from

which to choose, including oral tablets; transdermal patches; and
topical sprays, gels, and lotions, as well as vaginal creams, tablets,
and rings. The choice of therapy is often based on patient
preference. Examples of estrogen and progestogen products for
menopause-related symptoms are presented in Box 29-5.
NAMS has extensive web based information on various hormonal
products which may be viewed at https://www.menopause.org/for-
professionals
THE NURSING ROLE IN MENOPAUSAL HORMONE THERAPY
COUNSELING
When counseling women about HT benefits and risks, it is helpful
to consider a number of factors, such as cardiac protection,
osteoporosis prevention, short- and long-term hormone use, and
alternatives to HT. Women who are taking or considering HT only for
the prevention of cardiovascular disease should be counseled about
other strategies to lower their risks of heart disease.
Patient Education
Bleeding Symptoms With Systemic HT
Nurses should educate women who plan to initiate HT about certain symptoms,
such as vaginal spotting and unscheduled bleeding, which often occur as the
body adapts to a new hormonal symptom. Nurses may offer the following
information:
• Vaginal bleeding and spotting are most likely to occur in the first 3 months
after initiation of therapy.
• Follow-up visits should be scheduled at 1 and 3 months—and improvement in
symptoms should be noted at that time.
• It is important to promptly report the following symptoms: persistent bleeding;
bleeding that stops but then starts again; or the presence of blood clots in the
vaginal discharge.
BOX 29-5
Examples of Estrogen and Progestogen

Products for Menopause-Related Symptoms
ESTROGEN ONLY
Estrace, Premarin (oral tablet, vaginal cream)
Femtrace, Ogen (oral tablet)
Alora, Climara, Estraderm, Menostar, Minivelle, Vivelle, (transdermal patch)
Divigel, Elestrin, EstroGel, Estrasorb (transdermal gel, emulsion)
Femring, Estring (vaginal ring)
Vagifem (vaginal tablet)
Evamist (topical spray)
PROGESTOGEN ONLY
Provera (oral tablet)
Prometrium (oral tablet)
ESTROGEN-PROGESTOGEN COMBINATIONS
CombiPatch (transdermal patch)
Climara Pro (transdermal patch)
Evidence that the risk of depression is higher in early menopause

is mixed. Although two small randomly controlled trials found that
short-term ET is effective for the treatment of affected
perimenopausal women, another trial found no such benefit for
depressed older postmenopausal women. At present, there is
insufficient evidence for using HT to treat depression in general.
EDUCATING PATIENTS ABOUT HORMONE THERAPY OPTIONS
In general, transdermal estrogen (estradiol) provides the same
relief of menopausal symptoms as do the oral preparations but
without the side effects of breast tenderness or fluid retention.
Transdermal estradiol delivery systems (i.e., patches, gels, sprays)
have been shown to be safer than oral administration in reducing
certain markers of cardiovascular risk. Because the hormones
bypass the liver and are directly absorbed into the bloodstream,
transdermal administration is more effective in maintaining stable
blood levels of estrogen. Also, because the transdermal estradiol is
absorbed directly into the body, first-pass metabolism by the
gastrointestinal tract and liver is avoided. When given orally, larger
doses of estrogen are required to achieve therapeutic levels and
offset metabolism by the liver and inactivation by the gut wall. In
addition, when compared with the transdermal formulations, oral ET
has been shown to increase the risk of venous thromboembolic
disease. With transdermal estradiol preparations, serum hormone
levels remain constant, and rapid cessation of drug administration is
possible with removal of the transdermal system.
Nurses can empower women with current, evidence-based
information about contraindications, risks, and side effects of various
hormone therapies. Providing this information helps guide patients to
make appropriate, informed decisions. The risks and side effects of
estrogen and progestogen are presented in Box 29-6.
FOCUS ON SAFETY
Contraindications to Estrogen
Nurses who care for patients who use ET must be knowledgeable of the
absolute contraindications to estrogen. These include:
• Known or suspected estrogen-dependent cancer
• Known or suspected history of breast cancer except in appropriately selected
patients being treated for metastatic disease
• Undiagnosed abnormal genital bleeding
• Active or history of deep venous thrombosis, pulmonary embolism
• Active or recent (within the past year) arterial thromboembolic disease (e.g.,
stroke, myocardial infarction)
• Liver dysfunction or disease
• Known or suspected pregnancy
• Known hypersensitivity to ET/EPT
BOX 29-6
Risks and Side Effects of Estrogen and

Progestogen
RISKS OF ESTROGEN
• Breast cancer
• Deterioration of liver function in women with severe liver disease
• Endometrial cancer
• Increased risk of stroke
• Possible small increase in the risk of coronary events
• Possible worsening of gallbladder disease
• Small increase in the risk of venous thromboembolism
• Worsening of edema in women with severe cardiac disease
• Worsening of hypertriglyceridemia
• Worsening of pain from benign breast disease
ESTROGEN SERIOUS SIDE EFFECTS
• Stroke or blood clots
• Endometrial cancer in women who still have their uterus and who do not use
progestin with estrogen-only medicines
• Dementia in women 65 years and older
• Gallbladder disease or high triglyceride (cholesterol) levels that could lead to
problems with your pancreas
• Vision loss caused by a blood clot in the eye
• Liver problems
• High blood pressure
• Severe allergic reactions
LESS SERIOUS, COMMON SIDE EFFECTS
• Headaches
• Painful or tender breasts
• Vaginal spotting
• Stomach cramps/ Bloating
• Hair loss
• Fluid retention
• Vaginal yeast infection
PROGESTIN ONLY SERIOUS SIDE EFFECTS
• Heart attack or stroke
• Blood clots
• Breast cancer
• Dementia in women 65 years and older
• Gallbladder disease or high triglyceride (cholesterol) levels that could lead to
problems with your pancreas
• Vision loss caused by a blood clot in the eye
• Liver problems
• High blood pressure
• Severe allergic reactions
LESS SERIOUS, COMMON SIDE EFFECTS
• Headaches
• Painful or tender breasts
• Vaginal spotting
• Stomach cramps/bloating
• Hair loss
• Fluid retention
• Vaginal yeast infection
Source: North American Menopause Society, 2021; U.S. Food and Drug
Administration, 2019a.
BIOIDENTICAL COMPOUNDS
The term “bioidentical hormones” was introduced by Jonathan
Wright, MD, a practitioner who used the term to communicate his
still-unsubstantiated claim that plant-derived hormones are “identical”
in molecular structure to human hormones. When used to describe
hormones, the term “bioidentical” simply means chemically
indistinguishable from the hormones produced in a woman’s body
(i.e., estradiol-176 and progesterone). “Bioidentical” is a marketing
term generally accepted to mean a hormone that is chemically
identical to the hormone produced in the body during women’s
reproductive years. Numerous FDA-approved drugs contain these
hormones and therefore are also “bioidentical” (Box 29-7).
Compounded bioidentical hormones are plant-derived (i.e., from
wild yam or soy) hormones that are prepared by a pharmacist and
can be custom made for a patient according to a physician’s
specifications. The use of bioidentical compounds has been
promoted as a natural approach because these substances claim to
replace specific hormones that are naturally present in a woman’s
body. Because the only truly natural source of human estradiol is the
human ovary, all plant sources must be processed to synthesize
estradiol. Therefore, all bioidentical products are actually synthetic.
Many bioidentical replacement hormones are compounded in
private laboratories or pharmacies as individualized made-to-order
products. Bioidentical hormones prepared by a compounding
pharmacist are not regulated and approved by the U.S. FDA.
Women need to be made aware of the limitations and poor results
that may be associated with this therapy.
Certain bioidentical preparations of estrogen or progestin are
approved by the FDA for oral, intravaginal, transdermal, or
percutaneous applications. These particular medications have
undergone strenuous testing for safety, efficacy, and quality control.
However, compounded bioidentical formulations are not FDA-
regulated in the same way. These products are not subject to
rigorous testing or quality control standards. Also, the compounded
products do not carry a package insert that lists important
contraindications, warnings, and precautions—which may make
them appear to be safer than traditional therapy medications. These
products lack standardization, and in many cases, the specific active
ingredients and minimally effective dosages are not known (NAMS,
2021).
BOX 29-7
FDA-Approved Pharmaceutical Bioidentical

Hormone Preparations
• Estradiol - injections (Delestrogen, Depot-Estradiol)
• Estradiol - oral (Estrace, Femtrace)
• Estradiol - spray (Evamist)
• Estradiol - topical emulsion (Estrasorb)
• Estradiol - transdermal gel (Divigel, Elestrin, EstroGel)
• Estradiol - transdermal patches (Alora, Climara, Esclim, Estraderm, Menostar,
Vivelle, Vivelle-Dot)
• Estradiol - vaginal cream (Estrace)
• Estradiol - vaginal ring (Estring, Femring)
• Estradiol - vaginal tablets (Vagifem, Vagifem LD)
Sources: Minkin (2010); Moore (2010); Pinkerton (2012).
Nonhormonal Prescription Medications

Women who experience debilitating vasomotor symptoms and wish
to avoid traditional HT may be willing to try certain prescription
medications including antidepressants, belladonna alkaloid
preparations, anticonvulsants, or antihypertensive agents.
Various nonhormonal medications have been prescribed for the
relief of severe vasomotor symptoms. Antidepressant agents
(SSRIs) including fluoxetine (Prozac), paroxetine (Paxil), citalopram
(Celexa), escitalopram (Lexapro), sertraline (Zoloft), and
serotonin/norepinephrine reuptake inhibitors (SNRI), including
venlafaxine (Effexor) and desvenlafaxine (Pristiq), may reduce hot
flashes. However, studies that compared the efficacy of venlafaxine
with that of medroxyprogesterone acetate (MPA, a progestational
agent) found that a single dose of MPA alleviated hot flashes more
effectively than did daily use of the antidepressant (Barbieri, 2013;
NAMS, 2010b; Pinkerton, Constantine, Hwang, & Cheng, 2013). In
some women, clonidine (Catapres), an antihypertensive medication,
and gabapentin (Neurontin), an anticonvulsant, have been useful in
controlling hot flashes. Transdermal clonidine therapy is preferred
over oral clonidine; gabapentin frequently causes nausea and other
gastrointestinal side effects (Barbieri, 2013; Nelson, 2011).
Gabapentin, taken 1 to 2 hours before bedtime, is useful for sleep
disorders in hypoestrogenic women; other therapies for sleep
difficulties include eszopiclone (Lunesta), zolpidem (Ambien), and
strategies to improve sleep hygiene such as keeping the bedroom
cool, avoiding naps, exercising daily, maintaining a regular sleep-
wake schedule, keeping the bedroom dark and quiet, dimming
ambient lighting in the evening, avoiding caffeine after lunch and
alcohol late in the evening, stopping smoking, and limiting fluids
before bedtime (Barbieri, 2013).
Optimizing Outcomes
Teach Women About Osteoporosis Early Warning Signs
Teaching women about the early warning signs of osteoporosis constitutes an
important nursing role in bone health promotion. Nurses should alert women to
the following signs and symptoms that may signal bone loss, and advise them
to promptly contact their health-care provider if they experience them:
• Sudden onset of insomnia and restlessness
• Leg and foot cramps that occur frequently during the night
• Persistent low back pain
• Gradual loss of height
• Development of gum disease or loose teeth
In the U.S., women typically reach menopause around age 51, and most
bone loss occurs during the first 5 to 7 years after cessation of menses. Thus, it
may be prudent to begin screening at an earlier age. It is generally
recommended that the bone mineral density (BMD) be reassessed every 3 to 5
years. For certain women, including those who are undergoing treatment for
osteoporosis and those who are immobilized, the BMD may need to be
measured beginning at an earlier age, and more often, such as every 6 to 24
months (ACOG, 2012; NAMS, 2010a; NOF, 2013a; USPSTF, 2011).
The American College of Obstetricians and Gynecologists (2012) has
published the following recommendations for BMD testing:
• BMD testing should be recommended to all postmenopausal women aged 65
years or older regardless of risk factors.
• BMD testing may be recommended for postmenopausal women younger than
65 years with any of the following risk factors: medical history of a fragility
fracture; body weight less than 127 lb; medical causes of bone loss
(medications or diseases); parental medical history of hip fracture; current
smoker; alcoholism; rheumatoid arthritis.
• Alternatively, FRAX, a risk assessment tool that estimates your 10-year
fracture risk, can be used in women younger than 65 if they are
postmenopausal and have other risk factors for fracture.
• Routine screening of newly menopausal women is not recommended nor is a
“baseline” screen recommended.
SUMMARY POINTS
■ Today, American women can expect to live to be 80 years old and spend
close to one-third of their lives as menopausal women.
■ Nurses can empower midlife women with factual, evidence-based information
about menopause, the normal aging process, and strategies to optimize
cardiovascular and skeletal health.
■ Complementary and alternative medicine approaches such as stress
management, guided imagery, biofeedback, yoga, and massage therapy may
be useful in minimizing various menopausal symptoms.
■ An important role for nurses centers on counseling women to become
informed about any herbal preparations they are considering and to consult
with their health-care providers before using any of them.
■ Estrogen-containing drugs for menopausal use are divided into two
categories: ET and combined EPT.
■ Women have reported more than 100 different physical and behavioral
symptoms during the premenstrual period.
■ The cause of PMS is believed to be multifactorial.
■ To meet the criteria for PMS, the woman’s symptoms must occur cyclically, be
unrelated to any physical or mental condition, and greatly disrupt one or more
areas of the woman’s life.
■ The diagnostic work-up for a premenstrual disorder includes the patient
history, a physical examination, appropriate laboratory tests, and review of the
daily symptom diary.
■ Management of PMS may include nonpharmacological and pharmacological
approaches.
■ Nurses are instrumental in helping women to deal with premenstrual disorders
by offering ongoing education and support.
■ Bone health promotion includes strategies such as optimizing calcium intake,
preventing the loss of calcium and other minerals from the bone, maintaining
the soft tissue components around the bone, and promoting the efficiency of
bone repair.
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Davis Advantage
CHAPTER 30
Promoting Breast Health
CONCEPTS
Female reproduction
KEY WORDS
fibrocystic changes
fibroadenomas
lipomas
intraductal papillomas
mammary duct ectasia
galactorrhea
false discharge
Mondor disease
peau d’orange
breast conservation therapy
simple mastectomy
LEARNING OBJECTIVES

■ Describe normal breast anatomy.
■ Teach a patient how to perform breast self-examination.
■ Differentiate among various breast abnormalities.
■ Discuss diagnostic modalities and treatment options for breast cancer.
■ Describe the nurse’s role in promoting breast health.
PICO(T) Questions
chapter.
1. For (P) women under age 40, is (I) obesity a greater risk factor in (O)
developing breast cancer than (C) alcohol intake of more than two drinks per
day?
2. What (I) complementary and alternative medicine strategies are reported as
(O) most beneficial in (P) women over 50 who have undergone mastectomy
with breast reconstruction?
INTRODUCTION
This chapter discusses the promotion of breast health in women.
Most concerns about breast care and problems are first voiced in the
primary care setting. Nurses who work with women are in an ideal
position to educate about the importance of breast health awareness
and suggest strategies to promote the early identification of benign
and malignant breast disease. As is true with other types of cancers,
early detection is key in the successful treatment of breast cancer.
Most experts agree that breast cancer is not a singular disease.
Instead, it is believed that malignancies of the breast stem from
many types of diseases, each with distinct histological, biological,
and immunological characteristics. A myriad of dietary,
socioeconomic, and environmental factors most likely serve as
causative or contributing influences in the development of breast
cancer. Breast health is an important issue for women; maintaining
breast health is an essential strategy for maintaining optimal physical
and psychological health.
ANATOMY OF THE BREAST

The female breasts, or mammary glands, are considered accessory
organs of the reproductive system. The two breasts lie over the
pectoral and anterior serratus muscles. Breast tissue, which consists
primarily of glandular, fibrous, and adipose tissue suspended within
the conical-shaped breasts by Cooper’s ligaments, is richly supplied
with a dense network of blood vessels and lymph vessels.
The glandular tissue contains 15 to 24 lobes that are separated by
fibrous and adipose tissue. Each lobe contains several lobules
composed of numerous alveoli clustered around tiny ducts that are
layered with secretory cuboidal epithelia called alveoli or acini (Fig.
30-1).
The epithelial lining of the ducts secretes various components of
milk. The ducts from several lobules come together to form the
lactiferous ducts, which are larger ducts that open on the surface of
the nipple. The lymphatic vessels carry lymph, an alkaline, clear,
colorless tissue fluid, away from the breast. Most of the lymph
vessels of the breast lead to the nodes in the axillae. The lymph
nodes are small, kidney-shaped organs of lymphoid tissue (Fig. 30-
2). An increase in the size of the node (lymphadenopathy) indicates
a high level of activity (e.g., infection or cancer).
FIGURE 30-1 Cross-section of breast; note lobe and lobule shown in
detailed area.
Outer parts of the breasts include the nipples, areolae, and

Montgomery tubercles. The nipples contain several pores that
secrete colostrum (breast fluid that precedes breast milk) and breast
milk during lactation. The nipples consist primarily of erectile tissue
to assist with infant latch-on during suckling. The areola is a more
deeply pigmented area that surrounds the nipple. Its diameter
ranges from 1 to 3.9 inches (2.5 to 10 cm). The Montgomery
tubercles are papillae located on the surface of the nipple and the
areola; they secrete a fatty substance that lubricates and protects
the nipple and areola during breastfeeding.
The primary function of the breasts is to provide nutrition to
offspring through the process known as lactation. In American
culture, the breasts are also closely linked with the societal idea of
womanhood. Many equate large breasts with increased sexiness
and eroticism. Because the breasts serve as a source of sensual
pleasure for both men and women, injury to or the loss of a breast
can trigger major psychological distress for both genders.
FIGURE 30-2 Lymph nodes.
BENIGN BREAST MASSES

Benign breast masses commonly affect women between ages 30
and 50 (Stachs et al, 2019; Venes, 2021). It has been estimated that
at some time during adulthood, 50% of women will experience a
breast problem. Fortunately, most breast tumors are benign. Breast
cysts are a common finding; they may be fluid-filled or solid. Fluid-
filled cysts, also termed fibrocystic changes, are often tender and
fluctuate in size with the menstrual cycle. These changes are the
most common benign breast condition and occur most often during
the childbearing years. During the clinical exam, palpation reveals
lumpy or nodular tissue and patients often complain of pain
(mastalgia) or tenderness. Patients may also report a change in
breast size and density as the menstrual cycle progresses. Although
the cause is unknown, an imbalance of estrogen and progesterone
may play a role in the development of fluid-filled breast masses
(Stachs et al, 2019).
Therapeutic interventions involve differentiating between
fibrocystic changes and breast cancer. Screening methods include
clinical breast examinations (CBE), mammography, and
ultrasonography. The physician may choose to aspirate fluid-filled
cysts for evaluation to determine if malignant cells are present.
Patients should be advised that although aspiration may eliminate
the cysts, they frequently reform.
Optimizing Outcomes
Fibrocystic Breast Changes and Mastalgia

When teaching women about breast health, nurses can include information
about fibrocystic changes, palpable thickening in the breasts often associated
with pain and tenderness that fluctuates with the menstrual cycle. Nurses can
reassure them that fibrocystic changes are common and benign and tend to
appear during the second and third decades of life and suggest strategies for
coping with mastalgia: use of a well-fitting supportive bra, analgesics, NSAIDs,
and consumption of dietary flaxseed (25 g/day).
Fibroadenomas are solid cysts composed of stromal (connective)

and glandular tissue. They are usually moveable and nontender.
Fibroadenomas are the most common benign breast tumor,
occurring in 25% of women and usually located in the upper outer
quadrant of the breast. This tumor occurs most often in women in
their 20s and 30s. The use of oral contraceptives (OCs) before age
20 has been linked to the risk of fibroadenomas (Stachs et al, 2019).
Lipomas are mobile, nontender fat tumors that are soft with
discrete borders. Lipomas may develop anywhere in the body,
including the breasts. Intraductal papillomas are small, wartlike
growths in the lining of the milk ducts near the nipple. These rare,
benign tumors usually produce a clear or bloody nipple discharge.
They may be felt as a small lump behind or next to the nipple.
Mammary duct ectasia is an inflammation of the ducts located
behind the nipple. Occurring most often in perimenopausal and
postmenopausal women, this condition produces a thick, sticky
nipple discharge that may be purple, brown, or white in color. Upon
inspection, the nipple and adjacent breast tissue may be tender and
red, and the nipple may be pulled inward. Duct ectasia may resolve
spontaneously, or it may require treatment with warm compresses
and antibiotics. In some situations, surgical removal of the abnormal
duct is necessary. This lesion does not increase the risk of breast
cancer.
The presence of cysts in the breasts does not necessarily increase
a woman’s risk for breast cancer. It has been estimated that
approximately 70% of fibrocystic changes are nonproliferative
lesions; 26% of changes are proliferative lesions without atypical or
unusual growing cells (termed “atypia”), and proliferative lesions with
atypical hyperplasia represent the remainder of fluid-filled breast
lesions. Nonproliferative (multiplying) lesions do not affect breast
cancer risk. Proliferative lesions without atypia may slightly increase
cancer risk, and proliferative lesions with atypical hyperplasia raise
the risk of cancer.
PREVENTIVE HEALTH
Clinical Breast Examinations
Annual CBEs performed by a trained health-care professional are an
important tool in the early detection of breast cancer, often before a
woman has any signs or symptoms. Many breast cancers go
undetected until a CBE is performed. For example, inflammatory
breast cancer, a rare and aggressive type that may cause swelling
and redness, often does not show up on mammography. Also, the
CBE provides an opportunity for the clinician to reinforce a woman’s
self-examination technique, discuss concerns, and emphasize the
value in becoming intimately familiar with the contour of one’s own
breasts.
The breast examination begins with the patient (disrobed from the
waist up) in a seated position. Facing the woman, the examiner
visually assesses the breasts for symmetry, skin changes such as
dimpling, puckering, retraction, or lesions, and changes in upper
extremity mobility. Inspection of the area beneath the breasts for the
presence of yeast infections and skin nodules is performed as well.
The woman is then assisted to a supine position and gentle
palpation is followed by deeper palpation using a vertical stripping
method (beginning at the clavicle, adjacent to the axilla, the fingers
are moved up and down in “vertical strips” over the breast). The
underlying ribs and costal cartilage are assessed as well (Centers for
Disease Control and Prevention, 2020a). Recommendations for CBE
vary depending on the organization. According to the American
Cancer Society, the examination serves as a complement to
mammography, and there may be some benefit in having the CBE
performed shortly before the mammogram. The American College of
Obstetricians and Gynecologists recommend that the CBE be
performed at least every 1 to 3 years for women aged 25 to 39, and
every year after age 40 (American College of Obstetricians and
Breast Self-Awareness
Breast self-awareness, and breast self-examination (BSE), can also
assist in early detection and early treatment. Patients should be
educated on the need to be familiar with how their breasts look and
feel as well as when to notify health-care professionals when they
notice concerning symptoms such as lumps, pain, or changes in size
as these may warrant further assessment and evaluations.
Familiarity with one’s breasts facilitates the early detection of
problems and allows for prompt evaluation. BSE, an option for
women starting in the 20s, is a way for women to learn how their
breasts normally feel. Routinely performing BSE is an approach that
focuses on the importance of self-awareness and helps women to
notice changes in breast tissue. When teaching women about BSE,
the nurse can display pictures of breast tissue and discuss the
normal irregular contours of breasts. Breast models are also helpful
and allow women to feel both normal and abnormal masses; these
teaching aides may be beneficial in diminishing women’s fears about
checking their own breasts.
Because menstruating women often experience increased
discomfort and lumpiness in their breasts during the second half of
the menstrual cycle, the ideal time to perform BSE is during the
week after menstruation. Routinely performing BSE helps women to
perfect their technique and become familiar with the contours and
tissue characteristics unique to their own breasts. Then, if they
detect changes that are worrisome to them or that persist, they can
schedule an evaluation.
Nurses can be instrumental in facilitating women’s awareness of
and comfort with detecting changes in their breasts. Women should
be told about the benefits and limitations of BSE, and those who
choose to perform BSE should have their technique reviewed during
their physical exam by a health-care professional. Women who
choose not to perform BSE should still be aware of how their breasts
look and feel and report changes promptly. There are many
limitations to a BSE and women should be aware that studies have
found an increase in false positives which may lead to unnecessary
invasive procedures. Given this information, many organizations do
not support routine SBE or limited recommending SBE to those with
higher risk categories (American College of Obstetricians and
Gynecologists, 2017; Thompson & Scannell, 2017; U.S. Preventative
Services Task Force, 2016).
Patient Education
Breast Self-Examination
Patients should be instructed that the best time to perform a BSE is 7 to 9 days
after menses, when the breasts are least likely to be swollen or tender due to
hormonal changes. Best places to perform the BSE include in front of a mirror
so that the women can see clearly, in the shower so the hand can easily slide
along the wet skin, or when lying down on a comfortable surface. Explain these
steps to your patient:
1. Lie down on your back and place your right arm behind your head.
Remember, this step is done while lying down. In this position, the breast
tissue spreads evenly over your chest wall and is as thin as possible. This
makes it much easier to feel all the breast tissue.
2. Use the pads of your three middle fingers on the left hand to feel for lumps in
the right breast. Use overlapping dime-sized circular motions of the finger
pads to feel all the breast tissue.
3. When feeling the breast tissue, you will use three different levels of pressure.
Light pressure is needed to feel the tissue closest to the skin. Medium
pressure allows you to feel a little deeper, and firm pressure allows you to
feel the tissue closest to your chest and ribs. Remember, it is normal to feel
a firm ridge in the lower curve of each breast. If you feel anything else out of
the ordinary, be sure to tell your health-care practitioner. It is important to
use each pressure level to feel all the breast tissue before you move on to
the next spot.
4. Move around the breast in an up-and-down pattern, starting at an imaginary
line drawn straight down your side from the underarm and moving across the
breast to the middle of the chest bone (sternum, breastbone). Make sure
that you check the entire breast area going down until you feel only your ribs
and then up to the neck or collarbone (clavicle). Using the up-and-down, or
vertical, pattern is probably the most effective way to examine the entire
breast without missing any breast tissue.
5. Repeat step 4 on your left breast, putting your left arm behind your head and
using the finger pads of your right hand to do the exam.
6. Stand before a mirror, place your hands on your hips, and press down firmly.
In the mirror, look at your breasts for any changes of size, shape, contour,
dimpling, or redness or scaliness of the nipple or breast skin. (Pressing
down on your hips contracts the muscles of the chest wall and enhances any
breast changes.)
7. Sit or stand with your arm only slightly raised so that you can easily feel the
underarm area. Do this on each side, feeling for lumps or thickened areas.
(Raising the arm straight up causes a tightening of the tissue and makes it
more difficult to examine.)
What to Say
On the Potential Benefits and Harms of BSE
When sharing information about breast awareness and BSE, it is useful to
consider the potential benefits and harms that are associated with this practice.
Potential benefits of BSE include empowerment (women gain a sense of
control over their health); comfort (noninvasive test that allows women to
become more comfortable with their own breasts); and enlightenment (women
develop an increased awareness of breast changes, can palpate lumps, and
may detect cancer). Potential harms include increased anxiety (heightened fear
of cancer that may require counseling) and increased health-care visits, costs,
and invasive interventions. Also, there is no change in mortality from breast
cancer with detection from BSE.
Women with breast implants may perform BSE. Following surgery,

it may be helpful for the surgeon to guide BSE teaching by
identifying the edges of the implant to enhance the patient’s
understanding of the new contours of her breasts. For some, the
increased prominence of the breast tissue following implant surgery
may make it easier to perform the examination. Women who are
pregnant or breastfeeding may also choose to examine their breasts
regularly.
The promotion of breast health encompasses several areas,
including cancer screening, optimal nutrition, and physical activity.
An important role for nurses centers on educating women throughout
the life span about strategies for promoting breast health. Personal
awareness of the normal appearance and feel of the breasts
constitutes an essential first step in promoting and maintaining
breast health. Nurses working with women in a variety of settings are
perfectly situated to offer evidence-based information about
strategies for promoting breast health and, for those who wish to do
so, performing self-examinations. By providing information in a
nonthreatening, therapeutic environment, nurses can help to allay
women’s fears and present breast self-awareness, and, when
desired, BSE, as a positive, empowering experience.
Patient Education
Teaching About Breast Health
During a discussion about breast health, the nurse may wish to include the
following information:
• As you age, your breasts experience loss of milk glands and shrinkage of
collagen. This causes an increase in the fat tissue and loosening of the breast
tissue. Instead of getting larger with the increase in fat tissue, however, the
breast tissue begins to sag, causing the breasts to drop.
• Breast tissue weighs less than most people think: An A-cup weighs 1/4 lb, a
B-cup weighs 1/2 lb, a C-cup weighs 3/4 lb, and a D-cup weighs about 1 lb.
• The skin covering the breasts stretches as you grow, causing the skin to
become thinner than the skin on other parts of the body.
• It is not uncommon for women to have some degree of hair surrounding their
nipples. The darker the skin, the more hair there is likely to be.
• A woman’s nipples may be different sizes and may be placed in slightly
different locations on each breast. This may cause the nipples to point in
different directions, which is considered a normal finding.
• Fluctuating hormone levels during the monthly cycle cause changes in breast
tissue. Following menstruation, when hormone levels are at their lowest, the
breast tissue is smooth and nontender.
As estrogen levels increase at midcycle, the breasts may become more
sensitive. Also, just before menstruation, when progesterone is elevated, many
women’s breasts become swollen and tender, with palpable nodules.
• Breast implants still pose health risks, including deflation, leakage, and
wrinkling. In addition, capsular contraction can occur, causing the scar tissue
surrounding the implant to tighten and the breast to become hard. Cosmetic
breast implants also hamper detection of breast malignancy.
• The area between the breasts has several oil and sweat glands, creating an
atmosphere conducive to the growth of bacteria.
• Sleeping on your side, with a pillow to support your breasts, provides the best
position for maintaining breast shape and contour over time.
• Regular exercise can strengthen the pectoral muscles, reducing sagging over
time and creating a natural lift.
• It is not uncommon to have a third nipple, stemming from breast buds that
form during early fetal development. These extra nipples, however, rarely
contain milk glands.
• Pregnancy darkens the color of the nipple, which is an enhancement for the
breastfeeding baby. This darker color does not disappear after pregnancy.
• The left breast is usually larger than the right breast.
• Breasts do not reach their full size until the early 20s.
Lifestyle Choices and Breast Health
Lifestyle choices, including moderate alcohol consumption, weight
maintenance, and avoidance of smoking, can affect breast health as
well. Alcohol consumption is associated with an increased risk of
breast cancer. The American Cancer Society recommends limiting
alcohol intake to one drink per day; compared with non-drinkers,
women who consume one alcoholic drink a day have a very small
increase in risk. The risk of breast cancer is increased 1.5 times in
women who consume two to five drinks per day.
Routine exercise, which helps to maintain a healthy weight, is
associated with a decreased risk of breast cancer. Maintenance of a
healthy weight is recommended for optimal breast health. Obesity is
associated with an increased risk of breast cancer, particularly in
postmenopausal women. Following menopause, estrogen is
produced in the fat cells. In combination with dietary fat, estrogen
significantly increases the likelihood of breast cancer development.
Smoking is associated with an increased risk of breast cancer, lung
cancer, and heart disease in women.
EVALUATING BREAST ABNORMALITIES

Over the past decade, breast cancer screening methods, especially
mammography, have become more precise, allowing for earlier
diagnosis. Improved screening and increased public awareness
have accounted for the dramatic increase in the detection of breast
cancer. Earlier diagnosis has resulted in a decrease in mortality
rates.
If an area of abnormal breast tissue is detected during the CBE,
unless there is a high index of suspicion, the woman is usually asked
to return for a second evaluation after her next menstrual period. In
many situations, she is also referred for a mammography. A
limitation of mammography is the inability of this modality to
differentiate between solid and cystic masses. An ultrasound
examination (ultrasonography; sonography) may be performed at the
time of the mammography to determine whether the lump is solid or
fluid-filled.
Diagnostic Tools
Mammography
A mammography examination is used to aid in the early diagnosis of breast
cancer (Fig. 30-3). The examination, which requires exposure to small doses of
ionizing radiation, allows for identification of small breast tissue abnormalities
that may require further investigation. In recent times, two enhancements have
been made to traditional mammography techniques: digital mammography and
computer-aided detection (CAD). Digital mammography, also called full-field
digital mammography (FFDM), converts the x-rays to electrical signals, similar
to those found in digital cameras. These signals produce images that can be
viewed on a computer screen or printed on special film. The images are stored
for future comparison. Digital mammography provides improved screening for
women determined to be at high risk for developing breast cancer. This latest
technology is enhanced with the use of computer software that highlights areas
of increased density, masses, and calcifications. The CAD systems provide an
additional feature similar to a computer’s spell-check function—they identify
visible patterns in images that could represent cancer.
The U.S. Food and Drug Administration (FDA) approved the first ultrasound
device (somo-v Automated Breast Ultrasound System, or ABUS) for use in
combination with a standard mammography in women with dense breast tissue
who have a negative mammogram and no symptoms of cancer. Mammograms
of dense breasts can be difficult to interpret because there is a higher
percentage of fibroglandular tissue present, which can obscure smaller tumors.
The somo-v ABUS, which consists of a specially shaped transducer that can
automatically scan the entire breast in minutes to produce several 3D images
for review, is approved for use in women who have not had previous clinical
breast intervention (e.g., surgery, biopsy), because these interventions may
alter the appearance of breast tissue in an ultrasound image (Nicosia et al,
2020).
Optimizing Outcomes
Counseling Women With Dense Breasts
It is estimated that 40% of women have dense breast tissue, which can mask
cancer. A radiologist determines the density of a woman’s breasts by examining
her mammogram. At present, some states mandate that each mammography
report provided to a patient include information about breast density and require
insurance coverage for comprehensive ultrasound screening of the breasts if
mammography demonstrates heterogeneous or dense breast tissue based on
the Breast Imaging Reporting and Data System (BIRADS) established by the
American College of Radiology. Two BIRADS scales are used to standardize
mammography reporting: One scale categorizes breast density, and the other
scale categorizes the findings that are seen on the mammogram; most
mammography reports reference this scale (Box 30-1). Nurses can counsel
women whose mammography reveals breast density to ask their health-care
providers which category of breast density they have (based on the BIRADS
scale) and use this information to guide care. To determine insurance laws in
each state, patients can visit http://Areyoudenseadvocacy.org/ (Are You Dense
Advocacy, 2014).
FIGURE 30-3 Mammography showing breast cancer.
NURSING INSIGHT
Calcium Deposits Within Breast Tissue
Calcifications (calcium deposits) detected on mammography may be identified
as macrocalcifications or as microcalcifications. Macrocalcifications,
degenerative changes resulting from old trauma, inflammation, or aging of the
breast arteries, occur in approximately one-half of women in the United States
who are over age 50 and are usually not related to malignancy.
Microcalcifications are small specks of calcium that may be present as
“residue” in areas of rapidly dividing cells (e.g., a neoplasm). A cluster of
microcalcifications may be indicative of a small cancer.
Screening mammography is beneficial as routine breast

surveillance for the asymptomatic woman. Clinical detection through
BSE (in women who wish to engage in this practice) generally does
not occur until the tumor approximates the size of a walnut. By the
time a palpable mass or lump is detected, the tumor most likely has
been growing for some time. Hence, routine screening
mammograms provide a much earlier, high-sensitivity study of
developing tumors at the lowest possible cost. In addition, a
screening mammogram enables the radiologist to identify changes
such as calcifications that may point to malignancy.
BOX 30-1
American College of Radiologists Breast

Imaging Reporting and Data Systems (BIRADS)
CATEGORIZES BREAST DENSITY
1 Almost entirely fatty (mammogram very effective)
2 Scattered fibroglandular tissue (minor decrease in sensitivity)
3 Heterogeneously dense tissue present (moderate decrease in sensitivity)
4 Extremely dense tissue present (marked decrease in sensitivity)
CATEGORIZES FINDINGS SEEN ON MAMMOGRAM
0 Incomplete; need additional imaging evaluation or prior mammograms for
comparison
1 Negative
2 Benign findings
3 Probably benign findings; short interval follow-up recommended
4 Suspicious abnormality; consider biopsy
5 Highly suggestive of malignancy; appropriate action should be taken
6 Known biopsy-proven malignancy
Sources: National Cancer Institute, 2021.

Screening mammograms are performed to check for breast cancer
in women who have no signs or symptoms of the disease. They
usually involve two x-rays of each breast. Diagnostic mammograms
are performed to check for breast cancer after a lump or other sign
or symptom of breast cancer has been detected. They may also be
used to evaluate changes discovered during a screening
mammogram or to view breast tissue when it is difficult to obtain a
screening mammogram because of special circumstances, such as
the presence of breast implants. Diagnostic mammography takes
longer to perform because more x-rays are taken to obtain views of
the breast from several angles according to the National Cancer
Institute (NCI).
The value of routine screening mammography for women aged 50
and older has been well-established. Recommendations for
mammography screening in women aged 40 to 49 have been met
with some controversy. Analysis of the major studies of women in
this age group has shown a marginal benefit in decreasing the death
rate from breast cancer. However, the following should be noted:
■ Findings from older studies may be flawed because
mammography was much cruder 30 years ago.
■ Breast cancer in women aged 40 to 49 occurs with less frequency.
■ Mammography in premenopausal women historically has not been
as accurate owing to the density of breast tissue in women in this
age group, as compared with breast tissue in postmenopausal
women. Mammography may miss as many as 25% of invasive
cancers in women aged 40 to 49 years, as compared with 10% in
women aged 50 years and older.
■ Certain tumors, even when detected early, are not curable. In
general, younger women tend to have more rapidly growing
tumors than do older women. This finding may be related to the
higher levels of estrogen in the blood and tissues of
premenopausal women that can stimulate tumor growth or a
genetic predisposition that becomes expressed in this age group.
In late 2009, the USPSTF issued updated breast cancer screening
recommendations for the general population. Based on evidence
review, the current guidelines recommend against routine
mammography screening for women before age 50 years, suggest
that screening end at age 75 years, and recommend changing the
screening interval from 1 year to 2 years. Over the years the task
force amended those recommendations, clarifying that regular
screening mammography before the age of 50 should be an
individual decision based on the patient’s needs, values, and
preferences. The guidelines were based on conclusions from
evidence reviews of the literature and statistical analysis. It should
be noted that the rationale for the change in screening
recommendations applies only to women with average risk for
developing breast cancer. When considering the benefits of
screening women beginning at age 40, it is important to note that the
benefit is smaller in this age group than in older women. Younger
women are more likely to have false-positive results, which leads to
additional and often unnecessary testing (repeat mammography,
increase in radiation exposure, ultrasound, biopsy), as well as
financial burdens, anxiety, and possible overdiagnosis (Centers for
Disease Control and Prevention, 2020a; U.S. Preventative Services
Task Force, 2016).
Assessment Tools
Preparing for a Mammogram
Nurses can counsel women about strategies to enhance mammography results
and minimize discomfort associated with the procedure. For example, the
nurse can provide the following information:
• Choose a mammography facility that is accredited by the American College of
Radiology; ensure that the mammogram is performed by a registered
technologist and that the radiologist is trained specifically to interpret
mammography.
• Remove powder, deodorant, and perfume prior to the mammogram (these
substances may create shadows).
• Schedule the mammogram when the breasts are less tender (e.g., after the
menstrual period).
• Ask for the use of a soft pad to cushion the breasts during mammography
compression.
• Take acetaminophen, ibuprofen, or aspirin as needed for relief of discomfort.
Mammography, which produces a two-dimensional x-ray image of

the breast, is the traditional first-choice modality for the early
detection of breast cancer. However, mammography interpretation,
especially in women with dense, fibroglandular breasts, has inherent
limitations. With a standard mammogram, normal breast structures
are superimposed on each other, creating an overlapping image that
may mimic or mask a lesion and lead to false-positive or false-
negative findings. Tomosynthesis produces breast views in
numerous thin slices, providing a three-dimensional image (and
better visualization) of breast tissue. Similar to mammography, the
breast is compressed with the tomosynthesis technique and the total
radiation dose is comparable to the dose of a singleview
mammogram. Complementary to standard mammography,
tomosynthesis is performed along with a standard mammogram, at
the same time and on the same scanner. The main benefits of this
imaging modality are lower recall rates and a slight increase in
cancer detection, especially cancers with a poor prognosis (Conant
et al, 2020; NCI, 2021).
Further testing is indicated if the breast mass persists after the
next menstrual period or if any abnormality is identified on
mammography or sonography. If the ultrasound examination reveals
that the lump is solid, the suspicious tissue is biopsied for further
analysis. If the mass is fluid-filled, a needle aspiration is performed,
and the woman is monitored for the development of additional cysts.
Ultrasound may be used to guide the needle aspiration. If a distinct,
palpable lump persists despite normal findings on mammography,
immediate follow-up and evaluation are indicated.
A biopsy of any suspicious area is needed to provide a tissue
sample for analysis so that a definitive diagnosis can be made.
Although mammography is considered the best detection method for
early breast cancer, it is often unable to distinguish between benign
and malignant tumors. The American Cancer Society estimates that
four out of every five biopsy results are not cancer (U.S. Department
of Health and Human Services, 2016).
Breast MRI is used with increasing frequency to evaluate
abnormal breast findings and to screen women at high risk for breast
cancer. This screening modality is especially beneficial for breast
masses that are not visualized mammographically, for lobular
cancers, and for patients at risk for bilateral disease. MRI of the
breast has shown an overall sensitivity to breast cancer of 95%.
Recent evidence suggests that this diagnostic method can detect
cancer in the contralateral breast that was missed by mammography
in women with recently diagnosed breast cancer. Although MRI does
not involve the use of radiation, effective cancer screening does
require the use of a nonradioactive intravenous contrast agent.
Hence, women with an allergy to the contrast agent, or poor renal
function, or those who are pregnant are not candidates for this
modality. Also, patients with certain devices (e.g., pacemakers)
cannot undergo MRI, and highly claustrophobic patients may not
tolerate the procedure.
The American Cancer Society recommends both MRI scans and
mammograms once per year for women considered as high risk—
those whose chance of developing breast cancer during their lifetime
is greater than 20%—beginning at age 30 (American Cancer
Society, 2021).
Optimizing Outcomes
Algorithms to Enhance Evaluation of Breast Masses

The CRICO breast care management algorithm, which has been continuously
updated since 1995, is available at http://www.rmf.harvard.edu/Clinician-
Resources/Guidelines-Algorithms/2019/Breast-Care-Management-Algorithm.
Biopsy
Most often, the diagnosis and treatment of breast abnormalities form
a two-step process: A biopsy is obtained and evaluated and then,
based on this information, decisions are made regarding the
treatment. Palpation alone cannot determine whether a suspicious
mass or lump is cancer. Likewise, neither the CBE nor available
technology can provide definitive proof that a suspicious lesion is
cancerous. All that can be concluded from these modalities is that
“no evidence of cancer is found.” Confirmation of cancer can be
made only by examining the suspicious tissue. A number of different
biopsy procedures may be used to obtain a sample of breast tissue
or fluid within the breast tissue for evaluation. These include fine
needle aspiration (FNA), core needle aspiration, and surgical or
open biopsy.
Fine Needle Aspiration (FNA)

The FNA technique involves the use of a fine needle that is carefully
guided into the suspicious area while the practitioner palpates the
lump. It is usually conducted in the office setting. If the abnormality is
too small to feel, ultrasound or a stereotactic biopsy can be used to
help locate and ensure an adequate sampling of the suspicious
tissue. In the latter technique, the biopsy is conducted with the aid of
mammography. The needle is guided to the area by computer-
assisted x-ray, which can help the examiner precisely control the
needle placement. Then suction is applied to the needle. FNA is
used to determine whether the lump is a fluid-filled cyst or a solid
tumor (Fig. 30-4).
Indications for Breast Biopsy

A biopsy obtained by FNA with a stereotactic core needle or by surgical
excision is usually recommended for any breast mass that does not resolve
spontaneously within one or two menstrual cycles and for all postmenopausal
women. It is important to note that negative results from mammography and
ultrasonography are not always accurate enough to rule out cancer (Venes,
2021).
If fluid is aspirated, the FNA procedure may eliminate the lump

altogether and provide a preliminary diagnosis. In some situations, it
is necessary to perform further testing. Additional evaluation may be
indicated if the fluid is dark in color, if the fluid-filled cyst has recurred
several times, or if the sample has been obtained from a
postmenopausal woman who would not be expected to have breast
cysts because of low estrogen levels. Clear fluid is usually indicative
of a benign cyst; cloudy or bloody fluid may be present in benign or
malignant tumors.
If no fluid is aspirated or if a residual thickened area remains after
aspiration of the fluid, a core needle biopsy is performed. The false-
positive rate for needle aspiration is almost zero. False-negative
results occur more frequently because the needle may have missed
the abnormal tissue. If no abnormalities are found with aspiration,
follow-up mammography or sonography is recommended in
approximately 2 to 4 months to assess for recurrence of the cyst.
Core Needle Biopsy

In this technique, a large-bore needle is used to remove a small
cylinder of tissue. The needle placement is often guided as with the
FNA procedure. Core needle biopsy may be performed with the use
of a local anesthetic in the office setting. The procedure may be
painful, but there is usually little or no scarring. The core needle
biopsy is preferred over the FNA, as this method can identify
invasive cancer and provide prognostic biomarkers to help direct the
course of treatment.
The Mammotome and Advanced Breast Biopsy Instrument (ABBI)
are stereotactic biopsy methods that remove more tissue than a core
needle biopsy. The Mammotome is a type of vacuum-assisted
biopsy that uses a hollow probe instrument to remove about twice as
much tissue as would a core biopsy. Performed in the outpatient
setting under local anesthesia, this procedure requires no stitches
and leaves minimal scarring. The ABBI method uses a rotating
circular knife equipped with a thin heated electrical wire to remove a
large cylinder of abnormal tissue. This procedure requires sutures
and is more likely to leave a minimal scar. In some centers, the
biopsy is guided by an MRI, which locates the tumor, plots its
coordinates, and precisely aims the stereotactic biopsy instrument
into the tumor. Automated tissue excision and collection (ATEC) is a
biopsy technique that combines vacuum-assisted breast biopsy with
MRI-assisted guidance. This method, which allows many samples to
be taken through one small cut in the skin, requires only a local
anesthetic. It is being studied in women who have had a personal or
family history of breast cancer, in those who have had previous
breast surgery, and in women with dense breast tissue who cannot
be accurately screened with tests such as mammography or
sonography (U.S. National Library of Medicine, 2021).
FIGURE 30-4 Fine needle breast biopsy.
Surgical or Open Biopsy

In many instances, removal of all or a portion of the tissue for
microscopic analysis may be indicated. When this is the case, a
number of decisions must be made concerning the amount of tissue
needed, because the goal is to obtain surgical margins that are free
of possible malignant tissue. If possible, the incision is made near
the areola of the nipple to minimize scarring and disfigurement. The
surgical or open biopsy is considered the most accurate biopsy
technique for large masses or for large areas under suspicion and
may involve removal of the entire tumor (excisional biopsy) or a
small part of a large tumor (incisional biopsy). Depending on the
situation, the procedure may be performed using local anesthesia or
regional anesthesia; if the tumor is deep inside the chest, general
anesthesia may be required.
Skin (“Punch”) Biopsy

A punch biopsy may be used to confirm a diagnosis of inflammatory
breast cancer or Paget’s disease (carcinoma of the mammary ducts)
of the nipple.
Testing for Estrogen and Progesterone Receptors

Normal breast tissue contains hormone receptors that respond to the
stimulatory effects of estrogen and progesterone. An estrogen
receptor is a cellular protein that binds the female sex steroid
hormones. When circulating estrogens attach to it, they stimulate the
cells to transcribe DNA and manufacture proteins. This process
typically leads to cellular growth and proliferation. Many types of
breast cancers retain estrogen receptors, and for these tumors,
estrogen enhances proliferation of the malignant cells. This also can
occur with progesterone receptors.
An important component in the evaluation of a woman with early
breast cancer is to test for the presence of hormone receptors. The
estrogen and progesterone receptor proteins are present in the cell
cytoplasm and may be located on the surface of some of the breast
cancer cells. When present, the receptors bind to the estrogen or
progesterone, and the binding promotes growth of the malignant
cells. A malignant breast tumor may have estrogen receptors,
progesterone receptors, or both types. Determining the patient’s
hormone receptor status through biological testing of the tumor type
provides valuable information concerning the predicted response to
hormone manipulation therapy. Tumors that lack hormone receptors
will not respond to hormone therapy. In general, postmenopausal
women tend to be estrogen-receptor positive; premenopausal
women tend to be estrogen-receptor negative (Venes, 2021).
EVALUATING BREAST SYMPTOMS

Breast symptoms may occur in benign and malignant conditions. For
example, the woman may experience nipple discharge, skin
changes, or breast pain. It is important that each symptom be
evaluated to determine its significance and the need for further
testing or treatment.
Signs that need to be evaluated for possible breast cancer include:
■ New lump in the breast or underarm (armpit)
■ Thickening or swelling of part of the breast
■ Irritation or dimpling of breast skin
■ Redness or flaky skin in the nipple area or the breast
■ Pulling in of the nipple or pain in the nipple area
■ Nipple discharge other than breast milk, including blood
■ Any change in the size or the shape of the breast
■ Pain in any area of the breast (Centers for Disease Control and
Prevention, 2020a)
Nipple Discharge
Any spontaneous nipple discharge should be promptly evaluated. In
most cases, nipple discharge results from a physiological event (e.g.,
infection) or hormonal imbalance. However, a small percentage of
women who experience this symptom are diagnosed with a serious
pituitary disorder or malignancy.
A ductogram is sometimes performed to determine the cause of
nipple discharge. Also called a “galactogram,” this test involves the
placement of radiopaque dye (instilled via a tiny plastic tube) into the
nipple. An x-ray is then taken to determine the presence of a ductal
mass.
Galactorrhea (the continuation of milk secretion after
breastfeeding has ceased) is characterized by a spontaneous
bilateral, milky, sticky discharge. Galactorrhea normally occurs
during pregnancy due to increased circulating levels of prolactin.
Elevated prolactin levels may also be associated with a thyroid
disorder, a pituitary tumor, chest wall surgery, or trauma. Some
women develop galactorrhea during therapy with certain neuroleptic
drugs or OCs. In addition to evaluation of serum prolactin levels,
diagnostic testing may also include a ductogram, microscopic
analysis of the nipple discharge, a thyroid profile, pregnancy testing,
and mammography.
Serous or bloody nipple discharge may be caused by an
intraductal papilloma, a rare, benign condition of unknown etiology
that develops in the terminal nipple ducts. Purulent nipple discharge
is typically associated with breast infection. Occasionally, breast
cancer produces a spontaneous unilateral discharge that may be
bloody, serous, or watery. The bloody discharge associated with
breast cancer ranges from bright red to black and the serous
discharge is thin, sticky, and yellow to light orange in color.
False discharge refers to fluid that appears on the nipple or
areola but is not secreted by breast tissue. False discharge may be
bloody, clear, colored, purulent, serous, or viscous. Various
conditions such as eczema, dermatitis, nipple trauma, and Paget’s
disease may be associated with false nipple discharge.
Paget’s disease is an inflammatory, malignant neoplasm that
originates in the nipple. This rare tumor accounts for only 1% of all
cases of breast cancer. It usually occurs with invasive ductal
carcinoma and can cause scaling, bleeding, oozing, and crusting of
the nipple. The woman may complain of burning or itching in the
affected area. Nurses should remind women that an important
component of breast awareness and self-examination involves
visualization and inspection of the nipples and that any changes
should be promptly reported.
Skin Changes
Erythema, or reddening of the skin, may be related to benign or
malignant conditions. Infection, the most common cause of breast
erythema in young women, is usually accompanied by increased
tenderness and localized warmth. Infection is treated with a course
of antibiotic therapy. Reddening that occurs at the end of the nipple
may be associated with Paget’s disease, and a biopsy is required for
diagnosis. Changes in the breast skin color and texture that
resemble orange peel (peau d’orange) may result from inflammatory
breast cancer and require immediate evaluation. Other skin changes
associated with inflammatory breast cancer include the presence of
pink, purplish, or bruised skin; a pitting or ridging of the skin; and a
nipple newly turning inward.
Mondor disease of the breast is a rare, self-limiting condition
characterized by thrombophlebitis of the superficial veins. Symptoms
include skin redness, edema, and pain in the affected area. The
condition may occur after trauma or appear without apparent cause.
Although Mondor disease is usually benign, it may be associated
with breast cancer and hypercoagulability (Venes, 2021).
Breast Pain (Mastalgia)

Evaluation of breast pain begins with a comprehensive health
history. It is important to inquire about the type of pain and its
relationship to menses, the duration, location, impact on activities of
daily living, factors that aggravate and alleviate the pain, and other
medical problems along with a list of the current medications and
use of alternative therapies and/or herbal remedies. The most
common type of breast pain occurs cyclically and is associated with
the period that immediately precedes the onset of menses. It usually
begins during the luteal phase of the menstrual cycle when ovulation
occurs and the estrogen-to-progesterone ratio is highest. While the
exact etiology is unknown, cyclical breast pain has been linked to
hormonal imbalances. The pain, often described as dull and aching,
may be experienced in one or both breasts; it may also radiate into
the axillary region and arm.
Noncyclical breast pain does not vary with menses and is less
common than cyclic pain. Usually unilateral and more localized than
cyclical pain, the discomfort, frequently described as a sharp,
stabbing pain, is generally experienced by older women (40s or 50s)
and extends into the postmenopausal years. Although the cause
may be related to breast trauma, mastitis, or benign tumors, the
cause may never be identified. Inflammatory breast cancer (see later
discussion) may produce noncyclical pain and pain that is unilateral
and noncyclical should be further investigated (Stachs et al, 2019).
Extramammary pain, the third type of breast pain, originates in
areas other than the breast, such as musculoskeletal pain, cardiac
pain, gastrointestinal pain, and Tietze syndrome (a form of
costochondritis of the upper front of the chest). Shingles may also
produce pain, which is unilateral and accompanied by the
characteristic zoster rash. Extramammary pain is typically treated by
managing the underlying cause. In general, breast pain is not
associated with breast cancer, although women with breast cancer
may complain of a localized tightening or pulling sensation or a
localized burning or itching.
BREAST CANCER
Risk Factors
Risk factors for breast cancer may be related to demographics,
personal health history, lifestyle choices, and defects in certain
genes. As is the case with many other diseases, the greater the
number of risk factors that are present, the greater the likelihood of
developing breast cancer. A listing of specific risk factors is
presented in Box 30-2. It is important to note, however, that
approximately 70% to 80% of women who develop breast cancer
have none of the known risk factors. Nurses may assist women in
assessing their personal risk for breast cancer with the Breast
Cancer Risk Assessment Tool.
BOX 30-2
Risk Factors Associated With Breast Cancer

• Defects in breast cancer gene 1 (BRCA1) or breast cancer gene 2 (BRCA2)
• Gender: 100 times more likely to occur in females than in males
• Age: Increasing age—two out of three invasive breast cancers occur in
women aged 55 and older
• Personal history of breast cancer in at least one breast
• Family history of breast cancer
• Exposure to chest radiation
• Excess weight
• Exposure to estrogen: early onset of menarche, late menopause, or use of
hormonal therapy
• Race: Caucasians more likely to develop breast cancer than Hispanics or
African Americans
• Smoking
• Exposure to carcinogens
• Excessive use of alcohol
• Diagnosis of precancerous breast changes
• Increased breast density
• Exposure to diethylstilbestrol (DES)—mothers and female offspring
• No prior pregnancy
Source: American Cancer Society, 2021; National Health Services, 2019; Venes,
2021.
Assessment Tools
The Breast Cancer Risk Assessment Tool
The NCI and the National Surgical Adjuvant Breast and Bowel Project
(NSABP) have developed an interactive computer tool to estimate a woman’s
risk of developing invasive breast cancer. The tool, designed for use by health
professionals, has recently been updated for African American women. The
tool predicts a woman’s risk of breast cancer in 5 years and over the lifetime (to
age 90 years). Various risk factors, including present age, number of first-
degree relatives affected, age at menarche, age at first live birth, the number of
breast biopsies, and a history of abnormal hyperplasia in breast biopsy
specimens, are assessed. The tool is available at the Web site
http://www.cancer.gov/bcrisktool/ (NCI, 2021).
Demographics and Personal Health History
Advancing age constitutes the single most important risk factor for
breast cancer. A woman’s risk increases as her age increases.
According to the American Cancer Society, approximately one out of
eight invasive breast cancer diagnoses are made among women
younger than age 45; approximately two out of three women with
invasive breast cancer are aged 55 or older when they are
diagnosed. Breast cancer is more prevalent in women than in men.
In males, breast cancer accounts for only 0.7% of all breast cancer
diagnoses (American Cancer Society, 2021; National Health
Services, 2019).
Caucasian women are more likely to develop breast cancer than
African American women are. Statistically, however, African
American women have a higher fatality rate and are also more likely
to be diagnosed with higher-grade tumors associated with a poorer
prognosis. Reasons for this finding may include an inability to obtain
health care or screening mammography, failure to follow up after
receiving abnormal test results, distrust of the health-care system,
and the belief that mammograms are not needed. Also, higher-grade
tumors may occur more frequently in African American women, even
those who receive regular screening. Asian, Hispanic, and Native
American women have an overall lower risk of developing and dying
from breast cancer (American Cancer Society, 2021; National Health
Services, 2019).
Women who currently have or have been previously diagnosed
with cancer in one breast have three to four times the risk of
developing new cancer in the same or other breast than do their
counterparts who have never had breast cancer. A history of a family
member, especially a mother or sister, who received a diagnosis of
breast cancer also increases the risk, especially if the cancer
occurred prior to menopause. Interestingly, however, approximately
70% to 80% of women who develop breast cancer do not have a
family history of this disease.
Lifestyle Factors
Women who have had no children or who had their first child after
age 30 have a slightly increased risk of breast cancer, owing to
increased exposure to estrogen. Also, women who use oral
contraceptives (OCs) have a slightly greater risk of breast cancer
than women who never used them. However, after discontinuation of
OC use, the risk decreases; approximately 10 years after
discontinuing the OC, there is no increased risk of breast cancer.
Postmenopausal combined hormone therapy (i.e., estrogen +
progestin) is associated with an increased risk of breast cancer; the
use of estrogen alone for less than 10 years does not appear to
increase the risk. Breastfeeding, especially for 1 to 2 years, appears
to slightly reduce the risk for breast cancer.
Being overweight or obese increases breast cancer risk, especially
for postmenopausal women, and especially if the extra weight has
been gained in adulthood and is accumulated at the waist. Following
menopause, adipose tissue becomes the primary source of
estrogen. Postmenopausal weight loss lowers circulating estrogen
levels, and because estrogens are directly related to the risk of
breast cancer, it is believed that weight loss may decrease the risk.
Regular exercise also appears to reduce breast cancer risk; the
American Cancer Society recommends 150–300 min of moderate-
intensity physical activity, or 75–150 min of vigorous-intensity
physical activity per week (ACS, 2021).
Recent research suggests an inverse relationship between vitamin
D deficiency and increased risk of breast cancer and recurrence of
breast cancer. Vitamin D comprises a group of fat-soluble
compounds naturally found in fish-liver oils, fatty fish, mushrooms,
egg yolks, and liver. The two physiologically relevant forms of vitamin
D are D2 (ergocalciferol) and D3 (cholecalciferol). Vitamin D3 is
photosynthesized in the skin by ultraviolet B (UVB) radiation, and
vitamin D2 is produced by the UV irradiation of ergosterol (a sterol
found in fungi). Active vitamin D, which functions as a hormone,
maintains serum calcium and phosphorus concentrations within a
normal range by enhancing the efficiency of the small intestine to
absorb these minerals from the diet (Atoum & Alzoughool, 2017).
Nurses can educate women about simple strategies to boost vitamin
D intake: Consume fatty fish and fortified foods; obtain direct sun
exposure (without sunscreen) to the face and arms three times a
week. Sunlight exposure should include 5–30 minutes of sun
exposure, particularly between 10 a.m. and 4 p.m., either daily or at
least twice a week to the face, arms, hands, and legs without
sunscreen (U.S. Health and Human Services, 2020). Some women
may benefit from vitamin D3 supplements.
Patient Education
Tips for Reducing Breast Cancer Risk
Nurses can teach families about simple at-home strategies that may reduce
breast cancer risk:
Diet and exercise: Reducing calories and engaging in regular exercise may
slow tumor growth and lower the amount of circulating leptin, a fat-
released protein that has been linked to breast cancer.
Extra-virgin olive oil: This oil contains polyphenol compounds that suppress a
breast cancer-promoting gene.
Apples: Phenols found in apples may combat malignant tumors.
Vitamin D: This vitamin prevents the division of cancer cells and activates a
tumor-suppressing protein.
Folate: Consuming foods that contain the B-vitamin folate (e.g., leafy green
vegetables, beans, and fortified cereals) may help to mitigate the
increased breast cancer risk associated with drinking alcohol.
Soy supplements: Soy contains isoflavones, substances that act like
estrogen and may stimulate the growth of certain types of breast cancers.
Supplements that contain concentrated amounts of isoflavones should be
avoided. However, healthy soy foods such as edamame, soy milk, and tofu
are not considered harmful.
Alcohol use increases breast cancer risk, especially for women who drink
more than one alcoholic beverage per day. Women who consume two to five
alcoholic drinks daily have about one and a half times the risk of women who
consume no alcohol. According to the American Cancer Society (2013),
women should limit their alcohol consumption to no more than one drink a day.
Smoking or secondhand exposure to tobacco smoke as a risk factor for breast
cancer is controversial; all women should be counseled to stop smoking and
avoid secondhand smoke as a health-promoting strategy (ACS, 2021).
Gene Defects
The identification of the BRCA1 and BRCA2 genes was a pivotal
discovery that clearly demonstrated the role of heredity and genetic
mutations in the development of breast and ovarian cancer. It is
estimated that approximately 10% of ovarian cancer cases and 3%
of breast cancer cases are due to genetic mutations in BRCA1 and
BRCA2. Hereditary breast and ovarian cancer syndrome is an
inherited cancer-susceptibility syndrome (Centers for Disease
Control and Prevention, 2020b).
Women of childbearing age who are BRCA-positive are not only at
increased risk for hereditary breast and ovarian cancer syndrome;
they also have a 50% chance of passing the mutation on to their
offspring. When taking the patient history, nurses must be aware of
the following indicators of hereditary breast and ovarian cancer
syndrome: multiple family members with breast cancer or ovarian
cancer or both; the presence of both breast cancer and ovarian
cancer in a single individual; and early age of breast cancer onset.
Women with these risk factors can be referred for clinical genetic
testing for gene mutations. Information gained from the testing
allows for the identification of individuals who are at substantial risk
of breast cancer and ovarian cancer and the timely institution of
screening and prevention strategies to reduce the woman’s personal
risk (Centers for Disease Control and Prevention, 2020b).
Tumor Types
There are several types of breast cancers. Most breast cancers
represent a type of adenocarcinoma, which arises from the glandular
tissue (i.e., ducts and lobules of the breast). Four subtypes account
for most breast cancers. Occasionally, a single breast tumor can
have a combination of these types or a mixture of invasive and in
situ cancer. The term in situ indicates that the cancer cells remain
confined to the ducts (ductal carcinoma in situ) or lobules (lobular
carcinoma in situ); they have not penetrated into deeper breast
tissues or spread to other organs in the body. Invasive carcinomas
have grown beyond the layer of cells where the cancer originated.
Most breast cancers are invasive carcinomas—either invasive ductal
carcinoma or invasive lobular carcinoma.
Ductal Carcinoma In Situ (DCIS) and Lobular Carcinoma In Situ
(LCIS)
The most common type of noninvasive breast cancer, ductal
carcinoma in situ, is confined within the ducts and has not spread
into the surrounding breast tissue. Ductal carcinoma in situ (DCIS)
accounts for approximately one in five new breast cancer cases. It is
most often detected by mammography and has an excellent cure
rate. DCIS is considered a stage 0 breast cancer and is considered a
noninvasive or preinvasive cancer (American Cancer Society, 2021).
Lobular carcinoma in situ (LCIS) (sometimes termed “lobular
neoplasia”) begins in the milk-producing glands and does not
penetrate the wall of the lobules. LCIS is not considered a true
cancer, although this neoplasm is sometimes classified as a type of
noninvasive breast cancer. LCIS is rarely an invasive cancer, but
women with this type have a higher risk of developing an invasive
breast cancer in the same breast or in the opposite breast (American
Cancer Society, 2021).
Invasive (Infiltrating) Ductal Carcinoma (IDC)

The most common type of breast cancer, invasive (infiltrating) ductal
carcinoma (IDC), originates in a mammary duct, penetrates through
the ductal wall, and grows into the fatty tissue of the breast (Fig. 30-
5). Metastasis (spread) to other parts of the body may occur through
the lymphatic system and bloodstream. Approximately 8 out of 10
invasive breast cancers are infiltrating ductal carcinomas. Women
with this type of tumor usually present with a discrete, solitary breast
mass (American Cancer Society, 2021).
Invasive (Infiltrating) Lobular Carcinoma (ILC)

Invasive (infiltrating) lobular carcinoma (ILC) originates in the lobules
(milk-producing glands) and spreads to surrounding breast tissue.
Like invasive ductal carcinoma, this neoplasm spreads into the fatty
tissue and can metastasize to other parts of the body. Approximately
1 out of 10 invasive breast cancers is an ILC, and women with this
type are more likely than those with other cancers to have bilateral
disease. ILC may be harder to detect by mammography; breast MRI
is often helpful in the diagnosis (American Cancer Society, 2021).
Inflammatory Breast Cancer (IBC)

Inflammatory breast cancer (IBC) is a rare neoplasm that occurs
more often in younger women and women of color and tends to grow
more quickly and aggressively than the more common types of
breast cancers. There is usually no lump or tumor, and the skin often
exhibits changes similar to an infectious process such as mastitis.
The affected breast may appear inflamed: red, thickened, tender,
itchy, or larger than the unaffected breast. Peau d’orange, another
characteristic physical finding, is an edematous thickening and
pitting of the skin that develops from edema surrounding the hair
follicle. Metastasis has usually occurred by the time of diagnosis,
and unfortunately the cure rate is lower with IBC than it is with other
types of breast cancers (NCI, 2016).
FIGURE 30-5 Invasive ductal carcinoma.
Although inflammatory breast cancer is rare, nurses should

educate women about these signs and symptoms:
■ Breast swelling, which is usually sudden with one breast much
larger than the other
■ Itching
■ A pink, red, or dark-colored area, sometimes appears ridged or
pitted like the skin of an orange
■ Sensation of heat in the breast
■ Heaviness or fullness in the breast
■ Nipple retraction
■ Breast pain, burning, or aching
In the early stages, IBC may be mistaken for infection, resulting in
a delay in diagnosis. Also, because there is no defined lump, this
neoplasm may not be detected by mammography. Breast
ultrasonography may reveal axillary lymphadenopathy and tumors.
MRI, which allows for precise measurement of the associated skin
changes, is the most sensitive imaging test for IBC. Positron
emission tomography (PET) scanning combined with computed
tomography (CT) may be used to detect areas of metastasis (lymph
nodes and organs). However, skin and tissue biopsies taken from
the affected areas of the breast constitute the gold standard for IBC
diagnosis.
Indicators of Disease Prognosis

A number of variables, such as the cancer stage, type, and tumor
size; the presence of lymph node involvement (Fig. 30-6); and the
presence of hormone receptor levels and human epidermal growth
factor receptor 2 (HER2/neu) in the tumor tissue, are associated with
the likelihood of breast cancer recurrence.
HER2/neu, a protein involved in normal cell growth, is found on
some types of cancer cells, including breast and ovarian.
Approximately 20% of breast cancers have an amplification (or
overexpression) of the HER2/neu gene. Overexpression of this
receptor in breast cancer is associated with increased disease
recurrence and a worse prognosis. All newly diagnosed breast
cancers should be tested for HER2/neu because HER2-positive
cancers are more likely to benefit from treatment with medications
that specifically target the HER2/neu protein, such as trastuzumab
(Herceptin), pertuzumab (Perjeta), and lapatinib (Tykerb) (American
Cancer Society, 2021; NCI, 2021).
Identification of these factors allows for development of an
individualized plan of treatment. The majority of women with
negative lymph nodes (approximately 60% of women diagnosed with
breast cancer today) will be cured by surgery alone. Approximately
30% of women with breast cancer will develop recurrent disease
within 10 years of the initial treatment. In addition to identifying
hormone receptor status and the histological tumor type, information
concerning the status of the axillary lymph nodes and the overall
tumor size is useful in determining the disease prognosis (Canadian
Cancer Society, 2021; NCI, 2021).
Axillary Nodes
It has long been recognized that tumor involvement of the axillary
nodes is an important indicator for breast cancer prognosis. Clinical
assessment of the axillary nodes is associated with a 30% false-
positive and false-negative rate. Thus, pathological staging of the
patient’s lymph nodes is an essential step in the development of the
treatment plan. Seventy percent of women with negative nodes
survive 10 years following their breast cancer treatment. The disease
prognosis worsens as the number of positive lymph nodes increases
as well as higher rates of recurrence when there has been lymph
node involvement.
Sentinel node mapping and biopsy target selected lymph nodes to
remove for an excisional biopsy. A radioactive tracer (dye) injected
into the region of the tumor travels through the lymphatic system to a
lymph node. This node, termed the “sentinel node,” is the first node
that receives lymphatic drainage from the tumor. If no cancer is
detected in this node, the patient is able to avoid more extensive
lymph node surgery with its accompanying side effects, such as
lymphedema (an accumulation of fluid and protein in the
extravascular space from trauma to the lymphatic system or
supporting structures; results in swelling of the arm).
FIGURE 30-6 Breast cancer: possible paths of lymphatic spread.
Tumor Size
There is a direct relationship between the size of the tumor and the
risk of recurrence. Prior to the widespread use of mammography,
fewer than 8% of women with node-negative breast cancer had
tumors that were less than 1 cm in diameter. Tumors of this size are
associated with a survival rate and increase in recurrence with larger
tumors. Tumor that are 1 cm or less have a low risk of recurrence,
tumors size of 5 cm have a moderate risk, and tumor 5 cm or greater
have a high risk of recurrence (Canadian Cancer Society, 2021;
American Cancer Society, 2021).
Cancer Staging System

The stage of cancer is based on the size of the tumor, the number of
lymph nodes involved, and whether the cancer has spread. The
American Joint Committee on Cancer TNM system is the most
commonly used system to describe the stages of breast cancer. The
clinical stage is based on findings from the physical examination,
biopsy, and imaging tests; the pathological stage combines these
three diagnostic modalities with the results of surgery. Pathological
staging, which includes detailed information about the breast mass
and adjacent lymph nodes, provides a more accurate description of
the tumor.
The TNM staging system classifies cancers based on their T, N,
and M stages:
T = Tumor: size and spread within the breast and to nearby organs
N = Nodes: spread to the lymph nodes
M = Metastasis: spread to distant organs
Additional letters or numbers are added after the T, N, and M to
provide further details about the tumor, lymph nodes, and metastasis
to distant organs, such as the bones, lungs, brain, and liver. Breast
cancer stage grouping is a process that combines the T, N, M
information to allow for the identification of cancers with similar
stages, which are usually treated in a similar way. Stage is
delineated in Roman numerals and progresses from Stage I (least
advanced) to Stage IV (most advanced); Stage 0 identifies
noninvasive cancer (NCI, 2021) (Box 30-3).
Breast Cancer Treatment

Treatment of breast cancer is complicated and may require a multi-
treatment approach, including surgery and adjunctive treatment,
such as radiation, chemotherapy, and hormone therapy.
Surgical treatment for breast cancer spans a wide range of
conservative treatment to surgical treatments that include
lumpectomies and radical mastectomies.
The simplest surgical treatment option is a lumpectomy, also
referred to as breast conservation therapy (BCT). The lump and
an area of surrounding normal tissue are removed. Factors that
indicate BCT instead of mastectomy (surgical removal of the breast)
include the tumor size, location, number, and patient preference. The
lumpectomy is usually followed by radiation treatment to remove any
remaining cancerous cells. A partial or segmental lumpectomy
involves removal of the tumor, the surrounding breast tissue, a
portion of the lining of the chest wall, and some of the axillary lymph
nodes. This procedure is usually followed with radiation therapy.
BOX 30-3
The Breast Cancer Staging System

Stage 0: Ductal carcinoma in situ (DCIS), the earliest form of breast cancer.
(Note: Under a new classification system proposed by the National Cancer
Institute, DCIS would no longer be labeled as “cancer” or “neoplasia.”)
Stage I: The tumor measures 2.0 cm in diameter or less and there is no
involvement of the lymph nodes and no distant metastasis.
Stage II: The tumor measures 2.0 cm in diameter to 5.0 cm. Depending on the
specific findings, the cancer may have spread to the axillary or internal
mammary lymph nodes but has not spread to distant sites.
Stage IIIA: One of the following applies:
1. The tumor is not more than 5.0 cm across and has spread to four to nine
axillary lymph nodes, or it has enlarged the internal mammary lymph
nodes; no distant metastasis.
2. The tumor is larger than 5.0 cm across and does not grow into the chest
wall or skin. It has spread to one to nine axillary nodes or to internal
mammary nodes; no distant metastasis.
Stage IIIB: The tumor has grown into the chest wall or skin and one of the
following applies:
1. No spread to the lymph nodes; no distant metastasis.
2. Spread to one to three axillary lymph nodes and/or small amounts of
cancer are found in the internal mammary lymph nodes (per sentinel
lymph node biopsy); no distant metastasis.
3. Spread to four to nine axillary lymph nodes, or enlargement of the internal
mammary lymph nodes; no distant metastasis.
Stage IIIC: The tumor is any size, and one of the following applies:
1. Cancer has spread to 10 or more axillary lymph nodes; no distant
metastasis.
2. Cancer has spread to the lymph nodes beneath the clavicle; no distant
metastasis.
3. Cancer has spread to the lymph nodes above the clavicle; no distant
metastasis.
4. Cancer involves the axillary lymph nodes and there is enlargement of the
internal mammary lymph nodes; no distant metastasis.
5. Cancer has spread to four or more axillary lymph nodes, small amounts of
cancer are present in the internal mammary lymph nodes (per sentinel
lymph node biopsy); no distant metastasis.
Stage IV: The cancer can be any size (any “T”), may or may not have spread to
nearby lymph nodes (any “N”). It has metastasized (“M”) to distant organs or
to distant lymph nodes.
Sources: ACS, 2013; National Cancer Institute, 2014.

A simple mastectomy involves the removal of all the breast
tissue along with the area surrounding the nipple and areola.
Radiation, chemotherapy, or hormone therapy may follow this
surgical procedure. In a modified radical mastectomy, the entire
breast and 20 to 30 axillary lymph nodes are removed, leaving the
chest wall intact. Although this procedure makes breast
reconstruction easier for the patient, complications including
lymphadenopathy and paresthesia are more likely to occur
(American Cancer Society, 2021; Venes, 2021).
Chemotherapy, a highly toxic medication that works by inhibiting
the growth of cancer cells, either by killing the cells or by stopping
them from dividing, is often used in conjunction with other breast
cancer treatments. Chemotherapy has significant side effects that
can have major physical impacts and affect daily life activities.
Chemotherapy can be administered orally or intravenously
(Canadian Cancer Society, 2021; NCI, 2021). Some chemotherapy
regimens include a combination of two or more drugs.
Chemotherapeutics may be administered orally or intravenously and
usually require four to eight treatments over 3 to 6 months. While
undergoing chemotherapy, patients are monitored for adverse
reactions (such as nausea, vomiting, anorexia, stomatitis,
gastrointestinal ulceration, anemia, leukopenia, thrombocytopenia,
and bleeding) (Venes, 2021). In the hospital setting with patients
getting intravenous chemotherapy, this may require daily blood work
and with patients in the outpatient setting and getting oral
chemotherapy this may involve weekly or 2–3 times a week of blood
draws to monitor lab values.
When counseling patients about expected side effects from
chemotherapy, nurses can reassure them about the availability of
highly effective medications that reduce nausea and vomiting, the
major symptoms traditionally associated with chemotherapy. Other
side effects include a change in appetite, loss of hair, mouth or
vaginal sores, cognitive disturbances, suppression of the immune
system that leads to an increased chance of infection, anemia,
fatigue, menstrual cycle changes, and infertility. Except infertility,
most of the side effects are temporary.
Optimizing Outcomes
Counseling Women About Fertility During Breast Cancer Treatment

Breast cancer treatment is associated with a myriad of potential gynecological
health issues such as fertility (may be compromised from medication and/or
surgery; pregnancy after breast cancer is not thought to increase breast cancer
recurrence), contraceptive management (options include barrier methods, the
copper intrauterine device, and sterilization; all hormonal methods are
contraindicated), menopause (hormone-blocking medications may produce
menopausal changes such as vasomotor symptoms and urogenital atrophy in
premenopausal women), sexual function (patients who undergo chemotherapy
are at higher risk of sexual dysfunction), and osteoporosis (in postmenopausal
women, treatment with aromatase inhibitors is associated with decreased bone
mineral density).
Adjuvant therapies may include radiation therapy or hormone-

blocking therapy. Radiation usually begins three to four weeks after
surgery, and treatments are given five days per week for five to six
weeks. Hormone-blocking therapy is most commonly used to treat
advanced metastatic cancer or as an adjuvant treatment to prevent
recurrence of cancer. Normally, estrogen and progesterone bind to
receptor sites in the breast tissue and encourage growth of
cancerous cells. Prescribed hormone medications bind to the sites
instead and prevent estrogen from reaching them. Medications used
in hormone-blocking treatment include tamoxifen (Nolvadex), a
selective estrogen receptor modulator (SERM), and aromatase
inhibitors, which block the conversion of androgens into estrogen.
Surgical treatment may include lumpectomy to that of radical
mastectomy. Many women choose to undergo breast reconstruction
after a mastectomy. This surgical option, performed by a plastic
surgeon, is a personal decision that requires considerable
individualized counseling and education. Because the reconstruction
can be performed at the same time as the mastectomy, it is
important to consider the options early. Breast reconstruction
methods include use of a synthetic breast implant or reconstruction
using one’s own tissue. Synthetic implants typically are composed of
a silicone shell filled with a saline solution. A tissue expander may be
needed to cover the implant. To accomplish tissue expansion, an
empty implant shell is placed under the skin and muscles and is
gradually filled with the saline solution over several months. Once
the skin is stretched sufficiently, the expander is removed and
replaced with a permanent implant. Recovery usually takes several
weeks.
Patients who have had to have a mastectomy may choose to
undergo breast reconstruction using their own tissue with a
transverse rectus abdominis myocutaneous (TRAM) flap procedure.
The breast is reconstructed using fat and muscle tissue taken from
the abdomen, back, and buttocks. Recovery following the procedure
usually takes 6 to 8 weeks, and there is an increased risk of infection
and tissue necrosis. Deep inferior epigastric perforator (DIEP)
reconstruction is a slightly less complicated surgical procedure. This
method is similar to the TRAM flap procedure, but the abdominal
muscles are left intact. The DIEP procedure is associated with fewer
complications and less postoperative pain. Following reconstruction
of the breast tissue, the surgeon can reconstruct the nipple and
areola using tissue from other areas of the body. A small mound is
constructed to resemble a nipple, and tattooing may be used to
create an areola. In this situation, the surgeon applies a skin graft to
the areolar region, slightly raises the skin, and then tattoos the skin
graft.
Genomic medicine encompasses the disciplines of gene mapping
and sequencing and the study of the functions and interactions of all
genes in the genome (a complete copy of the genetic material in an
organism). Genomics focuses on developing tests that are both
prognostic (i.e., based on factors such as tumor size, lymph node
involvement, hormone receptor status) and predictive. Prognostic
testing identifies the likelihood of cancer recurrence; predictive
testing identifies the relative resistance of a cancer to specific
treatments. Breast cancer specialists use information from
genomics-driven specialized tests (e.g., Mammoprint; Oncotype DX;
HOXB13/IL17BR) to develop an individualized treatment approach
based on recurrence risk and predicted benefits of specific therapies.
Cancer Recurrence
Cancer recurrence is a serious concern for anyone with a history of
cancer. Some cancers recur because treatment did not eliminate all
cancer cells and the cells resume growing. In other cases, the
cancer has spread and continues to grow in other areas of the body.
Types of cancer recurrence include:
■ Local recurrence, when the cancer is in the same place as the
original cancer or very close by.
■ Regional recurrence means that the tumor has grown into lymph
nodes or tissues near the original cancer.
■ Distant recurrence means the cancer has spread to organs or
tissues far from the original cancer. When cancer spreads to a
distant place in the body, it is called metastasis or metastatic
cancer. When cancer spreads, it is still the same type of cancer but
is found in a different part of the body (NCI, 2021).
Nursing Care for Women Dealing With Breast Cancer

Nurses must be sensitive to the fact that once a woman has received
a diagnosis of breast cancer, her life is forever changed.
Compassionate care during this difficult time includes providing
emotional support; empowering the patient and her family with
current, evidence-based information; assisting them with immediate
needs; and directing them to available resources. Personal and
professional resources are essential as the woman works her way
through the diagnostic process, the necessary decision-making
concerning treatment and possible breast reconstruction, the surgery
and adjuvant therapies, and the future with its uncertainties. Women
who are confronted with breast cancer frequently discover an inner
strength that they did not know existed.
Nurses can be a tremendous source of support and advocacy for
women who are diagnosed with breast cancer. It is important to
encourage patients to carefully consider all options and seek other
opinions or other providers if they do not feel comfortable with
recommendations. Nurses can direct women to the wealth of reliable
information about breast cancer treatment and recovery available in
books and on Internet sites and to the opportunities for personal
sharing through local and national support groups.
Resources for Women With Cancer
An important nursing role in the care of women with cancer centers on sharing
information about the various resources that are available to them. These
include:
• National Breast and Cervical Cancer Early Detection Program, NCCDPHP,
CDC
• NCI, NIH, HHS
• Office of Minority Health, OPHS, OS, HHS
• American Cancer Society
• Cancer.net
• BreastCancerTrials.org
• Celebrating Life Foundation
• Sisters Network Inc.
• Susan G. Komen
• LiveStrong Cancer Survivorship Center
• NCI Community Cancer Centers Program
• National Coalition for Cancer Survivorship
• Living Beyond Breast Cancer
Living Beyond Breast Cancer (LBBC) and the Metastatic Breast Cancer
Network (MBCN) released a free publication, The Metastatic Breast Cancer
Series: Guide for the Newly Diagnosed, to address the needs of women in the
first few months after receiving a diagnosis of metastatic (Stage IV) breast
cancer. The publication is designed to help women make the best and most
informed decisions for themselves and their families when facing a breast
cancer diagnosis and when considering various options for treatment.
Additional information is available at http://www.lbbc.org/Understanding-Breast-
Cancer/Guides-to-Understanding-Breast-Cancer/Metastatic-Breast-Cancer-
Series-Guide-for-the-Newly-Diagnosed.
Complementary and Alternative Medicine for Cancer Patients

For many, holistic medicine offers an additional healing approach to
assist the body, mind, and spirit through the rigors of cancer
diagnosis and treatment and foster healing throughout the recovery
process. The woman’s immune system can be supported and
enhanced naturally through dietary and safe herbal remedies, along
with practices that reduce stress and help restore physical and
emotional harmony and balance. For example, patients may benefit
from imagery, aromatherapy, meditation, music therapy, dance
therapy, journal writing, humor, art therapy, and hypnosis. Other
modalities such as acupuncture, Ayurveda, Qigong, yoga, and tai chi
may provide relief from unpleasant symptoms and be instrumental in
lifting the body and spirit during the journey to recovery.
Many women find that various complementary and alternative
medicine (CAM) therapies help to relieve cancer side effects and
discomforts and enhance and enrich their lives during treatment and
into recovery. Nurses can empower women with specific information
and direct them to available resources. The American Cancer
Society provides an up-to-date source for complementary and
alternative therapies, available at
http://www.cancer.org/cancer/breastcancer/detailedguide/breast-
cancer-treating-c-a-m.
An increasing number of studies have demonstrated the value of
exercise in enhancing certain outcome variables (e.g.,
cardiovascular fitness, fatigue, nausea, malnutrition, preservation of
lean body mass, immune system functioning) and quality of life
among cancer survivors (Mohr & Whyte, 2013). Strength & Courage:
Exercises for Breast Cancer Survivors, available as a traditional
DVD or as a digital download (can be viewed on tablets and
smartphones), is a home-based exercise program specially designed
to help breast cancer survivors regain strength and mobility during
and following breast cancer treatment. At the same time, the
program strives to enhance a woman’s ability to lead an active life
after breast cancer surgery. The exercises, which can be started as
soon as 1 day after surgery, focus on increasing muscle strength and
flexibility and range of motion, which can help reduce fatigue during
and after treatment. Information about the program and DVD/digital
download is available at http://www.strengthandcourage.net/.
Cancer Survivorship Care Plans

First introduced for survivors of childhood cancers, cancer
survivorship care plans have recently been recommended for adult
survivors. Components of the survivorship plan, which should be
provided to the patient’s primary care physician, include a summary
of treatment, the possible short- and long-term effects of treatment,
late toxicity monitoring, monitoring for primary cancer recurrence or a
second cancer, identification of the provider responsible for survivor
care, psychological and vocational needs, community support
resources, and recommendations for preventive care and practices.
For women, additional information should include genetic issues, the
effects of treatment on future pregnancy and fertility, and
menopausal issues.
Nurses are perfectly situated to provide cancer survivor care. With
a holistic and family-centered approach that emphasizes patient
education, health promotion, and preventive care practices, nursing
can fully embrace the cancer survivorship movement to empower
women and their providers with a comprehensive, holistic plan for
continuing care in the aftermath of cancer. Because of the dynamic
nature of the survivorship plan, evolving scientific evidence about the
specific cancer type, management of short- and long-term treatment
sequelae, and the need for screening for recurrence and other
cancers can be readily incorporated into the plan. This information
can help to inform the woman’s decision making and allow her and
her care provider to be proactive in both the planning and
management of her health after cancer.
CASE STUDY
Breast Cancer: Eduedima T.
Eduedima T. is a 56-year-old postmenopausal Nigerian woman who received a
diagnosis of early-stage breast cancer approximately 6 months ago.
Eduedima’s treatment, which included a lumpectomy followed by radiation
therapy, was uncomplicated and her physician has told her that her chance for a
cure is “excellent.”
Today, during an interview at the woman’s health clinic, Eduedima confides in
the nurse that she is concerned about herself because she feels “down and
out.” She admits that physically, she feels just fine and is very relieved to have
the treatment behind her. Lately, however, she has been concerned about “the
way my body looks.” As a result of the surgery and radiation therapy, Eduedima
has experienced a decrease in breast size in the affected breast. Although she
acknowledges that “in the grand scheme of things, this change is a minor thing,”
the alteration in breast appearance is concerning to her.
1. What is a priority nursing intervention for Eduedima?

2. What information should the nurse provide to Eduedima?
3. What other actions should the nurse take?
SUMMARY POINTS
■ Maintaining breast health is an essential strategy for maintaining optimal
physical and psychological health.
■ Nurses are in an ideal position to educate women about breast health and
strategies for the identification of benign and malignant breast disease.
■ Breast cancer is the most common cancer in women in the United States,
except for skin cancer, and it is the second leading cause of cancer deaths in
women.
■ Dietary, socioeconomic, and environmental factors most likely contribute to
the development of breast cancer.
■ A number of screening and diagnostic methods, including mammography,
ultrasonography, magnetic resonance imaging, and biopsy, may be used in
the clinical evaluation of the breasts.
■ Risk factors for breast cancer may be related to demographics, personal
health history, lifestyle choices, and defects in certain genes.
■ The cancer staging system, based on the size of the tumor, the number of
lymph nodes involved, and the presence of metastasis, is used to guide the
development of a treatment plan for breast cancer.
■ Breast cancer treatment may include surgery, radiation, chemotherapy,
hormone therapy, and complementary and alternative therapies.
■ The nursing role in caring for women with breast cancer includes providing
emotional support, empowering the patient and her family with current
information, assisting them with immediate needs, and directing them to
available resources.
REFERENCES
American Cancer Society (ACS). (2013). Breast cancer overview. Retrieved from
http://www.cancer.org/cancer/breastcancer/overviewguide/breast-cancer-
overview-key-statistics
American Cancer Society. (2021). Breast cancer.
https://www.cancer.org/cancer/breast-cancer.html
American Cancer Society and the National Cancer Data Base. (2012). Cancer
treatment and survivorship facts & figures 2012–2013. Retrieved from
http://www.cancer.org/research/cancerfactsfigures/cancertreatmentsurvivorship
factsfigures/index
American College of Obstetricians and Gynecologist. (2017). Breast Cancer Risk
Assessment and Screening in Average-Risk Women.
https://www.acog.org/clinical/clinical-guidance/practice-
bulletin/articles/2017/07/breast-cancer-risk-assessment-and-screening-in-
average-risk-women
Are You Dense Advocacy. (2014). About D.E.N.S.E. Retrieved from
http://Areyoudenseadvocacy.org/
Atoum, M., & Alzoughool, F. (2017). Vitamin D and breast cancer: Latest evidence
and future steps. Breast Cancer: Basic and Clinical Research 11,
1178223417749816.
Canadian Cancer Society. (2021). Risk of recurrence after surgery and additional
treatments. Cancer Information. https://www.cancer.ca/en/cancer-
information/cancer-type/breast/treatment/risk-of-breast-cancer-recurrence-and-
adjuvant-therapy/?region=on
Centers for Disease Control and Prevention. (2020a). Breast Cancer.
https://www.cdc.gov/cancer/breast/index.htm
Centers for Disease Control and Prevention. (2020b). The BRCA1 and BRCA2
Genes. Hereditary Breast and Ovarian Cancer.
https://www.cdc.gov/genomics/disease/breast_ovarian_cancer/genes_hboc.ht
m
Conant, E. F., et al. (2020). Five consecutive years of screening with digital breast
tomosynthesis: Outcomes by screening year and round. Radiology 295(2),
285–293.
Gierach, G., Ichikawa, L., Kerlikowske, K., Brinton, L., Farhat, G., Vacek, P., …
Sherman, M. (2012). Relationship between mammographic density and breast
cancer death in the Breast Cancer Surveillance Consortium. Journal of the
National Cancer Institute 104(16): 1218–1227.
Mohr, C. R., & Whyte, J. (2013). The role of exercise for patients with cancer.
Consultant 53(5): 363–366.
National Cancer Institute. (2016). Inflammatory Breast Cancer.
https://www.cancer.gov/types/breast/ibc-fact-sheet
National Cancer Institute. (2021). Breast Cancer.
https://www.cancer.gov/types/breast
National Health Services. (2019). Breast Cancer in Women.
https://www.nhs.uk/conditions/breast-cancer/causes/
Nicosia, L., et al. (2020). Automatic breast ultrasound: State of the art and future
perspectives. Ecancermedicalscience 14: 1062.
Stachs, A., Stubert, J., Reimer, T., & Hartmann, S. (2019). Benign breast disease
in women. Deutsches Arzteblatt International 116(33–34): 565–574.
Thompson, J., & Scannell, M. (2017). Assess female breasts, axillae, and
reproductive systems. In Essential health assessment (1st ed. pp. 343–368).
U.S. Department of Health and Human Services. (2016). Having a Breast Biopsy.
Agency for Healthcare Research and Quality.
https://effectivehealthcare.ahrq.gov/products/breast-biopsy-update/consumer
U.S. Food and Drug Administration. (2012). FDA approves first breast ultrasound
imaging system for dense breast tissue.
U.S. Health and Human Services. (2020). Vitamin D. National Institutes of Health.
https://ods.od.nih.gov/factsheets/VitaminD-health%20Professional/
U.S. National Library of Medicine. (2021). Breast biopsy—stereotactic.
U.S. Preventative Services Task Force. (2016). Recommendation: Breast Cancer:
Screening.
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cancer-screening
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cancer. Guide to preventive services, 2009, Section 2. Recommendations for
adults.
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cancer: U.S. Preventive Services Task Force recommendation statement.
Annals of Internal Medicine, 151(10), 716–726.
Venes, D. (2021). Taber’s cyclopedic medical dictionary. Philadelphia:. F.A. Davis.

Davis Advantage
CHAPTER 31
Promoting Reproductive Health:

Various Gynecological Disorders
CONCEPTS
Female reproduction
KEY WORDS
primary amenorrhea
secondary amenorrhea
menorrhagia
metrorrhagia
menometrorrhagia
polymenorrhea
intermenstrual bleeding
oligomenorrhea
postcoital bleeding
bacterial vaginosis (BV)
candidiasis
uterine leiomyomas
LEARNING OBJECTIVES

■ Describe various gynecological disorders and discuss implications for patient
counseling and teaching.
■ Develop a nursing plan of care for a patient with a diagnosis of endometriosis.
■ Develop a nursing plan of care for a patient with a diagnosis of polycystic
ovary syndrome (PCOS).
■ Identify signs and symptoms that may be associated with vaginal, ovarian,
endometrial, and vulvar disorders.
■ Describe a strategy for increasing women’s awareness of potential
gynecological cancer symptoms.
■ Teach a woman how to perform vulvar self-examination.
PICO(T) Questions
chapter.
1. What (I) complementary or alternative practices (O) are beneficial for (P)
women with symptoms of dysmenorrhea?
2. Does (I) routine screening for symptoms that could indicate ovarian cancer
lead to (O) earlier detection of the disease in (P) women over age 60 (C)
compared with women under age 60?
INTRODUCTION
This chapter explores several gynecological disorders in women. To
deliver safe, effective care, nurses who care for women should be
familiar with the special aspects of various gynecological conditions.
It is important to remember that the human body functions as a
whole system. Although a gynecological problem may initially appear
to be confined to the pelvis, it could actually result from a host of
other influences, activities, and imbalances. For example,
amenorrhea, or absence of menses, may be related to excessive
exercise, eating disorders, obesity, weight loss, stress, chronic
illness, or endocrine disorders that adversely affect the normal
functioning of the menstrual cycle.
Mutual trust and respect in the nurse-patient relationship help to
facilitate appropriate discussion of questions and concerns about
various health issues. Women’s emotional responses to certain
gynecological disorders may profoundly affect their quality of life and
ability to function. The nurse must always remain sensitive to
women’s unique problems related to the functioning of their
reproductive systems and offer holistic, individualized care that
empowers them to seek and embrace strategies to restore balance
and control over their lives.
MENSTRUAL DISORDERS
Menstrual disorders, specifically amenorrhea, irregular bleeding, and
dysmenorrhea, constitute some of the most common reproductive
problems in women. Potential nursing diagnoses for women with
various menstrual disorders are presented in Box 31-1.
Amenorrhea
Under normal circumstances, the menstrual cycle is dependent on
the integrated functioning of the hypothalamus, pituitary gland,
ovaries, uterus, cervix, and vagina. Amenorrhea, or a lack of
menstruation, may result from abnormalities of the structure or
function of any of these organs.
BOX 31-1
Potential Nursing Diagnoses for Women With

Menstrual Disorders
• Ineffective Coping related to emotional and physical effects that stem from the
disorder
• Knowledge Deficit related to the cause, treatment, and self-care strategies of
the disorder
• Disturbed Body Image related to sexual dysfunction associated with the
disorder
• Situational Low Self-Esteem related to an inability to conceive
• Acute Pain related to the menstrual disorder
The term amenorrhea is rooted in the Greek “a” = no + “men” =

month + “rhoia” = flow = “no monthly flow.” Amenorrhea may be
classified as “primary” or “secondary.” With primary amenorrhea,
menstruation never takes place. With secondary amenorrhea,
menstruation starts but then stops. The nurse should refer the
patient for an evaluation for amenorrhea when the following
circumstances are present:
Primary Amenorrhea
■ Lack of secondary sex characteristics by age 14 to 15
■ Lack of menarche (the initial menstrual period) by age 15
■ Lack of menses within 3 years after breast development
(thelarche) or the appearance of pubic or axillary hair (pubarche or
adrenarche)
Primary amenorrhea may be caused by a number of conditions,
including pregnancy, lactation, missed abortion, malnutrition, eating
disorders (e.g., anorexia nervosa, bulimia), obesity, excessive
workouts, hyperthyroidism, hypoglycemia, stress, cystic fibrosis,
Crohn’s disease, chromosomal disorders, genetic abnormalities,
congenital absence of the cervix and/or vagina, and PCOS (Venes,
2021).
Secondary Amenorrhea
Secondary amenorrhea is defined as an absence of menses for at
least 3 months in a woman who has previously had regular monthly
menses or a lack of menses for at least 6 to 12 months in a woman
who normally experiences irregular menses. The term delayed
menses is used in situations wherein the amenorrhea occurs for a
shorter period of time. Pregnancy, lactation, premature ovarian
failure (menopause before age 40), weight loss, eating disorders,
and obesity are conditions that may cause secondary amenorrhea.
Other causes include hormonal contraceptive effects and post-oral
contraceptive pill amenorrhea, or other medications such as
antidepressants, pituitary gland dysfunction (e.g.,
hyperprolactinemia), PCOS, emotional or physical stress, frequent
strenuous exercise, chronic illness (e.g., colitis, kidney failure, cystic
fibrosis), cancer chemotherapy, ovarian cysts or tumors, certain
endocrine disorders such as Cushing’s syndrome and thyroid
dysfunction, and extreme workouts (Venes, 2021).
When evaluating a patient for amenorrhea, the first step is to test
for pregnancy, which is often the number one cause for secondary
amenorrhea. Once pregnancy has been ruled out, the patient
undergoes a thorough physical examination and, depending on the
findings, additional testing that may include laboratory testing such
as thyroid function tests, hormonal testing (FSH, LH, and
androgens), chromosomal testing, and diagnostic testing (e.g.,
ultrasonography or CAT scan). In many situations, a careful review
of the woman’s health history can provide clues as to the cause(s) of
the amenorrhea (U.S. Department of Health and Human Services,
2017).
Abnormal Genital Bleeding
Any bleeding other than what is expected in a normal ovulatory cycle
is considered abnormal genital bleeding, one of the most frequent
reasons for patient visits to the clinic or private office. The source of
the bleeding may be the rectum, urinary tract, vulva, vagina, cervix,
or uterus. Conditions that may cause abnormal bleeding include
pregnancy and pregnancy-related complications, medications
(anticoagulants or ceasing contraception), bleeding disorders,
trauma, infection, endocrine abnormalities, lesions, fibroids, tumors,
and cancer (Ministry of Health, 2017).
What to Say
Correct Terminology for Abnormal Genital Bleeding
Nurses who care for women should be familiar with terminology for abnormal
genital bleeding, classified by the timing of the bleeding and the duration of the
flow. The use of accurate terminology promotes effective communication and
justifies appropriate work-ups and therapies. Patient-recorded menstrual
calendars and pictorial bleeding assessment calendars are beneficial to
accurately document bleeding patterns.
• Menorrhagia is excess bleeding (80 mL or more, or bleeding that lasts longer
than 7 days) during the expected time of menstrual flow.
• Metrorrhagia, also known as intermenstrual bleeding, is bleeding that occurs
at abnormal times during an ovulatory cycle. Vaginal bleeding occurs more
frequently than every 21 days.
• Menometrorrhagia, also known as heavy menstrual bleeding, is a combination
of the previous two bleeding abnormalities. The woman experiences
excessive and frequent bleeding at abnormal times during the cycle.
• Polymenorrhea is bleeding that occurs at short intervals (less than 21 days).
• Intermenstrual bleeding is bleeding of variable amounts that occurs between
regular menses.
• Oligomenorrhea is bleeding that occurs less frequently than every 35 days.
• Postcoital bleeding is bleeding that occurs after sexual intercourse.
Several possible diagnoses are associated with bleeding

disorders. Although many factors influence a woman’s menstrual
patterns, one of the first considerations is the patient’s age. In an
adolescent female, approximately 20 hormonal cycles occur before
ovulation takes place on a regular basis. Bleeding that is irregular in
both timing and amount tends to be the rule rather than the
exception during early adolescence.
During adolescence, a common cause is persistent anovulation, or
failure to ovulate, which may be related to contraception, pregnancy,
PCOS, or coagulopathies. During midlife (30s–40s), women most
often develop abnormal genital bleeding from pregnancy, structural
lesions (e.g., leiomyomata [fibroid tumors], polyps), and anovulation,
including that caused by PCOS, hormone therapy, and endometrial
hyperplasia. The cause of abnormal genital bleeding can range from
simple to complex. Evaluation requires a careful and thorough
history and work-up, including a physical examination, laboratory
tests, and appropriate diagnostic tests such as ultrasonography
(American College of Obstetricians and Gynecologists, 2019;
Ministry of Health, 2017).
Dysmenorrhea
Dysmenorrhea, defined as painful menstruation, is one of the most
common gynecological problems occurring in women of all ages. For
most, the pain develops during or shortly before the onset of
menstruation and is most intense in the suprapubic region or in the
lower abdomen. Symptoms including nausea, vomiting, diarrhea,
headaches, and lightheadedness may accompany the pain.
Dysmenorrhea can cause significant disruption with daily activities
each month, resulting in absence from school and missed time from
work. Dysmenorrhea may be classified as primary (intrinsic and
usually early onset) or secondary (results from some other physical
cause and usually has a later onset) (Venes, 2021).
Primary dysmenorrhea usually begins within 1 to 3 years following
menarche and results from physiological causes, hormonal
imbalances, psychogenic factors, and increased prostaglandin
secretion. In general, women with primary dysmenorrhea are
ovulatory and produce progesterone in the luteal phase.
Progesterone stimulates the production of prostaglandins in the base
of the endometrium. Found in various tissues throughout the body,
prostaglandins are substances that control local functions such as
vasodilation and vasoconstriction. Women with primary
dysmenorrhea produce excessive amounts of prostaglandin F2-
alpha, which increases the force of the uterine contractions. Uterine
contractions reduce blood flow to the uterus, causing ischemia and
pain. The pain usually begins at the onset of menstrual flow and
persists for 8 to 48 hours. During menstruation, the highest levels of
prostaglandins are released during the first 48 hours. When the
prostaglandins are introduced into the general circulation by uterine
contractions, they can produce symptoms of headache, nausea,
vomiting, and diarrhea (Venes, 2021).
Secondary dysmenorrhea is due to some other physical cause
and usually is of a later onset. Women with secondary
dysmenorrhea also complain of painful uterine cramping with
menstruation but frequently have other accompanying complaints,
such as dyspareunia or nonmenstrual pelvic pain. Pain that occurs
with secondary dysmenorrhea is related to uterine or pelvic
pathology. The treatment for secondary dysmenorrhea should be
targeted to the underlying cause and should be reflective of the
patient’s desire for fertility. When surgical intervention is not required,
the treatments helpful for primary dysmenorrhea are often successful
in reducing the symptoms of secondary dysmenorrhea.
The most common causes of secondary dysmenorrhea are
adenomyosis, endometriosis, pelvic adhesions, neoplasia, uterine
malposition, and pelvic inflammatory disease (PID). Adenomyosis is
a condition characterized by the presence of endometrial glands and
stoma that are embedded in the myometrium (the deep muscle layer
of the uterus). Adenomyosis most commonly occurs in parous
women. Each month, normal ovarian hormonal changes cause
stimulation of the ectopic (abnormally located) endometrial tissue
and produce sloughing within the myometrium. In addition to
dysmenorrhea, women with adenomyosis may also experience
heavy menses and perimenstrual pain. The uterus is enlarged,
boggy, and tender immediately before and during menses (Venes,
2021).
Health-care teaching for women experiencing dysmenorrhea
should be holistic in nature and include relaxation and breathing
techniques, the use of heat to reduce uterine contractions and
increase blood flow to the uterine tissues, exercise or rest, and the
use of NSAIDs to inhibit the synthesis of prostaglandin. These drugs
not only improve the cramping pain but also reduce backache,
headaches, and gastrointestinal symptoms. When taken at the onset
of menses, NSAIDs reduce the release of prostaglandins and
considerably decrease menstrual blood loss. Other therapeutic
interventions for dysmenorrhea include hormonal contraceptives
(e.g., combined oral contraceptive pills, depot medroxyprogesterone
acetate [Depo-Provera], and the IUD: levonorgestrel-releasing
intrauterine systems), which reduce menstrual blood loss and
decrease the production of prostaglandins.
Throughout the ages, women have resorted to the use of various
herbal remedies such as cramp bark, wild yam, black haw, ginger,
and raspberry leaf to ease the pain of menstrual cramps. The nurse
should counsel patients that because herbal preparations may be
toxic or interact with other medications, only preparations obtained
from reputable companies should be used. Physical activity
enhances blood flow to the pelvis and reduces pelvic congestion.
Dietary strategies include the use of natural diuretics such as
peaches, parsley, and cranberry juice to reduce edema and limiting
the intake of junk food with little nutritional value and foods high in
sugar, salt, caffeine, fruit juices, and added fats (Armour et al, 2019;
Najafi et al, 2018; Venes, 2021)
COMMON VAGINAL INFECTIONS

Under normal circumstances, the vaginal environment functions as
an ecosystem that maintains a steady state as it interacts with the
environment outside the vagina. Many organisms, including certain
bacteria and yeast, normally reside in the vagina. In fact, at any
given time, from 5 to 10 different types of microorganisms are
normally present in the vaginal flora. Lactobacillus is the dominant
bacterial genus. It plays an essential role in helping to maintain the
vaginal balance by producing by-products such as lactic acid and
hydrogen peroxide. These by-products allow the vagina to maintain
a healthy acidic pH of less than 4.5, which prevents the overgrowth
of less desirable vaginal microorganisms. If the delicate balance of
microorganisms is upset, the potentially pathogenic minor bacteria
can proliferate to a concentration that causes symptoms.
During the reproductive years, the normal vaginal pH range is
between 3.8 and 4.2, which falls within the acidic spectrum of the pH
scale. Anaerobic bacteria are unable to colonize and thrive in the
normally acidic vaginal environment, and lactobacilli become the
predominant bacteria. When anaerobic bacteria are able to colonize,
they eradicate the lactobacilli, creating an alkaline environment that
allows continued colonization. Vaginal infections primarily occur in
two ways: An imbalance and overgrowth of organisms that normally
inhabit the vagina proliferate and cause symptoms, or organisms are
introduced into the vagina, usually from intimate sexual contact.
Factors that may cause an alteration in the normal vaginal
environment include stress, douching, feminine hygiene products,
harsh soaps, dietary changes (e.g., an increase in sugar, caffeine),
sexual intercourse, barrier contraceptive methods (e.g., condoms,
diaphragms), spermicides, synthetic underwear or tight-fitting pants,
scented wipes, deodorants, illness, chronic metabolic conditions
(e.g., diabetes), immunosuppression, certain medications, and
pregnancy (Crann et al, 2018; National Health Service, 2018b).
Patient Education
Teaching Strategies to Promote Vaginal Health
Nurses can be instrumental in promoting vaginal health by teaching women
about the normal functioning of their bodies. Women can be taught that
leukorrhea is a normal vaginal discharge that undergoes hormonally mediated
changes throughout the menstrual cycle. In the early (proliferative) phase,
estrogen promotes a clear, thin, stretchy vaginal discharge. Later, the
discharge becomes thick and tacky in response to the effects of progesterone,
the dominant hormone during the second half of the cycle. The normal vaginal
discharge varies in quantity from woman to woman, and often from cycle to
cycle. Nurses can help patients explore ways to promote a balanced vaginal
environment through alterations in lifestyle and choice of birth control method.
Women should be discouraged from douching, which has a drying effect on the
vagina and disrupts the normal vaginal flora. Douching can also cause an
increase in the amount of vaginal discharge normally present and has been
shown to contribute to serious infection of the upper reproductive tract. Nurses
should also ask about products that are being used, as some products are not
intended for use in the vagina, such as skin lotion, powders, medicated sprays
and ointment, deodorants and shaving creams, and oils (Crann et al, 2018;
National Health Service, 2018b).
A number of infections and conditions that involve the vaginal

environment are commonly seen in women with gynecological
disorders. These include candidiasis, sexually transmitted diseases
(STDs), cervicitis, and PID. Cervicitis may be accompanied by a
purulent discharge, which may be a symptom of infection with
gonorrhea or chlamydia. Less commonly encountered conditions
include vaginal carcinoma (primary, which is rare, or secondary,
which results from the spread of cancer to the vagina from another
site), cancer associated with in utero exposure to diethylstilbestrol
(DES), and toxic shock syndrome (TSS). STDs and PID are
discussed in a separate chapter.
Bacterial Vaginosis
Bacterial vaginosis (BV) was previously called nonspecific
vaginitis, Haemophilus vaginitis, or Gardnerella. BV is the most
common vaginal infection in women, and although it is a sexually
associated condition, it is not usually considered to be a specific
STD. This vaginal infection is related to a lack of hydrogen peroxide–
producing lactobacilli (microorganisms that normally maintain a low
vaginal pH) and a dramatic overgrowth of the vaginal resident
bacterium Gardnerella vaginalis and anaerobic bacteria (e.g.,
Mycoplasma hominis, Mobiluncus, Bacteroides, Prevotella,
Peptostreptococcus, Eubacterium, Escherichia coli, and group B
streptococci). Anaerobic bacteria thrive in a low-oxygen
environment.
Women with BV may be asymptomatic. When present, symptoms
include a thin white or gray adherent vaginal discharge with a “fishy”
amine odor, and women often report that the odor is worse after
intercourse and following menses. Other symptoms include pain,
burning or itching around the vagina, and/or burning with urinating.
The diagnosis is made on the basis of a positive finding on the
“whiff” test—the characteristic amine odor is produced when a
sample of the discharge is combined with a 10% solution of
potassium hydroxide (KOH). Microscopic examination of the vaginal
fluid (i.e., a wet mount) reveals the presence of clue cells, which are
sloughed vaginal epithelial cells coated with bacteria that cling to the
edges of the cells. Clue cells have a granular appearance with
indistinct, blurry borders (Fig. 31-1).
Risk factors for BV include:
■ Having a new sex partner or multiple sex partners
■ Having sex with someone with BV
■ Using vaginal products such as douching
■ Using feminine products such as washes and gels
■ Using products not designed for the vagina such as creams,
lotions, and gel sanitizers
■ Using an IUD (Centers for Disease Control and Prevention, 2020a;
Crann et al, 2018; National Health Service, 2018a)
Diagnostic Tools
The Vaginal Wet Mount
A wet mount, also known as a “wet-prep” or “wet smear,” is frequently used in
the clinical setting to diagnose three of the most common vaginal infections:
BV, trichomoniasis, and yeast (candidiasis). To perform this test, the clinician
inserts a speculum and uses a moist cotton swab to take a sample of the
discharge from the posterior vaginal fornix. The discharge is then placed on a
glass slide and viewed under a microscope. Alternately, a dry swab may be
used: The sample is placed in 1 mL of saline, mixed, and placed on a slide, or
a drop of saline is placed on a slide and the sample is added to it. A cover slip
is then applied and the slide is promptly viewed.
Typically, when BV is present, the vaginal pH is above the normal value of
4.5. Because BV may occur concurrently with other STDs (e.g., chlamydia,
gonorrhea, genital herpes), it is important to screen for STDs as well.
FIGURE 31-1 Clue cell.
FIGURE 31-2 Gram’s stain of Candida albicans (purple) in blood (x

640).
Assessment Tools
Vaginal Swab Testing Kits for Home and Clinical Use
Self-diagnosis of vaginal infections based on symptoms alone is inaccurate and
often lead to expensive testing in unnecessary treatments/medications. Over-
the-counter vaginal pH screening tests can help distinguish vaginal symptoms
that require attention from a health-care provider. One such product, the Vagisil
Screening Kit, contains plastic wands with attached pH paper; the woman
touches the wand to the vaginal wall to moisten the pH paper and withdraws
the device. The vaginal pH level is then compared with the color on the pH
guide. A pH value of 4.5 suggests that the vaginal symptoms are due to
candidiasis (yeast); a pH reading of 5.0 or higher indicates that the vaginal
symptoms are likely due to BV, trichomoniasis, or a mixed infection, and office
follow-up is necessary.
The VS-SENSE PRO is a swab-based test to detect vaginitis in the clinical
setting. The VS-SENSE indicates by color change the elevated vaginal acidity
levels associated with BV and trichomoniasis. The screening test offers
immediate results and assists in detecting BV and trichomoniasis even when
Candida (yeast) symptoms mask the more serious infections. The self-
screening tool has been found to effectively and easily detect BV (Nyirjesy et
al, 2017).
Symptomatic women are typically treated with metronidazole

(Flagyl), given either orally (500 mg twice a day for 7 days) or
vaginally (metronidazole gel, 0.75% [Metro-Gel], 5 grams via an
applicator intravaginally for 5 days). Flagyl should not be used in
women with a history of seizures. No alcohol should be ingested 24
hours before or after taking this medication, because the
combination of metronidazole and alcohol causes significant
abdominal discomfort, nausea, vomiting, and headache. Nausea is
the most common side effect; nurses should advise women to
always take the medication with food. Metronidazole readily crosses
the placenta and should not be taken during the first trimester of
pregnancy; it is also contraindicated in breastfeeding women.
Clindamycin (Cleocin) is given in a 2% vaginal cream (5 grams via
an applicator intravaginally for 7 days).
Candidiasis
Commonly known as a yeast infection, candidiasis is generally
caused by Candida albicans (Fig. 31-2). Other related yeast species
(e.g., C. tropicalis, C. glabrata, C. parapsilosis, C. krusei, C.
lusitaniae), however, can also be causative agents. Infection with
candidiasis is usually characterized by intense vulvar pruritus
(itching) and irritation and a thick, white, cottage cheese–like vaginal
discharge that may have a sour odor. The discharge may be
observed on the vaginal walls, cervix, and labia, and the vulva and
labial folds are red and edematous. The patient may complain of
dyspareunia and dysuria, although symptoms are subtler in some
women. Only 20% of women will be asymptomatic and diagnosis
typically occurs during routine gynecological exams (Centers for
Disease Control and Prevention, 2020d). The diagnosis of
candidiasis is made on the basis of microscopic examination of the
vaginal discharge. A saline and KOH wet smear reveals budding
yeast or pseudohyphae. The vaginal pH is usually unaltered,
although it may be slightly more acidic than normal. During the
examination, it is important to rule out STDs.
NURSING INSIGHT
Recognizing Factors Associated With Vulvovaginal Candidiasis
Certain factors are associated with vulvovaginal candidiasis, such as the use of
broad-spectrum antibiotics and systemic corticosteroids, which can cause a
reduction in the normal protective vaginal flora; high-dose oral contraceptives;
and uncontrolled diabetes and allergies, especially allergic rhinitis. Spermicidal
creams have also been associated with vaginal yeast infections. Nurses can
advise women who use these medications or products about strategies to
enhance the normal vaginal environment and reduce the likelihood of
vulvovaginal candidiasis.
Candidiasis is treated with antifungal medications, and many over-

the-counter agents such as miconazole (Monistat) and clotrimazole
(Gyne-Lotrimin) are available. Most of the commercial products are
fungistats that inhibit the organisms from reproducing, so the
woman’s immune system can suppress the yeast. Patients can apply
a topical antifungal cream to the vulva as well as the intravaginal
cream or suppositories. It is important to remind women that creams
and vaginal suppositories are oil-based and may weaken latex
condoms or diaphragms. Although these medications are available
without prescription, the nurse should advise patients to avoid self-
treatment without first undergoing a clinical evaluation to confirm the
diagnosis of vulvovaginal candidiasis. Treatment of asymptomatic
sexual partners is not generally necessary (Centers for Disease
Control and Prevention, 2020d).
Nurses can educate women about strategies to relieve symptoms
of candidiasis and help prevent recurrent yeast infections. For
example, women can be advised to take sitz baths for comfort and
add Aveeno powder to the bath. Boric acid, 600 mg in size 0 gelatin
capsules inserted in the vagina each night for 14 days, has been
reported to be effective against resistant infections (HealthlinkBC,
2019). Vaginal suppositories containing acidophilic bacteria, as well
as long-term (6 months) daily ingestion of dairy products or powders,
capsules, or tablets that contain Lactobacillus acidophilus, or other
strategies such as use of vaginal products such as yogurt, garlic, tea
tree oil, eating a low carbohydrate diet, and douching have not been
proven to be effective, and evidence supporting this intervention is
conflicting (American College of Gynecologists and Obstetricians,
2020). Nurses can also teach women to wear cotton underwear to
enhance ventilation of the genital area; avoid wearing tight-fitting
pants or wet clothing (e.g., bathing suits) for prolonged periods of
time; avoid potential irritants such as perfumed soaps, creams, and
wipes; and avoid bubble baths, hot tubs, and the application of
perfumes, sprays, or powder near the vaginal area.
Stronger antifungal prescription medications are available in
creams or suppositories, along with oral preparations, including
fluconazole (Diflucan), itraconazole (Sporanox), and ketoconazole
(Nizoral). Although the oral medications are associated with various
side effects (e.g., nausea, vomiting, diarrhea, abdominal pain,
headache), they tend to be well tolerated by most women.
Ketoconazole is associated with hepatotoxicity, and baseline and
ongoing liver function monitoring is recommended. Oral antifungals
and boric acid suppositories should not be used during pregnancy.
Topical antifungals have limited systemic absorption and are
considered safe for maternal use. Women who have recurrent yeast
infections should be evaluated for diabetes and/or infection with HIV
(Centers for Disease Control and Prevention, 2020d).
TOXIC SHOCK SYNDROME

Toxic shock syndrome is a rare, sometimes fatal condition that
affects many body systems. Although this disorder is not well
understood, TSS is believed to be associated with tampon use
during menses. However, TSS can also occur in children, pregnant
women, and nonmenstruating women. Nonmenstrual TSS risk is
increased for women who use vaginal barrier contraceptives. The
incidence of TSS peaked during the late 1970s and 1980s, most
likely because of the widespread availability of superabsorbent
tampons. A few specific tampon designs and high-absorbency
tampon materials were found to have some association with an
increased risk of TSS; these products are no longer sold in the
United States.
Common signs of TSS include fever of sudden onset greater than
102.2°F (38.9°C), diffuse, macular (flat) erythematous rash, vomiting,
diarrhea, malaise, muscle aches, disorientation, platelets less than
100,000/mm3, and hypotension with a systolic blood pressure less
than 90 mm Hg. Patients who experience these symptoms should
seek medical care immediately; left untreated, TSS can be fatal
within hours (Centers for Disease Control and Prevention, 2020c;
Venes, 2021).
Toxic shock syndrome is caused almost exclusively by toxins
produced by some strains of the colonized bacterium
Staphylococcus aureus. Toxins produced from the bacterium
Streptococcus pyogenes may also cause TSS (sometimes referred
to as toxic shock–like syndrome [TSLS] or streptococcal toxic shock
syndrome [STSS]). Although the exact mechanism of cause is
unknown, several conditions are believed to contribute to the
development of menstrual TSS. These include alterations in the
normal vaginal flora, a neutral vaginal pH, mechanical blockage of
menstrual flow, contamination of tampons by the bacterium S.
aureus, absorption of bacteria-resistant cervical fluids, the
superabsorbent or synthetic materials found in some tampons, and
damaged cervical or vaginal tissue. The toxin implicated in menstrual
TSS is capable of entering the bloodstream by crossing the vaginal
wall in the absence of ulcerations (Centers for Disease Control and
Prevention, 2020c; Venes, 2021).
Optimizing Outcomes
Strategies to Reduce Risk for Menstrual TSS

Nurses can teach women about strategies to minimize the risk of contracting
menstrual TSS. For example, menstruating women may use sanitary pads or
choose a tampon with the minimum absorbency needed to manage the
menstrual flow and use the tampons only during active menstruation. Women
should be instructed to wash their hands before using a tampon and use it
immediately once the package has been open. Women can be taught to change
tampons frequently (at least every 6 hours) and alternate sanitary pads with
tampons, especially during the night. Nurses should emphasize that if
symptoms suggestive of TSS occur, the tampon should be removed and
medical attention sought immediately.
The diagnosis of TSS is made on the basis of physical

examination findings and symptoms, along with results of a complete
blood count, which often shows an elevated white blood cell count
indicative of an acute infectious process. Treatment of this potentially
life-threatening condition involves immediate hospitalization with fluid
replacement and aggressive antibiotic therapy. Antibiotics should
cover both S. aureus and S. pyogenes and may include a
combination of cephalosporins, penicillins, and vancomycin, along
with clindamycin or gentamicin. With appropriate care and prompt
treatment, patients usually recover within 2 to 3 weeks.
URINARY TRACT INFECTIONS

Urinary tract infection (UTI) is defined as significant bacteriuria in the
presence of symptoms. UTIs occur more frequently in women than in
men because of the shorter route from the external environment to
the bladder in women, along with the close proximity of the urethra to
the vaginal and anal areas. UTIs account for a significant number
(>6 million) of physician/health clinic visits each year, and the
American College of Obstetrics and Gynecology estimates that 20%
of women will be affected by a UTI at some time during their lifetime.
Under normal circumstances, the flow of urine keeps bacteria
flushed from the urinary tract, and the entire urinary system remains
sterile. The bladder wall possesses antibacterial properties, and the
urine is usually acidic, which inhibits growth of bacteria.
The female and male urinary tracts are relatively the same except
for the length of the urethra. Owing to this difference, women are 30
times more likely to develop UTIs than men. The female urethra is
approximately 1.5 inches long; the male urethra is approximately 8
inches long. In women, bacteria from fecal matter can be easily
transferred to the vagina or the urethra. Most UTIs arise from one
type of bacteria, Escherichia coli, which normally lives in the colon.
Other common culprits include Enterococcus faecalis,
Staphylococcus saprophyticus, Klebsiella pneumoniae, and Proteus
mirabilis. Chlamydia and mycoplasma may also cause UTIs in both
women and men, but these infections tend to remain limited to the
urethra and reproductive system. Unlike E. coli, chlamydia and
mycoplasma may be sexually transmitted.
Risk factors for UTIs include extremes of age, altered immunity,
anatomical anomalies, diabetes, urinary tract obstructions,
pregnancy, sexual activity, and diaphragm use. Irritation of the
urethra during sexual activity can cause bacteria to migrate upward
into the urinary tract. Spermicides may alter the vaginal pH and
decrease levels of normal protective bacteria, allowing harmful
bacteria to grow in the vagina, which can then migrate to the bladder.
Allergy to certain ingredients in soaps, vaginal creams, bubble baths,
or other chemicals used in the genital area may cause tissue injury
that can allow for the introduction of bacteria.
Nurses should be alert to certain patient symptoms that may be
indicative of a UTI. Dysuria (pain with urination), urinary frequency,
urgency, a sensation of bladder fullness, suprapubic tenderness, and
cloudy, foul-smelling urine are classic symptoms associated with a
UTI. If the infection has ascended to the kidneys, the woman may
experience pain in the lower back region where the vertebrae and
ribs meet (costovertebral angle tenderness), and fever may be
present.
Diagnosis for a UTI varies according to the location and extent of
the infection. Cystitis is the term used for infection of the lower
genitourinary tract; pyelonephritis is the term used for infection of the
upper tract. Symptoms associated with cystitis include dysuria and
increased urinary frequency and urgency; symptoms associated with
pyelonephritis include fever (temperature greater than 38°C
[100.4°F]), chills, flank pain, and nausea and vomiting. For
uncomplicated infection of the lower urinary tract, the diagnosis is
made on the basis of symptoms and urinalysis, including the
microscopic examination of a clean-catch (midstream) urine sample
for the presence of white or red blood cells and bacteria.
Complicated cases require a urine culture and sensitivity. In some
practice settings, a leukocyte esterase (an enzyme present in white
blood cells) or nitrite urine dipstick screening test to detect
bacteriuria in women with suspected uncomplicated UTIs is used
(Centers for Disease Control and Prevention, 2019).
Teach the patient to recognize common signs of a UTI:
■ Dysuria—pain (burning sensation) on urination
■ Urinary urgency and frequency associated with small amounts of
urine
■ Hematuria—blood or red blood cells in the urine
Treatment for uncomplicated lower UTIs may be initiated in
nonpregnant women with antibiotic therapy given over a 3-day
course. Medications commonly used include
trimethoprim/sulfamethoxazole (e.g., Bactrim, Septra TMP/SMX),
nitrofurantoin monohydrate macrocrystals (e.g., Macrodantin), and
amoxicillin/clavulanate (e.g., Augmentin). If the woman complains of
intense dysuria, a bladder analgesic such as phenazopyridine
(Pyridium), given for 1 to 2 days, is beneficial in alleviating the
bladder discomfort (Centers for Disease Control and Prevention,
2019).
UTI Risk Among Pregnant Women

Pregnant women are at an increased risk for developing UTIs, especially if they
are diabetic or have gestational diabetes. Urinary tract infections may also
predispose the woman to the onset of preterm labor.
Patient Education
Teaching Strategies to Decrease UTI Incidence and Promote Bladder
Health
Nurses can teach women about strategies to promote bladder health and
decrease the likelihood of developing a UTI. For example, the nurse may
advise the patient to:
• Void frequently (every 2–4 hours); avoid postponing urination (allowing urine
to remain in the bladder allows bacteria to multiply).
• Empty the bladder before and after intercourse; drink liquids before and after
intercourse.
• Remain hydrated to keep bacteria flushed out of the urinary tract system.
• Drink fruit juices to acidify the urine; take vitamin C regularly to inhibit
bacterial growth.
• Wipe the urethral meatus and perineum from front to back after voiding.
• Avoid harsh soaps, powders, and sprays; avoid bubble baths and bath oils.
• Wear cotton underwear; avoid tight-fitting underwear and pants.
• Take showers instead of baths if able.
• Minimize douching, sprays, or powders in the genital and vaginal areas.
CASE STUDY
Inger P.: Urinary Tract Infection
Inger P. is a 20-year-old foreign exchange student from Norway. She visits the
campus student health center complaining of mild dysuria and urinary frequency
and urgency for the past 3 days. Inger explains to the nurse that her symptoms
were “mild” at first but have grown progressively worse, and this morning she
noticed blood in her urine. She denies fever, chills, flank pain, or other
symptoms and states that she has never experienced any similar symptoms.
Inger is sexually active and uses oral contraceptives for birth control. Her
menstrual history is normal, and she uses tampons. She has no known
allergies.
1. What testing/evaluation does the nurse anticipate?

2. What will most likely happen next?
Inger’s physical examination is unremarkable, she appears to be in no acute
distress, and her vital signs, including temperature, pulse, respirations, and
blood pressure, are within normal limits. She does complain of suprapubic
tenderness on palpation. A laboratory dipstick test is performed on the urine
sample and is positive for blood and leukocyte esterase.
3. Based on results of the physical examination and laboratory testing, what is
the diagnosis?
4. What can the nurse teach Inger about her medication?
5. What other information should the nurse provide?
ENDOMETRIOSIS
First described by Dr. John Sampson in the 1920s, endometriosis is
defined as the growth, adhesion, and progression of endometrial
glands and tissue outside of the uterine cavity with cellular activity
evident in lesions, nodules, and cysts. Women aged 30 to 40 years
are most likely to develop endometriosis, and the condition is found
in 20% to 50% of infertile women and in up to 87% of women with
chronic pelvic pain. Endometrial lesions have been discovered on
the ovaries, fallopian tubes, lining of the inside of the pelvic cavity,
cervix, bladder, bowel, brain, nostrils, liver, and lungs (Fig. 31-3)
(U.S. Department of Health and Human Services, 2020).
Each month, the misplaced endometrial tissue responds to cyclical
hormonal stimulation during the secretory and proliferative stages of
the menstrual cycle, growing and thickening in a similar fashion to
the endometrial tissue normally lining the uterus. During the ischemic
and menstrual phases of the cycle, however, the misplaced
endometrial tissue breaks down and bleeds into the surrounding
tissue, causing inflammation. The released blood becomes trapped
in the surrounding tissues, causing the development of blood-
containing cysts. The recurrence of inflammation in the areas outside
of the uterus eventually results in scarring, fibrosis, and the
development of adhesions, scar tissue that binds the organs
together, causing increased abdominal pain and a risk of infertility
PROCEDURE ■ Obtaining a Midstream Urine

Sample
PURPOSE
To assist the woman in providing a suitable urine specimen for laboratory
testing
PREPARATION
1. Complete the information requested on the container label. Include the
patient’s full name and the date and time of collection of the specimen. If a
requisition is needed, note the date and time on the requisition.
2. Explain the procedure to the woman to ensure she understands why a urine
sample is requested, the purpose of any tests to be performed, and
directions on how to obtain a midstream urine sample.
EQUIPMENT
• Approved empty sterile container for collection
• Towelette for cleaning in between the labia
• Tissue
PROCEDURAL STEPS
Instruct the patient to do the following:
1. Wash and dry your hands thoroughly or use an alcohol-based hand rub.
RATIONALE: To reduce the risk of specimen contamination. Alcohol-based
hand rubs are fast acting, reduce the number of microorganisms on the
skin, and may cause less skin irritation or dryness.
2. Remove the container cap and set it on a clean, even surface with the inner
surface pointing up. Do not touch the inner surface of the lid or the
container.
RATIONALE: To reduce the risk of specimen contamination.
3. Sit on the toilet seat and separate the labia (vaginal lips) using your
nondominant hand. Clean the urogenital area from the front to back with the
towelette provided. Wipe for only one stroke and then discard the towelette.
RATIONALE: To reduce the risk of specimen contamination and to reduce
the number of microorganisms on the skin. Cleansing from front to back
prevents bringing rectal contamination forward.
4. Holding the labia apart, begin to pass urine. Allow the beginning urine to go
directly into the toilet. RATIONALE: The initial stream of urine washes
urethral microorganisms and other debris away from the urethral meatus.
The midstream collection ensures that a sterile specimen is obtained.
5. Continue to urinate and hold the container under the urine stream. Avoid
touching the inside of the container. Remove the container when it is
approximately half full.
6. Carefully replace the cap and secure tightly. RATIONALE: Placing the cap
on the container prevents inadvertent spilling and possible contamination of
the urine specimen.
7. Wash your hands again after the specimen collection.
FIGURE 31-3 Possible sites of occurrence of endometriosis.
Endometriosis is the presence of endometrial glands and tissue

outside the uterus. An endometrioma is a solitary, non-neoplastic
mass that contains endometrial tissue. An endometrioma is also
referred to as an endometrioid cyst. Endometrioid cysts, often filled
with dark, reddish-brown blood, may range in size from 0.75 to 8
inches (19.05 mm-20.32 cm). An endometrioid cyst is sometimes
called a chocolate cyst because it is filled with old blood.
Etiology, Pathogenesis, and Risk Factors

The exact cause and pathogenesis of endometriosis is not known.
One of the most widely accepted theories is Sampson’s theory, or
“retrograde menstruation.” This theory postulates that during
menstruation, endometrial tissue is transported through the fallopian
tubes into the peritoneal cavity, where it implants on the ovaries and
other structures. Although retrograde menstruation occurs in most
women, it is not clear why some develop endometriosis and others
do not. The level of functioning of the immune system is thought to
be a factor in the development of endometriosis, although the exact
mechanism is unknown. Interestingly, women with endometriosis
tend to develop additional symptoms such as allergies, fibromyalgia,
asthma, eczema, autoimmune inflammatory disease, chronic fatigue
syndrome, and hypothyroidism. Also, there is a higher risk of breast
cancer in women diagnosed with endometriosis after age 40
because of their prolonged exposure to elevated endogenous
estrogen.
Risk factors for developing endometriosis include early age at
menarche (onset of menstruation before age 11 years), short
menstrual cycles (less than 27 days), low birth weight, nulliparity,
and heavy, prolonged menstrual periods and infertility. Endometriosis
also has a strong familial component: first-degree relatives of
individuals with endometriosis are 7 to 10 times more likely to
develop the disease. Higher parity and increased duration of
lactation are associated with a decreased risk of endometriosis
among parous women. Also, regular exercise (more than 4 hours per
week) and eating a diet rich in citrus fruits is associated with a
reduced risk of developing endometriosis (U.S. Department of Health
and Human Services, 2020).
Signs and Symptoms

The signs and symptoms of endometriosis vary from woman to
woman, and the severity of symptoms may increase over time.
However, the most common symptom is pelvic pain. The pain, which
usually begins 1 or 2 days before the expected menses, may be
unilateral or bilateral and frequently lasts until the end of
menstruation. Some patients experience a constant, debilitating pain
that interferes with their normal daily activities. Bowel symptoms
such as diarrhea, pain with defecation, constipation, and rectal
bleeding with significant bowel involvement may also occur. Other
symptoms include dyspareunia, dysuria, various gastrointestinal
symptoms, low back pain, infertility, and menstrual dysfunction.
Interestingly, the severity of pain does not correlate well with the
extent of the condition. Thus, severe disease may go undetected
Diagnosis
The diagnosis of endometriosis can be difficult to confirm owing to
the wide variation in symptoms. Diagnostic laparoscopy to allow for
visualization and biopsy of the lesions remains the gold standard for
diagnosis, after other causes of pelvic pain (e.g., upper genital tract
infection, PID) have been ruled out. A vaginal ultrasound may also
be performed to provide imaging of the displaced endometrial tissue
or cyst(s), although it may be difficult to differentiate between other
pathological entities such as tubal cysts, abscesses, and ectopic
pregnancy (U.S. Department of Health and Human Services, 2020).
Optimizing Outcomes
Endometriosis Staging to Guide Care

The American Society for Reproductive Medicine (ASRM) has developed
classification and staging guidelines to assist with endometriosis diagnosis,
prognosis, treatment, and progress and communication among health
professionals. Staging is based on the extent of the spread of the lesions, the
density of pelvic adhesions, involvement of pelvic organs, and the degree of
fallopian tube occlusion. In the standardized schema, endometriosis is classified
into four stages: Stage 1—minimal, Stage 2—mild, Stage 3—moderate, and
Stage 4—severe. Interestingly, women with minimal or mild endometriosis have
been shown to have high degrees of pain and infertility, whereas women with
Stage 4 disease have been asymptomatic and diagnosed during laparoscopy
for various procedures such as tubal ligation.
Treatment Options
Treatment for endometriosis should be individualized and holistic as
this disease can persist during a woman’s entire reproductive life.
When determining the best approach for therapy, many factors must
be considered, such as the woman’s age, desire for future
pregnancy, the size of her current family, and general lifestyle
patterns. Although there are no ideal treatments for endometriosis,
the planned course of therapy is based on the severity of symptoms
and the woman’s or couple’s goals. Treatment plans generally begin
with the least invasive approach and progress to more invasive
therapies. Regardless of the treatment, however, approximately 10%
to 20% of women with endometriosis experience a recurrence of the
condition.
Medical Therapy
The goal of medical treatment is to reduce pain and the amount of
estrogen in the body so that menstruation and the subsequent
growth of endometrial tissue are suppressed. To accomplish the
suppression of endogenous estrogen, two main classes of drugs are
used: GnRH-agonists and gonadotropin inhibitors. GnRH-agonists
such as leuprolide (Lupron), goserelin (Zoladex), elagolix (Orilissa®),
and nafarelin (Synarel) suppress the secretion of pituitary
gonadotropins. This action causes anovulation and amenorrhea,
which result in shrinkage of the endometrial tissue. The patient
experiences significant pain relief and an interruption in the further
development of endometrial lesions. Unfortunately, recurrence rates
are high after the medication is discontinued. Common side effects
are similar to those associated with natural menopause and include
hot flashes; vaginal dryness; loss of libido; emotional lability; and
mild, reversible bone loss. Treatment is limited to 24 months of low
dose because of the decrease in bone mineral density associated
with these medications. These medications can come in different
forms with some GnRH medicines that come in a nasal spray taken
daily, as an injection given once a month, or as an injection given
every 3 months (U.S. Department of Health and Human Services,
2020).
Danazol (Cyclomen) is a synthetic androgen that acts as a
pituitary gonadotropin inhibitor. This medication causes anovulation
by suppressing the secretion of follicle-stimulating hormone (FSH)
and luteinizing hormone (LH). Pain relief results from the
hypoestrogenic environment, endometrial atrophy, and regression of
the endometrial lesions. This medication is an androgenic synthetic
steroid, and masculinizing side effects such as acne, hirsutism,
deepening of the voice, weight gain, decreased breast size, and oily
skin are common. Other side effects include headaches, flushing,
sweating, atrophic vaginitis, and edema. The duration of treatment is
approximately 6 months because of the multitude of adverse side
effects. Preventing pregnancy is essential due to the detrimental
effects of the medication on a pregnancy; however, hormonal birth
control methods are not recommended for women taking danazol.
Instead, health-care providers recommend using barrier methods of
birth control, such as condoms or a diaphragm (U.S. Department of
Health and Human Services, 2018a; Vallerand, 2021).
Contraceptive medications are also used to treat endometriosis.
Combination oral contraceptives contain progestins and estrogen—
hormones that suppress gonadotropins, prevent ovulation, shorten
the frequency and duration of menstrual flow and cause endometrial
atrophy. Pain relief, related to a thinning of the endometrial lining and
regression of the endometriotic implants, is achieved in
approximately 75% of patients. Side effects include irregular
bleeding, weight gain, headache, thrombophlebitis, benign liver
tumors, and gallbladder disease. Medroxyprogesterone (Depo-
Provera) is an injectable progesterone that also suppresses
gonadotropins and thins endometrial tissue. Potential adverse side
effects associated with this medication include weight gain,
headache, abdominal discomfort, and irregular bleeding. Treatment
outcomes are similar to those achieved with oral contraceptives. The
IUD Mirena® may be effective in reducing endometriosis-associated
pain due to its ability to reduce the size of lesions and reduce
menstrual flow (U.S. Department of Health and Human Services,
2020).
Anastrozole (Arimidex) and letrozole (Femara) are antineoplastic
aromatase inhibitors that decrease levels of circulating estrogen by
inhibiting the peripheral conversion of androgens. Potential adverse
effects include headache, nausea, diarrhea, hot flashes, and an
increased risk of osteoporosis with long-term use. Treatment is
limited to 6 months because of the decrease in bone mineral density.
Up to 90% of patients experience alleviation of symptoms during and
up to 15 months post-treatment. These medications are considered
high risk and routine blood work may be necessary to monitor for
elevated liver enzymes and cholesterol. In addition, women of
childbearing age should have a negative pregnancy test due to the
teratogen risk for anomalies and should be counseled on the need
for contraception and pregnancy prevention measures while taking
the medication (Vallerand, 2021).
Surgical Treatment
Laparoscopy with biopsy of the lesions is the only accurate method
to diagnose and determine the severity of endometriosis. During the
laparoscopy, surgical removal of the lesions, adhesions, and cysts
may be conducted via excision, electrocautery, or laser vaporization.
The recurrence rate of endometriotic lesions after 5 years is 19%
with laparoscopic removal of the lesions and 10% with hysterectomy
(removal of the uterus) and bilateral oophorectomy (removal of the
ovaries). Women who undergo a bilateral oophorectomy are usually
treated with hormone therapy, as the benefits outweigh the risk of
endometriosis recurrence.
Implications for Nurses

Counseling and support constitute the cornerstone of nursing care
for women diagnosed with endometriosis. It is incumbent upon
nurses who care for women with this chronic condition to remain
knowledgeable about endometriosis so that they can provide factual
information about treatment options, including the risks and benefits
of each. Therapeutic listening reflects respect and encourages
patients to share intimate details about sensitive issues, such as
dyspareunia. Teaching patients about endometriosis empowers them
to participate in their treatment plan and explore approaches such as
alternative methods of pain control and lifestyle and diet
modifications (e.g., regular exercise and balanced nutrition) that may
enhance well-being and improve functionality.
In addition to the traditional medical/surgical therapies for
endometriosis, women may wish to engage in the following
complementary therapies:
■ Yoga—to enhance stress reduction and relaxation, and to
strengthen the abdominal and back muscles compromised by
surgical trauma
■ Acupuncture—to provide pain control and fertility enhancement
through increased pelvic blood flow
■ Stress reduction techniques—to diminish stress and enhance
overall feelings of well-being
■ Massage—to enhance relaxation and promote release of
endorphins
■ Physical therapy—to diminish symptoms of chronic pelvic pain and
dyspareunia
■ Exercise—to improve blood flow, release circulating endorphins
and decrease pain
■ Electrotherapy—using transcutaneous electrical nerve stimulation
to decrease pain (Mira et al, 2018)
Assisting Women With Endometriosis
Women with endometriosis can benefit from a multidisciplinary approach to
treatment. The health-care team, composed of professionals with skills to
address the many difficulties associated with this chronic condition, may
include dietitians, physiotherapists, psychologists, and chronic pain specialists.
Nurses may suggest referral to local support groups and national organizations
such as Resolve (http://www.resolve.org), an organization for infertile couples,
or the Endometriosis Association (http://www.endometriosisassn.org). Nurses
can remain up-to-date on evidence-based guidelines for the treatment of
endometriosis through the European Society for Human Reproduction &
Embryology (SHRE) Web site (http://www.guidelines.endometriosis.org) or the
National Guideline Clearinghouse Web site (http://www.guideline.gov).
LEIOMYOMAS (FIBROIDS)
Uterine leiomyomas (also called fibroids) are the most common
solid pelvic tumors in women and the leading indication for
hysterectomy. A leiomyoma, or fibroid, is a benign tumor composed
of nonstriated muscular tissue. Fibroids arise from a singular
neoplastic smooth muscle cell in the uterus and grow slowly.
Although the exact cause is unknown, the growth of leiomyomas is
dependent on estrogen; both estrogen and progesterone play a key
role in the pathogenesis of leiomyomas. They are almost always
benign (U.S. Department of Health and Human Services, 2019).
Leiomyomas may be located in various places in and around the
uterus (Fig. 31-4). The most common fibroids form within the uterine
wall. They can vary greatly in size and may protrude into the uterine
cavity, bulge outward through the uterine wall and into the pelvic
cavity, or grow on a stalk called a pedicle that can become twisted
and cause pain.
■ Submucosal fibroids that grow into the uterine cavity.
■ Intramural fibroids that grow within the wall of the uterus.
■ Subserosal fibroids that grow on the outside of the uterus (U.S.
Department of Health and Human Services, 2019).
Leiomyomas are more common in women age 30 to 40, those with
a family history of fibroids, African American women, women who
are obese, and those with a diet high in red meat. Stimulated by
estrogen and progesterone, the tumors occur more frequently with
increasing age and regress after menopause in which they often
shrink.
Signs, Symptoms, and Diagnosis

The two most common symptoms of uterine leiomyomas for which
women seek medical treatment are abnormal uterine bleeding and
pelvic pressure. Frequently, however, fibroids cause no symptoms
and are first discovered during a routine bimanual pelvic
examination. When abnormal bleeding is present, it is usually
reported as heavy or prolonged menstrual bleeding, which may
result in iron-deficiency anemia. In some situations, the bleeding
significantly disrupts the woman’s normal daily activities. The pelvic
and abdominal discomfort is often described as “pressure.”
Depending on the location of the leiomyoma, pressure may be
experienced in the bladder or rectal regions, leading to difficulty with
urination or defecation or dyspareunia. Also, depending on their size
and location, leiomyomas can interfere with fertility.
FIGURE 31-4 Uterine fibroids.
On examination, the uterus is nontender and may feel enlarged,

irregularly shaped, or both. Pregnancy must always be ruled out. An
ultrasound examination can confirm the presence of the leiomyoma
and provide baseline measurements. Sometimes a hysteroscopy, an
office procedure that uses an instrument to view the uterine cavity, or
a laparoscopy, an outpatient hospital procedure that uses an
instrument to view the uterus and surrounding structures, is
performed to aid the diagnosis.
Diagnostic Tools
Sonohysterography
Sonohysterography is the evaluation of the endometrial cavity using the
transcervical injection of sterile fluid (e.g., normal saline solution) under real-
time ultrasound imaging. The primary goal of this office-based diagnostic
procedure is to visualize the endometrial cavity in more detail than is possible
with routine transvaginal ultrasonography; it may also be used to assess tubal
patency and is less painful than hysterosalpingography (dye test to evaluate
tubal patency). Sonohysterography should be scheduled during the follicular
phase of the menstrual cycle, after the menstrual flow has ceased, but before
ovulation (i.e., by the 10th day of the menstrual cycle). Indications for use
include evaluation of the following: abnormal uterine bleeding; congenital
uterine anomalies; infertility; abnormalities detected on transvaginal
ultrasonography; the presence of abnormalities in the uterine cavity (e.g.,
leiomyomas, polyps); and recurrent pregnancy loss. The procedure should not
be performed in pregnant patients or in women with existing pelvic infections or
unexplained pelvic tenderness (U.S. Department of Health and Human
Services, 2018b).
Treatment
In general, patients with leiomyomas are seen in the office every 3 to
6 months as long as they are experiencing mild symptoms. If heavy
and prolonged bleeding or severe pain occurs, however, referral to a
specialist for further evaluation is indicated. Interventions may
include drug therapy; uterine artery embolization; myomectomy;
hysterectomy; and laser surgery, electrocauterization, or magnetic
resonance imaging (MRI)–guided focused ultrasound surgery.
Drug Therapy
Contraceptive steroids (estrogen and progestin combination and
progestin alone) may be prescribed to control heavy periods and
dysmenorrhea. The levonorgestrel intrauterine system (LNG-IUS)
has been shown effective to decrease menorrhagia and improve
quality of life. Gonadotropin-releasing hormone (GnRH) agonists,
including leuprolide acetate (Lupron, Synarel), suppress the
production of estrogen and progesterone and shrink the tumors,
although the effects of these agents are temporary, with gradual
recurrent growth of leiomyomas within several months following the
cessation of treatment. Also, the significant menopausal symptoms
such as vaginal dryness, hot flashes, and mood changes along with
decreased bone mineral density limit use of these medications to no
more than 6 months. Antiprogesterone agents such as mifepristone
(Mifeprex) may also be useful in controlling leiomyoma symptoms.
Recurrence of tumor growth following cessation of treatment tends to
be slower than with other medications; however, further study is
needed. Potential side effects include endometrial hyperplasia and
alterations in liver functioning (U.S. Department of Health and
Human Services, 2018b; Vallerand, 2021).
Uterine Artery Embolization (UAE)

Performed by interventional radiologists, this treatment involves the
injection of polyvinyl alcohol pellets into selected blood vessels to
block the blood supply to the fibroid and cause shrinkage and
resolution of symptoms. UAE is performed under local anesthesia
and conscious sedation. An incision is made into the groin, a
catheter is threaded from the femoral artery into the uterine artery,
and an arteriogram identifies the major blood vessels that supply the
leiomyoma. Most tumors shrink in size by 50% within 3 months
following treatment. Women who wish to undergo this procedure
should be advised that data are lacking about the long-term effects
on fertility and future pregnancies.
Myomectomy and Hysterectomy

For women who desire uterine preservation (e.g., those who desire
future fertility), myomectomy (removal of the leiomyoma) may be an
option. Depending on the size and number of tumors, this surgical
procedure may be accomplished during a laparotomy, a laparoscopy,
or a hysteroscopy. Myomectomy can be performed through a
laparoscopic (conventional or robot-assisted) approach, an
abdominal incision approach, or a vaginal (hysteroscopic) approach.
The uterus (and therefore childbearing potential) is preserved,
although most myomectomy patients will require a cesarean birth.
Myomectomy is associated with significant improvements in
symptoms and health-related quality of life. Hysterectomy (removal
of the uterus) may be the treatment of choice if heavy, persistent
bleeding cannot be controlled by any other means.
Laser Surgery, Electrocauterization, and MRI-Guided Focused

Ultrasound Surgery
Laser surgery and electrocauterization may be used to destroy small
leiomyomas with a vaginal (hysteroscopic) or abdominal
(laparoscopic) approach. Laser coagulation vaporizes the fibroids
and produces necrosis. However, although the uterus remains intact,
endometrial scarring may diminish future fertility (ACOG, 2008a).
Magnetic resonance-guided focused ultrasound surgery
(MRgFUS) is a noninvasive approach that uses MRI to deliver high-
intensity ultrasound waves into the leiomyoma. The ultrasound
energy penetrates soft tissue and causes necrosis. Adverse effects
include heavy menses and persistent pain; further studies regarding
the long-term efficacy of this treatment modality are indicated.
Optimizing Outcomes
Following Surgical Intervention for Leiomyomas

Nurses can educate women undergoing surgical interventions for leiomyomas
about strategies to enhance comfort and promote healing. Nurses can teach
women to:
• Take all prescribed medications.
• Contact the physician for symptoms including bleeding, cramping, fever of
39°C (102.2°F) or greater, gastrointestinal changes, signs of wound infection
(redness, swelling, heat, or pain at the incision site), urinary retention,
abnormal vaginal discharge.
• Consume foods high in protein, iron, and vitamin C to facilitate tissue healing;
drink plenty of fluids.
• Avoid straining during bowel movements.
• Follow the physician’s recommendations regarding physical activity and
driving.
• Follow the physician’s orders regarding tub baths and the resumption of
intercourse.
ABNORMAL UTERINE BLEEDING
Abnormal uterine bleeding, a common problem for women, may be
associated with major disruptions in daily functioning. In the past,
various inconsistent definitions were used to describe abnormal
uterine bleeding, which was categorized as either structural or
dysfunctional; the diagnosis of dysfunctional uterine bleeding was
made only after all pathological causes of bleeding, such as
leiomyomata, polyps, endometrial hyperplasia, and cancer, had been
excluded. In 2011, the Federation of Gynecology and Obstetrics
(FIGO) endeavored to create a universally accepted system of
nomenclature to describe uterine bleeding abnormalities in
reproductive-aged women. Adoption of the classification system
(polyp, adenomyosis, leiomyoma, malignancy and hyperplasia,
coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not
yet classified), known by the acronym PALM-COEIN, is an
assessment tool to help with identifying possible causes of abnormal
bleeding (International Federation of Gynecology and Obstetrics,
2021).
Prior to treatment, an accurate diagnosis for the cause of the
bleeding should be established. Based on age alone, endometrial
assessment to exclude cancer should be performed on any woman
older than 35. In addition to a physical examination,
diagnostic/laboratory tests used to evaluate women with abnormal
uterine bleeding may include a pregnancy test to rule out ectopic
pregnancy, Pap test, testing for the presence of Chlamydia
trachomatis, complete blood count, evaluation for endocrine
dysfunction (e.g., thyroid-stimulating hormone, prolactin),
endometrial biopsy, transvaginal ultrasound, hysteroscopy, and
dilation and curettage (D & C). Owing to issues such as fatigue;
anxiety; social embarrassment; and restrictions on social, leisure,
and physical activities, heavy menstrual bleeding may significantly
diminish women’s quality of life; the diagnosis, evaluation, and
treatment of heavy menstrual bleeding should be based on the
“patient experience”—the woman’s personal assessment of her
blood loss and its effect on her life (Matteson et al, 2013).
What to Say
Asking About Menstrual Blood Loss
When interviewing patients about menstrual blood loss, the nurse may ask the
following questions:
• How many days does your menstrual period usually last?
• Would you describe your monthly flow as “unusually heavy”?
• Do you ever pass large blood clots?
• What size/kind/brand of protection do you use—and on your heaviest days,
do you need to use extra protection such as a tampon plus a napkin?
• Do you ever leak and stain your underclothes, outer clothes, or bed sheets?
• Do you ever miss school/work because of a heavy menstrual flow?
• Do you ever have to limit any activities because of a heavy menstrual flow?
• Does a heavy menstrual flow affect your relationships/sex life/quality of life?
PALM: Structural Causes

Structural causes of uterine bleeding include Polyps, Adenomyosis
(a condition in which endometrial tissue grows into the myometrium),
Leiomyomata, and Malignancy and hyperplasia. Uterine fibroid
tumors are often asymptomatic and first detected during a bimanual
pelvic examination. Precancerous or cancerous conditions of the
uterus or cervix can also cause abnormal bleeding (International
Federation of Gynecology and Obstetrics, 2021).
COEIN: Nonstructural Causes

Nonstructural causes of uterine bleeding, which include
Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and
Not yet classified (entities that are poorly defined or not well
examined), produce noncyclical menstrual blood flow that is derived
from the endometrium. The bleeding may range from spotty to
excessive and may be prolonged. It is most commonly caused by
hormonal imbalances, which account for approximately 75% of
cases of irregular bleeding. Heavy bleeding is a common problem for
women during the perimenopausal period between the ages of 40
and 50. As ovulation becomes more erratic, levels of progesterone
decrease. An important function of progesterone is to stabilize the
uterine endometrial lining. In the absence of progesterone, the
bleeding may become unpredictable, excessive, or prolonged.
Abnormal uterine bleeding may also occur during adolescence
before a pattern of regular ovulatory cycles has been established.
Other conditions that may cause abnormal bleeding include thyroid
or adrenal gland disorders, PCOS, clotting disorders, liver or kidney
disease, and leukemia. Taking herbal preparations, such as ginseng,
or medications, such as anticoagulants, may also cause abnormal
bleeding (International Federation of Gynecology and Obstetrics,
2021).
Nurses should be aware that abnormal uterine bleeding may be
related to an undiagnosed coagulopathy such as defects in primary
hemostasis, platelet deficiency (e.g., leukemia, idiopathic
thrombocytopenia), platelet dysfunction (e.g., von Willebrand
disease), and abnormalities of secondary homeostasis (congenital
factor deficiencies). Von Willebrand disease is a genetic bleeding
disorder caused by a defect or deficiency of a blood-clotting factor
(von Willebrand factor). This condition occurs in approximately 1% of
all women and is the most common inherited bleeding disorder
among American women (Venes, 2021).
Treatment
Depending on the cause, treatment for abnormal uterine bleeding
may include drug therapy and/or surgery. Medical management is
the preferred method of therapy for anovulatory uterine bleeding.
The goals of medical treatment are to alleviate the acute bleeding,
prevent future episodes of noncyclical bleeding, decrease the
woman’s risk of long-term complications from anovulation, and
improve her overall quality of life. It is important for nurses to counsel
patients that the treatment may initially cause heavy menstrual
bleeding related to buildup of the endometrium. However, the
bleeding should diminish over the course of 3 to 4 months.
Depending on the patient’s age and physical findings, medications
used include conjugated equine estrogens, low-dose combination
oral contraceptives, an LNG-IUS, cyclical progestogens, iron
supplementation, prostaglandin synthetase inhibitors (e.g.,
indomethacin [Indocin]), and NSAIDs (e.g., aspirin, ibuprofen,
naproxen). Tranexamic acid (Lysteda), an oral nonhormonal,
prothrombotic medication to treat heavy menstrual bleeding, works
by stabilizing a protein that helps blood to clot. Because the use of
this medication while taking hormonal contraceptives may increase
the risk of blood clots, stroke, or heart attack, women using hormonal
contraception should take tranexamic acid only if there is a strong
medical need and the benefits outweigh the potential risks. The most
common adverse effects of tranexamic acid are menstrual
discomfort/cramps, headache, back pain, and nausea, and the
medication is contraindicated in women who have active
thromboembolic disease or a history of thrombosis or
thromboembolism.
Surgical procedures to treat abnormal uterine bleeding include
dilation and curettage (D & C), endometrial ablation, and
hysterectomy. These interventions are indicated for patients who fail
to improve with medical therapy and who desire no future fertility.
Women with significant acute bleeding may need a D & C for the
immediate control of bleeding as well as for diagnosis. However, the
beneficial effects associated with this surgical intervention are only
temporary, and the D & C procedure is no longer the mainstay of
treatment.
A surgical alternative to hysterectomy is endometrial ablation, a
procedure that uses a lighted viewing instrument (hysteroscope) and
other instruments to destroy (ablate) the uterine lining. Depending on
the method used, endometrial ablation may be performed in the
physician office, outpatient facility, or hospital. The procedure may be
done using a local or spinal anesthesia, although general anesthesia
is sometimes used. Recovery following endometrial ablation
generally ranges from a few days to a couple of weeks.
The goal of endometrial ablation is to restore menses to normal or
less. Endometrial ablation is used to control heavy, prolonged
vaginal bleeding for the following circumstances: The bleeding has
not responded to other treatments; childbearing is completed; the
patient prefers not to have a hysterectomy to control the bleeding; or
other medical problems prevent a hysterectomy. The five FDA-
approved methods use a variety of energy sources to achieve
endometrial destruction via hyperthermic or hypothermic methods,
and each is designed to ablate down to the basal layer to prevent
regeneration and subsequent menstrual flow. Hyperthermic
endometrial ablation may be accomplished by laser beam (laser
thermal ablation), electricity (electrothermal ablation), microwave
(microwave endometrial ablation), or radiofrequency energy
(radiofrequency ablation); hypothermic endometrial ablation is
accomplished by freezing (cryoablation). With heat-based ablation
(hyperthermia), the endometrium undergoes necrosis and then heals
by scarring, which usually reduces or prevents uterine bleeding.
Compared with hyperthermic ablation, cryoablation is less likely to
stimulate the process of scar tissue formation and, owing to the
anesthetic effect related to the cooling of tissues and nerves, may be
less painful than the heat-based thermal ablation techniques.
Regardless of the ablation method used, fertility is not preserved,
although there is a remote possibility of pregnancy if a portion of the
endometrium is left intact. Contraception is recommended for women
who have not completed menopause.
HYSTERECTOMY
A hysterectomy is a surgery to remove the uterus. After cesarean
section, hysterectomy is the second most frequently performed
major surgical procedure for women of reproductive age in the
United States. Each year in this country, approximately 600,000
hysterectomies are performed, and an estimated 20 million women
have had a hysterectomy. The three conditions most commonly
associated with hysterectomy are uterine leiomyomata,
endometriosis, and uterine prolapse. Other indications include
cancer (i.e., uterine, ovarian, cervical, endometrial), adenomyosis,
chronic pelvic pain, and abnormal vaginal bleeding.
During the surgery, the whole uterus or a part of it may be
removed. A partial, subtotal, or supracervical hysterectomy involves
removal of the upper part of the uterus, leaving the cervix in place. A
total hysterectomy removes the whole uterus and cervix, and a
radical hysterectomy removes the whole uterus, along with the tissue
on both sides of the cervix and the upper part of the vagina. This
surgery is done typically when there is cancer present.
Patient Education
Explaining Surgical Approaches for Hysterectomy
Several different surgical approaches are used to perform removal of the
uterus. To determine the most appropriate method, the physician assesses a
number of factors, including the patient’s health history, reason for the surgery,
and personal preference. The nurse can explain the various procedures:
Abdominal hysterectomy: A 5- to 7-inch incision is made in the low abdomen,
just above the pubic hairline. The incision may be in a vertical or horizontal
direction. The uterus is removed through the incision. Recovery time varies
from 4 to 6 weeks.
Vaginal hysterectomy: An incision is made in the vagina, and the uterus is
removed through the vagina.
Laparoscopic hysterectomy: An instrument with a thin, lighted tube and small
camera (laparoscope) is inserted into the abdomen to allow for
visualization of the pelvic organs. Three or four small cuts are made in the
abdomen for insertion of the laparoscope and other instruments. The
uterus is divided into small segments and removed through the incisions.
Laparoscopically assisted vaginal hysterectomy (LAVH): The uterus is
removed through the vagina, and the laparoscope is used to guide the
procedure.
Robotic surgery: The doctor uses a special machine to perform the surgery
as in laparoscopic surgery. This method is most often used when a patient
has cancer or is very obese and vaginal surgery is considered unsafe.
Recovery from vaginal or laparoscopic surgery generally takes

from 3 to 4 weeks. As with any surgical procedure, hysterectomy
may be associated with complications (e.g., infection, venous
thromboembolism, genitourinary and gastrointestinal tract injury,
bleeding, nerve injury, vaginal cuff dehiscence), which vary based on
route of surgery and surgical technique.
Prior to the surgery, a psychological assessment is an essential
component of care. The nurse should ensure that the woman has an
opportunity to consider the personal significance of the loss of her
uterus, discuss misconceptions about the effects of the surgery, and
ensure that she has an adequate support system for postoperative
care and concerns. Recovery from a hysterectomy is a very personal
experience that is shaped by a myriad of factors, such as the
woman’s age, her physical and emotional health, reason for the
surgery, and type of surgery performed. The nurse can help to
empower women facing uterine surgery by creating a therapeutic
environment where the patient feels safe in sharing feelings and
expressing concerns. Other nursing actions to help prepare the
woman for the surgery and promote a healthy recovery include
providing information, engaging the assistance of other health
professionals, and making referrals when appropriate.
OVARIAN TUMORS
The ovary is composed of many different tissue types; growths or
tumors involving the ovary may be of various types. Interestingly,
more than 50 different types of ovarian tumors have been identified.
Two of the most common types of ovarian tumors are follicular cysts
and corpus luteum cysts, which are included in this discussion.
Ovarian cysts affect women of all ages; the vast majority of them
are considered functional, or physiological. Most disappear within a
few weeks without treatment. Ovarian cysts occur most often during
the childbearing years and typically represent a normal process. A
dermoid cyst is an abnormal cyst that usually affects younger
women; it may range in size from 1 cm (less than a half inch) up to
45 cm (17 inches) in diameter. A dermoid cyst is usually a benign
tumor (2% are malignant) sometimes referred to as a mature cystic
teratoma. Originating from a potential germ cell (i.e., capable of
developing into any variety of body cells), the cyst is similar to those
present on skin tissue and can contain fat and occasionally bone,
hair, and cartilage. A dermoid cyst can cause the ovary to twist
(“torsion”) and produce severe abdominal pain.
Follicular Cysts
A follicular cyst is the most common growth that occurs on the ovary.
It develops during the first half of the menstrual cycle, called the
follicular phase. This type of ovarian cyst, termed a functional or
simple cyst, forms when ovulation does not occur. Instead, the
developing dominant follicle continues to grow and evolves into a
large, fluid-filled cyst that contains a high concentration of estrogen.
The follicular cyst can also form from one of the smaller follicles that
failed to regress after another ovarian follicle gained dominance.
Follicular cysts usually produce no symptoms and disappear
spontaneously within a few months. However, approximately one-
fourth of women with follicular cysts report symptoms such as pain or
the sensation of a heavy, achy feeling in the pelvis.
The diagnosis is generally made on the basis of symptoms and
bimanual examination. Ultrasonography may be used to confirm the
findings and rule out pregnancy. Expectant management (“watch and
wait”) and a repeat examination in 6 to 10 weeks is the treatment of
choice unless symptoms worsen. The majority of follicular cysts
resolve after two to three menstrual cycles without intervention. On
occasion, oral contraceptive pills are prescribed to hasten cyst
resolution.
Corpus Luteum Cysts

A corpus luteum cyst forms from the corpus luteum during the
second half, or luteal phase, of the menstrual cycle. The woman with
a corpus luteum cyst may experience menstrual irregularity (e.g.,
delayed menses), although most often, the cyst regresses and
disappears spontaneously within one or two menstrual cycles. The
cyst may, however, fill with fluid or blood and persist on the ovary.
Less commonly, the cyst ruptures and can cause severe abdominal
pain from the associated bleeding. When this occurs, surgical
removal of the cyst may be necessary.
POLYCYSTIC OVARY SYNDROME

Polycystic ovary syndrome, also called Stein-Leventhal syndrome, is
one of the most common endocrine disorders in reproductive-age
women, affecting approximately 6% to 25% of women. The disorder
occurs when an endocrine imbalance results in elevated levels of
estrogen, testosterone, and LH and a decreased secretion of FSH.
Multiple follicular cysts develop on one or both ovaries and produce
excessive amounts of estrogen. Clinical findings associated with
PCOS include obesity, hirsutism, acne, and infertility. Menstrual
irregularity, which occurs in approximately in the majority of women,
may be the first presenting symptom suggestive of the disorder.
Women with this condition often have insulin resistance and are at
an increased risk for developing type 2 diabetes mellitus. There is
also an increased risk for coronary artery disease, hypertension,
cancer (e.g., endometrial, ovarian, breast), and dyslipidemia. PCOS
is often diagnosed during adolescence, and the prevalence of the
disorder in Mexican Americans is twice that of other ethnic groups
Centers for Disease Control and Prevention, 2020b; Setji & Brown,
2014).
Diet, exercise, and weight loss are considered the best first-line
interventions to improve PCOS. An increase in exercise combined
with dietary change has been shown to reduce diabetes risk
comparable to or better than medication. Weight control improves
many aspects of the condition, leading to more regular menstrual
cycles, reduced androgen levels, lowered lipid levels, and better
glucose metabolism. To achieve weight loss, a low-fat, high-fiber diet
with low-glycemic-index carbohydrates is recommended.
Typically, women with PCOS have unique challenges achieving
and maintaining healthy weights. Because they consume less
energy metabolizing their food, they often require a lower-calorie diet
than other women to lose weight. Obese women with PCOS should
follow a hypocaloric diet (500 kcal/day deficit) that reduces the
glycemic load. Reducing alcohol consumption is another way to
decrease caloric intake. Moderate physical activity combined with
muscle-strengthening exercises improves insulin sensitivity and
helps to limit the loss of lean muscle mass. Cognitive behavior
therapy, which involves teaching problem-solving skills and
enhancing and reframing perceptions, may be useful in helping
women with PCOS to overcome the barriers to adopting lifestyle
changes needed to improve health (American College of
Obstetricians and Gynecologists, 2018; Centers for Disease Control
and Prevention, 2020b).
MEDICATION: Enhancing Ovulatory Function
With Insulin Resistance
Owing to the fact that PCOS, one of the most common causes of infertility, is
associated with insulin resistance, the use of insulin-lowering or insulin-
sensitizing therapy may help to improve ovarian function and menstrual
cyclicity. Myo-inositol, a dietary vitamin belonging to the B complex, has been
shown to support and maintain menstrual cyclicity, oocyte quality, and ovulatory
function through its effect on insulin receptor activity. Commercially available by
its brand name Pregnitude, myo-inositol is an oral powder formulation mixed
with water that combines 2 grams of myo-inositol with 200 micrograms of folic
acid. Results from observational and controlled clinical investigations have
shown that myo-inositol, an over-the-counter dietary supplement, improves
ovarian function and ovulation induction in patients with oligomenorrhea or
amenorrhea plus PCOS.
Nurses can counsel women with PCOS about their chronic

disorder and the potential long-term effects on their health. A holistic
approach to care encompasses a variety of lifestyle strategies, such
as diet, exercise, and weight loss along with prescribed medications,
when needed, to achieve good clinical outcomes and a better quality
of life. Referrals for resources including cognitive behavior therapy,
counseling for issues concerning body image and self-esteem, and
support groups and nutritional information may be appropriate as
well. In some settings, an intervention called the group medical visit
(GMV) has been shown to enhance care for women with chronic
diseases such as PCOS. With this care delivery model, patients
receive individualized care and counseling, as well as educational
information and the opportunity to network with other women dealing
with the same problems (American College of Obstetricians and
Gynecologists, 2018; Centers for Disease Control and Prevention,
2020b).
DISEASES OF THE VULVA

The external female genital organs, or vulva, include all visible
structures that extend externally from the mons pubis to the
perineum. The vulvar tissue is richly supplied with sweat and
sebaceous glands, and some areas contain hair follicles as well. The
vulvar region supports a moist environment that contains increased
concentrations of skin bacteria.
Symptoms of vulvovaginal disorders are common, often chronic,
and can significantly interfere with a woman’s sexual function and
sense of well-being. Obtaining a detailed health history is an
essential tool in the patient assessment, and it is important to
remember that systemic conditions such as Crohn’s disease can
cause vulvar symptoms. Vulvar pruritus, or itching, is the most
frequent symptom, and women often delay evaluation because they
self-treat with readily available vaginal preparations. Other
commonly reported symptoms in the vulvar region include a
sensation of burning, the presence of a lump or sore, vaginal
discharge, a rash, and pain. Frequently encountered vulvar
conditions include vaginal infections, Bartholin’s gland abscess,
parasites, molluscum contagiosum, and vulvar warts.
Bartholin’s Gland Abscess

The Bartholin’s glands, also known as the greater vestibular or
vulvovaginal glands, are located deep within the posterior portion of
the vestibule near the posterior vaginal introitus. The vestibule is
essentially an oval-shaped space enclosed by the labia minora. It
contains openings to the urethra and vagina, the Skene’s glands,
and the Bartholin’s glands. This area of a woman’s anatomy is
extremely sensitive to chemical irritants. The Bartholin’s glands
secrete a clear mucus that moistens and lubricates the vagina during
sexual arousal.
Bartholin’s cysts are the most common benign lesions of the vulva.
Obstruction of the Bartholin’s gland duct leads to enlargement and
formation of a cyst. The cyst may cause no symptoms, but if it
enlarges or becomes infected, the woman frequently experiences
pain, dyspareunia, and an awareness of a tender mass in the area.
When symptomatic, incision and drainage provide temporary relief.
Because Bartholin’s cysts tend to recur, a permanent opening for
drainage may be recommended. Rarely, the abscess is caused by
gonorrhea. Bartholin’s abscesses are highly unusual in
postmenopausal women and should be evaluated to rule out
malignancy.
Parasites
Lice or mites may infect the vulva. Intense itching of the skin that
contains hair follicles is characteristic of infestation. Scabies, a
dermatitis caused by the itch mite Sarcoptes scabiei, produces areas
of excoriation composed of scaly papules and insect burrows.
Scabies is transmitted by person-to-person contact or through
infested bedding and clothing. The itching tends to worsen at night.
Scabies spreads on the skin by fingernail contamination. Diagnosis
is made by microscopic examination of skin scrapings to detect the
presence of the mite, its eggs, or its excretions (Scannell, 2020).
Nursing diagnoses for patients with scabies usually focus on
impaired skin integrity related to the presence of invasive parasites
and the development of pruritus and deficient knowledge regarding
the communicable nature of the infestation, possible complications,
therapy, and self-care needs related to a lack of information or
misinterpretation.
Molluscum Contagiosum (Seed Wart)

Molluscum contagiosum is a rash composed of small, dome-shaped
papules with a central crater filled with a cheesy (caseous) material
(Fig. 31-5). The lesions of molluscum contagiosum are caused by a
pox virus. In adults, transmission is primarily sexual; in children,
transmission is nonsexual and via fomites, substances that adhere to
and transmit infection (Venes, 2021).
Vulvar Condylomata
A condyloma (plural: condylomas, condylomata) is a growth that
resembles a wart on the skin or mucous membrane, usually of the
genitals or anus. Vulvar condylomata, also known as warts, genital
warts, and venereal warts, are caused by certain strains of the
human papillomavirus, different from those that produce cervical
lesions. Condylomata can appear as small, thickened growths or
large cauliflower-like masses on the vulva, along the perineum, or in
and around the anus. The benign growths can be treated with
chemicals, cryosurgery, electrosurgery, or laser vaporization. None
of the treatments are fully successful, however, and recurrence is
common. Despite removal of the lesions, surrounding tissues
continue to harbor the human papillomavirus. Condylomata may be
spread by physical contact with an area containing a wart, and the
spread of a wart from one labium to the other by autoinoculation is
possible (Scannell, 2020).
Vulvar Lichen Simplex Chronicus, Lichen Sclerosus, and Lichen

Planus
Lichen simplex chronicus of the vulva is a chronic eczematous
condition characterized by scaling and intense and unrelenting
pruritus. It occurs primarily in mid- to late-adult life and represents an
end-stage response to a wide variety of causative factors including
environmental agents (e.g., heat, excessive sweating, irritation from
clothing) and dermatological disease (e.g., candidiasis, lichen
sclerosus). Lichen simplex chronicus affects quality of life including
sexual and psychological well-being and has been associated with a
number of psychological problems such as sleep disturbances,
obsessive-compulsive disorder, anxiety, and depression. Treatment
involves identification and elimination of the causative
irritant/allergen; nighttime pruritus may be alleviated with oral
amitriptyline, ice, and the topical application of high-potency
corticosteroids.
FIGURE 31-5 Molluscum contagiosum.

Lichen sclerosus, an autoimmune inflammatory disorder of the
skin, primarily affects women in the fifth to sixth decades of life,
although it may occur at any age, including prepuberty. Patients
most often complain of pruritus, burning, dyspareunia, tearing, and
chronic vulvar pain. The skin typically appears thin, crinkled, and
waxy, with porcelain-white papules and plaques—often described as
a “cigarette paper” appearance. Progression of the disease results in
purpura, hyperkeratosis, fissures, erosions, ulceration, scarring and
narrowing of the introitus, fusion of the labia minora, fissures, and
phimosis of the clitoral hood (Fig. 31-6). Treatment involves the
topical application of a high-potency steroid ointment (Fruchter et al,
2017).
Lichen planus, an autoimmune inflammatory mucocutaneous
disorder, affects approximately 1% of women, primarily during the
fifth to sixth decades of life. Symptoms include pruritus, burning,
dyspareunia, postcoital bleeding, and vaginal discharge. Lichen
planus may markedly alter vulvovaginal anatomy, causing loss of the
labia minora, narrowing of the introitus, and obliteration of the
vagina, severely affecting sexual interaction. Initial treatment
involves the topical application of a high-potency steroid ointment;
systemic treatment with an oral corticosteroid and surgical lysis of
vulvovaginal adhesions may be necessary (Fruchter et al, 2017).
The Nurse’s Role in Promoting Vulvar Health

Nurses should be aware of common vulvar irritants and allergens
(Box 31-2) so that they can provide appropriate patient counseling
and offer strategies for promoting and maintaining a healthy vulvar
environment to reduce the risk of irritation and infection. Nurses can
also teach women to wear cotton underwear, keep the vulvar area
clean and dry, avoid douching, and perform monthly vulvar self-
examination.
Patient Education
Performing Vulvar Self-Examination
To prepare for vulvar self-examination, the woman places a flashlight and
mirror within easy reach. She washes her hands, removes clothing from the
waist down, and sits comfortably on the floor or bed, with a pillow support
behind her back. The following steps should then be performed:
1. While bending her knees, she leans backward and allows her knees to fall
slightly apart to expose the genital area. The mirror and flashlight should be
positioned for optimal visualization.
2. External inspection of the genital area includes visualizing the labia, the
clitoris, the urethral meatus, the vaginal opening, and the anal opening. Each
area can be both looked at and touched gently with a finger, beginning with
the mons pubis, which is the area above the vagina around the pubic bone
where the pubic hair is located.
3. Using her fingers, the woman should gently spread the labia and inspect the
vaginal vault. The vaginal walls should be pink and contain small folds or
ridges called rugae.
4. The vaginal discharge should be evaluated at this time as well. Normal
vaginal discharge is clear to cloudy and white, with a slightly acidic odor; it
may be thick or thin, depending on the timing of the examination with regard
to the menstrual cycle.
5. Findings that need to be reported to the health-care provider include the
presence of thickening, ulcers, sores, or growths on the labia or vaginal
walls; an unpleasant odor to the vaginal discharge, and changes in the color
of the vulvar skin, such as whitening or an increase in skin pigmentation.
Sores, redness, abnormal growths, malodorous or excessive vaginal
discharge, and persistent itching may indicate irritation or infection; these
symptoms should also be reported.
Vulvar self-examination should be performed once a month in between
menstrual periods, or any time symptoms such as vulvar itching or pain, pain
on penetration during sex, or vulvar lumps or thickening of the skin are noted
(National Vulvodynia Association, 2021).
FIGURE 31-6 Lichen sclerosus.

BOX 31-2
Common Vulvar Irritants and Allergens

Adult or baby wipes Antibiotics
Antiseptics (e.g., povidone-iodine, hexachlorophene)
Body fluids (e.g., semen, saliva)
Colored or scented toilet paper
Condoms (lubricant or spermicide containing)
Contraceptive creams, jellies, foams, nonoxynol-9, and lubricants
Douches
Dyes
Emollients (e.g., lanolin, jojoba oil, glycerin)
Heat
Laundry detergents, fabric softeners, and dryer sheets
Nickel (from piercings)
Nylon underwear
Rubber products (including latex)
Sanitary products, including tampons and pads
Soaps, bubble baths and salts, shampoos, and conditioners
Tea tree oil
Topical anesthetics (e.g., benzocaine, lidocaine, dibucaine)
Topical antibacterials (e.g., neomycin, bacitracin, polymyxin)
Topical antimycotics (e.g., imidazoles, nystatin)
Topical corticosteroids
Topical medications, including trichloroacetic acid, 5-fluorouracil, and
podofilox or podophyllin
Vaginal hygiene products, including perfumes and deodorants
Sources: American College of Obstetricians and Gynecologists (2008); Krapf &

Goldstein (2012); Lipkin & Kwon (2014).
SUMMARY POINTS
■ Menstrual disorders, such as amenorrhea, irregular bleeding, and
dysmenorrhea, constitute some of the most common reproductive problems in
women.
■ Endometriosis is a chronic condition characterized by the presence of
endometrial glands and tissue outside the uterus.
■ Uterine leiomyomas are the most common solid pelvic tumors in women and
the leading indication for hysterectomy.
■ The acronym PALM-COEIN classifies uterine bleeding abnormalities by
etiology and comprises two separate entities: structural abnormalities and
nonstructural causes of abnormal uterine bleeding.
■ Ovarian cysts affect women of all ages, although they occur most often during
the childbearing years and typically represent a normal process.
■ Polycystic ovary syndrome occurs when an endocrine imbalance results in
elevated levels of estrogen, testosterone, and LH and a decreased secretion
of FSH.
■ Ovarian cancer is the leading cause of gynecological deaths and the fourth
most common cause of cancer deaths in women.
■ In the United States, cancer of the endometrium is the most common
gynecological malignancy, and approximately 70% of all cases are found in
women in the 50 to 69 age group.
■ Nurses can promote vulvar health by teaching women about strategies such
as the avoidance of common vulvar irritants and how to perform vulvar self-
examination.
REFERENCES
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Nonpregnant Patients. Practice Bulletin No. 215.
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Syndrome. Committee Opinion No. 194. https://www.acog.org/clinical/clinical-
guidance/practice-bulletin/articles/2018/06/polycystic-ovary-syndrome
American College of Obstetricians and Gynecologists. (2019). Screening and
Management of Bleeding Disorders in Adolescents With Heavy Menstrual
Bleeding. Committee Opinion No. 785.
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Centers for Disease Control and Prevention. (2020a). Bacterial Vaginosis.
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Crann, S. E., Cunningham, S., Albert, A., Money, D. M., & O’Doherty, K. C. (2018).
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review. International Journal of Women’s Dermatology 3(1): 58–64.
HealthlinkBC. (2019). Boric Acid for Vaginal Yeast Infection.
https://www.healthlinkbc.ca/health-topics/tn9595
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for Menstrual Disorders. https://www.figo.org/figo-committee-menstrual-
disorders
Krapf, J. M., & Goldstein, A. (2012). The vulvar dermatoses. The Female Patient
37(4): 28–33.
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dermatologic disorders. Journal of Obstetric, Gynecologic & Neonatal Nursing
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Matteson, K., Rahn, D., Wheeler, T., Casiano, E., Siddiqui, N., Harvie, H., … &
Sung, V. (2013). Nonsurgical management of heavy menstrual bleeding.
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Manatū Hauora. https://www.health.govt.nz/your-health/conditions-and-
treatments/diseases-and-illnesses/abnormal-vaginal-bleeding
Mira, T. A. A., Buen, M. M., Borges, M. G., Yela, D. A., & Benetti-Pinto, C. L.
(2018). Systematic review and meta-analysis of complementary treatments for
women with symptomatic endometriosis. International Journal of Gynaecology
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Gynaecology and Obstetrics 143(1): 2–9.
Najafi, N., Khalkhali, H., Moghaddam Tabrizi, F., & Zarrin, R. (2018). Major dietary
patterns in relation to menstrual pain: A nested case control study. BMC
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National Health Service. (2018a). Bacterial vaginosis.
https://www.nhs.uk/conditions/bacterial-vaginosis/
National Health Service. (2018b). Keeping your vagina clean and healthy.
https://www.nhs.uk/live-well/sexual-health/keeping-your-vagina-clean-and-
healthy/
National Vulvodynia Association. (2021). Vulvar Self-Examination.
https://www.nva.org/learnpatient/vulvar-self-examination/
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alternatives to antibiotics for UTI prevention? OBG Management 25(2): 17–26.
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of peritoneal endometriosis. American Journal of Obstetrics and Gynecology
40(6): 549–557.
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Davis.
F.A. Davis.
Davis Advantage
CHAPTER 32

Sexually Transmitted Diseases
CONCEPTS
Infection
Sexuality
KEY WORDS
sexually transmitted disease (STD)
sexually transmitted infection (STI)
chlamydia
expedited partner therapy (EPT)
gonorrhea
pelvic inflammatory disease (PID)
syphilis
gummas
trichomoniasis
wet mount
vesicles
hepatitis B virus (HBV)
hepatitis C virus (HCV)
hepatitis D virus (HDV)
chancroid
LEARNING OBJECTIVES

■ Discuss signs and symptoms, modes of transmission, and treatment options
for the most common sexually transmitted diseases (STDs).
■ Identify various safer sex strategies.
■ Describe the nurse’s role in STD counseling and education.
PICO(T) Questions
chapter.
1. Is the (I) incidence of sexually transmitted diseases (O) lower among (P) high
school students who receive education on prevention of STDs than (C)
among high school students who do not receive education on prevention?
2. What are the (O) most important prevention (I) strategies nurses should
teach (P) people at risk of becoming infected with hepatitis B?
INTRODUCTION
This chapter focuses on sexually transmitted diseases (STDs).
Information regarding signs, symptoms, modes of transmission, and
treatment options for various STDs is presented, along with a
discussion of the nurse’s role in promoting reproductive health. STDs
encompass more than 25 infectious organisms that cause
reproductive tract infections that are primarily transmitted by close,
intimate contact. Nurses are perfectly situated to provide evidence-
based, culturally sensitive STD counseling and education that
facilitates understanding of these potentially lethal health threats and
empowers women to make informed choices in their intimate
relationships.
According to the Centers for Disease Control and Prevention
(CDC), an important component of STD health care is using
language patients can understand. In many clinical settings, the
terms sexually transmitted disease and sexually transmitted
infection are used interchangeably. “Sexually transmitted disease”
is the accepted subject heading in the PubMed database, and STD
is also the term used by the CDC. There are, however,
distinguishable differences between and STI and STD. A STI is the
beginning phase in which a pathogen has entered the body and
started replicating but may not cause symptoms. An STD is the
result of an STI and describes the symptoms and changes to the
body that result from the pathogen (Rudderow, 2019).
Stigma associated with an STD can be a barrier to appropriate
diagnosis and treatment. Sexual contact is the most common route
of transmission of an STD, including vaginal, rectal, and oral, as well
as skin-to-skin contact or sharing equipment (sexual toys) in some
instances. STDs can cause short-term emotional and physical
distress as well as serious long-term effects. Potential complications
include fallopian tube blockage with resultant infertility, an increased
risk of ectopic pregnancy, chronic pelvic pain, an increased risk of
liver cancer and serious liver disease, and death. Women suffer
more long-term reproductive consequences from STDs than do men,
and women are more likely than men to acquire an infection from
any single sexual encounter. Unfortunately, owing to the
asymptomatic nature of many STDs, treatment is often delayed, and
this factor increases the likelihood of more serious long-term
consequences.
STDs are a global health problem affecting one in five Americans,
about 68 million people (CDC, 2021). Nurses need to understand the
various modes of transmission of STDs, signs and symptoms for
early identification, and knowledge of treatment and prevention
efforts so that they can provide appropriate care and education to
those impacted.
Several Healthy People 2030 National Health Goals specifically
focus on STDs:
■ Increase the proportion of adolescents who get formal sex
education before age 18.
■ Increase the proportion of sexually active female adolescents and
young women who get screened for chlamydia.
■ Reduce the syphilis rate in females.
■ Reduce pelvic inflammatory disease in female adolescents and
young women.
■ Reduce infections of HPV types prevented by the vaccine in young
adults.
■ Reduce the number of new HIV infections (U.S. Department of
Health and Human Services, 2021).
Optimizing Outcomes
STD Counseling and Screening Across the Lifespan
Nurses can help the nation meet these goals by providing education about
methods of preventing STDs and information about how to recognize the signs
and symptoms of these illnesses. Nurses can design studies and engage in
research to provide evidence-based practice strategies for issues such as
teaching women about safer sex practices, teaching youth about the methods of
transmission of infection and the long-term consequences of the diseases, and
providing ways that health professionals can increase STD awareness in their
practice settings.
Over the past decade, the prevalence of STDs among older adults has risen
steadily. Unfortunately, prevailing societal perceptions often incorrectly view
senior citizens as sexually inactive. In actuality, older adults engage in more
sexual activity than previously believed. It is important that nurses who work
with women across the life span routinely include sexual health assessments
during the physical health evaluation, offer STD information and counseling
when appropriate, and conduct STD screening when indicated.
CHLAMYDIA TRACHOMATIS
Chlamydia trachomatis infection is the most common bacterial STD
in the United States and the leading cause of preventable infertility
and ectopic pregnancy. Other potential complications include pelvic
inflammatory disease (PID) and an increased risk of HIV infection
due to impaired integrity of mucosa. Chlamydia can be transmitted
through unprotected vaginal, anal, or oral contact. The reported rate
of chlamydia infection for women substantially exceeds the rate for
men, primarily due to increased detection of asymptomatic infection
in women through screening. It is estimated that 1 in 10 adolescent
girls tested for chlamydia is infected. Teenage girls tend to have the
highest rates of chlamydial infection. C. trachomatis is widespread
geographically and is highly prevalent among economically
disadvantaged young women (CDC, 2021).
Patient Education
Teaching Patients About STD Prevention
Chlamydia can be transmitted during vaginal, anal, or oral sex and has been
referred to as a “silent” disease because women are often unaware that they
are infected. Nurses can teach patients about strategies to prevent or decrease
the transmission of chlamydia and other STDs: practicing abstinence from
sexual intercourse or sharing a mutually monogamous relationship with a
partner who has been tested and is known to be uninfected and correctly and
consistently using latex condoms, and avoiding condoms lubricated with the
spermicide nonoxynol-9 (N-9), an agent that has been associated with
disruption of the genital epithelium, which may increase the risk for the
transmission of infection (Fantasia, Fontenot, Sutherland, & Harris, 2011).
Signs and symptoms of chlamydia vary depending on the area

that is infected. Many people with active disease will be
asymptomatic; however, symptoms may include abnormal vaginal
bleeding, frequent urination, dysuria, pain during intercourse,
postcoital bleeding, and cervicitis with mucopurulent endocervical
discharge and friability. Infected women who use oral contraceptives
may report breakthrough bleeding. Chlamydia infection of the cervix
causes inflammation that produces microscopic ulcerations, which
may increase the risk for contracting HIV. Symptoms of rectal
infection include rectal pain, discharge, and bleeding (CDC, 2021;
U.S. National Library of Medicine, 2020).
The CDC and the U.S. Preventive Services Task Force (USPSTF)
recommend annual screening for chlamydia in all sexually active
women aged 25 years and younger. Chlamydia infection can be
diagnosed using several different testing methods, such as culture,
direct immunofluorescence, nucleic acid hybridization, and enzyme
immunoassay (EIA), all of which require a pelvic examination to
collect cervical epithelial cells. The nucleic acid amplification test
(NAAT), which can detect chlamydia from a cervical or vaginal swab
(self- or clinician-collected) or urine sample (using a “clean-catch
method”), is considered to be the most sensitive and specific test
(CDC, 2021).
Chlamydia bacterium is susceptible to antibiotics. Recommended
antibiotic regimens for treatment of C. trachomatis include
zithromycin (Zithromax) 1 g orally, given in a single dose (preferred),
or doxycycline (Doxycin) 100 mg orally twice a day for 7 days.
Alternative regimens are erythromycin base (E-Mycin) 500 mg orally
four times a day for 7 days or erythromycin ethylsuccinate (E.E.S.)
800 mg orally four times a day for 7 days or levofloxacin (Levaquin)
500 mg orally once daily for 7 days or ofloxacin (Floxin) 300 mg
orally two times a day for 7 days. The erythromycin-based regimens
are frequently associated with gastrointestinal side effects that can
lead to noncompliance and should be used as a second-line therapy.
Although levofloxacin and ofloxacin are effective treatment
alternatives, these agents are more expensive and offer no
advantage in the dosage regimen. The CDC recommends treating all
sex partners of those who test positive for chlamydia. Coinfection
with C. trachomatis frequently occurs among patients who have
gonococcal infection, so presumptive treatment of such patients for
chlamydia is also recommended. To enhance compliance with
recommended treatment, the CDC urges health-care providers to
dispense medications on site and observe ingestion of the first dose.
Also, persons treated for chlamydia should be instructed to abstain
from sexual intercourse for 7 days after single-dose therapy or until
completion of a 7-day regimen and abstain from sexual intercourse
until all sex partners have been treated (CDC, 2021).
Optimizing Outcomes
Expedited Partner Therapy
Expedited partner therapy (EPT), also known as patient-delivered partner
therapy (PDPT), is the practice of treating sex partner(s) of patients with an
STD without health-care practitioner evaluation or professional prevention
counseling. This approach involves delivering a prescription (written in the
partner’s name) of the medication; informing the partner(s) of the infection; and
providing them with written materials about treatment instructions, appropriate
warnings, and the importance of seeking evaluation for any symptoms
suggestive of complications. EPT, which can decrease reinfection rates (e.g.,
gonorrhea, chlamydia) compared with standard partner referrals for examination
and treatment, is endorsed by many professional organizations including the
American Medical Association, the American Academy of Pediatrics, the
American Bar Association, and the American College of Obstetricians and
Gynecologists. EPT may be prohibited in some states; state-specific information
can be obtained by visiting the CDC Web site at www.cdc.gov/std/ept.
Prevention measures should be part of the assessment and

examination. Patients should be counseled on barrier protective
measures including condoms and dental dams. Patients should also
be instructed that their partner should be treated and should not
have unprotective intercourse with their current partners if
retransmission can occur requiring an additional dose of antibiotics.
NEISSERIA GONORRHOEAE
Gonorrhea is caused by the gram-negative intracellular diplococcal
bacterium Neisseria gonorrhoeae. Approximately 700,000 new
cases of gonorrhea occur each year, making it the second most
commonly reported bacterial STD in the United States (Patel et al,
2018).
Neisseria gonorrhoeae is a gram-negative intracellular diplococci
bacteria that spreads through sexual contact with the penis, vagina,
mouth, or anus from an infected person. The majority of females
infected with vaginal GC are asymptomatic. If symptoms are present,
they are often mild, including dysuria, vaginal discharge, vaginal
bleeding, irregular menses, postcoital bleeding, low backache, and
urinary frequency and dysuria. If symptoms do develop, it often takes
longer for them to begin (5 to 10 days or as long as 60 days). Clinical
signs of a rectal infection can include anal itching, rectal bleeding,
discharge, and/or pain. With pharyngeal transmission, the patient
may have an erythematous, sore throat as well as enlarged lymph
nodes in the neck (CDC, 2021).
The USPSTF recommends targeted screening of young women
(25 years or younger) at increased risk for infection (e.g., women
with previous gonorrhea infection, other STDs, new or multiple sex
partners, and inconsistent condom use; those who engage in
commercial sex work and drug use; women in certain demographic
groups; those living in communities with a high prevalence of
disease); the CDC supports these recommendations. Gonorrhea is
most often tested through government screening programs;
gonorrhea and chlamydia testing are often performed together.
Testing methods include culture, nucleic acid hybridization, and
NAAT. Either cervical swab or urine can be used as the specimen for
NAAT.
The CDC initiated recent changes in 2021, and the recommended
treatment regimen for uncomplicated gonococcal infection of the
cervix is ceftriaxone 500 mg in a single intramuscular dose plus
azithromycin 1 g orally in a single dose or doxycycline 100 mg orally
twice daily for 7 days. If ceftriaxone is not available, the alternative
treatment regimen is cefixime (Suprax) 400 mg in a single oral dose
plus azithromycin 1 g orally in a single dose or doxycycline 100 mg
orally twice daily for 7 days plus a test-of-cure in 1 week. If the
patient has a severe cephalosporin allergy, the recommended
therapy is azithromycin 2 g in a single oral dose plus a test-of-cure in
1 week. Prophylactic treatment for chlamydia is given concurrently
with gonorrhea treatment. Sex partners also require treatment.
Health professionals should consult the CDC’s Web site
(http://www.cdc.gov/std/treatment) for frequent updates regarding
treatment recommendations.
Pelvic inflammatory disease (PID) develops in up to 40% of
untreated women with cervical gonorrhea and may progress to a
systemic infection. Gonorrhea can be transmitted by vaginal, oral, or
anal sex; patients with gonorrhea who have oral sex should be
evaluated and treated for pharyngeal gonorrhea as necessary.
Rectal testing for chlamydia and gonorrhea may improve case
finding for both STDs. Maternal transfer of both gonorrhea and
chlamydia may occur during childbirth, causing neonatal eye
infection (ophthalmia neonatorum), scalp abscess at the site of fetal
monitors, rhinitis, or anorectal infection. All infected individuals who
remain untreated are at risk for disseminated gonococcal infection.
Prevention efforts should focus on safe sex education practices.
Patients should be counseled on having their partner treated as
reinfection can occur.
PELVIC INFLAMMATORY DISEASE (PID)

Pelvic inflammatory disease is an acute infection of the uterus and
fallopian tubes, which, if left untreated or unresolved, results in
scarring, adhesions, or blockage of the fallopian tubes. A number of
organisms (e.g., Escherichia coli, Mycoplasma hominis, Mycoplasma
genitalium) are usually involved, but the most common causative
agents are Chlamydia trachomatis (more than 50%) and Neisseria
gonorrhoeae. In the United States, PID accounts for nearly 180,000
hospitalizations every year, and one in seven reproductive-aged
American women reports having received treatment for PID.
Because PID may be caused by many organisms and encompasses
a wide spectrum of pathological processes, the infection may be
acute, subacute, or chronic. The two greatest reproductive
consequences of acute PID are infertility and tubal pregnancy
resulting from scarring of the fallopian tubes (Marrazzo & Cates,
2011; Soper, 2010).
NURSING INSIGHT
Recognizing Risk Factors for PID
When taking a sexual history, nurses should be aware of certain factors—such
as a history of multiple sexual partners, a new partner in the past 6 months,
lower age at first intercourse, lower economic status, vaginal douching, and
cigarette smoking—that place women at increased risk for PID. Cigarette
smoking may alter the cervical mucus by decreasing estrogen activity, thereby
increasing the risk for bacterial ascent. Age constitutes another risk factor:
Adolescents have the highest incidence of PID of any age group, and 70% of
all cases of PID occur in women under age 25. Women who use intrauterine
devices (IUDs) are also at increased risk if they have more than one sexual
partner or if their partner has other sexual partners, because they are at higher
risk for an STD (Marrazzo & Cates, 2011; Turner, 2012).
Symptoms of PID can range from none to severe abdominal,

uterine, and ovarian pain and tenderness; abnormal bleeding or
discharge; low back pain; nausea; and vomiting. The infected
individual may also experience extreme tenderness when the cervix
is moved on examination (“cervical motion tenderness”; the
“chandelier sign”). Fever, chills, and an elevated white blood cell
(WBC) count and erythrocyte sedimentation rate (ESR) may also be
present, and women with more severe disease may demonstrate
“peritoneal signs” such as shuffling gait associated with painful
ambulation (Holland-Hall, 2012; Soper, 2010).
PID can be treated on an outpatient basis, but hospitalization may
be necessary, depending on the individual case. For patients treated
on an outpatient basis, reexamination within 48 to 72 hours is a
crucial part of therapy. Combined drug therapy is advised, especially
at the initiation of treatment, because the full spectrum of all
organisms involved is often unknown. The CDC provides specific
guidelines for PID treatment
(https://www.cdc.gov/std/pid/treatment.htm).
SYPHILIS
One of the oldest known STDs, syphilis is caused by the bacteria
spirochetal bacterium Treponema pallidum. According to the CDC,
rates of syphilis have increased almost every year since 2001 and
are now at the highest rates since the 1990s (CDC, 2021). This is a
significant public health concern for pregnant women because
untreated syphilis can cause serious fetal anomalies.
Transmission is believed to occur through microscopic abrasions
that can occur during unprotected sexual intercourse (vaginal and
anal). Kissing, biting, and oral-genital sex may also be modes of
transmission but pose a lower risk. Congenital syphilis occurs via
maternal-fetal transmission. Syphilis cannot be contracted through
toilet seats, daily activities, hot tubs, or sharing eating utensils or
clothing. Left untreated, syphilis can cause severe systemic disease
and death. Risk factors for transmission include unsafe sexual
practices, history of STDs, sexual partner who has tested positive for
syphilis, incarceration, working in sex trades, and having sex with
sex workers.
Syphilis is a complex disease with several stages: primary,
secondary, latent, and tertiary. Different manifestations occur
depending on the stage of the disease. In the primary stage,
approximately 10 to 90 days after the initial exposure, a painless
ulcer (chancre) appears at the point of contact, which is usually the
genitalia. These sores may be hidden and often go undetected.
Lymphadenopathy may also be present. The lesion may persist for 4
to 6 weeks and usually resolves on its own without treatment (CDC,
2021; Hollins & Maccini, 2020).
Secondary syphilis occurs 6 weeks to 6 months after the
appearance of the chancre. During this stage, patients may have
fever; a sore throat; weight loss; skin rash on the trunk and
extremities (Fig. 32-1); headache, generalized malaise; mucous
patches on the genitals or in the mouth; lymphadenopathy; hair loss
on the head, eyebrows, and eyelids; and the appearance of moist,
flat warts in the genital and anal areas (condylomata lata). If left
untreated, the symptoms resolve within 2 to 10 weeks.
Approximately one-third of infected individuals will then develop
tertiary syphilis (CDC, 2021; Hollins & Maccini, 2020).
Latent syphilis is defined as having serological proof of infection
without signs or symptoms of the disease. Latent syphilis may be
“early” or “late.” By definition, early latent syphilis is having the
infection for greater than 2 years but without clinical evidence of the
disease. This stage is treated with a single intramuscular injection of
a long-acting penicillin. Late latent syphilis requires three weekly
intramuscular injections of a long-acting penicillin (CDC, 2021).
FIGURE 32-1 Secondary syphilitic rash on chest and palms.
Tertiary syphilis usually occurs 10 years after the initial infection,

although in some cases systemic symptoms may not appear until 30
to 50 years later. This stage is characterized by the formation of
gummas (soft, tumorlike balls of inflammation). Other manifestations
of tertiary syphilis include neuropathic joint disease (degeneration of
joint surfaces), neurosyphilis, and cardiovascular syphilis. It is
estimated that approximately 20% to 30% of untreated individuals
with syphilis develop tertiary syphilis (CDC, 2021; Hollins & Maccini,
2020).
Effective tests and treatments for syphilis were developed during
the 20th century. Microscopy of fluid from the primary or secondary
lesion using darkfield illumination is highly accurate in detecting T.
pallidum. Screening tests include the Rapid Plasma Reagin (RPR),
the Venereal Disease Research Laboratory (VDRL), and the Syphilis
Health Check, a 10-minute test that detects syphilis antibodies in
human whole blood, serum, and plasma. When positive, the
screening tests should be followed up by a more specific treponemal
test. Tests based on monoclonal antibodies and
immunofluorescence, including treponema pallidum
hemagglutination assay (TPHA) and fluorescent treponemal
antibody absorption (FTA-ABS), are more specific tests. Tests based
on ELISAs are also used to confirm results of the simpler screening
tests for syphilis. Neurosyphilis is diagnosed via analysis of the
cerebrospinal fluid. Because there is some evidence that the
incidence of neurosyphilis is higher in HIV patients, some experts
recommend that all HIV-positive individuals have a lumbar puncture
to assess for asymptomatic neurosyphilis (CDC, 2021).
Penicillin, in the form of penicillin G, is the treatment of choice for
syphilis, and the specific regimen and duration depends on the
length of infection. Doxycycline and tetracycline may be used as
alternative treatments for individuals who are allergic to penicillin
(CDC, 2021).
Jarisch-Herxheimer Reactions
The Jarisch-Herxheimer reaction occurs when large quantities of toxins are
released into the body as bacteria, typically spirochetal bacteria, and die during
treatment with antibiotics. Death of the bacteria and the associated release of
endotoxins occurs more quickly than the liver and kidneys can remove the
toxins. Fever, chills, headache, myalgia, and exacerbation of skin lesions are
the hallmarks of this acute reaction. In syphilis, the duration is usually only a few
hours but can persist for much longer with other diseases. Treatment, aimed at
reducing symptoms, centers on the use of analgesics and antipyretics.
PARASITIC STDS
Trichomoniasis
Trichomoniasis, a parasitic STD caused by the protozoan
Trichomonas vaginalis, is the most common curable STD in the
United States. An estimated 7.4 million new cases occur in this
country each year. Prevalence rates differ by gender with higher
rates in women (1.8%) compared to men (0.5%) (Patel et al, 2018).
Risk factors include unsafe multiple sexual partners, previous history
of STDs, history of working in the sex trade or having sex with those
working in the sex trade, recent incarceration, poor hygiene, and
substance abuse. Infection with trichomoniasis causes inflammation
and compromises the integrity of mucosal tissue, which has been
shown to increase the risk of HIV transmission. Although infection
with T. vaginalis may be asymptomatic, it often produces a profuse
frothy gray or yellow-green vaginal discharge with a foul odor.
Erythema, edema, and pruritus of the external genitalia may be
present, and the patient may report dysuria and dyspareunia. Upon
examination, small red ulcerations in the vagina or on the cervix
(“strawberry cervix”) may be observed (Fig. 32-2). The pH of the
vaginal discharge is usually higher (more alkaline) than normal
(CDC, 2021).
Microscopic evaluation is used to confirm trichomoniasis.
Microscopic examination of the vaginal secretions on a wet-prep
reveals the motile trichomonad parasites (Fig. 32-3). T. vaginalis can
also be detected by culture, or by a Trichomonas Rapid Test (results
available in 20 minutes), a DNA hybridization probe test (Affirm
VPIII) (results available in 50 minutes), or a nucleic acid amplification
test (APTIMA TV) (results available in 24 hours) (CDC, 2012b;
Chapin, 2013; Schwebke, 2012, 2013).
FIGURE 32-2 Strawberry cervix.
FIGURE 32-3 Trichomonas vaginalis (arrow) and bacteria in vaginal

smear (x 1,000).
FIGURE 32-4 Pubic louse.
Assessment Tools
The Vaginal Wet Mount
A wet mount, also known as a “wet-prep” or “wet smear,” is frequently used in
the clinical setting to diagnose three of the most common vaginal infections:
bacterial vaginosis, trichomoniasis, and yeast (candidiasis). To perform this
test, the clinician inserts a speculum and uses a moist cotton swab to take a
sample of the discharge from the posterior vaginal fornix. The discharge is then
placed on a glass slide and viewed under a microscope. Alternately, a dry swab
may be used; the sample is placed in 1 mL of saline, mixed, and placed on a
slide, or a drop of saline is placed on a slide and the sample is added to it. The
slide may be warmed briefly (to increase motility of the trichomonads). A cover
slip is then applied, and the slide is promptly viewed.
Metronidazole (Flagyl), the medication of choice for

trichomoniasis, is associated with a 95% cure rate. Metronidazole
may be administered as a single dose—2 g orally—or 500 mg orally
twice daily for 7 days. Alternately, tinidazole (Tindamax) 2 g orally as
a single dose may be used, and this medication is recommended for
the treatment of metronidazole-resistant T. vaginalis infections.
Partners should be simultaneously treated, and patients should be
counseled to use condoms to prevent future infections and to avoid
drinking alcohol until 24 hours after completing metronidazole
therapy and 72 hours (3 days) after completing tinidazole therapy.
Combining these medications with alcohol ingestion may produce a
reaction characterized by flushing, nausea, vomiting, headache, and
abdominal cramps (CDC, 2021).
Pediculosis Pubis
Pediculosis pubis (Pthirus pubis) also known has pubic lice, is an
ectoparasitic blood sucking parasitic insect found on pubic hair or
other coarse hair on the body such as armpits, eyebrows, eyelashes,
armpits, or beards. Pediculosis pubis is often called crabs due to the
crab-like appearance of the insect. Human lice survive by feeding on
human blood. Lice infestations are primarily spread by close person-
to-person contact. Lice move by crawling—they are unable to hop or
fly. The Pthirus pubis (pubic louse, “crab” louse) is very short (1.1 to
1.8 mm in length) and crablike in appearance (Fig. 32-4).
Pubic lice are different from body or head lice and will not go away
without treatment. Symptoms of a pubic lice infection typically
involve itching in the area of the infestation; however, not all people
will have itching. In some cases, the lice or larvae can be seen on
the shaft of the hair follicle or crawling around. Bites from the mites
cause small, flat, blue-grey marks that look like small bruises and
can last for several months, even after treatment. Other symptoms
include bloodstained underwear and, in some cases, inguinal
lymphadenopathy (CDC, 2021; Chu & Scannell, 2020; HealthlinkBC,
2020).
Sexual transmission is common with pediculosis pubis, which
most often affects teenagers and young adults. Rates of pediculosis
pubis have declined over the years due to the increase of pubic hair
removal (Chu & Scannell, 2020). Other methods of transmission
include sharing unwashed clothing or bed linens or towels. Pubic lice
develop in three phases. Nits, or lice eggs, are typically yellow to
white colored with an oval shape. A mature female can lay several
eggs on a single hair which hatch in 6–8 days. A nymph hatches
from the nit egg and must feed on blood to survive. The nymph fully
matures into an adult within 2 to 3 weeks. It is uncommon for pubic
lice to be transmitted by sitting on a toilet seat as they require a
warm human body host to feed from within 1 to 2 days (CDC, 2021;
HealthlinkBC, 2020).
Diagnosing pediculosis pubis is based on the patient’s history, risk
factors, and clinical symptoms. Treatment is typically Permethrin 1%
cream rinse, which is found over the counter. Patients will need to
wash the infected area with soap and water or shampoo and then
apply Permethrin to the affected area. The eye regions must be
avoided. Those with significant infestations may need a second
application may in 1 to 2 weeks when new eggs are likely to hatch or
in 9 to 10 days if lice are still found.
Patient Education
Prevention and Control of Pubic Lice
The nurse counsels infected women about strategies to help prevent and
control the spread of pubic lice. Patients are taught to:
• Machine-wash bedding, towels, and clothes in hot water that the infected
person has been in contact with for the 3 days prior to treatment.
• Dry clothing in a hot dryer.
• Clothing and items that are not washable can be dry-cleaned or sealed in a
plastic bag and stored for 2 weeks.
• Vacuum the home, including mattresses.
• Avoid sharing clothing, bedding, and towels.
• Avoid the use of fumigant sprays or fogs as these products can be toxic if
inhaled or absorbed through the skin.
• Avoid sexual contact until treatment and reevaluation are complete.
• All sex partners from the last month should be treated as well to prevent
reinfections (CDC, 2021; Chu & Scannell, 2020; HealthlinkBC, 2020).
Scabies
Scabies, a dermatitis caused by the itch mite Sarcoptes scabiei,
produces areas of excoriation composed of scaly erythematous
papules and insect burrows. This is from the mite burrowing itself
under the skin and leaving eggs. The infected individual typically
experiences intense itching, especially at night, and a pimplelike skin
rash. Upon examination, scaly papules and insect burrows may be
observed in the interdigital spaces of the hands and flexor areas of
the wrist; in the axillae; and on the waist, feet, ankles, genitals, and
buttocks (Fig. 32-5) as these areas tend to be warmer environments
for the scabies to thrive in (Chu & Scannell, 2020).
Scabies is highly transmittable by person-to-person through close
contact or through infested bedding and clothing. Poor hygiene and
living in overcrowded places have been shown to increase the risk
and rates of scabies (Ong & Vasanwala, 2018). The itching tends to
worsen at night and can cause a secondary bacterial infection.
Diagnosis is made by microscopic examination of skin scrapings to
detect the presence of the mite, its eggs, or its excretions (Venes,
2021).
Diagnosis can be made by visual of the mite or mite eggs and with
the characteristic rash distribution. Providers can also get a skin
scraping to remove the mite from the end of the burrow with a needle
and examine the mite or droppings of a mite under a microscope to
confirm diagnosis (Federal Drug Administration, 2017). Scabicides,
prescription-only products that kill scabies mites, are used to treat
infestations. Permethrin cream 5% is the recommended choice
followed by Crotamition lotion 10% and Sulfer ointment 5% to 10%
(Chu & Scannell, 2020).
Patient Education
Scabies Treatment
Patients must be educated on how to apply the medication creams. Provide
these instructions:
• Thoroughly massage a thin layer of cream all over the skin from your neck
down to your toes (including the soles of your feet).
• Apply cream in all skin folds, such as between the toes and fingers and
around the waist and buttocks.
• Apply the cream up to the scalp or hairline, temples, and forehead.
• Avoid contact with the eyes and flush immediately with water if contact
occurs.
• Leave the permethrin cream on the skin for 8 to 14 hours.
• After 8 to 14 hours, wash off the cream by taking a shower or bath.
• Put on clean clothes.
• After treatment, itching may continue for up to 4 weeks.
• Treat all household members, as individuals may have scabies and not show
symptoms yet and should be treated regardless of symptoms (Federal Drug
Administration, 2017).
VIRAL STDS
Human Papillomavirus (HPV)
Human papillomavirus (HPV) is one of the most common viral STDs.
There are over 200 different types of the HPV virus, divided into two
different categories: low-risk HPV and high-risk HPV. The majority of
types are low-risk and may cause benign genital warts (also called
condylomata acuminata). High-risk HPV has the ability to change
normal cells into cancerous ones. There are about 14 high-risk types
currently known, including two that cause cancer: HPV 16 and HPV
18 (CDC, 2019).
According to the CDC, HPV accounts for the majority of newly
acquired STDs. Although more than 90% of HPV infections are
cleared by the body’s immune system within 2 years and cause no
harm, some infections persist and can potentially lead to serious
disease, including cervical cancer. Approximately one-half of all HPV
genital infections occur in women and men between the ages of 15
and 24 years. The majority of HPV infections are asymptomatic,
unrecognized, or subclinical. Genital HPV infection can cause warty
growths in the vagina or on the vulva, perineum, inner thighs, or anal
area. Warts can also grow outside the genital area including on the
mouth, tongue, throat, and lips (U.S. National Library of Medicine,
2021). The growths can be single or multiple, and they are soft and
fleshy and usually painless. The warts can be large or small, raised
or flat, and sometimes they are cauliflower-shaped (Fig. 32-6) The
warts can take weeks to months to develop after sexual contact with
an infected person. Individuals can also be infected with more than
one type of HPV stain (Gayoski, 2020).
HPV is transmitted most often by skin-to-skin contact from an
infected individual to a noninfected individual. Most of the
transmission of HPV is through sexual contact including penile,
vaginal, anorectal, and oral sex, but transmission does not require
penetration (American Cancer Society, 2019). In addition, the
infected person can be symptom-free and still pass the virus
unknowingly to an uninfected person. Risk factors for genital warts
include:
■ Having multiple sexual partners
■ Becoming sexually active at an early age
■ Using tobacco or alcohol
■ Having a viral infection, such as herpes, along with excessive
emotional stress
■ Being pregnant
■ Having a weakened immune system due to a condition such as
diabetes, pregnancy, HIV/AIDS, or from medicines (U.S. National
Library of Medicine, 2021)
FIGURE 32-5 Scabies.
FIGURE 32-6 Genital HPV infection.

Diagnosis is usually made by visual confirmation of the lesions;
confirmatory biopsy is rarely needed in uncomplicated cases. Biopsy
may be warranted if the patient is immunocompromised, the wart
has an atypical or pigmented appearance, and if the treatment is not
effective or clinical symptoms worsen (CDC, 2021). Genital warts
can be treated; however, many cases resolve spontaneously, and
treatment may not be necessary. In addition the HPV virus can lie
dormant in the body; there isn’t a complete cure and sometimes
despite treatment the warts can remain, reoccur, and at times even
grow in size and number. Treatment for genital warts can consist of a
medicated ointment, cryotherapy, electrodesiccation, or laser surgery
to burn the warts off. Treatment is either patient-administered,
provider-administered, or a combination of both. Treatment options
are often dependent on the goal of treatment, reducing symptoms,
patient preference, area the wart is located, and the size and number
of warts presenting (Centers for Disease Control and Prevention,
2021). Topical patient-administered treatment include imiquimod
cream, podofilox gel or solution 0.5% (Condylox), or sinecatechins
ointment 15%, a green tea extract (Table 32-1).
Provider-administered treatments include trichloroacetic acid
(TCA) or bichloroacetic acid 80% to 90% (BCA). These highly
caustic agents destroy warts by chemical coagulation of proteins.
Providers start by applying to a small area and allowing to dry, which
will then cause the tissue to become a frosted white in color. Caution
is critical in using these treatments due to their low viscosity, which
can easily spread and damage other tissue nearby. If a solution
accidentally gets on healthy tissue, then immediate application of
sodium bicarbonate and washing with soap will help neutralize the
acid and prevent further damage.
Cryotherapy (freezing) is a topical treatment of liquid nitrogen that
destroys warts by thermal-induced cytolysis. Treatment is done
weekly until the warts are ablated. Patients may experience
blistering or pain at the site, and side effects may include scarring,
hypopigmentation, or hyperpigmentation at the area of cryotherapy.
Surgical treatment includes excising and surgical removal of the
warts, CO2 laser removal, and electrosurgery (Centers for Disease
Control and Prevention, 2021).
Typically, the range of treatment is 3 months. When clinician-
administered agents are used, the nurse should stress the
importance of returning for regular treatment (typically within one
week of the first week then periodically depending on the provider)
until the lesions have resolved. Once the warts have responded to
therapy, no special follow-up is necessary. Owing to the risk of
sequelae from cervical cancer, regular Pap tests are crucial for all
women with documented HPV infection. Nurses should also
encourage tobacco cessation to reduce the risk of HPV and
neoplasia. Patients should be instructed about prevention measures
and safe sexual practices of male and female condoms. In general
patients should abstain from sexual activities until treatment is
complete and sex partners should be notified of diagnosis.
TABLE 32-1
Patient-Applied Treatments for Genital Warts
TOPICAL AGENT APPLICATION CAUTIONS
INSTRUCTIONS
Imiquimod • 5% cream should be applied Local inflammatory
once at bedtime, three times reactions, including
a week for up to 16 weeks redness, irritation,
• 3.75% cream should be induration,
applied once at bedtime, but ulceration/erosions,
is applied every night and vesicles might
occur with the use of
imiquimod, and
hypopigmentation
Not to be used for
internal warts
Contraindicated in
pregnancy
Podofilox • Solution should be applied Mild to moderate
using a cotton swab and gel pain or local irritation
with a finger might develop after
• Medication should be treatment
applied to warts twice a day Contraindicated in
for 3 days, followed by 4 pregnancy
days of no therapy
• Can be repeated up to 4
cycles and not to exceed 10
cm2, or .5 mL of medicine
per day
• The first dose should be
demonstrated by a health-
care provider to show the
proper technique and
location of warts to be
treated
Sinecatechins • 15% ointment should be Reactions include
applied three times daily (0.5 erythema,
cm strand of ointment to pruritus/burning,
each wart) using a finger to pain, ulceration,
ensure coverage with a thin edema, induration,
layer of ointment until and vesicular rash
complete clearance of warts Not recommended in
persons who are
• Should not exceed 16 weeks immunocompromised
of use (HIV)
Optimizing Outcomes
HPV Prevention and Vaccination

Strategies for prevention of HPV include sexual abstinence, confining sexual
intimacy to a long-term monogamous relationship, and prophylactic vaccination.
The first HPV vaccines were bivalent vaccines and covered the high-risk
oncological strains HPV 16 and 18. Newer vaccines included a quadrivalent
vaccine which protects against HPV types 6, 11, 16, and 18 and is effective in
preventing HPV related cancers as well as genital warts (Navarro-Illana et al,
2017).
The quadrivalent vaccine Gardasil first became available in 2006 and is
recommended for all females aged 9 to 26 years and for boys aged 11 or 12
years to age 21 years. In late 2014, the FDA approved a 9-valent recombinant
HPV vaccine (Gardasil 9) that also covers HPV types 31, 33, 45, 52, and 58.
These latter five are responsible for roughly one in five cases of cervical cancer.
Gardasil 9, also administered as three intramuscular injections given over 6
months, is approved for use in females aged 9 through 26 and in males aged 9
through 15. Another immunogen, Cervarix, is a bivalent vaccine that protects
against HPV 16 and 18. Available since 2009, Cervarix is licensed for use in
females aged 10 to 25 years. All HPV vaccines are most effective if given
before potential exposure to HPV through sexual contact.
Herpes Simplex Virus (HSV) 1 and 2

Herpes simplex virus 1 and 2 (HSV-1 and HSV-2), also known as
human herpes virus 1 and 2 (HHV-1 and HHV-2), are members of
the herpes virus family Herpesviridae. HSV can be transmitted
sexually and can cause chronic genital and/or oral herpes infections.
Both HSV-1 and HSV-2 are transmitted horizontally during close
contact with an infected person who is shedding virus from the skin,
often in saliva or in genital secretions. Although transmission occurs
most often when lesions are present, viral shedding and
transmission can also occur in the absence of visible sores. HSV-1 is
usually transmitted during childhood via nonsexual contacts. It is
most commonly associated with cold sores on the mouth or face.
Genital HSV-1 may result from oral-genital sexual contact with a
person infected with oral HSV-1 and transmitted to the genital area
of their sexual partner.
HSV-2 is primarily an STD and is associated with genital lesions,
although depending on sexual practices, HSV-1 and HSV-2 are not
exclusively associated with the respective sites. HSV-2 occurs more
frequently in women than in men, which most likely results from the
greater incidence of male-to-female transmission.
Most infected persons have no or only minimal symptoms from
HSV-1 or HSV-2 infection. As a result, genital herpes infections are
transmitted by persons unaware that they have the infection or who
are asymptomatic when transmission occurs. If symptoms develop
during the first (primary infection) HSV-1 or HSV-2 outbreak, they
usually appear within 2 weeks after exposure and can be very
pronounced. Because the body has not had an opportunity to
develop antibodies, symptoms that result from a primary HSV
infection are usually much more severe than with subsequent
outbreaks.
The initial HSV genital infection generally produces flu-like
symptoms including malaise, muscle aches, headaches
accompanied by dysuria, and the appearance of multiple painful
open fluid-filled blister-like ulcers/lesions on the genitals which can
be extremely tender and persist for 2 to 3 weeks (Fig. 32-7). Before
the appearance of the lesions, the patient may experience a period
of prodromal symptoms characterized by skin sensitivity and nerve
pain in the area where the lesions will appear. Reddening of the skin
frequently follows these symptoms. The lesions form pustules and
ulcers that dry up, crust over, and then heal without scarring. The
woman may also experience itching, inguinal tenderness, vulvar
edema, and a heavy watery or purulent vaginal discharge. In some
instances, women with “chronic yeast infections” are experiencing
herpes outbreaks that go undiagnosed because the typical herpetic
lesions are not present (Centers for Disease Control and Prevention,
2021; National Health Service, 2020).
HSV outbreaks can recur after an individual has a primary
infection. The virus will often lie dormant, and outbreaks will occur
during immunocompromised or stressful periods. Typically, recurrent
outbreaks are less severe than the primary infection and usually
involve localized symptoms with less severe lesions that last 5 to 7
days. The prodromal characteristic is notable skin sensitivity, and
nerve pain in the affected area may precede the outbreak of lesions.
Genital tingling sensation is common with recurrence. The virus then
enters a latent stage in the nerves at the base of the spine, only to
reactivate when the patient’s immune system is weakened. The
lesions may occur along any skin surface supplied by that particular
distribution (e.g., vulva, vagina, cervix, urethral meatus, buttocks).
Transmission of the virus is most likely during an active outbreak,
and patients should abstain from sexual contact during this time.
However, viral transmission may occur at any time when the infected
individual is producing and releasing (“shedding”) the virus, and
some individuals shed virus between active outbreaks.
FIGURE 32-7 Herpes vulvovaginitis.
In most situations, a diagnosis of HSV is suspected based on the

patient history and physical examination; however, HSV serological
testing is often the preferred method as it can confirm HSV infection
in the absence of symptoms. Cell culture, polymerase chain reaction
(PCR), or the NAAT are the preferred HSV tests for individuals who
seek medical treatment for genital lesions. The sensitivity of viral
culture testing is low, especially for recurrent lesions (blisters), and
declines rapidly as the lesions begin to heal whereas NAAT testing is
highly reliable. Testing for the presence of HSV antibodies in
capillary blood or serum (i.e., HSV glycoprotein G-specific
antibodies, IgG by immunoblot [HerpeSelect]) is also available for
clinical use.
The goal of treatment for herpes is to hasten healing and reduce
symptoms. Several oral antiviral medications (e.g., acyclovir
[Zovirax], valacyclovir [Valtrex], famciclovir [Famvir]) are available
and may be used for primary or recurrent episodes or as daily
suppressive therapy. The doses of the medications are often the
same but primary episodes typically have a longer course between 7
to 10 days and recurrent episodes 2 to 5 days of treatment. The
medications do not eradicate the infection, nor do they alter
subsequent risk, frequency, or recurrences once the medication has
been stopped. When indicated, acyclovir may be administered
intravenously for 2 to 7 days (followed by oral antiviral therapy to
complete at least 10 days of total therapy) for severe symptoms.
Counseling and education form an essential component of holistic
care for women with herpes infections. Nurses should offer
information about the etiology, signs, symptoms, modes of
transmission, treatment options, and the possibility of suppression
therapy to prevent partner transmission. It is important to advise
women about the times when transmission is most likely and the
need to avoid sexual contact beginning with the onset of prodromal
symptoms until all lesions have healed. Patients should be aware
that the virus can be transmitted even when there are no active
lesions present. During the prodromal phase when symptoms recur,
the virus can spread and be transmitted. Some experts recommend
the consistent use of condoms and dental dams for all individuals
with genital herpes. Nurses can help women explore potential
precipitating factors in the reactivation of the latent herpes virus.
Triggers may include stress, menstruation, febrile illnesses, chronic
illnesses, being immunocompromised, and ultraviolet light. Some
patients find that keeping a personal diary provides insights about
precipitating events for their herpetic outbreaks.
Optimizing Outcomes
Measures to Reduce HSV Discomfort and Outbreaks

For many women, certain comfort measures and dietary changes are useful in
decreasing HSV symptoms and the frequency and severity of HSV outbreaks.
Comfort measures may include taking warm sitz baths with baking soda or
oatmeal; wearing cotton underwear; using a hair dryer (on the cool setting) to
enhance drying of the lesions; applying compresses containing peppermint oil
and clove oil to the lesions; and applying cool, wet, black tea bags or tea tree oil
to the lesions. Oral analgesics including aspirin or ibuprofen may help relieve
pain. Dietary strategies center on consumption of a diet rich in vitamin C, B-
complex vitamins, zinc, and calcium and the daily use of kelp powder and
sunflower seed oil as well as the amino acid l-lysine, which is thought to
suppress the herpes simplex virus. Strategies to help reduce the emotional
symptoms associated with herpes include support groups, relaxation
techniques, self-hypnosis, biofeedback, and individual therapy (e.g.,
psychologist, social worker).
CASE STUDY
Efinanya T.: Painful Vaginal Vesicles
Efinanya T. is a 22-year-old Nigerian graduate student who visits the local
health department because of her concerns over several vaginal “bumps” that
she noticed a few days ago. During the interview, she tells the nurse that she
first noticed a slight soreness in the area, but it had become increasingly more
painful. She has never “had anything like this before.” Efinanya denies vaginal
discharge but has experienced dysuria over the past 2 days. She also has felt
tired and achy. Efinanya is sexually active and uses oral contraceptives for birth
control. She and her boyfriend engage in oral and vaginal sex; upon
questioning, Efinanya remembers that he recently has had a fever blister on his
lip. Her physical examination reveals a temperature of 100.0°F (37.8°C),
positive inguinal nodes, vulvar edema, and the presence of several vesicles
surrounding the vaginal introitus.
1. What is the likely diagnosis?

2. What treatment may be prescribed for Efinanya?
3. What should the nurse teach Efinanya about this medication?
4. What else should the nurse teach Efinanya about herpes simplex virus?
HIV/AIDS
In the years since acute HIV infection was first described, research
has identified the cellular mechanisms that accompany its clinical
presentation. HIV most commonly enters the host through
percutaneous or genital routes. Once the virus has penetrated the
mucosal epithelium, it infects macrophages, CD4+ T cells, and
dendritic cells and spreads to the systemic lymph nodes within 2
days after infection. Within 3 days, it is detectable in the plasma.
Plasma viremia then results in dissemination to various body organs,
including the brain and spleen.
Infection with HIV leads to a progressive disease that results in
AIDS. The AIDS epidemic has in some way touched everyone’s life,
and the health profession has been affected profoundly. However,
many individuals living in the United States remain ignorant of the
fact that HIV and AIDS affects men, women, and children and has
reached epidemic proportions in many areas.
In 2019, 38 million people were infected with HIV globally
(UNAIDS, 2021). In the United States, more and more young people,
especially women, are contracting HIV. Individuals between the ages
of 13 and 24 represent more than one-fourth of new HIV infections
each year, and most of them are unaware they are infected,
according to a Vital Signs report from the CDC.
Risk Factors
Lifestyle behaviors that place a woman at risk for contracting HIV are
listed in Box 32-1. When obtaining the patient history, it is important
to routinely inquire about symptoms that may be associated with HIV.
Although primary HIV infection is typically asymptomatic, women
may describe nonspecific flu-like discomforts such as fever,
headache, night sweats, malaise, muscle aches, nausea, diarrhea,
weight loss, sore throat, skin rash, and lymphadenopathy.
A number of socioeconomic factors also affect HIV risk. Poverty,
for example, can limit access to health care, HIV testing, and
medications that can lower serum HIV levels and help prevent
transmission. Also, individuals who cannot afford basic necessities
may be confronted with circumstances that increase their HIV risk.
Discrimination, and stigma, may discourage individuals from seeking
testing, prevention, and treatment services. As the prevalence of HIV
and other STDs in a community increases, so does an individual’s
risk of infection with each sexual encounter, especially if, within
those communities, people select partners who are from the same
ethnicity. In any community, higher rates of undiagnosed/untreated
STDs can increase the risk of both acquiring and transmitting HIV,
and higher rates of incarceration among men can disrupt social and
sexual networks and decrease the number of available partners for
women, fueling the spread of HIV.
BOX 32-1
Risk Factors for HIV Infection

• Current or past history of drug use, especially IV drug use
• Engaging in unsafe sexual practices
• History of working in the sex trade
• History of intercourse with individuals working in the sex trade
• Frequent sexual intercourse with multiple partners
• Engaging in sexual intercourse under the influence of drugs
• Engaging in sexual intercourse with men who also have sex with men
• Residing or having intercourse with someone who from an area with a high
prevalence of HIV infection (e.g., rural South and Northeast United States, or
South Africa)
• Having received a blood transfusion or blood products before 1985
Detection, Testing, and Documentation

Detecting HIV is a primary step in prevention of the virus. Currently it
is estimated that 15% of people who are HIV positive do not know
their status, and this group of individuals is believed to cause 40% of
transmission of the virus to uninfected individuals (USPSTF, 2019).
The CDC recommends opt-out HIV testing for all patients in all
health-care settings, including pregnant women. Opt-out testing is
defined as performing HIV screening after notifying the patient that
the test will be performed. The patient may elect to decline or defer
testing. Assent is inferred unless the patient declines testing. Studies
show that the opt-out approach increases the testing rates among
pregnant women (thereby increasing the number of pregnant women
who know their HIV status), increases the number of HIV-infected
women who are offered treatment, and reduces maternal HIV
transmission. Consent for HIV screening must be obtained verbally
in all states with an opt-out option for those who do not wish to be
tested. Testing procedures for HIV have often been debated with
disagreement over the years. Initially, HIV testing required written
consent for all patients to be informed that the test was being
performed, and this testing needed to be coupled with pre- and post-
test counseling as dictated by law. Laws varied by state, but this was
the primary trend in most states in the 1980s and 1990s. Changes
have occurred in most states since then, and the current standards
generally include verbal consent and an opt-out approach for those
who do not wish to be tested (Bayer, Philbin & Remien, 2017).
The American College of Obstetricians and Gynecologists (ACOG)
supports routine screening for women aged 19 to 64 years and
targeted screening for women with risk factors outside of that age
range (e.g., sexually active adolescents younger than 19 years).
ACOG recommends a combination of testing, education, and brief
behavioral interventions to reduce the rate of HIV infection.
Additional approaches include early recognition of positive HIV
testing results, safe sex practices, and training of office personnel in
risk reduction interventions (American College of Obstetricians and
Gynecologists, 2017). The U.S. Preventive Services Task Force
published a recommendation that clinicians screen for HIV infection
in adolescents and adults aged 15 to 65 years (U.S. Preventative
Services Task Force, 2019). Younger adolescents and older adults
who are at increased risk should also be screened. The latest
guidelines are aimed at improving access to HIV testing across the
country and increasing the number of individuals who are tested
each year. It is estimated that up to 25% of persons infected with HIV
are unaware of their status, and universal testing may identify more
of them (Centers for Disease Control and Prevention, 2021).
Diagnostic Tools
HIV Testing Recommendations
Patients in all health-care settings:

• Perform HIV screening on every patient after informing the patient that testing
will be performed unless the patient declines (opt-out testing).
• Screen patients at highest risk for HIV at least annually.
• General consent for medical care should be sufficient to encompass consent
for HIV testing; no separate written consent should be required.
• Prevention counseling should not be required with HIV testing.
Pregnant women:
• Include HIV screen in routine prenatal testing for all pregnant women.
• Screening should be on an opt-out basis.
• General consent for medical care should be sufficient to encompass consent
for HIV testing; no separate written consent should be required.
• Repeat HIV testing in the third trimester is recommended.
It is important for the nurse to assess the patient’s level of understanding to
ensure that she is aware of the legal, emotional, and medical implications of a
positive or negative HIV test before she takes the test. Pregnancy is not
encouraged for women who are HIV positive; contraceptive counseling should be
offered to HIV-positive women who do not desire pregnancy. Post-test counseling
centers on telling the patient her test results, explaining the meaning of the
results, and reinforcing infection prevention measures. Women should be advised
that if they have been exposed in the past 6 months, they should be retested. All
pre- and post-test counseling should be documented on the patient’s chart (U.S.
Preventative Services Task Force, 2019).
If the HIV test results are to be placed on the patient’s medical record, they are
then available to everyone who accesses the chart. The patient must be advised
of this policy before testing. Health-care facilities must have policies in place to
safeguard patient information from inadvertent or inappropriate breaches of
confidentiality. In some clinical settings, HIV-related information is maintained in a
separate chart and a code is assigned for HIV test results. In other facilities, HIV-
related information is removed from the medical record before it is released.
Federal regulations set forth in the Health Insurance Portability and Accountability
Act (HIPAA) also provide specific rules for what information may be shared with
other practitioners and agencies with and without an individual’s permission.
Results of HIV testing may need to be recorded and stored in a certain way. It is
incumbent upon nurses to be familiar with the legal requirements that exist in the
particular practice setting. Also, many states require reporting when HIV is
detected; state-specific information is available at
https://www.cdc.gov/hiv/policies/law/states/index.html.
HIV infection is usually diagnosed via the HIV-1 and HIV-2

antibody tests. A schema for HIV screening in women is presented in
Figure 32-8. Antibody testing is first performed with a sensitive
screening test such as the enzyme-linked immunoassay (ELISA)
(also known as EIA), which detects serum antibodies to HIV.
Reactive screening tests are then confirmed by an additional test
such as the Western blot or, less commonly, an immunofluorescence
assay (IFA). If a positive antibody test is confirmed by a
supplemental test, the woman is infected with HIV and is capable of
infecting others. These diagnostic tests are very reliable; false-
positive and false-negative results are rare. In general,
seroconversion for HIV in adolescents and adults occurs from 6 to
12 weeks after transmission of the virus; HIV antibodies are
detectable in at least 95% of patients within 3 months after infection.
FIGURE 32-8 Screening for HIV in women.
Methods of rapid testing for HIV antibodies use a blood sample

obtained by finger stick, venipuncture, or an oral fluid sample. The
rapid tests can help to reduce unrecognized infections by improving
access to testing in both clinical and non-clinical settings and
increase the proportion of those tested who learn their results. Rapid
testing facilitates patients receiving their test results the same day,
usually at the encounter where the test specimen was collected. Like
the conventional HIV EIAs, the rapid HIV tests are screening tests
that require confirmation if reactive. Although false negatives are
rare, they may occur in an individual who has been acutely infected
but who has not yet developed HIV antibodies. All rapid tests are
interpreted visually and require no instrumentation.
Patients who are reluctant to visit a care provider for testing can
purchase a home collection kit at a pharmacy and collect their own
finger-prick blood sample. The sample is then mailed to a laboratory
and the patient may call for anonymous results and telephone
counseling a few days later. An FDA-approved over-the-counter
rapid HIV test kit for home use is also available. Individuals can
perform this test at home by swabbing the upper and lower gums
inside the mouth to collect an oral fluid sample. After placing the
sample into the vial, the test results are available within 20 to 40
minutes (Marrazzo & Cates, 2011).
Currently, no cure is available for HIV. Current standard of care for
HIV is highly active antiretroviral therapy (HAART), a combination of
oral antiretroviral agents that inhibit different targets of the virus. The
use of antiretroviral agents has been demonstrated to be effective in
maintaining the health of HIV-positive women and in reducing or
preventing the perinatal transmission of the virus. The primary goals
of antiretrovirus therapy are to improve and/or preserve immune
function and to reduce HIV-associated morbidity and mortality.
Antiretrovirals reduce the amount of HIV the body generates,
allowing the immune system to be restored, and reducing or
preventing the risk of HIV transmission (Atkin et al, 2019).
Information and current guidelines about management are available
at the CDC AIDS Prevention hotline (1-800-CDC-INFO [232-4636])
and at its Web site, http://www.cdc.gov/hiv/.
Special Concerns for HIV-Positive Women

Women who are HIV positive may experience a number of
psychosocial issues. They are often primary caregivers who bear the
burden of responsibility for the care of their children. The illness
presents major challenges in keeping appointments, receiving
adequate rest, and complying with medication regimens. Other
immediate needs may involve housing and financial difficulties, and
in many situations, other family members are infected as well.
Gynecological problems are also a major concern. Owing to the
immunocompromised state, vulvovaginal candidiasis, genital warts
caused by HPV, and genital herpes lesions are more common and
more severe in HIV-infected women. Menstrual problems such as
heavy bleeding may require hormonal intervention to address the
anemia and lessen the discomfort. However, because the
relationship between HIV and menstrual disruption is unclear, all
menstrual irregularities should be investigated.
HEPATITIS
Hepatitis is the leading cause of liver cancer and the most common
reason for liver transplant. In the United States, an estimated 1.4
million individuals are living with chronic HBV and 3.2 million persons
are living with chronic HCV. Many are unaware that they are
infected. Although there are many different forms of hepatitis, only
hepatitis B and C are bloodborne viral infections that can be
transmitted through sexual contact (Centers for Disease Control and
Prevention, 2020).
Hepatitis B Virus (HBV)

Each year, thousands of Americans die of complications resulting
from HBV infection. The rate of new HBV infections has declined by
approximately 82% since 1991, when a national strategy was
initiated to eliminate HBV infection in the United States; the decline
has been greatest among children born since 1991, when routine
vaccination of children was first implemented (Centers for Disease
Control and Prevention, 2020).
Hepatitis B virus is a species of the genus Orthohepadnavirus,
which is a part of the Hepadnaviridae family of viruses. This virus
causes the disease hepatitis B. The incubation period from the time
of exposure to the onset of symptoms is 3 to 6 months. HBV is found
in highest concentrations in blood and in lower concentrations in
other body fluids such as semen, vaginal secretions, and wound
exudates. Although heterosexual intercourse is the predominant
mode of transmission, HBV may also be spread through blood-to-
blood contact. Blood-to-blood contact can occur through the sharing
of razors, toothbrushes, and manicure tools, as well as through
contaminated instruments used for dental procedures, tattooing, and
body piercing. Vertical transmission occurs when a pregnant woman
passes the virus to her fetus. HBV is not spread through food or
water, sharing eating utensils, breastfeeding, hugging, kissing, hand
holding, coughing, or sneezing (Centers for Disease Control and
Prevention, 2020).
Optimizing Outcomes
Identifying Populations at Increased Risk for HBV

Nurses should be aware of certain factors that place men, women, children, and
intimate partners at increased risk for HBV. Taking a detailed patient history can
help nurses to identify these individuals, who include:
• Infants born to infected mothers
• Sex partners of infected persons
• Sexually active persons who are not in a long-term (greater than 6 months)
mutually monogamous relationship
• Men who have sex with men or sex workers
• Injection drug users
• Household contacts of persons with chronic HBV infection
• Health-care and public safety workers at risk for occupational exposure to
blood or blood-contaminated body fluids
• Hemodialysis patients
• Residents and staff of facilities for developmentally disabled persons
• Travelers to countries with intermediate or high prevalence of HBV infection
On average, symptoms appear from 60 to 150 days after exposure

to HBV and last for several weeks and include:
■ Fever
■ Fatigue
■ Nausea
■ Vomiting
■ Abdominal pain
■ Dark urine
■ Clay-colored bowel movements
■ Joint pain
■ Jaundice (Centers for Disease Control and Prevention, 2020)
Acute HBV infection ranges from asymptomatic or mild disease to
fulminate hepatitis (rare). The disease is more severe among older
adults (older than 60 years). The risk for chronic infection varies
according to the age at infection and is greatest among young
children: Approximately 90% of infants and 25% to 50% of children
(aged 1–5 years) will remain chronically infected with HBV. The vast
majority (more than 95%) of adults with HBV infection recover
completely and do not become chronically infected. Approximately
25% of those who become chronically infected during childhood and
15% of those who become chronically infected after childhood die
prematurely from cirrhosis or liver cancer, and the majority remain
asymptomatic until the onset of cirrhosis or end-stage liver disease.
In the United States, chronic HBV infection results in an estimated
2,000 to 4,000 deaths each year (CDC, 2012a). Nearly 90% of
individuals living in the United States with chronic HBV infection are
immigrants born in areas (e.g., Africa, Asia, Caribbean [Haiti,
Jamaica, Dominica, St. Lucia], South America) where the virus
prevalence is greater than 2% (Tarrant, Block, & McMahon, 2013).
Individuals at high risk for contracting HBV should be screened on
a regular basis. The USPSTF recommends that all women should be
screened for HBV at the first prenatal visit, regardless of whether
they have been tested previously, and screening should be repeated
later in the pregnancy for women with high-risk behaviors. No routine
screening is recommended for the general population. Testing for
HBV is complex. There are a number of different markers identified
in a blood test, some of which indicate active infection, chronic
carrier state, or past infection (ACOG, 2011b; CDC, 2012a; USPSTF,
2012).
Vaccines for Hepatitis B Prevention
Two single-antigen vaccines (Engerix-B and Recombivax HB) and three
combination vaccines are licensed in the United States. The combination
vaccines include the following: Comvax (combined hepatitis B-Haemophilus
influenzae type b [Hib])—cannot be administered at birth, before age 6 weeks,
or after age 71 months); Pediarix (combined hepatitis B, diphtheria, tetanus,
acellular pertussis [DtaP], and inactivated poliovirus [IPV] vaccine)—cannot be
administered at birth, before age 6 weeks, or after age 7 years; and Twinrix
(combined hepatitis A and hepatitis B vaccine—recommended for persons
aged 18+ years who are at increased risk for both HAV and HBV). The
vaccination schedule most often used for children and adults is three
intramuscular injections; the second and third doses administered 1 and 6
months after the first dose. After a person has been exposed to HBV,
appropriate prophylaxis (i.e., hepatitis B vaccine), given as soon as possible
but preferably within 24 hours, can effectively prevent infection. Although
persons who have already been infected with HBV will receive no benefit from
vaccination, there is no risk to a previously infected person who receives the
vaccination (CDC, 2012a).
The CDC Advisory Committee on Immunization Practices has

published recommendations for hepatitis B vaccination. At-risk
individuals who should receive HBV vaccination are presented in
Box 32-2. The CDC Advisory Committee has also determined that
adults who receive care in certain evaluation and treatment settings
should also receive HBV vaccination (Box 32-3).
There is no specific therapy for acute hepatitis B infection;
treatment is supportive. Several antiviral drugs (adefovir dipivoxil
[Preveon, Hepsera], interferon alfa-2b [PEG-Intron], pegylated
interferon alfa 2a [Pegasys], lamivudine [Epivir], entecavir
[Baraclude], telbivudine [Tyzeka]) are used for treatment of chronic
infection. Individuals with chronic HBV infection require medical
evaluation and regular monitoring to determine whether the disease
is progressing and to identify liver damage or hepatocellular
carcinoma (cancer of the liver) (CDC, 2012a; Rustgi, Carriero,
Bachtold, & Zeldin, 2010).
Once a person has received a diagnosis of HBV, the nurse should
stress the importance of HBV screening for close family members,
household contacts, and sexual partners. Uninfected close family
members, household contacts, and sexual partners should then be
vaccinated, and the infected individual provided with disease-
management information and referral to a specialist (Tarrant et al,
2013).
Hepatitis C Virus (HCV)

Hepatitis C (Flaviviridae hepacivirus) is a small, enveloped, single-
stranded RNA virus. Largely unknown to the American public,
hepatitis C virus (HCV) infection is the most common chronic
bloodborne infection in the United States. According to the CDC
(2012b), approximately 3.2 million persons are chronically infected.
Previously known as “non-A, non-B hepatitis,” up to 85% of
individuals infected with HCV will progress to chronic viral hepatitis.
There are six genotypes of the virus; genotype 1, the most difficult to
treat, makes up approximately 75% of the HCV population in the
United States (Page, 2012; Rapsilber, 2012).
BOX 32-2
Individuals Who Should Be Vaccinated Against

Hepatitis B
• All infants, beginning at birth
• All children aged less than 19 years who have not been vaccinated previously
• Susceptible sex partners of hepatitis B surface antigen (HbsAg)—positive
persons
• Sexually active persons who are not in a long-term, mutually monogamous
relationship (e.g., more than one sex partner during the previous 6 months)
• Persons seeking evaluation or treatment for an STD
• Men who have sex with men
• Injection drug users
• Susceptible household contacts of HbsAg-positive persons
• Health-care and public safety workers at risk for exposure to blood or blood-
contaminated body fluids
• Persons with end-stage renal disease, including predialysis, hemodialysis,
peritoneal dialysis, and home dialysis patients
• Residents and staff of facilities for developmentally disabled persons
• Travelers to regions with intermediate or high rates of endemic HBV infection
• Persons with chronic liver disease
PERSONS WITH HIV INFECTION
• Unvaccinated adults with diabetes mellitus who are aged 19 through 59 years
(discretion of clinicians for unvaccinated adults with diabetes mellitus who are
aged older than 60 years)
• All other persons seeking protection from HBV infection—acknowledgment of
a specific risk factor is not a requirement for vaccination
Source: CDC (2012a).
BOX 32-3
Settings Where Hepatitis B Vaccination Should

Be Administered to All Adults Who Receive
Care
• STD treatment facilities
• HIV testing and treatment facilities
• Facilities providing drug-abuse treatment and prevention services
• Health-care settings targeting services to injection drug users
• Correctional facilities
• Health-care settings targeting services to men who have sex with men
• Chronic hemodialysis facilities and end-stage renal disease programs
• Institutions and nonresidential day-care facilities for developmentally disabled
persons
Source: CDC (2012a).

HCV is primarily spread through blood-to-blood contact and less
efficiently through semen, saliva, or urine. As with HBV, transmission
of HCV can potentially occur through blood contact with shared
needles, razors, and toothbrushes. Persons at risk for HCV include
those with STDs such as hepatitis B and HIV and those with multiple
sex partners, a history of blood transfusions, or a history of IV drug
use. Currently, no vaccine for HCV infection is available (CDC,
2012a).
The average time period from exposure to symptom onset (if any)
is 4 to 12 weeks and symptoms may include:
■ Fever
■ Fatigue
■ Dark urine
■ Clay-colored stool
■ Abdominal pain
■ Nausea
■ Vomiting
■ Joint pain
■ Jaundice (Centers for Disease Control and Prevention, 2020)
Hepatitis C causes tissue inflammation, which results in hepatic
fibrosis, which leads to scarring. The scarring adversely affects liver
function, leading to the development of cirrhosis, which eventually
leads to liver failure and transplant. Of every 100 persons infected
with HCV, approximately 75 to 85 will develop chronic infection; 60 to
70 will develop chronic liver disease; 5 to 20 will develop cirrhosis
over a period of 20 to 30 years; and 1 to 5 will die of the
consequences of chronic infection (e.g., liver cancer [hepatocellular
carcinoma] or cirrhosis). Chronic HCV infection, the leading
indication for liver transplantation in this country, accounts for more
than thousands of deaths in the United States each year (Centers for
Disease Control and Prevention, 2020).
According to the CDC, certain individuals and populations should
be tested for HCV infection (Box 32-4). Blood tests that may be
performed to test for HCV infection include screening tests for
antibody to HCV (e.g., EIA, enhanced chemiluminescence
immunoassay [CIA], recombinant immunoblot assay [RIBA]),
qualitative tests to detect the presence or absence of the virus, and
quantitative tests to detect the amount of virus.
Following diagnosis, HCV-infected patients should be evaluated
for the presence of chronic liver disease and determination of the
need for hepatitis B vaccination. Combination therapy with pegylated
interferon and ribavirin is the treatment of choice for individuals with
chronic hepatitis C. Success rates are improved with the addition of
polymerase and protease inhibitors to standard pegylated
interferon/ribavirin combination therapy. The goal of therapy is to halt
the progression of fibrosis and to prevent the development of
cirrhosis by eradicating the virus.
BOX 32-4
Testing for HCV Infection

The CDC (2012a) recommends that the following individuals are at increased
risk for HCV infection and should undergo testing:
• Persons born from 1945 through 1965
• Persons who have ever injected illegal drugs, including those who injected
only once many years ago
• Recipients of clotting factor concentrates made before 1987
• Recipients of blood transfusions or solid organ transplants before July 1992
• Patients who have ever received long-term hemodialysis treatment
• Persons with known exposures to HCV (e.g., health-care workers after needle
sticks involving HCV-positive blood, recipients of blood or organs from a
donor who later tested HCV positive)
• All persons with HIV infection
• Patients with signs or symptoms of liver disease (e.g., abnormal liver enzyme
tests)
• Children born to HCV-positive mothers (to avoid detecting maternal antibody,
testing should not be performed prior to 18 months of age)
Patient Education
Holistic Nursing Care for Women With Chronic Hepatitis
Nurses can empower women with chronic hepatitis infection by providing
education and counseling about strategies to optimize health, reduce the
transmission of infection, and communicate concerns with intimate sexual
partners. Referrals to local resources such as professional counselors and peer
support groups may also be of benefit. Nurses can teach women about the
importance of maintaining a high level of personal hygiene with measures such
as performing strict hand washing after toileting and ensuring the careful
disposal of all tampons, sanitary pads, and bandages. Patients can also be
taught to avoid sharing razor blades, toothbrushes, needles, and manicure
implements and to promptly clean blood spills with soap and water. Non-HBV-
vaccinated male sexual partners should consistently use latex condoms.
Nutritional strategies may include the consumption of a low-protein, low-fat
diet; avoidance of protein or amino acid supplements; the use of an antioxidant
formula vitamin supplement; and the avoidance of alcohol and tobacco.
Patients are also taught about medication side effects (e.g., fatigue, headache,
gastrointestinal symptoms, rash, and hematological symptoms [anemia,
neutropenia, thrombocytopenia]) and strategies for coping with them (e.g.,
hydration, energy-conservation, skin moisturizers, antiemetics, NSAIDs) and
advised to avoid medications that are hepatotoxic (e.g., Tylenol).
Hepatitis D Virus (HDV)

Hepatitis D virus (HDV), also known as “delta hepatitis,” is a single-
stranded circular RNA molecule with some double-stranded
attachments. HDV infection can only occur in a person already
infected with HBV; a person can be infected by HBV and HDV
simultaneously or by HBV first. Infection with HDV is clinically
indistinguishable from other forms of hepatitis. After exposure, the
incubation period is 21 to 45 days. Up to 90% of cases of HDV are
asymptomatic, but when present, symptoms include jaundice,
fatigue, abdominal pain, confusion, pruritus, anorexia, nausea,
vomiting, and joint pain. Chronic hepatitis D, a long-term liver
infection, is possible (Hepatitis Foundation International, 2013).
Serum testing is complex and includes assays for serum HDAg,
serum HDV RNA, anti-HDV antibody, and tissue markers for HDV
infection. Transmission of HDV occurs through body fluids, including
blood, semen, vaginal fluids, and saliva. Perinatal transmission is
rare. Nurses can teach women to reduce their risk of contracting
HDV through the avoidance of exposure to infected blood,
contaminated needles, and an infected person’s personal items such
as toothbrushes, razors, and nail clippers, and the consistent
practice of safer-sex strategies (e.g., latex condoms during vaginal,
anal, and oral sex). Women may also wish to consider vaccination
against hepatitis B. Interferon alfa-2b treatments may be of benefit to
a small proportion of infected individuals (Hepatitis Foundation
International, 2013).
CHANCROID
Caused by the gram-negative streptobacillus Haemophilus ducreyi,
infection with chancroid begins with a small bump (usually on the
labia majora) that quickly develops into a painful ulcer with a base
that is covered with a gray or yellow-gray material. Symptoms
include dysuria and dyspareunia. Inguinal adenopathy is present in
approximately one-third of infected individuals. The diagnosis is
made via special culture media. Treatment consists of a single oral
dose (1 g) of azithromycin (Zithromax) or a single intramuscular dose
(250 mg) of ceftriaxone (Rocephin) or oral ciprofloxacin (Cipro) (500
mg bid) for 3 days or oral erythromycin base (E-Mycin, E.E.S.) (500
mg tid) for 7 days (CDC, 2011).
THE NURSE’S ROLE IN FOSTERING

REPRODUCTIVE HEALTH THROUGH STD
EDUCATION AND COUNSELING
When educating women about STDs, nurses should include basic
information along with sexual decision-making skills. When dealing
with adolescents, it is often helpful to discuss basic communication
skills needed to negotiate in a relationship and how to operate from
an internal value system rather than submit to peer pressure.
Educating women about the workings of their bodies and
encouraging them to be active participants in their own health care
enhance their personal control over their reproductive health. Nurses
can empower women of all ages by providing them with specific
strategies for making safe choices in their intimate relationships.
When appropriate, teaching about strategies for “safer sex” provides
guidance and serves to foster wellness and promote reproductive
health (Box 32-5). During STD counseling, the nurse can emphasize
that condoms offer the best protection against the transmission of
disease and stress that intimate sexual contact should be avoided if
the person or partner has any sore areas or visible lesions (Marrazzo
& Cates, 2011; Matkins, 2013).
BOX 32-5
Safer Sex Strategies for Sexual Intimacy and

HIV and STD Prevention
STRATEGIES CONSIDERED TO BE SAFE
• Sexual fantasies
• Massage
• Hugging
• Body rubbing
• Dry kissing
• Masturbation without contact with the partner’s semen or vaginal secretions
• Erotic conversation, books, movies, videos, or DVDs
• Eroticizing feet, fingers, buttocks, abdomen, ears, or other body parts
• All sexual activities when both partners are monogamous and known by
testing to be free of HIV and other STDs
STRATEGIES WITH A LOW RISK, CONSIDERED TO BE POSSIBLY SAFE
• Wet kissing with no broken skin, cracked lips, or damaged mouth tissue
• Hand-to-genital touching or mutual masturbation
• Vaginal or anal intercourse using latex or plastic condom
• Oral sex on a woman using a latex or plastic barrier, such as a female
condom, dental dam, or modified male condom (especially if the woman does
not have a vaginal infection with discharge and is not menstruating)
• Oral sex on a man using a latex or plastic condom
• All sexual activities when both partners agree to a monogamous relationship
and trust each other
STRATEGIES CONSIDERED UNSAFE IN THE ABSENCE OF HIV TESTING
AND TRUST AND MONOGAMY
• Blood contact of any kind, including menstrual blood
• Any vaginal or anal intercourse without a latex or plastic condom
• Oral sex on a woman without a latex or plastic barrier, such as a female
condom, dental dam, or modified male condom, especially if she has a
vaginal infection with discharge or is menstruating
• Semen in the mouth
• Oral-anal contact
• Sharing sex toys or douching equipment
• Any sex that causes tissue damage or bleeding (e.g., rough vaginal or anal
intercourse, rape, fisting)
During private counseling sessions, it is important to inquire about

substance use and other high-risk behaviors that may increase the
likelihood of exposure to an STD. A woman who drinks heavily or
who practices binge drinking may not remember the details of sexual
encounters that took place while intoxicated. A history of injected
drug use increases the risk for infection with hepatitis and HIV;
women who smoke have a higher rate of cervical cancer (Marrazzo
& Cates, 2011).
What to Say
Contraceptive Choices and Safer Sex
Nurses should recognize that women who use nonbarrier contraceptive
methods (e.g., oral contraceptive pills [OCPs], IUDs, subdermal hormonal
implants) usually choose these methods for the freedom involved. Thus, it is
important to inform oral contraceptive users that the pill may cause changes in
the cervix and in the immune system that increase susceptibility to HIV
infection. Women who are in new or nonmonogamous relationships should be
encouraged to use a barrier method along with the OCP, IUD, or subdermal
hormonal implant.
The nurse should approach the counseling sessions with sensitivity and
awareness that the individual may feel uncomfortable with sharing personal
information about the sexual history or STD infection in the past. When
possible, partners should be included in discussions concerning reproductive
health issues.
To promote health maintenance and safety and reduce the

likelihood of STD transmission, nurses can teach women:
■ How to use condoms (male and female, if appropriate) properly
■ How to perform a genital self-examination
■ To limit the number of sexual partners
■ To avoid the sharing of personal care items, such as toothbrushes
and razors
■ To promptly report signs and symptoms of infection (e.g., vaginal
discharge, pelvic pain, dysuria, irregular bleeding, dyspareunia,
bleeding with intercourse)
■ To take all prescribed antibiotics, even if symptoms resolve
■ To abstain from sexual intercourse until both partners have
completed treatment (to prevent reinfection)
■ To return for evaluation, as indicated, after treatment has been
completed
All women are potentially at risk for STDs and should be screened
appropriately. Women who are sexually active in same-sex
relationships, particularly adolescents, young women, and women
with both male and female partners, might be at increased risk for
STDs and HIV as a result of certain risk behaviors. Women who
have sex with women (WSW) are at risk for acquiring bacterial, viral,
and protozoal infections from current and prior partners, both male
and female. Although the efficiency of STD transmission is greater
with penile-vaginal intercourse, infection is also spread via other
practices such as oral-genital sex, oraldigital sex, skin-to-skin
contact, and through the sharing of sex toys. As with any population,
effective STD communication should include honest, open
discussion about sexual and behavioral risks.
Douching increases the risk for STDs by washing away the
resident lactobacilli, which increase vaginal acidity, thereby creating
an inhospitable environment for pathogens. The lactobacilli also
adhere to epithelial cells that prevent pathogen adherence. Without a
preponderance of beneficial lactobacilli, vaginal acidity decreases
and pathogens can more readily adhere to the vagina. Younger
women who douche and are more sexually active may be at an
especially high risk for contracting an STD; the risk with douching
may not be as great for older women.
Nurses who work with women of all ages can provide counseling
about the harmful effects of douching. The information should be
presented in a patient-centered, nonjudgmental manner that is
appropriately attuned to the patient’s age, culture, sexual orientation,
and developmental level. When appropriate, engaging the support of
influential family members (e.g., mothers, sisters, mothers-in-law)
may also be of benefit in effecting the desired behavioral change.
Nursing interventions center on the use of therapeutic
communication to foster nonjudgmental, culturally appropriate
discussion to facilitate learning and understanding. Providing
emotional support is an essential component of care. The nurse
assesses the patient’s (and partner’s, if appropriate) level of
knowledge about the infection and uses this information to develop
an individualized teaching plan. Emphasis is placed on the use and
importance of safe sexual practices and, depending on the treatment
regimen, the need to complete all prescribed medication and return
for further evaluation.
Safe or safer sexual practices involve avoiding contact with one’s
partner’s blood or body fluids (e.g., seminal fluid) by wearing
condoms during any form of oral, vaginal, or anal intercourse.
Activities with the lowest risk for STD transmission include:
■ Celibacy
■ Masturbation
■ Dry kissing
■ Masturbation of a partner on healthy, intact skin
■ Oral sex with use of a condom or dental dam
■ Touching
Condom-protected vaginal or anal intercourse carries a low risk of
STD transmission. High-risk activities for STD transmission include:
■ Wet kissing
■ Oral sex (without a dental dam or latex or plastic barrier or
condom)
■ Unprotected sex of any kind (Venes, 2021)
In some situations, the patient may confide that she is too
embarrassed to reveal information about the STD to her intimate
partner and ask for guidance. The nurse can assist her by offering
strategies, such as role-playing, for approaching the partner and
sharing the information. It is important to emphasize that although
this is a difficult topic for discussion, most individuals would rather
know about the possibility that they are infected rather than not
know. Exploring ways of communicating sensitive information is an
important nursing intervention that can strengthen the therapeutic
relationship, enhance adherence with the treatment plan, and
improve STD case finding.
SUMMARY POINTS
■ STDs encompass more than 25 infectious organisms that cause reproductive

tract infections.
■ Potential complications of STDs include infertility, ectopic pregnancy, chronic
pelvic pain, liver disease, liver cancer, and death.
■ Chlamydia, the most commonly reported infectious disease in the United
States, is the leading cause of preventable infertility and ectopic pregnancy.
■ Once on the verge of elimination, syphilis has re-emerged as a common STD.
■ In the United States, women represent one of the fastest growing segments of
the HIV epidemic.
■ Gonorrhea and chlamydia are prevalent in the adolescent population and
disproportionately prevalent in minority groups.
■ Infection with Trichomonas vaginalis increases the risk of HIV transmission.
■ Pelvic inflammatory disease is most often caused by the organisms
Chlamydia trachomatis and Neisseria gonorrhoeae.
■ Hepatitis is the leading cause of liver cancer and the most common reason for
liver transplantation.
■ In the area of reproductive health promotion, an important nursing role
centers on education about STDs, safer sex strategies, and actions to reduce
the likelihood of STD transmission.
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immunodeficiency-virus-hiv-infection-screening

Davis Advantage
CHAPTER 33

Common Reproductive Cancers
CONCEPTS
Cellular regulation
Female reproduction
KEY WORDS
squamous epithelium
columnar epithelium
squamocolumnar junction (SCJ)
Bethesda System
conization of the cervix
implant radiation
neoadjuvant chemotherapy
invasive vulvar cancer
Paget’s disease
LEARNING OBJECTIVES

■ Describe the cervical epithelium and the process of metaplasia.
■ Discuss methods of cervical cytology screening.
■ Identify treatment options for various preinvasive conditions of the cervix.
■ Identify risk factors for human papillomavirus (HPV).
■ Discuss the HPV-cervical cancer link and identify risk factors for cervical
cancer.
■ Develop materials for patient education and counseling regarding cervical
cytology screening, human papillomavirus, and cervical cancer.
■ Identify signs and symptoms that may be associated with vaginal, ovarian,
endometrial, and vulvar carcinoma.
■ Describe a strategy for increasing women’s awareness of potential ovarian
cancer symptoms.
PICO(T) Questions
chapter.
1. Does (I) health education regarding HPV awareness and prevention lead to
(O) higher condom use among (P) sexually active high school students
compared with (C) students who do not receive HPV health education?
2. What (O) nursing interventions are shown to provide support to (P) women
who undergo a follow-up procedure for (I) abnormal cervical cytology
findings?
INTRODUCTION
This chapter describes different reproductive cancers, cervical
cytology, and Pap test screening, and concludes with a discussion of
human papillomavirus (HPV) and its association with premalignant
and malignant cervical disease. According to the Centers for
Disease Control and Prevention (CDC), approximately 79 million
Americans are currently infected with HPV, and another 14 million
people become newly infected each year. HPV is so common that
nearly all sexually active men and women get it at some point in their
lives. Around 360,000 sexually active adults in the United States
acquire (HPV-related) genital warts each year, and approximately
12,000 American women get cervical cancer each year. HPV
infection is known to be the primary cause of cervical cancer. Other
cancers that may be caused by HPV include pharyngeal, vulvar,
vaginal, penile, and anal.
Although HPV has been recognized since 1907, it has only been
within the past three decades that an understanding of the virus has
evolved and its link to cervical and other cancers has been clearly
established. The past 10 years have brought major advances in
cervical screening technologies with the advent of liquid-based Pap
tests and HPV DNA testing. Most recently, three HPV vaccines have
become available. The vaccines are indicated for the prevention of
cervical cancer, genital warts, and dysplastic or precancerous
cervical lesions caused by several of the HPV virus types.
THE CERVIX AND THE CERVICAL

TRANSFORMATION ZONE
To enhance understanding about the uterine cervix and the cervical
Pap test to screen for cancer, it is important for the nurse to be
knowledgeable about cervical cytology and the normal cellular
changes that occur throughout a woman’s life. The surface of the
cervix and the canal that leads into the uterus—termed the
“endocervical canal”—is composed of two types of cells: squamous
epithelium and columnar epithelium.
The cervix, which is typically 2.5 cm long, communicates with the
endometrial cavity of the corpus uteri (uterine body) through the
internal os and with the vagina through the external os. The vaginal
portion (also called the exocervix, ectocervix, or portio vaginalis) is
covered by stratified squamous epithelium. The squamous
epithelium is smooth and light pink in appearance. The cervical canal
is covered by columnar epithelium, which also forms endocervical
glands, more correctly called “clefts.” In young women, columnar
epithelium can also be noted on the outer surface of the cervix
around the external cervical os. The glandular tissue has a rough
texture and is dark pink in color.
The area in which the squamous epithelium and the columnar
epithelium come together on the cervix is called the
squamocolumnar junction (SCJ). The SCJ is located where the
more delicate, darker pink columnar cells that line the uterus meet
the sturdier, lighter pink squamous epithelium of the vagina.
Throughout the reproductive years, some columnar cells at the SCJ
are replaced by squamous epithelium through a process termed
squamous metaplasia. The area between the old and new SCJ is
called the transformation zone (Fig. 33-1). The size of the
transformation zone varies from 2 to 15 mm. In most adult women,
the SCJ is not an abrupt meeting point but a zone containing
irregular areas of glandular and squamous epithelium. This site
undergoes continuous cell growth and replacement. The squamous
type of cell replaces the columnar type of cell in a constant cycle of
cell turnover, which is influenced by the female hormones.
Metaplasia, which is a normal process of cell turnover, occurs most
rapidly during adolescence and pregnancy. Cervical cancer usually
develops in this area of rapid cell division. The immature cells
undergoing the transformation from columnar to squamous tissue
are especially vulnerable to events that can change the genetic
material of the cells. These changes, or mutations, may result in the
development of premalignant or malignant cells.
FIGURE 33-1 The transformation zone. A, Sagittal section of uterine
corpus, uterine cervix, and vagina. B, Cross-section of cervix at level
of external os.
CERVICAL CANCER
Cervical cancer is a malignant neoplasm that forms in the tissues of
the cervix. Worldwide, cervical cancer is the second most common
type of cancer in women. It is much less common in the United
States because of the routine use of cervical cytological screening.
However, the American Cancer Society estimates that 12,360
women were diagnosed with invasive cervical cancer and 4,020
women died of cancer of the cervix in 2014 alone. Cervical cancers
originate in the cells on the surface of the cervix, which are
composed of squamous and columnar epithelium.
Approximately 80% to 90% of cervical cancers are squamous cell
carcinomas—neoplasms that originate in the squamous cells that
cover the surface of the exocervix. Most of the remaining cervical
cancers are adenocarcinomas, which are becoming increasingly
more common in women born in the past 20 to 30 years. Cervical
adenocarcinoma develops from the mucus-producing gland cells of
the endocervix. Less commonly, cervical cancers have features of
both squamous cell carcinomas and adenocarcinomas and are
called adenosquamous carcinomas or mixed carcinomas (ACS,
2014).
The development of cervical cancer, typically a very slow process,
begins as dysplasia, a precancerous condition. Dysplasia, which can
be detected by a Pap test, is 100% treatable. Most women who are
diagnosed with cervical cancer today have not had regular Pap tests
or they have not followed up on abnormal results. Undetected,
precancerous changes can develop into cervical cancer and spread
to the bladder, intestines, lungs, and liver.
Risk Factors
Although the exact mechanism for the progression of cervical cancer
is unknown, several key contributing factors have been identified
(Box 33-1). Nurses must remain up-to-date about cancer risk factors
so that they can appropriately identify and screen individuals at risk
and provide accurate, culturally centered patient counseling and
education. As is true in other areas of health promotion, it is useful to
focus teaching efforts on risk factors such as lifestyle choices (e.g.,
tobacco and alcohol use, diet, sexual practices, HPV exposure) over
which the woman has some control.
Symptoms
Most of the time, early cervical cancer produces no symptoms. In
fact, patients with cervical cancer usually do not experience any
problems until the cancer is advanced and has spread. An important
nursing role in cervical cancer education centers on emphasizing the
importance of routine cervical cancer screening and teaching women
about symptoms that may be associated with cancer of the cervix.
BOX 33-1
Cervical Cancer Risk Factors

• HPV infection (the most important risk factor)
• Cigarette smoking (causes damaging cellular changes within the cervix;
doubles the risk for cervical cancer)
• Immunosuppression (HIV increases the likelihood for infection with HPV,
which increases the risk for cervical cancer. Also, the immune system
normally destroys/slows the growth of cancer cells.)
• Coinfection with other STDs (e.g., Chlamydia trachomatis, herpes simplex
virus)
• Diet (low in fruits and vegetables increases the risk; obesity increases the risk
of cervical adenocarcinoma)
• Early onset of sexual activity (before age 18) (During adolescence, the
process of metaplasia is heightened, increasing the likelihood of HPV-related
cellular changes.)
• Clinical history of condyloma acuminata (Infection with a low-risk HPV type
increases the likelihood for coinfection with a high-risk type.)
• Inadequate cervical screening
• Male sexual partner who has had other partners, especially if a previous
partner had cervical cancer
• Multiple sexual partners (three or more in a lifetime)
• An uncircumcised sexual partner
• Oral contraceptives (Long-term use [>5 years] increases the risk; however,
the risk returns to normal after discontinuation.)
• Multiple full-term pregnancies (Three or more full-term pregnancies are
associated with an increased risk; reasons unknown.)
• Young age at first full-term pregnancy (Women younger than 17 years with
first full-term pregnancy are almost two times more likely to get cervical
cancer later in life than those who postpone pregnancy until 25 years or older;
this is attributed to the combination of pregnancy-induced hormonal effects on
the cervix and the presence of HPV, both of which contribute to neoplastic
changes.)
• Poverty (most likely related to lack of cervical cancer screening)
• In utero exposure to DES (increased risk for clear-cell adenocarcinoma of the
vagina or cervix; risk is greatest if DES exposure occurred during the first 16
weeks of pregnancy; there may also be an increased risk of squamous cell
cancers and precancers of the cervix linked to HPV)
• Family history of cervical cancer (If the mother or a sister had cervical cancer,
the woman’s chances of developing the condition are two to three times
higher.)
• Alcoholism
Sources: Adams & Carnright (2013); ACS (2014); McCormish (2012); Whyte
(2012).
Patient Education
Teaching About Symptoms of Cervical Caner
Nurses should emphasize that although early cervical cancer usually produces
no symptoms, patients should remain alert to the following signs and symptoms
that may be associated with the disease:
• Continuous vaginal discharge, which may be pale, watery, pink, brown,
bloody, or foul-smelling
• Abnormal vaginal bleeding between menstrual periods, after intercourse, or
after menopause
• Menstrual periods that become heavier and last longer than usual
• Any vaginal bleeding after menopause
Signs and symptoms that may be associated with advanced cervical cancer
include:
• Loss of appetite
• Weight loss
• Fatigue
• Pelvic pain
• Back pain
• Leg pain
• Single swollen leg
• Heavy vaginal bleeding
• Leaking of urine or feces from the vagina
• Bone fractures
Diagnostic Tools
Development of the Papanicolaou (Pap) Test
One of the best methods in preventing diagnosing cervical cancer is with
cervical cancer screening. Prior to the 1940s when the Papanicolaou (Pap) test
for cervical cytological screening became widely available, cervical cancer was
the most common cause of cancer death in women in the United States. Over
the past 30 years, the incidence of invasive cervical cancer has decreased by
70%. This dramatic improvement in cervical cancer–related morbidity and
mortality has largely been attributed to screening with the Pap test.
The Pap test is named for Dr. George Papanicolaou, the physician who,
along with Dr. Herbert Traut, developed the procedure in the 1930s. The Pap
test is a cytological study used to detect cancer in cells that an organ has shed.
Although used most often in the diagnosis and prevention of cervical cancers,
the Pap test is also of value in detecting pleural or peritoneal malignancies and
evaluating cellular changes caused by radiation, infection, or atrophy. In
women’s health, the Pap test is a screening technique used to detect cervical
cancer or cervical abnormalities that may progress to cancer. The test can
detect 95% of all cervical cancers and precancerous abnormalities. In the years
since World War II, the Pap test has become the most widely used cancer
screening method in the world, and it is the most successful cancer screening
technique in medical history. Pap screening reduced cervical cancer death
rates by almost 70% between 1955 and 1992, and the rate continues to decline
by about 2% each year (Venes, 2021).
Screening and Early Detection

The goal of screening for cervical cancer is to detect cervical cell
changes, precancerous cells, and early cervical cancers before any
symptoms develop. Screening refers to the use of tests (e.g., the
Pap test) and exams to find a disease, such as cancer, in individuals
who have no symptoms. Early detection means applying a strategy
that results in an earlier diagnosis of cervical cancer than otherwise
might have occurred. Screening tests offer the best chance to detect
cervical cancer at an early stage when successful treatment is likely.
Screening for cervical cancer is especially beneficial because it
affords an opportunity to detect abnormal cell changes (precancers)
so that they can be treated before they progress to cervical changes
(Centers for Disease Control and Prevention, 2020a). An HPV test
can be done with a Pap test (called a co-test) or as a standalone
test. The HPV test is testing for high-risk HPV strains that are likely
to cause pre-cancers and cancers of the cervix. The American
Cancer Society recommends a primary HPV test as the preferred
way to screen for cervical cancers or pre-cancers in individuals 25 to
65 years with a cervix (American Cancer Society, 2020; National
Cancer Institute, 2019).
Pap Test Techniques

The Pap test may be included in a pelvic examination. A sample of
cervical epithelium is gathered from the SCJ, which can often be
visualized on the cervix. An adequate Pap test should contain both
columnar cells and squamous cells, which indicates that the SCJ
was sampled. The Pap test is obtained before any digital
examination of the vagina is performed and before any endocervical
bacteriological specimens are collected. Prior to insertion, the
vaginal speculum may be moistened with warm water, saline, or an
aqueous gel; level I evidence indicates that modest lubrication of the
external surface of the speculum does not impair cytological and
infectious evaluation of the cervix. The examiner may use a large
cotton-tipped applicator to remove excess cervical discharge before
the cytological specimen is obtained (U.S. National Library of
Medicine, 2020; Venes, 2021).
Various sampling devices (e.g., spatula [paddle], cervix brush,
plastic “broom”) may be used (Fig. 33-2). When conventional Pap
tests are performed, a single microscope slide, combining both the
endocervical and ectocervical samples, or two separate glass slides
can be used. The exocervix (outer area) is first sampled with the
spatula (Fig. 33-3). This is done first to minimize the possibility of
obscuring the cells with blood. The endocervix (inner area) is then
sampled with the brush placed into the cervical os. The plastic
“broomlike” brush is designed to simultaneously sample the
endocervix and the exocervix. This device is inserted and rotated
360 degrees for a total of three to five times. If the patient has had a
hysterectomy, the vaginal cuff (the portion of the vagina that remains
open to the peritoneum following removal of the uterus) is sampled.
The vaginal wall is usually not sampled unless the woman is
approaching menopause, and in that case, a second sample may be
obtained to evaluate the hormonal effects on vaginal tissue.
FIGURE 33-2 Tools for the Pap test (top to bottom): Cytobrush,
cervical cytobroom, and wooden spatula.
FIGURE 33-3 Taking a cervical smear.
The cytology sample is promptly transferred onto one or two thin

glass slides and the sampling device is discarded. With this method
of Pap testing, the most important consideration is rapid fixation. The
slide should be sprayed with a preservative within 5 seconds to
prevent drying of the specimen (Fig. 33-4). Drawbacks of the
conventional “slide method” of Pap test collection include the
possibility of inadequate cellular sampling, the presence of artifacts
(e.g., blood, discharge, lubricant) that obscure the cervical cells, the
clinician’s failure to properly “fix” the specimen in a timely manner,
and inaccurate interpretation by the laboratory cytologist.
Today, the majority of cervical cytology screening performed in the
United States uses a liquid-based process (e.g., ThinPrep Pap Test,
BD SurePath Pap Test). With the liquid-based technique, exfoliated
cells are collected from the transformation zone of the cervix and
transferred to a vial of liquid alcohol-based preservative. The sample
is then processed in the laboratory and a slide is produced for
interpretation. With this method, almost all of the sample cells are
transferred to the liquid preservative, and most of the contaminating
blood, inflammatory cells, and debris are filtered out. However,
heavy menstrual blood may limit the number of squamous cells
available for interpretation. Prompt suspension of the cells in the
liquid preservative eliminates the problem of air-drying artifact, a
factor that can limit the interpretation of conventional cervical
cytology (BD SurePath, 2021; Hologenic, 2020).
FIGURE 33-4 A cytology brush and spatula are used for specimens
obtained during a conventional Pap test. The specimen is placed
onto a thin glass side and immediately sprayed with a preservative
(fixative).
In the conventional Pap test, cell samples are obtained from the
vagina, cervix, and cervical canal and spread on a glass slide. In
liquid-based Pap testing, cell samples are collected using a special
brush that is immediately washed in an alcohol-based fluid. In the
laboratory, a special machine filters out the cells from the solution
and deposits them in a thin, uniform monolayer (a single layer of
cells) on a glass slide. Analysis usually includes initial computer
screening followed by slide review by a cytotechnologist. The liquid-
based Pap test method removes contaminants such as blood and
mucus, which frequently obscure cells in the conventional Pap test.
The monolayer of cells is also easier to examine under the
microscope, resulting in an increased rate of detection of abnormal
cells. The disadvantage of the liquid-based method primarily centers
on the increased cost incurred by the collection fluid and the
continuing operation of the laboratory-filtering machine.
According to the laboratory-based cytotechnologists, the liquid-
based tests are easier to read. Although the liquid-based cytology is
more expensive than conventional cytology, it provides the added
ability to test for HPV, Neisseria gonorrhoeae, and Chlamydia
trachomatis from the same sample (BD SurePath, 2021; Hologenic,
2020).
What to Say
Informing Patients of Pap Test Limitations
Counseling patients about Pap test limitations constitutes a central role for
nurses in women’s health care. Nurses can advise about the limits of Pap test
accuracy while reassuring them that the Pap test is one of the most reliable
methods for detecting preinvasive cancer of the cervix. However, there is no
guarantee that any single Pap test will identify abnormal cells that may be
present. Rescreening, when necessary, carries the burden of an additional
expense, which may or may not be covered by insurance, whether funded by
private, state, or federal sources.
Initiation and Recommended Frequency of Cervical Cancer

Screening
Cancer of the cervix is usually a slow-growing neoplasm that is
almost always caused by infection with the sexually transmitted
disease HPV. Speculum examination for cervical cytology screening
should begin at age 21 years, regardless of the patient’s history of
sexual activity. Cervical neoplasia develops in susceptible individuals
in response to infection with a high-risk type of HPV (i.e., types 16
and 18, which cause about 70% of all cervical cancers). HPV causes
carcinogenesis in the transformation zone of the cervix, where the
process of squamous metaplasia replaces columnar epithelium with
squamous epithelium. Squamous metaplasia is particularly active in
the cervix during adolescence and early adulthood. HPV is
commonly acquired by young women shortly after the initiation of
vaginal intercourse, but in most situations, the HPV is cleared by the
immune system within 1 to 2 years without producing neoplastic
changes. The risk of neoplastic transformation increases in women
whose HPV infections persist. The recommendation to initiate
cervical cancer screening at age 21 years regardless of the age of
onset of sexual intercourse is based in part on the very low incidence
of cancer in younger women. It is also based on the potential for
adverse effects associated with follow-up of young women with
abnormal cytology screening results.
Current screening recommendations include:
■ Women ages 21 through 29 should be screened with a Pap test
every 3 years
■ Women ages 30 through 65 should be screened with any of three
tests:
■ every 5 years with high-risk HPV testing alone
■ every 5 years with Pap and high-risk HPV testing
■ every 3 years with a Pap test alone
■ Women with certain risk factors may need to have more frequent
screening or to continue screening beyond age 65. These risk
factors include:
■ being infected with the human immunodeficiency virus (HIV)
■ being immunosuppressed
■ having been exposed to diethylstilbestrol (DES) before birth
■ having been treated for a precancerous cervical lesion or
cervical cancer
■ Screening for cervical cancer is not recommended for:
■ women younger than 21 years
■ women older than 65 years who have had adequate prior
screening, with normal results, and who are not otherwise at
high risk for cervical cancer
■ women who have had a total hysterectomy (surgery to remove
the uterus and cervix) and have no history of high-grade cervical
lesions or cervical cancer
■ Women with any of the following risk factors may require more
frequent cervical cytological screening:
■ Women who are infected with HIV
■ Women who are immunosuppressed (e.g., those who have
received solid organ transplants)
■ Women who were exposed to DES in utero
■ Women previously treated for cervical intraepithelial neoplasia
(CIN) 2, CIN 3, or cancer (U.S. Preventative Services Task
Force, 2018) (Table 33-1)
Screening in the Adolescent Population

Initiating cervical cancer screening in the adolescent population may
result in increased anxiety, morbidity, and expense from the testing
and overuse of follow-up procedures. The emotional impact of
labeling an adolescent with both a sexually transmitted disease (i.e.,
HPV) and a potential precancer must be considered in light of the
fact that the adolescent period is characterized by emerging
sexuality and a heightened concern for self-image. Sexually active
adolescents (i.e., females younger than 21 years) should be
counseled and tested for STDs and educated about safer sex and
contraception. These measures may be carried out without cervical
cytology screening and, in the asymptomatic patient, without the use
of a speculum.
TABLE 33-1
Cervical Intraepitelia Neoplasia Grading System
CIN 1 Called low-grade, mild dysplasia, or cervical squamous
intraepithelial neoplasia 1. Slightly abnormal cells are
found on the surface of the cervix. Typically goes away
spontaneously, and observation is the only treatment
recommendation.
CIN 2 Called high-grade or moderate dysplasia or cervical
squamous intraepithelial neoplasia 2. Moderately
abnormal cells found on the surface of the cervix that
may become cancer and spread to nearby normal tissue.
Treatment for CIN 2 may include cryotherapy, laser
therapy, loop electrosurgical procedure (LEEP), or cone
biopsy to remove or destroy the abnormal tissue.
CIN 3 Called high-grade severe dysplasia or cervical squamous
intraepithelial neoplasia 3. Severely abnormal cells are
found on the surface of the cervix. CIN 3 is not cancer,
but may become cancer and spread to nearby normal
tissue if not treated. Treatment for CIN 3 may include
cryotherapy, laser therapy, loop electrosurgical procedure
(LEEP), or cone biopsy to remove or destroy the
abnormal tissue.
Source: American College of Obstetricians and Gynecologists (2020); National

Cancer Institute (2019); U.S. Preventative Services Task Force (2018).
Optimizing Outcomes
Strategies to Optimize Cervical Cancer Screening

Nurses can teach patients about strategies to optimize cervical cancer
screening. In the ideal situation, the Pap test should be collected at midcycle.
Patients should avoid intercourse, douching, or the use of vaginal medications
for 24 to 48 hours prior to the test. The presence of infection (e.g., yeast) can
cause vaginal inflammation and interfere with the test results. Over-the-counter
vaginal creams, gels, foams, or suppositories used within 24 to 48 hours before
the Pap test is obtained may interfere with the collection of an adequate
cytological specimen.
Cervical Cancer Screening in the Older Woman

Cervical cancer tends to occur in midlife. It rarely develops in women
younger than age 50, and most cases of cervical cancer and related
deaths occur in women older than age 50. The U.S. Preventive
Services Task Force (USPSTF) recommends screening cessation in
women older than 65 years with negative test results who have had
adequate prior screening and are not otherwise considered to be
high risk for cancer. All expert groups agree that cervical cancer
screening can be discontinued in women who have had a
hysterectomy if the surgery was performed for benign reasons and
there is no past history of high-grade cervical lesions.
Interpreting Cervical Cytology Findings: The Bethesda System

Terminology
The Bethesda System is the classification for abnormal cervical
cytology and histology that is most commonly used today. The 2001
Bethesda System terminology is presented in Box 33-2. First
developed in 1988 under sponsorship of the National Institutes of
Health (NIH), the updated 2001 Bethesda System standardizes the
terminology used to describe the categories of epithelial cell
abnormalities, including atypical squamous cells (ASC), low-grade or
high-grade squamous intraepithelial lesions (LSIL or HSIL), and
glandular cell abnormalities, including atypical glandular cells (AGC)
and adenocarcinoma in situ (AIS). Histology diagnoses of
abnormalities are reported as CIN 1–3.
BOX 33-2
The Bethesda System Terminology

The Bethesda System considers abnormalities of squamous cells and glandular
cells separately. Squamous cell abnormalities are divided into the following
categories, ranging from the mildest to the most severe.
ASCs are the most common abnormal finding in Pap tests. The Bethesda
System divides this category into two groups, ASC-US and ASC-H:
• ASC-US: ASCs of undetermined significance. The cells do not appear
completely normal, but the cause is unclear. The changes may be related to
an HPV infection, but they can also be caused by other factors.
• ASC-H: ASCs, cannot exclude a high-grade squamous intraepithelial lesion.
ASC-H lesions may be at higher risk of being precancerous than ASC-US
lesions.
• Low-grade squamous intraepithelial lesions (LSILs) are considered mild
abnormalities caused by HPV infection. LSILs often return to normal as the
immune system controls the infection, especially in younger women.
• High-grade squamous intraepithelial lesions (HSILs) are more severe
abnormalities that have a higher likelihood of progressing to cancer if left
untreated.
• Carcinoma in situ (CIS) refers to severely abnormal cells that resemble
cancer cells but remain on the surface of the cervix and have not invaded
more deeply or spread beyond the cervix.
• Squamous cell carcinoma is cervical cancer. The abnormal squamous cells
have invaded more deeply into the cervix or into other tissues or organs. In a
well-screened population, such as that in the United States, a finding of
cancer during cervical screening is extremely rare.
* SIL: cytological abnormalities identified on the Pap test, classified as low-grade

(LSIL) or high-grade (HSIL).
** CIN: cervical cancer precursor (confirmed by biopsy), divided into low-grade
(CIN 1) and high-grade (CIN 2/3).
Source: National Cancer Institute (2019)
Depending on the woman’s age and the Pap test result, further
evaluation, treatment, or both may be indicated. Young women aged
21 to 24 are at high risk for HPV infection but very low risk for
cancer. Because aggressive management usually involves more
harm than benefit, observation without HPV testing is recommended
for this population and depending on the test results, some women
will only need repeat screening in a year because some
abnormalities, especially more minor ones (ASC-US), will resolve on
their own. For women 25 years and older, reflex HPV DNA testing is
performed to determine whether HPV is present and whether referral
for colposcopy is indicated. The liquid-based Pap samples can be
immediately tested for HPV if there is an ASC-US (ASCs of
undetermined significance) result. Women with an ASC-US Pap test
result who test positive for HPV should have a repeat co-test in 1
year; those who are HPV positive with LSIL should be referred for
colposcopy with directed biopsy and endocervical sampling. If a
woman has more severe cell changes (ASC-H or HSIL) and/or
evidence of HPV16 or HPV18, it is recommended to have a
colposcopy (American College of Obstetricians and Gynecologists,
2020; National Cancer Institute, 2019).
Follow-Up for Unsatisfactory Pap Test Results and Abnormal

Cervical Cytology Screening Results
The American Society for Colposcopy and Cervical Pathology
(ASCCP) updated guidelines for the management of abnormal
cervical cytology and cervical cancer precursors. The guidelines,
which apply only to women who are found to have abnormalities
during routine screening, are stratified by risk, according to the
woman’s age, cytological diagnosis, and HPV status. The guideline
algorithms are available at www.jlgtd.com and www.greenjournal.org.
Updated guidelines for the management of women with
unsatisfactory Pap test results are presented in Box 33-3.
Unsatisfactory results can indicate an issue with collecting the
sample or contamination and understanding when retesting should
occur is essential (Perkins et al, 2020).
BOX 33-3
Updated Guidelines for the Management of

Unsatisfactory Pap Test Results—American
Society for Colposcopy and Cervical Pathology
If unsatisfactory Pap test results and:
• No HPV testing, repeat age-based testing in 2–4 months
• HPV negative and age greater than 25 years old, repeat age-based testing
If the unsatisfactory Pap test is part of a co-test, the following strategies are
appropriate:
• If the HPV test is positive, age greater than 25 years old, repeat the Pap test
or perform colposcopy
• If HPV genotyping was reported and is positive for type 16 or 18, perform
colposcopy
Perform colposcopy when two consecutive Pap tests are unsatisfactory.
Source: Perkins et al (2020)
Colposcopy
Colposcopy is a medical diagnostic procedure that uses a
colposcope to provide an illuminated, magnified view of the cervix
and the tissues of the vagina and vulva. The colposcope is a low-
powered binocular microscope with a powerful light source mounted
to allow visualization of the vagina and cervix during a pelvic
examination. This instrument allows for a close-up view of the cervix
and surrounding tissue for evaluation. The main goal of colposcopy
is to prevent cervical cancer by the early detection and treatment of
precancerous lesions.
What to Say
Preparing the Patient for Colposcopy
The nurse can do much to allay a patient’s anxiety about colposcopy. You may
offer the following description of the procedure to help the patient understand
what to expect:
“Once you have emptied your bladder, I will assist you into position (dorsal
lithotomy) for a pelvic examination. The clinician (colposcopist) will insert a
vaginal speculum and most likely use cotton swabs to apply an acetic acid
(vinegar) solution to the cervix. Abnormal areas turn white (acetowhite) and
become more prominent in response to the acetic acid, allowing for improved
visualization. Areas that turn white after the application of acetic acid or have
an abnormal vascular pattern are often considered for biopsy. If no lesions are
visible, an iodine solution (Schiller’s or Lugol’s solution) may be applied to the
cervix and vagina to help highlight areas of abnormality. The colposcopist
determines the areas with the highest degree of visible abnormality and may
obtain biopsies from these areas. A numbing medication (lidocaine) is used to
diminish discomfort, especially if many biopsy samples are taken. Although not
common, potential complications include bleeding and infection. To minimize
the risk of infection, you should use a panty liner or sanitary napkin and avoid
sexual intercourse until all vaginal bleeding or discharge has stopped. Your
health-care provider may advise you to take a mild pain reliever such as
ibuprofen approximately 30 minutes to 1 hour before the procedure and
afterward as needed for cramping and discomfort. Be sure to promptly notify
your health-care provider if you develop any signs of infection, such as fever,
continued pain, bleeding, foul-smelling vaginal discharge, or painful urination
(dysuria), or have any concerns. Also, it is a good idea to bring a support
person with you.”
Endocervical Sampling
Endocervical sampling is performed if the colposcopy is
unsatisfactory (e.g., no lesions are identified, or the endocervical
canal cannot be fully visualized) and in women who have follow-up
colposcopy after treatment for CIN 2 or 3 with a positive endocervical
margin. Endocervical sampling may be conducted either with
vigorous endocervical brushing or by the traditional endocervical
curettage (ECC), a procedure that uses a sharp, spoon-shaped
instrument (curette). A small tissue sample is obtained and sent to a
pathology laboratory for evaluation. Examination of the tissue allows
for determination of whether abnormal lesions are located inside the
endocervical canal; this information is an important determinant in
the treatment plan (Perkins et al, 2020).
During the endocervical sampling procedure, which usually takes
only a few minutes, the patient will most likely experience abdominal
pain and menstrual-like uterine cramps. Endocervical sampling is not
indicated in the pregnant patient. Monsel’s solution (basic ferric
sulfate solution, a hemostatic agent) is applied with large cotton
swabs to the surface of the cervix to control bleeding. This solution,
which is mustard colored, turns black when exposed to blood. After
the procedure, the Monsel’s solution is expelled naturally. The nurse
can explain to the patient that she may experience a thin, coffee
ground-like vaginal discharge for several days after the procedure.
Optimizing Outcomes
Addressing Abnormal Pap Test Results During Pregnancy

The management of abnormal Pap test results during pregnancy considers the
duration of the pregnancy, the woman’s desire to maintain the pregnancy, and
the degree of cellular abnormality. Colposcopy is used for diagnosis, and the
primary goal of both cytology and colposcopy is to identify invasive cancer that
requires treatment before or at the time of delivery. Cervical biopsies are safe
and should be performed for suspected high-grade disease or cancer. Biopsy
during pregnancy has not been linked to fetal loss or preterm birth. Endocervical
sampling should not be performed. Unless invasive cancer is identified,
treatment is postponed until after the pregnancy has ended (Perkins et al,
2020).
Management of Abnormal Cervical Cytology/Colposcopy

Findings
There are several ways to treat the lesions identified in a colposcopic
examination; the treatment depends on the location and severity of
the lesions. Four types of interventional techniques are available:
cryosurgery, laser ablation, conization, and the loop electrosurgical
excision procedure.
Cryosurgery
Cryosurgery (cryotherapy), a gynecological treatment that involves
the freezing of cervical tissue, is performed in the office setting. This
procedure is used for patients with high-grade cervical cell changes.
The patient is assisted into a dorsal lithotomy position and a vaginal
speculum is inserted. Cryoprobes are placed over the abnormal
areas on the cervix. Liquid nitrogen flows through the cryoprobes at
a temperature of approximately –50°C, making the metal cold
enough to freeze and destroy the tissue. Cryosurgery is relatively
painless and produces very little scarring. An “ice ball” forms on the
cervix, killing the superficial abnormal cells. The most effective
treatment result is obtained by a process of freezing for 3 minutes,
allowing the area to thaw, and then refreezing for 3 more minutes.
Throughout the procedure, the patient may experience slight
cramping and/or a sensation of cold or heat. Cryosurgery effectively
destroys all the abnormal cervical tissue in the majority of cases
(National Cancer Institute, 2019).
Offering explanations about what to expect following cryosurgery
and alerting patients to danger signs constitutes an important
nursing role. The nurse can counsel the patient that she:
■ May return to most normal activities the day following the
cryosurgery
■ Will experience a foul-smelling, watery vaginal discharge, caused
by sloughing of the necrotic cervical tissue, for a few weeks
■ Should avoid inserting anything (tampons, douches) into the
vagina and refrain from intercourse for at least 2 to 3 weeks
■ Should promptly call her health-care provider if she experiences
any symptoms of infection (fever, vaginal bleeding heavier than a
normal menstrual cycle, severe or increasing pelvic pain, foul-
smelling or yellow-green vaginal discharge)
■ Should be sure to return for her follow-up appointment and comply
with her health-care provider’s recommendations for repeat Pap
testing
A long-term complication of cryosurgery concerns the migration of
the SCJ (the transformation zone—the area on the cervix where the
outer squamous cells meet the inner glandular columnar cells).
Following the procedure, the SCJ migrates upward into the cervical
canal. The relocation of the transformation zone may create the
need for a more invasive procedure in the future if abnormal lesions
occur that are not visible with the colposcope (i.e., the abnormal cells
are located inside the endocervical canal). Although rare,
cryosurgery may cause scarring of the cervix and lead to stenosis
(narrowing) of the cervical opening, making future cervical cytology
screening (Pap testing) and evaluation (colposcopy) difficult
(American College of Obstetricians and Gynecologists, 2020).
Laser Ablation
Laser ablation (destruction) involves the use of a thin, high-energy
beam of light precisely directed at the abnormal tissue to cause cell
destruction through vaporization. Depending on the circumstances,
the procedure may be performed in the office or outpatient setting of
the clinic or hospital. The technique uses a laser (mounted on a
colposcope) to vaporize the transformation zone, where the
abnormal cells are located. Advantages of laser ablation include
rapid healing (3–4 weeks), minimal scarring, and no retraction of the
transformation zone. Following laser ablation, patients may
experience less vaginal discharge than with cryosurgery, but they
may experience more discomfort immediately after the procedure.
Vaginal spotting or bleeding may occur for several days after the
surgery.
Prior to the procedure, the nurse provides information, answers
questions, and asks the patient to empty her bladder. The nurse may
offer the following description of the procedure to help the patient
understand what to expect:
■ Medication will be given to decrease cramping and to numb the
area to be treated.
■ Everyone in the room will wear special glasses and surgical
masks.
■ Because laser burns or vaporizes cells, there will be a small
amount of smoke present, and a smoke evacuator is used to
remove the smoke from the air.
■ The entire procedure (when done in the office or clinic) will take
approximately 5 to 20 minutes, depending on the size of the
abnormal area.
■ Recovery time is minimal; most women leave within 20 minutes
following the procedure.
■ Some vaginal discharge is normal, but immediately report bleeding
heavier than a menstrual period or yellow-green, foul-smelling
discharge.
■ A mild analgesic such as acetaminophen or ibuprofen may be
taken as needed for pain, but severe abdominal pain should be
reported immediately.
■ Intercourse, douching, and tampon use should be avoided for 3
weeks.
■ A fever above 100°F (38°C) should be reported immediately.
■ Tub baths and showers may be taken, and you may return to work
the day after the treatment.
■ It is a good idea to ask a support person to accompany you to the
appointment.
■ Be sure to keep your follow-up appointment and follow your health-
care provider’s recommendations for repeat Pap testing.
Conization: Cold Knife Conization; Laser Conization; Loop

Electrosurgical Excision Procedure (LEEP)
Conization of the cervix is defined as excision of a cone-shaped or
cylindrical wedge from the uterine cervix that includes the
transformation zone and all or a portion of the endocervical canal
(Fig. 33-5). This procedure may be done when the lesion found on
colposcopy extends into the endocervical canal and cannot be fully
seen. Cold knife conization (CKC; also known as “cone biopsy”)
involves the use of a scalpel without electrosurgical current; laser
conization employs use of a laser for the excision of tissue. Cold
knife and laser conization, which are usually performed in the
hospital outpatient surgical center, may be done for diagnostic
purposes, or for therapeutic purposes, to remove precancerous cells.
Techniques for diagnostic and therapeutic conization are virtually
identical. Depending on the circumstances and setting, patients may
receive a local anesthetic with IV sedation, regional anesthesia, or
general anesthesia. Potential complications of cervical conization
include infection, bleeding, and cervical scarring or stenosis
(narrowing); the procedure may also increase the risk of cervical
incompetence and preterm birth (National Cancer Institute, 2019).
Conization performed with electrosurgical loop is called the loop
electrosurgical excision procedure (LEEP), or large loop excision of
the transformation zone (LLETZ). LEEP uses a low-voltage electrical
current to remove abnormal cervical tissue. With this procedure, the
cervix is anesthetized with a local anesthetic, and a fine wire loop
electrode is used to simultaneously remove and cauterize a portion
of the cervix. The advantage of the electrosurgical loop procedure
and other excisional techniques (e.g., CKC) over the ablative
therapies (e.g., cryosurgery, laser vaporization) is that the tissue is
removed, not destroyed. Thus, the tissue is available for evaluation
by a pathologist. Also, the LEEP procedure is fast (20–30 minutes),
virtually bloodless, and may be performed in the office. Following the
procedure, healing is rapid, and there is only a mild vaginal
discharge afterward. Patients may experience mild pain and
cramping for the first few hours after the LEEP; the discomfort can
be relieved by oral medications. Possible short- and long-term
complications include bleeding, cervical stenosis, preterm birth,
infertility, and loss of cervical mucus (American College of
Obstetricians and Gynecologists, 2020; National Cancer Institute,
2019; U.S. Preventative Services Task Force, 2018).
An important nursing role in caring for the patient who will undergo
cervical conization centers on education and support. Prior to the
conization, the nurse answers questions and addresses concerns.
The nurse may offer the following description of the procedure to
help the patient understand what to expect:
FIGURE 33-5 Cervical conization.
■ The procedure will take less than 1 hour.

■ Some form of anesthesia will be used to control pain.
■ Depending on the type of anesthesia to be used, nothing should
be taken by mouth for 8 hours prior to the procedure (when IV
sedation or general anesthesia is planned).
■ The physician will first insert a vaginal speculum and then use a
knife (CKC), laser, or heated loop (LEEP) to remove a cone-
shaped section of tissue (containing any abnormal cells) from the
cervix.
■ Self-absorbable sutures may be placed in the cervix to control
bleeding.
■ Analgesics may be taken as needed for pain control after the
conization.
■ If the conization is performed in an outpatient surgery center, and
depending on the type of anesthesia used, you may leave after
you are fully awake, but someone must be with you to drive you
home.
■ If the conization is planned as an office procedure (LEEP), an
electrosurgical dispersive pad (a gel-covered adhesive electrode
that provides a safe return path for the electrosurgical current) will
be placed on your thigh and removed after the procedure.
■ Vaginal bleeding or discharge may be present for several days
after the conization; a panty liner or sanitary napkin should be
worn to protect clothing.
■ Tampons, douches, and sexual intercourse should be avoided for
4 to 6 weeks.
■ You should avoid lifting items heavier than 25 pounds for at least 1
week.
■ Tub baths and showers may be taken as desired.
■ Any signs of infection or other complications (e.g., fever, chills,
foul-smelling discharge from the vagina, worsening abdominal
pain, heavy vaginal bleeding [may not occur until about 1 week
after the procedure, when the healing scar is shed from the cervix])
should be promptly reported to your health-care provider.
■ It is important to return for the postoperative examination and to
follow your health-care provider’s recommendations for repeat Pap
testing.
Diagnostic Work-Up and Treatment of Cervical Cancer

Once a diagnosis of cervical cancer has been made, the physician
orders additional tests to determine whether the cancer is confined
to the local area or has spread to distant organs. This process is
termed staging. Tests that may be appropriate include x-ray
computed tomography (CT scan), magnetic resonance imaging
(MRI), positron emission tomography (PET scan), cystoscopy, chest
x-ray, and intravenous pyelogram (IVP). The cancer stage is based
on where the cancer is found (Box 33-4).
Treatment for cervical cancer depends on the stage of the cancer
—whether it is localized or has spread to surrounding tissues or
distant organs. A high-grade, preinvasive lesion (i.e., carcinoma in
situ [CIS]) is removed to prevent progression to invasive disease. A
conization procedure is usually recommended, although
hysterectomy may be advised, depending on the individual situation
National Cancer Institute, 2019; U.S. Preventative Services Task
Force, 2018).
BOX 33-4
Stages of Invasive Cervical Cancer

STAGE I
The tumor has invaded the cervix beneath the top layer of cells. Cancer cells
are located only in the cervix.
STAGE II
The tumor extends to the upper part of the vagina. It may extend beyond the
cervix into nearby tissues toward the pelvic wall. The tumor does not invade the
lower third of the vagina or the pelvic wall.
STAGE III
The tumor extends to the lower part of the vagina. It may also have invaded the
pelvic wall. If the tumor blocks the flow of urine, one or both kidneys may not be
working well.
STAGE IV
The tumor invades the bladder or rectum, or the cancer has spread to other
parts of the body.
RECURRENT CANCER
The cancer was treated but has returned after a time during which it could not
be detected. The cancer may show up again in the cervix or in other parts of
the body.
Source: National Cancer Institute (2020).

Depending on the cervical cancer stage, the health-care provider
may wish to refer the woman to the care of a gynecological
oncologist, a surgeon who specializes in treating gynecological
cancers. Other members of the health-care team who may be
involved in the patient’s treatment plan include medical oncologists,
radiation oncologists, oncology nurses, mental health professionals,
and registered dieticians.
Radiation Therapy
Radiation therapy (RT) uses high-energy x-rays to destroy cancer
cells. Cancers that extend beyond the cervix into the pelvis, lower
vagina, and urinary tract typically receive radiation. RT may be
combined with surgery or chemotherapy to treat early cervical
cancers and more invasive stages of the disease; it can also be used
to relieve symptoms caused by advanced cancer. Radiation may be
delivered by external beam, by radioactive implants placed directly at
the cancerous site (“internal therapy”), or by a combination of these
two therapies.
EXTERNAL THERAPY
External beam radiation, administered the same way as a
diagnostic x-ray, is usually given five times a week for 5 or 6 weeks,
with an extra boost of radiation at the end of that time. With this
treatment modality, the entire pelvic area is irradiated, including the
rectum, large intestine, small intestine, bone, and skin. Providing
education and emotional support are key components of nursing
care for women receiving external beam radiation. The nurse can
encourage the patient to remain as active as possible throughout the
course of therapy. Patients should be counseled that they might
experience certain side effects in the treatment target area, such as
hair loss, dry or irritated skin, or permanent darkening of the skin.
While undergoing external RT, patients are cautioned not to remove
any skin markings made by the radiologist (National Cancer Institute,
2017).
Nurses can teach women undergoing external beam RT about
various strategies to promote comfort and healing. For example, the
nurse can suggest that the patient:
■ Practice good personal hygiene
■ Use lotions or creams only with the physician’s approval, and
remain vigilant about skin care and the condition of the treatment
area
■ Wear loose clothing over the treatment area
■ Wear cotton underwear
■ Expose the treatment area to air whenever possible
■ Avoid exposing the treatment area to temperature extremes
■ Avoid the use of adhesive tape in the treatment area
■ Consider meditation and other stress reduction modalities
■ Consider acupuncture for persistent nausea and vomiting
After completion of the external RT, patients are taught about self-
care strategies to promote comfort and healing, and they are advised
that side effects from the therapy may persist for weeks after the
therapy has ended.
Patient Education
Self-Care Strategies After External Radiation Therapy
Nurses can empower women with self-care strategies to promote comfort and
healing after the completion of external RT. For example, the nurse may advise
the patient to do the following:
• Be sure to consume a nutritious diet.
• Drink plenty of fluids.
• Obtain adequate rest, and take naps as needed.
• Take medications as prescribed; check with your health-care provider before
taking any nonprescribed medications.
• Maintain good oral and skin care.
• Anticipate that the effects from the radiation may persist for 10 days to 2
weeks after the last treatment.
• Anticipate that signs of healing will occur in about 3 weeks after the last
treatment.
• Avoid infection; report any symptoms of infection to your health-care provider.
• Promptly report symptoms of complications, such as gastrointestinal
symptoms (e.g., continued nausea, vomiting, anorexia, diarrhea) or skin
symptoms (e.g., redness, swelling, pain, pruritus at the radiation site) to your
INTERNAL THERAPY
Implant radiation, also known as brachytherapy (“slow therapy”),
involves placement of the radioactive material as close to the tumor
as possible while sparing the adjacent healthy tissue. The
radioactive material is either placed in a capsule and inserted into
the cervix or placed in thin needles that are inserted directly into the
tumor. This method of treatment takes place in the hospital setting.
The patient stays in the hospital for 1 to 3 days while the implants
remain in place; during this time, the patient is considered
radioactive. The device is removed before discharge. Brachytherapy
is then repeated several times over a period of 1 to 2 weeks. Once
the radioactive material has been removed, no radioactivity remains
in the body. In some situations, the internal RT is delivered during a
brief treatment session, and the patient can go home afterward. In
premenopausal women, sterility and cessation of menstruation
usually occur after brachytherapy. Patients should be advised to
promptly report signs of infection (i.e., vaginal or rectal bleeding,
hematuria, foul-smelling vaginal discharge, fever, abdominal
distention or pain) to their health-care provider (National Cancer
Institute, 2017).
Optimizing Outcomes
Monitor and Limit Personal Radiation Exposure

Nurses and other health-care providers who come in direct contact with patients
receiving internal RT should monitor their personal radiation exposure by
wearing a film badge or other device to determine the amount of exposure
received. When providing direct patient care, isolation techniques (i.e., good
hand washing technique, wearing gloves when handling bodily fluids) are
observed, and time spent in proximity to the patient is limited to 30 minutes or
less per 8 hours to avoid exposure to gamma rays. It is important to use the
principles of time, distance, and shielding to protect from personal radiation
exposure and to explain to the patient and her family why nursing care is
focused on providing only essential care during internal RT. Also, the nurse
explains that pregnant women and children younger than 16 years should not
visit the patient. If the radiation source becomes dislodged, a radiation specialist
uses special long-handled tongs to remove the device and place it in a lead
container. All linens and dressings are considered contaminated (Venes, 2021).
Along with physical care, education and emotional support remain

central in the nursing care for all patients undergoing RT.
Understandably, patients experience considerable emotional distress
related to their diagnosis, fear of the anticipated treatment (e.g.,
pain, perceived personal radioactivity, adverse effects on bodily
functions), and concerns about the impact of their treatment on
family members. Potential nursing diagnoses for patients undergoing
RT for the treatment of cervical cancer are presented in Box 33-5.
Nurses can advise patients undergoing external RT that although
the affected area may look and feel sunburned, the treated tissues
usually regain their normal appearance within 6 to 12 months. It is
also important that all patients be counseled about common RT side
effects, such as fatigue; diarrhea; frequent or uncomfortable
urination; loss of hair in the genital area; and vaginal dryness,
itching, and burning. Patients should also be advised to abstain from
intercourse until a few weeks following completion of the RT. In
general, patients who are treated with internal RT may resume
intercourse in 7 to 10 days. Altered patterns of sexuality related to
RT side effects are not unusual. Patients may experience a
decrease in vaginal secretions and sensation, as well as vaginal
stenosis (narrowing). These aftereffects can cause coital pain and
discomfort and can contribute to diminished sexual desire.
Depending on the specific problem, the nurse may offer suggestions
such as applying water-based lubricants for vaginal dryness and/or
the regular use of a vaginal dilator for vaginal stenosis;
patient/partner referral to other resources may be appropriate. Other
complications of external beam radiation and brachytherapy are
listed in Box 33-6.
BOX 33-5
Potential Nursing Diagnoses for Patients

Undergoing Radiation Therapy for Cervical
Cancer
Knowledge Deficit related to planned treatment procedures Fear and Anxiety
related to:
• diagnosis
• pain
• interference with sexual functioning
• concerns about personal radioactivity
• responses of family members and significant others Disturbed Sensory
Perception related to:
• internal radiation therapy
• restricted contact with visitors and health-care professionals Risk for Skin
Integrity Impairment related to:
• external radiation exposure
• immobility and bedrest (with internal radiation therapy)
Risk for Physical Injury related to dislodgment of the radiation source (with
internal RT)
Acute Pain related to internal radiation applicators
Surgery
For invasive cancer, RT can be used alone or in combination with
some form of surgery. Surgery options range from cervical conization
to radical hysterectomy. A radical trachelectomy involves removal of
the cervix, part of the vagina, and the lymph nodes in the pelvis. This
surgery is reserved for a small number of women with small tumors
who desire pregnancy in the future. Total hysterectomy involves
removal of the cervix and the uterus. Radical hysterectomy involves
removal of the uterus, cervix, parametrium (tissue surrounding the
uterus), ovaries, fallopian tubes, upper vagina, and some of or all the
local lymph nodes (National Cancer Institute, 2017).
BOX 33-6
Complications of External Beam Radiation and

Brachytherapy
Anemia and/or bruising
Cystitis (inflammation of the bladder)
Increased risk of infection
Premature menopause
Proctitis (inflammation of the rectum)
Sexual difficulties
Skin rash, inflammation, pruritus
Thrombophlebitis, pulmonary embolism, pneumonia (related to immobility
associated with internal radiation therapy) Vaginal scarring and stenosis
Vesicovaginal fistula (development of an abnormal connection between the
vagina and the bladder or rectum)
Source: National Cancer Institute (2020).
Chemotherapy
Chemotherapy may be used for cervical cancer that has either
metastasized too far from its origin to be treated by surgery or
radiation or that has recurred. It may also be used to relieve pain
associated with advanced cervical cancer or to shrink cancer to an
operable size before surgery is performed. This treatment modality is
termed neoadjuvant chemotherapy, and it can help to prevent
cervical cancer from spreading. Chemotherapeutic agents approved
to treat advanced or recurrent cervical cancer include cisplatin (Cis-
Platinum, Platinol), bleomycin (Blenoxane), and topotecan
hydrochloride (Hycamtin). The medications are either administered
by mouth or via IV infusion. Chemotherapy treatments are usually
alternated with “recovery periods” that allow the patient a rest time
before beginning a new cycle of therapy (NCI, 2020).
Combination chemotherapy, which involves the combination of two
or more chemotherapy medications, may be more effective than any
single agent. When used in association with surgery or radiation,
chemotherapy can help to prevent the spread or recurrence of
cervical cancer. Nurses can counsel patients undergoing
chemotherapy about common side effects associated with these
medications, which include nausea and vomiting, change in appetite,
oral lesions, vaginal sores, temporary hair loss, fatigue, bruising and
bleeding, skin rash, joint pain, swelling in the legs and feet,
susceptibility to infection, anemia, menstrual cycle changes, onset of
early menopause, and infertility. In most situations, women who
undergo chemotherapy for cervical cancer are already infertile as a
result of surgery or RT. Physicians may prescribe hormones to help
offset the symptoms associated with premature menopause.
Biological therapy, designed to repair, stimulate, or enhance the
immune system’s responses, may be used to treat cancer that has
metastasized to other body organs. Interferon alfa, a cell protein that
provides immunity to viral infections, is the type of biological therapy
most often used. Biological therapy is usually administered on an
outpatient basis and is sometimes combined with chemotherapy.
Nurses can counsel women about possible side effects associated
with this treatment modality, including:
■ Flu-like symptoms: fever and/or chills; muscle aches; weakness;
diarrhea, nausea, or vomiting
■ Rash
■ Easy bleeding or bruising
Nurses can inform women who have received a diagnosis of
cancer about supportive care that is available at any stage of the
disease. Patients may find information about relief from the side
effects of treatment, tips to help to control pain and other symptoms,
and emotional support to help them cope with the feelings
associated with a diagnosis of cancer. Resources for coping are
available on the NCI Web site at
http://www.cancer.gov/cancertopics/coping and from NCI’s Cancer
Information Service at 1-800-4-CAN-CER or LiveHelp Online Chat
(https://livehelp.cancer.gov/app/chat/chat_launch).
Nurses are perfectly situated to provide women with information
about cervical cancer screening, HPV, and cervical cancer. For
example, nurses can explain that although HPV is the cause of
cervical cancer, most HPV infections resolve without treatment and
do not progress to cervical cancer, especially when regular
screening is performed. Most new HPV infections occur in women in
their 20s, but the most common decades of life for cervical cancer to
be diagnosed is in the 40s and 50s, and 25% of new diagnoses
occur in women over age 60. Sharing this information empowers
patients with the essential knowledge they need to make informed
choices about seeking continued screening at the recommended
intervals.
Teaching women about risk factors for cervical cancer may
motivate them to stop smoking or seek regular cervical cancer
screening, if they have not done so in the past. Sharing information
about strategies to reduce exposure to HPV (e.g., using condoms,
limiting sexual partners, practicing monogamy) may assist in making
decisions about intimate relationships. Women of all ages should be
educated about the HPV vaccine—although the upper age limit for
the vaccine is 26, they may be mothers, grandmothers, aunts, or
sisters of preteen or teen girls. Because one concern about the HPV
vaccine centers on a potential for patient and care provider
complacency about cervical cancer screening, it is imperative that
nurses continue to emphasize the importance of routine screening
according to current early-detection guidelines.
Nurses who care for pregnant women can use prenatal visits as
an opportunity to counsel patients about the HPV vaccine and
cervical cancer prevention and encourage them to begin the series
during the postpartum visit. Nurses can support funding for programs
that increase access to Pap testing and HPV vaccination for
economically disadvantaged women. Finally, through age-
appropriate, culturally sensitive educational efforts, nurses can
empower patients to make informed choices about the HPV vaccine
and, if they do choose to initiate the vaccine, encourage completion
of the series.
HUMAN PAPILLOMAVIRUS
The human papillomavirus (HPV), a double-stranded DNA tumor
virus, is the most common sexually transmitted disease in the United
States. More than 40 HPV types can infect cutaneous and mucosal
surfaces, including the anogenital epithelium and the mouth and
throat. Although anogenital and cutaneous HPV infections are very
common, only a small fraction of genital infections actually progress
to cancer. Cervical cancer, rarely found among women in celibate
religious orders, has long been associated with intimate sexual
activity. Owing to the rising epidemic of the sexually transmitted HPV
infection, the average age of women with abnormal Pap test findings
is declining steadily. HPV is most prevalent among the younger
population of women, although it does occur with the same
frequency in older women as well (Gayoski, 2020).
Many of the papilloma viruses cause papillomas. Papillomas are
not cancers and are more commonly called warts. The most
important risk factor in the development of cervical cancer is
infection with a high-risk strain of HPV. The virus-cancer connection
occurs as a result of alterations in the cervical cells that can lead to
the development of CIN, which can then lead to cancer. HPV is
passed from one individual to another during skin-to-skin contact.
Although the virus is frequently transmitted during vaginal
intercourse, anal intercourse, or oral sex, intercourse does not have
to take place for HPV to be spread from one person to another. Skin-
to-skin contact with an area of the body infected with HPV is the only
requirement for transmission.
NURSING INSIGHT
The National Health Initiative Addresses HPV
An important Healthy People 2020 National Health Goal specifically focuses on
HPV:
• Reduce the proportion of females with HPV infection
• Reduce the proportion of females with HPV types 6 and 11
• Reduce the proportion of females with HPV types 16 and 18
• Reduce the proportion of females with other HPV types
Nurses can help the nation to meet this goal and objectives by providing
education about methods of preventing HPV and information about how to
recognize the signs and symptoms of HPV-related infection. Nurses can design
studies and engage in research to provide evidence-based practice strategies
for issues such as teaching women about safer sex practices, teaching youth
about the methods of transmission of HPV infection and the long-term
consequences of the disease, fostering HPV prevention through vaccination
and exploring the use of alternative sites for vaccination delivery, and ways that
health professionals can increase HPV awareness in their practice settings.
HPVs are a family of more than 100 virus types with a multitude of
manifestations that include common warts, plantar warts, skin cancers, anal
and genital warts, recurrent respiratory papillomatosis (a rare, benign infection
of type HPV 6 or 11—it passes from mothers to neonates during vaginal
childbirth), head and neck cancers, genital cancers, and cervical cancer. Young
men and women between the ages of 15 and 24 account for approximately half
of all new HPV infections according to the CDC.
Vertical transmission of oncogenic HPV from the mother to her

fetus via the placenta is possible but not fully understood; additional
research in this area is indicated. Transmission to the infant of HPV
type 6 or 11 is known to be possible during vaginal childbirth, but it is
rare. Most experts believe that the risk of cesarean birth to both the
mother and her infant exceeds the risk of neonatal genital warts or
laryngeal papillomatosis (the presence of HPV 6– or 11–induced
warts in the larynx or upper airway). However, cesarean birth may be
indicated for women with genital warts if the pelvic outlet is
obstructed or if vaginal birth would result in excessive bleeding.
Once the maternal warts are no longer present, especially if the
woman has had no detectable HPV lesions for 6 months or more,
transmission of HPV to the infant during a vaginal birth becomes
increasingly unlikely.
Approximately 40 HPV strains are believed to be capable of
infecting the genital tract. HPV types 6 and 11 have been identified
as “low risk,” or nononcogenic (not capable of causing cancer).
These are the types most likely to be associated with condylomata
acuminata (genital warts), benign cervical changes, and low-grade
cervical intraepithelial lesions. HPV types 42, 43, 44, 54, 61, 70, and
72 are also considered nononcogenic. Important associations have
been identified between HPV type 16 and squamous cell carcinoma,
and between type 18 and cervical adenocarcinoma. Many other HPV
types (i.e., types 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, 82)
are also considered to be “high risk,” or oncogenic (they carry the
potential to cause cervical cancer), and one or more of these
particular types is detected in nearly every patient diagnosed with
cervical cancer. Oncogenic types have been identified in cervical,
vaginal, vulvar, anal, penile, and oropharyngeal cancers, and HPV
types 16,18, 31, and 45 cause the greatest number of cancers. High-
risk HPV produces no visible symptoms; instead, it is detected by
DNA testing for the virus or on the basis of abnormal Pap test results
(ACS, 2014; Chelmow, Waxman, Cain, & Lawrence, 2012; Gattoc,
Flowers, & Ault, 2012; Gisvold, 2013; Schwartz, 2011).
HPV DNA Testing

Most HPV infections produce no symptoms, and frequently a woman
learns that she has been exposed to the virus only after undergoing
a routine Pap test. Reflex HPV DNA testing, performed on a sample
of vaginal or cervical cells collected during a pelvic examination, is
most commonly performed on cells collected from residual
preservative when liquid-based cytology is used. The HPV DNA test
can often be performed on the same sample collected for the Pap
test. HPV DNA testing assesses exfoliated cervical cells for the
presence of one or more of 13 or 14 of the 15 to 18 potentially
cancer-causing HPV types (ACOG, 2012a).
Although the Pap test can detect cellular changes caused by high-
risk types of HPV, it is not as sensitive as is the HPV test, which
specifically detects the viral DNA. DNA testing for HPV has gained
widespread acceptance as an additional cervical cancer screening
tool and as follow-up to abnormal changes detected with a Pap test.
Today, several DNA HPV tests can detect either the majority of the
high-risk types of HPV or specific subtypes, such as HPV 16 and
HPV 18. The tests are performed on cervical or vaginal cells
collected through self-sampling or obtained by a health-care provider
during a pelvic examination. In 2014, the Food and Drug
Administration (FDA) recommended that the cobas HPV test
(manufactured by Roche Pharmaceuticals) be used as a first-line
primary screening tool in women aged 25 years and older to assess
their risk of cervical cancer based on the presence of clinically
relevant high-risk HPV DNA. The cobas HPV test detects DNA from
14 high-risk HPV types including HPV 16 and 18 and 12 others.
Presently, ACOG recommends that women 30 years or older be
offered an HPV DNA test in addition to their Pap test and pelvic
exam, and this recommendation is supported by various
organizations, including the ACS, the National Institutes of Health
(NIH), the ASCCP, the NPWH, and the American Medical Women’s
Association (AMWA). The HPV DNA test is not recommended for
screening adolescents because infections with HPV are relatively
common in this age group and often resolve without treatment or
complications (ACOG, 2013; FDA, 2014; Massad et al, 2013).

In women with HPV infection, abnormal findings on Pap screening
are common. Of persons infected with HPV, only about 1% develop
external genital warts, while approximately 10% develop cervical
lesions. When present, HPV lesions most often occur on the
posterior part of the vaginal introitus. Other locations include the
buttocks, vulva, vagina, urethra, anus, and cervix. Four different
types of genital warts have been identified (Box 33-7). It is possible
to be infected with several different genotypes of HPV; some may be
associated with a low risk, whereas others are associated with a high
risk for the development of cervical cancer (ACS, 2014; ACOG,
2013).
What to Say
Counseling Patients About Abnormal Pap Test Results and HPV
It is incumbent upon the nurse to listen carefully and fully to patient concerns
about HPV and cervical cancer and offer support in coping with abnormal or
positive results. Nurses should be sensitive to the fact that sharing the results
of an abnormal Pap test with a patient can evoke feelings of anxiety, fear, and
difficulty assimilating the implications of the results. In this situation, the nurse
may wish to include the following information:
“Your abnormal Pap test result is not a diagnosis of a disease; it merely
alerts us to the fact that there is a need for closer surveillance (e.g., more
frequent testing) or further evaluation (e.g., colposcopy). Because it takes so
long for cervical changes caused by HPV to develop into cancer, women who
obtain Pap tests regularly are very unlikely ever to develop cervical cancer
because there is plenty of opportunity to identify and treat the problem at an
early stage” (Woodson, 2010).
HPV is an elusive virus with a clinical course that is characterized

by spontaneous regressions and recurrences. Once a woman
contracts genital HPV, she may develop a latent HPV infection, a
subclinical HPV infection, a clinical HPV infection (manifested by the
appearance of warts and/or cervical changes), or regression of the
HPV lesions (Box 33-8). For most women, HPV infection resolves
without intervention. It is estimated that up to 70% of HPV infections
clear in 1 year and 91% of infected women do not have detectable
levels of cervical HPV infection after 2 years. It is unknown whether
the virus is truly absent or is simply reduced to undetectable levels.
For the remaining 10% of women, persistent infection with certain
types of HPV constitutes the major risk factor for cervical cancer
(ACOG, 2012a; Kahn, Feemster, & Hillard, 2011).
BOX 33-7
Types of Genital Warts

Condyloma acuminata are soft, moist, pink, red, or gray lesions that may occur
singularly or in multiples. The warts occur on moist surfaces and often cluster to
form a cauliflower shape.
Smooth papular warts are small, dome-shaped papules that are usually skin
colored. They occur on hair-bearing or non-hair-bearing skin and do not occur
on mucosal tissue.
Keratotic genital warts have a thick layer and often look like “common” warts.
They develop on hair-bearing or on non-hair-bearing skin and other nonskin
tissues.
Flat warts are generally flat or slightly raised with flat tops. These lesions can
occur on moist or on dry tissue.
Source: Cox et al (2011)
BOX 33-8

Following exposure to HPV, one or more of the following may occur:
Latent HPV infection: No detectable warts are present (i.e., undetectable by
visual inspection, cytology, or HPV testing) and the person is noncontagious.
However, because the virus can move from latency to “expressed” HPV
disease (e.g., warts, cervical cell changes), there is no guarantee that the
person will remain noncontagious indefinitely.
Subclinical HPV infection: Applies to changes in the skin cells of the lower
genital tract that cannot be seen with the naked eye. The most common
subclinical change is intraepithelial neoplasia of the cervix (cervical
“precancerous change”; dysplasia; CIN 1, 2, or 3) that can be seen following
the application of vinegar (acetic acid) to the skin, followed by close
examination (e.g., colposcopy magnification) of areas that turn white
(acetowhitening). Although subclinical HPV may appear anywhere in the lower
genital tract, acetowhitening is very nonspecific and often unrelated to HPV.
Tissue biopsy must be used to confirm the diagnosis of HPV infection.
Clinical HPV: The presence of warts and precancerous changes on the
external genitalia (vulvar and perianal intraepithelial neoplasia; cervical and
other lower genital tract cancers) that can be seen with the naked eye.
Common clinical manifestations of HPV are:
• Condyloma acuminata: Raised, cauliflower-appearing (papillary) warts. Most
are caused by the low-risk HPV 6 or 11 and are generally found on the
external vulva, although they may also appear in the vagina, cervix, and anus.
• Condyloma planum: “Flat” warts; although most are caused by HPV 16 or
other high-risk types, they should be treated as genital warts and not as a true
precancerous condition.
• High-grade intraepithelial neoplasia: “Precancerous” flat HPV lesions that may
appear on the vulva and the perianal and anal canal area. They can be very
white (due to thick layers of keratin) or red (due to an increased blood supply)
or various shades of brown to dark gray (due to increased pigment).
• Cancer: HPV is the cause of virtually all cancers of the cervix, as well as
about 80% of vaginal cancers and 90% of anal cancers. In any of these
areas, the cancer may appear as a nodule, erosion, ulcer, or thickening.
IMMUNE-MEDIATED REGRESSION
• Most HPV lesions eventually resolve because of a host immune response to
the virus. This is especially true for genital warts and CIN 1 because neither is
truly precancer. Approximately 40%–50% of CIN 2 will resolve spontaneously;
CIN 3 is considered a true cancer precursor, although some CIN 3 may
resolve spontaneously to an immune-mediated regression.
• It is not known whether an immune-mediated regression clears that particular
HPV type from the body completely or just suppresses it to the point where it
is not likely to be contagious or cause HPV-induced disease in the future.
Sources: American Cancer Society (2014); Gravitt (2011)
NURSING INSIGHT
HPV and Chronological Age; STD Screening
HPV infections are most common in teenagers and women in their early 20s,
with prevalence decreasing as women age. Most women will come in contact
with HPV shortly after they become sexually active. Couples who are
contemplating a sexual relationship should always be encouraged to undergo
STD testing prior to initiating intercourse. However, because HPV is so very
common and most often undetectable, neither the CDC nor the American
Medical Association recommends clinical examinations for HPV as a
component of STD screening. By age 50, more than 80% of women will have
had HPV at some time in their lives. In adolescents and young women, HPV
infections and dysplasia are likely to resolve spontaneously. This finding
suggests that HPV infections detected in older women are more likely to reflect
persistent infections acquired in the past (ACOG, 2010, 2012).
The Nursing Role in Reducing Patient Risk of Cervical Cancer

Currently, researchers continue to investigate factors that may
promote the development of cervical cancer. The role and the
progression of HPV-induced lesions into cancer have recently
become clearer. Research has demonstrated that cigarette smoking
interferes with women’s ability to clear an HPV infection and is
associated with an increased risk of new HPV infection, persistent
HPV infection, and cervical cancer. Also, a dose-response
relationship with the amount of tobacco consumed has been noted.
Cessation of smoking can lead to a decrease in cervical lesion size,
whereas continuing to smoke can negatively affect the treatment
outcome once cervical changes have become apparent (Fonseca-
Moutinho, 2011). Other potential factors that link HPV with cervical
cancer include long-term oral contraceptive use, young age,
nutritional deficiency, presence of other genital tract infections, and
immunodeficiency, such as occurs with HIV infection. For women
with a healthy immune system, it may take decades for cervical
cancer to develop from an initial exposure to high-risk viral types
(ACOG, 2012a).
To guide clinical HPV screening and educational efforts, nurses
who work with women of all ages should be aware of certain risk
factors that are associated with HPV infection and/or HPV-related
cervical disease, including the following:
■ A sex partner more than 2 years older
■ More than three lifetime sex partners
■ A new sex partner in the past 12 months
■ Illegal drug use in the past 12 months
■ Engaging in intercourse while impaired by alcohol
■ Never having been married
■ Having a male partner who is not circumcised (ACS, 2013; Mayo
Clinic, 2014; National Cancer Institute, 2012)
A recent review of the literature revealed that several studies have
linked HPV and cervical cancer to intimate partner violence in
women, likely because women victims are less able to successfully
negotiate strategies for safer sex, such as condom usage and
monogamy, with an abusive partner. Also, female victims of violence
are more likely to smoke, which increases the risk for cervical
cancer. Women who have sex with women (WSW) are also at risk of
contracting HPV. Although less common than heterosexual
transmission, woman-to-woman HPV transmission is possible. Many
WSW report a history of sexual encounters with men and may have
engaged in intercourse without condoms. WSW may be less likely to
seek regular pelvic examinations and Pap tests, although these
health-promoting practices are recommended for women regardless
of their sexual partners’ gender (Crane, 2010; Hrivnak, 2013;
Institute of Medicine, 2011; McCormish, 2012; Pruitt, 2012).
Women who have sex with women should be made aware that
they are at risk for HPV infection and therefore require Pap
screening. Nurses must educate all women about the
contagiousness of HPV and emphasize that it is not exclusive to
women who have heterosexual intercourse. It is also essential that
patients understand that HPV risk increases with the number of
sexual partners, regardless of gender, and that certain sexual
practices (e.g., engaging in oral-genital and genital-genital contact
without barrier devices; not cleaning sex toys between use; engaging
in digital penetration without gloves, condoms, or finger cots) are
associated with infection risk. Vaccination against HPV should be
offered to all women who meet the prescribing criteria (i.e., younger
than age 26).
An important role for nurses in reproductive health promotion
centers on counseling and education about strategies to enhance
the immune system and reduce the risk for contracting HPV and
other STDs. For example, the nurse can teach patients that
refraining from smoking; limiting the use of alcohol; consuming a
healthy, nutritious diet; maintaining a healthy weight; and avoiding
exposure to chemical and environmental hazards are health
practices that enhance the strength of the immune system.
Observing sexual abstinence or, if sexually active, consistently using
condoms or receiving prophylactic HPV vaccination are other
preventive strategies to reduce the risk for infection. The nurse can
counsel women that they can lower their chance of getting HPV by
remaining in a faithful relationship with one partner, by limiting the
number of sex partners, and by choosing a partner who has had no
or few prior sex partners (CDC, 2013a; Linton, 2013).
The patient with genital warts may benefit from HPV counseling
sessions that include her intimate partner. Meeting with both partners
provides an opportunity for the couple to learn that HPV infection is
common and probably shared between partners and affords the
possibility for other STD evaluation and screening along with Pap
screening. The nurse can again emphasize the importance of routine
cytological screening for cervical cancer.
Optimizing Outcomes
Condoms to Reduce the Risk of Contracting HPV
Latex condoms offer some protection against HPV, and consistent condom use
appears to reduce the risk of HPV transmission by about 70%. However,
condoms protect only those areas of skin that they cover—and many infected
individuals have HPV in noncovered areas of their skin that come into contact
with their partner’s skin. Secretions may also be a source of HPV-infected skin
cells that could come into contact with a partner’s uncovered skin areas.
Spermicides and condoms coated with spermicide are not effective in
preventing HPV and may cause microscopic abrasions that facilitate
transmission of HPV and other STDs. Because female condoms cover more of
the female introital epithelium at risk for HPV, they may provide a more
protective barrier for both partners. However, the female condom may also be
more easily dislodged during intercourse (CDC, 2014; Schiffman &
Wentzensen, 2010).
What to Say
When Discussing HPV With Patients
The nurse can be instrumental in dispelling various myths and misconceptions
about genital HPV. Providing current, evidence-based information empowers
the woman to make informed choices and decisions about her reproductive
health. Depending on the situation, sharing the following information may be
appropriate:
“Genital HPV is very common. It is primarily transmitted through sexual
contact involving genital skin, and penetrative intercourse is not required. The
only way to entirely eliminate the possibility of being exposed to HPV is
abstinence from any form of genital-genital or oral-genital contact. The lifetime
likelihood of getting genital HPV is estimated at 75% to 90%, and the risk of
exposure to HPV is estimated to be approximately 15% to 25% per partner.
That is, for every sexual partner one has, there is up to a 25% chance of being
exposed to some type of HPV. Because HPV rarely causes symptoms, most
people who get HPV never know they have it—they do not develop genital
warts, receive an abnormal Pap test result, or develop any other manifestations
of HPV that they can identify. An HPV diagnosis does not necessarily mean
that your partner has not been monogamous; it means only that the infection
was contracted at some point in that person’s life. HPV testing is not indicated
for partners of persons with genital warts. An abnormal Pap test result does not
necessarily mean that a woman is at high risk for cervical cancer. The
abnormal result can be related to infection, local irritation, a low-risk HPV type,
or a higher risk HPV type. Depending on your age and the degree of
abnormality, further evaluation or co-testing for HPV DNA may be
recommended. Only one in four cases of cervical lesions, if left untreated, will
progress to cancer, and treatment is almost always successful in preventing
cancer if the cells are discovered early. Undergoing routine Pap testing
according to the recommendations of your health-care provider is an important
preventive strategy” (ACOG, 2010, 2012a; CDC, 2014).
HPV Vaccines
A vaccine (Gardasil) against HPV types 6, 11, 16, and 18 became
available in 2006. Gardasil is the first HPV vaccine in the United
States. The quadrivalent recombinant (nonlive virus) vaccine is
recommended for females aged 9 to 26 years. (The quadrivalent
HPV vaccine may also be given to males aged 9 through 26 years to
reduce their likelihood of acquiring genital warts; ideally, the vaccine
should be administered before potential exposure to HPV through
sexual contact.) Vaccination consists of three intramuscular
injections given over 6 months, with the second dose to be given 2
months after the first dose and the third dose given 6 months after
the first dose. If the HPV vaccine schedule is interrupted, the vaccine
series does not need to be restarted (ACOG, 2014; CDC, 2014;
Linton, 2013).
The HPV vaccine is supplied in prefilled syringes for single use
only and in single-use vials; the vials must be stored under
refrigeration and protected from light. The vaccine is highly
protective, especially when the vaccination occurs before sexual
activity. Although the vaccine does not prevent infection with all
types of HPV, it provides protection against the HPV types
associated with 70% of cervical cancers (16, 18) and 90% of
external genital warts (6, 11). It is also effective in the prevention of
vaginal, vulvar, and anal dysplasia and cancer caused by HPV types
16 and 18. However, if a woman has already been infected with HPV
16, 18, 6, or 11, the vaccine offers no protection, and only limited or
no protection against the other HPV types. Hence, the protection
afforded by the vaccine is lower in women who have had sex prior to
vaccination. The quadrivalent vaccine has also been demonstrated
to protect against vulvar and vaginal cancers (CDC, 2014; Gattoc et
al, 2012; Linton, 2013; McGuire, 2011).
In late 2014, the FDA approved a 9-valent recombinant HPV
vaccine (Gardasil 9) that also covers HPV types 31, 33, 45, 52, and
58. These latter five are responsible for roughly one in five cases of
cervical cancer. Gardasil 9, also administered as three intramuscular
injections given over 6 months, is approved for use in females aged
9 through 26 and in males aged 9 through 15 (FDA, 2014).
Cervarix is a bivalent vaccine that protects against HPV 16 and
18. Approved by the FDA in 2009, Cervarix also consists of three
intramuscular injections given over 6 months; the second dose is
given 1 month after the first dose and the third dose is given 6
months after the first dose. Cervarix is approved for use in girls and
women aged 10 through 25 to prevent cervical cancer (Carlos,
Dempsey, Patel, & Dalton, 2010; CDC, 2014).
Offer HPV Vaccines to Appropriate Patients

It is important that an HPV vaccine be administered before people become
sexually active. The CDC’s Advisory Committee on Immunization Practices
recommends that Gardasil and Cervarix be routinely given to girls when they
are 11 or 12 years old. However, Gardasil can be started as early as age 9 and
can also be given to women 13 to 26 years old. Cervarix is approved for use in
females 9 through 25 years of age. Although the vaccine series should begin
before the initiation of sexual intercourse, a “catch-up” series is recommended
for young women in the older age group who are already sexually active. HPV
testing should not be conducted before HPV vaccination. HPV vaccines are not
recommended for use in pregnant women, but pregnancy testing is not needed
before vaccination. Completion of the HPV vaccine series should occur before
pregnancy or after a pregnancy is complete. The HPV vaccines are
contraindicated for persons with a history of immediate hypersensitivity to any
vaccine component. The quadrivalent HPV vaccine (Gardasil) is contraindicated
for persons with a history of immediate hypersensitivity to yeast. The bivalent
HPV vaccine (Cervarix) in prefilled syringes is contraindicated for persons with
an anaphylactic latex allergy. Because the HPV vaccines are not live vaccines,
they may be administered either simultaneously or at any time before or after an
inactivated or live vaccine. Syncope may occur after vaccination; to avoid
patient injury related to a syncopal episode, the nurse should observe the
patient for 15 minutes after any vaccination, with the adolescent seated or lying
down. The most commonly reported adverse reactions to the vaccinations
include pain, redness, and swelling at the injection site and fever, fatigue,
headache, muscle and joint aches, and gastrointestinal distress. Because the
vaccines do not cover all of the HPV types that can cause cervical cancer,
routine Pap test screening is still recommended for those who have been
vaccinated against HPV.
Funding Resources for HPV Vaccination
Most health insurance plans cover the recommended HPV vaccines, although
some plans may not cover any or all vaccines. The Vaccines for Children (VFC)
program helps families of eligible children who may not otherwise have access
to vaccines. The program provides vaccines at no cost to physicians who serve
eligible children. Children younger than 19 years of age are eligible for VFC
vaccines if they are Medicaid-eligible, American Indian, or Alaska Native, or
have no health insurance. “Underinsured children” who have health insurance
that does not cover vaccination can receive VFC vaccines through Federally
Qualified Health Centers or Rural Health Centers. For more information about
the program, nurses may visit the CDC Web site at
http://www.cdc.gov/vaccines/programs/vfc/index.html.
HPV Education and Counseling for Teens and Their Parents

An essential area for nurses in HPV awareness and prevention
centers on education and counseling for adolescents and teens and
their parents. Because both males and females may be at risk for
acquiring HPV, educational efforts should target both genders. It is
important that reproductive health counseling provide
developmentally appropriate information. Preteens tend to be
concrete thinkers, and teenagers are more likely to engage in risky
health behaviors. Understanding the tasks associated with normal
adolescent development is an essential element that guides the
nurse in establishing and directing a therapeutic dialogue.
Communicating with young patients about HPV, the HPV vaccine,
and other health issues may be enhanced by listening attentively,
using terms the adolescent understands, remaining focused, and
avoiding lectures and writing during the conversation.
OVARIAN CANCER
Ovarian cancer is the leading cause of gynecological deaths and the
fifth most common cause of cancer in women in the United States
(Centers for Disease Control and Prevention, 2020b). Although the
cause is unknown, there are identified risk factors, including
increasing age (the highest incidence is between 60 and 64);
nulliparity; pregnancy later in life; obesity (body mass index of at
least 30); the presence of BRCA1 and BRCA2 genes; a personal
history of breast cancer; and a family history of breast, ovarian, or
colorectal cancer. Associative causes include a history of
endometriosis, the use of ovarian hyperstimulation medications
prescribed for infertility or hormone replacement therapy; exposure
to asbestos; genital exposure to talcum powder; smoking; a diet high
in fat, meat, and sweets (National Health Service, 2020). Pregnancy
and oral contraceptive use provide some protection against ovarian
cancer, and the use of postmenopausal estrogen may increase the
risk (Centers for Disease Control and Prevention, 2020b).
Unfortunately, the signs and symptoms of ovarian cancer are often
vague until late in development. Although once termed a “silent
killer,” ovarian cancer should instead be considered a “whispering
disease,” whose symptoms must be listened to carefully by patients
and providers alike. Ovarian cancer should be considered in any
woman over age 40 who has complaints of vague abdominal or
pelvic discomfort, pain, or enlargement; back pain; indigestion;
inability to eat normally; feeling full after eating only a small amount;
a sense of bloating; constipation; urinary incontinence; urinary
frequency or urgency of recent onset; or unexplained weight loss.
Ovarian cancer symptoms are likely to be progressive, persistent,
frequent, and severe, and they are also more likely to occur in
synchrony with other symptoms. Enlargement of the abdomen due to
accumulation of fluid (ascites) is the most common sign. Because
ovarian cancer is a rapidly growing neoplasm, the diagnosis is often
not made until the cancer has metastasized (Centers for Disease
Control and Prevention, 2020b). Staging information for uterine
cancers appears in Table 33-2.
TABLE 33-2
Staging of Uterine Cancer
STAGE DESCRIPTION
Stage 1 Cancer is found in one or both ovaries or
fallopian tubes.
Stage II Cancer is found in one or both ovaries or
fallopian tubes and has spread into other
areas of the pelvis, or primary peritoneal
cancer is found within the pelvis.
Stage III Cancer is found in one or both ovaries or
fallopian tubes, or is primary peritoneal
cancer, and has spread outside the
pelvis to other parts of the abdomen
and/or to nearby lymph nodes.
Stage IV In stage IV, cancer has spread beyond
the abdomen to other parts of the body.
Source: National Cancer Institute (2021)
Optimizing Outcomes
Biomarkers for Epithelial Ovarian Cancer

Cancer antigen 125 (CA-125) is a serum protein that is higher in many women
with epithelial ovarian cancer. In premenopausal women with symptoms, a CA-
125 measurement is frequently not useful because elevated levels of the protein
are associated with a variety of common benign conditions (e.g., uterine
leiomyomata, PID, endometriosis, pregnancy). In postmenopausal women with
a pelvic mass, a CA-125 measurement may be helpful in predicting a higher
likelihood of a malignant tumor than a benign tumor, although a normal CA-125
measurement alone does not rule out ovarian cancer (American College of
Obstetricians and Gynecologists, 2017; U.S. National Library of Medicine,
2020).
A strong family history of breast cancer may be caused by an

inherited mutation in the BRCA1 or BRCA2 gene. Because
alterations in these genes have been detected in women with
ovarian cancer, screening women with the BRCA mutations can be
performed to determine whether they carry these genes.
Interestingly, these mutations also increase the risks for primary
peritoneal carcinoma and fallopian tube carcinoma. Furthermore,
research has shown that the fimbriated end of the fallopian tube
contains precursor lesions that lead to the development of ovarian
cancers in both BRCA-positive and BRCA-negative populations.
Based on this information, some experts suggest that offering
patients a salpingectomy (removal of the fallopian tubes) during
benign gynecological surgeries may provide an option for ovarian
cancer prophylaxis for the general population (American College of
Obstetricians and Gynecologists, 2017; Centers for Disease Control
and Prevention, 2020c; National Health Service, 2020).
Laparotomy is performed for surgical confirmation and clinical
staging, which provides direction to the treatment and prognosis of
the cancer. The preferred treatment for ovarian cancer is surgical
removal and usually requires a hysterectomy with bilateral salpingo-
oophorectomy. After surgery, chemotherapy (administered
intravenously and intraperitoneally), sometimes combined with
immunotherapy, is used to treat any remaining cancer. Radiation
therapy may be used as a palliative measure, although it is not
typically used as a treatment option for ovarian cancer.
Treatment for ovarian cancer will often depend on the patient’s
stage of disease. There are currently three main types of treatment:
surgery, chemotherapy, and targeted therapy. The goal of surgery is
to remove as much of the tumor as possible. A hysterectomy is the
most common type of surgery in cases of ovarian cancer. Different
degrees of a hysterectomy will be performed; for example, if just the
uterus needs to be removed then a partial hysterectomy will be
performed. Chemotherapies often include a wide range of different
neoplastic treatments. One treatment modality for women with
ovarian cancer is receiving intraperitoneal chemotherapy, which is
direct administration of chemotherapy into the peritoneal cavity to
directly target the uterine cancer. Target therapy is a novel type of
treatment in which immune system monoclonal antibodies are
modified in a lab to target and destroy specific cancer cells (National
Cancer Institute, 2021).
ENDOMETRIAL CANCER
In the United States, cancer of the endometrium is the most common
gynecological malignancy. Most uterine malignancies arise within the
inner lining of the uterus and are adenocarcinomas that develop from
overgrowth (hyperplasia) of the endometrium. Uterine cancer is
rarely found in women under age 40; approximately 70% of all cases
are found in women in the 50 to 69 age group. However, certain
conditions (e.g., chronic anovulation, diabetes, obesity, genetic
predisposition) predispose some premenopausal women to
excessive levels of circulating estrogen, increasing their risk for
endometrial cancer. The average chance of a woman being
diagnosed with endometrial cancer during her lifetime is about 1 in
38. Currently, there are more than 500,000 survivors of endometrial
cancer living in this country. Interestingly, this cancer is more
common in white women, but African American women are more
likely to die of it (ACOG, 2019).
NURSING INSIGHT
Estrogen and Endometrial Cancer
There is an established relationship between unopposed (i.e., absence of
progesterone) exogenous estrogen and uterine cancer. Progesterone inhibits
the growth of cells stimulated by estrogen and causes them to enter a more
mature secretory state. Postmenopausal women who receive estrogen therapy
without progesterone have much higher rates of uterine cancer.
The exact cause of uterine cancer is not known. However, risk

factors have been established. These include unopposed estrogen
therapy, nulliparity or low parity, early menarche (before age 12), late
menopause (after age 55), therapy with tamoxifen (an antiestrogen
medication used in the prevention and treatment of breast cancer),
infertility, diabetes, gallbladder disease, PCOS, a history of ovarian
granulosa-theca cell tumors, hypertension, diabetes mellitus, a high
sugar, high-fat diet (which increases the levels of circulating
estrogen), and obesity. Factors associated with a lower risk for
endometrial cancer include multiparity, use of combination oral
contraceptives, use of an intrauterine device, and menopausal
estrogen therapy combined with progesterone therapy for women
who have a uterus. A genetic syndrome known as Lynch syndrome
(previously termed hereditary nonpolyposis colorectal cancer) has
also been associated with both endometrial and ovarian cancer
(ACOG, 2019).
Endometrial cancer is slow growing, and more than 75% of the
neoplasms are adenocarcinomas that develop from endometrial
hyperplasia. Most women are symptomatic in the early stages of this
cancer, a factor that leads to early diagnosis and, frequently,
successful treatment. There are no effective screening methods to
detect endometrial cancer. Instead, women and their health-care
providers must rely on signs and symptoms of the condition. For
postmenopausal women, the cardinal symptom is vaginal bleeding;
perimenopausal women may experience heavy or prolonged
menstruation or spotting or bleeding between menses. Other
symptoms for women in all age groups include pelvic pain, pain with
intercourse, dyspareunia, and weight loss (American College of
Obstetrician and Gynecologists, 2019; National Cancer Institute,
2020).
Pelvic examination may reveal a uterine enlargement or mass. A
patient who has abnormal vaginal bleeding should have an
endometrial biopsy. Fractional curettage, a procedure that involves a
scraping of the endocervix and the endometrium to obtain tissue for
histological evaluation, may also be performed. Other diagnostic
tests that may be conducted include hysteroscopy (examination of
the uterus through an endoscope) and transvaginal ultrasound. If
invasive endometrial cancer is present, systematic surgical staging is
performed. The work-up may also include chest radiography,
abdominal computed tomography (CT) scan, MRI, cystoscopy,
proctoscopy, liver function tests, renal function tests, bone scans,
and serum testing for the presence of cancer antigen 125 (CA-125,
released by some endometrial and ovarian cancers) to determine the
extent of metastasis.
Endometrial cancer is staged based on its location and extension
into surrounding tissue and distant metastases. Treatment involves
total abdominal hysterectomy along with removal of the ovaries,
fallopian tubes, and local lymph nodes. Following the surgery, RT,
chemotherapy, or hormone therapy may be prescribed, depending
on the clinical findings. When endometrial cancer is diagnosed and
treated early, survival rates are good (American College of
Obstetrician and Gynecologists, 2019).
Addressing Sexual Issues in Women With Gynecological Cancer
A woman’s sexual response is often affected by the myriad of physiological and
psychological effects of cancer and cancer treatment. Physical factors include
fatigue, pain, alopecia, weight change, loss of control over various bodily
functions, and symptoms of menopause. Psychological effects on sexuality
may stem from anxiety, depression, fear of dying or cancer recurrence, feelings
of vulnerability and isolation, and, for many, the realization of an end to
reproductive opportunity. It is important to establish communication about
sexual issues early in the course of treatment; individualized interventions can
help patients maintain their sexual quality of life after cancer. A multidisciplinary
approach with a care team that includes psychologists or sex therapists with
specialized training can be useful in addressing the various facets of sexual
impairment in women after gynecological cancer.
PREMALIGNANT AND MALIGNANT VULVAR

LESIONS
Most vulvar cancer is squamous in origin. Because the vulva is
covered with skin, any malignancy that appears elsewhere on the
skin can also occur on the vulva. Vulvar intraepithelial neoplasia
(VIN) is a cancer precursor often associated with HPV. The most
common symptom of VIN is persistent itching; localized burning
and/or skin thickening or discoloration (e.g., red, pink, lighter, or
darker) in the affected area may also be present. Diagnosis is limited
to visual assessment, and biopsy is indicated for any pigmented
vulvar lesion. Treatment includes wide surgical excision (when
cancer is suspected), laser ablation (when cancer is not suspected),
and the application of topical imiquimod 5% (off-label use). Women
with VIN are at risk of recurrent VIN and vulvar cancer throughout
their lifetimes and should continue to receive monitoring.
Immunization with the quadrivalent HPV vaccine (effective against
HPV genotypes 6, 11, 16, and 18) has been shown to decrease the
risk of VIN. Women who have a history of genital warts and who
smoke have an increased risk of developing vulvar cancer. Invasive
vulvar cancer is the presence of a malignant lesion that breaks
through the cellular basement membrane. This type of cancer occurs
most often in older (70+ years) women, and in the United States it is
responsible for 5% of all female genital malignancies.
Melanoma is the second most common type of invasive vulvar
malignancy, but it is extremely rare, accounting for less than 5% of
all vulvar cancers. Most melanomas are located on the labia minora
or clitoris and are blue-black in color. They have a jagged or fuzzy
border, and the lesions may be raised or ulcerated. Although the
condition may affect women of all ages, vulvar melanoma is more
common in older (70+ years) women, and more than 90% occur in
white women. Biopsy is needed for diagnosis, and treatment
involves surgical excision and, in some situations, inguinal
lymphadenectomy.
Paget’s disease is another rare neoplasm of the vulva. It also
occurs more commonly in older (70+ years) women. Symptoms
include intense vulvar itching and soreness, usually of long duration.
Lesions of Paget’s disease are thick, often leading to an impression
of leukoplakia. The affected area may also be red, moist, and
elevated; biopsy is necessary for diagnosis. Treatment consists of
surgical excision (Fruchter et al, 2017).
SUMMARY POINTS
■ Cervical cancers originate in the cells on the surface of the cervix, which are
composed of squamous and columnar epithelium.
■ Cytological screening for cervical cancer should begin at age 21 years,
regardless of the woman’s sexual history.
■ An important nursing role in cervical cancer education centers on
emphasizing the importance of compliance with recommended cervical
cancer screening and teaching women about symptoms that may be
associated with cancer of the cervix.
■ Infection with HPV is known to be the primary cause of cervical cancer.
■ An essential area for nurses in HPV awareness and prevention centers on
education and counseling for adolescents and teens and their parents.
■ The HPV vaccines are indicated for the prevention of cervical cancer, genital
warts, and dysplastic or precancerous cervical lesions caused by several of
the HPV virus types.
■ Routine Pap test screening is recommended for women regardless of whether
they have received the HPV vaccine.
■ Nurses are perfectly situated to provide women with factual information about
cervical cancer screening, HPV, and cervical cancer.
■ Ovarian cancer is the leading cause of gynecological deaths and the fourth
most common cause of cancer deaths in women.
■ In the United States, cancer of the endometrium is the most common
gynecological malignancy, and approximately 70% of all cases are found in
women in the 50 to 69 age group.
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Davis Advantage
APPENDIX A
Centigrade to Fahrenheit
Temperature Conversions
CONVERSION FORMULAS
°F = (°C × 9/5) + 32, or (°C × 1.8) + 32
°C = (°F – 32) × 5/9, or (°F – 32) × 0.55
°C °F
35.0 95.0
35.2 95.4
35.4 95.7
35.6 96.1
35.8 96.4
36.0 96.8
36.2 97.2
36.4 97.5
36.6 97.9
36.8 98.2
37.0 98.6
37.2 99.0
37.4 99.3
37.6 99.7
37.8 100.0
38.0 100.4
38.2 100.8
38.4 101.1
38.6 101.5
38.8 101.8
39.0 102.2
39.2 102.6
39.4 102.9
39.6 103.3
39.8 103.6
40.0 104.0
40.2 104.4
40.4 104.7
40.6 105.1
40.8 105.4
APPENDIX B
Expected Temperatures in Children
AGE FAHRENHEIT (°F) CENTIGRADE

(°C)
2 months 99.4 37.5
4 months 99.5 37.5
1 year 99.7 37.7
2 years 99.0 37.2
4 years 98.6 37.0
6 years 98.3 36.8
8 years 98.1 36.7
10 years 98.0 36.7
12 years 97.8 36.6
Glossary
Abortion Termination of pregnancy before the fetus reaches a viable

age, usually less than 20 weeks of gestation, or when the fetus
weighs less than 500 grams
Complete a. The total products of conception have been expelled
Elective a. Voluntary termination of a pregnancy for nonmedical
reasons
Habitual a. Three or more consecutive spontaneous abortions
Imminent a. Impending abortion characterized by bleeding and
abdominal pain
Incomplete a. An abortion in which part of the products of
conception has been retained in the uterus
Induced a. The intentional termination of a pregnancy by means
of dilating the cervix and evacuating the uterus
Inevitable a. An abortion that cannot be halted
Missed a. An abortion in which the fetus has died before
completion of the 20th week of gestation but the products of
conception are retained in the uterus for 8 weeks or longer
Recurrent a. Three or more pregnancies that have ended in
spontaneous abortion, often due to genetic, chromosomal, or
anatomical irregularities
Septic a. An abortion in which there is infection of the products of
conception and the endometrial lining of the uterus
Spontaneous a. Abortion occurring without apparent cause
Therapeutic a. Abortion performed when the pregnancy
endangers the mother’s mental or physical health or when the
fetus has a known condition that is incompatible with life
Threatened a. The appearance of signs and symptoms of
possible loss of the fetus; first sign is usually vaginal bleeding
with or without intermittent pain
Acrocyanosis Peripheral cyanosis; bluish coloration of the hands
and feet present in most infants at birth
Acromioclavicular joint (AC joint) A gliding or plane joint between
the acromion and the acromial end of the clavicle
Addison’s disease Chronic adrenocortical insufficiency, the result of
an underactive adrenal gland
Adjourning Also called terminating, represents the final stage in a
group when it has accomplished its goals and disbands to possibly
form a different group. Families experience this stage when
members die, divorce, or leave the family to begin their own
families.
Adrenal glands Located on the top of each kidney. Each gland has
an outer (cortex) portion and an inner (medulla) portion. The
hypothalamus controls the adrenal glands by directing the anterior
pituitary to release adrenocorticotropic hormone (ACTH) releasing
hormone.
Agoraphobia May be related to contact with feared situation (public
place, crowds), possibly evidenced by tachycardia, chest pain,
dyspnea, gastrointestinal distress, faintness, and sense of
impending doom
Allergic shiners Dark undereye rings
Allogeneic transplant When the recipient’s human leukocyte
antigens (HLAs) are matched to a compatible donor, usually a
sibling
Alopecia Loss of hair in sharply defined patches, usually involving
the scalp or beard
Alternative and complementary medicine/therapies (CAM)
Nontraditional approaches to healing and health care; therapies
are philosophically different from Western medicine; often involve
interventions believed to induce healing from within to allow the
body, mind, and spirit to heal
Amenorrhea Absence of menses
Amnioinfusion Infusion of warmed normal saline into the uterus via
sterile intrauterine catheter; performed in an attempt to increase
the fluid around the umbilical cord and prevent compression during
uterine contractions
Amnion The innermost of the two fetal membranes that form the sac
and contain the fetus and the fluid that surrounds it in utero (also
called the amniotic sac)
Amniotomy Artificial rupture of the fetal membranes (AROM)
Anaerobic Occurring in the absence of oxygen
Analgesia Relief, to some degree, of pain without loss of
consciousness
Anaphylaxis Immediate hypersensitivity reaction to an excessive
release of chemical mediators affecting the entire body; a medical
emergency
Anaplasia Abnormal cells
Anesthesia Partial or complete absence of sensation with or without
loss of consciousness
Anisometropia A condition in which the refractive power of the eyes
is unequal
Anorexia nervosa Eating disorder marked by weight loss,
emaciation, a disturbance in body image, and fear of weight gain
Anthropometric measurements Growth measurements of length,
weight, head circumference, and skin-fold thickness
Antibodies Specific protein substance produced by the body that
exerts restrictive or destructive action on specific antigens (e.g.,
bacteria, toxins, Rh factor)
Anticipatory guidance Information and examples given to children
and families concerning normal growth and development
expectations
Antidiuretic hormone (ADH) Acts on the kidneys to conserve water
by controlling the kidneys’ urine output. ADH is secreted by the
hypothalamus and stored in the posterior pituitary gland before it is
released into the bloodstream.
Antigens Proteins foreign to the body, causes the body to develop
antibodies (e.g., bacteria, dust, Rh factor)
Apnea Temporary cessation of breathing that lasts more than 20
seconds, associated with generalized cyanosis
Apophysis An offshoot or projection, especially from a bone
Arterial blood gas (ABG) test Uses the blood taken from an artery
to measure partial pressure of oxygen, partial pressure of carbon
dioxide, bicarbonate, pH, oxygen content, and saturation values.
ABG testing can identify how efficiently the lungs remove carbon
dioxide from the blood and move oxygen into the blood.
Arteriovenous (AV) fistula Joining of artery and vein for the
purpose of hemodialysis
Arthralgias Joint pain
Articular Joint capsule
Asplenic Without a spleen
Aspiration Drawing in or out by suction; foreign bodies can be
aspirated into the lungs; entry of secretions into tracheobronchial
passages
Assisted reproductive techniques/therapies (ARTs) Treatments
for infertility; include in vitro fertilization (IVF) and therapeutic
insemination
Asynclitism Oblique presentation of the fetal head at the superior
strait of the pelvis—the pelvic planes and those of the fetal head
are not parallel
Atherosclerotic Marked by cholesterol-lipid-calcium deposits in the
walls of arteries that may restrict blood flow
Atopic Hypersensitivity, allergic
Attachment A specific affective tie that binds one person to another;
the bond or emotional and physical connection that develops
between an infant and caregiver, which tends to endure
Augmentation of labor Stimulation of ineffective uterine
contractions after labor has begun spontaneously but is not
progressing satisfactorily
Autoimmune disorder Body produces antibodies against itself that
cause tissue damage
Autologous transplant Child’s own cells are taken, stored, and
reinfused after the child has received chemotherapy
Autosomes Any of the paired chromosomes other than the sex (X
and Y) chromosomes
B-natriuretic peptide A hormone secreted by the left or right
ventricle of the heart; concentration of this peptide in the
bloodstream rises during episodes of decompensated heart failure
Bacterial vaginosis (BV) The most common vaginal infection in
women. Although it is a sexually associated condition, it is not
usually considered to be a specific STD.
Bandl ring Pathologic retraction ring composed of an abnormally
thickened ridge of uterine musculature that develops between the
upper and lower uterine segments; occurs after a mechanically
obstructed labor
Baroreceptors A sensory nerve ending stimulated by changes in
pressure
Baseline fetal heart rate Average fetal heart rate observed between
contractions
Beneficence Ethical principle that emphasizes doing what is best for
the patient
Bethesda system The most commonly used classification for
abnormal cervical cytology and histology
Bereavement team A group of trained professionals who know how
to approach the topic of organ tissue donation while maintaining
dignity and respect for the deceased child
Biliary atresia An idiopathic, progressive, inflammatory process that
may involve absence of some or all the major intrahepatic and
extrahepatic biliary ducts, resulting in fibrosis and obstruction.
Biliary atresia is the second most common liver disease diagnosed
in infants.
Bilious vomiting Vomit containing bile
Biophysical profile (BPP) Noninvasive assessment of the fetus,
uses ultrasonography and uterine fetal monitoring; includes fetal
breathing movements, gross body movements, fetal tone, reactive
heart rate (nonstress testing), and qualitative amniotic fluid volume
Bipolar disorder A psychological disorder marked by manic and
depressive episodes. Bipolar disorders are divided into four main
categories: bipolar I, bipolar II, cyclothymia, and nonspecified
disorders; mania is the essential feature of bipolar I, whereas
recurrent moods of both mania and depression mark bipolar II.
Bishop score tool Rating system to evaluate cervical inducibility; a
higher score is associated with a greater likelihood for successful
labor induction
Blastocyst Stage in development of a mammalian embryo that
follows the morula; consists of an outer layer (trophoblast) and an
inner cell mass, from which the embryo develops
Body mass index (BMI) An index for estimating obesity. The BMI
can be obtained by dividing weight in kilograms by height in
meters squared, or according to the following formula: BMI =
(Weight/2.205) /(Height/39.37)2. In adults, a BMI greater than 30
kg/m2 indicates obesity; a BMI greater than 40 kg/m2 indicates
morbid obesity; and a BMI less than 18.5 kg/m2 indicates that a
person is underweight.
Bradycardia Baseline fetal heart rate of less than 110 to 120 beats
per minute
Braxton Hicks sign Mild, intermittent uterine contractions; a
probable sign of pregnancy
Breast conservation therapy (BCT) The lump in the breast and an
area of surrounding normal tissue are removed, also called
lumpectomy. Factors that indicate BCT instead of mastectomy
(surgical removal of the breast) include the tumor size, location,
number, and patient preference.
Bronchodilator A drug that expands the bronchi by relaxing
bronchial muscle
Bronchopulmonary dysplasia (BPD) A chronic lung disease in
which the newborn remains oxygen-dependent past 36 weeks’
gestation. BPD is a complication produced by long-term oxygen
use, especially with mechanical ventilation therapy.
Brown adipose tissue Also known as “brown fat”; unique neonatal
heat source that is capable of greater thermogenic activity than
ordinary fat; deposits located around the adrenal glands, kidneys,
neck, between the scapulas, and behind the sternum
BUBBLE-HE A mnemonic that guides postpartum nursing care by
reminding the nurse to assess the breasts, uterus, bladder, bowel,
lochia, and episiotomy (perineum), Homan’s sign/DVTs, and
emotions
Bulimia nervosa Eating disorder marked by recurrent episodes of
binge eating, self-induced vomiting and diarrhea, excessive
exercise, strict dieting or fasting, and an exaggerated concern
about body shape and weight
Burnout State of physical, emotional, and mental exhaustion caused
by long-term involvement in emotionally demanding situations;
emerges gradually and is a result of emotional exhaustion and job
stress
Candidiasis Commonly known as a yeast infection, generally
caused by Candida albicans
Cardiac output Amount of blood discharged from the left or right
ventricle per minute; product of stroke volume and heart rate
Cardinal movements of labor Mechanism of labor in a vertex
presentation; describes how the fetus passes through the birth
canal and the positional changes required to facilitate birth
Caregiver burden Unrelenting pressure and anxiety in providing
daily care to a child with disabilities while meeting other family
needs; can be a major source of stress
Carrier One who carries a gene that does not exhibit itself in
physical or chemical characteristics but that can be transmitted to
children (e.g., hemophilia trait, carried by the female but
expressed in male offspring)
Cast syndrome Condition that occurs when a child is placed in a
spica cast and a portion of the duodenum is compressed between
the superior mesenteric artery and the aorta, causing vomiting,
abdominal distention, and bowel obstruction
Cellulitis A bacterial infection that occurs when bacteria, most
commonly streptococcus and staphylococcus, enter through a
crack or break in the skin
CenteringParenting An innovative model of centering health care in
which 5 to 6 mother-infant dyads continue group care throughout
the baby’s first year of life. The model incorporates 10 postpartum
and well-baby examinations and provides an avenue of continued
support for the woman’s transition to motherhood.
Cephalic Pertaining to the head
Cephalocaudal Progression from head to tail (top to bottom)
Cephalopelvic disproportion (CPD) Condition in which the fetal
head is of a shape, size, or position that prohibits it from passing
through the maternal pelvis; may also be caused by maternal
pelvic problems
Cerclage Placement of nonabsorbable suture to keep a prematurely
dilating cervix closed
Cerebral palsy (CP) The most common permanent physical
disability of childhood, characterized by physical impairment and
mild to severe physical and mental dysfunction.
Ataxic CP Causes difficulties with balance and depth perception.
Children walk with an unsteady gait, demonstrate poor
coordination, and often have fine motor control problems.
Athetoid CP Characterized by uncontrolled involuntary writhing
movement of extremities. In severe cases, the facial muscles
may be affected, and drooling, speech difficulties, and grimacing
may occur.
Mixed CP The child has two or more types of CP
Spastic CP The most common type. A child with spastic CP has
stiff muscles because of increased muscle tone, and the
muscles are predisposed to contracture.
Cerebrospinal fluid (CSF) The fluid of the brain and spinal cord that
supplies nutrients and removes waste products and also serves as
a watery cushion that absorbs shock to the central nervous system
Cerumen Ear wax
Chadwick’s sign Bluish-purple coloration of the vaginal mucous
membrane caused by increased vascularity; visible from
approximately the fourth week of pregnancy; a probable sign of
pregnancy
Chalazion Small discrete swelling of the upper eyelid that develops
when a meibomian oil gland becomes blocked
Chancroid Infection by the gram-negative streptobacillus
Haemophilus ducreyi. Causes a small bump (usually on the labia
majora) that quickly develops into a painful ulcer with a base that
is covered with a gray or yellow-gray material.
Chief complaint The current medical issue for which the patient is
seeking care
Chlamydia Chlamydia trachomatis infection; the most common
bacterial sexually transmitted disease in the United States and the
leading cause of preventable infertility and ectopic pregnancy
Chloasma Increased pigmentation over the cheeks, hairline, brow,
and nose of the pregnant woman and in some women taking oral
contraceptives; also called the “mask of pregnancy” or melasma
gravidarum
Cholinergic crisis Pronounced muscular weakness and respiratory
paralysis caused by excessive acetylcholine found in patients with
myasthenia gravis as a result of overmedication with
anticholinesterase drugs
Chorionic villi Vascular projections from the chorion, which forms
the fetal portion of the placenta
Chronic condition A health situation that persists over time, usually
longer than 3 months, or one in which recovery progresses slowly
Chronic sorrow Period of episodic grieving interspersed by periods
of denial
Climacteric Transitional time in a woman’s life marked by declining
ovarian function and decreased hormone production
Cobb’s angle A measure of the curvature of the spine in degrees
Cohabitation Also called domestic partnership, describes an
unmarried man and woman who share a household and may or
may not have children together or from other previous
relationships
Cold stress Extreme loss of heat that results in increased
respirations and nonshivering
Columnar epithelium Rough, dark-pink cells noted on the outer
surface of the cervix around the external cervical os in young
women
Comedo (comedones) A papule associated with acne
Closed c. “whitehead”
Open c. “blackhead”
Commune A group of men, women, and children living together
Communicable period The time during which an infected person
can transmit a pathogen to other people
Compartment syndrome Condition caused by an accumulation of
fluid in the fascia; increases the pressure on the muscles, blood
vessels, and nerve tissue that surround the fascia; causes
decreased arteriovenous pressure and decreased muscular
perfusion; too much pressure can cause tissue ischemia, nerve
damage, and necrosis
Compassion fatigue syndrome Characterized by a sense of
helplessness, confusion, and isolation from supporters and can
have a more rapid onset and resolution than burnout
Conduction The loss of heat after birth to a cooler surface via direct
skin contact
Congenital adrenal hyperplasia (CAH) Lack of ability to produce
cortisol
Congenital anomalies Structural abnormalities present at birth, also
called birth defects
Conization of the cervix Excision of a cone-shaped or cylindrical
wedge from the uterine cervix that includes the transformation
zone and all or a portion of the endocervical canal to diagnose a
lesion or remove cancerous cells
Constipation The difficult or infrequent passage of hard stool, which
is often associated with straining, abdominal pain, or withholding
behaviors in children
Contact transmission Of a contagious infection through skin, vomit,
feces, urine, mucous membranes, and wounds
Contraction stress test (CST) Test to stimulate uterine contractions
to assess fetal response: a healthy fetus does not react to uterine
contractions; a compromised fetus demonstrates late heart rate
decelerations that are indicative of uteroplacental insufficiency
Convection The loss of heat after birth from the warm infant body
surface to the cooler air currents
Coombs’ test A laboratory test for the presence of antibodies in
serum
Direct Identifies the presence of maternal Rh-positive antibodies
in the neonate’s blood
Indirect Detects Rh-positive antibodies in maternal blood
Couvelaire uterus The accumulation of blood between the
separated placenta and the uterine wall, often as a result of
abruptio placentae
Craniosynostosis A premature fusing of one or more of the cranial
sutures
Craniotomy An incision through the cranium
Crepitus Crackling or rattling sound made by part of the body
Croup A generic term encompassing a heterogeneous group of
illnesses affecting the larynx, trachea, and bronchi of children ages
3 months to 5 years, with peak incidence around age 2
Cryotherapy Removal of a lesion by freezing with liquid nitrogen
Cullen sign Bluish discoloration of periumbilical region caused by a
hemorrhage
Culture An external and acquired phenomenon; the complex set of
beliefs and attributes passed on within a group
Curettage Scraping of a cavity/lesion
Defecation The evacuation of the bowels, or feces
Deformational posterior plagiocephaly Asymmetrical head shape
characterized by the
Denver Developmental Screening Test (DDST) A developmental
assessment for children from birth to 6 years of age, the DDST
assesses personal—social, fine motor—adaptive, gross motor,
and language skills
Development The ongoing process of adapting throughout the life
span
Developmental disability A group of conditions due to an
impairment in physical, learning, language, or behavior areas
Diabetes insipidus (DI) A hypofunction of the posterior pituitary
gland and is classified by either a deficient production of
antidiuretic hormone (ADH) or lack of response to ADH
Diagnostic tool Technological device that can diagnose and treat
diseases that previously were either undiagnosed or untreatable
Diastasis recti abdominis Separation of the two rectus muscles
along the median line of the abdominal wall
Dilated (DCM) or congestive cardiomyopathy Cardiomyopathy
associated with enlargement of the left ventricle of the heart and
congestive heart failure
Dilation of the cervix The stretching and enlargement of the
external cervical os; occurs progressively throughout labor
Direct bilirubin A neurotoxic water-soluble substance excreted by
the liver into the bile duct and duodenum
Disseminated intravascular coagulation (DIC) Hematologic
disorder characterized by a pathologic form of clotting that is
diffuse and consumes large amounts of clotting factors; causes
widespread external or internal bleeding or both
Diversity Refers to the fundamental differences between cultures
Domestic violence (DV) A term that encompasses intimate partner
violence as well as violence among other members of a
household, such as siblings, parents, grandparents, relatives, and
unrelated roommates
Ductus arteriosus In fetal circulation, an anatomic shunt between
the pulmonary artery and arch of the aorta; following birth, it is
obliterated by a rising PO2 and a change in intravascular
pressures (with normal pulmonary function); normally becomes a
ligament after birth but sometimes remains patent
Ductus venosus In fetal circulation, a vascular channel that carries
oxygenated blood between the umbilical vein and the inferior vena
cava, bypassing the liver; following birth, becomes a ligament
Duncan mechanism Delivery of the placenta with the maternal
surface presenting
Dysmenorrhea Painful menstruation that interferes with daily
activities
Dyspepsia Also called heartburn, results from reflux of acidic gastric
contents into the lower esophagus
Dysphagia Difficulty swallowing or inability to swallow
Dysplasia Abnormal development of tissues or organs
Dysthymic disorder A chronically depressed or dysphoric mood
that is present more than 50% of the time for at least 2 years in
adults or as an irritable mood for 1 year for children or
adolescents; affected people describe themselves as being
chronically sad and “down in the dumps”
Dystocia Long, difficult, or abnormal labor and birth; may arise from
any of the major components of the labor process: the powers, the
passenger, or the passage
Economic abuse Occurs when the abuser controls all aspects of
the victim’s finances, refuses to share money, forces the victim to
account for any money spent, and forbids the victim to work
outside of the home
Ectoderm In the embryo, the outer layer that gives rise to the skin,
nails, hair, teeth, and glands of the mouth and nervous system
Effacement Shortening and thinning of the cervix
End-of-life care Holistic approach to care that includes physical,
emotional, social, and spiritual interventions, and complementary
care
Endoderm In the embryo, the inner layer that gives rise to
epithelium of the respiratory, digestive, and genitourinary tracts
Engorgement Distention or vascular congestion
Breast e. Excessive swelling of the breast and areola brought
about by an increase in blood and lymph supply to the breast,
which precedes lactation; typically occurs between the third and
fifth postpartum day and lasts about 24 hours
Enteral feedings Prescribed formula or breast milk given through
either a nasogastric or orogastric tube begin as soon as the
preterm newborn is stable to prevent gastrointestinal damage
Epidemiology Statistical analysis of the distribution and
determinants of disease in populations over time
Epispadias Defect in which the urethral canal terminates on the
dorsal surface of the penis or above the clitoris (rare); in the male,
the urinary meatus is superior to its usual position
Erythema Reddening of the skin
Erythema migrans Red, roundish, flat, nonpruritic, and non-
vesicular rash characteristic of the early stages of Lyme disease
Erythema nodosum A tender, red, nodular rash on the shins
Erythroblastosis fetalis Hemolytic disease of the newborn, usually
caused by isoimmunization that has resulted from Rh
incompatibility or ABO incompatibility
Eschar Burned tissue with a waxy, white, gray, black, bright red, dry,
and leathery appearance
Estrogen plus progestogen (EPT) A combination of estrogen and
progestogen (either progesterone or progestin, synthetic forms of
progesterone)
Estrogen therapy (ET) Exogenous estrogen given to peri- and
postmenopausal women to prevent hot flashes, osteoporosis,
mood changes, and genitourinary system changes
Ethnicity Refers to groups of people who share similar cultural
characteristics (e.g., common language, religion, food, and beliefs
about health)
Ethnocultural beliefs The specific beliefs associated with a
particular ethnic group
Evidence-based practice Practice based on analysis of research
findings
Expedited partner therapy (EPT) Also known as patient-delivered
partner therapy (PDPT), the practice of treating sex partner(s) of
patients with an STD without health-care practitioner evaluation or
professional prevention counseling
Extravasation Leaking of vesicants
Extremely low birth weight (ELBW) Newborns who weigh less
than 1,000 grams (2.2 lbs)
False discharge Fluid that appears on the nipple or areola but is not
secreted by breast tissue. False discharge may be bloody, clear,
colored, purulent, serous, or viscous. Various conditions such as
eczema, dermatitis, nipple trauma, and Paget’s disease may be
associated with false nipple discharge.
Family-centered care An approach that supports the round-the-
clock presence and participation of parents in the care for
hospitalized children
Family of choice Family adopted through marriage or cohabitation
Family of origin Family that reared the individual
Fasciotomy Surgical incision where a division of a fascia occurs,
often used to treat a deep full-thickness burn
Fertility awareness method (FAM) A strategy in which the women
identifies the fertile time during her cycle and uses abstinence or
other contraceptive methods during these fertile periods
Fetal attitude Body posture or position
Fibroadenomas Solid cysts composed of stromal (connective) and
glandular tissue. They are usually moveable and nontender.
Fibroadenomas are the most common benign breast tumor,
occurring in 25% of women and usually located in the upper outer
quadrant of the breast.
Fibrocystic changes in the breast Fluid-filled cysts that are often
tender and fluctuate in size with the menstrual cycle. These
changes are the most common benign breast condition and occur
most often during the childbearing years.
Fine motor skills Any of the motor skills that require greater control
of the small muscles than large ones, esp. for hand-eye
coordination or for precise hand and finger movement. Fine motor
skills include handwriting, sewing, and fastening buttons. Most
movements require both large and small muscle groups, and there
is considerable overlap between fine and gross motor skills.
Folic acid Vitamin B9, a water-soluble vitamin that is closely related
to iron. Working with vitamin B12, folic acid helps to regulate red
blood cell development and facilitates the oxygen-carrying
capacity of the blood. Folic acid deficiency is primarily responsible
for the development of neural tube defects (NTDs), including spina
bifida, cleft lip and palate, and anencephaly and is essential in the
early days of pregnancy and pre-pregnancy to prevent NTD.
Fomite Any substance that adheres to and transmits infectious
material
Fontanelle Unossified membrane or soft spot that lies between the
cranial bones of the skull of a fetus or infant
anterior f. Diamond-shaped area positioned where the sagittal,
frontal, and coronal sutures intersect
posterior f. Triangular fontanel located at the junction of the
sagittal and lambdoid sutures; ossified by the end of the first
year
sagittal f. Soft area located in the sagittal suture, halfway between
the anterior and posterior fontanels
Foramen ovale Opening in the septum between the right and left
fetal atria; normally closes shortly after birth
Forming The beginning phase of a group. In families, the forming
stage usually occurs through marriage or cohabitation.
Fundus Dome-shaped upper portion of the uterus between the
points of insertion of the fallopian tubes
Galactorrhea The continuation of milk secretion after breastfeeding
has ceased, characterized by a spontaneous bilateral, milky, sticky
discharge. Galactorrhea normally occurs during pregnancy due to
increased circulating levels of prolactin.
Gamete A mature male or female reproductive cell (spermatozoon
or ovum)
Gastroesophageal reflux disease (GERD) A frequent and
sometimes normal occurrence in high-risk newborns. It is treated
as a disease when excessive amounts of formula or breast milk
are being regurgitated or it causes complications such as failure to
gain weight.
Gavage Feeding a patient via a feeding tube passed through the
nose into the stomach
Generalized anxiety disorder May be related to real or perceived
threat to physical integrity or self-concept (may or may not be able
to identify the threat), unconscious conflict about essential
values/beliefs and goals of life, or unmet needs; characterized by
negative self-talk, possibly evidenced by sympathetic stimulation,
extraneous movements (foot shuffling, hand/arm fidgeting, rocking
movements, restlessness), persistent feelings of apprehension
and uneasiness, a general anxious feeling that patient has
difficulty alleviating, poor eye contact, focus on self, impaired
functioning, free-floating anxiety, and nonparticipation in decision
making
Genome A complete copy of the genetic material in an organism
Gestational age In fetal development, the number of completed
weeks of development, counting from the first day of the last
normal menstrual period
Gingivitis Inflammation of the gums, characterized by redness,
swelling, and a tendency to bleed
Glutamine A nonessential amino acid synthesized within the body
primarily by skeletal muscle cells
Glycogenesis The formation of glycogen from glucose
Glycosylated hemoglobin (GHb) Glycohemoglobin (a minor
hemoglobin) with glucose attached; GHb/HbA1c concentration
represents the average blood glucose level over the preceding 5
to 6 weeks
Gonad Sex gland that produces hormone (ovary and testis)
Gonadotropin Gonad-stimulating hormone
Gonorrhea A common STD caused by the gram-negative
intracellular diplococcal bacterium Neisseria gonorrhoeae
Goodell sign Softening of the tip of the cervix; a probable sign of
pregnancy
Graves’ disease An autoimmune disorder that represents the most
frequent cause of hyperthyroidism in children. It may occur at any
time during childhood, but its frequency increases with age,
peaking during adolescence.
Grey Turner sign A discoloration or bruising and induration of the
skin on the flank
Gross motor skills The group of motor skills (including walking,
running, and throwing) that require large muscle groups to
produce the major action, and require less precision than that
exerted by small muscles. Most motor activities combine some
elements of both fine and gross motor function.
Group B streptococcus (GBS) The leading cause of neonatal
sepsis in the United States. One in three women has colonized
GBS in the vagina, and it can be spread to the newborn during the
labor process, which is called vertical transmission.
Growth The continuous adjustment in the size of the child, internally
and externally
Growth hormone deficiency (GHD) Children with this condition
present with short stature (below the 5th percentile) and
demonstrate delayed skeletal growth
Gummas Soft, tumorlike balls of inflammation that occur in the late
stages of untreated syphilis
Hashimoto’s thyroiditis The most common cause of acquired
hypothyroidism in children ages 6 and older in the United States
Health surveillance Continuous observation related to tracking
health conditions and risk behaviors
Heliotropic rash Violaceous (red-purple) rash around eyes and
upper eyelids
Hematochezia Stools containing red blood rather than tarry stool
Hemofiltration Also known as continuous renal replacement therapy
(CRRT), used to treat acute kidney injury and end-stage renal
disease
Hepatitis B (HBV) Hepatitis caused by hepatitis B virus (HBV), a
double-stranded DNA virus. It may appear as an asymptomatic,
acute, chronic, or fulminant infection. It can be transmitted by
blood or bodily fluid.
Hepatitis C (HCV) Primarily spread through blood-to-blood contact,
HCV causes tissue inflammation, which results in hepatic fibrosis,
which leads to scarring. The scarring adversely affects liver
function, leading to the development of cirrhosis, which eventually
leads to liver failure and transplant.
Hepatitis D (HDV) A viral infection that occurs only in individuals
already infected with another form of hepatitis.
Heterozygous Having two nonsimilar genes at the same site, on
paired chromosomes
Homeothermic The ability of newborns to regulate and maintain
their internal core temperature regardless of varying external
environmental temperatures
Homologous Similar in structure and in origin but not necessarily in
function
Homozygous Having two similar genes at the same site, on paired
chromosomes
Honeymoon period A tranquil, loving period of calm and remorse
that characteristically occurs after domestic violence as part of the
three phases of abuse
Hormone replacement therapy (HRT) Estrogen and progestin
given for menopausal symptoms
Hospice care A program that focuses on quality of life for dying
persons; method of treating a serious illness when cure or
meaningful improvement is no longer possible; end-of-life care that
describes a certain timeframe where care is given during the final
6 months of life
Human chorionic gonadotropin (hCG) Hormone produced by the
chorionic villi; the biologic marker in pregnancy tests
Hydramnios (polyhydramnios) Amniotic fluid in excess of 2.0 liters
Hyperemesis gravidarum Abnormal condition of pregnancy
characterized by protracted, persistent vomiting, weight loss, and
fluid and electrolyte imbalance
Hyperaldosteronism Production of excessive secretion of
aldosterone, which may be caused by an adrenal tumor or
syndrome that is a result of an enzyme deficiency
Hyperkalemia Elevated serum potassium level
Hypermetabolic A state of increased metabolism that can result in
high fevers, tachycardia, nausea and vomiting, tremulousness,
agitation, and psychosis if left untreated
Hyperpnea Increased rate and depth of respiration
Hyperstimulation In intrapartum fetal heart rate monitoring, greater
than five uterine contractions in 10 minutes, averaged over a 30-
minute window. Also called tachysystole.
Hypertonia High muscular tension
Hypertonic labor Uterine contractions that are uncoordinated,
painful, and frequent but do not result in cervical dilation and
effacement
Hypertrophic cardiomyopathy (HCM) An autosomal dominant
cardiomyopathy marked by excessive and disorganized growth of
myofibrils, impaired filling of the heart (diastolic dysfunction), a
reduction in the size of ventricular cavities, and, often, ventricular
arrhythmias and sudden death
Hypertrophy Enlargement of existing cells
Hyponatremia Low serum sodium of less than 125 mEq/L
Hypopnea Decreased rate and depth of respiration
Hyposmia Decreased sense of smell
Hypospadias Anomalous positioning of the urinary meatus on the
undersurface of the penis or close to or just inside the vagina; in
the male, the male urinary meatus is inferior to its usual position
Hypothalamus Located in the center of the brain, the main control
center of the body. Its function is to communicate the messages of
the central autonomic nervous system to the organs and glands of
the endocrine system, thus maintaining homeostasis throughout
the body.
Hypothermia Temperature below the normal range (< 35°C; < 95°F)
Hypothyroidism Thyroid insufficiency; can be congenital or
acquired
Hypotonia Low muscular tension
Hypotonic labor Uterine contractions that are weak and ineffective;
this labor pattern usually occurs during the active phase of labor
Idiopathic thrombocytopenia purpura (ITP) An immune disorder
in which low levels of platelets in the blood prevent normal clotting
Immune response Defends the body against microorganisms,
parasites, and foreign cells such as cancer cells and transplanted
cells; key to a normal immune response is the body’s ability to
recognize foreign substances as nonself and then to mobilize
defenses and attack the invaders
Immunity Protection from diseases, especially infectious diseases
Acquired i. Immunity that results either from exposure to an
antigen (response to the infection) or from the passive injection
of immunoglobulins
Active i. Immunity that develops in response to actual infection or
vaccination
Natural i. Immunity that is genetically determined in a specific
species; the first line of defense
Passive i. Immunity that is acquired by the introduction of
preformed antibodies into an unprotected individual (e.g.,
maternal antibodies that pass to the fetus through the placenta)
Imperforate anus Congenital absence of an opening in the anal ring
Implant radiation Also known as brachytherapy (“slow therapy”),
involves placement of the radioactive material as close to the
tumor as possible while sparing the adjacent healthy tissue. With
cervical cancer, the radioactive material is either placed in a
capsule and inserted into the cervix or placed in thin needles that
are inserted directly into the tumor.
Increased afterload In cardiac physiology, afterload is the force that
impedes the flow of blood out of the heart. The heart contracts
against a resistance primarily composed of the pressure in the
peripheral vasculature, the compliance of the aorta, and the mass
and viscosity of blood.
Increased preload In cardiac physiology, preload is the end-
diastolic stretch of a heart muscle fiber. In the intact ventricle, this
is approx. equal to the end-diastolic volume or pressure. At the
bedside, preload is estimated by measuring the central venous
pressure or the pulmonary capillary wedge pressure.
Incubation period The period of time when an organism invades
the body and the infected person develops an onset of symptoms
Induction (of labor) Stimulation of uterine contractions before the
onset of spontaneous labor
Infectivity The mode of transmission, incubation period, and
communicable period of an infectious agent
Informed consent Choice based on a full comprehension of
relevant information; providing the patient with the necessary
knowledge to make a decision regarding health care; permission
that is given freely and that protects a person’s right to autonomy
and self-determination
Intermenstrual bleeding Bleeding of variable amounts that occurs
between regular menses.
Intimate partner violence (IPV) Physical, sexual, or psychological
harm or social isolation perpetrated by a current or former partner
(adult or adolescent)
Intracranial pressure (ICP) Pressure of the cerebrospinal fluid in
the subarachnoid space between the skull and the brain
Intraductal papillomas Small, wartlike growths in the lining of the
milk ducts near the nipple. These rare, benign tumors usually
produce a clear or bloody nipple discharge.
Intrathecally Through the theca of the spinal cord into the
subarachnoid space
Invasive vulvar cancer The presence of a malignant lesion that
breaks through the cellular basement membrane. This type of
cancer occurs most often in older (70+ years) women, and in the
United States it is responsible for 5% of all female genital
malignancies.
Involution Reduction in uterine size following birth
Jaundice Yellow discoloration of the body tissues (skin, sclera, oral
mucous membranes) caused by the deposit of bile pigments
(unconjugated bilirubin); icterus
Breastfeeding j. (Early-onset jaundice) Occurs when there is a
decreased intake of breast milk and a decreased passage of
meconium
Breast milk j. (Late-onset jaundice) Typically occurs in the full-
term infant after the fifth day of life; peaks around day 10
Pathologic j. (Nonphysiological jaundice) Jaundice usually
noticeable within the first 24 hours of life; caused by an
abnormal condition such as Rh or ABO incompatibility and
results in bilirubin toxicity (e.g., kernicterus)
Physiologic j. (Nonhemolytic) Yellow tinge to skin and mucous
membranes related to increased serum levels of unconjugated
bilirubin, typically occurs after the first 24 to 48 hours of life
Justice (fairness) Patients are to be treated equally
Ketoacidosis Accumulation of ketone bodies in the blood, a
consequence of hyperglycemia; leads to metabolic acidosis
Diabetes k. (DKA) Caused by adrenal deficiency
Kirschner wire (K-wire) Steel wire placed through a long bone to
apply traction to the bone
Kleihauer-Betke test Blood test that detects the presence of fetal
blood cells in the maternal circulation
Kussmaul’s respirations Very deep, laborious breaths; in an
attempt to correct the metabolic acidosis, the respiratory system
works hard to “blow off” excess carbon dioxide
Lanugo Fine, downy hair characteristic of the fetus between 20
weeks of gestation and birth
Laparoscopy Examination of the interior of the abdomen by
insertion of an endoscope through the anterior abdominal wall
Laparotomy Surgical opening of the abdomen
Latch-on Proper attachment of the infant to the breast for feeding
Leiomyoma A fibroid; a benign smooth muscle uterine tumor
Let-down reflex Also termed “milk ejection reflex”; release of milk
from the breast, caused by the contraction of the myoepithelial
cells within the milk glands in response to oxytocin
Leukocoria Cat’s eye reflex
Leukorrhea Whitish-yellow discharge from the cervical canal or the
vagina; may be normal physiologically or caused by
vaginal/endocervical pathology such as infection
Ligamentous laxity The amount a joint or ligament deviates from its
initial position when a force is applied to it
Ligamentum arteriosum Functional closure of the ductus
arteriosus, which in a term infant typically occurs within the first 72
hours of life
Ligamentum venosum Closure of the nonfunctional ductus
venosus, which in a term infant usually occurs by the end of the
first week of life
Lightening Sensation of decreased abdominal distention produced
by uterine descent into the pelvic cavity as the fetus settles
downward into the pelvis
Linea nigra Line of darker pigmentation seen in some women during
the latter part of pregnancy; appears on the middle of the
abdomen, extending from the umbilicus to the mons pubis
Lipomas Mobile, nontender fat tumors that are soft with discrete
borders. Lipomas may develop anywhere in the body, including
the breasts.
Local ET therapy Vaginal ET administration that does not result in
clinically significant systemic absorption
Lochia Vaginal discharge during the postpartal period, consists of
blood, tissue, and mucus
l. alba Thin, yellowish-white vaginal discharge that follows lochia
serosa on approximately the 10th day after birth
l. rubra Bright red vaginal flow that follows birth and lasts 2 to 4
days
l. serosa Serous, pinkish-brown thin vaginal discharge that follows
lochia rubra until about the 10th day following birth Low birth
weight (LBW) An infant birth weight of less than 2,500 g
Lund and Browder chart Used in pediatric burn care to estimate
total burn surface area, size, and percent of burn injury
Lymphadenopathy Swollen lymph nodes
Macrosomia Large body size; fetal birth weight above the 90th
percentile on an intrauterine growth chart for that gestational age;
often seen in neonates of diabetic or prediabetic mothers
Major depression A mood disorder characterized by a period of at
least 2 weeks of depressed mood or the loss of interest or
pleasure in nearly all activities
Malnutrition Lack of the basic caloric requirements for healthy
growth and development
Mammary duct ectasia An inflammation of the ducts located behind
the nipple. Occurring most often in perimenopausal and
postmenopausal women, this condition produces a thick, sticky
nipple discharge that may be purple, brown, or white in color.
Mandatory reporting Certain states mandate that injuries resulting
from criminal conduct (which encompasses intimate partner
violence) be reported. Also, some states require medical
personnel to report specific types of injuries (i.e., burns, firearms,
stab or knife wounds, strangulation, and injuries resulting from a
deadly weapon) to law enforcement regardless of the victim’s
statement.
Marfan’s syndrome A hereditary degenerative disorder of
connective tissue, bones, muscles and ligaments
McRoberts maneuver Often the first maneuver for fetal delivery
after a diagnosis of shoulder dystocia is made. The woman is
placed in a dorsal lithotomy position, and her thighs are sharply
flexed on her abdomen. This position increases the angle between
the symphysis pubis and the sacral promontory, allowing for
greater room in fetal descent.
Mean arterial pressure (MAP) Average of the systolic and diastolic
blood pressures
Meconium First stools of the infant; characteristically viscid, dark
greenish brown, sticky, sterile, and odorless
m. aspiration syndrome (MAS) A respiratory condition that
occurs when the newborn aspirated meconium into the
respiratory system, often occurring when a newborn is delivered
through meconium stained amniotic fluid (MSAF)
m.-stained amniotic fluid In response to hypoxia, fetal intestinal
activity increases and the anal sphincter relaxes; results in the
passage of meconium into the amniotic fluid, which imparts a
greenish coloration; normally seen in breech presentations
Medical history A complete recounting of past acute illnesses and
history of chronic illnesses, immunization history, hospitalizations,
emergency room visits, serious injuries, operations, and current
medication usage. Inquiries are made as to the use of any over-
the-counter medications, herbal preparations, or folk remedies and
any history of allergic reactions to food, medications, and
environmental allergens should also be reviewed.
Meiosis Process by which the germ cells divide and decrease their
chromosomal number by one-half
Menarche Initial menstrual period
Menometrorrhagia Also known as heavy menstrual bleeding, a
combination of menorrhagia and metrorrhagia. The woman
experiences excessive bleeding and frequent bleeding at
abnormal times.
Menopause Permanent cessation of menstrual periods; can only be
dated with certainty 1 year after menstruation ceases
Menorrhagia Menstrual bleeding that is excessive in number of
days or amount of blood
Mesoderm Embryonic middle layer of germ cells, gives rise to the
connective tissue
Methicillin-resistant S. aureus (MRSA) A strain of S. aureus
resistant to methicillin (and other beta-lactams). MRSA is a
common cause of boils (skin abscesses) and an occasional cause
of pneumonia. MRSA is resistant to most antibiotics and is usually
acquired in hospitals or nursing homes, where it may be spread
from patient to patient by contaminated hands, clothing, and
equipment.
Metrorrhagia Also known as intermenstrual bleeding, bleeding that
occurs at abnormal times during an ovulatory cycle. Vaginal
bleeding occurs more frequently than every 21 days.
Microcephaly Congenital anomaly characterized by abnormal
smallness of the head in relation to the rest of the body,
underdevelopment of the brain, and mental retardation
Micrognathia Shortened chin
Milia Small white papules or sebaceous cysts that may be present
on the newborn’s forehead, nose, cheeks, and chin
Mitosis Process of the formation of two identical cells that are the
same as the original cell and contain the normal (diploid) amount
of chromosomes
Mode of transmission The route by which a pathogen enters the
body
Mondor disease of the breast A rare, self-limiting condition
characterized by thrombophlebitis of the superficial veins.
Symptoms include skin redness, edema, and pain in the affected
area. The condition may occur after trauma or appear without
apparent cause. Although Mondor disease is usually benign, it
may be associated with breast cancer and hypercoagulability.
Montgomery tubercles (glands) Small, nodular sebaceous glands
on and around the areolas that provide lubrication for the nipple
tissue
Moral distress Occurs when the nurse is unable to translate
personal moral choices into action; the nurse acts in a manner
contrary to personal or professional values, which undermines
integrity; during moral distress, the nurse experiences feelings of
frustration, anger, and anxiety
Morula Solid mass of cells, resembling a mulberry, resulting from
cleavage of an ovum
Mucositis Diffuse inflammation of the mucosa of the mouth, a
change in the integrity of the mucus membrane
Multiagent chemotherapy Using more than one type of
chemotherapy; also called combination therapy
Mutation Spontaneous, permanent change in the normal gene
structure
Neoadjuvant chemotherapy The use of chemotherapy to relieve
pain associated with advanced cancer or to shrink cancer
Nephron The nephron consists of a renal corpuscle and renal
tubule. The renal corpuscle is made of a capillary network called a
glomerulus surrounded by the Bowman capsule. The renal tubule
extends from the Bowman capsule. The parts, in order, are as
follows: proximal convoluted tubule, loop of Henle, distal
convoluted tubule, and collecting tubule, all of which are
surrounded by peritubular capillaries.
Neural tube Tube formed from the fusion of the neural folds; from
which the brain and spinal cord arise
n.t. defect A group of congenital structural disorders that result
from a failure of the embryonic neural tube to close during
development (i.e., cranial fusion disorders: anencephaly,
encephalocele; spinal fusion disorders: spina bifida,
meningomyelocele, meningocele)
Neutral thermal environment (NTE) Range of temperatures in
which the newborn’s body temperature can be maintained (at least
36.5°C [97.88°F]) with minimal metabolic demands and oxygen
consumption
Neutropenia Condition that occurs when an absolute neutrophil
count is less than 1,000/uL in infants less than 1 year of age and
1,500/uL for those older than 1 year of age
Nevi Natural blemish or mark, a congenital deposit of pigmentation
in the skin; mole
Nevus flammeus “Port wine stain”; a nonelevated capillary angioma
located directly below the epidermis
Nevus vasculosus (strawberry hemangioma) Elevated lesion of
immature capillaries and endothelial cells; slowly regresses over a
period of years
Nidation Implantation of the fertilized ovum into the endometrium
Nissen fundoplication Surgical treatment for GERD that involves
wrapping the gastric cardia with adjacent portions of the gastric
fundus
Nonmaleficence Credited to Hippocrates, meaning “First, do no
harm,” or “Primum non nocere” in Latin
Nonnutritive sucking (NNS) Promoted for the preterm and high-risk
newborn for physiological and psychological reasons. Using a
pacifier promotes comfort, and NNS may promote breastfeeding in
the high-risk newborn.
Nonshivering thermogenesis Infant’s method of producing heat
from brown adipose
Norming How groups (or families) adjust to individual members by
applying rules and procedures that the members agree to follow
Nosocomial infection An infection acquired in the hospital
Nuchal cord Encircling of the fetal neck by one or more loops of the
umbilical cord
Nuclear family Consists of a male partner, female partner, and their
children; actually represents only a small number of families
Nursing Interventions Classification (NIC) Comprehensive
standardized classification of interventions that nurses perform
Nursing Outcomes Classification (NOC) Standardized system for
identifying outcomes and related measures that can be used for
evaluation of care of individuals, families, and communities across
the care continuum
Nursing process A framework of systematic problem-solving and
actions for nurses to use in identifying, preventing, or treating the
individual health needs of patients
Oligohydramnios Abnormally small amount of amniotic fluid
Oligomenorrhea Abnormally light or infrequent menstruation
Oliguria Abnormally low amounts of urine
Omphalitis Inflammation of the umbilical stump, characterized by
redness, edema, and purulent exudate in severe infections
Open reduction Treatment of bone fractures by the use of surgery
to place the bones in their proper positions
Operculum Plug of mucus that fills the cervical canal to protect a
pregnancy from outside pathogens
Opportunistic infections Any infection that results from a defective
immune system that cannot defend against pathogens normally
found in the environment; common types include bacterial
(Pseudomonas aeruginosa), fungal (Candida albicans), protozoan
(Pneumocystis jirovecii), and viral (cytomegalovirus); opportunistic
infections are seen in patients with impaired defenses against
disease, such as those with cystic fibrosis, poorly controlled
diabetes mellitus, acquired or congenital immune deficiencies, or
organ transplants
Orchiectomy Removal of one or both testicles
Osteoblasts Bone-forming cells
Osteomyelitis Inflammation of bone and marrow, usually caused by
infection
Osteotomy Cuts through a bone
Paget’s disease A rare neoplasm of the vulva that primarily affects
women in their 70s
Palliative care Nursing care that emphasizes physical, emotional,
and spiritual care of the child and family; type of care that the child
receives at the end of life after it becomes obvious that no cure is
possible
Palmar erythema Rash occurring on the surface of the palms;
sometimes seen during pregnancy
Pancytopenia Reduction in all cellular elements of the blood caused
by bone marrow hematopoiesis failure
Panic disorder An anxiety disorder characterized by panic attacks,
e.g., agoraphobia with panic attacks
Papilledema Mass of blown-out blood vessels located around the
optic nerve; important sign of increased intracranial pressure
Parathyroid glands Produce parathyroid hormone (PTH) and
responsible for calcium regulation
Parturition The act of giving birth
Pathogenicity After being exposed to a pathogen, the percentage of
those exposed who will eventually develop the disease
Pathological grief Intense grief feelings or a dysfunctional
personality may easily bring on deviation from a healthy or normal
grief, such as violence, addictions, or poor decision making
Patient-centered medical home (PCMH) A model for providing
comprehensive primary care that facilitates partnerships among
patients, clinicians, medical staff, and families
Peau d’orange A characteristic physical finding of breast cancer, an
edematous thickening and pitting of the skin that develops from
edema surrounding the hair follicle
Pectus carinatum An abnormal protrusion of the chest, sometimes
called pigeon chest
Pectus excavatum Abnormal depression of the chest
Pediatric Glasgow Coma Scale (GCS) The pediatric GCS consists
of three components of assessment for children in an altered state
of consciousness: eye opening, motor, and auditory/visual
responses
Pediatric polysomnography (PSG) A sleep study test used in
diagnosing sleep disorders in children. During polysomnography,
information is collected about brain waves, blood oxygen levels,
eye and leg movements, respiratory effort or events, and heart
rhythm. The resulting report is called a polysomnogram.
Pelvic inflammatory disease (PID) A complication that develops in
up to 40% of untreated women with cervical gonorrhea and may
progress to a systemic infection
Performing The ideal stage in which the group (i.e., the family)
accomplishes their goals and produces results. In the family,
desirable results would include good citizenship, education and
health of its members, and active contribution to society.
Perimenopause Period of transition of changing ovarian activity
before menopause and through the first few years of amenorrhea
Perinatal loss Death of a fetus or infant from the time of conception
through the end of the newborn period 28 days after birth
Periodic breathing Sporadic episodes of cessation of respirations
for periods of 5 to 15 seconds, not associated with cyanosis
Peritoneal dialysis Cleansing the blood through the peritoneal wall,
in renal disease
Persistent vegetative state A complete unawareness of the
environment accompanied by sleep-wake cycles
Petechiae Pinpoint hemorrhagic areas; caused by certain disease
states involving infection and thrombocytopenia; small (1–2 mm)
red or purple spot on the body caused by blood leaking though the
capillaries
Philtrum Vertical groove from the bottom of the nose to the upper lip
Pica Unusual craving during pregnancy for substances that are
nonnutritive (e.g., clay, dirt, ice, laundry starch)
Piloerection Elevation of the hair above the skin
Piokilothermia A body temperature that varies with the temperature
of its surroundings
Pituitary gland Connected to the hypothalamus and often called the
“master gland” because of its effect on growth and the functions of
other glands in the body
Pituitary hyperfunction Also called precocious puberty (early or
premature), a condition that occurs with overactivity of the pituitary
gland
Pituitary hypofunction Also called hypopituitary, causes growth
hormone deficiency (GHD), an endocrine condition resulting from
a decreased production of growth hormone (GH)
Placenta From the Latin term meaning “a flat cake”; the oval or
discoid spongy structure in the uterus that provides nourishment
and oxygen for the fetus; also called the afterbirth
Abruptio p. Partial or complete separation of a normally implanted
placenta
p. accreta Invasion of the uterine muscle by the placenta;
separation of the placenta may be impossible
p. increta Deep penetration in the myometrium by the placenta
p. percreta Perforation of the uterus by the placenta
p. previa Placenta that is abnormally implanted in the lower
uterine segment; typed according to the proximity to the cervical
os: total: completely covers the cervical os; partial: partially
occludes the cervical os; marginal: placental edge encroaches
on the margin of the cervical os
p. succenturiata Accessory placenta
Plasmapheresis Removal of plasma containing harmful
components such as circulating complexes, antibodies (IgM, IgG),
and cholesterol; the plasma is replaced with another solution
(usually saline), and the remaining components (mostly red blood
cells) are returned to the donor
Plethora Deep purplish-red coloration of a newborn caused by an
increased number of circulating red blood cells
Poikilothermia A body temperature that varies with the temperature
of its surroundings
Polycythemia Increased number of erythrocytes per volume of
blood
Polymenorrhea Menstrual bleeding that occurs at short intervals
(less than 21 days).
Position Location of a fixed reference point on the fetal presenting
part in relation to a specific quadrant of the maternal pelvis
Postcoital bleeding Bleeding that occurs after sexual intercourse
Postmenopause Time after menopause
Postpartum Occurring after birth (mother)
p. hemorrhage Excessive bleeding after childbirth; traditionally
defined as a blood loss greater than 500 mL following a vaginal
birth and 1,000 mL or more following a cesarean birth
Posttraumatic stress disorder (PTSD) Intense psychological
distress, marked by horrifying memories, recurring fears, and
feelings of helplessness that develop after a psychologically
traumatic event, such as combat, rape, criminal assault, life-
threatening accident, or natural disaster. The symptoms of PTSD
include flashback; avoidance of stimuli associated with the trauma;
disturbances of memory; psychological or social withdrawal,
increased aggressiveness; and irritability, insomnia, startle
responses, and vigilance. The symptoms may last for years after
the event but can often be managed with supportive
psychotherapy or medications such as antidepressants.
Precipitous labor Rapid or sudden labor that lasts less than 3 hours
from the beginning of contractions to birth
Preconception The period of time before pregnancy during which
health-care providers can address family planning. The goal is
health promotion to protect the health of the baby and women for
future pregnancies.
Preeclampsia Pregnancy-specific vasospastic disease that occurs
after 20 weeks of gestation or early during the postpartal period;
characterized by hypertension, proteinuria, and
hemoconcentration
Premenopause The time up to the beginning of perimenopause, but
the term is also used to define the time up to the last menstrual
period
Premenstrual syndrome (PMS) the presence of behavioral,
emotional, and physical symptoms that occur during the second
half, or luteal phase, of the menstrual cycle
Presentation Part of the fetus that enters the pelvic inlet first and
leads through the birth canal during labor; may be cephalic,
breech, or shoulder
cephalic p. Presentation of the fetal head
breech p. Presentation of the fetal buttocks or feet
shoulder p. Presentation of the fetal shoulder
Primary adrenal insufficiency Caused by the gradual destruction
of the adrenal cortex, the outer layer of the adrenal glands, by the
body’s own immune system
Primary amenorrhea Absence of menses by age 14 if there are no
secondary sexual characteristics
Prolactin Hormone produced by the anterior pituitary gland that
triggers milk production
Prostaglandin Chemical mediators produced by the tissues and
found in many parts of the body; play important role in menstrual
cramps
Proximodistally Progression from midline to periphery
Pruritis gravidarum Severe itching during pregnancy
Pseudoseizure False seizures
Puberty Biological timeframe between childhood and adulthood;
during this time the reproductive organs mature and the individual
becomes functionally capable of reproduction
Puerperal infection A bacterial infection that occurs within 28 days
after miscarriage, induced abortion, or childbirth. Puerperal
infections are one of the leading causes of maternal morbidity and
mortality worldwide.
Puerperium Period that begins after the third stage of labor and
lasts until uterine involution is complete, usually 3 to 6 weeks
Pulmonary embolism A complication of deep venous thrombosis
that occurs when part of a blood clot dislodges and travels to the
pulmonary artery, where it causes vessel occlusion and
obstruction of blood flow to the lungs
Purpura Discoloration caused by a hemorrhage beneath the skin;
appears red and darkening into purple
Pustular melanosis A condition in which small pustules form prior
to the birth
Pyelonephritis Infection in the renal pelvis that causes renal
scarring and, with repeated infections, hypertension or end-stage
renal disease
Pyloromyotomy An incision and suture of the pyloric sphincter
performed by laparoscopy (abdominal exploration) with an
endoscope
Pyrosis Burning sensation in the epigastric and sternal region due to
stomach acid; also known as heartburn
Radiation Heat loss after birth that occurs because of heat transfer
between objects that are not in direct contact with each other. For
example, radiation heat loss can involve heat transfer from the
infant to the incubator or nursery walls.
Recanalization Re-establishment of an opening through a vessel
that had been previously occluded
Recommended daily allowance (RDA) The RDA for caloric intake
for nonpregnant women ranges from 1,200 to 2,400 kcal/day
depending on activity level. During pregnancy, the RDA for caloric
intake increases by about 300 kcal/day from prepregnant needs.
Rectal atresia Closure of the rectal passage; immediate surgical
intervention is mandatory
Rectal stenosis Constriction or narrowing of the rectal passage and
includes vomiting, abdominal distention, and difficult stooling; may
present with a ribbon-like or narrow stool, which is not always
readily apparent at birth
Referred pain Discomfort that originates in a local area such as the
cervix, vagina, or perineal tissues but is felt in the back, the flanks,
or down the thighs
Regression Abnormal return to an earlier reaction, characterized by
emotions or behaviors that are inappropriate for the current age
and may include the loss of recently acquired skills
Regurgitation A backward flowing, as in the return of solids or fluids
to the mouth from the stomach or the backflow of blood through a
defective heart valve
Remodeling Rounding off angles and filling in hollows
Renal biopsy Obtaining a tissue sample from the kidney
Reproductive life plan (RLP) A reflection of a person’s intentions
about the number and timing of pregnancies in the context of their
personal values and life goals. It may serve as the starting point of
focused, personalized counseling to improve birth outcomes.
Respect for autonomy Patients have a right to make decisions
about themselves as well as the right to have the information that
is needed to make certain decisions
Respiratory distress syndrome (RDS) Also known as hyaline
membrane disease; developmental disorder that results from
decreased pulmonary gas exchange leading to carbon dioxide
retention (increased arterial PCO2); in the neonate, most
commonly associated with prematurity, perinatal asphyxia, and
maternal diabetes mellitus
Restrictive cardiomyopathy (RCM) Cardiomyopathy associated
with lack of flexibility of the ventricular walls
Retinal hemorrhage A classic sign of abusive head trauma
Retinopathy of prematurity (ROP) Changes in the retina of the eye
Retractions (1) In-drawing of soft tissues of the chest; indicates an
obstruction at any level of the respiratory tract from the oropharynx
to the alveoli; (2) retraction of the uterine muscle fiber; following a
contraction, the muscle fiber does not return to its original length
but remains slightly shortened; this unique characteristic of uterine
muscle aids in preventing postdelivery hemorrhage and facilitates
involution
Review of systems A series of questions about each body system
Rule of 2s A framework used to describe a GI malformation called
Meckel’s diverticulum. It affects 2% of the population and most
(well over 50%) present before age 2 years. The resulting bulge in
the small intestine is located within 2 ft (60–100 cm) of the
ileocecal valve and is usually 2 in. (5 cm) long
Rule of nines Used to calculate total burn surface area in
adolescents
Salpingectomy Surgical removal of a fallopian tube
Salpingostomy Surgical opening of a fallopian tube
Schultze mechanism Delivery of the placenta with the shiny fetal
surface presenting
Scotomata Blind spots, specks, or spots in the vision
Seborrhea A disease of sebaceous glands, abnormal/excess fat
secretion
Seborrheic Like seborrhea
Secondary amenorrhea Menses have occurred, but are absent for
6 months with regular cycling or three cycles with irregular cycling
Seizure An electrical disturbance within the brain, resulting in
changes of motor function, sensation, or cognitive ability
Self-efficacy Sense of self
Separation anxiety disorder Occurs when children experience
overwhelming fear of becoming separated from or losing a
caregiver
Septicemia Infection of the blood
Sexual assault nurse examiner (SANE) A registered nurse who
has received certification after specialized training and education
in providing medical-forensic examinations with evidence
collection kits for victims of sexual assault. SANE nurses provide
care within a trauma-informed framework that includes immediate,
compassionate, culturally sensitive, and comprehensive evaluation
and treatment.
Sexual coercion Occurs when the victim is coerced to carry out
sexual intercourse or other sexual activities (whether or not they
are completed) against his or her will. It may also include forced
participation in an early initiation of sexual activity; forced
participation in sexual activity viewed as humiliating or degrading,
or forced participation in sexual activities with others.
Sexually transmitted disease (STD) Infection transmitted as a
result of sexual activity with an infected individual
Sexually transmitted infection (STI) Sometimes used
interchangeably with STD, infection transmitted as a result of
sexual activity with an infected individual. An STI is the beginning
phase of a sexually transmitted disease (STD).
Simple mastectomy The removal of all the breast tissue along with
the area surrounding the nipple and areola. Radiation,
chemotherapy, or hormone therapy may follow this surgical
procedure.
Sitz bath Application of moist heat to the perineum; may be
accomplished by sitting in a tub or basin filled with warm water
Sleep efficiency Minutes of sleep divided by minutes in bed,
breathing irregularities, oxygen saturation, and cardiac rhythm
abnormalities
Sleep onset latency Time elapsed from lights out to onset of sleep
Sleep stages REM (rapid eye movement) sleep, slow wave sleep,
and two stages of light sleep
Social anxiety disorder Persistent irrational fear of, and the need to
avoid, any situation in which one might be exposed to potentially
embarrassing or humiliating scrutiny by others
Somatic pain Perineal discomfort that results from stretching and
distention of the perineal tissues
Specific phobia Any persistent, intensely felt, and irrational fear of a
specific object, activity, or situation that results in a compelling
desire to avoid the feared stimulus
Spermatogenesis Process of meiosis in the testes to produce
sperm cells
Spica hip cast Immobilizes the hips and thighs so that bones or
tendons can heal properly after hip surgery
Spinnbarkheit Formation of a stretchable thread of cervical mucus;
occurs at the time of ovulation due to the influence of estrogen
Squamocolumnar junction Also called the “transformation zone”;
area on the cervix where the squamous tissue of the outer aspects
of the cervix and the glandular tissue arising in the cervical canal
meet
Squamous epithelium Smooth, light-pink cells that cover the
vaginal portion of the cervix
Stadiometer Device used to measure a standing height
Staging Describes the severity of the patient’s cancer; the process
of classifying tumors in relation to the degree of differentiation,
possibility of responding to therapy, and prognosis
Standards of Practice Guidelines that determine the scope and
practice of nurses. The state nurse practice act of each state is the
most important law that affects nursing practice. Each nurse
practice act protects the public by defining the scope of nursing.
Station Level of the presenting fetal part in relation to the maternal
ischial spines
Status asthmaticus Refers to persistent and intractable asthma
where the child does not respond to therapy and a medical
emergency ensues
Steeple sign Soft tissue imagining of the neck and chest
demonstrates the classic presentation of subglottic narrowing
Stenosis The constriction or narrowing of a passage or orifice
Storming The disordered time of confusion or chaos in a family unit
when two or more distinct personalities discover their differences
Strabismus A condition of nonparallelism in the different fields of
gaze causing visual lines to cross even when focused on the same
object
Striae gravidarum “Stretch marks”; reddish lines on the breasts,
abdomen, and thighs caused by stretching of the skin during
pregnancy
Stroke volume Amount of blood ejected by the left ventricle with
each heartbeat; product of preload, afterload, and contractility
(inotropy)
Substance abuse A maladaptive pattern of behavior marked by the
use of chemically active agents (e.g., prescription or illicit drugs,
alcohol, and tobacco)
Substance dependence Also called addiction, refers to the
physiological and/or emotional reliance on that substance with
tolerance and withdrawal symptoms noted
Superolateral Above and to the side
Supine hypotension syndrome (vena caval syndrome) Fall in
blood pressure caused by decreased venous return when the
gravid uterus presses on the ascending vena cava when the
woman is lying flat on her back
Surfactant Phosphoprotein necessary for normal respiratory
function; prevents alveolar collapse and permits reexpansion
following exhalation
Syngeneic transplant When the donor of the bone marrow is an
identical sibling
Synovitis Inflammation of a synovial membrane
Syphilis One of the oldest known STDs, caused by the bacteria
spirochetal bacterium Treponema pallidum
Systemic HT therapy HT administration that results in absorption in
the blood high enough to provide clinically significant results
Tachycardia Baseline fetal heart rate greater than 160 beats per
minute
Tanner scale A tool to measure the stage of puberty based on the
development of secondary sex characteristics
Technology dependent Child is reliant on some type of medical
device to compensate for the loss of normal use of a vital body
function
Telangiectatic nevi “Stork bite”; “angel kiss”; small, red, localized
area of capillary dilation frequently seen in neonates; may occur
on the nape of the neck, eyebrows, eyelids, nose, or upper lip
Telehealth The removal of time and distance barriers for the delivery
of health-care services or related activities
Temperament Those characteristics present at birth that govern the
way in which an infant responds to his or her surroundings
Tenesmus The feeling of constantly needing to pass stools (or, in
less common sense, urine), even if bowels (or the bladder) are
already empty; can involve pain, straining, and cramping
Tenotomy The operation of cutting and repositioning a tendon
Teratogen Substance that adversely affects normal cellular
development in the embryo/fetus
Teratogenic effects Causing abnormal embryonic development
Testicular torsion Process vaginalis around spermatic cord and
testes twists, causing vascular compromise
Thelarche Beginning of breast development
Theories of development Various theories, stages, principles, and
models that typically describe child development as an organized
sequence of advancing milestones
Thrombin Problems with postpartum maternal coagulation
Thrombocytopenia An abnormal decrease in number of blood
platelets
Thrombosis Formation or presence of a blood clot within the
vascular system
Superficial venous thrombosis Involves the superficial
saphenous venous system
Deep venous thrombosis May extend from the foot to the
ileofemoral region
Thyroid storm A rare and potentially fatal complication of
hyperthyroidism. It typically occurs in patients who experience a
precipitating event such as surgery, infection, or trauma.
Tics Sudden, painless, nonrhythmic behaviors that are either motor
(related to movement) or vocal and that appear out of context—for
example, grimacing in class. They are fairly common in childhood;
tics are generally temporary conditions that resolve on their own.
Tinea capitis Infection of scalp hair and is characterized by scaly,
pruritic patches; can be associated with breakage of the hair; and
is usually seen in prepubertal children between ages 1 and 10
Tinea corporis Infection of body surfaces other than the feet, groin,
face, scalp hair, or beard hair characterized by a round to oval
lesion with maculopapular border with central clearing and often
with scaling, except the scalp, groin, hands, and feet; seen in
children and adolescents; sometimes referred to by the common
term ringworm even though no “worm” is involved
Tinea cruris Infection of the groin commonly known as “jock itch,” is
characterized by red, scaly skin that involves the inner thighs,
inguinal creases, or perineal area (rare before adolescence)
Tinea pedis Infection of the foot, also known as “athlete’s foot,” is
characterized by red, scaly, pruritic skin that may develop weeping
and involves the kinesthetic webbed areas of the toes and feet.
This infection can occur in children and adolescents.
Tinea unguium (dermatophyte onychomycosis) Infection of the
nail
Tocodynamometer Pressure-sensitive device applied against the
uterine fundus to measure and record contractions
Tocolysis Use of medications to inhibit uterine contractions
Tonometry Measurement of tension; used to evaluate intraocular
pressure
Tonsillectomy Surgical removal of the tonsils
Total burn surface area (TBSA) Percentage of body surface area
that has been affected by a burn injury
Total parenteral nutrition (TPN) The initial essential type of IV
nutritional support for high-risk newborns who cannot tolerate
other forms of nutrition. This therapy is used to establish positive
nitrogen and energy balance to promote growth.
Trabeculated Covered with trabeculae, cords of tissue that serves
as a supporting structure by forming a septum that extends into an
organ from its wall or capsule
Trauma-informed care (TIC) A strength-based framework that
recognizes the impact of trauma on a patient’s physical and
emotional well-being of the patient. As a patient-centered
approach to providing care, TIC places patient central as the
expert in making the health-care decisions that are best for them.
Trial of labor Observation period to determine if a woman in labor is
likely to successfully progress to a vaginal birth
Trichomoniasis A parasitic STD caused by the protozoan
Trichomonas vaginalis, the most common curable STD in the
United States
Tripod position A classic sign of acute epiglottitis in which a child
sits upright with the chin thrusted out (sniff position)
Trisomy Condition whereby a chromosome exists in triplicate
instead of the normal duplicate pattern
Tympanogram Radiographic examination of the eustachian tubes
and middle ear after introduction of a contrast medium
Unconsciousness A state in which a child’s cerebral function is
depressed; ranges from a stupor (aroused only with vigorous or
unpleasant stimulation) to a coma (state of unconsciousness when
the child cannot be aroused even by painful stimuli)
Uterine atony A failure of the uterine myometrium to contract and
retract following birth that represents the leading cause of early
postpartum hemorrhage
Uterine inversion Condition in which the uterus is turned inside out;
the fundus intrudes into the cervix or vagina; caused by vigorous
efforts to remove the placenta before it is detached by the natural
process of labor
Uterine tubes Also called fallopian tubes; two canals that extend
laterally from each side of the uterus through which the ovum
travels to the uterus
Uteroplacental insufficiency (UPI) Decline in placental function,
leading to fetal hypoxia and acidosis
Uterus Muscular, hollow, pear-shaped organ situated in the
midpelvis between the sacrum and the pubic symphysis; serves as
a reproductive organ for containing and nourishing the embryo
fetus from the time of implantation of the fertilized egg to the time
of birth; the womb
Coulevaire u. Accumulation of blood between the separated
placenta and the uterine wall following premature separation
(abruption) of the placenta; uterus takes on a bluish tinge as
blood extravasates from the clot into the myometrium
Uveitis Inflammation of the eye
Valine A branched-chain amino acid, C5H11NO2, derived from
digestion of proteins. It is essential in the diet, esp. for normal
growth in infants.
Vasa previa Condition where the umbilical cord is implanted into the
fetal membranes rather than the placenta
Vector A carrier, usually an insect, that transmits the causative
organism of disease
Version Act of turning the fetus in the uterus from one presentation
to another
Very low birth weight (VLBW) Infant weighing 1,500 g or less at
birth
Vesicle Raised, circumscribed, superficial skin elevation, filled with
serous fluid, 1 cm in diameter
Virulence Severity of the health problems caused by the agent
Visceral pain Discomfort related to cervical changes (i.e., dilation
and effacement), distention of the lower uterine segment, and
uterine ischemia; the predominant discomfort experienced during
the first stage of labor; pain located over the lower portion of the
abdomen that radiates to the lumbar area of the back and down
the thighs
Vulvovaginitis Inflammation of the vagina and vulva
Wet mount A test frequently used in the clinical setting to diagnose
three of the most common vaginal infections: bacterial vaginosis,
trichomoniasis, and yeast (candidiasis)
Wharton’s jelly Specialized white, gelatinous connective tissue that
surrounds the umbilical vessels within the cord
Photo & lustration Credits
Chapter 1
Figure 1-2 From EBM Pyramid and EBM Page Generator,
copyright 2006 Trustees of Dartmouth College and Yale
University. Produced by Jan Glover, David Izzo, Karen Odato,
and Lei Wang.
Figure 1-7 Townsend, M. C., & Morgan, K. I. (2018). Psychiatric
Mental Health Nursing: Concepts of Care in Evidence-Based
Practice, 9th edition. Philadelphia: F.A. Davis Company.
Figure 1-11 Center for Disease Control and Prevention, National
Center for Health Statistics. Infant Mortality Rates by State.
Chapter 2
Figures 2-1, 2-3, 2-11, and 2-13 Dillon, P. (2016). Nursing Health
Assessment: The Foundation of Clinical Practice, 3rd edition.
Figures 2-2, 2-4, 2-10, 2-15, and 2-16 Scanlon, V. C., & Sanders,
T. (2019). Essentials of Anatomy and Physiology, 8th edition.
Figure 2-17 Hatcher R. A., et al. (2005). Managing Contraception:
A Pocket Guide. Managing Contraception LLC.
Chapter 3
Figures 3-1, 3-14, 3-15, and 3-16 Courtesy of National Human
Genome Research Institute, Bethesda, Maryland.
Figures 3-2, 3-3, 3-5, 3-7, 3-8, 3-9, and 3-10 Scanlon, V. C., &
Sanders, T. (2019). Essentials of Anatomy and Physiology, 8th
edition. Philadelphia: F.A. Davis Company.
Figures 3-12 and 3-13 Smith, B. R. (2013). The multidimensional
human embryo, Carnegie Stages. Retrieved from
http://embryo.soad.umich.edu/carnStages/carnStages.html
Figure 3-18 Venes, D. (2021). Taber’s Cyclopedic Medical
Dictionary, 24th edition. Philadelphia: F.A. Davis Company.
Chapter 4
Figures 4-2, 4-6, and 4-8 Dillon, P. (2016). Nursing Health
Figure 4-3 Durham, R., & Chapman, L. (2019). Maternal-Newborn
Nursing: The Critical Components of Nursing Care, 3rd edition.
Chapter 5
Figures 5-1, 5-2, 5-3, 5-4, 5-5, 5-6, 5-7, 5-8, and 5-9 Dillon, P.
(2016). Nursing Health Assessment: The Foundation of Clinical
Practice, 3rd edition. Philadelphia: F.A. Davis Company.
Figure 5-14 Durham, R., & Chapman, L. (2019). Maternal-
Newborn Nursing: The Critical Components of Nursing Care,
3rd edition. Philadelphia: F.A. Davis Company.
Procedure: Performing Leopold Maneuvers Venes, D. (2021).
Taber’s Cyclopedic Medical Dictionary, 24th edition.
Chapter 6
Figure 6-3 Wedding, M. S., & Toenjes, S. A. (1998). Medical
Laboratory Procedures, 2nd edition. Philadelphia: F.A. Davis
Company.
Figures 6-4, 6-5, 6-6, 6-7, 6-9, 6-14, and 6-15 Durham, R., &
Chapman, L. (2019). Maternal-Newborn Nursing: The Critical
Components of Nursing Care, 3rd edition. Philadelphia: F.A.
Davis Company.
Figure 6-8 Gilbert, E. S., & Harmon, J. S. (2003). Manual of High
Risk Pregnancy and Delivery, 3rd edition. St. Louis: Mosby.
Figures 6-10 and 6-11 Dillon, P. (2016). Nursing Health
Figure 6-12 Scanlon, V. C., & Sanders, T. (2019). Essentials of
Anatomy and Physiology, 8th edition. Philadelphia: F.A. Davis
Company.
Chapter 7
Figures 7-1, 7-7, 7-9, 7-11, 7-12, 7-14, 7-15, 7-16, 7-17, 7-18, 7-
19, 7-20, 7-21, 7-22, 7-23, 7-24, 7-25, 7-26, 7-27, 7-28, 7-29, 7-
31, 7-34, and 7-49 Durham, R., & Chapman, L. (2019).
Maternal-Newborn Nursing: The Critical Components of Nursing
Care, 3rd edition. Philadelphia: F.A. Davis Company.
Figure 7-30 Lyndon, A., & Ali, L. U. (2009). Fetal Heart Rate
Monitoring: Principles and Practice, 4th edition. Dubuque, IA:
Kendal/Hunt.
Chapter 8
Figures 8-1, 8-2, 8-4, 8-16, 8-17, 8-18, and 8-19 Durham, R., &
Chapman, L. (2019). Maternal-Newborn Nursing: The Critical
Components of Nursing Care, 3rd edition. Philadelphia: F.A.
Davis Company.
Chapter 9
Figures 9-12, 9-13, 9-14, 9-15, 9-25, 9-27, 9-29, 9-30, 9-32, 9-34,
9-35, 9-36, 9-39, 9-40, 9-42, 9-43 Procedure: Performing the
Barlow Test (Steps 2 and 3) and the Ortolani Maneuver (Step 4)
Figures, and Table 9-5 Figures Dillon, P. (2016). Nursing Health
Figure 9-16 Courtesy of Mead Johnson Nutritionals
Figure 9-17 Ballard, J. L., Khoury, L. C., Wedig, K., et al. (1991).
New Ballard Score, expanded to include extremely premature
infants. Journal of Pediatrics 19(3): 417–423.
Figures 9-18, 9-19, 9-21, 9-23, 9-31, 9-38, 9-41, 9-48, and 9-49
Durham, R., & Chapman, L. (2019). Maternal-Newborn Nursing:
The Critical Components of Nursing Care, 3rd edition.
Figure 9-37 DeSevo, M. (2014). Pediatric Nursing: Review Plus
Practice Questions. Philadelphia: F.A. Davis Company.
Figure 9-44 Goolsby, M. J. (2018). Advanced Assessment:
Interpreting Findings and Formulating Differential Diagnoses,
4th edition. Philadelphia: F.A. Davis Company.
Chapter 10
Figure 10-1 Stevens, B., Johnston, C., Petryshen, P., & Taddio, A.
(1996). Premature infant pain profile: Development and initial
validation. Clinical Journal of Pain 12(1): 13-22.
Figures 10-2, 10-9, 10-12, 10-13, and 10-14 Courtesy of St. Luke’s
Hospital, Bethlehem, PA.
Figures 10-6, 10-7, 10-8, 10-11, 10-18, and 10-19 Courtesy of
McLeod Regional Medical Center Florence, SC.
Figure 10-10 Courtesy of William A. Silverman, MD.
Chapter 11
Figures 11-1, 11-4, 11-7, 11-12, 11-14, 11-15, and 11-16 Durham,
R. & Chapman, L. (2019). Maternal-Newborn Nursing: The
Critical Components of Nursing Care, 3rd edition. Philadelphia:
F.A. Davis Company.
Figure 11-5 Dillon, P. (2016). Nursing Health Assessment: The
Foundation of Clinical Practice, 3rd edition. Philadelphia: F.A.
Davis Company.
Figures 11-9 and 11-10 A,C Courtesy of Medela Corporation,
McHenry, IL.
Chapter 14
Davis Company.
Figure 14-6 B. Copyright 1983 Wong-Baker FACES Foundation,
www.WongBakerFACES.org. Used with Permission. Originally
published in Whaley & Wong’s Nursing Care of Infants and
Children. Copyright Elsevier, Inc.
Figure 14-18 Durham, R., & Chapman, L. (2019). Maternal-
Newborn Nursing: The Critical Components of Nursing Care,
3rd edition. Philadelphia: F.A. Davis Company.
Chapter 15
Davis Company.
Figure 15-10 Asthma Action Plan used with permission. Copyright
2020 American Lung Association, www.Lung.org.
Chapter 17
Figure 17-23 B. Myers, S., & Curran, A. (2014). General & Oral
Pathology for Dental Hygiene Practice. Philadelphia: F.A. Davis
Company.
Chapter 18
Figure 18-1 Jones S. (2017). Pocket Anatomy and Physiology, 3rd
edition. Philadelphia: F.A. Davis Company. Table 18-3 Figures
Centers for Disease Control and Prevention, Public Health
Image Library.
Chapter 19
Figure 19-1 A Gylys, B., & Wedding, M. (2017). Medical
Terminology Systems: A Body Systems Approach, 8th edition.
Philadelphia: F.A. Davis Company. B Thompson, G. (2019).
Understanding Anatomy & Physiology: A Visual, Auditory,
Interactive Approach, 3rd edition. Philadelphia: F.A. Davis
Company.
Chapter 20
Figure 20-1 Hoffman, J., & Sullivan, N. (2019). Davis Advantage
for Medical-Surgical Nursing: Making Connections to Practice,
2nd edition. Philadelphia: F.A. Davis Company.
Figure 20-2 Piña-Garza, J. E. (2013) Fenichel’s Clinical Pediatric
Neurology: A Signs and Symptoms Approach, 7th Edition.
Philadelphia, PA: Elsevier Saunders.
Figure 20-3 Teasdale, G., & Jennett, B. (1974). Assessment of
coma and impaired consciousness. A practical scale. The
Lancet 2(7872): 81-84.
Figure 20-4 Wong, J., Wong, S., & Dempster, J. K. (1984). Care of
the unconscious patient: A problem-oriented approach.
American Association of Neuroscience Nurses, 16, 145.
Figure 20-8 Williams, L. S., & Hopper, P. D. (2019). Understanding
Medical Surgical Nursing, 6th Edition. Philadelphia: F.A. Davis
Company.
Chapter 21
Figure 21-1 Thompson, J. (2017) Essential Health Assessment.
Chapter 22
Figure 22-1 Scanlon, V.C., & Sanders, T. (2019). Essentials of
Anatomy and Physiology, 8th Edition. Philadelphia: F.A. Davis
Company.
Figure 22-3 Goldsmith, L. A., Lazarus, G. S., & Tharp, M. D.
(1997). Adult and Pediatric Dermatology. Philadelphia: F.A.
Davis Company.
Figures 22-4 and 22-6 Williams, L. S., & Hopper, P. D. (2019).
Understanding Medical Surgical Nursing, 6th edition.
Table 22-1 Figures Dillon, P. (2016). Nursing Health Assessment:
The Foundation of Clinical Practice, 3rd edition. Philadelphia:
F.A. Davis Company.
Chapter 23
Figure 23-1 Scanlon, V. C., & Sanders, T. (2019). Essentials of
Anatomy and Physiology, 8th edition. Philadelphia: F.A. Davis
Company.
Chapter 24
Figure 24-1 Cowen, V. (2015) Pathophysiology for Massage
Therapists. Philadelphia: F.A. Davis Company.
Figure 24-2 Harmening, D. L. (2009). Clinical Hematology and
Fundamentals of Hemostasis, 5th edition. Philadelphia: F.A.
Davis Company.
Chapter 26
Figure 26-1 Jones, S. (2017) Pocket Anatomy and Physiology, 3rd
edition. Philadelphia: F.A. Davis Company.
Figures 26-3 and 26-5 Harmening, D. (2009). Clinical Hematology
and Fundamentals of Hemostasis, 5th edition. Philadelphia: F.A.
Davis Company.
Figures 26-6 and 26-7 McKinnis, L. (2021). Fundamentals of
Musculoskeletal Imaging, 5th edition. Philadelphia: F.A. Davis
Company. Figure 26-12 Nicklaus Children’s Hospital, Miami, FL.
Chapter 28
Figure 28-1 Futures Without Violence (formerly Family Violence
Prevention Fund), www.futureswithoutviolence.org. It is the
recommendation of the National Health Resource Center on
Domestic Violence, a project of Futures Without Violence, that in
the case that screening is required, it be done in addition to a
Universal Education approach to violence prevention. Violence
prevention and safety resources should be offered to each
patient when discussing IPV, whether or not they disclose their
own experiences.
Chapter 31
Figures 31-1, 31-2, 31-5, and 31-6 Venes, D. (2021). Taber’s
Cyclopedic Medical Dictionary, 24th Edition. Philadelphia: F.A.
Davis Company.
Figure 31-4 Eagle, S., Brassington, C., Dailey, C., & Goretti, C.
(2009). The Professional Medical Assistant: An Integrative,
Teamwork-based Approach. Philadelphia: F.A. Davis Company.
Chapter 32
Figure 32-2 Gashi AM. Trichomonas Vaginalis-A Clinical Image.
Arch Case Rep. 2017; 1: 001-002.
Figures 32-3 and 32-5 Venes, D. (2021). Taber’s Cyclopedic
Medical Dictionary, 24th edition. Philadelphia: F.A. Davis
Company.
Figure 32-6 Center for Disease Control and Prevention, Public
Health Image Library/Joe Millar.
Chapter 33
Figures 33-3 and 33-4 Dillon, P. (2016). Nursing Health
Figure 33-5 Williams, L. S., & Hopper, P. D. (2019). Understanding
Medical Surgical Nursing, 6th edition. Philadelphia: F.A. Davis
Company.
Index
Note: The letter b indicates a boxed feature on the page; the letter f
indicates a figure; the letter t indicates a table; and the letter e
indicates e-only.
A
Abdominal system
abdominal distention, 386
abdominal wall defects, 364, 364f
after cesarean birth, 386
with chronic kidney disease (CKD), 807t
incision wound care after cesarean birth, 386, 400
medical emergencies with cancer, 897
postpartum physiological adaptations, 383, 383f
prenatal examination of, 120
traumatic injury to, 549
in Wilms’ tumor, 880
Abnormal genital bleeding, 979–980e
ABO incompatibility, 171
Abortion, 11, 53–54
spontaneous, 147–148, 148f
Abruptio placentae. See Placental abruption
Abstinence, 45
Abuse
child, 857–859, 858t
intimate partner violence (IPV) (See Intimate
partner violence (IPV))
phases of, 928e
sexual violence (SA), 934–937e, 934te
victims’ reactions to phases of, 928e
Abuse Assessment Screen (AAS), 930e, 930fe
Abusive head trauma, 706
Acceptance in grieving, 914
Accessory glands, male reproductive system, 41
Acetaminophen, 477
Acetylsalicylic acid, 696t. See also Aspirin
Acid-base calculators, 345
Acne, 757–759, 758f
during adolescence, 757–758
medications for, 759, 760–761t
neonatal, 304–305, 304f
Acrocyanosis, 285, 302, 302f
Acromioclavicular joints, 743
Active acquired immunity, 294
Active immunity, 592
Active phase of labor, 216–217
Activity, early stages of neonate, 294–295, 295f
Acupressure, 223
Acupuncture, 99
for premenstrual disorders, 945e
Acute adrenocortical insufficiency, 658–659
Acute diarrhea, 538
Acute epiglottitis, 506–507
Acute intracranial hemorrhage (ICH), 357, 357b
Acute kidney injury (AKI), 802–803, 803t, 804t
renal replacement therapy for, 807–810, 809b, 810f
Acute lymphocytic leukemia (ALL), 874, 875–876, 875–876f
Acute myelogenous leukemia (AML), 874, 876–877, 876f
Acute respiratory distress syndrome (ARDS), 499–500
Acute violence and explosion phase in abuse, 928e
Acyclovir (Zovirax), 619
Adapalene (Differin), 760t
Addison’s disease, 659–661
Adjourning, 12
Admission, birthing center, 198–199
Adolescents
acne in, 757–758
anticipatory guidance for, 452, 453b
burn injuries in, 773
cervical cancer screening in, 1022–1023e
cognitive development in, 451t, 452, 453b
discipline of, 452, 453b
discussions about losing weight with, 14
effect of chronic condition on, 906–907
human immunodeficiency virus (HIV [AIDS]) in, 598
human papillomavirus (HPV) in, 1032e, 1034–1035e
informed consent process and, 453
injuries in, 457t
intimate partner violence (IPV) and, 929e
labor and birth complications in, 263–264
language development in, 451t
laws about reproductive care for, 43
making good decisions, 452
moral development in, 452
perception of death, 910
peritoneal dialysis in, 808
physical development in, 450–451, 451t, 453b
postpartum care in, 402–403
pregnancy in, 180
preparation for procedure with, 479
prevention of unintentional injuries in, 451–452
psychosocial development in, 451t, 452, 452f
safety of, 453b, 487
sensory development in, 451t
substance use and abuse by, 859–860
urinary tract infections (UTI) in, 789
Adoption, infants placed for, 403
Adrenal glands, 634
acute adrenocortical insufficiency, 658–659
chronic adrenocortical insufficiency, 659–660
congenital adrenal hyperplasia (CAH), 662–664
Cushing’s syndrome, 661–662
hormones, 638–639t
hyperaldosteronism, 664–665
laboratory testing, 642t
during pregnancy, 94
primary adrenal insufficiency, 660–661
Adrenocorticotropic hormone (ACTH), 33
source and function, 637t
Afterload, heart, 555
After-school activities, 461
Agoraphobia, 849
Ainsworth, Mary, 433
Air pollution, 116
Airway, neonate, 296
Alcohol
breast cancer and, 970e
breastfeeding and, 393–394
breast health and, 963e
during pregnancy, 74, 116
Alcohol-related birth defects (ARBDs), 116
Aldosterone, 639t
Alert state, 682t
Allergic reactions, 602–605
blood transfusion, 842–843
Allergic rhinitis, 515–516
Allergic shiners, 464
Alopecia, 621, 893f
due to cancer treatment, 892
Alpha blockers, 853t
Alpha-fetoprotein, 79
Alpha-methyldopa, 159t
Altered level of consciousness, 682, 682t
Alternative medical systems, 950e, 951be
Ambiguous genitalia, 315–316
Ambivalent attachment, 433
Ambulatory surgery centers, 471
Amenorrhea, 39, 812–813, 978–979e
as sign of pregnancy, 96
American College of Nurse Midwives, 246
American Nurses Association (ANA) clinical practice guidelines, 5–9, 7–9f
Aminophylline, 352
Amnihook, 246f
Amniocentesis, 80
Amnion, 67, 69
Amniotic fluid, 69
breech presentation and meconium in, 257
complications of, 261–262
detecting, 196, 197
premature rupture of membranes and, 155
rupture of membrane, 196
Amniotomy, 196, 244, 246, 246f
AmniSure test, 196, 197
Amoxicillin, 622
Amphetamines, 74
Ampicillin (Principen), 791t
Analgesia, 223–224, 224b. See also Anesthesia
combined spinal-epidural, 230–231
epidural, 226, 226t, 228–229f, 228–231
lumbar epidural, 228–229
nerve block, 225–226, 226t
opioid agonist, 224, 225t
opioid agonist-antagonist, 225
systemic, 224
Anal stage of psychosexual development, 431–432, 432b, 437t, 443
Anaphylactoid syndrome of pregnancy, 269–270
Anaphylaxis, 602–605
Anaplasia, 873
Anastrozole (Arimidex), 987e
Androgens, 44t
Android pelvic type, 31, 32f
Anemia
aplastic, 836–838, 837b
cancer and, 894
collaborative care, 825
common causes, 823b
definition of, 820, 822
diagnosis, 823, 824t
fatigue with, 820
iron-deficiency, 825–827
patient education, 825
prevention, 824
signs and symptoms, 822–823
Anemia of prematurity (AOP), 355
Anencephaly, 322, 362
Anesthesia, 223–224, 224b. See also Analgesia
enhancing maternal knowledge about, 272
epidural, 228–229f, 228–230
general, 231–232, 231f
nerve block, 225–226, 226t
recovery from, after cesarean birth, 386
safe administration of, 892
spinal block, 227–228, 227f
Anger in grieving, 914–915
Angiography, 584
Angioplasty, 584–585, 585f
Animal-borne infectious diseases
cat scratch disease, 623–624
rabies, 622–623
West Nile virus, 624
Anisometropia, 711
Anorectal malformations, 315, 527–528
Anorexia nervosa, 132, 861–862
Antenatal corticosteroids, 153
Anterior cruciate ligament (ACL), 734–735
Anterior pituitary
growth hormone deficiency (GHD), 635, 639–641, 647–648, 648t
hormones of, 637–638t
pituitary hyperfunction, 648–649
Anthropoid pelvic type, 31, 32f
Anthropometric measurements, 462, 462f
neonate, 298–299, 298f, 299f
Antibiotic-resistant organisms, 629–630, 630t
Antibiotics
amoxicillin, 622
for hemolytic uremic syndrome (HUS), 798
for Lyme disease, 771
for respiratory conditions, 496, 503, 504, 510
for urinary tract infection (UTI), 790, 791t
Antibodies, 592
Antibody deficiency, 593–594
Anticholinergics for respiratory conditions, 496
Anticipatory guidance, 430
adolescence (12-19 years), 452, 453b
infants, 442, 442b
preschoolers, 447, 448b
school-age child (6-12 years), 450, 450b
toddlers, 445, 445b
Anticoagulants, 415, 575
Anticonvulsants, 853t
Anti-D antibody, 834–835
Antidepressants, 44t, 422, 422t, 853t
for premenstrual disorders, 946e
Antidiuretic hormone (ADH)
diabetes insipidus (DI), 649–652
syndrome of inappropriate antidiuretic hormone (SIADH), 652–653
Antiemetics, 223, 892, 893f
Antiepileptic drugs, 689–690, 690t
Antigens, 592
Antihistamines
for blood transfusion allergic reaction, 843
for respiratory conditions, 496
Antihypertensives, 44t
Antiphospholipid syndrome, induction of labor for, 246
Antipsychotics, 44t, 422t, 853t
Antithymocyte globulin (ATG), 837
Antiviral agents for respiratory conditions, 496
Anxiety, 849–850, 849f
in grieving, 914
medications for, 853t
mindful breathing for, 850, 850f
during pregnancy, 102–103, 177
resources on, 850b
Aortic stenosis, 568–569, 568f
APGAR score, 296–298, 297t
Apheresis, 843–844
Aplastic anemia, 836–838, 837b
Apnea, 285
Apnea of prematurity (AOP), 351–353, 352f
Appendicitis, 534
Apples and breast cancer risk, 969e
Appropriate for gestational age (AGA), 299, 336t
AquaMEPHYTON, 312–313
Areola, breast, 32f, 33
Arginine vasopressin (AVP), 644t
Armstrong, Thomas, 435
Aromatherapy, 222
Arterial blood gases (ABGs), 346t
testing of, 496, 516–517
Arterial switch (ASO), 558t
Arteries, 820f
Arteriovenous (AV) fistula, 809
Arthritis, juvenile, 740–743, 740t
Artificial rupture of membranes (AROM). See Amniotomy
Artificial sweeteners, 131
Asexual orientation, 42t
Asparaginase (Elspar, Kidrolase), 888t
Aspiration, foreign body (FB), 514–515
Aspirin, 415, 822t
medications containing acetylsalicylic acid, 696t
Reye syndrome and, 477, 514, 695–696
Assessment. See also Diagnosis
blood pressure, 463, 463t, 557
blood sugar, 666
breast cancer risk assessment tool, 969e
breath sounds, 467
cancer treatment and oral, 894
chest, 466
daily maintenance fluid requirements, 784
developmental surveillance and screening, 445–446
Doppler ultrasonography, 177, 815
ears, 465, 465f
eating disorders, 861
endocrine system, 640–641t
eyes, 464–465
fractures, 737
general impression, 463
head, 464, 464f
head circumference measurement, 701
hematological disease, 821t
hemolytic uremic syndrome (HUS), 798
Hirschberg asymmetrical corneal light reflex test, 712
hypoglycemia, 666
increased intracranial pressure (ICP), 684–685, 684f
infectious disease, 615
intussusception, 530
irritable bowel syndrome (IBS), 537
lungs, 466–467
maternal-infant attachment, 396
meningitis, 691
neck, 464, 464f
newborn
airway, breathing, circulation, and thermoregulation, 296
APGAR score, 296–298, 297t
blood pressure, 336, 336t
cardiovascular system, 311–314, 311–314f
gastrointestinal system, 313–314, 313–314f
genitourinary system, 314–315f, 314–316
gestational age, 300, 301f
head, eyes, ears, nose, and throat, 306–308f, 306–309
head-to-toe physical, 302–322
immediate, 296–300
integumentary system, 302–305f, 302–306
length and weight, 298–299, 298f, 299f, 300f, 300t
level of reactivity, 299–300
metabolic screening tests, 301–302
musculoskeletal system, 316–317f, 316–318
neurological system, 318–322, 319–321t
normal newborn parameters, 300t
preterm newborns, 349–350t
respiratory system, 310–311, 310f
skin probes, 342
vital signs, 298, 298b
nose/sinus, 465–466
pediatric history, 459
postpartum
bladder, 376–377, 377t
bowel, 377, 377b
breasts, 374–375, 375f
episiotomy, 378
hemorrhoids, 379
lochia, 377–378, 378f
maternal physiological adaptations and continued, 381–383
pain, 379–381
perineal, 378, 379t
uterus, 375–376, 375t, 376f
postpartum depression, 421–422
premenstrual disorders, 943e
preparing for mammogram, 965e
recognizing physical signs of impending death, 911
scabies, 769
secondary sex characteristics, 466, 466t
skin, 463–464
slipped capital femoral ephysis (SCFE), 731
soft tissue injuries, 734
states of consciousness, 682t
strangulation, 927e
suicidal ideation, 852–853
throat/mouth, 466
vaginal swab testing kits for home and clinical use, 982e
visual acuity, 464–465
Assisted operative/vaginal delivery, 250–252, 251–252f
Assisted reproductive technologies (ART), 57
Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), 219
Postpartum Hemorrhage Project, 412
Asthma, 171–172, 516–519, 517f, 518b, 518t, 519f, 520–521f
Astigmatism, 711
Ataxia, 892
Ataxic cerebral palsy (CP), 703
Atherosclerotic lesions, 578
Athetoid cerebral palsy (CP), 703
Athlete’s foot, 621t
Atopic dermatitis, 765–766, 766f
Atraumatic care, 458
Atrial septal defect (ASD), 562–564, 563f
Atrioventricular canal defect (AVC), 566–567, 566f
Attachment
phases of, 434t, 441
promotion of, 327–328, 328f, 395–398, 396f, 397t
reactive attachment disorder (RAD) and, 854–855
theories of, 433
types of, 433
Attention-deficit/hyperactivity disorder (ADHD), 855–856
Auditory brainstem evoked response (ABER), 715
Augmentation of labor, 250
Auscultation
fetal heart, 120, 122, 122f, 203–205
heart murmurs, 572, 572f
Authoritarian parenting style, 13b
Authoritative parenting style, 13b
Autism spectrum disorder (ASD), 848, 866–868, 867f
Autoimmune disorders, 600t
dermatomyositis, 601–602
hypermobility syndrome, 602
juvenile arthritis, 740–743, 740t
juvenile myasthenia gravis (MG), 697
medications for, 602b
systemic lupus erythematosus (SLE), 599–601
Autologous blood, 840t
Automated auditory brainstem response (AABR), 309
Automated tissue excision and collection (ATEC), 968e
Autonomic dysreflexia, 707
Autonomy vs. shame and doubt, 432, 437t, 443–444, 472t
Autosomal dominant inheritance, 62, 63f, 63t
Autosomal recessive agammaglobulinemia, 594
Autosomal recessive inheritance, 62–63
Avian influenza, 624–625
Avoidant attachment, 433
Awake states, neonates, 295t
Axillary nodes, breast cancer of, 971–972e, 971fe
Axillary temperature, 323, 323f
Ayurveda, 951be
B
B2 agonists, 496
Babinski reflex, 320t, 438
Baby blues, 398–399
Backache, 100
Baclofen (Lioresal), 693t
Bacterial infections, 622
skin, 757–763
Bacterial vaginosis (BV), 981–982e, 982fe
Balloon atrial septostomy, 585
Ballottement, 97
Bandl ring, 245
Bandura, Albert, 433–434
Barbiturates, 223
Bargaining in grieving, 914
Bariatric surgery, prenatal care after, 131
Barium enema, 530
Barlow Test, 318
Baroreceptors, 580
Bartholin’s glands, 26f, 27
abscess of, 993e
Baseline fetal heart rate, 206–207, 207f
Bathing
holistic nursing care and, 474
of neonate, 324
Battledore placenta, 268–269
B-cell disorders, 593–594
combined deficiency T- and, 594
Bedrest, 179–180, 179f
Behavioral contraceptive methods, 44–45
Beneficence, 10
Benign breast masses, 960–961e
Benzodiazepines, 223
Beractant (Survanta), 351
Bereavement teams, 916
Beta blockers, 44t, 853t
Betamethasone, 256t
Bethesda System, 1023–1024e, 1023be
Bicarbonate therapy, 345
Bilateral tubal ligation (BTL), 52, 52f
Biliary atresia, 546
Bilirubin, 292, 292f
monitoring levels of, 344
Bimanual compression, 412, 412f
Biofeedback, 222
Bioidentical compounds, 955be, 955e
Biologic response modifiers (BRMS), 876
Biophysical profile, fetal, 177, 178t
Biopsy
bone, 741, 883
breast, 966–967e, 966fe
cardiac, 584
renal, 802
Bipolar disorder, 176
Bipolar disorder (BPD), 852, 852t
Birth defects. See Congenital conditions
Birthing From Within, 140t
Birthmarks, 305
Birth order, 13
Birth partner, caring for, 232
Birth plans, 140, 140b
Birth trauma, 306
Birth weight, 299, 336, 336t
Bisexual orientation, 42t
Bishop score tool, 246, 247t
Bites and stings
cat scratch disease (CSD), 623–624, 772
insect, 769–770
Lyme disease from tick, 770–771
Rocky Mountain spotted fever (RMSF) from tick, 771–772
Black cohosh, 946te, 952e
Black widow spider bite, 770
Bladder
exstrophy of, 799
female, 32
during pregnancy, 93, 93f
postpartum assessment, 376–377, 377t
Blalock-Taussig shunt, 557t, 559t
Blastocyst, 66
Blastogenesis, 69
Bleach solution, 763
Bleeding. See Hemorrhage
Bleomycin (Blenoxane), 888t
Blepharitis marginalis, 710t
Blocked tear duct, 710t
Blood circulation, 820f
Blood components in neonates, 290–291
Blood cultures, 741
Blood glucose, 291
heel stick for checking, 343–344, 343f
ketone monitoring and, 668
Blood pressure
hypertension (HTN), 578–579
hypertensive (See Hypertensive disorders of pregnancy)
maternal postpartum, 373
measurement of, 463, 463t, 557
newborn, 336–337, 336t
postinterventional catheterization, 585
pulmonary arterial hypertension (PAH), 579
Blood sample collection, 481–482
Blood transfusion therapy, 839–841t, 839–843
Blood type, 841–842
Blood urea nitrogen (BUN), 789
Blood volume
in neonates, 289
postpartum adaptations, 381
Bloody show, 196
Blunt cardiac trauma (BCI), 577–578
Bodily kinesthetic learning, 435t
Body image changes during pregnancy, 102
Body mass index (BMI), 119, 462
Body temperature. See also Cold stress
axillary, 323, 323f
fever, 615
infant skin and, 752–753
maternal postpartum, 373
measuring, 462, 463f
normal newborn, 342b
postpartum, 400
Bonding, family and infant, 395–398, 396f, 397t
Bone marrow transplantation, 843
Bones, 720–721
biopsies of, 741, 883
tumors of
Ewing’s sarcoma, 882–883, 883f
osteosarcoma, 882, 882f
Bony pelvis, female, 30, 30f, 190
Botulism, 697–698
Bowel sounds, 313, 314f
Bowen family systems theory, 13
Bowlby, John, 433
Bowman’s capsule, 783
Boys. See Males
Brachial plexus injuries (BPI), 322, 347–348, 347b
Brachytherapy, 1029be
Bradley Method, 140t
Bradycardia, 207, 207f
rupture of uterus and, 266
Brain. See also Head; Neurological conditions; Neurological system
traumatic brain injury (TBI), 704–706, 705f
tumors of, 878–879
Braxton-Hicks contractions, 88, 97, 196
BRCA1 and BRCA2 genes, 970e, 1035e
Breast cancer, 953be
complementary and alternative medicine (CAM) for, 974–975e
demographics and personal health history in, 969e
gene defects and, 970e
indicators of disease prognosis, 971–972e, 971e, 972be
lifestyle choices and, 963e
lifestyle factors in, 969–970e
mammography for detecting, 963–964e
nursing care for women dealing with, 974–975e
ovarian cancer and, 1035e
recurrence of, 974e
resources on, 974e
risk factors for, 968be, 968e, 969e
tips for reducing, 969–970e
staging system, 972be, 972e
survivorship care plans, 975e
treatment of, 972–974e
tumor types, 970–971e, 970fe
Breast conservation therapy (BCT), 972–973e
Breast crawl, the (TBC), 389
Breastfeeding, 328
appetite and digestion with, 525
benefits of, 386–387, 387b
difficulty in, 392
education about, 141
high-risk newborns, 338
infant feeding-readiness cues, 390b
infant weaning from, 393
infant weight gain with, 391
iron supplementation and, 823
jaundice associated with, 354
latch-on in, 388–389, 389f, 390
let-down reflex, 94, 387, 390
by mothers with physical disabilities, 390
physiology of lactation and, 387–388, 388f
positions for, 391–392, 391f
postpartum medications and, 374t
sleepy infants, 390
strategies for success with, 388–390, 389f, 390b
tobacco, alcohol, and, 393–394
Breast implants, 963e
Breast milk
donor, 393
electric expression of, 393, 393f
storage of, 392–393, 392t
Breast milk jaundice, 354
Breasts, 32–33, 32f
abnormality evaluation
algorithms for, 966e
biopsy, 966–967e, 966fe
mammography, 963–966e, 964be, 964fe
testing for estrogen and progesterone receptors, 967e
anatomy of, 959–960e, 960fe
benign masses, 960–961e
calcium deposits within, 964e
dense, 964e
endocrine system assessment, 641t
engorgement of, 392
examination of, 119
hematological disease and, 821t
let-down reflex, 94
lifestyle choices and health of, 963e
mastitis, 417–418, 418f
menopause and, 949e
postpartum assessment, 374–375, 375f
preventive health, 961–962fe, 961–963e
symptoms evaluation
nipple discharge, 967–968e
pain, 968e
skin changes, 968e
Breast self-examination (BSE), 961–962fe, 961–963e
Breast shells, 392
Breathing, neonate, 296
Breath sounds, assessment of, 467
Breech presentation, 192–193, 193f, 257, 258–259f
Bronchiolitis, 508–509
Bronchitis, 507–508
Bronchodilators, 353
Bronchopulmonary dysplasia (BPD), 353
Bronfenbrenner, Urie, 434, 437t
Brown adipose tissue (BAT), 288, 288f
Brown recluse spider bite, 770
Brow presentation, 192, 192f
Brudzinski’s sign, 691, 692f
Bryant’s traction, 724
BUBBLE-HE mnemonic, 374, 374t, 386
Bulbourethral glands, 41
Bulimia nervosa, 132
Bullae, 753, 754t
Burn centers, 773–774
Burnout, 917
Burns, 772
child development and, 773
depth of, 774, 774f
eschar, escharotomy, and fasciotomy with, 778
fluid resuscitation, 776, 777b
home care for, 778
maintaining circulation with, 777–778
nursing care for minor, 778
pain management in, 777
prevention of, 773
prevention of infection in, 776–777
promotion of good nutrition with, 778
severity of, 774–775
size or extent of, 774–775, 775–776f
types of, 774
Butorphanol, 225
C
Café-au-lait birthmarks, 305
Caffeine
during pregnancy, 74, 130–131
for respiratory conditions, 496
Caffeine citrate (Cafcit), 353
CAGE tool, 861t
Calcifications, breast, 964e
Calcitonin, 95
Calcium
hypocalcemia in large for gestational age (LGA) newborns and, 347
laboratory testing of, 741
musculoskeletal health and, 738t
safe administration of, 657
Calories, 128
Canavan disease, 63t
Cancer
endometrial, 953be, 1036e
ovarian, 1035e, 1035te
vulva, 1036–1037e
Cancer, breast, 953be
complementary and alternative medicine (CAM) for, 974–975e
demographics and personal health history in, 969e
gene defects and, 970e
indicators of disease prognosis, 971–972e, 971e, 972be
lifestyle choices and, 963e
lifestyle factors in, 969–970e
mammography for detecting, 963–964e
nursing care for women dealing with, 974–975e
recurrence of, 974e
resources on, 974e
risk factors for, 968be, 968e, 969e
tips for reducing, 969–970e
staging system, 972be, 972e
survivorship care plans, 975e
treatment of, 972–974e
tumor types, 970–971e, 970fe
Cancer, cervical
cervical intraepitelia neoplasia grading system, 1023te
diagnosis
colposcopy, 1024e
endocervical sampling, 1024–1025e
Pap test, 1020e, 1021–1024e, 1021fe, 1024be
diagnostic work-up and treatment of, 1027–1030e, 1027be, 1029be
chemotherapy, 1029–1030e
radiation therapy, 1027–1029e, 1029be
surgery, 1029e
management of abnormal cervical cytology/
colposcopy findings, 1025–1027e, 1026e
nursing role in reducing patient risk of, 1032–1033e
risk factors for, 1019e, 1020be
screening and early detection, 1021–1025e, 1021fe, 1023be, 1023te, 1024be
stages of invasive, 1027be
symptoms of, 1019–1020e
Cancer, childhood, 872–873
alopecia and, 892, 893f, 894
anemia and, 894
bone tumors
chemotherapy
acute lymphocytic leukemia (ALL), 876
acute myelogenous leukemia (AML), 877
agents and common cancer drugs, 888–889t, 888–890
brain tumor, 879
chronic myelogenous leukemia (CML), 877
Hodgkin’s lymphoma (HL), 884, 884f
liver cancer, 885
negative effects of, 890
non-Hodgkin’s lymphoma (NHL), 885
osteosarcoma, 882
venous access devices for, 890, 890t
waste receptacle for, 885f
Wilms’ tumor, 880
chronic health conditions in survivors of, 886
diarrhea and constipation, 894
effect on growth and development, 886
epidemiology of, 873
Hodgkin’s disease (HD), 883–885
holistic nursing care of child with, 885–886
infection and, 887, 890–891
leukemia
acute lymphocytic leukemia (ALL), 874, 875–876, 875–876f
acute myelogenous leukemia (AML), 874, 876–877, 876f
factors predisposing to childhood, 875t
liver, 885
long-term effects of treatment for, 895
lymphomas, 883–885
medical emergencies with, 895–897
hemorrhagic cystitis, 895–896, 897b, 897f
septic shock, 896–897
tumor lysis syndrome, 896
mucositis and, 894
nausea and vomiting, 892
neutropenia and, 894–895
nutrition for children with, 886, 886f, 887b
pain management, 891–892
physiology of, 873–874, 873f
prevention, 874
psychological effect of, 897–898, 898f
psychosocial support, 892
radiation therapy, 891
solid tumors
brain, 878–879
neuroblastoma, 879–880
retinoblastoma, 881
rhabdomyosarcoma, 881
Wilms’ tumor, 880–881
staging of, 874
surgery, 891
thrombocytopenia and, 894
Cancer, reproductive
addressing sexual issues in women with, 1036e
breast (See Breast cancer)
cervical cancer (See Cervical cancer)
endometrial cancer, 953be, 1036e
human papillomavirus (HPV) and (See Human papillomavirus (HPV))
ovarian cancer, 1035e, 1035te
premalignant and malignant vulvar lesions, 1036–1037e
Candida albicans
oral thrush, 620–621
vaginal candidiasis, 982–983e, 983fe
Cannabis, 74, 116
Capillary refill time, 738, 739f
Caput succedaneum, 307, 307f
Carbamazepine (Tegretol), 694t
Carbohydrates, daily requirement of, 461
Carboplatin (Paraplatin, Paraplatin AQ), 888t
Carboprost tromethamine (Hemabate), 411t
Cardiac catheterization, 583–584, 584b
Cardiac diseases
cardiomyopathy (CM), 575–577
Kawasaki disease, 574–575, 585f
risks from, 573
subacute bacterial endocarditis (SBE), 566, 574
Cardiac glycosides, 44t
Cardiac insufficiency, 312
Cardiac output
neonatal assessment, 312
physiology of, 555
Cardiac transplantation, 585–586, 586f
Cardiac trauma, 577–578
Cardinal movements, 234–235, 234f
Cardiogenic shock, 897
Cardiomyopathy (CM), 575–577
Cardiopulmonary exercise test (CPET), 495
Cardiopulmonary resuscitation (CPR), 588
Cardiopulmonary transitions, 285
Cardiorespiratory monitor, 352, 352f
Cardiovascular conditions, 553, 553f
auscultation of heart murmurs, 572f
cardiac diseases, 573–577, 575f
cardiac trauma, 577–578
carding for child with, 556
chronic, 902b
community-based nursing care for child with, 587–589
complex single ventricle-type defects, 572–573, 573f
congenital heart disease (CHD) (See Congenital heart disease (CHD))
congestive heart failure (CHF), 556–560, 557–560t
heart murmurs, 572–573, 572f, 573t
hemorrhagic disease of the newborn, 312–313
hormone therapy use and, 953be
hypercholesterolemia-hyperlipidemia, 578, 578t
hypertension (HTN), 578–579
invasive tests, 583–585, 584b, 585f
long QT syndrome (LQTS), 580–581, 580f
menopause and, 949e
neurally mediated syncope (NMS), 579–580
nursing care for hospitalized child with, 586–587
prevention of, in children, 555–556
pulseless electrical activity (PEA), 583
rhythm disturbances, 581–583, 581f
segmental classification of congenital heart defects, 562–573
subacute bacterial endocarditis prophylaxis, 566
surgical interventions, 585–586, 586f
syndromes associated with, 554t
Cardiovascular system
childbirth complications and, 253
heart
auscultation of fetal, 120, 122, 122f
cardiac output, 90, 312, 555
chambers, 553, 554f
normal cardiac function, 553–555, 553–555f, 554t
normal flow through, 555, 555f
physiology of, 555, 555f
during pregnancy, 89–90, 89f
preload, afterload, and contractility, 555
stroke volume, 555
valves, 553–555, 554f
vessels, 555, 555f
neonatal assessment, 311–314, 311–314f
neonate physiological transition, 285–287, 286–287f, 287t
postpartum physiological adaptations, 382
Caregiver fatigue and burden
child with chronic condition and, 908
child with disability and, 470
Care settings
community, 486–489, 486f
hospital, 470–471
school, 488–489
Carpal tunnel syndrome, 101
Carrier screening, 79, 81
Car seat safety, 328, 353
Carvedilol, 576
Casts, 721–724, 722–723f, 722b
caring for child with fracture in, 737–738, 738f
Cast syndrome, 724
Cataracts, 310, 713
Cat scratch disease (CSD), 623–624, 772
Cefixime (Suprax), 791t
Cefotaxime (Claforan), 791t
Ceftriaxone (Rocephin), 791t
Celiac disease, 544–545, 600t
Cell-free fetal DNA, 79
Cellular division, 64–65
Cellulitis, 762–763, 762f
CenteringParenting, 403
Central nervous system (CNS), 681–682, 681f
pre-eclampsia and, 161–162
Central venous access, 480
for short bowel syndrome (SBS), 545–546
Cephalexin (Keflex), 791t
Cephalic presentation, 192, 192f
Cephalocaudal development, 430
Cephalopelvic disproportion, 259–260
Cerclage, 148–149, 149f
Cerebral palsy (CP), 681, 702–704, 703f
Cerebrospinal fluid (CSF), 682
collection of, 482
Certified-nurse midwife (CNM), 4t, 111
precipitous labor and, 244–245
Certified registered nurse-anesthetist (CRNA), 223–224
Cerumen, 465
Cervarix, 627t, 1006e, 1034e
Cervical cancer
cervical intraepitelia neoplasia grading system, 1023te
diagnosis
colposcopy, 1024e
endocervical sampling, 1024–1025e
Pap test, 1020e, 1021–1024e, 1021fe, 1024be
diagnostic work-up and treatment of, 1027–1030e, 1027be, 1029be
chemotherapy, 1029–1030e
radiation therapy, 1027–1029e, 1029be
surgery, 1029e
management of abnormal cervical cytology/colposcopy findings, 1025–1027e,
1026e
nursing role in reducing patient risk of, 1032–1033e
risk factors for, 1019e, 1020be
screening and early detection, 1021–1025e, 1021fe, 1023be, 1023te, 1024be
stages of invasive, 1027be
symptoms of, 1019–1020e
Cervical cap, 46
Cervical insufficiency, 148–149, 149f
Cervical length (CL), 152–153
Cervical ripening agents, 247–248, 247–248t
administration of, 248–250, 249f
Cervix, 29, 29f, 30f
bloody show, 196
cervical mucus, 38, 38f
and cervical transformation zone, 1018–1019e, 1019e
changes with impending labor, 196
conization of, 1026–1027e, 1026fe
dilation and effacement of, 189–190, 190f
Leopold maneuvers, 123–124, 124f
during pregnancy, 88, 88f
Cesarean birth. See also Labor and birth
areas for continued research, 274–275
breech presentation, 257
care of patient after, 386
definition and incidence, 270
diabetes mellitus and, 255
impact of surgical adhesions on subsequent, 271
incision wound care after, 386, 400
indications for, 270–271
nursing care for, 272, 272f
nursing implications, 274
postoperative care, 272
surgical care, 272, 273f
surgical procedures, 271–272, 271f
vaginal birth after, 272–274, 274b
wound infections, 417
Chadwick’s sign, 88, 88f, 97
Chain of Infection model, 605–606, 605f
Chalazion, 710t
Chambers, heart, 553, 554f
Chamomile, 946te
Chancroid, 1013e
CHARGE syndrome, 554t
Chasteberry, 946te, 952e
Chemotherapy
agents and common cancer drugs, 888–889t, 888–890
anemia and, 894
brain tumor, 879
breast cancer, 973e
cervical cancer, 1029–1030e
diarrhea and constipation with, 894
hair loss with, 892, 893f, 894
Hodgkin’s lymphoma (HL), 884, 884f
liver cancer, 885
long-term effects of, 895
nausea and vomiting with, 892, 893f
negative effects of, 890
osteosarcoma, 882
thrombocytopenia and, 894
venous access devices for, 890, 890t
waste receptacle for, 885f
Wilms’ tumor, 880
Chest assessment, 466
Chest physiotherapy, 502, 502f
Chest tubes, 498–499, 498f
Chickenpox, 75, 607t
vaccine, 114
Childbirth. See Labor and birth
Childbirth education, 139f
birth plans, 140, 140b
breastfeeding, 141
finding information on, 139
kick counts, 141, 141f
methods of, 139–140, 140t
Child life specialist (CLS), 458, 906, 906f
Child maltreatment, 857–859, 858t
Chlamydia trachomatis, 117, 811
sexual violence (SA) and, 936e
Chloral hydrate (Aquachloral), 486
Cholelithiasis, 536
Cholesterol levels, 578, 578t
Cholinergic crisis, 697
ChooseMyPlate, 132
Chorioamnionitis, 246, 261–262
Chorionicity determination, multiple gestation, 165
Chorionic villi, 66
Chorionic villus sampling, 80
Chromosomes, 61–62, 61–62f
abnormalities in sex, 61–62
congenital anomalies, 72
deletion and translocation, 78–79, 78–79f
genotype differentiated from phenotype, 62
karyotyping, 81, 81f
maternal age and, 78–79
Chronic adrenocortical insufficiency, 659–660
Chronic conditions. See also Disability, care of child with
defined, 901
education for child with, 909
effect of, 903–904
on adolescents, 906–907
on infants, 904–905
on preschooler, 905–906
on school-aged child, 906
on toddlers, 905
emotional responses to, 908–909
establishing a therapeutic relationship with family and child with, 909
examples of, 902b
medical home for child living with, 907–908
prevalence of, 901–902, 902b
technology and, 903, 903f
Chronic diarrhea, 538
Chronic hypertension, 156
induction of labor for, 246
Chronic kidney disease (CKD), 803–807, 804–808t
renal replacement therapy (RRT) for, 807–810, 809b, 810f
stages of, 804t
Chronic lymphocytic leukemia (CLL), 874
Chronic myelogenous leukemia (CML), 877
Chronic pulmonary disease, induction of labor for, 246
Churches, synagogues, and mosques, 488
Ciprofloxacin (Cipro), 791t
Circulatory system
arteries and veins, 820f
burns and, 777–778
changes after birth, 287t
fetal, 67–69, 69f, 333
neonate, 296
persistent pulmonary hypertension of the newborn (PPHN) and, 358–359,
359f
Circumcision, 325–326, 325f
Circumvallate placenta, 268
Cirrhosis, 546–547
Classical conditioning, 433
Clavicle fractures, 348
Cleaning and disinfection, 606
Cleft lip and cleft palate, 363, 363f, 525–526
Client rights, 9–11
Climacteric phase, 947e
menstrual cycle, 38
Clindamycin (Cleocin), 760t
Clinical breast examination, 961e
Clinical nurse specialist (CNS), 4t
Clinical pelvimetry, 124–125, 125f
Clitoris, 26, 26f
Closed-glottis pushing, 232
Closure devices, cardiac, 584
Clotrimazole (Mycelex), 812, 982e
Clubfoot, 317, 727–729, 728f
Cluster headache, 708–709
Coagulation
idiopathic thrombocytopenic purpura (ITP), 408
thrombin disorders and, 408
von Willibrand disease, 408
Coagulation factors, 822t
Coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified
(COEIN) causes of abnormal uterine bleeding, 990e
Coarctation of the aorta (CoA), 567, 567f
Cocaine and crack, 74, 116
Cognitive aging and dementia, 953be
Cognitive and psychosocial conditions, 847–848
anxiety, 849–850, 849f
attention-deficit/hyperactivity disorder (ADHD), 855–856
barriers to child and adolescent mental health and, 848–849
bipolar disorder (BPD), 852, 852t
child maltreatment and, 857–859, 858t
chronic, 902b
common pediatric, 854–857
culture, diversity, and health disparities, 848
depression (See Depression)
developmental disabilities, 848, 864–869, 866t, 867f
eating disorders, 860–862
learning disabilities and cognitive
impairments, 863–864
mental illnesses, 849–851
mood disorders, 851–854
oppositional defiant disorder (ODD) and conduct disorder (CD), 856–857
post-traumatic stress disorder (PTSD), 850–851
reactive attachment disorder (RAD), 854–855
schizophrenia, 176–177, 854
sleep disorders, 862–863, 863b
substance use and abuse, 859–860, 861t
suicide and, 852–854, 853–854t
Cognitive development
adolescence (12-19 years), 451t, 452, 453b
early childhood (preschooler), 445, 446t, 448b
infant, 438–439t, 440–441, 441f, 442b
pain and, 467
school-age child (6-12 years), 449, 449t, 450b
toddler, 443, 443t, 445b
Cognitive theories, 434, 437t
Cohabitation, 11
Coitus interruptus, 45
Cold stress, 289
hypothermia, 778–780, 779t
normal temperature readings and, 342b
in small for gestational age (SGA) newborns, 341–342, 341f
Coloboma, 310
Color blindness, 64, 64f
Colostrum, 388
Colposcopy, 1024e
management of abnormal findings of, 1025–1027e, 1026e
Columnar epithelium, 1019e
Coma, 682t
pediatric Glasgow Coma Scale (GCS), 684, 684f
Combined deficiency T- and B-cell disorders, 594
Communes, 11
Communicable period, 605
Communication
about abnormal Pap test results and HPV, 1031e
about acne in adolescent, 758
about congenital adrenal hyperplasia (CAH), 663
about disseminated intravascular
coagulopathy (DIC), 836
about fetal heart rate patterns, 216
about hair loss with chemotherapy, 892
about hypoglycemia, 173
about immune thrombocytopenia (ITP), 834
about impetigo, 759
about lice, 766
about methicillin-resistant Staphylococcus aureus (MRSA), 762
about newborn screening, 301
about Pap test limitations, 1022e
about prenatal identification of fetal anomaly, 79
about severity of fracture, 736
about sexual activity during pregnancy, 137
about sexual identity and gender
orientation, 43
about strategies for premenstrual disorders
symptoms, 944–945e
about tobacco, alcohol, and breastfeeding, 393–394
at adolescent mother’s hospital discharge, 402–403
with adolescents, 180
after death of child, 913
among health-care team members, 270
asking about potential for toxic exposure, 115
asking difficult questions, 199
assessing a child’s respiratory system, 495
to assist mother whose infant will not awaken to breastfeed, 390
building a trusting nursing-patient relationship, 9
on children as more vulnerable to infection, 593
conducting intimate partner violence (IPV) interview, 931e
before examining victim of sexual assault, 935e
exploring new mother’s feelings, 421
during good-bye at child’s death, 915–916
with hearing-impaired child, 715
helping adolescents make good decisions, 452
helping children express themselves, 648
home care instructions, 630
in information gathering from parents, 805
language disorders and, 715–716
malpractice and, 10
to mother whose newborn has died, 276
nonverbal, 123
patterns of family, 13
during perinatal emergencies, 270
for preparing child for procedure, 478–480
preparing patient for colposcopy, 1024e
questions to assess attachment, 327
with siblings of child with cancer, 898
suggestions to help prevent postpartum thrombophlebitis, 379
in telemedicine, 19
therapeutic, with patient and family, 11, 79, 112, 114
through touch, 396
tips for effective discipline of toddlers, 444
using correct terminology for abnormal
genital bleeding, 979e
when child is diagnosed with brain tumor, 878
when discussing HPV with patients, 1033e
when infant has ambiguous genitalia, 316
when newborn has a disfigurement, 309
when nonreassuring fetal heart rate pattern is detected, 261
when parents ask about their child’s development, 433
when patient expresses suicidal ideation, 853
when practicing trauma-informed care, 103
when sibling acts out, 907
Community care settings, 486–489, 486f
for child with cardiac condition, 587–589
Community resources for new family, 403
Compartment syndrome, 722, 737
Compassion fatigue, 917
Complementary and alternative therapies (CAM), 18–19, 18f
acupuncture during pregnancy, 99
breast cancer and, 974–975e
menopause and, 950–955e, 951be, 953be, 954be, 955be
postpartum depression and, 422t
Complement defect disorders, 594
Complete abortion, 147
Complete blood count (CBC), 741
anemia diagnosis, 823
pediatric ranges by age, 825–826t
urinalysis, 772–773, 789
Complete (full) breech presentation, 193, 193f
Complete (total) placenta previa, 150, 150f
Complex single ventricle-type defects, 572–573, 573f
Complications, labor and birth, 242–243. See also
Cesarean birth
amniotic fluid, 261–262
amniotomy for, 196, 244, 246, 246f
anaphylactoid syndrome of pregnancy, 269–270
assisted operative/vaginal delivery, 250–252, 251–252f
associated with the fetus, 256–261, 257–259f
associated with the placenta, 262–270, 262t
cephalopelvic disproportion, 259–260
disseminated intravascular coagulopathy (DIC), 264–265, 264–265t
dystocia, 243–246, 243f, 245–246f
fetal malpresentation, 256–258, 257–258f
induction of labor, 246–250, 247–248t, 249f
maternal conditions and, 253–256, 253b, 254b, 256t
multiple gestation, 260
nonreassuring fetal heart rate patterns, 260–261
nuchal cord, 261
pelvic structure alterations, 245
perinatal loss, 275–276
placenta, 262–270, 262t
post-term pregnancy, 246, 275, 275f
precipitous labor, 244–245, 245f
preterm labor and birth, 255–256, 256t
rupture of uterus, 265–266, 265f
shoulder dystocia, 258–259, 259f
trial of labor, 245
umbilical cord prolapse, 266–267f, 266–268
variations related to umbilical cord insertion on placenta, 268–269, 268f
Complications, postpartum
hematomas
after episiotomy, 378
collaborative management of, 413–414
definition, incidence, and risk factors, 412–413, 413f
signs and symptoms of, 413
vulvar, 413–414
bimanual compression for, 412, 412f
blood work in, 412
characteristics of blood in, 408
collaborative management of, 409–412, 411t, 412f
early vs. late, 407
fundal massage and, 410–411
incidence and definition, 406, 407t
medications and nursing considerations for, 411t
placental tissue and, 408
thrombin and, 408
trauma and, 407–408, 408t
uterine atony and, 407, 407t
psychosocial, 420–424, 421b, 422t
puerperal (postpartum) infections
definition and incidence, 417
endometritis (metritis), 417, 417f, 419t
mastitis, 417–418, 418f, 419t
methicillin-resistant Staphylococcus aureus (MRSA), 418–420
MRSA, 418–420
septic pelvic thrombosis, 419t
urinary infection, 419t
wound infections, 417, 419t
thrombophlebitis and thrombosis
deep vein thrombosis (DVT), 414–416, 414f
definition, incident, and risk factors, 414
diagnosis, 414–415
prevention of, 379
pulmonary embolus (PE), 175, 416–417
signs and symptoms of, 414, 414f
Complications, pregnancy
assessment and diagnostic tools to determine fetal well-being, 177–179, 178t,
179f
bleeding
early pregnancy, 145–149, 145f, 147–149f
later in pregnancy, 149–151, 150–151f, 151–152b
diabetes, 172–174, 174f
disseminated intravascular coagulopathy (DIC), 164
hypertensive disorders
classifications and definitions, 156
eclampsia, 156, 162–163
HELLP syndrome, 163–164
pre-eclampsia, 156–162, 157b, 157f, 158f, 159t, 161b, 162f
infections, 166–168, 167–168t
group B streptococcal, 166
premature rupture of membranes and, 155
preterm labor and, 153
TORCH, 75, 76b, 166–168, 167–168t
urinary tract, 166
multiple gestation, 164–166, 164f
premature rupture of membranes, 155–156
preterm labor
assessment of cervical length and funneling, 152–153
etiology and risk factors, 152, 153b
interventions to prevent, 153
management of, 153–154, 154–155b
morbidity and mortality, 152
psychiatric, 175–177
respiratory, 171–172
RHo(D) isoimmunization, 169–171, 170b, 170f
special conditions and circumstances, 179–181, 179f
systemic lupus erythematosus, 168–169
thyroid gland, 174–175
venous thrombosis and pulmonary embolism, 175
Computerized axial tomography (CAT/CT) scan, 495
Conal-truncal defects, 570–572, 571–572f
Conception. See also Embryos; Reproduction process
basic concepts of genetics and, 61–62, 61–62f
cellular division and, 64–65
disease inheritance and, 62–64, 63–64f, 63t
fertilization process, 65–66, 65f
implantation and placental development
process, 66–67, 66f
preembryonic period, 69
Concept mapping, 7, 7f, 9
Concrete operational stage of cognitive development, 434, 437t
Condoms, 46–47, 1014e
human papillomavirus (HPV) and, 1033e
Conduct disorder (CD), 856–857
Conduction, 288, 289f
Congenital adrenal hyperplasia (CAH), 662–664
Congenital conditions, 72, 77
cleft lip and cleft palate, 363, 363f
clotting disorders, 408
congenital diaphragmatic hernia (CDH), 363–364, 363f
congenital heart disease (CHD) (See Congenital heart disease (CHD))
congenital hypothyroidism (CH), 360, 362, 362t, 653–654
cystic fibrosis (CF) (See Cystic fibrosis (CF))
developmental dysplasia of the hip (DDH), 316–317, 316f
disfigurement, 309
facial features and, 310
immunodeficiency, 593–595, 594f
metabolic errors, 360, 361–362t
neurological, 322
respiratory, 496–503, 498f, 502f
Congenital diaphragmatic hernia (CDH), 363–364, 363f
Congenital heart disease (CHD), 553, 553f, 560–562, 561t
aortic stenosis, 568–569, 568f
atrial septal defect (ASD), 562–564, 563f
atrioventricular canal defect (AVC), 566–567, 566f
coarctation of the aorta (CoA), 567, 567f
complex single ventricle-type defects, 572–573, 573f
conal-truncal defects, 570–572, 571–572f, 571f
cyanotic defects, 569–570, 569–570f
cyanotic vs. acyanotic, 560t
left-to-right shunt lesions, 562–567, 563–566f
nursing care of child with, 566
obstructive lesions, 567–568f, 567–569
patent ductus arteriosus (PDA), 565–566, 565f
prevention of, in children, 555–556
pulmonary atresia (PA), 569
pulmonic stenosis, 567–568, 568f
segmental classification of, 562–573, 563t
Tetralogy of Fallot (TOF), 312, 571–572, 572f
total anomalous pulmonary venous return (TAPVR), 570, 570f
tricuspid atresia (TA), 569, 569f
truncus arteriosus, 571, 571f
ventricular septal defect (VSD), 564–565, 564f
Congenital hypothyroidism (CH), 361, 362, 362t
Congestive heart failure (CHF), 556–560, 557–560t
Conization, cervical, 1026–1027e, 1026fe
Conjoined twins, 80, 164
Conjugate vera, 125, 125f
Conjunctivitis, 709t
Constipation, 540–541
Contact dermatitis, 766–767
patch testing for, 766, 766f
Contact transmission, 606
Continuous glucose monitoring (CGM), 173–174, 174f
Continuous positive airway pressure (CPAP)
for meconium aspiration syndrome (MAS), 358
for respiratory distress syndrome (RDS), 351
Continuous RRT (CRRT), 808
Contraception
abstinence, 45
barrier methods, 45–47
behavioral methods, 44–45
cervical cap, 46
coitus interruptus, 45
condoms, 46–47
contraceptive sponge, 47
diaphragm, 46, 46f
and drugs that adversely affect female reproductive system, 43, 44t
emergency contraceptive pill, 51
hormonal methods, 47–51
injectable hormonal contraceptive methods, 50
intrauterine devices, 50–51, 50f, 52
lactational amenorrhea method (LAM), 45
low-dose progestin-only contraceptive pills, 49
for minors, 43
natural family planning (NFP) and fertility awareness methods (FAMs), 45, 45b,
45f
obtaining sexual history and, 43–44
oral contraceptives, 47–49, 48b
permanent contraceptive methods, 52–53
planning and implementation, 43
safer sex and, 1014e
spermicides, 47
transdermal contraceptive patch, 49
vaginal contraceptive ring, 49–50
Contraceptive sponge, 47
Contractility, heart, 555
Contraction stress test (CST), 178
Convection, 289, 289f
Conventional morality, 436, 436t, 437t
Coombs’ test, 171
Coping patterns with death, 915
Core needle biopsy, 966–967e
Coronary circulation, 820f
Corpus, uterus, 29
Corpus luteum cysts, 992e
Corticosteroids, 44t, 888t
for Crohn’s disease, 533
for nephrotic syndrome (NS), 799
for respiratory conditions, 496, 505–507, 510
for seborrheic dermatitis, 767
Corticotropin-releasing hormone (CRH), 33
Cortisol
source and function, 638–639t
Cough etiquette, 606
Cough suppressants, 497
Couvelaire uterus, 263
COVID-19, 519
vaccine, 114–115
CRAFFT tool, 860, 861t
Craniosynostosis, 464, 726–727
Craniotomy, 687
Crawling reflex, 321t
C-reactive protein (CRP), 741
urinalysis, 789
Critical care unit, 471, 471f
Critical congenital heart disease (CCHD), 311
Crohn’s disease, 532–533
Crossed extension reflex, 321t
Croup, 505–507
Crowning, 232–233, 233f
Crusts, 753, 755t
Crutchfield tongs, 724–725, 724f
Cryoprecipitate (CRYO), 840t
Cryosurgery, 1025e
Cryptorchidism, 813–814
Cullen sign, 535
Cultural diversity
breastfeeding and, 387
health disparities and, 848
Mongolian spots, 305, 305f
skin color, 302, 302f, 303, 304f
type 2 diabetes mellitus and, 672
Culturally and linguistically appropriate services, 14, 14b, 383–384, 459
Cultural practices, 13–14
communication patterns, 13
feeding practices, 14
psychosocial influences on childbirth, 194
Cultural sensitivity, 383–384
Culture, 848
Cushing’s triad, 683
Cutis marmorata, 305
Cyanotic congenital heart defects, 569–570, 569–570f
Cyclophosphamide (Cytoxan, Neosar, Procytox), 888t
Cystic fibrosis (CF), 63t, 118t, 470t, 493–494, 500–501
causes of, 501
collaborative care, 501–502, 502f
diagnosis of, 501
education/discharge instructions, 502
nursing interventions, 502–503
signs and symptoms, 501
sweat test for, 496
Cysts, ovarian, 992e
Cytomegalovirus (CMV) infection, 617–618
Cytotoxics, 44t
D
Daily activity patterns, 460
Daily caloric requirements, 460–461, 461t
Dairy products, 128–129
Damus-Kaye-Stansel procedure, 558t
Danazol (Cyclomen), 987e
Dandy-Walker syndrome, 700
Daunorubicin (Daunomycin, Cerubidine), 888t
Death
coping patterns with, 915
Do Not Resuscitate (DNR) requests and, 910
grieving after, 913–915, 913f
nursing care of child before, 910–912, 911f, 913t
organ tissue donation after, 916–917
perceptions of, 910
physical signs of impending, 911
saying good-bye and, 915–916
Decongestants, 497
Deep tendon reflexes, 254
Deep vein thrombosis (DVT)
diagnosis of, 414–415, 414f
DEET, 693, 770, 772
Dehydration
collaboration with parents on, 652
hypernatremic, 651
maternal, 206
pathophysiology of, 785–786, 786f
signs of, 650
types of, 785
Deletion and translocation, 78–79, 78f, 79f
Delivery. See Labor and birth
Denial and isolation in grieving, 913–914
Dental problems during pregnancy, 92, 92f, 99, 133
Dental procedures, subacute bacterial endocarditis prophylaxis for, 566, 574
Denver Developmental Screening tool (DDST), 446, 902
Department of Health and Human Services, 488
Dependent edema, 100
Depo-Provera, 50
Depression, 851–852
in grieving, 914
postpartum (PPD), 399, 420–422, 421b, 422t
Dermatitis
atopic, 765–766, 766f
contact, 766–767, 766f
seborrheic, 767, 767f
Dermatomyositis, 601–602
Descent during birth, 234, 234f
Desferrioxamine (Desferal), 822t
Desmopressin (DDAVP), 822t, 833
Developmental care for high-risk newborns, 339–340
Developmental delays, 366, 366t, 445–446
in child with a disability, 469
Developmental disabilities, 848
autism spectrum disorder (ASD), 848, 866–868, 867f
as chronic conditions, 902
Down’s syndrome (DS), 78, 78f, 79t, 312, 470t, 554t, 848
fetal alcohol spectrum disorder (FASD), 116, 848, 868–869
fragile X syndrome, 470t, 848, 864–865
intellectual disabilities, 866, 866t
Developmental dysplasia of the hip (DDH), 316–317, 316f, 729–730
Developmental neurological conditions
cerebral palsy (CP), 681, 702–704, 703f
hydrocephalus, 700–702, 700f, 701f
spina bifida, 322, 698–700
DHEA-S, 642t
Diabetes insipidus (DI), 649–652
Diabetes mellitus (DM)
childbirth complications and, 253, 255
definition and classification of, 172
fetal surveillance and, 174
hyperglycemia in newborn of mother with, 345
hypotonic labor, 244
management of, 173–174, 174f
maternal and perinatal morbidity and mortality with, 172–173
quality of life (QOL) with, 634
type 1
alternative therapies, 669–670
defined, 665
diagnosis, 665
glucose balance in, 672, 673t
home monitoring, 669f
insulin, 668–669, 669–670t
nursing care, 666–667, 667–668t
prevention, 665
team approach to, 672
type 2
defined, 672
diagnosis, 673
management, 674
nursing care, 673–674, 674f
patient education, 674, 675–676t
prevention, 673
signs and symptoms, 672–673
Diabetic ketoacidosis (DKA), 665, 674
diagnosis, 676
medical care, 677
nursing care, 676–677
patient education, 677
prevention, 676
signs and symptoms, 674, 676
Diagnosis. See also Assessment
abdominal wall defects, 364
abusive head trauma, 706
acne, 758
acrocyanosis, 302
acute adrenocortical insufficiency, 659
acute diarrhea, 538
acute kidney injury (AKI), 802–803
acute respiratory distress syndrome (ARDS), 500
amenorrhea, 812
anaphylaxis, 603
anemia, 823, 824t
anemia of prematurity (AOP), 355
anencephaly, 362
anorectal malformations, 527
anxiety, 849
aortic stenosis, 568
aplastic anemia, 837
appendicitis, 534
asthma, 516
atopic dermatitis, 765
atrial septal defect (ASD), 564
atrioventricular canal defect (AVC), 566
attention-deficit/hyperactivity disorder (ADHD), 856
autism spectrum disorder (ASD), 867
birth injuries, 347
botulism, 697
brain tumor, 878
bronchitis, 507
candida albicans (oral thrush), 620
cardiac trauma, 577
cardiomyopathy (CM), 576
cat scratch disease, 623
cat scratch disease (CSD), 772
celiac disease, 544–545
cellulitis, 762
cerebral palsy (CP), 703
cervical cancer, 1021–1025e, 1021fe, 1023be, 1023te, 1024be
child maltreatment, 859
chorioamnionitis, 262
chronic kidney disease (CKD), 806, 806–807t
cirrhosis, 547
clubfoot, 317, 727
coarctation of the aorta (CoA), 567
conal-truncal defects, 571
congenital adrenal hyperplasia (CAH), 663
congenital heart disease (CHD), 561
congenital hypothyroidism (CH), 360, 654
congenital immunodeficiency disorders, 594
congestive heart failure (CHF), 556
constipation, 383
contact dermatitis, 766
craniosynostosis, 727
Crohn’s disease, 532
croup, 506
cryptorchidism, 814
Cushing’s syndrome, 662
cystic fibrosis (CF), 501
cytomegalovirus (CMV) infection, 617
deep vein thrombosis (DVT), 414
depression, 851
dermatomyositis, 601
detecting amniotic fluid, 196
developmental dysplasia of the hip (DDH), 317
diabetic ketoacidosis (DKA), 676
disseminated intravascular coagulopathy (DIC), 836
Down’s syndrome (DS), 865
dysfunctional elimination syndrome (DES), 800
ectopic pregnancy, 146
encephalitis, 693
encephalocele, 362
endometriosis, 986e
esophageal atresia (EA) and tracheoesophageal fistula (TEF), 497
Ewing’s sarcoma, 883
exstrophy of the bladder, 799
fetal alcohol spectrum disorder (FASD), 868
fetal malpresentation, 257
fifth disease, 616
foreign body (FB) aspiration, 514
fracture, 736
fragile X syndrome, 864
frostbite, 780
gallbladder disease, 536
gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD),
541–542
glomerulonephritis, 795–796
growth hormone deficiency (GHD), 641
Guillain-Barré Syndrome (GBS), 696
headache, 709
hematuria, 794
hemophilia, 831, 833
hepatitis, 548–549, 1011e, 1012e, 1013e
herpes simplex virus (HSV) 1 and 2, 618, 1007e
herpes zoster (shingles), 618
Hirschsprung’s disease, 543
HIV/AIDS, 1008–1010e, 1009fe
Hodgkin’s lymphoma (HL), 884
human immunodeficiency virus (HIV [AIDS]), 596
human papillomavirus (HPV), 1005e
hydrocephalus, 700
hyperaldosteronism, 664
hyperparathyroidism, 658, 659
hypertension (HTN), 578
hyperthyroidism, 174
hypertrophic pyloric stenosis, 528
hypocalcemia, 347
hypomagnesemia, 347
hypoparathyroidism, 656
hypospadias and epispadias, 814
hypothermia, 779
immune thrombocytopenia (ITP), 834
imperforate anus, 315
impetigo contagiosa, 759
increased intracranial pressure (ICP), 683–684
infections, 615
infectious mononucleosis, 620
influenza, 513
inguinal hernia, 526
insect bites, 770
intellectual disabilities, 866
intimate partner violence (IPV), 929–930e, 930fe
intussusception, 530
iron-deficiency anemia, 825
jaundice, 354
juvenile arthritis, 741
juvenile myasthenia gravis (MG), 697
Kawasaki disease, 575
kyphosis, 745
labial adhesions, 811–812
lactose intolerance, 544
learning disabilities and cognitive impairment, 863
lice, 766
liver cancer, 885
long QT syndrome (LQTS), 580
lordosis, 745–746, 745f
Lyme disease, 771
malrotation and volvulus, 531
Meckel’s diverticulum, 535
meconium aspiration syndrome (MAS), 358
meningitis, 691
methicillin-resistant Staphylococcus aureus (MRSA), 418, 759
molluscum contagiosum, 763
nasal patency, 310
neonatal fractures, 318
nephrotic syndrome (NS), 798
neurally mediated syncope (NMS), 580
neural tube defects (NTD), 698
neuroblastoma, 879
neutropenia, 838
nonalcoholic fatty liver disease (NAFLD), 548
nuchal cord, 261
oppositional defiant disorder (ODD) and conduct disorder (CD), 857
osteogenesis imperfecta (OI), 746
osteomyelitis, 739
pancreatitis, 535–536
patent ductus arteriosus (PDA), 565
patient education about, 108
pelvic ultrasound, 98
peptic ulcer disease (PUD), 531
persistent pulmonary hypertension of the newborn (PPHN), 359
pertussis, 510
pituitary hyperfunction, 649
polycythemia, 344
portal hypertension, 547
postpartum depression (PPD), 421, 421b
postpartum psychosis, 423
post-traumatic stress disorder (PTSD), 850
pregnancy, 96–97
preterm labor, 153
primary adrenal insufficiency, 660
proteinuria, 793, 793f
pulmonic stenosis, 568
rabies, 623
reactive attachment disorder (RAD), 855
renal trauma, 801
respiratory syncytial virus (RSV), 508
retinoblastoma, 881
Reye’s syndrome, 695
rhabdomyosarcoma, 881
rheumatic fever (RF), 577
rhinosinusitis, 503
rhythm disturbances, 581
Rocky Mountain spotted fever (RMSF), 771–772
schizophrenia, 854
scoliosis, 743, 743f
seizure disorders and epilepsy, 687, 688f
septic shock, 896
short bowel syndrome (SBS), 545
shoulder dystocia, 259
sickle cell disease (SCD), 828
sleep disorders, 862
slipped capital femoral ephysis (SCFE), 731
soft tissue injuries, 734
SPASMS, for pre-eclampsia, 156
spinal cord injury (SCI), 707
subacute bacterial endocarditis (SBE), 574
substance use and abuse, 860, 861t
syndrome of inappropriate antidiuretic hormone (SIADH), 652
testicular torsion, 815
tetralogy of Fallot (TOF), 572
thalassemia, 830
torticollis, 727
total anomalous pulmonary venous return (TAPVR), 570
transient tachypnea of the newborn, 345
traumatic brain injury (TBI), 705
tricuspid atresia (TA), 569
truncus arteriosus, 571
tuberculosis (TB), 511
type 1 diabetes mellitus, 665
type 2 diabetes mellitus, 673
ulcerative colitis, 533
urinary retention, 386
urinary tract infection (UTI), 789, 789t
varicocele, 813
vasa previa, 268
venous thromboembolism and pulmonary embolism, 175
ventricular septal defect (VSD), 565
vomiting, 539
vulvovaginitis, 811
West Nile virus, 624
Wilms’ tumor, 880
Diagnostic tools
absolute neutrophil count (ANC), 895
acid-base calculators, 345
acute respiratory distress syndrome (ARDS), 500
amenorrhea, 812
anaphylactoid syndrome of pregnancy, 269
audiological testing, 715
Ballard Gestational Age by Maturity, 300, 301f
Barlow Test, 317
Bishop score tool, 246, 247t
cardiac catheterization, 584
for chronic conditions, 903
CRAFFT and CAGE, 860, 861t
deep vein thrombosis (DVT), 415
Denver Developmental Screening Tool (DDST), 446, 902
detecting amniotic fluid, 196, 197
eating disorders, 861
ectopic pregnancy, 146
Friedman curve, 217, 218f
gestational diabetes mellitus (DM) screening, 173
health screenings, 489
hepatitis C (HCV), 1013be
HIV/AIDS, 1008–1010e, 1009fe
Homan’s sign for DVT, 379
human immunodeficiency virus (HIV [AIDS]), 596
hydrocephalus, 700
increased intracranial pressure (ICP), 684
infectious disease, 615
infertility, 57t
lumbar puncture, 875, 876t
mammography, 963–966e, 964be, 964fe
neurally mediated syncope (NMS), 580
newborn hearing screening, 309, 309f
newborn metabolic screening, 302
nuchal cord, 261
Ortolani Maneuver, 317
pain scales, 468, 468f, 468t
Papanicolaou (Pap) test, 1020e, 1021–1024e, 1021fe, 1024be
patient education about, 108
pelvic ultrasound, 98
postpartum depression, 421–422
pregnancy testing, 97
preterm labor, 153
pulmonary tests for pediatric lung disorders, 495–496
pulse oximetry, 351, 352
renal biopsy, 802
risk of preterm delivery, 255
sickle cell disease (SCD), 828
Silverman and Andersen Index Evaluation of Respiratory Status, 346f
skin probes, 342
sleep disorders, 496
sonohysterography, 989e
SPASMS, for pre-eclampsia, 156
tilt test, 580
urinary tract, 790
vaginal wet mount, 981e, 1003e
VCUG radiography, 792
Diagonal conjugate, 124–125, 125f
Diaper dermatitis, 766–767
Diapering, 324–325
Diaphragm (contraceptive device), 46, 46f
Diarrhea
acute, 538
chronic, 538
Dichorionic/diamniotic twins, 164
Diethylstilbestrol (DES), 115
Dietitians, 887
Differentiation of self, 13
DiGeorge or velocardiofacial chromosome, 554t
Digestion, 524–525
Dilated (DCM) or congestive cardiomyopathy, 575
Dilation and curettage (D and C), 148
for abnormal uterine bleeding, 991e
Dilation and effacement, 189–190, 190f
Dinoprostone (Prostin E2), 411t
Diphenhydramine (Benadryl), 604–605
Diphtheria, 608t
vaccine, 114, 627t
Direct bilirubin, 292
Direct Coombs’ test, 171
Disability, care of child with, 469–470, 470t. See also Chronic conditions
education and, 909
Discharge planning
adolescent mother, 402–403
after sexual violence (SA), 936–937e
high-risk newborns, 366–367
hospital birthing center, 328–329
postpartal, 399–402, 399f, 401b
Discipline
adolescent, 452, 453b
infant, 441–442, 442b
preschooler, 447, 448b
school-age child (6-12 years), 450, 450b
toddler, 444, 444b, 445b
Disease inheritance
multifactorial, 62
unifactorial, 62–64
X-linked dominant, 63–64, 63t, 64f
Dislocated radial head, 733
Disseminated intravascular coagulopathy (DIC), 164, 264–265, 264–265t, 835–
836
Distributive shock, 897
Divalproex sodium (Depakote), 694t
Diversity, definition of, 848
DNA (deoxyribonucleic acid), 61
deletion and translocation, 78–79, 78–79f
embryonic stem cells, 66
human papillomavirus (HPV) testing, 1031e
testing, 79
Documentation
of admission, 199, 200–202
HIV/AIDS, 1008–1010e, 1009fe
of intimate partner violence (IPV), 931–932e
Donor breast milk, 393
Do Not Resuscitate (DNR) requests, 910
Doppler ultrasound, 177, 815
Douching, 1014–1015e
Doulas, 197
Down’s syndrome (DS), 78, 78f, 79t, 312, 470t, 848
health-related issues with, 554t, 865
Doxorubicin (Adriamycin, Adria, DOX, Rubex), 888t
Doxycycline (Vibramycin), 759, 761t
for Rocky Mountain spotted fever (RMSF), 772
Drug formulary restrictions, 606
DTaP vaccine, 510
Duchenne’s muscular dystrophy, 63t
cardiac disease and, 554t
Ductal carcinoma in situ (DCIS), 970e
Ductogram, 967e
Ductus arteriosus, 68, 286, 286f, 287f
Ductus venosus, 286f, 287
Duncan mechanism, 235
Dunlop traction, 725, 725f
Dynamometer, 189
Dysfunctional elimination syndrome (DES), 799–801
Dysfunctional labor patterns, 243–244, 243b, 243f
Dysmenorrhea, 39, 980e
Dyspepsia, 99
Dysplasia, 77
Dystocia
shoulder, 258–259, 259f
uterine, 243–246, 243f, 245–246f
E
Early childhood. See Preschoolers
Early postpartum hemorrhage (PPH), 407
Ears
assessment of, 465, 465f
hearing disorders, 714–715, 714f
medication administration for toddlers, 494
neonatal examination, 308–309, 308f
Eating disorders, 860–862
during pregnancy, 132, 132f, 177
Eclampsia, 156, 162–163
magnesium sulfate for, 160
management of, 158
Ecological definition of development, 434, 437t
Economic abuse, 926be, 928e
Ectopic pregnancy, 145–146, 145f
Eczema and dermatitis, 594, 757, 765–767, 766–767f
Edema
pre-eclampsia, 161
Education for child with chronic condition/disability, 909
Edwards Syndrome. See Trisomy 18 (Edwards Syndrome)
Effacement and dilation, 189, 190f
Effleurage, 221
Egg donation, 57
Elder abuse, 929be, 929e
Elective or therapeutic abortion, 148
Electrocardiogram (ECG), 582–583
Electrocauterization of leiomyomas (fibroids), 989e
Electroencephalogram (EEG), 687, 688f
Electronic fetal heart rate monitoring (EFM), 178–179, 179f, 204, 205f
interpretation of tracings, 215
Elimination, postpartum, 384–385
Embryos. See also Conception; Fetus; Reproduction process
development of, 67–69, 68f
embryonic period, 69–71, 70t, 71f, 72t
factors that may adversely affect development of, 72–77
fetal circulatory system and, 67–69, 69f
gender inheritance, 61, 61f
germ layers, 69–70, 70t
nurse’s role in minimizing threats to, 80–81
preembryonic period, 69
sexual differentiation in, 25
Emergencies
with cancer
hemorrhagic cystitis, 895–896, 897b, 897f
septic shock, 896–897
obstetrical
seizures, 162–163
in situ drills to enhance response to, 409
Emergency department (ED)
care setting, 471
reasons for visits to, 457–458, 457t
Emergency Medical Treatment and Active Labor Act (EMTALA), 9–10
Emergency postcoital contraception, 51–52
Emotional abuse
child, 857, 858t
intimate partner violence (IPV), 926be, 927e
Emotional and physiological adjustments
to chronic conditions, 908–909
during puerperium, 398–399
Emotional development
adolescent, 453b
infant, 442b
preschooler, 448b
school-age child (6-12 years), 450b
toddler, 445b
Encephalitis, 692
complications from, 693
Encephalocele, 362
Endocervical sampling, 1024–1025e
Endocrine conditions
adrenal conditions, 658–665
effects of, 634
growth hormone deficiency (GHD), 635, 639–641, 647–648, 648t
laboratory tests for, 642–647t
parathyroid conditions, 656–658, 658f
pituitary hyperfunction, 648–649
polycystic ovary syndrome (PCOS), 992–993e
primary adrenal insufficiency, 660–661
thyroid conditions, 360, 362, 362t, 653–656, 656t
Endocrine disruptors, 649
Endocrine system, 633–634. See also Hormones
anatomy and physiology, 634–635, 635–636f
critical nursing assessment, 640–641t
positive and negative feedback loops, 635, 640t
during pregnancy, 93–94
Endocytosis, 67
End-of-life care
caring for child receiving, 909–910
before child dies, 910–912, 911f, 913t
Do Not Resuscitate (DNR) requests and, 910
grieving and, 913–915
perceptions of death and, 910
Endometrial ablation, 991e
Endometrial cancer, 953be, 1036e
Endometriosis, 985–988e, 986fe
Endometritis (metritis), 417, 417f, 419t
Endotracheal tubes, 498–499, 498f
End-stage renal disease (ESRD), 804–805
renal replacement therapy for, 807–810, 809b, 810f
Enema, 542
Energy medicine, 950e, 951be
En face position, 395
Engagement (fetal presentation), 193
Engorgement, 392
Enoxaparin (Lovenox), 822t
Enteral feedings, 338, 338f
for short bowel syndrome (SBS), 546
Enteropathic arthritis, 600t
Enuresis and dysfunctional elimination syndrome (DES), 799–801
Environmental health assessment, 115–116
Enzyme-linked immunosorbent assay (ELISA), 771
Epidemiological triangle, 605, 605f
Epidemiology
cancer, 873
trends in maternal, infant, and child, 15–18, 16–17t, 17f
Epididymis, 40
Epidural and intrathecal opioids, 231
Epidural anesthesia and analgesia block, 226, 226t, 228–229f, 228–230
contraindications to, 231, 231b
shiver response after, 230
Epidural space, 228, 228f
Epiglottitis, 482
acute, 506–507
Epinephrine
EpiPen, 604, 767
Episiotomy, 233, 233f
postpartum assessment, 378
Epispadias, 315, 814
Epoetin/erythropoietin (Epogen, EPO, Erythropoietin, Procrit), 355, 822t, 889t
Epstein-Barr virus, 619–620
Epstein pearls, 308, 308f
Epstein’s malformation, 570, 570f
Erb’s palsy, 322
Erikson, Erik, 432, 437t, 441
Erosions, skin, 753, 756t
Errors, medical, 10–11
Erythema, breast, 968e
Erythema infectiosum, 616–617
Erythema toxicum, 305
Erythrocytapheresis, 844
Erythrocytes. See Red blood cells (RBCs)
Erythrocyte sedimentation rate (ESR), 741
Erythromycin (E-Mycin), 326–327, 760t
Eschar, 778
Escharotomy, 778
Escherichia coli, 606, 788, 796–797, 797f, 811
Esophageal atresia (EA), 497–499, 498f
Esophagus, 524
Estimated date of birth/delivery (EDB/EDD), 97–98, 98b, 98f
Estrogen, 34, 35t, 37
adverse effect on female reproductive system, 44t
endometrial cancer and, 1036e
for menopause-related symptoms, 953be, 954be
postpartum adaptations, 381
testing breast tissue for, 967e
Ethical considerations
ANA clinical practice guidelines, 5
ANA Code of Ethics for Nurses, 10
Ethnicity, 848
Evaporation, 288, 289f
Evening primrose oil, 946te
Evidence-based practice, 6
nursing process and, 6–9, 7–9f
Exanthem subitum, 612t
Exercise
breast health and, 963e
menopause and, 949e
during pregnancy, 133–134, 133b, 134b
for premenstrual disorders, 945be, 945e
resumption after birth, 400–401
testing and training in children with
congenital heart disease, 567
Exercise-induced asthma challenge, 495
Exosystem, 434, 437t
Expectorants, 497
Expedited partner therapy (EPT), 1000e
Expulsion during birth, 234f, 235
Exstrophy, bladder, 799
Extension during birth, 234–235, 234f
External cephalic version (ECV), 258, 258f
External radiation therapy, 1027–1028e, 1029be
External rotation during birth, 234f, 235
Extracorporeal membrane oxygenation (ECMO), 359, 359f, 500
Extrahepatic biliary atresia (EHBA), 546
Extremely low birth weight (ELBW), 336
Extrusion reflex, 319t
Eyes
assessment of, 464–465
care of newborn, 326–327
color of, 62, 62f
common disorders of, 709, 709–710t
foreign body (FB) in, 714
neonatal assessment, 307, 309–310
refractive disorders of, 710–714
retinoblastoma, 881
retinopathy of prematurity (ROP), 356–357, 356b
F
Face presentation, 192, 192f
Factor IX Concentrate, 841t
Factor VII, 841t
Factor VIII concentrate, 841t
Faith community health centers, 488
Fallopian tubes, 27–30f, 28
in fertilization process, 65–66, 65f
Falls, 747–748, 893f
False discharge, 968e
False labor, 195, 196t
Familial dysautonomia (Riley-Day syndrome), 63t
Families
of choice, 11
definitions of, 11–12f, 11–13
of origin, 11
theories and development frameworks, 12–13
types of, 11, 11–12f
Family and Medical Leave Act of 1993, 135
Family-centered care (FCC), 6, 11, 458
for child with chronic condition, 907
for human immunodeficiency virus (HIV [AIDS]), 599
respite care, 908
therapeutic relationship in, 909
Family development theories, 436
Family dynamics, 459
Family history, 81
first prenatal visit, 115
medical and social history, 459–460
Family nurse practitioner (FNP), 4t
Family systems theory, 12
Bowen, 13
Fasciotomy, 778
Fast-track care, 471
Fat, dietary, 461
Fatherhood
assumption of paternal role, 397
readiness for, 105–106
transition to, 395
Fatigue
management of, 820
postpartum, 399, 400
Fat-soluble vitamins, 73
Feeding practices, 14
enteral tube, 483–484, 483f
in holistic nursing care, 475
Female condoms, 47, 1014e
Females
assumption of maternal role, 395–396, 397t
embryonic development, 26
menstrual disorders (See Menstrual disorders)
pregnancy in (See Pregnancy)
premenstrual syndrome (PMS), 39
defined, 940–941e
nonpharmacological measures for menstrual migraines, 942e
phases of uterine (endometrial) cycle and, 941e
prevalence and economic effect, 941e
symptoms, 941be, 941e
readiness for motherhood, 101–102, 101f
reproductive system
adaptations in pregnancy, 88–89, 88–89f
amenorrhea, 812–813
breasts, 32–33, 32f
contraception (See Contraception)
drugs that adversely affect, 43, 44t
external structures, 26–27, 26f
hormones, 34–35, 34f, 644t, 943e
infertility (See Infertility)
internal structures, 27–32, 27–32f
labial adhesions, 811–812
menstrual cycle, 36–39, 38f
premenstrual dysphoric disorder (PMDD), 942e
secondary sexual characteristics, 36, 36f, 36t
sexual maturation, 35–36, 36f, 36t
sterilization, 52, 52f
vulvovaginitis, 811
transition to parenthood, 395
Femoral traction, 725, 725f
Fencing reflex, 320t, 322
Fern test, 196
Ferrous sulfate, 129
Fertility awareness methods (FAMs), 45, 45b, 45f
Fertilization process, 65–66, 65f
Fetal alcohol effects (FAEs), 116
Fetal alcohol spectrum disorder (FASD), 116, 848, 868–869
Fetal alcohol syndrome (FAS), 116
cardiac disease and, 554t
Fetal anemia, 206
Fetal attitude, 191–192, 192f
Fetal biophysical profile, 177, 178t
Fetal fibronectin (fFN) testing, 152
Fetal heart rate (FHR)
accelerations, 208, 209f
amniotomy and, 246
auscultation of fetal heart sounds, 120, 122, 122f, 203–204, 204f, 205
baseline, 206–207, 207f
baseline variability, 207–208, 208t
bradycardia, 207, 207f
chorioamnionitis, 262
communicating about, 216
decelerations, 208–209, 210–211t, 210f, 211–213, 211f, 213f
decision making in assessment of, 214f
diabetes mellitus and, 255
documentation, 215f
electronic monitoring, 178–179, 179f, 204, 205f, 260
interpretation of tracings, 215
fetal scalp blood sampling, 216
fetal scalp stimulation, 216
forceps-assisted birth and, 252
influences on, 206b
intermittent auscultation, 204
nonreassuring patterns, 260–261
nursing interventions, 210–211t, 216
perinatal fetal loss and, 275–276
periodic and episodic changes, 208–213, 208t, 209–213f, 210–211t
preterm labor, 256
repetitive early decelerations, 211
tachycardia, 206, 207f
tachysystole, 207, 208f
terms and interpretation of patterns of, 213–214b
umbilical cord acid-base assessment, 216
Fetal hypoxia, 206
Fetal lie, 191, 191f
Fetal malpresentation, 256–258, 257–258f
Fetal mortality
abruptio placentae and, 151
diabetes mellitus (DM), 172–173
pre-eclampsia, 157–158
preterm labor, 152
Fetal movements, 141, 141f
Fetal nuchal translucency, 80
Fetal period, 71–72
Fetal presentation, 192–193, 192f, 193f, 217
identifying, 203
Fetal scalp blood sampling, 216
Fetal scalp stimulation, 216
Fetal surveillance, 174
Fetus. See also Embryos; Labor and birth; Pregnancy; Reproduction process
assessment and diagnostic tools to determine
well-being of, 177–179, 178t, 179f
biophysical profile, 177, 178t
breathing movements by, 284
cephalopelvic disproportion, 259–260
circulatory system, 67–69, 69f, 333
complications of labor and birth associated with, 256–261, 257–259f
contraction stress test (CST), 178
crowning of, 232–233, 233f
development of, 67–69, 68f
Doppler ultrasound blood flow studies, 177
electronic fetal heart rate monitoring (EFM), 178–179, 179f
factors that may adversely affect development of, 72–77
fetal assessments, 199
abdominal ultrasound, 203
fetal heart rate (FHR), 120, 122, 122f, 203–216
fetal position, 203
fetal scalp stimulation, 216
physiological responses to labor, 202b
vaginal examination, 203
fetal attitude, 191–192, 192f
fetal lie, 191, 191f
fetal period, 71–72, 72t
heart auscultation, 120, 122, 122f
induction of labor and compromised, 246
induction of labor and demise of, 246
lung maturity in, 333
macrosomia, 244
membranes and amniotic fluid, 69
in multifetal pregnancy, 80, 80f, 164–166, 164f
nonreassuring fetal heart rate patterns, 260–261
nonstress test (NST), 177–178, 178t, 179
nuchal cord, 261
nurse’s role in minimizing threats to, 80–81
perinatal loss, 275–276
presentation, 192–193, 192f, 193f, 203, 217
shoulder dystocia, 258–259, 259f
skull of, 190–191, 191b, 191f
Fever, 615–616
maternal, 206
medications for reducing child, 477–478
pathophysiology of, 615
Fibrinogen, 90
Fibroadenomas, 960e
Fibrocystic breast changes, 960e
Fibromyalgia, 600t
Fick equation, 555, 555f
Fifth disease, 616–617
Filgrastim (GCSF-granulocyte colony-stimulating factor) (Neupogen), 889t
Fine motor skills
adolescence (12-19 years), 451t, 453b
infant, 430, 438–439t, 442b
school-age child (6-12 years), 449t, 450b
toddler, 443, 443t, 445b
Fine needle aspiration (FNA), 966e, 966fe
First breath, 284–285
First stage of labor, 216–232
active phase, 216–217
characteristics of, 218t
comfort
focusing strategies, 221
massage and touch, 221–222
music, 221
nonpharmacological measures, 221–223, 222–223f
pain management for, 220
pain neurology, 220
pharmacological pain relief measures, 223–232
position changes for, 219–220, 219b, 219f, 220f
relaxation, 221
types of pain and, 220–221
labor support, 218–219
latent phase, 216
nursing care during, 218–232
spirituality and, 219
transition phase, 217
Fissures, 753, 756t
FLACC pain scale, 468, 468t, 906
Flexion during birth, 234, 234f
Fluid and electrolytes, 784–786, 785t
assessing peripheral IV infiltration and, 786
deficit and excess, 785t
dehydration
pathophysiology of, 785–786, 786f
types of, 785
imbalances in, 787–788t
measuring intake and output, 481, 481t
premenstrual disorders and, 945e
risk for imbalance of, 785
Fluid aspiration from joints, 741
Fluid resuscitation with burns, 776, 777b
Fluoridation, water, 394
Focused assessment, 198–199
Focused obstetric examination, 119–120
Focusing strategies, 221
Folic acid, 130
Follicle-stimulating hormone (FSH), 33, 35t, 37–38
Follicular cysts, 992e
Follicular phase, hypothalamic-pituitary-ovarian cycle, 37–38
Fontanelles, 190, 191f, 306–307, 306f, 464, 464f
Fontan procedure, 559t
Foodborne illness, 130
Food intake, daily, 131–132
Food safety practices, 130
Footling breech presentation, 193, 193f
Foramen ovale, 286, 286f
Forceps-assisted birth, 250, 251–252, 251f
Foreign body (FB), eye, 714
Foreign body (FB) aspiration, 514–515
Formal operational stage of cognitive development, 434, 437t
Forming, 12
Formula-feeding, 328
appetite and digestion with, 525
assisting mother who chooses, 394–395, 394f
Fourth stage of labor, 237t
Fractures, 736–738
caring for child in cast with, 737–738, 738f
complications with, 738, 739f
neonatal, 317–318
clavicle, 348
Fragile X syndrome, 470t, 848, 864–865
Frames of Mind, 434–435
Frank breech presentation, 193, 193f
Fresh frozen plasma (FFP), 840t
Freud, Sigmund, 431–432, 432b, 437t
Friedman curve, 217, 218f
Frostbite, 780
Functional disorders of the urinary tract, 799–801
Functional voiding disorders, 800
Fundal massage, 410–411
Fundus, 88
massage of, 410–411
measuring height of, 89, 120, 120f, 376, 376f
patient teaching on locating, 399
Fungal infections
candida albicans (oral thrush), 620–621
coccidioidomycosis, 621–622
histoplasmosis, 621
medications, 764, 765t
pneumocystis jiroveci pneumonia, 594, 622
tinea capitis, 621, 621t, 764
tinea corporis, 764
tinea cruris, 621t, 764
tinea pedis, 621t, 764
vaginal candidiasis, 982–983e, 983fe
Futures Without Violence, 933e
G
Galactorrhea, 967e
Galactosemia, 361t
Galant reflex, 321t, 322
Galeazzi’s maneuver, 317
Gallbladder, 524
Gallbladder disease, 536
Gametes, 64–65
Ganciclovir (Cytovene), 617–618
Gardasil, 627t, 1006e, 1034e
Gardner, Howard, 434–435
Gastroesophageal reflux (GER), 541–543
Gastroesophageal reflux disease (GERD), 356, 541–543
Gastrointestinal conditions
acute diarrhea, 538
anorectal malformations, 315, 527–528
biliary atresia, 546
celiac disease, 544–545
chronic, 902b
chronic diarrhea, 538
cirrhosis, 546–547
cleft lip and cleft palate, 363, 363f, 525–526
constipation, 540–541
functional, 537–544, 539t, 543f
gastroesophageal reflux (GER), 541–543
gastroesophageal reflux disease (GERD), 524, 541–543
hepatic disorders, 546–549
hepatitis, 548–549
Hirschsprung’s disease, 543–544, 543f
hypertrophic pyloric stenosis, 528–529, 528f
inflammatory bowel disease (IBD), 532–534
inflammatory disorders, 531–536
inguinal hernia, 526
intussusception, 529–530, 529f
lactose intolerance, 544
malabsorption disorders, 544–546, 545f
malrotation and volvulus, 530–531
necrotizing enterocolitis (NEC), 338, 355–356
nonalcoholic fatty liver disease (NAFLD), 547–548
nutrition for child with, 523–524
obstructive, 528–531, 528f, 529f
peptic ulcer disease (PUD), 531–532
portal hypertension, 547
short bowel syndrome, 545–546, 545f
structural, 525–528
umbilical hernia, 314, 526–527, 527f
vomiting, 539–540, 539t
Gastrointestinal system
anatomy and physiology, 524
developmental aspects, 524–525
neonatal assessment, 313–314, 313–314f
neonate physiological transition, 292–294, 294f
postpartum assessment, 377, 377b
postpartum care, 400
Gastroschisis, 364, 364f
Gastrostomy tubes, 483, 483f
Gay orientation, 42t
Gender
embryonic development, 26
inheritance of, 61, 61f
Gender identity, 42, 42t
Gender orientation, 43
General anesthesia, 231–232, 231f
General color, 302, 302f
Generalized anxiety disorder, 849
Genetic counseling, 78, 81, 81f
Genetics
basic concepts, 61–62, 61–62f
cellular division, 64–65
common disorders of, 470t
congenital anomalies and, 72, 77
cystic fibrosis (CF) and (See Cystic fibrosis (CF))
defects, 72
developmental disabilities and, 864
disease inheritance, 62–64, 63f, 63t, 64f
eye color, 62, 62f
HPV DNA testing, 1031e
laboratory testing, 79–80
screening tests during pregnancy, 117, 117–118t
Genitalia. See also Reproductive system
Genital stage of psychosexual development, 431–432, 432b, 437t
Genital warts, 1031be
Genitourinary system. See also Urinary system; Urinary system disorders
anatomy and physiology, 783–784, 784f
fluid and electrolyte balance, 784–786, 785t
menopause and, 947te, 948–949e
reproductive disorders affecting boys, 813–815, 814f
reproductive disorders affecting girls, 811–813
Genomic medicine, breast cancer and, 973–974e
Genotype, 62
Gentamicin (Gentamicin Pediatric), 791t
Germ layers, 69–70, 70t
Gestational age, 300, 301f
Gestational diabetes mellitus (GDM), 172
management of, 173–174
Gestational hypertension, 156
Gestational trophoblastic disease (GTD), 146–147, 147f
Gingivitis, 92, 92f
Ginseng, 952e
Girls. See Females
Glabellar reflex, 320t
Glaucoma, 713–714
Glenn procedure, 559t
Global health, 15
Glomerular filtration rate (GFR), 804t
Glomerulonephritis, 794–796, 794f
Glucagon
laboratory testing, 644–645t
Glucocorticoids, 638–639t
Glucose-6-phosphate dehydrogenase (G6PD) deficiency, 118t
Gluten intolerance, 544–545
Glycogen, 291
Glycogenolysis, 291
Glycosylated hemoglobin A1c, 173
Gonadal hormones, 34–35, 35t
Gonadotropin-releasing hormone (GnRH), 33, 33f
Gonadotropins, 33
Gonads, 634
Gonorrhea, 117
Goodell’s sign, 88, 97
Grandparents
adaptations to pregnancy by, 106
adjustment to newborn, 398, 398f
Granulocytes, 841t
Graves’ disease, 654–656
Grey Turner sign, 535
Grieving, 913–915, 913f
Epperson’s theory of, 914–915
Kübler-Ross stages of, 913–914
Miles and Perry’s stages of, 914
Gross motor skills
adolescence (12-19 years), 451t, 453b
infant, 430, 438–439t, 442b
school-age child (6-12 years), 449t, 450b
toddler, 443, 443t, 445b
Group A beta-hemolytic streptococci (GABHS), 503–504, 622
Group A hemolytic streptococcal infection, 577
Group A streptococcus, 763
Group B streptococcal infection, 166, 622
neonatal sepsis and, 365, 365t
Group health appointments, 19
Group theory, 12–13
Growth and development
assessment of, 640–641
attachment theories, 433, 434t
burn injuries and, 773
child temperament, 437
in child with cardiovascular condition, 556
chronic kidney disease (CKD) and, 804
cognitive theories, 434
considerations for PICU patients, 587
delays in, 366, 366t, 445–446, 469
developmental tasks during hospitalization and, 472–473t
effect of cancer on, 886
effect of chronic conditions on, 903–907, 905f, 906f
effect of endocrinological conditions on, 634
effect of infectious conditions on, 591–592
effect of musculoskeletal conditions on, 719–720
effect of neurological conditions on, 681–682
emotional effect of integumentary conditions, 752
family development theories, 436
health-care team collaboration and, 436
influences on, 429–430
intelligence theories, 434–435, 435t
with kidney impairment, 784
managing fatigue and, 820
milestones in, 437–438
adolescence (12-19 years), 450–453, 451t, 452f, 453b
in comprehensive health history, 460
early childhood (preschooler), 445–447, 446t, 447f, 448b
newborn and infant, 438–439t, 438–442, 440–442f, 442b
school-age child (6-12 years), 447–450, 449t, 450b, 450f
toddler, 442–445, 443t, 444b, 444f, 445b
moral development theories, 435–436, 436t
paradigm shift in, 430b
principles of, 430–431, 430b, 431b
promoted through play in care settings, 458
psychosocial development theories, 431–433, 432b
respiratory system, 493–496, 494t
social learning theories, 433–434
theories of, 429, 431–436, 437t
touchpoint examples, 431b
type 1 diabetes mellitus and, 666–667
Growth hormone (GH), 33
deficiency of, 635, 639–641, 647–648, 648t
Growth hormone deficiency (GHD), 635, 639–641, 647–648, 648t
Growth hormone-inhibiting hormone (GH-IH), 33
Growth hormone-releasing hormone (GH-RH), 33
cost of treatments, 649
Guided imagery, 221, 473
Guillain-Barré Syndrome (GBS), 696–697
Gummas, 1002e
Gynecoid pelvic type, 31, 32f
Gynecological disorders
abnormal uterine bleeding, 990–991e
cervical cancer (See Cervical cancer)
endometriosis, 985–988e, 986fe
hysterectomy for, 989e, 991–992e
leiomyomas (fibroids), 988–990e, 988fe
menstrual disorders
abnormal genital bleeding, 979–980e
amenorrhea, 39, 978–979e
dysmenorrhea, 39, 980e
potential nursing diagnoses for women with, 979be
ovarian tumors, 992e
polycystic ovary syndrome (PCOS), 992–993e
toxic shock syndrome (TSS), 47, 983e
urinary tract infections (UTI), 983–985e
vaginal infections, 980–981e
bacterial vaginosis (BV), 981–982e, 982fe
candidiasis, 982–983e, 983fe
vulva
Bartholin’s gland abscess, 993e
common irritants and allergens, 995be
condylomata, 994e
lichen simplex chronicus, lichen sclerosus, lichen planus, 994e, 995fe
molluscum contagiosum, 994e, 994fe
nursing role in promoting health of, 994–995e
parasites, 993–994e
H
H1N1 influenza, 624–625
H1-receptor antagonists, 223
Haemophilus ducreyi, 1013e
Haemophilus influenzae, 622
Haemophilus influenzae type b, 609t, 627t
Hair
chemotherapy and loss of, 892, 893f, 894
menopause and, 949e
Hand hygiene, 130, 606
Handling and overstimulation of high-risk newborns, 339–340
Hashimoto’s thyroiditis, 653–654
Head. See also Neurological conditions; Neurological system
abusive head trauma, 706
assessment of, 464, 464f
circumference of, 462, 462f, 701, 702
neonatal assessment, 306–308f, 306–309
prenatal health examination, 119
traumatic brain injury (TBI), 704–706, 705f
Headaches, 708–709
migraine, 708
menstrual, 942e
post-anesthesia, 386
postpartum physiological adaptations, 381–382
pre-eclampsia, 161
Head righting reflex, 322
Head Start, 15
Health assessment, 461–462
anthropometric measurements in, 462, 462f
health screenings for, 489
physical assessment in, 463–467, 464f, 465f, 466t
vital signs in, 462–463, 463f, 463t
Health care trends
group health appointments, 19
medical homes, 19
telemedicine, 19
Health disparities, 17–18, 848
Health history, child
asking questions on, 459
comprehensive, 459–461, 461t
developmental milestones in, 460
establishing relationship with patient and family and, 458–459
family medical and social history in, 459–460
immunizations in, 460
nutrition in, 460–461, 461t
past medical history in, 460
patterns of daily activities in, 460
play, activities, and school in, 461
review of systems in, 461
use of culturally appropriate care and, 459
Health Information Technology for Economic and Clinical Health Act (HITECH), 10
Health Insurance Portability and Accountability Act (HIPAA), 4–5, 10
Health promotion
adolescents, 453b
breast, 961–962fe, 961–963e
burns and, 778
infants, 442b
during menopause, 949–956e, 951be, 953be, 954be
preschoolers, 448b
school-age child (6-12 years), 450b
toddlers, 445b
vaginal health, 981e
Health surveillance, 489
Healthy People 2030, 6, 19
hearing screening national objective, 309
intimate partner violence, 923e
Hearing disorders, 714–715, 714f
Hearing screening, 309, 309f
Heart. See also Cardiovascular system
auscultation of fetal, 120, 122, 122f
cardiac output, 90, 312, 555
chambers, 553, 554f
circulation, 820f
normal flow through, 555, 555f
physiology of, 555, 555f
preload, afterload, and contractility, 555
stroke volume, 555
valves, 553–555, 554f
vessels, 555, 555f
Heart murmurs, 572–573, 572f, 573t
Heat and cold application, 222, 222f
Heat loss
hypothermia, 778–780, 779t
in neonates, 288–289, 289f
Heat production by neonates, 288, 288f
HEENT, 807t
Hegar’s sign, 97
Helicobacter pylori, 531, 532
HELLP syndrome, 163–164, 408
childbirth complications and, 253
Hematocrit (HCT), 820
in neonates, 290
Hematological conditions
anemia, 820, 822–825
apheresis for, 843–844
aplastic anemia, 836–838, 837b
assessment of child with, 821t
blood transfusion therapy for, 839–841t, 839–843
bone marrow transplantation for, 843
disseminated intravascular coagulopathy (DIC), 164, 264–265, 264–265t, 835–
836
hemophilia, 63t, 118t, 831–832
immune thrombocytopenia (ITP), 833–835, 835f
iron-deficiency anemia, 825–827
neutropenia, 838–839
sickle cell disease (SCD), 63t, 64f, 117t, 470t, 827–830, 827f
thalassemia, 118t, 470t, 830–831
von Willebrand (vW) disease, 408, 832–833, 833f
Hematological system, 819
circulation, 820f
maternal physiological adaptations, 381
pediatric ranges by age, 825–826t
Hematopoiesis, 67
Hematopoietic adaptation, 289–291
Hematopoietic stem cell transplant (HSCT), 843
Hematuria, 794, 801
Hemodialysis, 808–810, 810f
Hemofiltration, 808
Hemoglobin (HGB), 290, 819, 820, 823
Hemolysis of blood specimen, 344
Hemolytic uremic syndrome (HUS), 796–798, 797f
Hemophilia, 63t, 118t, 831–832
Hemorrhage
abnormal genital, 979–980e
abnormal uterine, 990–991e
bimanual compression for, 412, 412f
blood work in, 412
characteristics of blood in, 408
collaborative management of, 409–412, 411t, 412f
early vs. late, 407
fundal massage and, 410–411
incidence and definition, 406, 407t
medications and nursing considerations for, 411t
placental tissue and, 408
thrombin and, 408
trauma and, 407–408, 408t
uterine atony and, 407, 407t
in pregnancy, 149
cervical insufficiency, 148–149, 149f
disseminated intravascular coagulopathy (DIC), 264–265, 264–265t
early identification of maternal hemorrhage, 149
ectopic pregnancy, 145–146, 145f
gestational trophoblastic disease (GTD), 146–147, 147f
hyperemesis gravidarum, 92, 149
placental abruption, 150–151, 151–152b, 151f, 263
placenta previa, 150, 150f, 263
rupture of uterus, 265–266, 265f
spontaneous abortion (SAB), 147–148, 148f
vasa previa, 150
recognizing additional indicators of, 407
vital signs and, 408
Hemorrhagic cystitis, 895–896, 897b, 897f
Hemorrhagic disease of the newborn, 312–313
Hemorrhoids
postpartum care, 379
Heparin (Calcilean, Calciparine, Hepalean, Heparin Leo, Hep-Lock, Hep-Lock
U/P), 822t
Hepatic adaptation, 291–292, 291b, 292b, 292f
Hepatic disorders, 546–549
Hepatitis, 548–549
as cause of liver cancer, 1010e
hepatitis A vaccine, 627t
hepatitis B, 1010–1011e
screening for exposure to, 117
vaccine for, 327, 627t, 1011e, 1012be
hepatitis C, 1011–1013e, 1013be
hepatitis D, 1013e
HER2/neu protein, 971e
Herbal and homeopathic preparations, 136–137
for induction of labor, 250
for menopause, 950–952e
for postpartum depression, 422t
for premenstrual disorders, 945e, 946te
Heredity. See Genetics
Hernia
inguinal, 526
umbilical, 314, 526–527, 527f
Herpes simplex virus (HSV) 1 and 2, 618, 811, 1006–1007e, 1006fe
in the newborn, 364–365
Herpes zoster (shingles), 75, 618–619
Heterocyclics, 422t
Heterosexual orientation, 42t
HiB vaccine, 506
Highly active antiretroviral therapy (HAART), 598, 1010t
High-risk newborns. See also Preterm newborns
abdominal wall defects in, 364, 364f
additional considerations for, 359–366
anencephaly in, 362
birth injuries in, 322, 347–348, 347b
birth weight, 299, 336, 336t
bottle and breastfeeding, 338
circulatory system in, 333
classification of, 335–336
clavicle fractures in, 348
cleft lip and cleft palate in, 363, 363f
congenital diaphragmatic hernia (CDH) in, 363–364, 363f
congenital hypothyroidism (CH) in, 361, 362, 362t
developmental care for, 339–340
developmental delays in, 366, 366t
discharge planning for, 366–367
enteral feeding of, 338, 338f
growth and development in, 333
infections in, 364–365, 365t
intake and output by, 338, 339f
intrauterine, intrapartum, and extrauterine risk factors, 335t
large for gestational age (LGA), 299, 336t, 344–347, 345b, 346f, 346t
microcephaly in, 362–363
in neonatal intensive care unit (NICU), 334–335, 334f
neurological system in, 334
conditions affecting, 362–363
newborn screening in, 360, 360b
nonnutritive sucking (NNS), 338
nutritional care of, 336–338, 338f
post-term, 358–359, 359f
premature infant pain profile (PIPP), 333, 333–334f
skin care for, 338–339
small for gestational age (SGA), 299, 340–344, 341f, 343f, 366t
total parenteral nutrition (TPN) for, 337–338
transport of, 340, 340b, 340f
Hirschberg asymmetrical corneal light reflex test, 712
Hirschsprung’s disease, 543–544, 543f
Histoplasmosis, 621
HIV (human immunodeficiency virus)
condoms for prevention of, 46–47
screening for exposure to, 117, 166
Hodgkin’s disease (HD), 883–885
Holistic nursing care
abortion and, 54
bathing, 474
emotional and spiritual support, 478
end-of-life, 912, 913t
feeding, 475
fever-reducing measures, 477–478
infection control measures, 476–477
medication administration, 475–476
rest, 475
safety measures in, 475
Holoprosencephaly, 363
Homan’s sign, 379
Home births, 198
Homeopathic medicine, 951be
Home visits, 403, 731
Homosexual orientation, 42t
Honeymoon period in abuse, 928e
Hormonal methods of contraception, 47–51
Hormonal therapies for menopause, 952–955e, 953be, 954be
Hormones
female, 34–35, 35t, 634, 644t, 943e
menopause and, 947e
functions of, 636–639t
hypothalamus, 33, 33f, 636–637t
male, 34, 42, 634, 646t
menstrual cycle, 34, 34f
ovaries, 644t
pituitary gland, 33–34
safety of exogenous, 649
Hospice care, 912
Hospital-based care, 470–471
Hospital birth centers, 198
discharge planning, 328–329
Hospitalized child
for cardiac conditions, 586–587
decreasing stress of, 471–473, 472–473t
holistic nursing care of
bathing, 474
emotional and spiritual support, 478
feeding, 475
fever-reducing measures, 477–478
infection control measures, 476–477
medication administration, 475–476
rest, 475
safety measures in, 475
parents with, 473–474, 474f
Hot flushes/flashes, 947te, 948e
Human chorionic gonadotropin (hCG), 34, 67
levels associated with viable pregnancy, 148, 148f
Human chorionic somatomammotropin (hCS), 94
Human immunodeficiency virus (HIV [AIDS]), 1007–1008e
collaboration care, 599
collaborative care, 596–597
detection, testing, and documentation of, 1008–1010e, 1009fe
diagnosis, 596
infants born with, 595
medical care for, 598, 598t
pancytopenia and, 595b
prevention, 596
risk factors for, 1008be, 1008e
signs and symptoms of, 595–596
Human papillomavirus (HPV), 627t, 763–764, 764f, 811, 1030–1031e
age and, 1032e
DNA testing, 1031e
education and counseling for teens and their parents on, 1034–1035e
nursing role in reducing patient risk of cervical cancer and, 1032–1033e
potential manifestations, 1031–1032e, 1031be, 1032be
as sexually transmitted disease (STD), 1004–1006e, 1005fe, 1005te
vaccines, 627t, 1006e, 1033–1034e
Human parvovirus B19, 75
Human placental lactogen (hPL), 94
Human sexual response, 42–43, 42t
Humiliation, Afraid, Rape, Kick (HARK) tool, 930e
Huntington’s disease, 63t
Hurt, Insult, Threaten, and Scream (HITS) tool, 930e
Hydatiform mole, 146–147, 147f
Hydralazine hydrochloride, 159t
Hydramnios, 261
Hydrocele, 814
Hydrocephalus, 700–702, 700f, 701f
Hydrochlorothiazide, 159t
Hydrotherapy, 221–222
Hydroxyurea (Droxia, Hydra, Mylocel), 822t
Hygiene, postpartum, 400
Hymen, 26f, 27
Hyperactive reflex, 254
Hyperaldosteronism, 664–665
Hyperbilirubinemia. See Jaundice
Hypercholesterolemia-hyperlipidemia, 578, 578t
Hyperemesis gravidarum, 92, 149
Hyperglycemia
in large for gestational age (LGA) newborns, 345
nursing care for, 668t
Hyperkalemia, 797, 804t
Hyperleukocytosis, 897
Hypermobility syndrome, 602
Hypernatremic dehydration, 651
Hyperopia, 710
Hyperparathyroidism, 657–658, 658f
Hyperpnea, 466
Hyperreflexia of muscles, 657
Hypersensitive skin reactions, 594, 765–767, 766–767f
Hyperstimulation, bradycardia, 207
Hypertension (HTN), 578–579
Hypertensive disorders of pregnancy
childbirth complications due to, 253, 253b, 254b
classifications and definitions, 156
eclampsia, 156, 162–163
HELLP syndrome, 163–164
pre-eclampsia, 156–162, 157b, 157f, 158f, 159t, 161b, 162f
Hyperthermia, 289
Hyperthyroidism, 174–175
Graves’ disease, 654–656
influence on fetal heart rate, 206
Hypertonia, 316, 703
Hypertonic labor, 243–244, 243f
Hypertrophic cardiomyopathy (HCM), 575–576
Hypertrophic pyloric stenosis, 528–529, 528f
Hyperventilation and shortness of breath, 100
Hypnobirthing, 140t
Hypnotherapy, 222
Hypocalcemia, 347, 804t
Hypogammaglobulinemia, 594
Hypoglycemia, 173
assessment of, 666
crisis, 672
in neonates, 291, 291b
nursing care for, 667–668t
in small for gestational age (SGA) newborns, 343–344, 343f
Hypomagnesemia, 347
Hyponatremia, 653
Hypoparathyroidism, 656–657
Hypoplastic left heart syndrome, 572, 573f
Hypopnea, 466
Hypospadias, 315, 814
Hypotension, severe maternal, 228
Hypothalamus, 634
fever and, 615
hormones, 33, 33f, 636–637t
hypothalamic-pituitary-ovarian cycle, 37–38
Hypothermia, 778–780, 779t. See also Cold stress
Hypothyroidism
congenital, 360, 362, 362t, 653–654
Hashimoto’s thyroiditis, 653–654
Hypotonia, 316, 703
Hypotonic labor, 243f, 244
Hypovolemic shock, 897
Hysterectomy, 989e, 991–992e
I
IBCLCs (lactation consultants), 388
Identification bracelets, 371
Identity vs. role confusion, 433, 437t, 473t
Idiopathic thrombocytopenic purpura (ITP), 408, 594
Ifosamide (Ifex), 889t
Imipramine (Tofranil), 800–801
Imiquimod, 1005te
Immigrant communities, intimate partner
violence (IPV) in, 929e
Immobilizing devices
casts, 721–724, 722–723f, 722b
principles of traction, 724–725f, 724–726
Immune conditions
allergic reaction, 602–605
autoimmune, 599–602, 600t, 602b
congenital immunodeficiency disorders, 593–595, 594f
dermatomyositis, 601–602
human immunodeficiency virus (HIV [AIDS]), 595–599, 595b, 598t
Immune system
anatomy and physiology, 591f, 592–593
immune response, 593
neonate physiological transition, 294
postpartum physiological adaptations, 382–383
skin as body’s defense and, 593, 593f
Immune thrombocytopenia (ITP), 833–835, 835f
Immunity
active, 592
passive, 592
Immunizations
anaphylaxis reactions to, 603
DTaP, 510
hepatitis B, 327, 549, 1011e, 1012be
HiB, 506
in HIV-infected children, 597–598
human papillomavirus (HPV), 627t, 1006e, 1033–1034e
influenza, 114, 513
local adverse effects, 629
medical history, 460
MMR (measles-mumps-rubella), 382–383
nursing care, 626–628
pertussis, 114
safety of, 867
tetanus, 114
vaccines, 625–626, 627–628t
Immunoassay, 771
Immunodeficiency disorders, 593–595, 594f
Immunofluorescence assay (IFA), 772
Immunoglobulins, 593
in neonates, 294
X-linked agammaglobulinemia, 594
Imperforate anus, 315, 527
Impetigo contagiosa, 759, 76

Davis Advantage For Maternal-Child Nursing Care, 3e

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F. A.

Copyright © 2022 by F. A. Davis Company

Copyright © 2022 by F. A. Davis Company. All rights reserved. This book is

Printed in the United States of America

Acquisitions Editor: Jacalyn Sharp

Library of Congress Cataloging-in-Publication Data

Names: Scannell, Meredith J. author. | Ruggiero, Kristine, author. | Ward, Susan L.

~Meredith and Kristine

Thank you all.

Davis Advantage for Maternal-Child Nursing Care springs from our

■ “Nursing Insight” boxes show students how experienced nurses

■ “Learning Objectives” offer a guided approach to chapter content

■ “PICO(T) Questions” foster students’ understanding of evidence-

■ “Labs” boxes present crucial information about laboratory testing

THE TEACHING AND LEARNING PACKAGE

Patricia Catlin, DNP, APRN, FNP

Georgina Colalillo, MS, RN, CNE

Leslie Collins, DNP, MS, RN

Mary Cousineau, MS, RN, PPCNP-BC, CNE

Cheryl DeGraw, EdS, RN, MSN, CRNP

Angela M. Durry, MSN-Ed, RN

Shaana Escobar, RN, DNP

Carolyn J. Godfrey, PhD in Nursing Education

Julie E. Grady, PhD, MSN, RN, CNL

Tricia L. Harrison, MSN, RNC, CNE

Constance D. Hill-Williams, PhD, RN

Sheila Kathleen Hurst, PhD, RN

Laura Karges, MS RN CPN

Francine Laterza, EdD, RN, PNP

Rebecca Luetke, PhD, MSN, RN, SANE-P

Barbara McClaskey, PhD, APRN-CNS BC, RNC

Deborah O’Hearn, DNP, RN

Lori M. Overstreet, PhD, MSN, RN-BC

Debra Pile, DNP, APRN, PCNS

Mimi Pomerleau, DNP, WHNP-BC, RNC-OB, CNE

Candice Rome, DNP, RN

Lisette Saleh, PhD, MSN, RNC-OB

Melissa Smiley, RN, MSN

Christine Stephens, MSN RN

Tama Stevens, MSN, RN

Zelda Suzan, EdD, RN, CNE

Laura J. Wallace, RN, CNM, PhD

Foundations in the Nursing Care

Core Concepts of Maternal and

FIGURE 1-1 Traditional nursing process.

The planning phase involves establishing priorities to identify and

ANA CLINICAL PRACTICE GUIDELINES

The Nursing Process and Evidence-Based Care

FIGURE 1-3 Concept map construction begins with gathering and

For step 2, the nurse gathers and categorizes the assessment

BUILDING A TRUSTING NURSING-PATIENT

FIGURE 1-4 Categorizing the assessment data.

FIGURE 1-6 Analyzing relationships and prioritizing patient

An Ethical Framework for Professional Practice

Implications of the Health Insurance Portability and

THE FAMILY UNIT

FIGURE 1-9 In some families, grandparents raise their grandchildren

Family Systems Theory

The nurse or family therapist assesses a repeating negative

Bowen Family Systems Theory

Types of Parenting Styles

Family assessment is integral to the delivery of competent,

National Standards on Culturally and