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4873298 Biologic Crisis

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Davao Doctors College, Inc.
Gen. Malvar St., Davao City

WELCOME TO NCM 104

MADELINE N. GERZON, RN, MM
Clinical Instructor

MNGerzon, BSN 4L, Sept 2008

Nursing Care Management 104
Care of the Patient with Acute

MNGerzon, BSN 4L, Sept 2008

Objectives
• Identify the different conditions that disturb pregnancy • Identify the signs and symptoms of problems during pregnancy • Identify and discuss management of conditions during pregnancy

MNGerzon, BSN 4L, Sept 2008

Objectives
• Identify and plan nursing actions for patients with problems during delivery • Identify needs for unborn baby…possible care • Identify needs for high risk newborn • Formulate nursing diagnoses
MNGerzon, BSN 4L, Sept 2008

Normal Pregnancy
• 38 weeks • Should have immunization required • Should have ideal weight gain for duration of pregnancy • Should maintain healthy lifestyle • Able to identify signs of possible problems during pregnancy
MNGerzon, BSN 4L, Sept 2008

What are we going to talk about?

MNGerzon, BSN 4L, Sept 2008

Adolescent Pregnancy Delayed Pregnancy Bleeding during Pregnancy Abortion Ectopic Pregnancy Hydatidiform Mole Placenta Previa Abruptio Placenta Incompetent Cervix PTL/PROM

Multiple Pregnancy Hydramnios Post-term Pregnancy Isoimmunization, (Rh) Fetal Death Uterine Hypofunction

MNGerzon, BSN 4L, Sept 2008

Pre-existing or Newly Acquired Illness
•STD •Hematologic disorder •Respiratory disorder •Rheumatic disorder •Gastrointestinal disorder •Neurologic disorder •Musculoskeletal disorder •Cardiovascular disorder •Cardiovascular disorder •Endocrine disorder •Cancer •Mental Illness •Trauma

MNGerzon, BSN 4L, Sept 2008

What age are we talking about?

MNGerzon, BSN 4L, Sept 2008

Contributing Factors
• • • • • • • Peer pressure  Self-esteem Lack of role models Gain attention Media Poverty Rite of passage
MNGerzon, BSN 4L, Sept 2008

What to assess?
Risks (nutrition, body structure) Fundal Height (concealment) # of sexual partners

MNGerzon, BSN 4L, Sept 2008

What to assess?

Knowledge on infant care/needs Family unit/support system Baseline VS/weight (PIH, etc)

MNGerzon, BSN 4L, Sept 2008

Socioeconomic •Reliance on welfare •Cycle repeats itself •Low knowledge how to take care of the newborn
MNGerzon, BSN 4L, Sept 2008

Maternal health •CPD •PIH •Anemia •Nutritional • mortality •Others
MNGerzon, BSN 4L, Sept 2008

Fetal Health •LBW, SGA, LGA •Prematurity •Resp complications (RDS, others) •Cognitive deficits (bec of nut deficits •Death
MNGerzon, BSN 4L, Sept 2008

What nursing diagnosis can you draw out?

MNGerzon, BSN 4L, Sept 2008

Nursing Management
• Health Education
– Prenatal, immunization, etc – Contraception, baby care – Nutrition

• Maternal assessment
– LMP/EDC, anemia, fundal height – Weight gain, LM
MNGerzon, BSN 4L, Sept 2008

Nursing Management
• Fetal assessment
– FHT, LM, weight monitoring

• Referral to support unit (if necessary) • Therapeutic communication • Assist in physical preparation for delivery (lamaze, exercise, etc)

MNGerzon, BSN 4L, Sept 2008

• • • • • • •

Pre-existing conditions Preterm labor SGA/LBW IUGR PIH Abruption C-section Uterine fibroids PP hemorrhage Chromosomal abnormalities – Why?
MNGerzon, BSN 4L, Sept 2008

What to assess?

• Pre-existing conditions • Fundal height • Anxiety
• Psychosocial issues (career vs baby)
MNGerzon, BSN 4L, Sept 2008

Delayed Pregnancy
What nursing diagnosis can you formulate out of this situation?

MNGerzon, BSN 4L, Sept 2008

Nursing Management
• Health Education
– Delivery process, proper diet & exercise – Discuss possible complications

• Maternal assessment
– Pre-existing conditions – Weight gain

MNGerzon, BSN 4L, Sept 2008

Nursing Management
• Health Education • Maternal assessment • Fetal assessment • Referral to support unit (if necessary) • Therapeutic communication • Assist in physical preparation for delivery
MNGerzon, BSN 4L, Sept 2008

BLEEDING DURING PREGNANCY

MNGerzon, BSN 4L, Sept 2008

BLEEDING DURING PREGNANCY
Blood loss in excess of what is considered normal in the Antepartum, Intrapartum and Postpartum periods

Normal blood loss
TYPE PF DELIVERY Vaginal Delivery

AMOUNT OF EXPECTED BLOOD LOSS 500 ml

Cesarean Section 1,000 ml Cesarean + hysterectomy 1,500 ml
MNGerzon, BSN 4L, Sept 2008

WHAT CONDITIONS DO YOU KNOW THAT BRING ABOUT BLEEDING DURING ANTEPARTUM?

MNGerzon, BSN 4L, Sept 2008

ABORTION
• Naturally occurring termination of pregnancy before viability • Usually before 20 wks gestation or weight less than 500 gm • Danger - bleeding and infection

MNGerzon, BSN 4L, Sept 2008

ABORTION
Types
• THERAPEUTIC - purposely terminating the pregnancy • THREATENED - any vaginal bleeding before 20 wks (slight & dark brown-red in color)

MNGerzon, BSN 4L, Sept 2008

ABORTION
Types
• INEVITABLE - occurs with gross ROM, moderate bleeding, cramping, open cervical OS, no tissue passage • INCOMPLETE – expulsion of parts of conceptus, with retention of some parts, there is heavy uterine bleeding, cervical OS close, severe cramping
MNGerzon, BSN 4L, Sept 2008

ABORTION
Types
• COMPLETE - the cessation of pain and bleeding after the entire conceptus has been passed • MISSED - occurs when the conceptus dies but is not expelled
• Recurrent or habitual - three or more consecutive 1st trimester abortion
MNGerzon, BSN 4L, Sept 2008

TYPES OF SPONTANEOUS ABORTIONS

MNGerzon, BSN 4L, Sept 2008

Abortion
Signs and symptoms
• Bleeding, clots, tissue • Abdominal pain or cramps • Dizziness, paleness, cold clammy skin • Anxiety, depression

MNGerzon, BSN 4L, Sept 2008

NURSING DIAGNOSIS?

MNGerzon, BSN 4L, Sept 2008

Nursing Care Management
• • • • Nursing history Identify symptoms Provide comfort measures Evaluate blood loss (padsfrequency of change) • Recognize S/S of shock (paleness, profuse sweating, tachycardia, hypotension)
MNGerzon, BSN 4L, Sept 2008

Nursing Care Management
• Monitor I & O • Replace fluids as ordered • Prepare for D & C as necessary • Provide emotional support (no false reassurance) • Health education
MNGerzon, BSN 4L, Sept 2008

Post Abortion Education
• Bleeding, cramping in the next 1-2 wks • Vaginal rest for 2 wks • Check body temp BID • Follow-up in 2 wks • Nutrition

MNGerzon, BSN 4L, Sept 2008

Ectopic Pregnancy
Ovum implants outside the uterus

MNGerzon, BSN 4L, Sept 2008

Ectopic Pregnancy
Clinical Manifestations • Missed menses, with signs of pregnancy • Sharp abdominal pain (stretching
of the tube)

• Vaginal spotting • Low abdominal stabbing pain
(tube rupture)

• hCG levels fall • No gestational sac on US
MNGerzon, BSN 4L, Sept 2008

SITES OF ECTOPIC PREGNANCY

MNGerzon, BSN 4L, Sept 2008

Surgical Management of Ectopic Pregnancy

MNGerzon, BSN 4L, Sept 2008

MNGerzon, BSN 4L, Sept 2008

Nursing Care Management
Ectopic Pregnancy • Assess for abdominal pain, provide measures • Monitor VS, observe for signs of shock • Maintain IV for plasma administration, blood, antibiotics and other required medication
MNGerzon, BSN 4L, Sept 2008

Nursing Care Management
Ectopic Pregnancy • Prepare for surgery • Give emotional support, fetal loss • POST-OP: VS, I&O, promote relaxation

MNGerzon, BSN 4L, Sept 2008

Hydatidiform Mole
• Abnormal development of placenta and proliferation of trophoblastic tissue • Complete - only placenta, no baby, sperm fertilized empty egg • Associated with choriocarcinoma • Partial – two sperm fertilized an egg
MNGerzon, BSN 4L, Sept 2008

Risk factors
• Age > 40 yrs • Previous miscarriages or ectopic pregnancy • Mexico, Phillippines, Southeast Asia

Incidence • 80% non-aggressive • 15% aggressive • 2% cancerous

MNGerzon, BSN 4L, Sept 2008

Hydatidiform Mole
Signs and Symptoms
• 1st trime vaginal bleeding, anemia • +/- passage of grapelike vesicles (12 wks) • Exagge pregnancy signs – hyperemesis, inc uterine size, cramps • No FHT • Increased N/V • Early PIH, Thyrotoxicosis
MNGerzon, BSN 4L, Sept 2008

Hydatidiform Mole
Signs and symptoms
• Abnormally high Hcg levels • Brownish vaginal discharge • Uterine enlargement may be greater than expected • Diagnosed with transvaginal ultrasound, Hcg (quantitative) testing
MNGerzon, BSN 4L, Sept 2008

“Molar” Pregnancy

MNGerzon, BSN 4L, Sept 2008

Treatment of H. Mole
• D and C or D and E; microscopic examination • Serum Hcg and pelvic exam q 2 wks X 3 months, then q 1 months for up to 1 year • Advised not to conceive for 1 year, contraception provided

MNGerzon, BSN 4L, Sept 2008

Treatment of H. Mole
• CXR q 4-6 weeks to r/o metastasis • With no increased Hcg for 1 year, low risk of recurrence or choriocarcinoma • Persistent GTD 100% curable • Methotrexate agent used for carcinoma

MNGerzon, BSN 4L, Sept 2008

Hydatidiform Mole

MNGerzon, BSN 4L, Sept 2008

Nursing Care Management
• Assess for abdominal pain and provide measures • Maintain IV for plasma administration, blood, antibiotics and other required medication • Give emotional support

MNGerzon, BSN 4L, Sept 2008

Nursing Care Management
EMPHASIZE
• Avoid pregnancy for 1 year • Need for 1 year follow-up/monitoring (HCG) • Examination=detect choriocarcinoma • Chemotherapy if indicated

MNGerzon, BSN 4L, Sept 2008

Placenta Previa
• Placenta is implanted in the lower uterine segment and located over the internal os • Complete, partial, marginal

MNGerzon, BSN 4L, Sept 2008

Placenta Previa
Signs and Symptoms
•Painless bleeding during late pregnancy (28th wks) and delivery •Sudden and profuse bleeding •Anemia •Often high fetal presentation

MNGerzon, BSN 4L, Sept 2008

High risk factors
->35 y. o. -multiparity -prior CS delivery -smoking

Placenta Previa
Causes
-Scarred/poorly vascularized endometrium -Curettage, delivery, CS & infection -Placental abnormality - Large placenta (multiple pregnancy) -Delayed development of trophoblast

MNGerzon, BSN 4L, Sept 2008

Placenta Previa
• Low lying previa – implantation on lower rather upper portion of uterus • Total placenta previa - the internal cervical os is covered completely by placenta • Partial placenta previa - the internal os is partially covered by placenta • Marginal placenta previa - the edge of the placenta is at the margin of the intenal os

MNGerzon, BSN 4L, Sept 2008

classification

MNGerzon, BSN 4L, Sept 2008

Medical Mgmt of Placenta Previa
Mom stable,
fetus immature

Fetus > 36 wks

S&S hypovol in mom

•Bedrest •no sex act •report bleeding

•Amnio to  lung maturity

•delivery

•delivery

MNGerzon, BSN 4L, Sept 2008

Nursing Care Management
• Complete nursing history • Take note duration of pregnancy, when bleeding begun • Ask patient estimate of blood loss, if with pain, what she did for bleeding • NO VAGINAL EXAMS!!!

MNGerzon, BSN 4L, Sept 2008

Nursing Care Management
• Strict bedrest and monitor closely • Ask whether there were prior episodes of bleeding during pregnancy • Assess for hemorrhage and infection • Ask if patient had cervical surgery

MNGerzon, BSN 4L, Sept 2008

Abruption Placenta






Premature separation of the placenta from the uterine wall Total Abruption – fetal death is inevitable Partial Abruption – fetus has a chance of survival
MNGerzon, BSN 4L, Sept 2008

Abruption Placenta
S/S
•Vaginal bleeding (unless concealed) •Abdominal pain

• U-activity
•Hemorrhage -boardlike abd

-late deceleration
-S/S of shock
MNGerzon, BSN 4L, Sept 2008

Med Mgmt of Placental Abruption
Mom stable, fetus immature  bleeding, fetal distress

bedrest tocolytics Emergency CS
MNGerzon, BSN 4L, Sept 2008

Nursing Care Management
Maintain bed rest  Monitor FHR and maternal VS  Assess blood loss and abdominal pain  Administer blood replacement as ordered


MNGerzon, BSN 4L, Sept 2008

Nursing Care Management
Monitor I & O  Nursing measures for shock  Emotional support  Prepare for emergency delivery


MNGerzon, BSN 4L, Sept 2008

INTRAPARTUM PERIOD BLEEDING

MNGerzon, BSN 4L, Sept 2008

Uterine Rupture
•Separation of uterine wall •Site of previous surgery •With or without expulsion of the fetus

MNGerzon, BSN 4L, Sept 2008

UTERINE RUPTURE
Signs and Symptoms
•Changes in FHR •Sharp abdominal pain @ height of contractions •“Something tore” •Profuse vaginal bleeding

MNGerzon, BSN 4L, Sept 2008

UTERINE RUPTURE
Signs and Symptoms
•Profuse vaginal bleeding •Sudden cessation of contractions (not always) •Loss of fetal station and FHR tracing •Ease in fetal palpation •Maternal shock
MNGerzon, BSN 4L, Sept 2008

Uterine Rupture
Medical Management
•Immediate cesarean delivery with preparation for massive hemorrhage •Uterine repair vs hysterectomy

MNGerzon, BSN 4L, Sept 2008

Uterine Rupture
Nursing Interventions
• • • • Allay fear and anxiety Monitor vital signs closely (shock) Pre-op/post-op care Emotional support for family

MNGerzon, BSN 4L, Sept 2008

Uterine Atony
•Failure of the uterus to contract after delivery of the placenta •Common cause of postpartum hemorrhage

MNGerzon, BSN 4L, Sept 2008

Uterine Atony
Signs and Symptoms
•Bleeding following delivery of placenta •“Boggy” fundus •Missing placental parts

MNGerzon, BSN 4L, Sept 2008

MNGerzon, BSN 4L, Sept 2008

Uterine Atony
Nursing Interventions
• • • • Monitor vital signs Monitor bleeding Palpate character of fundus Icepack over fundal area

MNGerzon, BSN 4L, Sept 2008

LABOR DISORDERS
•Incompetent Cervix •PTL and PROM •Postterm pregnancy

MNGerzon, BSN 4L, Sept 2008

Incompetent Cervix
• Begins to dilate @ 2nd or 3rd trime without uterine contractions • Progressive cervical effacement & dilation

MNGerzon, BSN 4L, Sept 2008

Incompetent Cervix
Predisposing Factors
• When 2 or more spontaneous abortions occur in the 2nd trimester • Usually a result of weak, torn, or absent sphincter muscle at cervical os

MNGerzon, BSN 4L, Sept 2008

Incompetent Cervix
Causes
• • • • • Cervical trauma Infection Multiple gestation LEEP procedure/cone biopsy Late term abortion

MNGerzon, BSN 4L, Sept 2008

Incompetent Cervix
Signs and Symptoms
•Cervical dilation (painless) •Low abd pressure •Contraction •Bloody show, bleeding •Urinary frequency
MNGerzon, BSN 4L, Sept 2008

Incompetent Cervix
Treatment
• Bedrest • Possible cerclage

MNGerzon, BSN 4L, Sept 2008

Cerclage
Surgical suture around internal os around week 13-15 Suture must be opened for delivery, usually around 37 weeks Mom must notify if SROM occurs Risks to fetus; not 100% effective

MNGerzon, BSN 4L, Sept 2008

Cerclage

MNGerzon, BSN 4L, Sept 2008

Nursing Care Management
• • • • Tell client to report signs of labor Monitor fetal growth to term Continue prenatal assessment and care Observe for signs of labor, infection and PROM

MNGerzon, BSN 4L, Sept 2008

Premature Rupture of Membranes
• Many risk factors • Maternal Sequelae: Abruption, amniotic infection, post-partum infection of endometrium • Fetal sequelae: Respiratory distress, sepsis, prolapsed cord • Diagnoses; nitrazine paper, microscopic test of amniotic fluid • No digital examination!!!

MNGerzon, BSN 4L, Sept 2008

Premature Rupture of Membranes
Signs and Symptoms
– contractions – cramps – backache – diarrhea – Vaginal discharge – ROM

MNGerzon, BSN 4L, Sept 2008

Premature Rupture of Membranes
• Treatment
– Tocolytics – IV hydration – bedrest – steroids, if needed

MNGerzon, BSN 4L, Sept 2008

Nursing Interventions
• • • • • Assess fetal well-being, gestational age Administer antibiotics < 37 weeks gestation, minimal options > 34 weeks, assess lung maturity of fetus Monitor for signs and prevent premature labor • Provide psychological support for mother and family

MNGerzon, BSN 4L, Sept 2008

Pre-term Labor
• Onset of Labor from 20-37 weeks • Rarely due to a single cause • Common problem-11.6% of all births are premature

MNGerzon, BSN 4L, Sept 2008

Pre-term Labor
• Multiple causes – Maternal renal, CV, DM, PIH, placental problems, trauma, PROM • Effects to fetus – Maturational deficiencies- no body fat – Respiratory Distress – Poor glucose, heat regulation

MNGerzon, BSN 4L, Sept 2008

Nursing Interventions/Care
• Assessment
– – – – Thorough hx check bleeding check ROM BP

• Teaching
– Infection Control – Report any leaking

MNGerzon, BSN 4L, Sept 2008

Postterm Pregnancy
Signs and Symptoms Wt loss –  uterine size – Meconium in AF Risks •  fetal mortalit • cord compression • mec asp • LGA  shoulder dystocia  CS • episiotomy/laceration • depression

MNGerzon, BSN 4L, Sept 2008

Postterm Pregnancy
Treatment fetal surveillance
• NST, q wk • mom monitors fetal movement

Induction
• Pitocin (10-20U/L) @ 1-2 mU/min every 20-60 min

MNGerzon, BSN 4L, Sept 2008

Disorders of Amniotic Fluid

MNGerzon, BSN 4L, Sept 2008

Disorders of Amniotic Fluid
Polyhydramnios Signs and Symptoms
• uterine distention • Dyspnea • edema of lower extr

Treatment
• Therapeutic • amniocentesis

MNGerzon, BSN 4L, Sept 2008

Disorders of Amniotic Fluid
Oligohydramnios Risks
• cord compression • musculoskeletal deformities • pulmonary hypoplasia

Treatment
• amnioinfusion

MNGerzon, BSN 4L, Sept 2008

Pregnancy Induced Hypertension
•Pre-eclampsia •HELLP •Eclampsia

MNGerzon, BSN 4L, Sept 2008

Pregnancy Induced Hypertension
Pre-eclampsia
•BP > 140 mmHg sys or 90 mmHg dias •with proteinuria (> 300mg/24 h) after 20 wks gestation •Can progress to eclampsia (seizures)

MNGerzon, BSN 4L, Sept 2008

Pregnancy Induced Hypertension
Signs and Symptoms of Pre-eclampsia
•Rapid wt gain •Edema of hands and face •Proteinuria •Hyperreflexic DTRs •Headache, visual disturbances •Epigastric pain
MNGerzon, BSN 4L, Sept 2008

Treatment of Pre-eclampsia
Mild: diastolic < 100,
1+ proteinuria, no H/A
  

Severe: diastolic > 110, 3+ proteinuria,  U/O, H/A, visual disturbances
 



Bedrest protein diet document fetal activity weekly NST

Bedrest,  stimuli Meds



Apresoline for severe HTN MgSO4 (anticonvulsant & antihypertensive)



Delivery

MNGerzon, BSN 4L, Sept 2008

ECLAMPSIA
Pre-eclampsia + seizures •80% seizures prior to delivery •Others postpartum (23 days post delivery) •Intrapartum and postpartum seizures

Management •Ante/intra - MgSO4 & delivery •Postpartum - MgSO4 •MgSO4 + antihypertensive to control BP
MNGerzon, BSN 4L, Sept 2008

Eclampsia
Signs and Symptoms
 facial

twitching  tonic-clonic seizures  pulmonary edema  circ/renal failure

MNGerzon, BSN 4L, Sept 2008

Eclampsia – Complications
•Placental abruption •Perinatal asphyxia •Maternal hemorrhage •CV damage •Severe respi insufficiency •DIC •Perinatal death •Maternal death
MNGerzon, BSN 4L, Sept 2008

HELLP
•Variant of severe pre-eclampsia •Characterized by: •Hemolysis •Elevated liver enzymes •Low Platelet •May not meet BP criteria for severe pre-eclampsia •“Great masquerader”

MNGerzon, BSN 4L, Sept 2008

HELLP Syndrome
Signs and Symptoms
RUQ pain  n/v  edema   plts   liver enzymes


MNGerzon, BSN 4L, Sept 2008

HELLP – Signs and Symptoms
•BP mildly elevated •Proteinuria +/•Malaise almost 100% •GI symptoms •Frequently referred •Frequently misdiagnosed

MNGerzon, BSN 4L, Sept 2008

HELLP – Complications
•Abruption 7-20% •Acute renal failure •Hepatic hematoma •Liver rupture •Hemorrhage •Fetal death •Maternal death
MNGerzon, BSN 4L, Sept 2008

Tx of Eclampsia/HELLP Syndrome
•Bed rest •Meds •MgSO4 •Valium/Phenobarb •Hydralazine •Steroids •Delivery

MNGerzon, BSN 4L, Sept 2008

Risk Control Strategies for PIH
 





Seizure precautions monitor for s/s Mg toxicity (RR<12, absent DTR’s, sweating, flushing, confusion,  B/P) Ca gluconate @ BS  Mg levels

MNGerzon, BSN 4L, Sept 2008

Risk Control Strategies for PIH
  

IV MgSO4 (should be “Y” connected to another primary bag) D/C MgSO4 for RR < 12 or absent DTR’s  renal function (30 mL/hr)

MNGerzon, BSN 4L, Sept 2008

PEGNANCY AND CARDIOVASCULAR DISORDERS

MNGerzon, BSN 4L, Sept 2008

Heart Disease
 Affects

small percentage of pregnant

women  Manifestations
 Increased


clotting causes predisposition to thrombosis
If cannot meet demand leads to CHF  Priority of care is limiting demands on heart throughout pregnancy, labor, delivery and postpartum period

MNGerzon, BSN 4L, Sept 2008

Heart Disease
 Nursing
 Teach

Care for Heart Disease

self-management to patient  Teach S/S of CHF  Diet modification  Teach about eliminated stress

MNGerzon, BSN 4L, Sept 2008

Cardiovascular Disorders
Anemia


Hgb levels < 10.5-11.0 g/dl in pregnancy

Signs and Symptoms
Paleness, conjunctiva Body malaise Easy fatigability Less ROM
MNGerzon, BSN 4L, Sept 2008

Cardiovascular Disorders
 Anemia
 Iron-deficiency
 RBCs

small and pale  Prevention – iron supplements  Treatment – elemental iron supplements

MNGerzon, BSN 4L, Sept 2008

Cardiovascular Disorders
 Anemia
 Folic

acid-deficiency

 Large,

immature RBCs  Iron-deficiency anemia may also be present  Prevention – folic acid supplement  Treatment – 1mg/day supplement over the amount of preventative supplement
MNGerzon, BSN 4L, Sept 2008

Cardiovascular Disorders
 Sickle

cell disease

 Abnormal

Hgb that causes erythrocytes to become sickle-shaped during hypoxia or acidosis  Autosommal recessive trait  Pregnancy may cause crisis  Risk to fetus – occlusion of vessels leading to preterm birth, IUGR, fetal death

MNGerzon, BSN 4L, Sept 2008

Sickle Cell Disease


Maternal Effects
pain  jaundice  Pyelonephritis  PIH/preeclampsia  leg ulcers  CHF




Fetal Effects
IUGR/SGA  skeletal changes


MNGerzon, BSN 4L, Sept 2008

Cardiovascular Disorders
Thalasemia
 Genetic

trait that causes abnormality in one of two chains of Hgb ,alpha or beta

MNGerzon, BSN 4L, Sept 2008

Cardiovascular Disorders
 Nursing

Care for Anemias during pregnancy
 Nutrition

education  Education about changes in stool pattern and characteristics  Taught to avoid dehydration

MNGerzon, BSN 4L, Sept 2008

Thromboembolic disease
• Pulmonary embolism is one of the leading causes of maternal death

• Thrombus-collection of platelets on the wall of a blood vessel

MNGerzon, BSN 4L, Sept 2008

Thromboembolic disease
• Embolus-thrombus that has detached from the vessel and is flowing in the blood • Thrombophlebitis-a thrombus that causes inflammation of a blood vessel wall

MNGerzon, BSN 4L, Sept 2008

Risk factors for thromboembolic disease
• Venous stasis • Increased blood volume • Increased clotting times

MNGerzon, BSN 4L, Sept 2008

thromboembolic disease
Assessment • Positive Homan’s sign • Warmth and redness of the calf • Dyspnea, chest pain, hemoptysis and tachycardia (pulmonary embolism) Treatment
– IV heparin, Coumadin, bed rest

MNGerzon, BSN 4L, Sept 2008

Hyperemesis gravidarum
• Excessive vomiting during pregnancy • Can lead to dehydration, starvation, weight loss and IUGR • Occurs more frequently with
– Multifetal pregnancy’s – First pregnancy’s – Hydatiform mole

MNGerzon, BSN 4L, Sept 2008

hyperemesis gravidarum
Management
• • • • • Hospitalization may be required IV fluids Vitamin & mineral supplements are given Strict I&O NPO-then gradual increase of diet & fluids
MNGerzon, BSN 4L, Sept 2008

hyperemesis gravidarm
Nursing Responsibilities
• • • • • VS, I & O cc/cc IV fluids Small frequent feedings (crackers) Bedrest Emotional support
MNGerzon, BSN 4L, Sept 2008

DIABETES MELLITUS
• Diabetes mellitus that occurs during pregnancy(GDM) • Women who have diabetes mellitus prior to pregnancy are referred to as pregestational diabetics (PGDM)

MNGerzon, BSN 4L, Sept 2008

Diabetes mellitus
• DM is an endocrine disorder of carbohydrate metabolism • Blood sugar rises (glucose)because the pancreas cannot produce enough or ineffective insulin • Insulin is needed to draw glucose out of the blood and allow it to enter the body’s cells

MNGerzon, BSN 4L, Sept 2008

Diabetes mellitus
• Pancreas produce insufficient insulin or cells resist effect of insulin • Cells cannot receive glucose

MNGerzon, BSN 4L, Sept 2008

DIABETES MELLITUS
• Body metabolizes protein and fat for energy – Ketones and acid accumulate – Person loses weight – Person experiences fatigue and lethargy – Fluid moves to tissues to dilute excess glucose leading to increased thirst resulting in tissue dehydration and glycosuria (glucose-bearing urine)

MNGerzon, BSN 4L, Sept 2008

Effect of Pregnancy on Glucose Metabolism
• Increased resistance of cells to insulin • Increased speed of insulin breakdown

MNGerzon, BSN 4L, Sept 2008

Pregestational diabetes
• Type I (IDDM)-insulin dependant diabetes mellitus • Type II (NIDDM)-non insulin dependant diabetes mellitus • Pregnancy will affect blood sugar control in both types

MNGerzon, BSN 4L, Sept 2008

Pregestational diabetes
• Oral hypoglycemics cannot be taken during pregnancy because of the potential adverse effects on the fetus • Insulin will need to be taken in both types through out pregnancy

MNGerzon, BSN 4L, Sept 2008

RISKS IN PGDM
• • • • • • • Spontaneous abortion Infections-urinary and vaginal Hydramnios PIH Ketoacidosis Hypoglycemia Macrosomia-increased fetal size
MNGerzon, BSN 4L, Sept 2008

Effects of Gestational Diabetes
• Maternal Effects
– UTI – hydramnios – PTL/PROM – shoulder dystocia – epis/lac – CS – HPN

• Fetal Effects
– macrosomia – hypoglycemia at birth – RDS

MNGerzon, BSN 4L, Sept 2008

Treatment of Pre-existing DM
• • • • • • Team approach Monitor glycosylated Hgb A Diet: 50% carb, 20% prot, 30% fat Insulin TID Hourly glucoses during labor NST’s weekly (starting at 28-30 wks)

• Amnio ( lung maturity)

MNGerzon, BSN 4L, Sept 2008

Predisposing factors to GDM
• • • • • • Obesity Chronic hypertension Maternal age over 25 years Family history of diabetes Previous birth of large infant Unexplained fetal anomaly or loss of previous pregnancy
MNGerzon, BSN 4L, Sept 2008

Signs & symptoms of GDM
• The three “P”’s
– Polyuria- excessive urination – Polyphagia- excessive hunger – Polydypsia- excessive thirst – weight loss, dizziness, feeling lightheaded when a meal is skipped – Other signs may be rapid growth of the fetusLGA- large for gestational age

MNGerzon, BSN 4L, Sept 2008

Effects of Gestational Diabetes
• Maternal Effects
– UTI – hydramnios – PTL/PROM – shoulder dystocia – epis/lac – CS – HPN

• Fetal Effects
– macrosomia – hypoglycemia at birth – RDS

MNGerzon, BSN 4L, Sept 2008

Diagnoses of GDM
• All pregnant women are screened for GDM • A glucose tolerance test is done between 24 and 30 weeks gestation • Routine testing of urine for glucose is done at every prenatal visit

MNGerzon, BSN 4L, Sept 2008

Glucose Tolerance Test
1 GTT (24 - 28 wks)
drink 50g glucose, if 1 BS > 140

3 GTT
•hi carb diet X 2 days, then NPO after MN
•FBS, then drink 100g glucose,

• 1, 2, 3 BS
Gestational Diabetes is diagnosed with FBS > 105 or with 2 of the following BS results:
1 > 190, 2 > 165, 3 > 145

MNGerzon, BSN 4L, Sept 2008

Effects of Gestational Diabetes
• Maternal Effects
– UTI – hydramnios – PTL/PROM – shoulder dystocia – epis/lac – CS – HPN

• Fetal Effects
– macrosomia – hypoglycemia at birth – RDS

MNGerzon, BSN 4L, Sept 2008

Management of GDM
• Diet-2200 –2400 calories per day with 50% fiber carbohydrates, 10-20% protein and 20-30% fat divided in 3 meals • Exercise adequate exercise enables body to burn excess glucose

MNGerzon, BSN 4L, Sept 2008

Glucose Monitoring
• Glucose monitoring- blood sugar levels should be under 105mg/dl fasting and below 120mg/dl after meals • blood sugar should be tested up to 4 times daily • Urine should be tested daily upon arising for ketones MNGerzon, BSN 4L, Sept 2008

Medications
• Insulin is given to women who have pregestational diabetes to control blood sugar • Some women diagnosed with GDM can be controlled with diet alone
MNGerzon, BSN 4L, Sept 2008

Fetal surveillance
• Prenatal fetal assessment is essential • Tests preformed include
– Biophysical profile – Serum alpha-fetoprotein (AFP) – Amniocentesis – NST- non stress test – Frequent kick counts

MNGerzon, BSN 4L, Sept 2008

Nursing diagnoses r/t GDM
• Knowledge deficit r/t metabolic disorder, self testing, and meaning of results • Nutritional, altered les than body requirements r/t potential glucose intolerance • Injury risk for to fetus and women r/t hyperglycemia

MNGerzon, BSN 4L, Sept 2008

Nursing diagnoses r/t GDM
• Injury risk for fetus r/t uteroplacental functioning • Family coping ineffective, r/t woman’s need to be hospitalized during pregnancy • Noncompliance related to need for close monitoring and additional prenatal visits

MNGerzon, BSN 4L, Sept 2008

Diabetes: Patient Education
• Glucose monitoring • insulin administration – type, onset, peak, duration, times, sites, injection technique • diet • s/s hypoglycemia – tremors, pallor, cold/clammy skin – give milk & crackers or glucagon inj • s/s hyperglycemia – fatigue, flushed skin, thirst, dry mouth, – check glu, call MD for insulin order
MNGerzon, BSN 4L, Sept 2008

Disseminated Intravascular Coagulation (DIC)
• May complicate abruptio placentae • Large clot behind placenta consumes clotting factors which leaves mother deficient • Clot formation and destruction occurs at the same time

MNGerzon, BSN 4L, Sept 2008

DIC
• Mother may bleed from all orifices due to depletion of clotting factors • Postpartum hemorrhage may occur • Infection likely due to damaged tissue being susceptible to bacteria

MNGerzon, BSN 4L, Sept 2008

DIC
Treatment
• 1st Choice – Immediate Cesarean • Blood and clotting factor replacement if necessary • After delivery problem quickly resolves

MNGerzon, BSN 4L, Sept 2008

DIC
Nursing Care
• Prepare for C-section • Close, continuous monitoring of mother and baby • Observe for S/S shock • Prepare for compromised infant • Prepare for grieving if infant dies

MNGerzon, BSN 4L, Sept 2008

MULTIFETAL GESTATION
Monozygotic (identical) •Dyzygotic (fraternal)

Assessment
•History •Wt gain •Abnormal palpation •Fundal height greater than expected •Asynchronous FHT
MNGerzon, BSN 4L, Sept 2008

Risks of Multifetal Gestation
• • • • • • • • PIH GDM PPH Anemia UTI PTL Placenta previa CS
MNGerzon, BSN 4L, Sept 2008

Multifetal Gestation
• Nursing Management
– Complete history – Health education – Compliance to prenatal check-up – Daily activities – Family support

MNGerzon, BSN 4L, Sept 2008

RH Incompatibility
•Rh factor antigens on fetal RBC differ from Mom’s RBC •Mom is Rh- and fetus is Rh+ •Not problem in first pregnancy unless exposed

MNGerzon, BSN 4L, Sept 2008

RH Incompatibility
•Other pregnancies: placenta tears,
fetal blood enters mom’s circulation

•Antigen-antibody reaction in fetus destroys fetal RBC •Coomb’s test •Passive immunity

MNGerzon, BSN 4L, Sept 2008

Rh Incompatibility
• Rh Incompatibility
– Rh blood factor = Rh+ – No Rh blood factor in erythrocytes = Rh– Rh+ person can receive Rh- blood if all other factors compatible because factor is not present – Rh incompatibility only occurs if the mother is Rh- and fetus is Rh+
MNGerzon, BSN 4L, Sept 2008

Rh Incompatibility
– Rh- is autosomal recessive trait – both parents must pass on this gene to the fetus – Rh+ is dominant gene – Rh+ person can inherit two Rh+ genes or one Rh+ and one Rh– Rh- mother does not have the factor and therefore if her fetus does her body may respond with antibody production as a defense mechanism (isoimmunization) • Typically occurs at delivery and would therefore affect subsequent pregnancies
MNGerzon, BSN 4L, Sept 2008

Rh Incompatibility
– Manifestations
• If mother produces anti-Rh antibodies no outward manifestation • Labs reveal increased antibody titers • When maternal anti-Rh antibodies cross the placenta fetal erythrocytes are destroyed (erythroblastocis fetalis)

MNGerzon, BSN 4L, Sept 2008

Rh Incompatibility
– Nursing Care
• Prevent antibody production
– Rhogam at 28 weeks and w/in 72 hours of delivery if mother Rh- and baby Rh+ »May also be given after amniocentesis as a precaution »Not effective if sensitization has already occurred
MNGerzon, BSN 4L, Sept 2008

Blood Incompatibility
– Nursing Care
• If antibody production occurs fetus is monitored carefully
–Coomb’s test – Amniocentesis – Percutaneous umbilical sampling test – Intrauterine transfusion if severely anemic

MNGerzon, BSN 4L, Sept 2008

Amniocentesis

MNGerzon, BSN 4L, Sept 2008

Percutaneous Blood Sampling

MNGerzon, BSN 4L, Sept 2008

(Fetal) S&S Rh Incompatibility
• Hyperbilirubinemia
– jaundice – Kernicterus (severe neuro d.o. r/t  bili)

• anemia • hepatosplenomegaly • Hydrops fetalis

MNGerzon, BSN 4L, Sept 2008

Sequence of Assessments for Rh BloodSensitization Test for Type & Rh Factor
Rh-negative Indirect Coombs Rh-positive No further testing

-

+

Give RhoGAM Titer not increasing  continue to monitor

Repeat frequently

Titer increasing  amniocentesis ( bilirubin)
Elevated  retest, U/S  intrauterine transfusion or early delivery

No change  retest prn

MNGerzon, BSN 4L, Sept 2008

Management of Rh Incompatibility
Prenatal •per algorithm

• Prevention
– RhoGAM at 28 weeks (unsensitized women only)

• Postpartum
–  direct Coomb’s – RhoGAM to mom if baby is Rh+ (within 72 hrs of birth)

MNGerzon, BSN 4L, Sept 2008

Infections in Pregnancy

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions • Infections
– TORCH - Devastating infections for fetus • T – toxoplasmosis • O – other infections • R – rubella • C – cytomegalovirus • H – herpes simplex virus
MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions
• Viral Infections
– Cytomegalovirus – May be asymptomatic in mother, but serious problem in infant
• • • • • • • Mental retardation Seizures Blindness Deafness Dental abnormalities Petechiae (blueberry muffin rash) No effective treatment, therapeutic abortion may be offered if early in pregnancy
MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions
Rubella – mild virus with low fever and rash, but effects on fetus can be devastating
• Microcephaly • Congenital cataracts • Deafness • Cardiac defects • IUGR • Treatment – Immunization prior to pregnancy
MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions
Herpes virus (Type 1 and 2) Type 2 affects pregnancy
• Infection in infant can be localized or widespread, may cause death or neurological complications

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions
Herpes virus (Type 1 and 2) Type 2 affects pregnancy
• Treatment and Care – Avoid contact with lesions, if active outbreak Cesarean delivery

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions
• Nonviral Infections
– Toxoplasmosis – caused by Toxoplasma gondii, a parasite that may be in cat feces in raw meat and transmitted through the placenta

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions
Toxoplasmosis • Possible S/S in newborn
– Low birth weight – Enlarged liver and spleen – Jaundice – Anemia – Inflammation of eye structures – Neurological damage
MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions
• Treatment and Nursing Care
– Cook all meats thoroughly – Wash hands after handling raw meat – Avoid litter boxes , soil and sand boxes – Wash fresh fruits and veggies well

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions
Group B streptococcus
 leading cause of perinatal infections  Organism found in woman’s rectum, vagina, cervix, throat or skin  Woman usually asymptomatic, but can be transmitted to baby at delivery

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions Group B streptococcus
• Diagnosis –+ culture of woman’s vagina or rectum at 35-37 weeks gestation • Treatment – Antibiotics to mother prior to delivery – Antibiotic therapy to infant after delivery

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions Tuberculosis S/S
– fatigue – weakness – loss of appetite and weight – fever – night sweats
MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions Tuberculosis
• Treatment and Nursing Care
– Isoniazid and Rifampicin to mother for 9 months – Infant may have preventative therapy for 3 months

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions
Sexually Transmitted Diseases
– Herpes – HIV – Syphilis – Gonorrhea – Chlamydia – Trichomoniasis – Genital Warts

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions

Hepatitis B
 transmitted by blood and body fluids, can also cross placenta
• Treatment and Care – screen during pregnancy, infants born to women who are Hepatitis B+ should be given Hepatitis B immune globulin (HbIG), followed by Hep B vaccine
MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions
HIV – causative organism of AIDS, cripples immune system
• Acquired one of three ways
– Sexual contact with infected person – Parenteral or mucous membrane exposure to infected body fluids

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions HIV – causative organism of AIDS, cripples immune system
• Perinatal exposure (20% - 40% chance of infecting infant)
Transplacentally Contact with infected maternal secretions at birth Breastmilk

MNGerzon, BSN 4L, Sept 2008

Women at Risk for HIV/AIDS Infection
• • • • History of drug use, especially intravenous History of prostitution Frequent sexual intercourse with multiple partners Sexual intercourse with men who have sex with other men

MNGerzon, BSN 4L, Sept 2008

Women at Risk for HIV/AIDS Infection
• Residence in an area of the country with high prevalence of HIV and AIDS • Received a blood transfusion or blood products prior to 1985 • Having sex with someone with any of the above risk factors
MNGerzon, BSN 4L, Sept 2008

Signs of HIV Infection in Infants
• Opportunistic infections such as PCP and interstitial lymphocytic pneumonia • Candida diaper rash, thrush, and diarrhea • Recurrent bacterial infections • Growth failure, neurologic problems, and developmental delays
MNGerzon, BSN 4L, Sept 2008

Antiretroviral Drug Therapy
• Nucleoside reverse transcriptase inhibitors: zidovudine, didanosine, salcitabine • Nonnucleoside reverse transcriptase inhibitors: nevirapine, delavirdine, lovirdine • Protease inhibitors: saquinavir, indinivir, ritonavir, nelfinavir
MNGerzon, BSN 4L, Sept 2008

AIDS
• Maternal Effects
– – – – – vag candidiasis PID genital herpes HPV PCP

• Fetal Effects
– – – – – Asymptomatic at birth Candidal diaper rash thrush diarrhea recurrent bacterial infections – FTT – dev delay

Treatment:

ZDV (zidovudine) during PG, L&D
ZDV to neonate for 6 wks
MNGerzon, BSN 4L, Sept 2008

Urinary Disorders in Pregnancy

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions Urinary Tract Infections
 Common in pregnancy due to pressure on urinary structures  keeps bladder from emptying completely and ureters dilate and lose motility under influence of relaxing effects of progesterone and relaxin

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions Urinary Tract Infections
 Cystitis – infection of bladder • S/S
– Burning with urination – Increased frequency and urgency – May have slightly elevated temp

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions
– Pyelonephritis – infection of kidney(s)
• S/S
– High fever – Chills – Flank pain – N/V

– Treatment for UTIs
• Antibiotic therapy

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions
– Nursing Care
• Teach to wipe front to back • Intake adequate fluid • Urinate before and after intercourse • Teach S/S

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions
• Substance Abuse – the use of illicit or recreational drugs during pregnancy
– Treatment and Nursing Care • Identify substance abused • Educate on potential effects of drug • Use nonjudgmental approach

MNGerzon, BSN 4L, Sept 2008

Effects of Substances Taken During Pregnancy
• Teratogens - a substance that produces defects in a fetus • Alcohol - may cause fetal alcohol syndrome • Tobacco - retards growth and increases risk of illness, disability, and death • Other Substances - steroids, antibiotics, excessive amounts of vitamins, caffeine

MNGerzon, BSN 4L, Sept 2008

Pregnancy with Pre-existing Medical Conditions
• Trauma During Pregnancy
– Manifestations of Battering
• May enter late to prenatal care • May make up excuses

– Treatment and Nursing Care
• • • • Provide for privacy Be nonjudgmental Offer resources Assessment of maternal and fetal well-being
MNGerzon, BSN 4L, Sept 2008

Special Considerations
• Blunt Abdominal Trauma • Penetrating Abdominal Trauma
– Stabbing injury – Gunshot injury

MNGerzon, BSN 4L, Sept 2008

Blunt Trauma
• Injuries
– Head injury most common – Retroperitoneal hemorrhage – Abruptio placenta – DIC – Uterine Rupture

MNGerzon, BSN 4L, Sept 2008

Blunt Trauma
Seatbelts – 3 Points Restraints
 1/3 – ½ improperly or don’t use belts  Unbelted is at 2.3X to give birth <48 hrs & 4.1X fetal death

MNGerzon, BSN 4L, Sept 2008

Penetrating Injury
GSW’s
– Gravid uterus alter injury pattern to the mother – If missile enter upper abdomen; increased probability of harm (upto 100%). – If enters below uterine fundus visceral injury less likely (0%)

MNGerzon, BSN 4L, Sept 2008 (1) Awwad JT et al: High-velocity penetrating wounds of the gravid uterus: Review of 16 years of civil war, Obstet Gynecol 83:259, 1994.

Trauma in Pregnant Women • Stabbing Injury
– Rare – Morbidity 93 % - Mortality 50 % – Many advocate exploratory laprotomy since uterus laceration is devastating b/c of its enlarged circulation.

MNGerzon, BSN 4L, Sept 2008resulting in fetal death, Isr J Med (1) Meizner I, Potashnik G: Sharpnel penetration in pregnanc Sci 24:431, 1988.

Pre-hospital Consideration
• • • • Oxygen Shock should be anticipated ED should be notified early, GA >24 wks Transport in L lateral position (GA > 20 wks)

MNGerzon, BSN 4L, Sept 2008

Effects of a High-Risk Pregnancy on the Family
• • • • Disruption of Roles Financial Difficulties Delayed Attachment Loss of Expected Birth Experience

MNGerzon, BSN 4L, Sept 2008

References
• Introduction to Maternity & Pediatric Nursing; Fourth Edition, 2003; Gloria Leifer, Ma, RN; Associate Professor Obstetrics, Pediatrics, and Trauma Nursing; Riverside Community College; Riverside, California; Saunders

MNGerzon, BSN 4L, Sept 2008

HEART DISEASE
• Pregnancy results in: increased cardiac output, heart rate, and blood volume • CONGENITAL HEART DISEASE • RHEUMATIC HEART DISEASE • these are the TWO MAJOR factors in heart disease in pregnancy • work load of the heart is increased
MNGerzon, BSN 4L, Sept 2008

PERIODS OF DANGER
• DURING LABOR & DELIVERY-cardiac output increases by 15%-20% and may trigger CHF • POSTPARTUM- decreased peripheral resistance and pulmonary embolism are two major problems

MNGerzon, BSN 4L, Sept 2008

SIGNS OF WORSENING HEART DISEASE
• • • • • • • FATIGUE SHORTNESS OF BREATH COUGHING WHEEZING WEIGHT GAIN EDEMA INABILITY TO SLEEP
MNGerzon, BSN 4L, Sept 2008

IMPORTANT TEACHING
• Advise about: Activity ( get 9-10 hrs rest daily) Diet- salt restriction, avoid excessive wt gain • Diuretics may be prescribed-Digoxin may be used in severe cases • L&D-position, pain control,pulse ox, IV fluid control

MNGerzon, BSN 4L, Sept 2008

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