Lecture Notes Sp13 PDF
Lecture Notes Sp13 PDF
PAGE
Lecture 1
Lecture 2
10
Lecture 3
34
Lecture 4
41
Lecture 5
53
Lecture 6
69
Lecture 7
Uncomplicated Pregnancy
88
Lecture 8
107
Lecture 9
Pregnancy at Risk #2
129
Lecture 10
140
Lecture 11
158
Lecture 12
168
Lecture 13
190
I.
II.
b.
c.
d.
Orientation Period/Specialization
-Labor and Delivery
-Nursery/Level II Nsy/NICU
-Postpartum/Mother-Baby- since 1990s
-Occasional problems with
comprehensive care-territorial
-Differences in opinions lead to pt
confusion
Nurse Practitioners
-Defined by ANA as: provide
comprehensive health assessments,
determine diagnoses
plan/prescribe treatment
manage healthcare regimens
for the individual, families, and the
community
-In 1960s, shortage of MDs lead to
1
2
creation of the RNP
-May provide family care or specialize
-Take part in a certificate program or
Masters Degree program
-Need at certification for third-party
reimbursement
-Requires documentation of continued
education and practice
b.
c.
3
Frontier Nursing Services-first NurseMidwife to practice in the US
-American College of Nurse Midwives
was incorporated in 1955
-provide care to women with low
incomes, uninsured, and minorities who
dont seek out regular health care
-lower rates of cesarean sections in
facilities where CNMs practice
d.
e.
Nurse Consultants
-experts in a specific area of nursing
-fee for service
-may act as expert witnesses
-used by corporations R/T developing
products/equipment
-consult to texts, electronic media, and
periodicals
3
B.
b.
c.
d.
e.
f.
g.
h.
5
II.
Inform e d C onsent
a.
b.
c.
d.
f.
types of consent:
-expressed-oral or written
-implied: nurse states here to draw blood
and the pt extends her arm
--may be used in emergency cases
--when pt continues to take tx without
objection
--during surgery, additional surgery is
indicated
g.
Informed refusal
-can take place at initiation of tx or any time
after start of tx
-refusal is valid even after informed consent is
given
-refusal must be voluntary, uncoerced, and not
made under fraudulent circumstances
-pt must refuse tx with knowledge and
understanding of the refusal
-chart should include signed refusal form by pt
and nursing notes should include time
left, left with whom, risks and
consequences of no further tx, and
who will be notified
6
III.
IV.
C ommon Le g al Pitfalls
a.
b.
reporting/recording errors:
-incomplete initial H & P
-failure to observe & take appropriate action
-failure to communicate changes in a pts
condition in a timely manner
-incomplete and/or inadequate documentation
-failure to use or interpret fetal monitoring
appropriately
-inappropriate pitocin monitoring/usage
-improper sponge/instrument count
c.
d.
e.
f.
g.
cost containments
-shorter hospital stays
-use of unlicensed asst personnel
-decrease in hospital staff
h.
Standardized procedures/policies
b.
VI.
b.
fetal surgery
-i.e.: bilateral hydronephrosis, congenital
diaphragmatic hernia
-what if mother refuses tx
c.
d.
artificial insemination
-AIH-husbands sperm-problem with
mother
-AID-donor sperm
-legal problems-donor relinquishes rights
e.
surrogate childbirth
-buying a child-$$$$
-biological mother may refuse to give up
the newborn
f.
g.
V.
C.
h.
The Neonate
-iatrogenic procedures
prolonged use of ventilators
O2 therapy
-problem: should we save the lives of infants
only to have them lead lives of pain,
disability, and deprivation?
-who decides if major intervention is used
-what kind of care do you give or deny the
infant to allow him to die with dignity
and comfort
i.
The Mother
-use life support in irreversible conditions?
Nursing Role
a.
Communication
-interactions between MDs, CNMs, &
nurses
-was a clear line of communication used
-was the chain of command followed
-was there informed consent
-the better the communication between
nurse and pt, less use of litigation
-earlier discharges home mean more
educational responsibilities for the
RN
b.
Use of EFM
-first introduced at Yale University in 1958
-In last 25 yrs of use, no in rate of CP
-is partially responsible for in C/S rate
-ordinary part of Intrapartum careconstant threat of legal action
01/13
10
11
2.
Fluids/electrolytes
a.
Diaphoresis, insensible water loss through
respirations, NPO status, and temp
b.
Voiding may be difficult r/t anesthesia or
Pressure from presenting part- sensation
of a full bladder
c.
Proteinuria- in amino acids may exceed capacity
of renal tubules to absorb
-may be renal damage caused by
vasospasms of tubules
3.
GI
a.
b.
4.
Respiratory
a.
O2 consumption, in resp. rate
b.
hyperventilation respiratory alkalosis
in pH, hypoxia, hypocapnia ( CO2)
metabolic
c.
2nd Stage-O2 consumption
acidosis uncompensated by resp. alkalosis
5.
Muscular/skeletal
a.
Fatigue of muscles/strain
b.
Separation of pubis symphysis
-May be related to pregnancy or
delivery process
(relaxin-polypeptide hormone-secreted
in corpus luteum during pregnancy-can
relax the symphysis, inhibit uterine
contractions, and softens the cervix)
c.
Breakdown of proteins may lead to
proteinuria-albumnin in the urine
12
B.
6.
Neurological
a.
Euphoria-believe it or not!
endorphins- pain threshold and produce
sedation
b.
anxiety
c.
partial to total amnesia in 2nd stage
7.
Integumentary
a.
diaphoresis
b.
temperature-may be R/T to maternal
efforts or infection
c.
exacerbation of pruritusmay be related to cholestasis (arrest of
the flow of bile) in pregnancy
Fetal Response
1.
CV
a.
in fetal heart rate (FHR)
-maternal hydration
N&V
maternal temp
insensible water loss
-maternal position
-medications to mother
-placental issues
post dates-calcifications
smoker/ BP- placental size
velamentous insertion (umbilical
cord attached to the
membrane a short distance
from the placenta
cord compresson
-maternal anxiety
13
II.
2.
Pulmonary
a.
thoracic cavity squeezed
-not as much in C/S cases
-precipitous deliveries (swift progression of
2nd stage of labor marked by rapid
descent/expulsion of the fetus)
-may need extra suction
b.
passing of meconium (1st feces of
neonate) may need resuscitation effort
3.
Catecholamines
a.
epinephrine & norepinephrine-active
amines (nitrogen-containing organic
compounds)
-have effect on CV, neuro, metabolic
rate, temp., and smooth muscle
b.
change R/T stress of labor
speed clearance of fluid
14
c.
2.
True pelvis
-inlet
-diagonal conjugate-lower border
of symphysis pubis-sacral
promontory
-usually 12.5 cm or greater
-obstetric conjugate- also called
anterior/posterior diameter
-measurement that determines
whether presenting part can
engage superior strait
-usually 1.5-2 cm less than
diagonal
-midpelvis-cavity, midplane
-transverse diameter-interspinous
diameter-10.5 cm
-outlet
-transverse diameter-intertuberous
diameter-> 8 cm
Pelvic shapes
a.
gynecoid-round
-50% of women
-most favorable
-usual mode of birth-vaginal
b.
android-heart shaped
-23% of women
-usual mode of birth-cesarean
possible forceps-difficult
c.
anthropoid-oval shaped
-24% of women
-usual mode of birth-vaginal
spontaneous or asst.
-may lead to OP position
d.
platypelloid-flat shaped
-3% of women
-not favorable for vaginal delivery
15
B.
Passenger
1.
Fetal skull
a.
made up of 6 bones
-frontal
-2 parietal
-2 temporal
-occipital
b.
not fused together-allow for molding,
overlapping of bones to pass thru pelvis
c.
sutures-membranes
-frontal
-sagittal
-lambdoidal
-coronal
d.
fontanels-where membranes intersect
-anterior (bregma)-diamond-shaped-2cm
by 3 cm
-closes by 18 months
-posterior-triangle-shaped-1cm by 2 cm
-closes by 8-12 weeks
e.
landmarks
-mentum-chin
-sinciput-brow
-vertex-between anterior/posterior
fontanel
-occiput-beneath the posterior fontanel
2.
Fetal Presentation
a.
fetal part entering the pelvis first
-cephalic (head)-96%
-breech (buttock)-3%
-transverse (shoulder)-1%
b.
factors that influence presentation
-fetal lie
-fetal attitude
-extension/flexion of fetal head
16
c.
d.
diagnosed using
-Leopolds maneuvers
-verify with ultrasound
external version-MD attempts to manually
rotate the fetus into a cephalic
presentation
-done in L &D
-ultrasound to check fetal/placental
position
-may use medications to relax uterine
muscle
-frequently uncomfortable for mother
3.
Fetal Lie
a.
relationship of long axis (spine) of fetus
to long axis (spine) of mother
b.
primary lies:
-longitudinal (vertical)-cephalic, breech
-transverse (horizontal or oblique)-shoulder
4.
Fetal Attitude
a.
relationship of fetal parts to one another
b.
general flexion
-back is rounded
-chin flexed onto chest
-thighs flexed on the abdomen
-legs flexed at the knees
-arms crossed over the thorax
-umbilical cord lies between arms/legs
c.
head flexion
-biparietal diameter-9.25 cm
-suboccipitobregmatic-9.5 cm
-occipitofrontal-12 cm
-occipitomental-13.5 cm
17
C.
5.
Fetal position
a.
relationship of presenting fetal part to
4 quadrants of maternal pelvis
b.
indicated using a 3-letter abbreviation
-1st letter-location of part in pelvis (R or L)
-2nd letter-presenting part of fetus (O,S,M)
-3rd letter-location of presenting part in
relationship to maternal pelvis (A,P,T)
6.
Station
a.
relationship of presenting fetal part to an
imaginary line at the maternal ischial
spines: 0 station is at the spines
b.
negative stations-higher in the pelvis
c.
positive stations-lower in the pelvis
Powers
1.
Primary Powers
a.
involuntary uterine contractions
-start at fundus-thickened uterine
muscle layer of upper uterine
segment
-upper segment thicker so more active
-lower segment has less muscle
-contractions move down muscle
in waves
-assessed by:
reports from mother
RN palpating fundus
monitor
b.
primarily responsible for dilation of
cx and descent of fetus
-drawing upward of the
musculofibrous components
of the cervix with fetal head compression
lead to dilation (opening)
-full dilation (10 cm) marks the end of
18
c.
d.
e.
2.
Secondary Powers
a.
bearing down effort at 10 cm
-contraction of diaphragm and
abdominal muscles while pushing
b.
intraabdominal pressure that
compresses uterus on all sides
c.
usually no effect on dilation-important
R/T expulsion of fetus and placenta
d.
better results when await maternal need
19
10
e.
f.
D.
Placenta
1.
Structure
a.
formed at implantation
b.
decidua (endometrium during
pregnancy) basalis-with the chorion
(extraembryonic membrane) forms the
placenta
c.
cotyledon-mass of villi on the chorionic
surface of the placenta
-15-20 in number
d.
structure is completed by 12 week
e.
breaks may occur in placental
membrane allowing mixing of maternal
and fetal blood-Rh sensitization
f.
position problems
-previa-implanted in lower uterine
segment-covers internal cx os
-abruptio-separation of placenta from
uterine wall
-accreta-cotyledons invaded uterine
musculature
-increta-invasion into the myometrium
-percreta-invasion to the serosa of the
peritoneum covering of the uterus
can lead to uterine rupture
20
11
g.
2.
Function
a.
endocrine gland-produces hormones to
maintain pregnancy
-hCG-human chorionic gonadotropin
-basis for pregnancy test
-preserves function of corpus luteum
-ensures continued supply of
estrogen/progesterone
-reaches max level at 50-70 days
-hPL-human placental lactogen
-similar to growth hormone
-stimulates maternal metabolism
- resistance to insulin and facilitates
glucose transport across
placental membrane (GDM?)
-estrogen (estriol)
-stimulates uterine growth
-stimulates uteroplacental blood
flow
-progesterone
-maintains endometrium
-decreases contractility of uterus
-stimulates development of breast
alveoli and maternal
metabolism
metabolic functions
b.
-respiration
-nutrition
-excretion
-storage
21
12
c.
E.
Psyche
1.
Factors influencing womans reaction to
physical/emotional crisis of labor
a.
accomplishment of tasks of pregnancy
b.
usual coping mechanisms in response to
stress
c.
support system-esp. partners
commitment
d.
preparation for childbirth
e.
cultural/religious influences
f.
social/economic responsibility
2.
22
13
F.
III.
Labor Physiology
A.
Labor Onset Theories
1.
Oxytocin Stimulation Theory
a.
stretching of cervical os causes in
exogenous oxytocin
b.
produced by posterior pituitary
c.
oxytocin stimulates smooth uterine muscle
contractions
d.
response to oxytocin as nears term
2.
3.
4.
5.
23
14
6.
B.
Prostaglandins
a.
stimulate smooth muscle to contract
b.
can have production stimulated by
various methods
- synthesis of PGE2 in amnion
c.
research varies whether concentration
of prostaglandins in amniotic fluid and
maternal blood just before labor onset
Signs of Labor
1.
Braxton-Hicks contractions
a.
4-6 weeks before onset of labor
b.
uterine muscle workout before labor
c.
may be strong and frequent but usually
are irregular in pattern
2.
Lightening
a.
fetal descent into the true pelvis
b.
2-3 weeks in primigravidas
closer to onset of labor in multiparas
c.
easier to breathe, need to void
3.
4.
24
15
C.
5.
Weight Loss
a.
R/T GI upset with N & V and diarrhea
b.
usually starts 1-2 days before onset
6.
Nesting
a.
have a burst of energy
b.
have a need to get everything in order
for arrival of baby
vary
stronger
milder
with walking
D.
with walking
with relaxation
techniques
Cervix
softens, effaces, dilates
no significant changes
Fetus
starts descent into pelvis
no change in position
25
16
E.
2.
Dilatation
a.
opening of cervical os from closed to
10 cm
b.
due to retraction of cervix into the lower
uterine segment R/T uterine contractions
and pressure from amniotic sac and fetus
c.
both dilation and effacement are
measured by fingertip palpation or visual
inspection with sterile speculum
3.
Station
a.
using imaginary line at ischial spines,
note location of presenting fetal part
b.
documented from 4 to +4
c.
ballottable-when presenting part is
floating in and out of the pelvis
26
17
b.
c.
3.
4.
5.
Stage 4-Recovery
a.
mom-1-4 hours
b.
baby-6 hours
27
18
F.
Flexion
a.
natural attitude of fetus
b.
fetal head flexes as it meets
resistance
3.
Internal Rotation
a.
to go thru transverse diameter
b.
rotates to occiput anterior
4.
Extension
a.
resistance of pelvic floor with vulva
opening forward and anterior
b.
fetal head begins to crown
5.
External Rotation
a.
shoulders rotate to anteroposterior
b.
fetal head rotates further to one side
6.
Expulsion
a.
anterior shoulder slips under
symphysis pubis
b.
posterior shoulder and body is then
delivered
28
19
G.
Labor Duration
1.
Nulliparas
a.
1st stage-13 hours (1.2 cm/hr)
b.
2nd stage-5 minutes-2 hours
c.
3rd stage-10-20 minutes
2.
IV.
Primi/multiparas
a.
1st stage-7 hours (1.5 cm/hr)
b.
2nd stage-5 minutes to 1 hour
c.
3rd stage-5-20 minutes
Plan of Care
A.
Assessment-Data Collection
1.
prenatal record
a.
assess attendance to PN appts
b.
any complications of pregnancy
c.
any high risk behaviors
d.
abnormal lab/ultrasound reports
1.
blood type/RH factor
2.
VDRL/RPR-syphilis screen
3.
HbsAG-surface antigen
4.
CBC
5.
Rubella immunity
6.
culture for GBS
7.
urinalysis
8.
HIV test
e.
primary language
2.
initial interview
a.
ask why she came in
b.
status of BOW
c.
any U/Cs?
d.
any bleeding?
e.
+ FM recently?
f.
any other symptoms?
29
20
3.
physical exam
a.
maternal vital signs
b.
FHR tracing
c.
palpate strength of U/Cs
d.
assess fetal presentation
e.
assess cervical dilation/effacement
4.
5.
6.
30
21
B.
Nursing Diagnoses
1.
Anxiety R/T labor and birthing process
a.
orient parents to unit
b.
explain admission protocol
c.
assess womans knowledge,
experiences, and expectations of
labor
d.
discuss progress of labor
e.
involve woman and partner in care
decisions during labor
2.
3.
4.
31
22
5.
C.
Interventions-Priority Setting
1.
Vital signs
a.
notify provider if BP above 140/90
b.
ck temp q 4 hrs if ROM
2.
Fetal monitoring
a.
assess FHR at least once hourly in
early phases
b.
may need continuous monitoring
c.
consider internal monitoring for poor
tracing, lack of progress, or meconium
3.
Hydration/oxygenation
a.
encourage po fluids or start IV if N & V
b.
ck oxygen saturation if decels noted
4.
Comfort measures
a.
breathing/focal points/distractions
-labor sh a k es are normal
b.
hydrotherapy/massage
c.
active listening R/T maternal behaviors
-0-3 cm: anticipation, excitement
-4-7 cm: seriousness, introspection
-8-10 cm: irritable, fatigue, amnesia
d.
use of support people
32
23
5.
Pain management
a.
showers/warm or cool packs
b.
massage
c.
oral medications
d.
IV or IM medications
e.
Epidurals
6.
33
24
7.
V.
VI.
01/13
34
La bor Pain
A.
Data C olle ction and Assessm ent
1.
Ask patient comfort level and current pain level
-0-10 scale or coping scale
-comfort level is when they can participate in
ADLs without the need of pain meds
2.
Be aware of cultural differences in response to
pain
-Asian populations may not exhibit pain or ask
for pain medications
-Hispanic women may be very stoic until just
before the delivery of the baby
-Middle Eastern groups may be very vocal in
requesting early use of medications for pain
3.
Anxiety and fear of the unknown might
heighten their level of pain
4.
Previous experiences with childbirth or other
painful procedures may lead to higher levels of
concern about pain management needs
5.
Attendance to childbirth classes may aid in the
patients ability to cope through contractions
B.
First Sta g e
1.
Early phase-0-3 cm
a.
nonpharmacological methods
1.
focal points
2.
massage/counterpressure
3.
hydrotherapy/aromatherapy
4.
music
5.
breathing techniques
6.
Transcutaneous Electrical Nerve
Stimulation unit (TENS)
7.
heat/cold packs
8.
hypnosis
9.
changing positions/walk/rocker
35
b.
2.
3.
C.
pain medications
1.
should be discouraged as they
could slow the labor process
2.
usually orals:
percocet
vicodin/norco
benadryl
acetaminophen
3.
occasionally IM:
morphine with phenergan
Active phase-4-7 cm
a.
may use many of the same
non-medication choices as above
b.
when pain is more intense, usually
requests IV medications for fast
action
-fentanyl
-nubain
-stadol
c.
may also request and receive an epidural
at this stage in labor
Transitional phase-8-10 cm
a.
may request epidural
b.
may want to be out of bed and push on
toilet to relieve backache
c.
encourage position changes if possible
d.
short acting IV narcotics still ok but have
Narcan available for infant resuscitation
Se c ond Sta g e
1.
May continue pushing with epidural pump on if
efforts are affective
2.
May receive local anesthesia for repair of
perineal laceration or episiotomy
3.
If no epidural is in place, may receive a
pudendal block which relieve pain in the
vagina, vulva, and perineal regions
36
D.
II.
III.
Third Sta g e
1.
If placenta is retained, may receive IV pain
medications or be moved to OR for twilight
sleep
2.
For laceration/episiotomy repairs, use of local
anesthetics or pudendal block (less common)
37
IV.
V.
38
B.
C.
39
3.
4.
40
b.
c.
d.
e.
e.
5.
General anesthesia
a.
while rarely used, may be needed for C/S
if unable to access regional block or in
emergency cases
b.
NPO, IV, oral sodium citrate before start
c.
RN may be asked to give cricoid pressure
to aid anesthesiologist in tube placement
d.
normally recovered in PACU (recovery rm)
so bonding with infant delayed
e.
higher risk of complications vs. regional
blocks-mother unconscious during birth
of infant
f.
as with all anesthesias used during C/S,
wedge should be placed under moms
R hip to displace uterus to the L
g.
besides C/S, general anesthesia may be
needed during manual placenta removal
or D & C
01/13
41
1
Nursing in the Normal Puerperium (the period of 42 days post
childbirth and expulsion of the placenta)
Le cture 4
I.
Cardiovascular
a.
CO remains elevated for 2 weeks-12 wks before
to prepregnancy values
b.
EBL 300-500 ml-vaginal birth
500-1000ml C/S
42
c.
d.
e.
f.
g.
3.
Gastrointestinal
a.
appetite
b.
no BM for 2-4 days post delivery
-encourage ambulation
-hydration
-fiber
-medications, i.e.: stool softeners
c.
tx hemorrhoids-ice packs, tucks, crm
-no pr meds if 3rd-4th degree laceration
d.
Kegel exercises to strengthen pelvic floor
4.
Renal
a.
returns to normal function 1 month after birth
-bladder tone returned by 5-7 days
b.
diuresis-from fluid retention, pitocin, etc
c.
excessive vaginal bleeding may be noted if
bladder is allowed to get distended with urine
5.
Musculoskeletal
a.
joints stabilize 6-8 weeks post birth
b.
may have permanent increase in shoe size
c.
may have separation of symphysis pubis or
rectus abdominis
43
6.
Integumentary
a.
chloasma (mask of pregnancy) usually fades
by end of pregnancy
b.
hyperpigmentation of areolae and linea nigra
may continue
c.
may note perfuse diaphoresis post delivery
7.
Endocrine
a.
Expulsion of placenta= in estrogen, cortisol
progesterone, and hPL (hCS)
[human placental lactogen/human chorionic
somatomammotropin]
-reverse diabetogenic effect-lower BS level
b.
if BF- prolactin levels for 6 weeks
if bottle-fed-usually means later ovulation in lactating
women
8.
Psychosocial
a.
parents acceptance of infants needs and
abilities
b.
need to learn cues, understand emotional
states
c.
bonding-proximity, touch, voice, interaction
d.
identify infant as an individual yet part of the
whole family
e.
mutuality-infants behaviors stimulate moms
f.
may feel attracted to alert, responsive infant
and repelled by irritable, disinterested infant
g.
attachment occurs more readily with the
infant whose temperament, social capabilities,
appearance, and sex fit parents expectations
h.
need to assess mother-infant communication
i.
behaviors
-entrainment-moving in time with adult speech
-biorhythmicity-soothed by moms heartbeat
-reciprocity-responds to cues
-synchrony-mutually rewarding
-engrossment-interest in baby by father
44
j.
k.
l.
II.
maternal adjustments
-taking in-first 24 hrs-focus on self and basic need
Dependent, passive
-taking hold-last 10 days to several weeks-focus
on care of baby and competent
mothering-dependent
-letting go-focus on forward movement of
the family unit
PP blues- 70% of women-mood swings, anger,
depression, letdown, fatigue, insomnia,
H/As, weepiness (resolves in 10-14 d a ys)
PP depression-7-30%-more severe syndrome
-depression, feeling of failure overwhelming
guilt, loneliness
Nursing Process
A.
Data c olle ction / Assessm ent
1.
Vital signs
2.
Fundus
a.
ck fundal location, tone, lochia
b.
have pt empty bladder before exam
3.
Bladder
a.
assess for distention
b.
measure first voids until 500 ml (voided out)
c.
catheterize if needed
4.
Perineum
a.
if repair done, assess site for intactness, edema,
hematomas, redness, or drainage (REEDA)
b.
assess for presence of hemorrhoids
5.
Breasts
a.
note if breast are filling-palpate
b.
note any redness, soreness, cracking of
nipples
B.
45
C.
III.
Interventions
1.
Safety
a.
infant ID bands
b.
orientation to unit
c.
staff picture IDs
d.
move infant in crib
2.
Standard precautions
a.
wash hands before handling baby
b.
change linens
c.
proper hygiene
d.
use of squeeze bottle for peri care
e.
wiping front to back
f.
teach pt about fundal massage
g.
use of peppermint or running water to aid in
voiding to prevent urinary retention
h.
use of ice packs for the first 12 hours post
repair of peri then instruct on use of sitz bath
i.
squeeze buttocks together when sitting or rising
from a chair to help keep repair intact
j.
wear good supportive bra
k.
use lanolin crm to prevent cracking of nipples
l.
warm packs before breast feeding, cool packs
post
m.
walk as soon as possible-helps with gas pains
n.
take pain meds prn
o.
encourage rubella vaccine if non-immune
pt should prevent g etting pre gnant for at le ast
4 we eks post v a c cination
p.
Tdap-Pertussisq.
rhogam given to Rh moms who had Rh+ babies
Early Discharge
A.
C andid ates and criteria
1.
Newborns and Mothers Health Protection Act of 1996
a.
48 hours minimum post vaginal delivery
b.
96 hours minimum post C/S
c.
pt and doctor may agree on earlier D/C
2.
Maternal criteria for early D/C
a.
VSS
b.
voiding
c.
Hgb >10
d.
no bleeding
e.
instructions on self-care
46
3.
IV.
C.
47
V.
C.
D.
48
8
4.
VI.
VII.
C ommon proble ms
1.
positioning-need to make sure milk covers nipple area
2.
warming-never microwave bottle
3.
propping-dont leave infant unattended while feeding
C.
Contraception Education
A.
C onsid erations for Choosing a Method
1.
resumption of sexual activities should wait 2-3 weeks
to decrease risk from infection
2.
best to use condoms/foam at this time
3.
when discussing contraception with your doctor,
-action
-safety
-effectiveness
-convenience
-availability
-expense
-personal preference
B.
49
2.
3.
Barrier methods
a.
sp ermicid es
-action-physical/chemical barrier to sperm
-safety-may provide some protection from STIs
-convenience-needs to placed before act
-availability-good if thought of in advance
-expense-cheap
b.
c ondoms
-action-physical barrier to sperm
-safety-protect against STIs/HIV if used properly
-effectiveness-can failure rate with use
of spermicides
-v a ginal she ath / c ondom
c.
dia phra gm
-action-mechanical barrier to sperm
-safety-see condoms, small amt of cases with
TSS-toxic shock syndrome
-effectiveness-needs to be fitted to womans
anatomy, needs to be used with
spermicide
-convenience-may be placed 6 hours before
intercourse but must be left in for 6 hours
post act, additional spermicide each time
-availability-MD appt
-expense-affordable
d.
c ervic al c a p /spong es
-cervical cap needs fitting
-must ck position of cap before intercourse
-failure rate in parous women-40%
-sponge-moisten with water before insertion
-have spermicide
50
10
-risk of TSS if not removed after 24 hours
4.
Hormones
a.
over 30 different formulations
b.
may have estrogen/progestin or only prog.
c.
may be oral, subdermal implantation, IM,
vaginal
d.
prevent pregnancy by stopping ovulation or
prevention of implantation
e.
do not protect against STIs
f.
not recommended for some women
-h/o thromboembolic
-smoker
-h/o estrogen dependent tumors
-h/o CAD
-h/o impaired liver
-over the age of 35
-HTN
g.
mini pill (progestin-only)
-problems with irregular menses
h.
inje cta ble prog estin-De po Provera
-injected q 11-13 weeks-may need appt.
- risk of venous thrombosis
i.
implante d prog estin-Nexplanon
-good for 3 years
-implanted in arm
-no STI protection
j.
Em erg enc y c ontra c e ption
Plan B-levonorg estrel
-needs to used within 72 hours of unprotected
intercourse
-prevents ovulation/implantation
-90% effective
-OTC-must be at least 17 years old to purchase
Ella -non-hormonal
-needs to used within 120 hours
-needs Rx
-90% effective
IUD insertion
-99% effective if inserted within 5-7 days
51
11
5.
Intrauterine Devices
a.
usually T-shaped
b.
loaded with either copper or levonorgestrel
c.
may be used for 5 yr (hormone)-10 yrs (copper)
d.
prevents fertilization
e.
Mirena (hormone IUD)-helps to diminish menses
f.
C op p er T-good choice for women over 35,
smokers, h/o CAD, HTN
g.
not recommended for women with:
-h/o PID
-suspected pregnancy
-teens
-h/o distorted uterine cavity
-h / o multiple p artners
6.
Sterilization
a.
females
- bilateral tubal ligation
-surgical procedure
-expense usually higher than vasectomy
-electrocoagulation, ligation, banded,
crushed, or plugged
-no protection against STIs
-should be considered permanent
-informed consent needed at least 72
hours before procedure
-eSSURE
-done in clinic or OR
-uses water to visualize fallopian tube
meatus
-coil placed and tissue collects on coil
creating a blockage
-HSG performed at 3 months to establish
closure
-back-up BC method used during this
period
b.
males-vasectomies
-done in clinics under local anesthetic
-vas deferens are ligated/cauterized
-takes multiple ejaculations to clear
remaining sperm from vas deferens
52
12
STD
MECHANISM OF ACTION
USER
method of
birth control
No Method
85
85
Spermicides
18
29
++++
42
Male Condoms
15
++++
++
53
Female Condoms
21
++++
++
49
Diaphragm
16
++++
57
Cervical FemCap
14
++++
57
16
++++
57
20
32
++++
46
Ovulation Method
22
+++
51
Sympto-Thermal
2.5
16
+++
51
Standard Days
Method
12
+++
Calendar Method
13-20 +++
Lactation (LAM)
0.5
++++
Withdrawal
27
++++
+++
68
0.3
+++
68
Nuva Ring
0.3
+++
68
Shot (DepoProvera)
0.3
+++
56
Shot (Lunelle)
0.05
+++
59
IUD (ParaGard
Copper)
0.8
0.6
++
++
80
IUD (Mirena)
0.1
0.1
++
++
80
Abstinence
++++
Sponge
w/o prior pregnancy
Sponge
w/ prior pregnancy
51
+
++++
43
++++
For added protection against pregnancy, you can use more than one method of
contraception at a time. For example, many clinicians recommend that when using
condoms, spermicides be used as well. If a woman is allergic to spermicides she can use
a natural method and a condom and for extra protection. Any of these combinations will
reduce the predicted failure rate
53
1
Nursing Care of the Normal Newborn
Lecture 5
I.
3.
4.
54
B.
II.
Cardiovascular transition
1.
air inflates the lungs
pulmonary vascular resistance
pulmonary artery pressure
in pressure in the R
atrium
pulmonary blood flow to L side of heart
the pressure in the L atrium=functional closing of the
foramen ovale (functionally closed-1-2 hrs,
anatomically closed-30 months
2.
3.
4.
Neurological adaptation
A.
Thermoregulation
1.
newborns ability to produce heat is often = to adults
but have a tendency towards rapid heat loss
2.
heat loss from: thin skin, little sub Q fat, blood vessels
close to surface, heat easily transferred from internal
to skin
3.
4.
5.
6.
55
B.
7.
8.
9.
Thermogeneis
a.
Nonshivering thermogenesis (NST)
primarily thru brown fat ( highly vascular fat
found only in infants with abundant supply of
blood vessels/nerve endings, found at neck,
kidneys, adrenals, sternum and intrascapulary
region) heat produced by lipid metabolic
activity
warm baby (preterm infants lack
brown fat)
b.
secondarily thru increased metabolic activity in
liver, brain, and heart
c.
shivering begins when thermal receptors in skin
detect a drop in the skin temp-rare in neonates
10.
cold stressa.
metabolism = need for O2 and glucose
regardless of gestational age or condition
b.
if prolonged-leads to resp. difficulty
c.
O2 consumption diverted from maintaining
brain/heart function to thermogenesis
d.
decreased pulmonary perfusion may lead to an
open ductus arteriosus
e.
hypoglycemia
f.
fatty acids released = metabolic acidosis
g.
fatty acids in blood can interfere with
bilirubin transport = risk for jaundice
Reflexes
1.
Moro (startle)
Usually present for first 3-4 months
2.
56
C.
3.
Tonic neck
fencing position
complete response gone by 3-4 months
4.
Sensory adaptation
1.
Vision
a.
at birth, muscles in eye area are immature
(transient strabismus)
b.
clearest vision within 10-20 inches
c.
sensitive to light
d.
at 5 days old, attracted to black/white patterns
e.
able to see colors at 2 months
f.
tear glands developed by 2-8 weeks
g.
by 6 months, their visual acuity is of adults
h.
prefer patterns to plain surfaces
i.
eye color will not be set until 3-12 months
2.
Hearing
a.
like an adults after draining of amniotic fluid
b.
loud sounds make baby have startle reflex
c.
decrease motor activity in presence of low
frequency sounds such as a heartbeat
d.
hearing loss is a common major abnormality
1-3/1000 normal term infants have bilateral
hearing loss
3.
Touch
a.
responses to touch on all parts of the body
b.
face, hands, soles being most sensitive
4.
Taste
a.
can distinguish tastes
b.
prefer glucose water to plain water
5.
Smell
a.
react to strong odors by turning head away
b.
can differentiate their mothers breast milk by
smell
57
5
III.
Hematological adaptation
A.
Neonatal differences
1.
RBCs and H & H
a.
at birth, levels are higher than adults
-Hgb14-24 g/dl
-Hct44-64% if > 65% = polycythemia
-RBC5.1-5.3/mm3-1st 24-48 hrs of life
(neonatal RBCs have a lower survival rate
compared to adults) physiological anemia
c.
delay of cord clamping shifts plasma to
extravascular spaces with lab results
2.
Leukocytes
a.
WBC 9-30,000 per mm3 is normal at birth
b.
will rise then decline to a level of 11,500
c.
infection not well tolerated in infants with
sepsis usually accompanied by a loss in WBC
3.
Platelets
a.
200,000-300,000/mm3
b.
factors II, VII, IX, and X decreased due to lack
of Vitamin K-not adult level until 9 months
4.
Blood Groups
a.
cord blood sample taken to determine infants
blood group and Rh status
b.
Rh neg moms receive Rhogam if Rh + baby
5.
Blood Volume
a.
80-85 ml/kg
b.
at birth, blood volume approx. 300 ml
c.
preterms have greater blood volume due to
a greater plasma volume, not RBC mass
6.
58
6
IV.
Musculoskeletal System
A.
Head and upper body
1.
at birth, more cartilage than bone
B.
2.
3.
fontanelles
a.
anterior closes at 12-18 months
b.
posterior closes at 8-12 weeks
c.
bulging fontanelles mean ICP
d.
sunken fontanelles mean dehydration
4.
5.
Caput succedaneum
a.
edema of the scalp
b.
may cross suture lines
c.
disappears in 1-4 dys
6.
Cephalohematoma
a.
collection of blood between the skull bone and
the periosteum-doesnt cross suture lines
b.
may be spontaneous or due to vacuum or
forceps delivery
c.
resolves in 2-4 weeks
d.
may lead to jaundice
7.
neck/shoulders
a.
shoulder dystocia brachial plexus injury
-fx of scapula or clavicle (clavicle is the most
commonly fx bone during delivery process)
-immobilize in a sling
Extremities
1.
arms
a.
Erbs palsy-injury to brachial plexus = paralysis of
affected arm/shoulder
-flaccid arm with absence Moro on affected side
-immobilize arm but follow exercise regimen
59
7
2.
hands
a.
polydactyl-extra fingers
b.
syndactyl-fused fingers
c.
simian crease found on palms (and soles of
feet) frequently present in children with Downs
3.
hips
a.
c.
d.
feet
a.
b.
poly/syndactyl
club foot-positional or casted to help rotate
b.
4.
C.
V.
3.
Gastrointestinal
A.
Mouth/throat
1.
mucous membranes of mouth moist and pink if
adequately hydrated
2.
3.
4.
5.
60
B.
C.
D.
6.
infant unable to move food from lips to pharynxneed to place nipple deep inside mouth
7.
8.
Stomach
1.
capacity varies from 30-90 ml depending on size of
infant
2.
3.
4.
Intestines
1.
no bacteria in intestines at birth
2.
3.
4.
5.
Digestive Enzymes
1.
full term newborns capable of swallowing, digesting,
metabolizing, absorbing proteins and simple carbs, and
emulsifying fats
2.
3.
61
4.
E.
VI.
Stool patterns
1.
meconium-first stools
a.
filled with amniotic fluid and its constituents,
intestinal mucus (bilirubin), and cells
b.
greenish black-may have occult blood
c.
initially sterile then contains bacteria
d.
usually fully passed in 24 hours
2.
3.
4.
milk stools
a.
breastfed-yellow to golden, pasty, and odor like
sour milk
b.
bottlefed-yellow-light brown, firmer, odorous
Hepatic System
A.
Liver function alterations
1.
hepatic system responsible for
a.
maintenance of blood sugar
b.
iron storage
c.
drug metabolism
d.
bilirubin conjugation
e.
coagulation
2.
glucose
a.
1/3 of stores as glycogen in liver
b.
need constant supply for brain
c.
blood glucose levels stabilize at
50-60 mg/dl after delivery
d.
by day 3, 60-70 mg/dl
e.
initiation of feeding assist in stabilizing
newborns glucose levels
f.
newborns increased energy needs in
first 24 hours of life can rapidly deplete
glycogen stores
62
10
g.
h.
i.
3.
iron storage
a.
fetal liver begins storing iron in utero
b.
proportional to total body Hgb content
and gestation age
c.
at birth, have enough iron stored for 4-6 months
4.
coagulation
a.
coag factors synthesized in liver Vit. K
b.
transient blood coagulation deficiency days 2-5
c.
Vit. K injection helps prevent clotting problems
d.
prenatal dilatin/phenobarb abnormal clotting
5.
conjugation of bilirubin
a.
bilirubin-yellow pigment derived from Hgb
released with breakdown of RBCs/myoglobin
b.
Hgb is converted to bilirubin in unconjugated
form (non-excretable form)-potential toxin
c.
unconjugated bilirubin-insoluble, bound to
circulating albumin-can permeate to other
areas (also called indirect bilirubin)
d.
in the liver enzyme glucuronyl transferase
conjugates bilirubin (now called direct bili)
-soluble, excreted from liver cells bile
e.
excreted thru urine and feces
f.
total bili is the sum of both levels of conjugated
and unconjugated bili
g.
factors that bili
-excess production of RBCs
-RBCs life shorter-more breakdown
-liver immature
-poor/delayed feedings-breastfeeding jaundice
63
11
-traumatic delivery
-fatty acids-bind with albumin instead of bili
B.
VII.
Hyperbilirubinemia/physiological jaundice
1.
Occurs 50% in full terms, 80% in premies
2.
3.
4.
5.
6.
levels
Genitourinary system
A.
Anatomy
1.
at term, kidneys take up area of the posterior abd.
wall
2.
3.
64
12
B.
C.
Voiding
1.
bladder capacity- 6-44 mLs at term
2.
3.
4.
5.
6.
3.
4.
5.
D.
GFR =
Na reabsorption =
and organic acids
Genitals
1.
Females
a.
in full term girls
-labia majora large and cover labia minora
-may be dark in pigment
-vaginal or hymenal tags are common
-vernix may be present between labia
-may have mucousy discharge
-may have false period (pseudomenses)
b.
in preterm girls
65
13
-clitoris is prominent
-labia majora are small and widely separated
2.
VIII.
Males
a.
testes in scrotum in 90% of males
b.
by year 1, incidence of cryptorchidism is < 1%
c.
tight prepuce (foreskin) is common
d.
smegma may be found under foreskin
-teach boys at 3-4 years old to retract and clean
under foreskin
e.
evaluate for hypo or epispadias
f.
scrotum more deeply pigmented and with deep
rugae in post term infants
g.
circumcision-personal decision
-may reduce UTIs
-may reduce STIs
-may reduce penile CA
-done on 8th day under Jewish faith
-complications-hemorrhage, infection
Integumentary system
A.
Vernix caseosa
1.
white, cheese-like substance
B.
C.
2.
3.
Lanugo
1.
fine, downy-like hair
2.
3.
Desquamation
1.
peeling of the skin
2.
D.
Birthmarks
1.
Mongolian spots
a.
blue-black areas of pigmentation
b.
more common on lower back and buttocks
66
14
c.
d.
IX.
2.
Nevia.
Telangiectatic nevi-Stork bites
-are pink and easily blanched
-appear on upper eyelids, nose, upper lip,
lower occiput bone, and nape of neck
-usually fade between 1-2 years
b.
Nevus vasculosus- Strawberry mark
-may be raised and be bright or dark red
-may last thru childhood
c.
Nevus flammeus- Port-wine stain
-red to purple, nonelevated
-varies in shape, size, and location
-do not blanch nor fade with time
-if neurological problems exist- for Sturge-Weber
syndrome
3.
Erythema toxicum
a.
transient rash also known as flea-bite rash
b.
thought to be a inflammatory response
c.
usually no clinical significance and needs no tx
Immune system
A.
Neonatal considerations
1.
cells that provide infant with immunity are present but
not activated for the first several months of life
2.
3.
immunoglobulins
a.
IgA
-cant cross placenta
-not produced in utero
-colostrum is high in IgA
-start producing about 4 weeks of age
b.
IgG
-can cross placenta
-passive immunity from mom-passed in 3rd
-very active against bacterial toxins
c.
IgM
-produced by fetus in utero
-reach adult levels at 9 months old
67
15
d.
e.
X.
Psychosocial Adaptation
A.
Behavioral states
1.
Infants differ in their activity levels, feeding/sleep
patterns, and responsiveness
2.
3.
4.
5.
Sleep/wake states
a.
2 sleep states
-deep sleep
-light sleep-REM
b.
4 wake states
-drowsy
-quiet alert/wide awake
-smile, vocalize, synchrony to voices
-watch & respond to their parents faces
-active alert
-crying
6.
Purposeful behaviors
a.
withdrawal by physical distance
b.
push away with hands/feet
c.
sensitivity by falling asleep
68
16
d.
e.
XI.
Measurements
a.
weight in pounds and grams
b.
Length-usually 18-22 inches
c.
head circumference-usually 33-36 cm
3.
4.
Administer medications
a.
erythromycin ointment-OU
b.
Vit. K IM
c.
Hep. B vaccine-IM
d.
HBIG IM-if needed
5.
6.
7.
8.
Newborn nutrition
a.
neonates need 110 kcal/kg/dy
b.
at 3 months, 100 kcal/kg/dy
c.
want to see 6-10 wet diapers/dy
9.
10.
01/13
69
1
The High Risk Newborn
Le cture 6
I.
B.
II.
3.
4.
3.
4.
5.
6.
70
B.
7.
8.
CV
a.
b.
c.
d.
3.
Thermoregulation
a.
lack glycogen stores in liver-created in 3rd
b.
brown fat
c.
larger body surface
d.
posture of extension
e.
less able to metabolism for heat
4.
GI
a.
b.
c.
71
3
d.
e.
f.
g.
5.
Renal
a.
at 35 weeks, kidneys have limited ability to dilute
or concentrate urine
b.
GFR secondary to renal blood flow
c.
at risk for edema (overhydration) or dehydration
d.
buffering = acidosis
e.
longer to excrete drugs from the system
6.
Hepatic
a.
glycogen stores = hypoglycemia
b.
iron stores
c.
impaired conjugation of bilirubin
7.
Immunologic
a.
dont receive passive immunity
b.
IgG-not until last trimester
8.
Hematologic
a.
increased capillary friability
b.
tendency to bleed
c.
blood loss from frequent lab work
d.
production of RBCs
9.
CNS
a.
high risk of brain hemorrhage from thin, fragile
vessel walls
b.
up to 34 weeks, the germinal matrix lines the
ventricles
c.
birth damage to immature structures
d.
may have been exposed to recurrent anoxic
episodes
10.
Risk of infection
a.
thin, fragile skin
b.
friable blood vessels
c.
storage of immunoglobulins
d.
inability to make antibodies
72
4
11.
C.
Fluid/electrolytes
a.
need 80-150 kcal/kg/dy- than term infants
b.
need protein 3-4 g/kg/dy-term 2-2.5g
c.
need addition iron, calcium, K
d.
usually get supplemental Vit. E (multi vitamin)
Apnea
a.
cessation of breathing > 20 seconds
b.
usually occurs < 36 weeks gestation
c.
R/T immature nervous system
d.
may be R/T
temp instability
maternal drugs in labor
h/o maternal drug abuse
infection
metabolic disorders
asphyxia
abdominal distention
73
e.
f.
3.
assessment
-observe breathing pattern
-stimulate-slap soles of feet
-suction-use with free-flow oxygen
watch for dusky, cyanosis, bradycardia
-prepare for possible intubation
-think possible septic workup
tx
-oxygen per order-usually started if PaO2<92%
warmed and humidified
nasal cannula, hood, PPV, ET tube
Dang er- exc essive oxyg en c an le a d to
retinop athy of pre m aturity or
bronchopulmonary dysplasia
-report ABG changes
-theophylline-CNS stimulant-stimulates resp ctr
relaxes smooth muscle of bronchial airway
and pulmonary blood vessels
-surfactant administration
-ECMO N OT used with premies due to risk of
intraventricular hemorrhage
74
4.
5.
Bronchopulmonary Dysplasia
a.
caused by barotraumas from pressure ventilation
and oxygen toxicity
b.
etiology is multifactorial
c.
S&S
-tachypnea
-retractions
-nasal flaring
- work to breath
-tachycardia
d.
Tx
-oxygen
-nutrition
-fluid restriction
-medications: diuretics, steroids, bronchodilators
e.
key management is thru prevention
f.
if untreated-can lead to death from cardiorespiratory failure
6.
Necrotizing Enterocolitis
a.
inflammatory disease of GI mucosa
b.
causes unknown-up to 25-30% mortality rate
c.
contributing factors
-asphyxia -UAC
-infection
-PDA
-RDS
-anemia/ischemia
-congenital heart disease
-early enteral feedings
75
7
d.
e.
f.
g.
7.
D.
Nursing C are
1.
Methods of feeding
a.
depend on gestational age, physical condition,
neuro status
b.
nip ple fe e ding-34 weeks ok
-need coordinated suck and swallow
-needs to have gag reflex, RR < 60, and steady
wt. gain
76
8
c.
d.
e.
f.
III.
2.
Assessments
a.
vital signs-watch for temp for heat loss
b.
urine-ck protein, glucose, SG
c.
strict I & O
-watch for vomiting, diarrhea
-watch IV site for infiltration
d.
watch for gastric residual 2 ml
e.
guaiac stools
f.
assess for abdominal distention
3.
Goals
a.
maintenance of respiratory function
b.
maintenance of neutral thermal environment
c.
maintenance of fluid/lytes
d.
prevention of infection
e.
prevention of fatigue
f.
adequate nutrition
g.
promotion of attachment
i.
promotion of sensory stimulation
Dysmature Neonates
A.
C are of the Post Term Ne onate
1.
Problems
a.
post maturity syndrome
b.
hypoglycemia-depleted glycogen stores
c.
meconium aspiration-stress
d.
polycythemia- RBC production R/T hypoxia
e.
congenital anomalies-unknown
f.
seizure activity-R/T hypoxia
g.
cold stress-R/T less sub Q fat
77
9
2.
3.
B.
Assessment
a.
post maturity syndrome
-dry, crackling skin
-mec staining
-long fingernails
-profuse scalp hair
-wasted appearance
b.
meconium aspiration syndrome
-watch for mec stained infant
-may not show signs of resp. depression at birth
-if mec migrates to terminal airways-becomes
meconium aspiration syndrome
m e chanic al obstruction
-if mec aspirated in utero chemical pneumonitis
c.
persistent pulmonary HTN (PPHN)
-pulmonary artery hypertension
-R to L shunting
-may need ECMO (extracorporeal membrane
oxygenation therapy)
Tx
-tx the S & S-ECMO, inhaled nitric oxide, etc
78
10
C.
2.
Problems
a.
perinatal asphyxia
-associated with h/o
smoker
low SES
preeclampsia
multifetal gestation
infections
DM
-watch for respiratory depression at birth
b.
hypoglycemia
-higher metabolic rate
-RBS < 40 mg/dl in term infant
<25 mg/dl in premie
-poor feeders, jittery, hypothermic
-watch for lethargy, floppy, seizures
c.
heat loss
-less muscle and brown fat mass
-little ability to control skin capillaries
-need to maintain thermoneutrality
d.
hypocalcemia-R/T birth asphyxia
e.
polycythemia-R/T RBCs R/T stress
3.
Tx
a.
b.
c.
d.
e.
Problems
a.
CPD- risk for C/S birth
b.
birth traumas-vacuum, forceps, asphyxia
shoulder dystocias, fx clavicle
c.
hypoglycemia/polycythemia
4.
79
11
IV.
Causes
a.
risk of incidence/severity
-African-Americans
-maternal steroid therapy
-stressors such as PIH
-PROM
-IUGR
-maternal drug use
b.
risk of incidence/severity
- in gestation age
-maternal hypotension
-Caucasians
-maternal diabetes
-C/S birth without labor
-second-born twin
-males
-perinatal asphyxia
3.
Problems
a.
lack sufficient surfactant
b.
weak respiratory muscles
g.
epithelial debris in airways
h.
leads to oxygenation, cyanosis, and resp./
metabolic acidosis
i.
can lead to R to L shunting and opening of
foramen ovale and ductus arteriosus
4.
S&S
a.
b.
c.
d.
e.
f.
tachypnea
grunting/nasal flaring
retractions
hypotension
cyanosis
self-limiting disease
-usually abates in 72 hours
-disappearance coincides with production of
surfactant in type 2 cells of alveoli
80
12
5.
B.
C.
V.
Tx
a.
b.
c.
d.
e.
f.
g.
h.
supportive-adequate ventilation/oxygenation
surfactant administration
oxygen therapy per orders
monitoring of acid/base balance
prevent cold stress
abx therapy for infection
proper nutrition and I & Os
possible need for blood transfusion R/T frequent
lab work
3.
4.
5.
-poor PN care
-substance abuse
2.
intrapartum
-PROM
-maternal fever
-chorioamnionitis -prolonged labor
-premature labor -maternal UTI
3.
neonatal
-twins
-birth asphyxia
-galactosemia
-LBW/premie
-male
-mec aspiration
-absence of spleen
-prolonged hospitalization
81
13
B.
Mod e of transmission
1.
vertical
a.
in utero
b.
at birth
c.
TORCH
2.
C.
D.
horizontal
a.
after birth
b.
environmental, i.e. Staph
3.
dysmaturity
3.
Viral infections
a.
may cause miscarriage, stillbirth, intrauterine
infections, and congenital malformations
b.
may cause chronic infection with subtle
manifestations
c.
may need isolation from other neonates
82
14
4.
E.
F.
Fungal infections
a.
greatest concern to immuno-compromised
or premature neonates
b.
thrush may be present in otherwise healthy kids
3.
4.
S&S
1.
Respiratory
-apnea
-grunting
-retractions
-tachypnea
-nasal flaring
-decreased O2 sat
2.
CV
-bradycardia
-decreased CO
-tachycardia
-hypotension
-decreased perfusion
3.
CNS
-temp instability
-hypotonia
-seizures
4.
GI
-vomiting
-diarrhea
5.
Skin
-jaundice
-petechiae
-lethargy
-irritability
-abdominal distention
-residuals > 50%
-pallor
83
15
G.
H.
VI.
Se psis workup
1.
lab work
-blood (CBC with diff)
looking for neutrophils, bands(immature WBC)
-urine
-CSF
-gastric aspiration
-culture nose, throat, skin, umbilical cord
2.
chest x-ray
Tx
1.
2.
3.
B.
Pathologic jaundice
a.
hyperbilirubinemia kernicterus
(bilirubin encephalopathy)
b.
apparent within 24 hours of birth
c.
serum bili of > 5mg/dl in cord blood
d.
serum bili > 15mg/dl at any time
C auses
1.
Maternal factors
a.
Rh/ABO incompatibility
-fetal antigen crosses placenta
-maternal antibodies cross placenta
-cause hemolysis of fetal RBCs
(erythroblastosis fetalis hydrops fetalis)
b.
infection
c.
diabetes
d.
oxytocin in labor
e.
drugs
84
16
2.
C.
Nursing c are
1.
Lab work
a.
direct comb-ck for maternal antibodies in
infants blood
b.
ck infants blood type
c.
serum bili level
2.
VII.
Fetal/newborn factors
a.
premies
b.
hepatic cell damage
c.
polycythemia
d.
intestinal obstruction
e.
pyloric stenosis
f.
biliary atresia (absent or closed bile ducts)
g.
blood swallowed by fetus
Tx
a.
b.
c.
macrosomia/birth trauma
85
17
-excessive glucose in blood = fetal insulin production
-enlargement of internal organ except brain
-high risk for fx of clavicle/scapula, cephalohematoma
B.
C.
VIII.
3.
RDS
-4-6X more likely to develop than in normal infants
4.
5.
hyperbilirubinemia/polycythemia
-excess RBC production leads to bili
Pathophysiology
1.
Normally:
maternal blood more alkaline pH than CO2-rich fetal
blood exchange of O2 & CO2 across placenta
2.
Maternal acidosis:
in gas exchange
3.
Goal:
Maternal control of BS thru pregnancy with PN care
Nursing c are
1.
Pediatric staff at delivery
2.
3.
4.
6.
86
18
b.
c.
d.
e.
f.
g.
h.
i.
j.
mouth
-poor suck
-cleft lip
-cleft palate
-small teeth
ears-deafness
skeleton
-fusion of cervical vertebrae
-restricted bone growth
heart
-atrial/ventricular septum defects
-Tetralogy of Fallot
-patent ductus arteriosus
kidney
-renal hypoplasia
-hydronephrosis
-urogenital sinus
liver
-hepatic fibrosis
immune system
-increase infections
-otitis media
-upper resp. infections -immune deficiencies
tumors-nonspecific neoplasms
skin
-abnormal palmar
-irregular hair
2.
Cocaine
a.
prematurity/SGA
b.
microcephaly/developmental delays
c.
poor feeder/diarrhea
d.
hyperactivity/difficult to console
e.
congenital anomalies
3.
Heroin
a.
LBW
b.
SGA
c.
neonatal withdrawal issues
4.
Amphetamines
a.
SGA/LBW/premie
b.
poor wt. gain
c.
lethargy
5.
Tobacco
a.
Premie/LBW/IUGR
b.
risk for SIDS
c.
risk for bronchitis/pneumonia
87
19
d.
6.
B.
IX.
developmental delays
Marijuana
a.
possible neonatal tremors
b.
LBW
Nursing C are
1.
Needs multidisciplinary approach for both neonate
and parents
2.
Supportive care
a.
fluid and electrolyte balance
b.
nutrition
c.
infection control
d.
respiratory care
3.
4.
Article
01/13
88
1
Normal Pregnancy
Le cture 7
I.
89
B.
2.
Cervix
a.
G ood ells sign-softening of cx-6 weeks
b.
Cha dwicks sign-bluish cast-8 weeks
c.
friability increases
d.
op erculum-mucus plug-endocervical glands
3.
Vagina
a.
increased vascularity
b.
leukorrhea-thick white vaginal discharge
c.
change in pH leads to higher risk for yeast inf.
4.
Breasts
a.
start to change by week 6 R/T hormone surge
b.
increase in sensitivity, breast and nipple size
c.
increase in feeling firm, heaviness, nipple erect
d.
nipples and areola become more pigmented
e.
vessels beneath the skin dilate-more visible
f.
stria e gra vid arum (stretch marks) may appear
g.
may leak colostrum as early as 16 weeks
Blood
a.
increase in blood volume 40-50% (1500ml)
-plasma-1000 ml
-RBCs-450 ml
b.
physiologic al ane mia-hemodilution of cells
-anemic if Hgb under 10g/dl, Hct under 35%
c.
increase in WBCs
d.
coag times
-circulation time decreases by week 32
near normal at term
- in clotting factors leads to tendency for
blood to coagulate
- risk for thrombosis-esp. with C/S
90
3.
C.
Blood Pressure
a.
1st trimester-no change in BP
b.
2nd trimester-BP 5-10 mm Hg
c.
3rd trimester-BP returns to 1st trimester values
d.
supine hypotensive syndrom e
-if they lie on their backs
-at 5 minutes, reflex bradycardia
-CO by half
-woman feels faint
Respiratory syste m
1.
flaring of the rib cage
2.
3.
4.
5.
pulmonary function
a.
deep breathing- airway resistance-Progesterone
b.
tidal volume
c.
resp rate 2 breaths/min
d.
awareness to breath
e.
sensitivity in medulla to CO2- depth, rate
6.
7.
acid-base balance
a.
pregnancy is a state of resp. alkalosis
compensated by mild metabolic acidosis
b.
facilitates maternal-fetal O2-CO2 transfer
91
4
D.
E.
Renal syste m
1.
anatomic changes
a.
estrogen and progesterone = uterus size and
blood volume
b.
dilations of ureters, pelvis, renal calyces large
amt. of urine
c.
urine flow rate slowed stasis/stagnation
medium for bacteria
d.
tubular reabsorption impaired glucose in urine
more alkaline urine
e.
urinary frequency from in bladder sensitivity
and compression from uterus
f.
2nd trimester, bladder pulled up into the
abdomen
g.
urethra lengthens-possible problem with cath
2.
functional changes
a.
in GFR
b.
most efficient in L lateral- perfusion to kidneys
3.
92
5
2.
F.
G.
Musculoskeletal
1.
lordosis-center of gravity is more forward
2.
3.
Neurologic syste m
1.
compression of pelvic nerves may cause sensory
changes in legs
-sciatica
2.
3.
4.
H.
other changes
a.
angiom as-vascular spiders
b.
p alm ar erythe m a-blotches on hands
c.
pruritus
d.
gum hypertrophy-bleeding gums
e.
accelerated nail growth
f.
hirsutism-excessive hair growth
g.
blood supply = perspiration
G astrointestinal
1.
peristalsis constipation, N & V
2.
3.
4.
estrogen =
5.
progesterone =
93
I.
6.
7.
8.
3.
4.
5.
II.
Diagnosis of Pregnancy
A.
Gra vidity and Parity
1.
gravida-woman who is pregnant
a.
nulligravida-never been pregnant
b.
multigravida-2 or more pregnancies
c.
primigravidas-first pregnancy
2.
94
B.
3.
4.
5.
6.
5-digit system
a.
gravida
b.
term-para
c.
preterm
d.
abortions-spontaneous or therapeutic
e.
living children
C.
D.
Na g eles Rule
1.
First day of LMP
subtract 3 months
probable
a.
Goodwells sign-week 5
b.
Chadwicks sign-weeks 6-8
c.
Hegars sign-weeks 6-12
add 1 week
95
8
d.
e.
f.
g.
h.
i.
3.
III.
positive
a.
visualization of fetus on U/S-weeks 5-6
b.
fetal heart tones by U/S-week 6
c.
fetal heart tones by Doppler-weeks 10-17
d.
FHT by stethoscope-weeks 17-19
e.
fetal movements palpated-weeks 19-22
f.
visibility-late pregnancy
First Trimester
A.
History ta king
1.
reasons for seeking care
a.
may have other concerns besides the preg.
b.
use open ended questions
2.
current pregnancy
a.
review signs and symptoms
b.
evaluate how pt is coping
3.
OB/Gyn history
a.
menstrual history
b.
contraceptive history
c.
any infertility concerns
d.
any Gyn concerns
e.
ck last Pap and cultures for STIs
4.
medical history
a.
pre-existing medical conditions/concerns
b.
history of surgical procedures
5.
nutritional history
a.
assess for food allergies
b.
any special dietary concerns
6.
96
B.
C.
7.
family history
8.
psychosocial history
a.
situational factors
b.
any previous care of infants
c.
coping mechanisms
9.
3.
4.
review of systems
a.
assess each sign/symptom for onset, character,
and course
b.
assess for aggravating/alleviating factors
La boratory tests
1.
blood work up
a.
CBC
b.
blood type and Rh factor
c.
rubella titer
d.
HIV screen
e.
HbsAG screen
f.
RPR/VDRL
g.
Tay-Sachs
h.
Sickle-cell
i.
glucose tolerance test
2.
urine screen
a.
urinalysis with culture
b.
UDAP
3.
pelvic
a.
Pap smear
b.
cultures for STIs
4.
TB skin test
97
10
5.
D.
IV.
3.
4.
5.
6.
7.
immunizations
a.
ok if killed-DT, Hep B, rabies (Tdap-after 20 wks)
b.
no ok if live-measles, MMR, C Pox, mumps, polio
8.
9.
Second trimester
A.
Ongoing c are
1.
physical examination
a.
weight-approx. 1 lb per week past 1st trimester
b.
BP-watch for 140/90 or systolic 30>baseline
diastolic 15>baseline
c.
dip urine for protein, glucose
d.
auscultate FHT
e.
assess breasts/nipples
f.
review birth plan
g.
ask about quickening-approx 20 weeks
98
11
2.
3.
potential complications
a.
bleeding
b.
decreased fetal activity
c.
PIH/GHTN
-headache
-swelling of face/fingers
-epigastric pain
-muscular irritability
-visual disturbance
d.
PROM
-amniotic fluid discharge
e.
infections
-chills
-fever
-burning with urination
4.
fundal height
a.
fundal height (from symphysis pubis to top of
uterus) # in cm = weeks of gestation
(weeks 18-36)
b.
stable or decreased fundal height-? IUGR
c.
excessive increase-multifetal gestation,
hydramnios
5.
gestational age
a.
determined from LMP, contraceptive history, and
pregnancy test results
b.
usually confirmed with U/S
6.
99
12
d.
e.
f.
g.
7.
V.
education topics
a.
warning signs
b.
assess nutrition status
c.
hygiene-R/T increase perspiration
d.
UTI prevention-hydration, freq. Voids
e.
breast shields for inverted nipples
-too much stimulation can lead to PTL
f.
dental care
g.
R&R
h.
risk factors at work-i.e. caustic agents
i.
travel-if not high risk, ok
j.
avoid alcohol, cigarettes
k.
need for support garments
Third Trimester
A.
History and physic al
1.
vaginal exams may begin in the last month
2.
B.
La boratory tests
1.
Group Beta strep culture-35-37 weeks
2.
3.
4.
C.
D.
100
13
e.
f.
g.
h.
i.
j.
k.
l.
2.
paternal tasks
a.
acceptance of pregnancy
-may express joy or dismay
-unwanted vs. unplanned
-affairs/battery of spouse
b.
c ouv a d es
-observance of rituals = transition to fatherhood
-may have psychosomatic symptoms of preg.
c.
participate in childbirth education
d.
identify with father role
-may be influenced by how their father was
e.
reordering personal relationships
-may see fetal as a rival
-may feel wife is too dependent on MD/CNM
f.
observer vs. expressive vs. instrumental
g.
establish relationship with fetus
-kiss or rub abdomen
-talk to fetus
-assist with preparing babys room
3.
sibling adjustment
a.
first crisis for a child
b.
may feel replaced
c.
need to prepared to become the big sister or
brother
d.
sibling classes
101
14
E.
4.
grandparent responses
a.
if only in 30s or 40s-may not be as interested
b.
may be non-supportive-try to decrease new
mothers self esteem
c.
most see the pregnancy as a renewal of their
youth
d.
continuity of past and present
e.
may help bridge a previous estrangement
f.
now have classes on being a grandparent
5.
3.
4.
102
15
VI.
B.
3.
4.
Substanc e a buse
1.
no such thing as a safe level of drugs
2.
3.
4.
C.
D.
Battering
1.
may increase with enlargement of abdomen
E.
VII.
2.
2.
must be reported
3.
Multifetal pregnancies
A.
M aternal c onc erns
1.
blood volume
2.
anemia
strain on CV system
103
16
3.
4.
5.
6.
7.
B.
VIII.
PROM
3.
types of twins
a.
dizygotic-from 2 fertilized ova/2 spermatozoa
1.
2 placentas
2.
2 chorions
3.
2 amnions
b.
monozygotic-originating from one fertilized ovum
1.
dichorionic -dia mniotic twins (20-30%)
-if division 3 days after fertilization
-may have separate or fused placentas
2.
mono chorionic -dia mniotic
-if division 5 days after fertilization
3.
mono chorionic -mono a mniotic
-if division 7-13 days after fertilization
-rarest
c.
risk of congenital malformations-in monozygotic
twins
d.
twin to twin shunting
e.
two-vessel cord
4.
delivery complications
104
17
B.
3.
dietary prescriptions/restrictions
a.
warm vs. cold
b.
like to like
c.
pica
4.
activity restrictions
5.
6.
consideration of modesty/religion
a.
clothing
b.
amulets, beads
7.
pain
a.
b.
c.
d.
8.
9.
10.
specific groups
a.
Mexicans
-stoic until just before delivery
-avoid eclipse of moon-cleft palate
-everybody present at delivery
b.
Middle Eastern
-only female attendants
-FOB usually not at delivery
c.
Asian
-prefer warm fluid
-natural childbirth
-labor in silence
-may eat during labor
-FOB may or may not be present
inevitable, to be endured
can be avoided completely
punishment for sin
can be controlled
Nursing c are
1.
support cultural belief-offer alternatives
2.
105
18
IX.
Maternal Nutrition
A.
Nutritional re quire m ents
1.
energy needs-additional 300 kcal greater than
pre-pregnancy
2.
protein
a.
needed for growing fetus
b.
milk, meat, eggs, cheese-complete proteins
c.
only slightly higher need than non-pregnancy
3.
fluids
a.
b.
c.
d.
4.
106
19
d.
e.
f.
B.
Weight g ain
1.
1st trimester-5 lbs (1-2 kg)
2nd-3rd trimester-1 lb/week (0.44 kg/week)
2.
3.
C.
Cultural differenc es
D.
01/13
107
1
Fetal Assessment
Le cture 8
I.
108
3.
4.
B.
II.
Nursing Interventions
1.
Complete PN interview with history
2.
3.
4.
5.
109
2.
ultrasound
a.
indicators
-gestational age
-multiple gestations
-fetal growth patterns
-fetal congenital anomalies
-placental position and maturity
-affects of disease process on the fetus
-assess fetal responses to intrauterine environ.
-assist with amniocentesis, CVS, fetoscopy, etc.
b.
data
-reflections of echoes that are produced when
sound waves are dispersed to and
absorbed by tissues being scanned
-no recognizable risks to mother or baby
-full bladder helps to lifts up the uterus
-tr a nsv a gin a l pro b e
1.
allows for better visualization of pelvis
2.
good to use on obese patients
3.
allows pregnancy to be determined
earlier
4.
well tolerated, no full bladder
5.
helps detect ectopic pregnancies
6.
used in adjunction with abdominal
scan to R/O PTL in 2nd & 3rd trimesters
- a b d o min a l sc a n
1.
full bladder helps move uterus up
2.
may be hard to use on obese pts.
3.
more useful after 1st trimester
-fetal heart activity by 6-7 week by echo scanner
-gestational age
1.
gestational sac dimensions-8 weeks
2.
crown-rump length-7-14 weeks
3.
biparietal diameter (BPD)-12+ weeks
4.
femur length-12+ weeks
-amniotic fluid volume (AFV or AFI)
1.
ck fluid-filled pockets without fetal
parts or cord
2.
AFI-depth of fluid in all 4 quads
-< 5cm=oligo
-5-19 cm=normal
-over 20 cm=poly
110
3.
4.
3.
B.
111
5
f.
C.
3.
4.
112
e.
f.
g.
3.
D.
Biophysic al profile
1.
noninvasive dynamic assessment of fetus/environment
2.
assessing 5 variables
a.
fetal breathing movements
-normal (2)-one or more episodes in 30 min
lasting > 30 seconds
-abnormal (0)-absent or no episode matching
requirement above
b.
gross body movements
-normal (2)-3 or more movements/30 min
-abnormal (0)-none or less than 3/30 min
c.
fetal tone
-normal (2)-1 or more active extension with
return to flexion
-abnormal (0)-slow extension with return
d.
reactive fetal heart rate
-normal (2)-2 or more accels with +FM/20 min
-abnormal (0)-less than requirement
e.
qualitative amniotic fluid volume
-normal (2)-1 or more pockets of fluid > 1 cm in
113
7
2 perpendicular planes
-abnormal (0)-pockets absent or below needed
3.
E.
F.
score
a.
normal = 8-10 if AFI ok
b.
equivocal = 6
c.
abnormal = <4
3.
patient teaching
a.
preparation for procedure
b.
interpreting the findings
d.
providing psychosocial support PRN
114
e.
-maternal anemia
-fetal activity
changes in FHR
-accelerations-usually assoc. with + FM
-decelerations-early, late, variable
2.
nursing role
a.
record information on strip if unable to chart
b.
vaginal exams
c.
assess if ROM
d.
VS assessments
e.
position changes when needed
f.
oxygen via mask
g.
medications
h.
emesis control
i.
assess need for internal monitors
3.
deceleration patterns
a.
early-rarely below 110 bpm
-periodic decels R/T intense fetal head
compression
-uniform shape, mirror image of U/C
b.
late
-uniform-reflects shape of contraction
-onset after peak of U/C
-repetitious
-cause-uteroplacental insufficiency
-hypotension
-PIH
-hypertonic contractions
-abruptio
-postmaturity
-IUGR
-DM
-action
-oxygen
-position change
-stop pitocin drip
-IV hydration
-assess other S & S
c.
variable
-U or V shaped
-with or without U/C
-R/T cord compression
-usually transient, changeable
-action
change to side lying
oxygen
external fetal manipulation
SVE
knee-chest position
amnioinfusion if ROM
115
9
Pre gnanc y at Risk
IV.
B.
2.
3.
4.
3.
4.
5.
late-12-20 weeks
a.
usually r/t maternal causes
-AMA
-parity
-chronic infections
-premature dilation of cx
-reproductive tract anomalies
-chronic diseases
-inadequate nutrition
-recreational drug use/abuse
116
10
C.
6.
types
a.
threatened-spotting, closed cervix, cramping
b.
inevitable-open cervix, mod-heavy bleeding,
mod-severe cramping
c.
incomplete-some POC retained
d.
complete-all POC removed
e.
missed-death in utero without obvious S & S
diagnosed by U/S
f.
recurrent-3 or more
7.
clinical manifestations
a.
increasingly severe as gest. age increases
b.
before 6 weeks-increased flow like heavy
menses
c.
6-12 weeks-moderate discomfort, blood loss
d.
12 weeks-severe pain
8.
assessment
a.
check PN history and hCG level
b.
U/S
c.
CBC
d.
blood type and Rh factor
e.
assess for infection
9.
plan of care
a.
rest and supportive care
b.
D&C
c.
D&E
d.
may need prostaglandins, IV, or pitocin for
fetal demise
10.
teaching
a.
report heavy or bright red bleeding
b.
some scant dark discharge 1-2 weeks post
c.
no vaginal insertions until bleeding stops
d.
take entire course of abx if prescribed
e.
grief counseling if needed
f.
refer to support group
induc e d a bortion
1.
elective-by request
2.
117
11
D.
3.
4.
assessment
a.
informed consent
b.
options explored
c.
discuss conflicts/fears
5.
procedure
a.
laminaria then vacuum aspiration (D & E )
b.
may use PG gel to ripen cx
c.
need to monitor temp. and bleeding
d.
may use RU486 (Mifepristone)
e.
may use methotrexate IM with vaginal
misoprostol
6.
complications
a.
infection
b.
retained POC
c.
clots
d.
bleeding
3.
4.
5.
assessment
a.
bleeding
b.
dull, colicky pain
c.
tenderness
d.
referred shoulder pain r/t diaphragmatic
irritation
e.
shock if ruptured
f.
Cullens sign-ecchymotic blueness around the
umbilicus indicating hematoperitoneum
118
12
F.
6.
diagnosis
a.
clinical picture sounds like other infections or
diseases
b.
need to r/o appendicitis, SAB, etc.
c.
beta hCG, CBC, and U/S
d.
progesterone 25ng/mL=intrauterine
progesterone <5ng/mL=dead fetus/ectopic
7.
procedure
a.
unruptured-methotrexate to dissolve residual
tissue
b.
salpingostomy
c.
ruptured-laparotomy with salpingectomy
8.
plan
a.
b.
c.
d.
e.
f.
g.
3.
4.
etiology unknown
5.
119
13
V.
6.
manifestations
a.
early part of pregnancy uncomplicated
b.
dark brown vaginal discharge or bright red
c.
higher than expected fundal height (50%)
d.
associated with anemia, hyperemesis
gravidarum, abdominal cramps
e.
PIH-9-12 weeks
f.
16 weeks-passage of vesicles
7.
labs/tests
a.
serial hCG
b.
U/S
8.
plan
a.
suction curettage of tissue
b.
induction with pitocin/prostaglandins NOT
recommended r/t increase risk of embolization
of trophoblastic tissue
c.
Rhogam if needed
9.
nursing plan
a.
care for grief/loss
b.
therapeutic communication
c.
return for serial hCG protocol for 1 year &
baseline chest x-ray to detect lung metastasis
e.
monitor hCG and increasing fundal height for
possible choriocarcinoma-chemo/methotrexate
types
a.
total-os totally covered when cervix dilated
b.
partial-incomplete
c.
marginal-edge extends to os but may increase
during dilation
d.
low-lying-implanted in lower uterine segmentdoesnt reach os
3.
120
14
B.
4.
5.
manifestations
a.
70% painless bleeding
b.
20% uterine activity
6.
diagnosis
a.
transabdominal ultrasound
b.
requires C/S
c.
ck NST, BPP, fetal lung maturity
d.
bed rest PRN
e.
observation for FHR, vaginal bleeding, VS
7.
plan
a.
b.
c.
d.
e.
f.
g.
h.
3.
risk factors
a.
HTN
b.
cocaine
c.
blunt trauma-battering, MVA
d.
smoking
121
15
e.
f.
malnutrition
risk of recurrence significant
4.
classification
a.
Grade 1-mild separation-10-20%
b.
Grade 2-moderate-20-50%
c.
Grade 3-severe->50%
5.
clinical
a.
significant uterine tenderness/pain
b.
vaginal bleeding
c.
contractions
d.
may have no bleeding
e.
hypovolemic shock
f.
coagulopathy
g.
couvelaire uterus-R/T blood trapped between
placenta and uterine wall hysterectomy
h.
DIC -disse minate d intra v ascular c o a gulation
i.
complications-hemorrhage, shock, infection
j.
perinatal mortality-hypoxia in utero, PTL, SGA,
neurological deficits
6.
diagnosis-U/S
7.
plan
a.
b.
c.
d.
9.
nursing care
a.
large bore IVs
b.
foley catheter
c.
watch for decrease in urinary output
d.
blood administration PRN
e.
monitor FHR
f.
monitor for pain
g.
monitor CBC, fibrinogen, PT, PTT
h.
therapeutic communication for anxiety, grief
122
16
VI.
Hyperemesis Gravidarum
A.
Risk fa ctors
1.
less than 20 yrs old, obesity, multifetal, molar
2.
B.
VII.
nursing care
a.
therapeutic communication
b.
I&O
c.
daily weight
d.
rest
e.
diet as tolerated
f.
small, frequent meals
g.
decrease fats and protein if not tolerated
h.
monitor IV site
3.
4.
5.
123
17
B.
C.
6.
7.
8.
Risk fa ctors
1.
chronic renal disease
2.
chronic hypertension
3.
4.
multifetal gestation
5.
primigravida
6.
7.
diabetes
8.
Rh incompatibility
10.
obesity
preeclampsia
a.
pregnant specific
b.
HTN after week 20
c.
multisystem vasopastic disease-HTN with
Proteinuria (1-2+)
124
18
d.
e.
f.
g.
3.
severe preeclampsia
a.
BP 160/110
b.
> 3+ or 4+ on dipstick: 5g 24 hr urine collection
c.
oliguria-<400-500 ml/dy
d.
visual disturbances/headaches/altered LOC
e.
hepatic involvement
f.
platelets-thrombocytopenia
g.
pulmonary/cardiac involvement
h.
development of HELLP syndrome
i.
severe fetal growth retardation
4.
eclampsia
a.
onset of seizure activity in the woman diagnosed
with PIH with no neurologic pathology
b.
may be initial sign patient has PIH
5.
6.
chronic HTN
a.
HTN before pregnancy or diagnosed before
week 20
b.
also considered chronic if HTN lasts longer than
6 weeks PP
c.
considered mild if diastolic remains below 110
d.
drug of choice: Aldomet (methyldopa)
125
19
D.
7.
8.
transient HTN
a.
development of HTN during pregnancy or
in the first 24 hours post partum
b.
no other S & S of preeclampsia
Pathophysiology / etiology
BP vasospams
placental perfusion
endothelial cell activation
vasoconstriction
activation of
coagulation
cascade
intravascular
fluid
redistribution
E.
1.
mild preeclampsia
or eclampsia
2.
3.
severe preeclampsia
HELLP
HELLP syndrom e
1.
is a laboratory, not clinical, diagnosis
a.
platelets < 100,000/mm3
b.
liver enzymes
-AST-aspartate aminotransferase
-ALT-alanine aminotransferase
c.
some evidence of hemolysis
126
20
d.
2.
F.
history
a.
headache
b.
epigastric pain
c.
visual disturbances
3.
4.
fetal assessment
5.
uterine tonicity
6.
vaginal exam
7.
lab tests
a.
CBC
b.
clotting factors
c.
liver enzymes
d.
chem panel: uric acid, creatinine, BUN, RBS
e.
type and screen
f.
urinalysis or 24 hr proteinuria
8.
nursing diagnoses
a.
anxiety
b.
altered tissue perfusion
c.
knowledge deficit
d.
risk for impaired gas exchange
e.
risk for CO
127
21
f.
g.
G.
3.
pharmacology
a.
magnesium sulfate
-helps prevent or treat convulsions
-interferes with acetylcholine at synapses
- neuromuscular and CNS irritability
- cardiac conduction
-increases blood flow in uterus to protect the
fetus
-increases prostracylins to prevent uterine
vasoconstriction
-secondary infusion
loading dose-4-6 gms over 20-30 min
maintenance-1-3 gms/hr
-mag level in 4-6 hrs (therapeutic level 4-8 mg/dl)
-frequently ck RR, UO, DTRs
-have calcium gluconate at bedside (antidote)
-toxicity-nausea, flushing, reflexes, slurred
speech, and muscle weakness
-may be given IM for transport yet absorption
rate isnt controlled, IM is more painful
-diuresis within 24 hours is an + prognostic sign
128
22
b.
c.
d.
01/13
129
1
Pregnancy at Risk, Part 2
Lecture 9
VIII.
IX.
Diabetes mellitus
A.
Classifications
1.
Type 1: pancreatic cell destruction-insulin deficient
prone to ketoacidosis (acidosis R/T excessive ketones)
B.
2.
3.
4.
Pathophysiology
1.
Group of metabolic diseases characterized by
hyperglycemia R/T defects in insulin secretion, action,
or both
2.
3.
4.
5.
6.
130
7.
C.
metabolic factors:
a.
1st trimester- estrogen/progesterone= insulin
production= peripheral glucose utilization
b.
tissue glycogen stores= hepatic glucose
production (this can affect insulin needs)
c.
2nd & 3rd trimesters- levels of hPL, estrogen,
progesterone, prolactin, cortisol, and insulinase
= insulin resistance (they are insulin antagonists)
(antagonists-counteract the action of another)
(synergists-enhances the action of another)
d.
maternal insulin requirements may double or
quadruple by 36 weeks of pregnancy
(leaves abundant supply of glucose for fetus)
Risk factors
1.
best predictor of pregnancy outcome=degree of
maternal control of glucose levels
2.
3.
4.
fetal risks
a.
stillborn-etiology unk, ?chronic hypoxia
b.
congenital anomalies (6-10% chance)
-cardiac most common
c.
macrosomia/birth traumas
d.
IUGR R/T vascular disease
e.
RDS
131
3
f.
D.
hypocalcemia, hypoglycemia,
hypomagnesemia, hyperbilirubinemia, and
polycythemia
Nursing Process
1.
Lab work
a.
euglycemia=65-130 mg/dl
b.
assessment of glycosylated hemoglobin A1c
-helps assess level of hemoglobin saturated
with glucose caused by hyperglycemia
-good control 7%
->10 % = risk for fetal anomalies (20-25%)
c.
urine screen for UTI, proteinuria, creatinine
clearance
d.
thyroid function screening
2.
3.
4.
5.
Insulin therapy
a.
1st trimester, insulin dosage may decrease
b.
oral agents may be viable solution
-Glyburide (sulfonylurea) insulin secretion
-doesnt cross the placenta
insulin resistance =
c.
2nd and 3rd trimesters
insulin dosage
d.
Some insulin can cross the placenta
e.
various regimens followed
f.
insulin pump may be used during pregnancy
g.
see California Diabetes and Pregnancy Program
-CDAPP
-Sweet Success
6.
132
E.
7.
8.
Intrapartum
a.
follow hospitals P & P
b.
watch for dehydration, hypo/hyperglycemia
c.
mainline usually D5LR with insulin on secondary
infusion
d.
sched C/S in morning-hold AM insulin, NPO
9.
Postpartum
a.
insulin needs drop dramatically with removal of
placenta
b.
several days before CHO homeostasis
c.
complications
-preeclampsia
-eclampsia
-hemorrhage
-infection
d.
breastfeeding encouraged
-helps use up CHO in milk production
-risk for hypoglycemia
-risk for mastitis
-may reduce infants risk for DM
-may need to recalculate insulin dose
e.
discuss contraceptive methods
-barrier method safest
-OCs have risk of thromboembolic/vascular
complications
-use of IUD risks infection
-tubal ligation if completed family
Gestational Diabetes
1.
4% of all pregnancies/90% of diabetic pregnancies
2.
133
X.
3.
risk factors
a.
obese
b.
over age 30
c.
family history
d.
h/o macrosomic infant
e.
unexplained stillbirth
f.
miscarriage
g.
having an infant with congenital anomalies
4.
screening
a.
1 hour glucola-50 gram oral glucose load
-considered + if >140 mg/dl
b.
3-hour glucose tolerance test
-fasting glucose
-drink a 100 gm loading dose
-ck serum and urine every hour
-+GDM if 2 or more of the results are elevated
fasting = 95
1 hour = 180
2 hour = 155
3 hour = 140
3.
134
6
-mortality rate of 25-50 %
-tx-treat the symptoms
B.
C.
Classifications
1.
Class I: Asymptomatic at normal levels of activity
mortality = 1%
a.
corrected Tetralogy of Fallot
b.
pulmonic/tricuspid disease
c.
mitral stenosis (class I, II)
d.
septal defects
2.
3.
4.
Nursing Process
1.
medical care is multidisciplinary
2.
135
7
-orthopnea
-tachypnea, over 25
-moist, frequent cough
-increasing fatigue
-cyanosis of lips and nail beds
3.
4.
5.
6.
support groups
consultation with dietician
7.
8.
9.
10.
11.
12.
labs/studies
a.
CBC, chem panel
b.
ECG
c.
chest x-rays
d.
EFM
13.
medications
a.
heparin for anticoagulation-doesnt cross
placenta
b.
coumadin-contradindicated-teratogenic
c.
abx- risk of bacterial endocarditis
d.
diuretics to treat CHF
e.
digitalis for arrhythmias and heart failure
14.
intrapartum
a.
side lying or semi-fowlers
b.
O2 via mask
136
8
c.
d.
e.
f.
g.
h.
i.
15.
XI.
postpartum
a.
1st 24-48 hours most important for hemodynamic
stability
b.
bed rest, asst. with ADLs as needed
c.
prevent constipation
d.
breastfeeding may be contraindicated in higher
classifications of disease
Anemias
A.
Iron deficiency anemia
1.
most common
a.
< 11 g/dl in 1st
b.
< 10.5 g/dl in 2nd
c.
< 11 g/dl in 3rd
B.
C.
2.
3.
4.
risk to fetus
a.
LBW
b.
preterm
c.
perinatal mortality-maternal Hbg < 6g/dl
3.
137
9
1.
2.
3.
4.
maternal/fetal risks
a.
pyelonephritis
b.
bone infection
c.
heart disease
d.
PIH
e.
fetal loss due to impaired oxygen supply
5.
tx:
a.
b.
c.
d.
folic acid-1mg/day
abx as needed
O2 and IVs
SCDs postpartum
XII.
Maternal infections
Pages 352-357
KNOW: Type of organism, S/S, tx, and implications for pregnancy
and fetussuch as:
T-toxoplasmosis-retinochoroiditis, convulsions, microcephaly
O-others-Hepatitis, HIV, syphilis-infection, SAB,
R-rubella-DM, hearing loss, glaucoma, encephalitis
C-cytomegalovirus-90% of survivors have neurological problems
H-herpes simplex-hyper/hypothermia, jaundice, seizures
XIII.
138
10
2.
3.
B.
C.
legal considerations
a.
risk to unborn may = criminal charges to mom
b.
may be arrested, jailed, housed in psychiatric
hospital for rest of the pregnancy
c.
baby may be give to child protective services
3.
risks
a.
b.
c.
d.
e.
f.
g.
3.
case management
a.
find out about pt.s environment, past drug use,
current drug use, and support systems
b.
drug testing-blood and urine
-alcohol can go undetected in urine
139
11
c.
d.
e.
f.
g.
h.
01/13
140
1
Complications of Labor and Delivery
Le cture 10
I.
Dysfunctional Labor
A.
Alterations in c ontra ction p atterns and quality
1.
Hypertonic Uterine Dysfunction
a.
usually in latent phase, before 4 cm
b.
cause unknown, maybe R/T anxiety/fear
c.
assessment
-pain out of proportion to intensity of U/C
-U/Cs in frequency but uncoordinated
d.
risk to mom
-loss of control
-exhaustion
e.
risk to fetus
-asphyxia
-passage of meconium
f.
tx
-analgesia
-rest for mom
g.
after 4-6 hours rest, usually awaken in normal
labor pattern
2.
141
3.
CPD-cephalopelvic disproportion
a.
R/T macrosomic infants
b.
maternal causes
-pelvis too small
-pelvis abnormally shaped
-pelvic deformity
3.
malpositions
a.
usually persistent OP (LOP or ROP)
b.
prolonged second stage
c.
usually c/o severe back pain
d.
may be able to change fetal position
-knee chest position
-squats
-lunges
-pelvic rocking
-rolling side to side
142
3
4.
C.
Pelvic alterations
1.
pelvic dystocia
a.
contractures (fibrosis of connective tissue in skin,
fascia, muscle, or a joint capsule) of the pelvis
b.
deformities from MVA, traumas
c.
immature pelvis in teens
2.
D.
malpresentation
a.
breech most common
-frank-thighs flexed, knees extended
-complete-thighs and knees flexed
-incomplete
one foot below the buttock or
one knee below the buttock
b.
breech presentations associated with:
-multifetal gestations
-preterm birth
-fetal and maternal anomalies
-hydramnios
c.
risk of prolapsed cord
d.
might attempt vaginal delivery in multiparas
e.
face/brow presentations
-uncommon
-associated with fetal anomalies or pelvic
contractures
-may need forcep delivery
f.
if external version fails to rotate a breech or
shoulder presentation = C/S
143
4
3.
E.
3.
precipitous labor/delivery
a.
labor less than 3 hours from start of U/Cs
b.
maternal complications
-uterine rupture
-lacerations
-amniotic fluid embolism
-PP hemorrhage
c.
risk to fetus
-hypoxia
-intracranial hemorrhage
-bruising of head/face
pattern
prolonged latent phase
nullips
>20 hrs
multips
>14 hrs
<1.2 cm/hr
<1.5 cm/hr
>2 hrs
>2 hrs
protracted descent
<1 cm/hr
<2 cm/hr
arrest of descent
>1 hr
>1/2 hr
failure of descent
precipitous labor
>5 cm/hr
10 cm/hr
144
5
F.
II.
monitor mother/fetus
3.
pitocin augmentation/vacuum/C/S
B.
2.
3.
4.
b.
d.
ck GBS status
r/o prolapsed cord
145
6
d.
e.
behavioral/environmental risks
-DES (diethylstilbestrol) exposure
-smoking
-poor nutrition
-substance abuse
-late on no PN care
other risks
-anxiety/stress
-uterine irritability
-long working hours
-inability to rest
2.
predicting PTL
a.
fetal fibronectin-biochemical marker
-glycoproteins-found in plasma
-appear in cervical canal early/late in preg.
-appearance between 24-34 weeks gest. is
an indicator for PTL
-negative predictive value=95%
-positive predictive value=25-40%
-easier to predict who will not have PTL
-expense=$180-215
b.
salivary estriol-biochemical marker
-form of estrogen produced by fetus and present
in plasma by 9 weeks
-levels have been shown to before PTL
-negative predictive value=98%
-positive predictive value=7-25%
-expense=$90 each test
c.
endocervical length
-lengths less than 30 mm in singleton may
predict risk for PTL
3.
causes of PTL
a.
unknown and thought to be multifactorial
b.
infection major etiological factor
c.
25% are iatrogenic-intentionally delivery of fetus
-R/T health of fetus/mom
d.
25% R/T PROM followed by labor
e.
50% idiopathic (conditions without recognizable
cause) preterm births
4.
assessment
a.
contractions <10 minutes apart in frequency
b.
persistent cramping
c.
clear, pink, or brownish discharge
d.
pressure in vagina or low back
146
7
e.
f.
g.
diarrhea
cervical effacement >80%
1 cm dilated
5.
pt. education
a.
bed rest-no studies have proven its efficacy
-wt. loss
-loss of muscle tone
-calcium loss
-fatigue
-depression
-constipation
b.
notify MD of changes in S & S
c.
home uterine activity monitoring
d.
discuss lifestyle adaptations-need to
-sexual activity
-heavy lifting
-long drives
-standing more than 50% of the time
-climbing stairs
-not stopping when tired
6.
pharmacology
a.
tocolytics
-magnesium sulfate
CNS depressant
can cause respiratory depression
flushing, N & V, DTRs and BP
-terbutaline/ritodrine
beta-adrenergic receptor stimulant
helps with hypertonic contractions
tachycardia, palpitations
fetal tachycardia
-nifedipine
calcium channel blocker
headache, hypotension
-indomethacin
prostaglandin inhibitor
risk of closure of ductus arteriosus
risk of NEC or IVH
147
8
b.
III.
antenatal glucocorticoids
-betamethasone-12 mg IM X 2 doses 24 hrs apart
-dexamethasone-6 mg IM 2 doses 12 hrs apart
stimulate lung maturity
promote release of enzyme to induce
surfactant production
can cause maternal infection, pulmonary
edema
can worsen HTN or GDM
Intrapartum emergencies
A.
Pla c ental a bnorm alities
1.
adherent retained placenta
a.
placenta accreta
-cotyledons invaded uterine muscle
b.
placenta increta
-chorionic villi invade the myometrium
c.
placenta percreta
-invasion of myometrium to the serosa of the
peritoneum covering of uterus
-can lead to rupture of uterus
2.
abruptio placenta
3.
vasa previa
-velamentous insertion-cord attached to membranes
-no Whartons jelly
-vessels exposes to laceration
-high incidence of fetal mortality
-Dx with U/S, palpation of vessels
4.
succenturiate
-accessory lobes of fetal villi developed
-vessels supported only by membranes
risk of retained POC
-fetal blood loss if vessel nicked
5.
battledore
-insertion at or near placental margin rather than
center
-increased risk of fetal hemorrhage
148
9
B.
C.
3.
4.
contributing factors
a.
long cord->100 cm
b.
malpresentation
c.
transverse lie
d.
unengaged presenting part
5.
risk to fetus
a.
hypoxia
b.
CNS damage
c.
Death
6.
care management
a.
hold presenting part off cord
b.
knee-chest or Trendelenburg position
c.
delivery
-possible forcep/vacuum if 10 cm
-usually stat C/S
Uterine rupture
1.
causes of rupture
a.
previous uterine scar
-classical C/S
-myomectomy
b.
uterine trauma
c.
congenital uterine anomalies
d.
multiparas
e.
intense spontaneous U/Cs
f.
hyperstimulation of uterine muscle
g.
overdistented uterus
h.
malpresentation
i.
external/internal version
j.
forceps
2.
classifications
a.
complete
-extends through the entire uterine wall into
the peritoneal cavity/broad ligament
149
10
b.
D.
incomplete
-rupture extends to peritoneum but not into
the peritoneal cavity/broad ligament
3.
4.
prevention
a.
no VBACs with classical uterine scar
b.
assess womans risk factors
c.
prevent hyperstimulation
d.
use of tocolytic drugs
5.
case management
a.
prepare pt for surgery-C/S, possible hysterectomy
b.
IV/oxygen
c.
type and cross for possible blood transfusion
d.
therapeutic communication/support
e.
fetal mortality>80%
f.
maternal mortality-50-75%
Uterine inversion
1.
classifications
a.
complete-protrudes
b.
incomplete-smooth mass palpated thru cervix
2.
risk factors
a.
fundal implantation of placenta
b.
leiomyomas
c.
vigorous fundal pressure
d.
abnormally adherent placental tissue
3.
S&S
a.
shock & pain
b.
hemorrhage (loss of 800-1800 ml)
150
11
4.
E.
interventions
a.
manual replacement
b.
oxytocin
c.
need for surgery is rare
3.
4.
risk factors
a.
multiparity
b.
tumultuous labor
c.
abruptio placenta
d.
oxytocin induction
e.
fetal macrosomia
f.
fetal death in utero
g.
meconium passage
5.
case management
a.
assess for manifestations of RDS
-restlessness
-dyspnea
-cyanosis
-pulmonary edema
-respiratory arrest
b.
assess for shock
-hypotension
-tachycardia
-cardiac arrest
-hemorrhage
-uterine atony
c.
oxygenate-10 L
d.
intubate/bag with 100% oxygen
e.
CPR-30 degree angle of uterus
f.
IVs
g.
blood transfusion/tx coagulation defects
h.
foley catheter
i.
prepare for possible C/S
j.
emotional support/counseling if death occurs
151
12
F.
Traum a
1.
leading nonobstetric reason for maternal mortality
2.
3.
4.
5.
types of trauma
a.
blunt abdominal trauma
-MVA, battering, falls, exsanguination
-fetal skull fx or ICH
-ck for abrupted placenta
-pelvic fx can cause injury to fetus
-uterine rupture rare
b.
penetrating abdominal trauma
-bullet, stab wound
-direct fetal injury from bullet, requires surgery
-fetal injury from stab wound
-better chances if injury occurs in upper maternal
abdomen
c.
thoracic trauma-25% of trauma deaths
-maternal life threatened by pulmonary
contusion
-can cause pneumo/hemothorax
6.
7.
8.
152
13
9.
G.
IV.
3.
4.
5.
6.
153
14
B.
3.
4.
5.
6.
7.
154
15
d.
e.
f.
2.
C.
mechanical methods
a.
dilators
b.
amniotomy
Version
1.
external
a.
attempt to rotate fetus from a malpresentation
b.
usually done at or after 37 weeks
c.
U/S scanning before to ck fetus and placenta
d.
may use a tocolytic agent like terbutaline
e.
obtain informed consent-usually done in L & D
due to risk of complications
f.
MD or CNM give gentle, constant pressure to
abdomen to rotate presenting fetal part
g.
Rh moms may receive Rhogam due to the risk
of fetomaternal bleeding
2.
D.
internal
a.
MD inserts hand into the uterus and changes
position or presentation
b.
may be used in multifetal pregnancies to rotate
second fetus
c.
maternal/fetal injury possible
d.
RN role to monitor FHR and support mother
Episiotomy
1.
incision in the perineum to enlarge the vaginal outlet
2.
types
a.
median-midline
-most commonly used
-effective, easily repaired
-can possibly extend into rectum
b.
mediolateral
-prevents 4th degree laceration
-repair most difficult
-more pain to mom
155
16
E.
F.
3.
pros
prevents tearing
decreases stage 2
enlarges vagina
cons
lacerations can occur
pain/discomfort
lateral position can
control head
4.
Forc e ps
1.
uses paired curved blades to asst. delivery of head
2.
3.
4.
conditions
a.
fully dilated
b.
empty bladder
c.
engaged presenting fetal part
d.
vertex
e.
ROM
f.
No CPD
5.
care management
a.
assess FHR before and after delivery
b.
Pedi MD at delivery
c.
assess mother for lacerations, urinary retention
d.
assess baby for facial bruising, abrasions, palsy
V a cuum
1.
attachment of vacuum cup and use of negative
pressure
2.
3.
156
17
4.
G.
Surgic al Birth
1.
birth of the fetus thru a transabdominal incision in the
uterus
2.
3.
4.
5.
6.
7.
8.
type of incisions
a.
skin-vertical or horizontal (Pfannenstiel, bikini)
b.
uterus-vertical (classical), low vertical, and
horizontal (low transverse)
-classical-faster to perform, is performed in other
countries, contraindication for VBAC
-transverse-easier, less blood loss, decrease risk
for infections, less likely to rupture, may
attempt VBAC with next pregnancy
157
18
9.
risks/complications
a.
aspiration
b.
pulmonary embolism
c.
wound infection
d.
wound dehiscence
e.
thrombophlebitis
f.
hemorrhage
g.
UTI
h.
injury to bladder or bowel or fetus
i.
anesthesia complications
j.
decreased satisfaction with the birth process
k.
loss of ability to accomplish vaginal deliveries
l.
increase financial expense
m.
longer hospital stay
n.
bonding and breastfeeding may be delayed
10.
types of anesthesia
a.
regional blocks
-epidural-most common, feel pressure, no pain
-spinal-no pain or pressure
b.
general
-higher risk of complications
11.
01/13
158
1
Complications of the Puerperium
Le cture 11
1.
Postpartum Hemorrhage
A.
Definition /Risk fa ctors
1.
500 ml or more blood loss after a vaginal delivery
2.
3.
4.
5.
159
g.
h.
i.
6.
7.
8.
B.
C.
160
i.
j.
D.
2.
3.
uterine inversion
a.
reposition uterus
b.
tx shock
c.
oxytocin
d.
broad spectrum abx
e.
NG tube if concerned R/T paralytic ileus
4.
subinvolution
a.
oxytocin/ergonovine
b.
D & C if placenta fragments retained
Te a ching
1.
normal lochia progression
2.
3.
4.
5.
assess fundus
161
4
6.
II.
Thromboembolic disorders
A.
Classific ations
1.
superficial venous thrombosis
a.
most common type PP
b.
involves superficial saphaneous vein
B.
C.
D.
2.
3.
pulmonary embolism
a.
blood clot dislodged-carried to pulmonary artery
b.
occludes vessel-obstruct blood flow to lungs
3.
4.
risk factors: C/S, obesity, AMA over 35 yrs, h/o DVT, DM,
smoker, varicose veins
Clinic al m anifestations
1.
superficial-pain/tenderness/warmth/redness
2.
3.
pulmonary-dyspnea/tachypnea/apprehension/cough
tachycardia/hemoptysis/pleuritic chest pain
162
III.
3.
4.
5.
6.
Infections
A.
Risk Fa ctors
-C/S
-prolonged labor
-poor health status
-OB trauma
-pre-existing vag. infection
-manual removal of placenta
B.
-PPROM
-multiple vaginal exams
-FSE/IUPC
-chorioamnionitis
-vacuum/forceps delivery
-lapse in aseptic technique
Classific ations
1.
puerperal sepsis-any infection of genital canal within
6 weeks of miscarriage, abortion, or birth
2.
3.
4.
wound infection
a.
often develops at home
b.
C/S site, episiotomy, laceration site
c.
broad-spectrum abx may be used
5.
UTIs
a.
occur in 2-4% of PP women
b.
risk factors: Foley, epidural, freq. exams, C/S
c.
most frequent culprit: E. coli
163
6
6.
C.
D.
IV.
mastitis
a.
affects 5-10%, most first-time mothers
b.
develops unilaterally
c.
usually Staph aureus, E. coli, Streptococcus
d.
if organism is Candida oral thrush in babies
M anifestations
1.
fever, chills,
2.
3.
4.
5.
redness, warmth
sed rate
3.
4.
5.
6.
7.
Psychiatric disorders
A.
PP Blues
1.
50-80% of women experience the baby blues
2.
3.
164
B.
4.
5.
etiology unknown
6.
7.
8.
9.
3.
4.
5.
6.
7.
8.
9.
10.
Tx
a.
b.
c.
d.
psychotherapy
antidepressants
anxiolytic agents
electroconvulsive therapy
165
8
C.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
166
9
V.
B.
2.
premature labor/birth
3.
C/section
4.
5.
6.
7.
8.
9.
intense grief
a.
loneliness, emptiness, guilt, yearning, anger
b.
have to accommodate the changes the
loss has created-i.e. the nursery, clothes
c.
have to return to work-possibly meet
insensitive coworkers/family
d.
difficulty handling leakage of breast milk-a
reminder of loss
e.
guilt feelings may intensify if mother thinks she
is being punished for a prior bad act
f.
responses: anger, bitterness, resentment
167
10
g.
h.
3.
C.
reorganization
a.
search for a meaning to the tragedy
b.
improved function at home and work
c.
start to enjoy simple pleasures without guilt
d.
reestablishing relationships
e.
bittersweet grief-grief response occurring with
reminders of the loss
f.
grief can also be triggered by subsequent births
3.
4.
5.
6.
offer options
a.
see and hold the baby
b.
bath and dress the baby
c.
privacy
d.
visitation for other family/friends
e.
religious rituals
f.
special memorials/pictures
01/13
168
1
Disorders of the Female/Male Reproductive Systems
Le cture 12
I.
Breast Masses
A.
Scre ening for bre ast m asses
1.
Breast self exams
a.
best if done 5-7 days after menses has stopped
b.
if periods are not regular, chose the same day
each month
c.
while on back, palpate each breast in a circular
or vertical motion to cover whole breast
d.
use finger pads to ck for indentations, change in
contour/texture, lumps
e.
compress nipple to ck for discharge
f.
may also do while standing/in the shower
g.
note size and shape usually equal but not always
symmetrical
h.
vary with womans age, nutritional status, and
heredity
i.
contour should be smooth without puckering
or dimpling
j.
assess nipples for shape, direction, rashes,
ulcerations, and discharge
k.
90% of brst lumps found by women
-20-25% will be malignant
2.
B.
Exam by clinician
a.
usually done with yearly pelvic exam
b.
should not be on period at time of exam
c.
may request mammogram for women with
dense breast tissue or palpable changes
-mammograms-ACS guidelines
annually age 40 and over if healthy and with no
risk factors-sooner if risk factors present
169
2.
3.
Ductus ectasia
a.
inflammation of ducts behind nipple
b.
etiology-unknown
c.
occurs most often in perimenopausal women
d.
characterized by thick, sticky nipple discharge either white,
brown, green, or purple in color
e.
other S & S: burning pain, itching, palpable mass
behind nipple
f.
workup: mammo, aspiration, culture of fluid
g.
Tx: symptomatic
-no stimulation
-good breast hygiene
-I & D if abscess develops
-abx
-may need affected duct excised
4.
Intraductal papillomas
a.
found in women 30-50 years of age
b.
rare, benign lesion in the terminal nipple ducts
-may be too small to palpate (2-3 cm)
c.
may note nipple discharge-serosanguinous
d.
do fluid Pap smear of nipple discharge
e.
Tx: excision
170
3
C.
Bre ast c anc er- C anc er.org (Am eric an C anc er Society)
1.
Pathophysiology
a.
most common infiltrating ductal carcinoma
-abnormal cells grow in the epithelial cells which
line the mammary ducts
-needs 5-9 years to be palpable
b.
noninvasive if stays in duct (ductal carcinoma in situ or
DCIS)
c.
invasive if penetrates the tissue around the duct
d.
invasion of lymphatic channels/lymph ducts carry
abnormal cells to lymph and to metastatic sites
e.
staging of disease must include lymph node examination,
especially axillary nodes
f.
metastatic sites include bone, lungs, brain, liver
2.
Etiology/risk factors/incidence
a.
exact cause unclear
b.
risk with of womans age
c.
other risk factors-family history
-previous h/o brst CA
-family history
-h/o ovarian, endometrial, colon, or thyroid CA
-early menarche (before age 12)
-later menopause (after age 55)
-nulliparity
-first preg. age 3
-HRT
-obesity
-h/o benign breast disease with hyperplasia
-Caucasians
-African-Americans have a higher mortality rate due to late
diagnosis
-sedentary lifestyle
-high SES
d.
incidence
-in US, 1 out of 8 women will develop brst CA
-risk factors help identify less than 30% of women
-5% of brst CA attributed to heredity
- risk for women with abnormal BRCA1/BRCA2 genes
-testing expensive
-often not covered by insurance
-debate R/T prophylactic mastectomies
or Tamofixen use
- risk of brst CA with use of HRT
-occurs in men < 1 %
3.
Clinical manifestations
a.
physical
-most lumps in upper outer quadrant
-may feel lump or thickening of brst
-hard and fixed, soft and spongy
-well-defined or irregular borders
-may cause dimpling due to fixed to skin (orange peel)
-may have nipple discharge-bloody or clear
171
4
b.
c.
d.
e.
f.
g.
h.
i.
psychosocial
-denial
-grief and loss behaviors
mammogram/U/S/MRI
nipple discharge exam-culture/specimen to lab
ductogram-fine plastic tube placed into duct,
contrast media injected, assess duct
FNA
biopsy-aspiration or core-may use guide wire
Triple test-physical exam, mammogram, FNA
-if any benign-98% of lesion being benign
staging-TNM-T=size, N=nodes, M=metastases
-Stage 0-ductal carcinoma (in situ)-earliest form
-Stage 1-2 cm tumor/hasnt spread
-Stage 2-tumor >2 cm-in axillary nodes on same
side
-Stage 3-tumor >5 cm-spread to lymph nodeslocalized spread, no other organs
-Stage 4-metastasis to distant-bones, lungs, liver
lymph nodes not local
4.
Nursing diagnoses
a.
pain R/T surgical procedure
b.
risk for infection
c.
body-image disturbance R/T loss of body part
5.
Management
a.
surgery
-lumpectomy (tylectomy, partial mastectomy)
-removal of tumor
-removal of small surrounding area
-sampling of axillary lymph node
-doesnt effect pectoral muscle
-may follow-up with 6-7 weeks of
radiation
-modified radical mastectomy
-removal of entire breast
-sample of lymph nodes
-spares pectoral muscle
-risks: infections, hematoma
lymphadema, limitation of
arm/shoulder mobility
-sentinel lymph node biopsy (SLNB)
-radioactive tracer/dye injected
-carried by lymph to sentinel node
which is first node to receive
lymph from tumor
-most likely to contain metastasis if
CA has spread
-if sentinel node is cancerous, more
nodes are excised
172
b.
c.
6.
II.
-reconstructive surgery
-goal is achievement of symmetry with
preservation of body image
-3 types of autologous flap reconst.
-latissimus dorsi
-TRAM-transverse rectus
abdominis myocutaneous
-inferior gluteus free
-monitor skin flap for cap. refill,
hematoma, infection, necrosis
-may also receive breast expanders implants
adjuvant therapy-radiation
-after lumpectomy in non/microinvasive cases
-any invasive ductal carcinoma <1 cm diameter
-interstitial or balloon brachytherapy
-intraoperative radiation
adjuvant therapy-drug therapies
-chemotherapy started soon after dx
-most useful in premenopausal women with
brst CA with + nodes
-can increase time without CA
-may be given alone or with HRT
-tamoxifen attaches to hormone receptor
on CA cell-cell unable to grow
-side effects-leukopenia, neutropenia, anemia,
thromobocytopenia, GI problems, hair loss
Discharge planning
-resources
ACS Reach for Recovery program
NCCN-National Comprehensive Cancer Network
ACS home page
173
j.
2.
3.
174
7
4.
5.
B.
Chancroid
Granuloma inguinale
175
2.
Gonorrhea
a.
caused by Neisseria gonorrhoeae-bacteria
b.
600,000 contract gonorrhea each year
c.
rising incidence of drug-resistance
d.
transmission: oral, genital, anal
e.
higher incidence in people under 20 years old
f.
higher incidence in African-Americans
g.
women most often asymptomatic
h.
may present with pain/burning with urination,
vaginal discharge, low back pain
h.
men may c/o pain with urination and yellowish
discharge from penis
i.
may take up to 3-10 days before symptoms present
j.
screening: cultures taken from endocervix,
rectum, and possibly pharynx
k.
people are frequently coinfected-should be
tested for other STIs
l.
management: usually single dose antibiotic:
ceftriaxone
m.
45% women will also have chlamydia so should
have concomitant tx
3.
Chlamydia
a.
caused by Chlamydia trachomatis
b.
most common/fast spreading STI in women
c.
untreated leads to PID and acute salpingitis
d.
may caused ulcers on the cervix increasing
risk to acquire HIV
e.
higher incidence in women under age 20
176
9
f.
g.
h.
i.
j.
k.
l.
m.
n.
4.
177
10
o.
p.
q.
III.
Gynecologic Disorders
A.
Postm enop ausal ble e ding-ble e ding 12 months post m enses
c essation
1.
Related factors
a.
atrophic vaginitis-tissues more sensitive, bleed
easily
b.
polyps-masses in/on the cervix
c.
endometrial problems
-endometrial hyperplasia may be a precursor to
endometrial CA-need a D & C to evaluate
d.
ovarian function
estrogen/progesterone
2.
Management
a.
for vaginitis-use of creams to protect tissues
b.
for polyps-removal
c.
HRT
3.
178
11
h.
B.
MI
emboli
thromboses
long term-may use estrogen alone or in
combination with progesterone or
testosterone
-may be continuous or cyclic
Endom etriosis
1.
Assessment
a.
benign disease characterized by implantation
of endometrial tissue outside the uterus
b.
implanted on the ovaries, cul-de-sac, uterine
ligaments, rectovaginal septum, sigmoid
colon, pelvic peritoneum, cervix, and
inguinal area
c.
endometrial lesions can be found in the vagina,
surgical scars, vulva, perineum, bladder,
and other sites such as thoracic cavity,
gallbladder and heart
d.
tissue responds to hormonal stimulation
e.
tissue bleeds during or after menses causing
inflammatory response by adjacent
organs/tissues
f.
can lead to scars and adhesions
g.
incidence
-10% in women of reproductive age
-25-35% infertile women
-28% of women with chronic pelvic pain
h.
each year account for almost 50,000
hysterectomies
i.
may remain asymptomatic and disappear
after menopause
j.
may worsen with repeated cycles
k.
found across all SES levels
l.
most widely accepted cause-retrograde
menstruation
-estimated to occur in 96% of women who
menstruate
m.
possible reasons why some women develop the
condition
-individual immune system fails to destroy tissue
-differences in genetic make-up
-environmental challenges
n.
S&S
-pain (dysmenorrhea)-possibly prior to menses
-lower abdomen pain
-dyspareunia
-painful defecation
-hypermenorrhea
-sacral back pain
-infertility
179
12
2.
C.
Management
a.
NSAIDs
b.
suppression of endogenous estrogen production
m e dic ally induc e d m enop ause
-GnRH agonists
(gonadotropin-releasing hormone)
i.e. Lupron, Synarel
pituitary gonadotropin secretion
FSH/LH stimulation of ovaries
ovarian function hot flashes, vaginal
dryness
limited to 6 months R/T bone loss
potential teratogen
-androgen derivatives
Danocrine (danozol)
suppress FSH/LH secretion
produces anovulation
regression of endometrial tissues
may produce masculinizing traits
weight gain
edema
deepening of voice
oily skin
hirsutism
in brst size
other side effects
H/A
hot flashes
vaginal dryness
libido
insomnia
fatigue
dizziness
HDLs
LDLs
contraindicated-h/o liver disease
use with caution if h/o heart or renal
disease
fetus-pseudohermaphroditism
c.
may use OCs with low E to P ratio
to shrink endometrial tissues
SE: N & V, bleeding, edema
d.
mifepristone (RU-486) being used with success
e.
surgery-nd to consider age, desire for children,
location of disease
-TAH-BSO
-laser surgery to remove adhesions/tissue
f.
40% reoccurrence-except in TAH-BSO cases
Possible causes
a.
anovulation-polycystic ovary syndrome
b.
pregnancy-related-SAB
c.
genital infections-chlamydial cervicitis
d.
neoplasms-CA of cx
180
13
e.
f.
g.
D.
trauma-foreign body
systemic diseases-DM
iatrogenic-herbal preparations-ginseng
3.
4.
Incidence
a.
teens-20%
b.
women under 50-50%
5.
Management
a.
oral cong. estrogen X 21 days with progesterone
(medroxyprogesterone-Provera) added for the
last 7-10 days
b.
low dose OCP
c.
ablation of endometrium
d.
hysterectomy
181
14
e.
2.
E.
etiology unknown
heavy gray frothy malodorous D/C
tx-oral metronidazole-Flagyl
antiprotozoal/antibacterial
contraindicated in women
who breast feed
may affect the CNS and
hematopoietic systems
with alcohol-can cause abdominal
distress, N & V, H/A
-trichomoniasis-anaerobic protozoan
may be asymptomatic or have frothy
musty-smelling discharge
itching on or around the vagina
spotting, urinary urgency
tx-Flagyl-tre at both p artners
since a STI-should screen for other STIs
atrophic vaginitis-irritation without discharge
-lack of estrogen due to childbirth, menopause,
bilateral oophorectomy, radiation tx
-estrogen creams restore lubrication and
decrease soreness/irritation
182
15
d.
e.
F.
tx: -pessaries
-estrogen creams
-abdominal/vaginal hysterectomy
education: use of Kegel exercises to strengthen
pelvic floor muscles
2.
Cystocele
a.
downward displacement of bladder-bulge
in anterior vaginal wall
b.
causes: genetics, obesity, childbirth, advanced
age
c.
S & S: urinary incontinence, vaginal fullness
bulge in vaginal wall
d.
complete emptying of bladder difficult R/T the
cystocele sags below the bladder neck
e.
tx: vaginal pessary or surgical repair
colporrhapy (anterior repair)-shortens
pelvic muscles to better support bladder
3.
Rectocele
a.
herniation of anterior rectal wall
b.
may lead to constipation, hemorrhoids, fecal
impaction, feeling of vaginal/rectal fullness
c.
found by rectal exam or barium enema
d.
need to promote bowel elimination
e.
surgery-posterior colporrhaphy or A & P repair
f.
follow surgery with low residue diet
183
16
2.
G.
Cervicala.
3rd most common CA of reproductive tract
b.
risk factors
-age (50-55)
-early childbearing
-non-Caucasians
-smoking
-multiple sexual partners
-HPV G ard asil va c cine
c.
testing
-Pap smear
-colposcopy
-punch biopsy
-ECC
d.
staging:
Stage 0-carcinoma in situ-superficial
Stage 1-invaded the cervix without spreading
Stage 2-CA has spread but remains in pelvis
-5 year survival rate 65-80%
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e.
3.
Ovariana.
most often occurs in 5th decade (age 45-65)
b.
most occur after menopause
c.
risk factors
-fertility drugs
-early menstruation
-nulliparity
-high fat diet
-smoking
-alcohol
-1st child after age 30
-h/o breast, colon, or endometrial CA
-family h/o breast or ovarian CA
d.
risk
-use of OCs
-h/o BTL
-BSO
e.
5 year survival rate-90% (Stage 1), 10% (Stage IV)
-discovery of CA not until advanced stage
f.
S&S
-irregular menses
-PM tension
-menorrhagia
-breast tenderness
-early menopause
-abdominal discomfort
-dyspepsia
-pelvic pressure
- abdominal girth
-urinary frequency
g.
in 75% of cases, CA had metastasized before dx
-60% beyond the pelvis
h.
dx: transvaginal U/S, laparoscopy, laparotomy
i.
tx:
-TAH/BSO
-tamoxifen
-chemo
-radiation
j.
CA 125-associated with various epithelial CA
may be used to assess response to tx
in women with known ovarian CA
4.
Vulvar
a.
90% squamous cell carcinomas
b.
accounts for 4% of Gyn malignancies
c.
more than 50% of cases occur in
postmenopausal women (age 65-70)
d.
usually localized, slow-growing, and marked
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18
e.
f.
g.
IV.
Pathophysiology
a.
germinal-sperm-producing cells-95%of cases
-2 types
seminomas- (40%)
-occur in men late 30s to early 50s
-localized-grow slow
-metastasized later
-response well to radiation
-5 year survival rate-95% with
surgery and radiation
nonseminomas-not sensitive to radiation
-occur in men late teens to early 40s
-need surgery or chemo
-embryonal carcinomas
common in men 19-26 yrs old
may spread via bloodstream
-teratomas
rarely occur
often mixed with other tumors
-choriocarcinomas
lethal, fast spreading
initial dx often in metastatic
stage
-25%-teratocarcinomas
b.
stromal-hormone producing
-interstitial cell tumors(arise from Leydig cells)
androgenic hormone secretions
rare, usually benign
-androblastomas
rare, usually benign
may secrete estrogen-feminization
gynecomastia
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19
3.
Causes
a.
mainly unknown
b.
may be R/T cryptorchidism
-if develops CA, 75% will be in the undescended
testis (assoc. with seminomas)
c.
may be R/T trauma, infection
4.
Testing
a.
tumor marker study
-benign tumors never elevate marker proteins
-AFP and HCG-for nonseminoma
-in seminomas- hCG/LDH but not AFP
if AFP, think mixed tumor-diff. Tx
-if tx effective, markers should fall
b.
CT scan, U/S
c.
Chest x-ray to r/o metastasis
d.
lymphangiography to ck retroperitoneal
lymph nodes
5.
Physical exam
a.
palpate for lump
b.
may see painless enlargement
c.
heaviness, dragging sensation
d.
dull ache in abdomen, inguinal
6.
Nursing diagnosis
a.
risk for sexual dysfunction R/T disease/surgery
b.
dysfunctional/anticipatory grieving
c.
disturbance of body image R/T dx and tx
d.
acute/chronic pain
e.
anxiety R/T dx of cancer
7.
Management
a.
sperm banking-before radiation and chemo
b.
chemo
c.
radiation-seminomas
-used after orchiectomy
-external beam therapy
nonseminomas-radical lymph node
dissection saves sympathetic ganglia
d.
stem cell transplantation-used with chemo to
help prevent infection/anemia
e.
unilateral orchiectomy
f.
radical retroperitoneal lymph node dissection
-helps to stage the disease and reduce tumor
8.
Post-op teaching
a.
watch for fever, chills, increasing tenderness,
pain around the incision, drainage, or
dehiscence of the incision
b.
no stair climbing or heavy lifting (>20 lbs)
c.
resume normal activities 1 week after discharge
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20
d.
B.
Spermatocele
a.
sperm-containing cystic mass on the epididymus
alongside the testicle
b.
usually small/asymptomatic-no intervention
c.
may be excised thru small incision in scrotum
3.
Varicocele
a.
cluster of dilated veins posterior/above testis
b.
uni or bilateral
c.
usually asymptomatic-no tx
d.
if painful-surgically removed
-inguinal incision
-may need to elevate scrotum with towel when
in bed to help with drainage
e.
can cause infertility by scrotal temperature
4.
Scrotal trauma
a.
torsion of testes-twisting of spermatic cord
-considered a surgical emergency
-S & S-pain, N & V
b.
ice, elevate, avoid heavy lifting, scrotal support
Cryptorchidism
a.
undescended testis
b.
mainly a pediatric problem
-3% full term males
-20% male premies
c.
80% will spontaneously descend
d.
orchidopexy-surgical placement of testis
into the scrotum
5.
6.
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21
7.
Phimosis
a.
prepuce constricted-cant retract over glans
b.
tx-circumcision
8.
Priapism
a.
uncontrolled, prolonged erection
b.
penis remains large, hard, and becomes painful
c.
causes
-neurological -vascular
-pharmacological
d.
urologic emergency
e.
need to improve venous drainage to corpora
cavernosa
f.
tx: Demerol, warm enemas, catheter, aspiration
of corpora cavernosa
9.
Epididymitis
a.
infection of the epididymis-tx with abx
b.
may come from infection of the prostate
c.
men under 35 yrs, chlamydia trachomatis
d.
c/o pain along inguinal canal and vas deferens
e.
may have pain and swelling of the scrotum
f.
if untreated, pyuria and bacteriuria may develop
g.
abscess may form necessitating an orchiectomy
10.
Orchitis
a.
acute testicular inflammation
b.
results from infection or trauma
c.
caused by bacteria from urethra or other
sources
d.
may be uni or bilateral
e.
risk for sterility R/T testicular atrophy
f.
tx: bedrest, scrotal elevation, ice, analgesics,
and antibiotics
g.
mumps orchitis-20% of males who have mumps
after puberty-given gamma globulins
-childhood vaccination is a good preventative
measure
11.
Prostatitis
a.
may be bacterial or abacterial (more common)
b.
abacterial-after a viral illness or assoc. with STI
-also called prostatodynia
c.
bacterial-assoc. with urethritis
-common bad guys-E. coli, Proteus, Enterobacter
and group D streptococci
-S & S-fever, chills, dysuria, urethral discharge,
and boggy, tender prostate
d.
can lead to inflammation of the bladder and
epididymus
e.
sexual dysfunction may occur R/T pain
f.
tx: antimicrobials-Geocillin, Cipro
g.
encourage sitz baths and completion of meds
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h.
i.
j.
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190
1
Infertility and Genetics
Le cture 13
I.
B.
2.
3.
Risk Fa ctors
1.
Females
a.
abnormal external genitals
b.
abnormal internal reproductive structures
c.
anovulation
-pituitary/hypothalamus hormone disorders
-adrenal gland disorders
d.
amenorrhea after stopping OCP
e.
early menopause
f.
increased prolactin levels
g.
tubal motility reduced
h.
inflammation within the tube
i.
tubal adhesions
j.
endometrial/myometrial tumors
k.
Ashermans syndrome-uterine adhesions/scars
2.
Males
a.
undescended testes
b.
hypospadias
c.
varicocele
d.
low testosterone levels
e.
testicular damage-trauma, mumps
f.
endocrine disorders
g.
genetic disorders
h.
STIs
i.
exposure to hazardous substances
j.
change in sperm
-smoking, heroin, marijuana, amyl nitrate, butyl
nitrate, methaqualone
1
191
k.
l.
m.
n.
C.
decrease in sperm
-hypopituitarism
-chronic disease
-gonadotropic inadequacy
obstruction of the vas deferens or epididymis
decreased libido
impotency
C omponents of Fertility
1.
Sperm viable in female reproductive tract for up to
48+ hours
-fertility potential-24 hrs
2.
3.
4.
5.
192
3
microscope
-sperm immobilization antigen-antibody reaction
-assessment of cervical mucus
spinnbarkeit-the formation of thread by
mucus from the cervix when spread on
a glass slide and drawn out by a cover
glass
-U/S dx of follicular collapse
-serum assay of plasma progesterone
-hormone analysis
estrogen, progesterone
FSH, LH
thyroid
-basal body temperature (BBT)
biphasic- temp 12-14 days before menses
ck temp before rising
0.5-1.00 rise=surge of LH, progesterone
ova released 24-36 hrs before temp
intercourse-3-4 days prior to 2-3 after
-endometrial biopsy
-laparoscopy
-U/S
6.
D.
Nonmedical therapies
a.
water soluble lubricants
b.
change to boxer shorts
c.
use of condoms if woman has immunologic
3
193
4
reaction to sperm-will reduce antisperm
antibody production
3.
Medical therapies
a.
ovulatory stimulants
-Clomid (clomiphene) stimulates the ovarian
follicle
-multifetal rates-less than 10%
-Parlodel (bromocriptine) inhibits release of
prolactin (elevated levels of prolactin have
an amenorrhea effect on the body)
-Bravelle, Menopur (human menopausal
gonadotropin)
extremely potent
requires daily monitoring
daily IM for 7-14 days-first half of
cycle
incidence of multifetal > 25%
-HCG-may be given to induce ovulations
after ovaries stimulated with HMG
-GnRH (gonadotropin-releasing hormone)
used with hypothalamic-pituitary
dysfunction or failure to respond
to clomiphene
b.
hormone replacement therapy
-use conj. estrogen and medroxyprogesterone
c.
male tx
-thyroid/adrenal gland correction
-abx for STI
-clomiphene-unsure effectiveness
-HCG-stimulates androgens- spermatogenesis
4.
Surgical treatments
a.
excise ovarian tumors
b.
removal of adhesions
c.
hysterosalpingography-may unblock tubes
d.
if uterine cavity too small to carry pregnancy,
no medical tx available-each successive
pregnancy enlarges uterus
e.
may be able to reconstruct uterus R/T bicornuate
f.
myomectomy
g.
chemo/thermocautery to eliminate chronic
inflammation and infection
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5
5.
E.
II.
Reproductive alternatives
a.
assisted reproductive alternative
(higher risk for ectopic)
-IVF-ET-in vitro fertilization-embryo transfer
-GIFT-gamete intrafallopian transfer
*after ovulation, ova and sperm moved into tube
-ZIFT-zygote intrafallopian transfer
-ovum transfer (oocyte donation)
-embryo adoption
-intracytoplasmic sperm injection
-assisted hatching
-TDI-therapeutic donor insemination
b.
preimplantation genetic diagnosis
-eliminate defect embryos before implantation
c.
surrogate mothers
-use surrogates ova and husbands sperm
-use mothers ova and husbands sperm
d.
adoption
Decisional conflict
3.
4.
195
6
2.
Chromosomes
a.
karyotype-pictorial analysis of chromosomesusually from peripheral blood but may
come from any body tissue
b.
autosomal chromosomes-22 pairs
control traits of the body
c.
sex chromosomes-pair 23
determines sex
controls some other traits
XX-female
XY-male
d.
dominant gene-their trait is expressed over
another (A A or A a)
e.
recessive gene-only expressed when another
another recessive is present (a a)
f.
terms-allele-gene that determines a specific trait
each trait has a pair of alleles
genotype-genetic makeup of an individual
phenotypephenotype-expression of genes function
either measurable or observed
homozygoushomozygous-has identical alleles on
each chromosome in the same locus
hetrozygoushetrozygous-2 different alleles at a given
locus
3.
196
7
impaired intelligence
most affected embryos SAB
-47XXY-Klinefelters
poorly developed secondary sexual
characteristics
small testes-infertile
tall, effeminate
subnormal intelligence usually present
4.
B.
Patterns of Inheritanc e
1.
Multifactorial
a.
combination of genetic and other factors such
as environment
i.e.: cleft lip/palate, neural tube defects
b.
malformation may be mild to severe depending
on # of genes affected
c.
tend to occur in families
d.
some malformations more common in one sex
e.
polygenic, multifactorial diseases: coronary
artery disease, obesity, HTN, psychiatric disorders
2.
Unifactorial-Single-gene disorders
a.
one gene controls a particular trait, disorder, or
defect
b.
# of unifactorial abnormalities exceed the # of
chromosomal abnormalities
-50-100,000 genes in 23 chromosomes
c.
autosomal dominant inheritance
-abnormal gene with trait is expressed even with
a normal member of the pair-no carriers
-mutation of the gene-spontaneous, permanent
change
-affected individual comes from a family with
generations of the disorder-50% chance of
have mutant allele if parent was affected
7
197
d.
e.
f.
C.
Testing
1.
Prenatal testing-see booklet
a.
MSAFP
b.
CVS/amniocentesis
c.
blood tests for:
-Tay-Sachs
-Sickle Cell Anemia
-Thalassemia
-Cystic Fibrosis
d.
U/S-fetoscopy
2.
198
9
g.
D.
biotinidase deficiency-neurologic
Nursing roles
a.
identify risk factors
b.
identify physical/developmental abnormalities
c.
assess need for referral
d.
prepare for genetic counseling
e.
correct misconceptions
f.
demonstrate support and sensitivity
g.
explain typical outcomes
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