3.2b Care Management Flashcards
Prenatal Care
- Promotes health of baby and family in office or health center
- Education on healthy lifestyles (nutrition and physical activity)
- Self-care for common pregnancy discomforts
- Information about changes in mother and development of fetus
- Routine screenings for risk factors and potential problems
- Emphasis on preventative care
Reasons people delay prenatal care
- Cost
- Lack of insurance
- Lack of childcare
- Transportation barriers
- Inability to take off work
- Lack of culturally sensitive providers
- Discrimination based on sexual orientation
- Barriers to communication
- Cultural differences regarding perceived value of prenatal care
Prenatal Visit Schedule
By Week 12 - First visit within the first trimester
Week 16-28 - Monthly Visits
Weeks 29-36 - Every 2 weeks
Weeks 36 - Weekly Visits
Group Prenatal Care
- Alternative to prenatal visits
Preconception Care (Important for Pregnancy Outcomes)
- Good Nutrition
- Entering pregnancy with healthy weight
- Adequate intake of folic acid
- Avoidance of alcohol and other substances
- Prevention of STI’s
- Special needs for women with chronic diseases such as DM
INITIAL PRENATAL VISIT
Prenatal Interview
- Therapeutic relationship built between woman and nurse
Reason for seeking Care
- Why the patient has come in
Current Pregnancy
- Signs of pregnancy such as nausea or vomiting
- Review of systems
- Early teachings
Childbearing and Reproductive System History
- Age at menarche (first menstrual period)
- Menstrual history
- Contraceptive history
- Infertility or reproductive system conditions
- History of STI’s
- Sexual history
- Detailed history of all pregnancies
- Date of last pap test
- Date of LMP to obtain EBP
Health History
- Physical condition and surgical procedures
- History of allergies and reactions
- Medication use
- Immunizations
Nutritional History
Diet assessment reveals
- Special dietary practices
- Food allergies
- Eating behaviors
- Practice of PICA
- BMI should be assessed to counsel weight gain, physical activity, and healthy food choices
Medication History
- OTC, vitamins, herbs, caffeine, alcohol, tobacco, drugs Immunizations should include - Rubella (German Measles) - Varicella (Chicken Pox) - Season influenza - Hepatitis B - Pertussis (whooping cough)
Family HIstory
- Information about immediate family (parents, siblings, children)
- Family history of patients partner (if the partner is the father)
Social, experimental and occupational history
- Ethnic/cultural background and socioeconomic status
Remain alert for potential parenting issues - Depression, lack of family support, inadequate living conditions, attitude towards health care, expectations of HCPs, patient view of patient-nurse relationship
Assessing patient knowledge in various areas - Pregnancy, maternal change, fetal growth, self-care, concerns and desires related to labor, understanding of newborn care, plan for infant feeding, attitudes towards medicated birth, knowledge of available parenting skills, decision making abilities and lifestyles such as exercise, sleep, diet, recreational interests, person hygiene.
Mental Health Screening
- All pregnant patients should be screened for mental health
- Perinatal depression is the most common complication of pregnancy
- RISK FACTORS
- Lack of support from partner
- Inadequate social support
- History of intimate partner violence
- Personal history
- Pregnancy complication or loss
- Stressful life events
Risk of Intimate Person Violence
- Abuse Assessment Screen is the most widely used tool
- Nurses can ask patients screening questions as routine assessments of pregnancy
Review of Systems
- For each system problem describe Onset Location Duration Characteristics Aggravating or relieving factors Treatments Associated symptoms
Physical Examination
- Provides baseline for subsequent changes
- BP should be measured every visit seated position with back and arm support
Lab Tests
- HIV
- Syphilis
- Hepatitis B
- Chlamydia or Gonorrhea
- The above are repeated at 3rd trimester for high risk patients
- Tuberculin test
Urine Test
(Protein, glucose, leukocytes, urine culture if indicated) - Pap test
- Genetic testing
Human Trafficking
- Use of force, fraud, or coercion to compel a person into commercial sex acts or labor against their will.
- Inducing a minor into commercial sex is human trafficking regardless of force
Action-Means-Proposal Model (AMP)
- Trafficker takes action and employs means of force for the purpose of compelling victim to provide labor services
- One of each element must be present to establish human trafficking
After First Interview
Follow up visits
- Briefer and less intensive than the initial visit
- Patient is asked to summarize relevant events that have occurred since previous visit
ASK ABOUT - Mood swings
- Reaction to changes in body image
- Bad dreams
- Worries
- Reactions of the partner and family member to the pregnancy
- Warning signs of emergency
- Signs of preterm and term labor
- Labor process
- Concerns about labor, fetal development, or methods to assess fetal well-being
- Whether patient is planning to attend child birth preparation classes
- Management of discomfort during labor
Physical Examination
- BP and weight
- Appropriate gestational weight gain
- Urine checked by dip stick
- Presence and degree of edema
- Supine Hypotension (low BP from lying on back)
LAB TESTS
Hemoglobin, Hematocrit, WBC, Differentials
- Detects anemia and infections
Hemoglobin Electrophoresis
- Identifies patients with hemoglobinopathies
Blood Type, RH, and Irregular Antibodies
- Patients whose fetuses are at risk for erythroblastosis fetalis or hyperbilirubinemia in neonatal period
Rubella Titer
- Determines immunity to Rubella
Tuberculin Test
- Screens for exposure to tuberculosis
Urinalysis
- Identifies patients with glycosuria, renal disease, hypertensive disease, disease of pregnancy, infection, occult hematuria, hCG for confirmed pregnancy
Urine Culture
- Identifies asymptomatic bacteriuria
BUN, Creatinine, Electrolytes, Creatinine Clearance, Total Protein Excretion
- Identifies level of renal compromise in diabetes patients
- Hypertension
- Renal Disease
Pap test
- Screens for cervical intraepithelial neoplasia and HPV
Cultures for gonorrhea and chlamydia
- Screens for asymptomatic infection
Vaginal/Anal culture
- GBS test done at 35-57 weeks for infection
RPR, VDRL, FTA-ABS
- Identifies untreated syphilis
HIV antibodies, Hepatitis B surface antigen, toxoplasmosis
- Screens for specific Infections
1-H Glucose Tolerance
- Screens for gestational diabetes
- Done at initial visit (for patients with risk factors)
- Done at 24-28 weeks for patients who came out negative but were at risk, or for first timers
3-H Glucose Tolerance
- Tests for gestational diabetes in patients with elevated glucose levels after 1-H test
- Must have 2 elevated readings for diagnoses
ECG, Chest X-Ray, Echocardiogram
- Evaluates cardiac function for patients with history of cardiac disease or hypertension
FETAL ASSESSMENT
Gestational Age
- Determined by menstrual history, contraceptive history, pregnancy test results, and findings
- Date/Size of first uterine evaluation
- Date and method of first fetal heartbeat
- Date of first feelings of fetal movement (quickening)
- Current fundal height and estimated fetal weight (EFW)
- Current week of gestation by history of LMP or ultrasound
Fetal Heart Tones
- Can be detected with ultrasound early in pregnancy
- Can be heard with doppler in late first trimester
Health Status
Determined By
- Fetal Movement
- Gestational hypertension
- Intrauterine growth restriction (IUGR)
- Prelabor rupture of membranes (PROM)
- Irregular or absent FHR
- Decreased or absent of movement after quickening
Fundal Hieght
- Uterus becomes abdominal organ during second trimester
- Measured by height of uterus above symphysis pubis
- Measurement provides estimation of duration of pregnancy
- Weeks 18-30 height of fundus in CM is same as weeks of gestation
- If bladder is empty at time of measurement, stable or decreased fundal height can indicate IUGR
- Excessive increase in height can mean multiple gestation or polyhydramnios (too much amniotic fluid)
Lab Tests
- Streptococcus (GBS) is recommended week 35-37
Genetics Screening
- Identify risks of inherited medical conditions and genetic disorders
Aneuploidy
- Can detect down syndrome
Non-Invasive Cell-Free DNA Testing (cfDNA)
- Early as 10 weeks to identify trisomies (chromosomal disease)
- ## Can indicate sex of baby
Maternal Serum AFP (MSAFP) Levels
- Screening for neural tube defects done in second trimester
Sequential Screening
- Done if risk of aneuploidy (down syndrome) is detected
Routine Fetal Ultrasound Examination
- Done to establish gestational age in first trimester
- Fetal autonomy scan done between 18-22
Ultrasonography
- Detects number of fetuses
- Fetal presentation
- Fetal biometry
- Location of placenta
- Amniotic fluid volume
- Cardiac activity
Personal Hygiene
- Extra important because apocrine (sweat) glands are hyperactive during pregnancy due to hormonal changes
Prevention of UTI
- Acute Urethritis
- Acute Cystitis
Commonly caused by Escherichia Coli
Symptoms
- Urinary frequency, urgency, hesitancy
- Dysuria, dribbling, gross hematuria
- Use appropriate hand hygiene, wipe perineum from front to back, bubble baths should be avoided, wear all cotton undergarments, cotton lined pantyhose, avoid tight jeans for long periods of time, drink at least 8-10 glasses of water a day, do not ignore need for urination, urinate before and after sex.
Kegel Exercises
- Results in fewer complaints of urinary incontinence in late pregnancy and post partum
Breast Feeding
- Education on benefits of breast feeding
- Denial of breast feeding is due to modesty issues, lack of support from partner, incompatible lifestyle, lack of confidence
- Breast assessment
Scars - Breast reduction surgery can affect milk production
Implants
Tubular shaped breasts - lack of glandular tissue
Flat or inverted nipples
Preparation includes cleansing of nipples (do not use soap, ointments, alcohol, tinctures)
Umbilical Cord Blood Banking
- Contains Hematopoietic Stem Cells
- Potential treatment of inborn metabolism errors, types of leukemia, immune system disorders, regenerative processes, and infectious disease
Oral Health
- Increased risk of gingivitis (inflammation of gums) and periodontitis (infection of gums)
- Periodontal disease could cause pre-term birth, LBW, preeclampsia and gestational diabetes
Physical Activity
- Minimal risk
- Promotes well-being, relaxation, rest
- Reduces risk of gestational diabetes, c-sections, LGA infants (Large gestational age)
Rest and Relaxation
- Side-lying position is recommended
- Rising slowly prevents strain on back and minimizes orthostatic hypotension
Conscious Relaxation - Deliberate release of tension
- Relieves normal discomfort
- Reduces stress and pain
- Heightened self-awareness
- Cope with stress and everyday life
Employment
- No adverse effects on pregnancy
- Exposure to toxins would be means to quit
- Walk around in sedentary jobs to counter sluggish leg circulation
- Avoid crossing legs at knees which increases risk of thrombophlebitis (swelling of vein)
- Avoid standing too long which can cause pre-term labor
Clothing
- Wear comfortable clothing with elastic hose to improve venous emptying
- Comfortable shoes with firm support promote good posture and balance
Travel
- Not contraindicated in low risk women
- High risk women should not travel
- Do not travel to areas where healthcare is poor
- Patients should assess healthcare to the places they travel
- Avoid prolonged periods of sitting in planes or cars as it increases risk of venous stasis and thromboembolism
- Always wear lap belt and harness
- Air travel up to 36 weeks of gestation domestic and 32-35 for international
Medication and Herbal Remidies
- Greatest risk of defects is in first trimester
- Self treatment with all drugs is discouraged
- Limited research on herbal preparations, should be discussed with PCP
Immunizations
Live vaccines are contraindicated in pregnancy
- Measles (rubella)
- Varicella
- Mumps
- Sabin Poliomyelitis
Vaccines okay during pregnancy
- TDAP (should be administered 27-36 weeks each pregnancy regardless of prior history)
If not given during pregnancy should be given immediately post-partum
- Recombinant Hepatitis B
- Influenza
Rh Immune Globin
- rH negative mothers carrying rH positive baby can develop antibodies against fetal blood cells causing lysis of blood cells
- This is when Rh immune globin should be administered
Recognizing Potential Complications
- Patients should be given printed warning signs
- Dangerous signs are vaginal bleeding, alterations in fetal movement, symptoms of preeclampsia, rupture of membranes, preterm labor
Psychosocial Support
Support - Satisfaction with partner and family Concerns - Fetal response to stimuli - Fetal patterns of waking and sleeping - Fear of loss of control - Birth of infant before reaching hospital Anxieties - Parenthood - Siblings acceptance of new baby - Social/Economic Responsibilities - Concerns about fathers commitment to relationship
EDB
- Most patients give birth within 1 week before to 1 week after of their EDB
Weight Gain
- Patient will gain 1-2.5 kg during their first trimester
Intervention - Assess current weight and diet history
- Teach patient about nutritional needs and recommended weight gain
- Advise to call HCP if vomiting and nausea persists
Fatigue Related to Pregnancy of Hormones
- Patient reports decreased fatigue after modifications to lifestyle with more rest periods
- Ask patient to describe their fatigue in terms of severity and how they deal with it
- Discuss support systems
Constipation
- What has the patient done to treat constipation
- Promote proper diet such as 8-10 glasses of water, increased fiber, and moderate exercise
- Patient should not use medications without consulting their doctor
Interrupted Sleep
- Assess what causes interruption in sleep
- Suggest sleeping in left lying with pillows between legs or semi-fowler
- Sleep aids such as reading and decreased activity before bed
Breast Pain, Tenderness, Enlargement
- Wear supportive maternity bras to absorb discharge
- May be worn at night
- Wash with warm water
- May interfere with sex but is temporary
Urgency/Frequency of Urination
- Empty bladder regularly
- Preform kegel exercises
- Limit fluid intake before bed
- Avoid caffeine
- Wear perineal pad
- Report pain to OB
Fatigue
- Rest when needed and eat a balanced diet
Nausea/Vomiting (Morning Sickness)
- Avoid empty or overloaded stomach
- Maintain good posture
- Eat dry carbohydrates upon awakening
- Remain in bed until nausea subsides
- Eat 5-6 small meals a day
- Avoid fried, spicy, greasy foods
- Wear acupressure bands to treat motion sickness
- Vitamin B6/doxylamine if weight loss occurs
Ptyalism (excess salivation)
- Use astringent mouth wash
- Chew Gum
- Eat hard candy for comfort
Gingivitis
- See dentist early in pregnancy
- Eat a well balanced diet
- Brush teeth gently with soft toothbrush
Epistaxis (nosebleed) or congestion
- Use humidifier
- Avoid trauma
- Normal saline nose drops
Leukorrhea (Vaginal Discharge)
- Not preventable
- Do not douche (wash inside of vagina)
- Wear perineal pads
- Wipe from front to back
- Report if accompanied by pruritis, foul odor, change in character or color
Mood Swings
- Participate in support groups
- Communicate concerns with partner, family, HCP
- Request financial assistance if needed
Spider Nevi and Pigmentations
- Not preventable
- Resolves during/after peurperium
Pruritis
- Contact OB for diagnosis
- Keep fingernails short
- Distractions
- Baths with sodium bicarbonate or oatmeal
- Lotion and oil
- Loose clothing
- Steroid cream if advised by doctor
Palpitations
- Contact PCP if accompanied with cardiac decompensation
Supine Hypotension (Inferior Vena Cava Syndrome)
- Side lying or semi sitting posture
Faintness/Syncope (Orthostatic Hypotension)
- Moderate Exercise
- Deep breathing
- Avoid sudden changes in position, warm or crowded areas
- Move slowly
- Eat 5-6 small meals a day to avoid hypoglycemia
Food Cravings
- Satisfy with well balanced diet
Heartburn
- Limit gas producing fatty foods and large meals
- Sip milk for temporary relief
- Drink hot herbal tea
Constipation
- Drink 8-10 glasses of water a day
- High fiber diet
- Moderate exercise
- Do not take medications without doctor approval
Flatulence
- Chew foods slowly and thoroughly
- Avoid gas producing foods
- Maintain moderate exercise
Varicose Veins (aching legs and tenderness)
- Avoid sitting or standing too long
- Moderate exercise
- Sitz bath to relieve swelling
Headaches (through week 26)
- Conscious relaxation
- Assess for preeclampsia
Carpal Tunnel Syndrome
- Elevate affected arms
- Splinting hand
- Regresses after pregnancy
Periodic Numbness
- Maintain good posture
- Wear supportive maternity bra
Round ligament pain (tenderness)
- Maintain good body mechanics
- Relieve cramping by squatting or bringing knees to chest
Joint pain/Back pain/Pelvic pressure
- Maintain good posture/body mechanics
- Avoid fatigue
- Sleep on firm mattress
- Pelvic tilt exercises
SOB/Dyspnea
- Sleep with extra pillows
- Avoid overloading stomach
- Stop smoking
Insomnia
- Conscious relaxation
- Support body parts with pillows
- No screens before bedtime
Mood Swings
- Reassure support from significant other and HCP
- Improve communication between family patient and partner
Perineal Discomfort/Pressure
- Conscious relaxation, good posture
Braxton Hicks Contraction
- Change position
- Breathing techniques
Leg cramps
- Stand on cold surfaces
- Dorsiflex foot until spasm relaxes
- Calcium carbonate with each meal (consult PCP)
Ankle Edema
- Ample fluid intake for diuretic effect
- Supportive stockings
- Rest periodically
- Exercise moderately
CAUSES OF SIGNS AND SYMPTOMS
Persistent severe vomiting
- Hyperemesis Gravidarum
- Hypertension
- Preeclampsia
Sudden discharge of fluid before week 37
- Prelabor rupture of membranes (PROM)
Vaginal Bleeding, Severe Abdominal Pain
- Miscarriage
- Placenta previa (Placenta covers cervix)
- Abruptio Placentae (Placenta separates from uterine wall before birth)
Chills/Fever/Flank Pain
- Infection
Severe Backache or Flank Pain
- Kidney infection/stones
- Preterm labor
Absence/Unusual Change in fetal movement or absence of Quickening
- Fetal Jeopardy
- Intrauterine Fetal Death
-Absence of Fetal Heartrate
- Intrauterine Fetal DEath
Uterine Contractions, Pelvic Pressure, Cramping before 37 weeks
- Preterm Labor
PreEclampsia
- Persistent severe vomiting
- Visual disturbances
- Blurring/Double Vision/Spots
- Swelling of face, fingers, sacrum
- Severe, frequent, continuous headaches
- Muscular Irritability/Seizures
- Epigastric or Abdominal Pain
Epigastric or Abdominal Pain
- Preeclampsia
- Abruptio Placentae (Placenta separates from inner wall before birth)
Glycosuria, Positive glucose tolerance reaction
- Gestational Diabetes Mellitus
