Advanced Directives Exam 2 Flashcards
1
Q
APGAR Scoring:
A
A-ppearance (Pallid, Cyanotic, or Pink Color)
P-ulse (auscultated or felt via umbilical cord)
G-rimace (response to suctioning of nares or nasopharynx) When suctioning the baby, it makes a look or cries.
A-ctivity (degree of flexion and movement)
R-espiration (observed movement of chest wall)
2
Q
What is the overall goal for APGAR score?
A
OVERALL GOAL is 10! It takes more than a min, needs to get all blood circulating 1st. APGAR is usually an 8 in the 1st one min. Color: is different in the 1st min. APGAR: 5 min they will have a 9 ! less than 7 (NICU to get APGAR score up). Less than 7 in 5 min need someone to help.
3
Q
When do you use APGAR and why do you use it?
A
When? 1 minute after birth, 5 minutes after birth, and 10 minutes after birth it need be.
Why? Physiologic state of the neonate and rapid need assessment for resuscitation.
4
Q
How is APGAR scored?
A
Appearance (color):
o 0= blue, pale 1= body pink, extremities blue 2= all pink: hands. Feet, body, etc.
· Pulse: HR
o 0=absent1=slow<1002=>100
· Grimace (reflex irritability) stimulation
o 0 = no response from the baby 1= grimace, trying to cry 2= cry
· Activity (Muscle tone): stretching, start reflex.
o 0= flaccid, do not move 1= some flexion, barely move, or only move arms and not legs or legs and not arms. 2=well flexed; moving everything
· Respiration (movement of chest wall)
o 0=absent 1= slow, weak cry 2= good cry, screaming head off and turning pink
5
Q
What is the 1st stage of labor?
A
Stage of Dilation
Begins with onset of labor, regular, painful, uterine contractions that cause cervical dilation
- Ends with complete dilation of the cervix
- Longest stage
- Length of time varies
- Divided into 2-3 phases: latent, active, and transition
6
Q
What is the latent stage of labor?
A
Beginning: onset of labor
- Dilation: 0-5 cm
- Timing of contractions: 2-30 min apart 30-45 sec
- Strength of contractions: mild
- Emotions: excited, talkative, confident, anxious, withdrawn
- Pain: mild (can talk through)
- Length of time: 10-14 H
- Show: scant amount brownish discharge, mucous plug, pale pink mucous.
7
Q
What is the active stage of labor?
A
Beginning: more active contractions
- Dilation: 6-10 cm
- Timing of contractions: 1.5-5 min apart 60-90 sec, regular
- Strength of contractions: moderate - strong
- Emotions: quite, concentrated
- Pain: moderate - breathing through contractions
- Length of time: 1 cm per H nulliparous/ 1.5 cm per H multiparous - Show: pink to bloody, moderate to copious
8
Q
What is the nursing care for the 1st stage of labor?
A
Nursing care for the First Stage:
-Assess pt
-Assess FHR
-Manage pain
-Emotional support
-Encourage or assist in position changes -Assisting with interventions
-Advocate for pts needs
9
Q
What is the second stage of labor?
A
Second Stage of Labor: PUSHING
- Begins with full dilation (10cm)
- Ends with birth of infant
- 15 mins to 4H
- Varied emotions —> burst of energy, exhaustion, excitement, fear - Cont. support necessary
10
Q
What is the nursing care for the 2nd stage of labor?
A
-Coach for effective pushing
- Assist with positioning
- Offer reassurance and encouragement
- Prepare for delivery
11
Q
What is the third stage of labor?
A
Third Stage of Labor: PLACENTA
- Begins with birth of infant - Ends with birth of placenta
- 5-10M can be up to 30M
- Maternal focus on infant, crying, relief.
- Some discomfort with placenta expelled.
12
Q
What is the nursing care for the 3rd stage of labor?
A
-Immediate infant care
- Assign APGAR score
- ID infant
- Administer Uterotonics
- Emotional support
- Assisting with interventions
13
Q
what is the 4th stage of labor?
A
Fourth Stage of Labor: RECOVERY
- Begins with birth of placenta
- 1-4H
- Uterus should be fully contracted - Lochia rubra
- Perineal discomfort
14
Q
What is the nursing care for the 4th stage of labor?
A
- Assist with the “golden hour”
- Assist with feeding
- Admin baby meds
- Assess BP, HR, and fundus every 15 M for the 1st 2 H
- Assess fundus (Check for tine by massaging (firm or boggy), Location in relationship to the umbilicus, Document in cm or finger-breaths)
-Take temp every 4H 2 times then every 8H - Assess bladder (Check for distension, Assist mom to void, Cath if necessary)
- Assess lochia: check for amount by looking at peri pad and linens
- Assess perineum (Turn pt on side, lift butt, have good lighting - Assess episiotomy or lacerations, Place ice pack, and Assess for hemorrhoids)
15
Q
What are the 5 essential factors of labor (5 p’s)?
A
- Passenger: fetus: size of fetal head: fetal position don’t forget the placenta
- Passageway: bony pelvis and soft tissue.
Position of Mother: maternal position should be comfortable and conductive to maternal blood flow to the placenta and the fetus. - Powers: Primary (involuntary uterine contractions) and Secondary (voluntary pushing —> abd muscles)
- Physiologic Adaptation and Psychological Response of Mother: mothers response to labor can affect progress of labor. How? Tight muscles, inefficient work, expended energy, hormones releases in coordinate with anxiety or stress.
16
Q
What is passenger?
A
Passenger: fetus: size of fetal head: fetal position don’t forget the placenta
- Size of fetal head
- Presentation
- Lie
- Attitude
- Position: station and engagement (- Fetal Station: presorting part in relation to imaginary line between the ischial spines.)
17
Q
What is passageway?
A
Passageway: bony pelvis and soft tissue. - 4 types of bony pelvis:
- Gynecoid is the most common: classic female type - Android: resembles the male pelvis
- Anthropoid: resembles the ape pelvis
- Platypelloid: flat pelvis
Soft tissues: lower uterine segment, cervix, pelvic floor muscles, vagina, and Introits.
- Lower uterine segment: distends to accommodate intrauterine contents
- Cervix: thins and opens to allow descent into the vagina
- Pelvic floor muscles: help rotate the fetus as it passes through the birth canal
- Vagina and introits: dilate to accommodate the fetus and permit passage to external world
18
Q
What is physiologic adaptation and psychological response of mother?
A
Prior to the onset of labor:
*surge of energy *nesting instinct
Response to: First stage of labor
Latent phase
*Alert & mildly anxious *Happy & excited *follows directions well
Active phase
*labor oriented
*May not want to be left alone
*alert/eager
*more demanding – wants encouragement *concentrating and focusing energy on contractions *some difficulty following directions
*irritable – fears loss of control
*fatigued
*frustrated
*intense concentration
*May become nauseated or vomits (Hormone surge)
Fourth stage of labor: Recovery
*excited
*exhausted
*emotionally labile – bonding
19
Q
Terbutaline (Brethine)
A
- Class: beta2-adrenergic agonist (beta1-stimulated cardiopulmonary and beta2-stimulated metabolic effects.)
- Action: relaxes smooth muscles, inhibiting uterine activity by stimulating beta2-receptors.
- Dosage & route: SubQ injection of 0.25 mg every Q4H
- SE: tachycardia and hyperglycemia
- Contraindications:
- HR >130 BPM
- Heart Dx
- Severe preeclampsia/eclampsia
- Gestational DM
- Hyperthyroidism
- Contraindications to Tocolytic:
Maternal: - Severe preeclampsia
- Eclampsia
- Bleeding with hemodynamic instability - Contraindications to specific meds
Fetal: - Intrauterine fetal demise
- Lethal fetal anomaly
- Non-reassuring fetal status - Chorioamnionitis
- Preterm premature ROM (PPROM)
20
Q
Magnesium Sulfate
A
- Class: CNS depressant
- Action: relaxes smooth muscle, including uterus
- Dosage & route: IV, loading dose 4-6 grams/ 30 M, maintenance dose 1-4 grams/H
- SE: hot flashes, N/V, HA, lethargy, dyspnea, hypocalcemia, blurred vision.
- Fetal SE: decreased breathing movement, reduced variability, non-reactive NST
- Nursing considerations:
- Assess women and fetus for baseline
- Drug almost always given IV
- Monitor serum mag levels, therapeutic range: between 4-7.5
- Be prepared to d/c if intolerable SE occur (respiratory rate <12, pulmonary edema, absent DTRs, chest pain, hypotension, altered LOC, urine output less than 25-30 mL/H, serum mag levels of 10 or >)
- Strict I&O
- Total iV intake at 125/H
- Calcium gluconate/calcium chloride readily available to reverse drug toxicity.
- Contraindications to Tocolytic:
Maternal: - Severe preeclampsia
- Eclampsia
- Bleeding with hemodynamic instability - Contraindications to specific meds
Fetal: - Intrauterine fetal demise
- Lethal fetal anomaly
- Non-reassuring fetal status
- Chorioamnionitis
- Preterm premature ROM (PPROM)
21
Q
Oxytocin (Pitocin)
A
Oxytocin (Pitocin): hormone normally produced by the posterior pituitary gland, which stimulates uterine contractions and aids in milk let-down. Synthetic oxytocin may be used either to induce labor or to augment labor that is progressing slowly because of inadequate uterine contractions. 1 milliunits/M increased by 1-2 milliunits/M no more than every 30 M to get good contraction pattern.
- Class: uterine hormone
- Action: acts directly on myofibrils, thereby producing uterine contractions; stimulated milk
action by the breast; vasoactive. - Dosage: IM: onset 2-7 M, duration 1 H, half-life 12-17 M
- SE:
- Seizures
- Intracranial hemorrhage
- Abruptio placentae
- Decreased uterine blood flow - Hypotension
- HTN
- Dysrhythmias
- Increased pulse
- Fetal SE:
- Bradycardia
- Jaundice
- Visual disturbances - Muscle tone
- Seizures
Nursing considerations:
- Assess for fetal presentation and pelvic dimensions before use
- Monitor all VS closely and continuously
- Monitor fetal distress or uterine hyperactivity (discontinue immediately) length and duration of contractions.
22
Q
Abortions and management and treatment options?
A
- Threatened: vaginal spotting early in gestation. No passage to embryonic or fetal tissue. Abdominal cramps. Cervix is closed. Threat = NO HR —> (ex: mom has a temp of 104 (mom septic and baby septic —> lead baby to die)
- Management and Treatment: possible mild activity restriction with bedrest 24-48 H, sedation. Instructed to avoid stimulation of sex and orgasm for 2 wks.
- Inevitable: Pregnancy loss that cannot be prevented. Bleeding may be moderate/ heavy. Cervix is dilated with tissue in cervix.
- Management and Treatment: if products of conception are not passed spontaneously, vacuum curettage or admin of prostaglandin analog to evacuate the uterus. A D&C may be performed.
- Incomplete: Passage of some of the products of conception. Ultrasound reveals retained material in the uterus. Cervix is open.
- Management and Treatment: cervix is open but may require additional dilation before curettage.
- Complete: all fetal tissue and products of conception passes in bleeding. Ultrasound reveals an empty uterus.
- Management and Treatment: no further intervention may be needed if uterine contraction adequate to prevent hemorrhage and there is no infection. No need for treatment but follow up care to discuss related issues.
- Septic: Fever, abd pain and tenderness. Bleeding from scant to heavy, usually malodorous. Cervix usually dilated.
- Management and Treatment: care includes termination of pregnancy; culture and sensitivity studies to initiate appropriate antibiotic therapy.
- Missed: Retained nonviable embryo or fetus for 6 weeks or more. Fetus has dies and placenta atrophied but products of conception retained. Cervix is closed.
- Management and Treatment: if spontaneous evacuation of the uterus does not occur within one month, uterus is evacuated by method appropriate to duration of the pregnancy. Blood clotting factors are monitored. DIC with uncontrolled hemorrhage may develop in cases of fetal death after week 12.
- Habitual or recurrent: 3 or more consecutive losses before 20 wks of gestation. Cervix open.
- Management and Treatment: Identification and treatment of underlying cause if possible. Prophylactic cerclage if r/t cervical insufficiency.
23
Q
what is the assessment for abortions?
A
- Less than 20 wks gestation fetus is nonviable
- Greater than 20 wks or 500 g, funeral arrangements are needed
- Symptoms include: uterine cramps, backache, and pelvic pressure.
- If bleeding is noted count of perineal pads/H
- Be aware of S/S of shock: HR elevated (weak thready pulse), Skin: pallor, cool, clammy, and Hypotension.
24
Q
Nursing Interventions for abortions?
A
- ID type of abortion and management - Monitor UC if necessary
- Monitor VS, LOC until stable
- Start IV with large bore (over 18G)
- Admin RhoGam to Rh neg clients with Rh+ baby
- Teach client to notify the nurse if: temp >100.4, foul odor to vaginal discharge, bright red bleeding, and/or bleeding with any tissue fragments.
25
What is preeclampsia mild and severe?
Pre-eclampsia: HTN and Proteinuria developed after 20 wks
- Mild:
- BP 140/90 mmHg x2 > 4-6H apart
- MAP >105
- 24H urine protein > 0.3g —> 300 mg of protein in urine; +1 or higher on the dipstick, make sure the pts BP doesn’t get worse
- Severe:
- BP > 160/110 mmHg on 2 occasions at least 4 H apart - MAP >105
- 24H urine protein > 2 grams
26
Preeclampsia etiology and causes?
- Etiology: disruption in placenta perfusions and endothelial cell dysfunction.
- Consequences of endothelial cell dysfunctions:
- Vasospasms & decreased organ perfusion —> HTN, Uteroplacental spasms, headaches, blurred vision, hyperreflexia, elevated liver enzymes, N&V, epigastric pain
- Intravascular coagulation: 50% more blood vol. —> Hemolysis or red blood cells, low platelet counts, DIC, Increased Factor VIII antigen
- Increased permeability and capillary leakage —> Proteinuria, generalized edema, pulmonary edema (Dyspnea), Hemoconcentration (Increased hematocrit)
- Causes: unknown, however, it is a condition unique to pregnancy and the only cure is delivery of the infant.
27
Effects of preeclampsia on the placenta, renal, hepatic, neurological system and the lab values?
- Placental: Impaired perfusion leads to early aging of the placenta and IUGR of the fetus
- Renal: Decreased glomerular filtration rate (GFR) results in oliguria, increased excretion of protein (mainly albumin) decreased uric acid clearance. Sodium and water retention.
- Hepatic: Hepatic-Decreased perfusion can result in hepatic edema and sub- capsular hemorrhage as evidenced by the complaint of epigastric pain or right upper quadrant pain- A sign of impending eclampsia. Liver enzymes become elevated (AST, ALT, and LDH).
- Neurological: *vasospasms and decreased perfusion can result in: Cerebral edema- change in emotion, mood, and LOC, CNS irritability-manifested as headache, hyperreflexia, positive ankle clonus, and occasionally eclampsia, and Visual disturbances- scotomata and blurring
- Lab Values: ↓ serum albumin-Results in ↓ plasma colloid osmotic pressure therefore, fluid moves out of the intravascular resulting in hemoconcentration, ↑ blood viscosity, and tissue edema.↑ Hct as a result of hemoconcentration. ↑BUN, serum creatinine, and serum uric acid as a result of degenerative glomerular change.
28
cervical changes and uterine contractions occurring between 20 and 36 6/7 weeks gestation. Preterm Birth is any birth that occurs between 20 0/7 and 36 6/7 weeks gestation.
preterm labor
29
what are the causes of preterm labor?
- Multifactorial:
- Contractions/Cervical Change/ ROM
- Placental implantation bleeding (1st and 2nd trimester)
- Maternal/fetal stress
- Uterine over-distension
- Allergic reaction
- Decrease progesterone level
- Infection: cervical, bacterial, and Urinary Tract
30
what are the S/S of preterm labor?
- Uterine contractions occurring more frequently then every 10 M persisting for 1 H or more
- Suprapubic or pelvic pain or pressure
- Low, dull backache
- Abd pain or champs with or w/o diarrhea
- Painful menstrual like cramps
- Change or increase in vaginal discharge
- ROM
- Urinary frequency
31
What is the education for preterm labor?
- Self management: empty bladder, drink 2/3 glasses of H20, lie down on side for 1 H, palpate for contractions, call your provider/go to the birthing facility if: contractions = cramping/abdominal/suprapubic/pelvic pain/pressure, low, dull backache, < Q10M w or w/o pain > 1 H. Vaginal bleeding, malodorous vaginal discharge, or fluid leaking from the vagina.
32
What are the nursing interventions for preterm labor?
- Assess for adverse effects of bedrest and initiate and administer appropriate interventions
- Psychological support for both patient and support system with referral to appropriate resources
- Other appropriate referrals [chaplain, nutritionist, social worker]
- Assist the patient in planning activities to aid in self-care and decrease boredom [Journaling Scrapbook , passive exercise, knitting etc.]
- Refer to support groups
- Nurses caring for patients that have been on prolonged bedrest should be aware that the adverse effects can carry over into the postpartum period. They have a longer recovery time due to the decreased endurance and muscle wasting. They also are at a higher risk for postpartum depression and other psychological issues like feelings of guilt for not being able to carry their baby to term. All of which can effect infant bonding.
33
S/S of postpartum hemorrhage?
- Drop in BP
- Increased HR
- Pale or clammy skin
- N/V
- Worsening of abdominal or pelvic pain
34
Treatment and rationals for postpartum hemorrhage?
- Nursing Action: Massage the fundus and put in a foley catheter if bladder is distended.
- Rationale: assess the blood clots expelling from the uterus. If the fundus is deviated to the L or R, then place a foley catheter to empty the bladder.
- Nursing Action: Call for oxytocin
- Rationale: Administer oxytocin to reduce contractions
- Nursing Action: Obtain VS
- Rationale: Observe respiratory rate, pule, BP, and O2 stat.
- Nursing Action: Administer IV fluids
- Rationale: Administer 2 L of LR or NS to replace lost fluid due to vaginal bleeding.
- Nursing Action: Call the DR
- Rationale: inform the DR on the pt is hemorrhaging and next order of action.
35
S/S of UTI?
- Burning sensation or cramps in lower back or lower belly
- Urine looks cloudy or has an odor
- Proteinuria
- Urgent to pee more often
- Lead to preterm labor
36
UTI effects on baby?
low birth weight
37
treatment/management for UTI?
antibiotic = amoxicillin and cephalexin (Keflex)
38
inflammation (swelling) of the breast tissue that can be caused by infection or milk remaining in milk tissue (Milk stasis)
Mastitis
39
S/S of Mastitis?
- Breast tenderness
- Pain or bring sensation continuously or while breast feeding
- Fever of 101 degrees Fahrenheit (38.3 C)
- Skin redness
40
Mastitis effects on the baby?
breast unable to supply milk
41
What is the prevention of mastitis?
-Fully drain the milk from your breast while breast feeding
- Change the position you use to breast-feed from one feeding to the next
- Make sure your baby latches on properly during feeding
- Allow baby to completely empty one breast before switching to the other breast during feeding.
42
what is a DVT?
a blood clot, usually in the lower extremities.
43
what are the S/S of a DVT?
- Unilateral leg pain
- Swelling
- Calf tenderness
- Edema
- Redness
44
what are the effects of a DVT on a baby?
reduce blood flow to the placenta
45
what is the treatment and management for a DVT?
- Elevation of affected extremity
- Graduated compression stockings
- Local application of moist, warm packs
- Warfarin (Coumadin) —> oral anticoagulant
46
What is postpartum depression?
10-15%, can lead to functional impairment. Duration: 2 weeks to 12 months. Treatment: antidepressant and psychotherapy. Persistent depressed state. Thought of hurting the baby or yourself, not having interest in the baby, last longer and can begin anytime within the first year, and needs to be treated by a DR.
47
S/S of postpartum depression?
- Intense fear, anxiety, anger
- Irritability
- Feelings of guilt
- Jealousy/rejection of infant
- No interest in the baby
- Thoughts of harming self or baby
48
What are the S/S, effects on the baby, and the treatment for GBS?
S/S:
- Asymptomatic
- UTI
- Effects on baby: intra-amniotic infection
- Treatment/management: Penicillin (Ampicillin)
49
What is Hyperemesis Gravidarum?
Persists longer than 1st trimester; severe vomiting of pregnancy that causes weightless of at least 5% of pre-pregnancy weight. Accompanied by dehydration, electrolyte imbalance, nutritional deficiencies and ketonuria. Could be caused by increasing levels of estrogen, progesterone, and HCG.
50
What are the S/S of hyperemesis gravidarum?
- Inability to retain even clear liquids - Significant weight loss >5%
- Symptoms of dehydration:
- Poor skin turgor, dry mucus membranes - Decreased BP
- Increase pulse
- Concentrated urine
- Low output
Symptoms of starvation:
- Elevated BUN and ketonuria
- Electrolyte imbalance of NA, Cl, and K+
51
What are hyperemesis gravidarum effects on the baby?
- Abnormal development (anomalies)
- Preterm birth
- SGA (small gestational age)
- Death from lack of nutrition, hypoxia or maternal ketoacidosis
52
What is the treatment for hyperemesis gravidarum?
- IV fluids with glucose, electrolytes, and vitamins to replace fluids and imbalances
- NPO until dehydration resolved and for 48 H after vomiting has stopped
- I&O including emesis
- Daily weights
- Small frequent meals once 48 H vomitus (Dry to Wet every 2-3 H)
- Meds
53
What are the meds for hyperemesis gravidarum?
Antiemetic to control N/V:
- Pryidoxine (B6) alone or with doxylamine (Unisom) - Vespirin or Compazine
- Phenergan
- Zofran
- Nexium (Purple pill) or Pepcid - Steroid therapy
- Eternal or parental nutrition
54
Describe a ruptured ectopic pregnancy (tubal pregnancy).
- Diagnosis: Abdominal pain, spotting, positive pregnancy test, verified by US, signs of shoulder pain (Ruptured tube), signs of shock.
- Management: Methotrexate to dissolve the pregnancy, may need a tubal ligation.
- Misc.: Double flush toilet (very toxic), avoid folic acid, sun exposure, sex, may cause: N/
V and gastric discomfort, and keep all appointments.
55
Describe a hydatidiform mole (molar pregnancy, grape cluster).
- Diagnosis: Trans-vaginal US and serum hCG
- Management: Dilation and curettage (D&C)
- Misc.: Not a true pregnancy, it is a gestational trophoblast disease. (empty egg) Places pt at high risk for cancer. Follow-up necessary. Weekly hCG levels until it becomes normal and stays normal for 3 weeks. Then monthly hCG levels for 6-12 months. DO NOT get pregnant for 1 year.
56
describe placenta previa.
placenta is implanted in lower uterine segment
- Diagnosis: painless bright red bleeding after 20 wks. DO NOT DO A VAGINAL EXAM —> fingers are going to go right into the placenta (disrupt everything with the placenta and the fetus). Painless. Complete placental previa = C-SECTION.
- Management: Observation and bedrest
- Misc.: NO vaginal exams, C-Section delivery, complete may have a gush where a
marginal may have a trickle.
57
describe placental abruption (abruptio placentae).
premature separation of the placenta.
- Diagnosis: Painful abd pain with or w/o bleeding, uterine tenderness, confirmed after delivery. Bright red bleeding, HA, feels like someone is stabbing you in the abd, etc. —> the mom NEEDS to come back to the hospital.
- Management: Immediate delivery
- Misc.: 3 grades based on separation —> 1 (mild) 10-20% <500mL, slight pain, no shock. 2 (moderate) 20-50% 1000-1500mL, mild pain, mild shock. 3 (SEVERE) >50% >1500mL, agonizing pain, sudden.
58
Describe Accretas Increta Percreta.
placenta is not on the uterine wall. Percreta —> attaches to other organs of the uterus.
- Management: delivered by C-section after US has determined where placenta is located. Also called a cesarean hysterectomy.
59
what is HELLP syndrome?
- Laboratory diagnosis, not a clinical diagnosis. Diagnoses by lab values.
- Variant of sever preeclampsia. Cause is unknown, thought to be a result of changes that occur with severe preeclampsia. Arteriole vasospasm, endothelial cell damage, and
platelet aggregation result in tissue hypoxia. Possible immunologic component as
well.
60
What does HELLP syndrome stand for?
- Hemolysis: breakdown of RBC as they pass through the small vessels with endothelial
cell damage and fibrin deposit.
- Elevated liver enzymes: a result of impaired hepatic blood flow and fibrin deposits.
Watch for RUQ pain, Epigastric pain unresponsive to med, and jaundice bc of decrease liver function.
- Low platelets: thrombocytopenia —> platelets less than 100,000. Less than 150
(platelets tell us how well a person will clot) —> dysfunction can lead to HELLP syndrome and that can lead to DIC, if those platelets are LOW pt cannot CLOT. DIC = DEATH.
61
What are the S/S of HELLP syndrome?
Range from no signs or symptoms of preeclampsia to N/V, epigastric pain or right upper quadrant pain, general malaise.
62
what are the complications of HELLP syndrome?
-Renal failure
- Pulmonary edema
- Ruptured liver hematoma - DIC
- Placental abruption
63
what are the nursing responsibilities of HELLP syndrome?
- Assess and observe for signs of bleeding (petechia or bruising from blood pressure cuff, IV site, gums.
- Epigastric or right upper quadrant pain or tenderness —> some women report it as bad indigestion
- Jaundice
- Monitor lab values and report to DR - Fetal status: at risk for abruption
64
What is disseminated intravascular coagulation (DIC)?
activation of coagulation sequence:
thrombi throughout microcirculation. Consumption of platelets and coagulation factors to sub hemostatic levels. Activation of fibrinolysis. Tissue hypoxia: micro infarcts. Hemorrhage from (minor) trauma due to consumption/depletion of clotting factors and fibrinolysis destroying clots. DIC = DEAD
- Primary Diagnosis: preeclampsia (always a secondary diagnosis) Lab test, may see CM upon assessment.
- Characterized by clotting, bleeding, and ischemia
- Possible causes: placental abruption, retained dead fetus syndrome, amniotic fluid
embolus, pre-eclampsia HELLP syndrome, gram neg sepsis.
65
What is disseminated intravascular coagulation (DIC)?
activation of coagulation sequence:
thrombi throughout microcirculation. Consumption of platelets and coagulation factors to sub hemostatic levels. Activation of fibrinolysis. Tissue hypoxia: micro infarcts. Hemorrhage from (minor) trauma due to consumption/depletion of clotting factors and fibrinolysis destroying clots. DIC = DEAD
- Primary Diagnosis: preeclampsia (always a secondary diagnosis) Lab test, may see CM upon assessment.
- Characterized by clotting, bleeding, and ischemia
- Possible causes: placental abruption, retained dead fetus syndrome, amniotic fluid
embolus, pre-eclampsia HELLP syndrome, gram neg sepsis.
66
What are the CM for DIC?
- CM: signs of thrombosis, bleeding from 3 unrelated sites, spontaneous epistaxis, oozing
from venipuncture sites, petechiae, ecchymosis (bruising), large SubQ hematoma,
hypotension, and tachycardia.
67
What are the lab results and management for DIC?
- Lab results: decreased platelets, decreased fibrinogen, prolonged prothrombin time,
prolonged activated partial thromboplastin time (APTT), increased fibrin degradation products (fibrin split), and increased D-dimer test.
- Management: correct the underlying cause, supportive management, and continue to monitor labs.
68
what is eclampsia?
Seizure activity or coma in a women with preeclampsia with no history of preexisting patho that can relate to seizure activity.
69
What do you need to do with a pt with eclampsia?
1. Keep pt safe
2. Turn onto side
3. Suction
4. O2
5. IV mag sulfate: CNS depressant; monitor moms LOC; urine output less than 40/30,
DTR, going to affect baby (monitor baby)
6. Monitor fetus
7. Uterine and cervical assessment
8. Document
70
What do you need to do with a pt with eclampsia?
1. Keep pt safe
2. Turn onto side
3. Suction
4. O2
5. IV mag sulfate: CNS depressant; monitor moms LOC; urine output less than 40/30,
DTR, going to affect baby (monitor baby)
6. Monitor fetus
7. Uterine and cervical assessment
8. Document
71
what is the assessment for eclampsia?
- History and S/S
- BP
- Edema and breath sounds
- DTRs/Clonus
- Fetus status
- Uterine tonicity
- Other maternal indicators
- Lab values?? Mg, platelets, H/H, liver enzymes, ALT, AST, uric acid
72
what is the management for mild eclampsia?
- Bedrest (home or hospital)
- Monitor BP
- Daily weights
- Fetal surveillance
- Monitor urine protein
- Educate on signs to report
- Healthy diet and adequate hydration
- Emotional support
73
What is the management for severe eclampsia?
- Hospital bed rest
- Maternal and fetal surveillance
- Quite, non-stimulating environment & seizure precautions
- Pharm interventions
- Delivery
74
What do you look at on a FHR strip for baby?
baseline, variability, accelerations, decelerations
75
what is normal baseline for a baby?
120-160 BPM
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What is variability?
- Absent: undetectable
- Minimal: < 5 BPM
- Moderate: 6-25 BPM
- Marked: >. 25 BPM
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what are accelerations?
increase in the FHR
- Peaks at least 15 BPM above the baseline and last 15 seconds (33 wks or greater)
- Peaks at least 10 BPM above the baseline and last 10 seconds (if 32 weeks)
- Prolonged accelerations is when the acceleration lasts longer than 2 minutes but less than 10 minutes.
- If longer than 10 minutes, the baseline has now changed
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What are decelerations?
temporary decrease in FHR
- Early: looks like a mirror image of a contraction, gradual descent from baseline and returns to baseline by the end of the contraction.
- Variable: abrupt rise and fall from the baseline. Looks like a “V” or “W”
- Late: FHR decreased often at the peak of the contraction and returns to baseline after
the contraction has already ended
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What do you look at for contractions on a FHR stirip?
frequency, duration, intensity, and resting tone
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what is frequency?
beginning of one contraction to the beginning of the next contraction, measured in M
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what is duration?
beginning of the contraction to the end of contraction. measured in seconds.
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what is intensity?
how strong the contraction feels upon palpation
- Mild (tip of nose), Moderate (chin), OR Strong (forehead)
- May also be measured by internal uterine pressure catheter (measured in the morning)
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what is resting tone?
palpation of uterus when no contractions taking place
- Top of strip = FHR (110-160) average HR measured for 2 “clear” minutes and
rounded to 5 BPM; uterus must be at rest, looking at 10 M strip
- Bottom of strip = uterine activity
- Each vertical dark line = 1 M
- Each lighter vertical line = 10 seconds
- 6 columns of 10 seconds = 1M
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Explain CHOP VEAL MINE?
VEAL: pattern
-variable deceleration
-early deceleration
-acceleration
-late deceleration
CHOP: cause
-cord compression
-head compression
-oxygenation
-placental/uterine insufficiency
MINE: action
-move the patient
-investigate if delivery is coming
-nothing is a good sign
-everything
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Describe category I.
CATEGORY 1: normal strip (reassuring)
- The baby is responding accordingly to contractions - Baseline = 110-160
- Okay if you have early decelerations
- accelerations, moderate variability
- No late or variable decelerations (variable is reassuring if it drops for less than 30 BPM)
- NO ACTION REQUIRED!
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Describe category II.
CATEGORY 2: neither category I or category III
- Not predictive of abnormal fetal and acid base status - variables, tachycardia, bradycardia
- absent/minimal/marked variability
- WE NEED TO RE-EVALUATE and SURVEILLANCE!
- Maybe we know what's going on, for example, mom is pushing and the baby cord is probably wrapped around the neck, so every
-time she pushes, we get a variable decelerations. So this only requires surveillance.
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Describe category III.
CATEGORY 3: Non-reassuring
- Abnormal fetal acid base status
- Absent variability plus lates, variables (non-reassuring if it drops more than 30 BPM)
or bradycardia
- Sinusoidal pattern (baby not doing well)
- ACTION REQUIRED!
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What is a non-stress test?
- Electronic fetal monitoring to determine fetal well being
- Monitor for 20-30 M unless baby is in a sleep cycle then it may take longer
- Looking for 2 15x15 accelerations in 20 M (on fetus greater than 32 weeks gestation) if less than 32 weeks 2 10x10 accelerations
- Documented as reactive or non-reactive
- Non-reactive: test does not demonstrate the 2 accelerations within 20 M
- Reactive: is only looking for accelerations in a 20 M strip
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what is a contraction stress test?
- Electronic fetal monitoring used to see how the fetus responds to contractions.
- If provides an early warning of fetal compromise
- Contractions decreased uterine blood flow and placental perfusion. If this decrease is sufficient to produce hypoxia in the fetus a deceleration in FHR results.
PROCEDURE:
- A 10-20 M baseline is obtained
- Oxytocin is introduced after the baseline monitoring by wither nipple stimulation or IV Pitocin and we look for how fetus responds to contractions
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Presentations could be a picture or words be able to determine presenting part, lie & anterior or posterior.
1st: the location of the presenting part in the R or L side of the mothers pelvis:
-R
-L
2nd: specific presenting part of the fetus:
- O for occiput
- S for sacrum
- M for mentum (chin)
- Sc for scapula (shoulder)
3rd the location f the presenting part in relation to the portion of the maternal pelvis:
- Anterior (A)
- Posterior (P)
- Transverse (T)
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Assess for Postpartum Hemorrhage, causes, interventions and evaluation.
- Etiology:
- Uterine atony
- Trauma to birth canal during labor and birth caused by lacerations, episiotomy or
uterine rupture - Hematomas
- Retention of placental or amniotic fragments
- Assessment:
- VS: Temperature, BP, respirations, pulse (VS are normal)
- Fundus: location: midline or deviated to R or L, Tone: firm or boggy
- Lochia: moderate rubra with no odor
- And hematoma: pulling of the blood; presence of swelling, pain, tightness, pressure,
and warmth
- Bladder: last time the pt voided, palpable or non-palpable bladder, and distention of
bladder.
- Post-epidural anesthesia recovery: returned sensation at the lower extremities (legs)
and able to void on her own
- Perineum: what does the acronym REEDA stand for:
R – Redness
E- Edema
E- Ecchymosis
D- Drainage
A- Approximation
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Nursing documentation & interventions for an episiotomy or laceration.
Laceration is a tear of the perineum
- 1st extends thru the skin & vaginal mucous membrane (NO fascia or muscle involved)
- 2nd extends through fascia and muscle but not the anal sphincter
- 3rd involves external and sphincter
- 4th extends completely thru rectal mucosa
Episiotomy is a cute of the perineum:
- Midline: directly down the middle - Left mediolateral
- Right mediolateral
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What do you need to know about Kegel exercises?
- Make sure the bladder is empty
- Tighten the pelvic floor muscles. Hold tight and count 3-5 seconds. Tighten like you
are trying to hold it and you need to pee bad. You should feel your muscles
tighten as you do this.
- Relax the muscles and count 3-5 seconds
- Repeat 10 times, 3 times a day (morning, afternoon, and at night)
- Strengthens the muscle tone from stretched and/or torn pelvic tissue - Reduces urinary incontinence
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What are the differences between T1DM, T2DM, and GDM?
- Type 1 DM: absolute insulin insufficiency
- Type 2 DM: an insulin resistance with varying degrees of insulin deficiency
- Gestational DM (GDM): any degree of glucose intolerance with onset or recognition
during pregnancy and screening and testing.
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What are maternal risk and complications?
- Worsening of pre-existing disease, vascular problems, retinopathy
- Hypoglycemia 1st half of pregnancy
- Hyperglycemia, ketoacidosis, 2-3rd trimester (high blood values)
- Preeclampsia and eclampsia
- Polyhydramnios in 10-20% of diabetic (amniotic fluid index (AFI) is greater than 24 cm in all pools or more than 8 cm in the deepest vertical pool)
- Dystocia (shoulder)
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what are the S/S of hypoglycemia?
- Nervousness
- HA
- Shaking/irritable - Hunger
- Blurred vision
- Diaphoresis
*These problems are more common in T1DM
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What are the effects on the baby?
- Macrosomia r/t excess glucose from mom
- Large for gestational age (LGA)
- IUGR r/t maternal vascular involvement
- Delayed lung maturity (RDS)
- Hypoglycemia after birth:
Symptoms:
- jittery
- Apnea
- Tachypnea
- Cyanosis
- Hypotonia
- Unstable temp
Congenital anomalies
- Neural tube defects
- Skeletal defects (sacral agenesis)
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What is the treatment for infant hypoglycemia?
- Normal serum glucose = 40-45
- Routine heel sticks for glucose checks
- Early and frequent feeding of breast milk, formula or D5W
- NGT if poor feeding or respiratory rate is increased
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what is postpartum blues?
50-85%. Functioning is not impaired. Duration: peak — day 5, resolves within 10 days. There is NO treatment. Transient, self limiting mood disorder, mood swings, tearful, insomnia, fatigue, and anxiety. Begins in the 1st week and usually last a few days or up to 2 weeks. Symptoms are not severe and don’t need treatment.
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what are the symptoms of postpartum blues?
- sadness/tearful
- restless/insomnia
- Fatigue
- Anxiety
- Mood swings
- Depressed affect
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what is postpartum psychosis?
0.1-0.2%. A psychiatric emergency. Duration: variable, typical onset within 2 weeks. Treatment: antipsychotics, mood stabilizers, inpatient psychiatric care. Rare condition (1 or 2 women/1000 births); psychiatric emergency. Hallucinations confusion, and bizarre behavior. Can begin as early as 2 days after birth but usually within the 1st 2 weeks. Psychiatric hospitalization to prevent suicide or infanticide.
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what are symptoms of postpartum psychosis?
- Auditory and/or visual hallucinations (25%)
- Delusions (50%)
- delirium/confusion
- Bizarre behavior
- Deficits in judgement
- Impulsiveness
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What are the nursing considerations for mood disorder?
- Assess risk factors for postpartum depression and psychosis.
- Utilize tools that assess symptoms/dimensions of PPD
- Educate mom and father/support person
- Continued screening
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what are the types of lochia?
- Day 1-3: Lochia Rubra
- Normal: bloody, small clots, fleshy, earthy odor, red or red brown
- Abnormal: large clots, saturated perineal pads, foul odor
- Day 4-10: Lochia Serosa
- Normal: decreased amount; serosangieous pink or brown tingled
- Abnormal: excessive amount, foul smell, continued or recurrent reddish color
- Day 11-21: Lochia alba (may last until 6th week for some women.
- Normal: white, chem, or light yellow color, decreasing amounts
- Abnormal: persistent lochia serosa, return to lochia rubra, foul odor, discharge
continuing
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What do you need to know about cerclage?
- Treatment of choice for cervical insufficiency, short cervix. (Inability of the uterine cervix to remain closed and support a growing pregnancy in the absence of preterm labor)
- Procedure: McDonald technique: stitch the cervix to keep the baby in the womb
- Measures from the top of the symphysis pubis to fundus, from approximately 24-34 weeks gestation
- Follow-up care: bed rest, pelvic rest (no sex), NOTHING in the vagina
Patient education:
- It may be electively placed before pregnancy, at 12-14 weeks of gestation as an emergency procedure
- It usually removed in office or clinical at 7 weeks of gestation to facilitate vaginal birth
- A new cerclage will need to be replaced with subsequent pregnancies - May also be left in place, necessitating a C-section delivery.
