Third Edition LWBK1005-FM.indd i 01/11/11 8:53 PM LWBK1005-FM.indd ii 01/11/11 8:53 PM Third Edition Editors Nan H Troiano, RN, MSN Carol J Harvey, RNC, C-EFM, MS Bonnie Flood Chez, RNC, MSN Director, Women’s and Infants’ Services Sibley Memorial Hospital Johns Hopkins Medicine Washington, D.C Clinical Specialist High Risk Perinatal Labor & Delivery Northside Hospital Atlanta, Georgia President, Nursing Education Resources Perinatal Clinical Nurse Specialist & Consultant Tampa, Florida LWBK1005-FM.indd iii 01/11/11 8:53 PM Acquisitions Editor: Bill Lamsback Product Director: David Moreau Product Manager: Rosanne Hallowell Development and Copy Editors: Catherine E Harold and Erika Kors Proofreader: Linda R Garber Editorial Assistants: Karen J Kirk, Jeri O’Shea, and Linda K Ruhf Creative Director: Doug Smock Cover Designer: Robert Dieters Vendor Manager: Cynthia Rudy Manufacturing Manager: Beth J Welsh Production and Indexing Services: Aptara, Inc The clinical treatments described and recommended in this publication are based on research and consultation with nursing, medical, and legal authorities To the best of our knowledge, these procedures reflect currently accepted practice Nevertheless, they can’t be considered absolute and universal recommendations For individual applications, all recommendations must be considered in light of the patient’s clinical condition and, before administration of new or infrequently used drugs, in light of the latest package-insert information The authors and publisher disclaim any responsibility for any adverse effects resulting from the suggested procedures, from any undetected errors, or from the reader’s misunderstanding of the text © 2013 by Association of Women’s Health, Obstetric and Neonatal Nurses © 1999 by Association of Women’s Health, Obstetric and Neonatal Nurses © 1992 by J B Lippincott Company All rights reserved This book is protected by copyright No part of it may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means—electronic, mechanical, photocopy, recording, or otherwise—without prior written permission of the publisher, except for brief quotations embodied in critical articles and reviews, and testing and evaluation materials provided by the publisher to instructors whose schools have adopted its accompanying textbook For information, write Lippincott Williams & Wilkins, 323 Norristown Road, Suite 200, Ambler, PA 19002-2756 Printed in China 10 Library of Congress Cataloging-in-Publication Data High-risk & critical care obstetrics / editors, Nan H Troiano, Carol J Harvey, Bonnie Flood Chez 3rd ed p ; cm High-risk and critical care obstetrics Rev ed of: AWHONN's high-risk and critical care intrapartum nursing / [edited by] Lisa K Mandeville, Nan H Troiano 2nd ed c1999 Includes bibliographical references and index ISBN 978-0-7817-8334-7 (pbk : alk paper) I Troiano, Nan H II Harvey, Carol J III Chez, Bonnie Flood IV AWHONN’s high-risk and critical care intrapartum nursing V Title: High-risk and critical care obstetrics [DNLM: Obstetrical Nursing methods Critical Care Delivery, Obstetric nursing Obstetric Labor Complications nursing Pregnancy Complications nursing Pregnancy, High-Risk Pregnancy WY 157] 618.20231 dc23 2011040224 LWBK1005-FM.indd iv 01/11/11 8:53 PM To my mother, Bonnie Lee Chappell Hamner; to my brother, Philip David Hamner; and in loving memory of my father, Harold Max Hamner Finally, to Bogart, my companion throughout, and Bacall —Nan H Troiano In loving memory of my parents, Mildred and Richard Harvey; to my husband, Scott Sneed; and to my sisters by birth and by choice —Carol J Harvey To my dad, Dr William A Flood; and to my George and Semi —Bonnie Flood Chez LWBK1005-FM.indd v 11/2/11 5:36 PM LWBK1005-FM.indd vi 01/11/11 8:53 PM P R E FA C E Since publication of the second edition of this text in 1999, we continue to appreciate the challenges and rewards associated with providing care to this unique patient population Time has granted us the benefit of a rapidly expanding knowledge base derived from ongoing research and clinical experience related to the care of pregnant women who experience significant complications or become critically ill during pregnancy Time has also gifted us with an appreciation for the value of advanced practice collaboration among clinicians who care for these women and their families Therefore, this edition includes extensive revisions that reflect evidencebased changes in clinical practice for specific complications, and new chapters have been added that address foundations for practice, adjuncts for clinical practice, and selected clinical guidelines One of the most challenging aspects of perinatal care continues to be meeting the clinical and psychosocial health care needs of an increasingly diverse obstetric patient population A general overview of today’s obstetric population depicts women who, in general, are older, larger in body habitus, more likely to have existing comorbid disease, more prone to high-order multiple gestations, known to have an increased incidence of operative intervention, less likely to attempt vaginal birth after a previous Cesarean birth, apt to have high expectations for care in terms of outcomes, and predisposed to complex clinical situations that may generate ethical issues related to their care It remains true that most pregnant women are without identified complications and proceed through pregnancy, labor, delivery, and the postpartum period without problems Accordingly, obstetric care remains based on a wellness-oriented foundation However, maternal mortality remains unacceptably high and there has been a renewed commitment to addressing this problem Significant complications may develop at any time during pregnancy without regard for a woman’s identified risk status Unfortunately, this very phrase has evolved into being synonymous with labels such as high risk or at risk However, we believe that use of such terms to designate levels of risk should be appreciated as being reasonably imprecise and nonspecific We should avoid any suggestion that categorical boundaries exist for patients or for the clinicians who care for them For example, there are women who manifest medical conditions during pregnancy who, absent appropriate recognition and management, may be more prone to adverse obstetric outcomes However, it is also recognized that this same population of pregnant women may, with appropriate management, experience no adverse perinatal outcomes above those of the general population Further, providing care to this unique population and their families within our evolving health care delivery system presents additional challenges to us as a society Efforts to reform health care continue to attempt to address the concepts of accessibility, affordability, quality, responsibility, safety, and cost-effectiveness Debate will no doubt continue regarding what is the best way to achieve reform measures This edition is reflective of these and other associated challenges However, the most significant intent of the format of this text is to promote appreciation for the importance of a collaborative approach to the care of this specific obstetric population Therefore, for the first time, most chapters are co-authored by nurse and physician experts in their respective areas of practice The first section is devoted to discussion of foundations for practice It includes an overview of the state of our specialty, the importance of collaboration in clinical practice, and the complexities of practice that often include ethical dilemmas that must be considered in the overall care of the patient and her family The second section presents information on adjuncts often used in the clinical care of this patient population We hope that this information proves useful for clinicians caring for obstetric patients with significant complications or who are critically ill during the intrapartum setting, as well as for those who provide consultation for such patients on other services The third section presents comprehensive critical concepts and current evidence-based information regarding specific clinical entities in obstetric practice The fourth section includes practice resources in the form of clinical guidelines, in an attempt to provide clinicians with references and tools to optimize clinical care of this special obstetric population On a personal note, we the editors feel that it is important to acknowledge that the evolution of this text over the past several years reflects the reality of accommodating to changes and challenges in our paths, much like the population of women for whom we provide care and our colleagues who care for them We all have our personal stories The interval between publication of the second and third editions bears witness to personal and professional stories for us all During this period of time, we have: celebrated years of remission from breast cancer; finished 60-mile Komen Foundation walks in Washington, DC, and vii LWBK1005-FM.indd vii 01/11/11 8:53 PM viii P R E FA C E Boston; lost beloved members of our family; grieved the loss of 10 precious pets; supported co-authors with professional and family tragedies and triumphs; changed jobs; endured the economy; found new love; gained energy and renewal because of the support of family and friends, and navigated significant challenges in order to bring this project to completion We are grateful for the overwhelmingly positive feedback from those who have read previous editions LWBK1005-FM.indd viii and provided us with direction to take this third edition to the next level We are in debt to the wonderful group of contributing authors for sharing their special expertise and time It has been an honor to work with these colleagues, AWHONN, and Lippincott Williams & Wilkins on this project Nan H Troiano Carol J Harvey Bonnie Flood Chez 01/11/11 8:53 PM CONTRIBUTORS Julie M.R Arafeh, RN, MSN Obstetric Simulation Specialist Center for Advanced Pediatric and Perinatal Education Lucile Packard Children’s Hospital Stanford, California Suzanne McMurtry Baird, RN, MSN Assistant Director, Clinical Practice Women’s Services Texas Children’s Hospital Houston, Texas Michael A Belfort, MD, PhD Professor and Chair, Obstetrics and Gynecology Baylor College of Medicine Houston, Texas Obstetrician/Gynecologist-in-Chief Texas Children’s Hospital Houston, Texas Frank A Chervenak, MD Given Foundation Professor and Chairman Department of Obstetrics and Gynecology New York Weill Cornell Medical Center New York, New York Bonnie Flood Chez, RNC, MSN President, Nursing Education Resources Perinatal Clinical Nurse Specialist and Consultant Tampa, Florida Steven L Clark, MD Medical Director, Women’s and Children’s Clinical Services Clinical Services Group Hospital Corporation of America Nashville, Tennessee Patricia Marie Constanty, RN, MSN, CRNP Clinical Nurse Specialist and Perinatal Nurse Practitioner Labor and Delivery and High Risk Obstetrics Thomas Jefferson University Hospital Philadelphia, Pennsylvania Deborah Anne Cruz, RN, MSN, CRNP Clinical Nurse Specialist and Perinatal Nurse Practitioner Labor and Delivery and High Risk Obstetrics Thomas Jefferson University Hospital Philadelphia, Pennsylvania Gary A Dildy III, MD Director of Maternal-Fetal Medicine MountainStar Division Hospital Corporation of America Nashville, Tennessee; Clinical Professor Department of Obstetrics and Gynecology Louisiana State University School of Medicine New Orleans, Louisiana; Attending Perinatologist Maternal Fetal Medicine Center at St Mark’s Hospital Salt Lake City, Utah Karen Dorman, RN, MS Research Instructor Maternal–Fetal Medicine University of North Carolina School of Medicine Chapel Hill, North Carolina Patrick Duff, MD Professor and Residency Program Director Department of Obstetrics and Gynecology University of Florida Gainesville, Florida Bonnie K Dwyer, MD Assistant Clinical Professor, Affiliated, Stanford University Division of Maternal–Fetal Medicine Department of Obstetrics and Gynecology California Pacific Medical Center San Francisco, California Sreedhar Gaddipati, MD Assistant Clinical Professor of Obstetrics and Gynecology Columbia University College of Physicians and Surgeons Medical Director, Critical Care Obstetrics Division of Maternal–Fetal Medicine New York, New York Lewis Hamner, III, MD Division of Maternal Fetal Medicine Kaiser Permanente Georgia Region Atlanta, Georgia ix LWBK1005-FM.indd ix 01/11/11 8:53 PM x CONTRIBUTORS Carol J Harvey, RNC-OB, C-EFM, MS Clinical Specialist High Risk Perinatal Labor and Delivery Northside Hospital Atlanta, Georgia Nan Hess-Eggleston, RN, BSN Clinical Nurse Specialist—Women’s and Infants’ Services Sibley Memorial Hospital Johns Hopkins Medicine Washington, DC Washington C Hill, MD, FACOG First Physician Group of Sarasota Medical Director, Labor and Delivery Director, Maternal–Fetal Medicine Sarasota Memorial Hospital; Department of Clinical Sciences OB-GYN Clerkship Director—Sarasota Campus Florida State University, College of Medicine; Clinical Professor Department of Obstetrics and Gynecology University of South Florida, College of Medicine Tampa, Florida Maribeth Inturrisi, RN, MS, CNS, CDE Coordinator and Nurse Consultant, Regions and California Diabetes and Pregnancy Program Assistant Clinical Professor, Family Health Care Nursing University of California San Francisco, California; Sweet Success Nurse Educator Physician Foundation Sweet Success Program California Pacific Medical Center San Francisco, California Thomas M Jenkins, MD Director of Prenatal Diagnosis Legacy Center for Maternal–Fetal Medicine Portland, Oregon Renee’ Jones, RNC-OB, MSN, WHCNP-BC Nurse Practitioner The Medical Center of Plano Women’s Link–Specialty Obstetrical Referral Clinic Plano, Texas Ellen Kopel, RNC-OB, MS, C-EFM Perinatal Nurse Consultant Tampa, Florida Stephen D Krau, RN, PhD, CNE, CT Associate Professor of Nursing Vanderbilt University School of Nursing Nashville, Tennessee Nancy C Lintner, RNC, MS, CPT Clinical Nurse Specialist and Nurse Consultant/ Educator Diabetes and Pregnancy Program University of Cincinnati Physicians/Greater Cincinnati Obstetrics & Gynecologists University of Cincinnati Medical School/Division of Maternal–Fetal Medicine Cincinnati, Ohio Marcy M Mann, MD Maternal Fetal Medicine Specialist Atlanta Perinatal Consultants Center for Perinatal Medicine Northside Hospital Atlanta, Georgia Brian A Mason, MD, MS Associate Professor Wayne State University St John’s Hospital / Medical Center Detroit, Michigan Laurence B McCullough, PhD Center for Medical Ethics and Health Policy Baylor College of Medicine Houston, Texas Keith McLendon, MD Staff Anesthesiologist Northside Anesthesiology Consultants Northside Hospital Atlanta, Georgia Richard S Miller, MD, FACS Professor of Surgery Medical Director, Trauma Intensive Care Unit Vanderbilt University School of Medicine Nashville, Tennessee Betsy B Kennedy, RN, MSN Assistant Professor of Nursing Vanderbilt University School of Nursing Nashville, Tennessee LWBK1005-FM.indd x 01/11/11 8:53 PM APPENDIX M Guidelines for the Care of the Critically Ill Pregnant Patient I Cardiovascular Assessment A General Assessment A complete cardiovascular assessment is performed every hours or more frequently dependent upon patient status Interpret the patient’s ECG from a graphic recording every hours Calculate/ document heart rate, rhythm, P-R interval, and QRS width Label with patient name, date, and time B Hemodynamic Monitoring Insertion: Record and save the pulmonary artery catheter (PAC) insertion strip recording Begin recording while catheter tip is in the right atrium prior to balloon inflation Label with patient name, date, and time Insertion graphic recording of central venous pressure (CVP), right ventricular pressure, pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP) should be obtained (if possible) All waveforms should appear continuously on the digital display and be inspected frequently for configuration changes Situations may occur that warrant intermittent interruptions in CVP waveform reading (e.g., volume resuscitation, cardiac output measurement, or medication administration) C Central Pressure Assessment Assessments may be performed from the digital display if waveform configurations are appropriate All assessments should be performed from the graphic recording for patients receiving artificial mechanical ventilation with positive end-expiratory pressure (PEEP) >10 cmH2O Routine assessment frequency may be as follows: a Patients who are undelivered or 12 hours post delivery—CVP and PAP every hour and PCWP every hours b Patients who are >12 hours post delivery—CVP and PAP every hour and PCWP every hours Assessments may be performed more frequently in the following situations: a The patient is hemodynamically unstable (abnormal central or arterial blood pressures) b The patient is receiving intravenous vasoactive medications PAC placement may be verified daily by chest x-ray PACs are usually repositioned and discontinued by a physician or designated advanced practice nurses PACs displaying a spontaneous occlusion waveform may be repositioned by the physician or registered nurse by withdrawing the catheter slowly with the balloon deflated until an appropriate PAP waveform returns D Derived Hemodynamic Assessment The following derived hemodynamic and oxygen transport parameters should be obtained for all patients with a PAC For patients without a fiberoptic continuous SvO2 PAC, a mixed venous blood gas is drawn from the distal port and analyzed with a Co-Oximeter a Cardiac index (CI) b Systemic vascular resistance (SVR) c Pulmonary vascular resistance (PVR) d Left ventricular stroke work index (LVSWI) 408 LWBK1005-Guideline_p369-412.indd 408 11/2/11 5:58 PM A P P E N D I X M | G U I D E L I N E S F O R T H E C A R E O F T H E C R I T I C A L LY I L L P R E G N A N T PAT I E N T e Arterial oxygen content (CaO2) f Venous oxygen content (CvO2) g Oxygen delivery (DO2) h Oxygen consumption (VO2) i Oxygen extraction ratio (O2ER) j Shunt fraction (Qs/Qt) Routine assessment frequency of derived hemodynamic and oxygen transport parameters may be as follows: a Cardiac index (CI) (1) Patients who are undelivered or 12 hours post delivery—every hours Assessments may be performed more frequently if patient is hemodynamically unstable E Instrumentation Pulmonary artery catheter pressure line set-up a Obtain from pharmacy-prepared heparin flush solution (e.g., 2500 units heparin to 500 cc bag 0.9% normal saline) b Place solution in pressure bag c Prepare pressure lines for CVP and pulmonary artery (PA) ports Flush tubing and transducer with heparin solution using gravity to remove air d Replace all stopcock ports with nonvented caps Ensure that system is free of air e Inflate pressure bag to 300 mmHg Pressure is maintained at 300 mmHg to ensure an infusion rate to each pressure line of 3–5 cc/hour f Zero each pressure line at the patient’s phlebostatic axis g Calibrate the transducer h Ensure that informed patient consent has been obtained by the physician i Initiate continuous electrocardiographic monitoring to detect ventricular ectopy, which may occur when the catheter enters the right ventricle Have available at the bedside lidocaine 1.0 mg/kg for suppression as needed j Test balloon for patency Hemodynamic Monitoring a Hemodynamic pressure readings may be taken with the patient in a position that allows for adequate cardiac output maintenance and patient comfort Following patient position change and prior to pressure readings, all pressure lines should be re-zeroed at the phlebostatic axis For LWBK1005-Guideline_p369-412.indd 409 409 patients with head elevation or deep side-lying position, the location of the right atrium is used for the zero reference point b For consistency, all PAPs should be assessed at the patient’s end-expiration c PCWP is assessed as a mean pressure at the patient’s end-expiration d In mechanically ventilated patients, all pressure measurements will be assessed with the ventilator remaining connected to the patient unless otherwise ordered e The PAC should be secured to the patient f Pressure bags should be maintained at 300 mmHg pressure g All ports on the pressure line will be protected with occlusive port covers h Stopcocks used for blood sampling should be flushed prior to replacing the nonvented cap i No fluids except the flush solution will be infused into the distal port of the patient Cardiac Output—Thermodilution cardiac output (CO) assessment may be routinely performed and documented as follows: a Patients who are undelivered or 12 hours post delivery—every hours c Assessment of CO may be performed more frequently if patient is hemodynamically unstable d All CO assessments should be performed using 10 mL iced injectate (0.9 sodium chloride) at a temperature between 6° and 12° C e The computation constant for CO measurement is PAC specific and should be determined prior to the procedure f CO injectate should be recorded as intake volume g Thermodilution technique is used for measuring CO by injecting 10 cc of iced saline into the CVP port Positioning for the obstetric patient to allow optimization of CO includes right side-lying and left side-lying Fiberoptic (SvO2) PAC a An in-vitro calibration should be performed prior to insertion of a fiberoptic catheter per manufacturer’s instructions b An in-vivo calibration should be performed by obtaining a mixed venous gas sample from the PA port: • as soon as possible after insertion if an in-vitro calibration is not performed 11/2/11 5:58 PM 410 II PA R T I V | C L I N I C A L C A R E G U I D E L I N E S • every 24 hours for all patients with AM labs, or per manufacturer’s instructions c If interruption of monitoring is necessary, the cable should be disconnected at the input jack If disconnection occurs at the optical module or continues beyond hours, an in-vivo calibration should be performed (See manufacturer’s instructions for specific model of PAC.) d An adequate signal quality index (SQI) should be verified (according to manufacturer’s recommendation) prior to documentation of SvO2) Arterial Blood Pressure (ABP) Monitoring a ABP and MAP are assessed every hour or more frequently based on patient condition b The catheter insertion site should serve as the zero-reference point for intra-arterial BP monitoring c The extremity containing the intra-arterial catheter should be assessed every hours d If unexplained direct ABP changes by >20 mmHg, an indirect assessment should be performed for comparison e An indirect ABP should be obtained and documented each shift for patients with an intra-arterial catheter Deep Vein Thrombus (DVT) Prophylaxis a All critical care obstetric (CCOB) patients >24 hours should be evaluated for the use of DVT prophylaxis The type of prophylaxis (anticoagulation, compression devices, filters, etc.) is based on individual patient condition and whether the patient is postoperative b If SCD hose/device is in use, it should be removed for hour every hours Respiratory Assessment A General Assessment—A complete respiratory assessment should be performed and abnormal findings documented each shift, or more frequently if evidence of respiratory compromise exists B Ongoing Assessment—Routine assessment of respiratory status should be performed as follows: Respiratory rate and arterial oxygen saturation (SaO2) every hour Venous oxygen saturation (SvO2) every hour for patients with a fiberoptic PAC Auscultate breath sounds every hours C Mechanical Ventilation After intubation, the following should be assessed and documented: Endotracheal LWBK1005-Guideline_p369-412.indd 410 tube (ETT) size and position at the patient’s teeth, date of placement, and breath sounds Placement of ETT should be verified by a chest x-ray as soon as possible after intubation Routine assessment should be performed as follows: a Ventilator settings (mode, rate, FiO2, Vt, PEEP, PSV, peak inspiratory pressure)— every hours and after any ventilator change b Arterial blood gases—after any change in ventilator settings, or more frequently as indicated by patient respiratory status Ventilator setting changes should be made according to hospital protocol In a STAT or emergency situation, when neither a physician nor a respiratory care practitioner is immediately available, a CCOB nurse should initiate changes necessary to meet a patient’s ventilatory needs A nasogastric tube should be inserted in patients requiring mechanical ventilation >4 hours and connected to low wall suction Suctioning of the patient via ETT or tracheotomy tube should be as follows: a Performed only when indicated by respiratory assessment (increasing peak inspiratory pressure, visible secretions, patient coughing, or decreasing SaO) b Preceded and followed by hyperoxygenation with FiO2 of 1.0 as necessary to maintain adequate SaO2 >95%) c Preceded by hyperventilation if open suction technique is used d Stabilization of ETT by additional personnel may be required during open suction procedure e Limit each suction episode to maximum of two catheter passes f Suction containers should be changed every 24 hours and emptied every shift A manual resuscitation bag, capable of delivering PEEP and connected to an oxygen source providing 1.0 FiO2 should be immediately accessible at all times at the head of the bed When the patient is intubated and on a ventilator, restraints may, in accordance with institutional policies and guidelines, be ordered by a physician and applied to patient’s extremities as necessary Application and removal should be documented in accordance with institutional policies and guidelines The need for and expected time 11/2/11 5:58 PM A P P E N D I X M | G U I D E L I N E S F O R T H E C A R E O F T H E C R I T I C A L LY I L L P R E G N A N T PAT I E N T III IV of restraint must be explained to the patient and family A physician’s order must be obtained D ETT and Tracheotomy Care Use disposable endotracheal tube holders to secure the ETT Assess tube holder every hours If soiled or no longer secure, apply new tube holder with assistance of another staff person Assess breath sounds to verify tube placement per unit guidelines An extra ETT or tracheotomy tube, identical to patient’s existing tube, should be immediately accessible at all times Respiratory therapy should be consulted when the ETT requires repositioning or alteration of length is needed No more than cm of tube should protrude from the patient’s mouth Neurologic Assessment A complete neurologic assessment will be performed and abnormal findings documented every hours, or more frequently when neurologic instability exists Gastrointestinal/Genitourinary (GI/GU) Assessment A General Assessment—A GI/GU assessment will be performed and abnormal findings documented every hours, or more frequently if instability exists B Nasogastric Tube (NG) Position of NG tube should be documented Gastric pH should be assessed and documented every hours Correct placement should be verified by auscultation prior to each irrigation or administration of medication Tape should be positioned to avoid pressure on the nares Tape should be changed when soiled C Feeding/Drainage Tubes Feeding bag and tubing should be changed every 24 hours Location of enteral feeding tube should be verified every 24 hours No more than hours of feeding solution will be to prevent risk of bacterial contamination Feeding tubes should be irrigated with 20 mL warm water before and after feeding or every hours Gastric residuals should be assessed every hours If residuals are greater than the hourly rate, feedings should be held and the physician notified LWBK1005-Guideline_p369-412.indd 411 V VI 411 D Bowel Function Passage of stool should be documented in medical record If a rectal tube is in place, the balloon should be deflated for 10 minutes every hours Rectal bags should be changed every 48 hours or PRN The rectal area should be cleaned and dried following bag change E Urinary Output Indwelling urinary catheters should be connected to a graduated urimeter and bedside drainage bag Urine output should be assessed and documented every hour Twenty-four-hour total urine output should be calculated and documented Integument Assessment A General Assessment—A skin assessment will be performed and abnormal findings documented every hours B Therapeutic Mattress/Bed—Therapeutic beds should be considered for patients with special skin care needs Use of these beds usually requires a physician order C Skin Care All patients should be repositioned/ turned at least every hours unless contraindicated Position changes should be documented Additional skin care protection (e.g., heel, elbow pads, and decubitus care) may be ordered by the nurse as needed A protective blanket should be applied between the skin and hyper/hypothermia blanket when in use If the corneal reflex is absent, a saline sponge should be placed over the patient’s eyes each shift or eyes may be taped closed Patients should be bathed each day as tolerated Hair care (combing and shampooing) should be done PRN Perineal care PRN D Mouth Care Mouth care at least daily Intubated patients should receive mouth care every hours and supplemented with swabbing with sponge and mouth wash every hours and PRN as part of a ventilator bundle to reduce the incidence of VAP Oral airways should be removed during mouth care Uterine Activity and Fetal Monitoring Most critically ill undelivered patients should have uterine activity and fetal assessments performed and documented according to institutional 11/2/11 5:58 PM 412 PA R T I V | C L I N I C A L C A R E G U I D E L I N E S policy and guidelines (See Guidelines for the Care of Patients in Labor and Guidelines for Fetal Heart Rate Monitoring.) VII Metabolic Assessment A Temperature Assessment—Temperature should be assessed and documented every hours Assessment should be performed and documented every hours in the following situations: Temperature is >100 degrees F Temperature is 160 mmHg B Diastolic blood pressure >110 mmHg C Respirations 26 per minute D Deep tendon reflexes absent E Urine output