The Past, Present and Future Chapter 1

Obstetrics and Pediatric Care in United States Before 1900’s babies were born at home; Maternal and child mortality and morbidity high Hospitals began to develop nursing training programs But then other things started to change and shift to hospitalization included: Physicians started to build relationships with hospitals Invention of obstetric instruments and anesthesia caused a change where mothers were being admitted to hospitals to birth children In 1960s Fathers were not involved and mother was sedated and did not participate much in delivery; mother and newborn kept separate; and children could not visit mother and baby Organizations were developed to help train nurses such as American College of Nurse Midwives and Association of Women’s Health, Obstetric and Neonatal Nurses, American Academy of Pediatrics ANA and States started to develop Scope of Practice for nurses

Family-Centered Care Recognizes:  Strength and integrity of the family  As caregivers and decision makers, family is an integral part of obstetric and pediatric nursing.  Empowerment is when the philosophy, goals, culture, and ethnic practices of family contribute to maintain control over health care of family members.

Current Maternity Practices Focuses on a high-quality family experience. Childbearing is seen as a normal and healthy event.  Treating each family according to its individual needs is paramount.

Karl Credé Karl Credé (1819-1892) German obstetric & gynecologist 1884 - Recommeded instilling 2% silver nitrate to the eyes of newborns to prevent blindness caused by gonorrhea. Standard procedure stayed the same, but now only 1% silver nitrate is administered or antibiotic ointments are used.

Ignaz Semmelweis Ignaz Semmelweis (1818-1865) 1840 – worked as asst. professor in maternity ward of Vienna general hospital.  Ignaz Semmelweis, hungarian physician developed some of the 1st microbial control practices for medical procedures. He introduced the “germ theory”.  He discovered a relationship between the incidence of puerperal fever and the examination of new mothers by student doctors, who had just returned from dissecting cadavers.  He deduced that puerperal fever was septic, contagious, and transmitted by the unwashed hands of physicians and medical students. It was not until 1890 that his teaching was finally accepted.

Louis Pasteur Louis Pasteur (1822-1895) – French chemist  Confirmed that puerperal fever was caused by bacteria and could be spread by improper handwashing and contact w/contaminated objects. The simple, but highly effective procedure of handwashing continues to be one of the most important means of preventing the spread of infection in the hospital and home today.

Joseph Lister Joseph Lister (1827-1895) – British surgeon  Influenced by Pasteur, experimented w/ chemical means of preventing infection and introduced antiseptic surgery.

Gov’t Influences in Maternity &Pediatric Care The high infant and maternal mortality rates motivated action by the federal government to improve care. Programs were established to improve care such as:  the Sheppard-Towner Act of 1921-state managed programs for maternity care  title V of the Social Security Act- funds for maternity care  NIH-maternity research & education Head Start-education for preschoolers  WIC program  Family and Medical Leave Act-enables employees to be able to take 12 weeks of unpaid l eave  Medicaid title XIX program-care for indigent women  HIPAA-2003 & HITECH 2004 Health Care Reform Bill of 2010

Welfare of Children Lillian Wald (1867-1940)  Credited w/suggesting the establishment of a federal children’s bureau which was established in 1912.  Focused on problems of infant and maternal mortality.  It also led to birth registration in all states.  1930’s Children’s Bureau research led to hot lunch programs in many schools.

White House Conferences 1909 - The First White House Conference on Children and Youth was called by President Theodore Roosevelt. (1858-1919)-still held every 10 years to help promote child welfare The White House Conference on Child Health and Protection of 1930-The Children’s Charter was created It lists 17 statements related to the needs of children in areas of education, health, welfare, and protection.  Also need to remember that nurses have a responsibility certain diseases or conditions such as foodborne infections, tuberculosis, STIs, or other communicable diseases; suspected child abuse or suicidal behavior

The Present – Maternity Care Family Centered Care-In hospitals the family is recognized as a unit that is unique Three separate sections of maternity unit Labor, delivery, and recovery merged All events in one unit in one room Birthing Centers-popular with low risk maternity patients Provide comprehensive care-antepartum, labor-delivery, postpartum, classes, follow up care, and family planning

Financial Considerations Includes monitoring and regulating expenditures of funds and involved budgets on an institution. Cost containment influenced maternity care by requiring the discharge of mother and newborn in 24 hours or less after delivery. Due to problems legislature allows up to 48 hours for vaginal deliveries and up to 4 days for cesarean sections Currently maternity practice deals with high quality family experience Midwives-RNs that has graduated from a midwife program. They can provide comprehensive prenatal and postnatal care in deliveries that were not complicated.

Cultural Considerations US is culturally diverse nation- Nurses need to develop: Cultural awareness and Cultural sensitivity that differ from their own This will lead to Cultural competence that will allow nurses adapt health care practices that will meet the needs of patients that have a variety of cultures Culture-encompasses inherited characteristics that are handed down from one generation to another. Including values, beliefs, and practices Need to develop cultural awareness and cultural sensitivity which helps meet the needs of various cultures Cultural background will influence how a person adapts to birthing experiences

Cross-Cultural Considerations Such information helps to promote understanding and individualize patient care. It also increases the satisfaction of patient and nurse with quality of care provided. One way in which the nurse gains important information about an individual’s culture is to ask the pregnant woman what she considers normal practice. A summary of data collection questions might include:  How does woman view her pregnancy?  Does she view the birth process as dangerous? Why?  What role does her significant other play in relation to the pregnancy and birth?  Is birth private or a public experience for her?

Genomics Study and function of all of the genes in the human body, with focus on the interactions of each other and the environment. The Human Genome Project has identified all genetic material present in human body. Medical researchers can now identify genes responsible for specific congenital disorders and develop “gene therapy”. Gene therapy replaces missing genes or alter defective genes. This technological advances can result in earlier diagnosis, earlier intervention and genome knowledge for patient education and therapy.

Health Care Delivery Systems Cost Containment-major motivation factor in health care Reimbursement an important consideration in health care Change instituted by the federal government for its Medicare and Medicaid programs was the diagnosis-related groups (DRGs) DRGs determine payment for hospital stay depending on diagnosis Patients are discharged from hospital and given more care in skilled nursing facilities or at home.

Common Vital Statistic Terms Birth rate – the number of live births per 1000 population in 1 year. Fertility rate – the number of births per 1000 women ages 15 to 44 years in a given population. Fertility mortality rate – the number of fetal deaths (fetuses weighing 500 g or more) per 1000 live births per year. 1 kg = 1000 g Perinatal mortality rate – Includes both fetal and neonatal deaths per 1000 live births per year. Infant mortality rate – the number of deaths of infants under age 1 year per 1000 live births per year. Maternal mortality rate – the number of maternal deaths per 100,000 live births that occurs as a direct result of pregnancy. Neonatal mortality rate – the number of deaths of infants less than age 28 days per 1000 live births per year.

Clinical Pathways (Critical pathways) The basis of the pathway is identification of expected progress within a set timeline. Expected progress of the patient becomes a standard of care. The use of clinical pathways improves the quality of care and reduces unnecessary hospitalization time contributing to cost containment. Any deviation in timeline would be considered a variance.

NIC, NOC, and NANDA The RN will initiate the Nursing Care Plan and the LVN will need to be able to understand and work with the care plan so it important that LVN understand the terminology and different areas. Nursing Interventions Classification (NIC) Nursing Outcomes Classification (NOC) North American Nursing Diagnosis Association (NANDA) are companions that helps in the critical thinking aspect of patient care. Nursing interventions (NIC) specifies actions that nurses perform to help patients toward a goal or outcome. The focus is on the action of the nurse. Nursing outcomes (NOC) identifies outcomes of nursing care that are directly influenced by nursing actions. Outcomes are defined as the behaviors and feelings of the patient in response to the nursing care given.

The Nursing Process and Critical Thinking The nursing process (assessment, diagnosis, planning (outcomes identification), implementation, and evaluation) is a tool for effective critical thinking. When nurses use the nursing process in critical thinking, a clinical judgment can be made that is specific to the data collected and the clinical situation. In every clinical contact a nurse must identify actual and potential problems and make decisions about a plan of action that will result in a positive patient outcome; know why the actions are appropriate; differentiate between those problems that can be cared for independently and those that require other members of the health care team; and prioritize those actions.

Documentation Has always been a legal responsibility of the nurse. When a medication is given or treatment is performed, it is accurately documented on the patient’s chart. Charting responsibilities also include head-to-toe assessment of the patient and a recording of data pertinent to the diagnosis and response to treatment.

Computerized Charting Has been fine-tuned and is used by most hospitals in the country. It is a paperless method of charting that can be accomplished w/a wireless pad and an electronic pen. Security features are usually built in, and integrated prompts encourage accurate and comprehensive charting by “forcing” certain entries to be made before the user can progress further through the system.

Healthy People 2020 Updates previous decade’s statement of national health and disease prevention Identifies objectives design to use vast knowledge and technology Objectives fall under broad categories Health promotion Health protection Preventive services Development of surveillance and data systems Specific goals include increasing the span of healthy life and reducing health disparities What would be some things that would fall under 2020? www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and- child-health

Community-Based Nursing The nurse must work w/the interdisciplinary healthcare team to identify needs within the community and create cost-effective approaches to comprehensive preventive and therapeutic care. The role of the nurse as an educator within the community is facilitated by the use of schools, churches, health fairs, computer websites, and media. Home health care team that includes the nurse would provide a variety of services that include monitoring, medication administration, nutritional options, and many other areas.