Advanced Directives Exam 2 Flashcards
APGAR Scoring:
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)
What is the overall goal for APGAR score?
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.
When do you use APGAR and why do you use it?
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.
How is APGAR scored?
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
What is the 1st stage of labor?
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
What is the latent stage of labor?
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- Emotions: excited, talkative, confident, anxious, withdrawn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.
What is the active stage of labor?
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
What is the nursing care for the 1st stage of labor?
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
What is the second stage of labor?
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
What is the nursing care for the 2nd stage of labor?
-Coach for effective pushing
- Assist with positioning
- Offer reassurance and encouragement
- Prepare for delivery
What is the third stage of labor?
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.
What is the nursing care for the 3rd stage of labor?
-Immediate infant care
- Assign APGAR score
- ID infant
- Administer Uterotonics
- Emotional support
- Assisting with interventions
what is the 4th stage of labor?
Fourth Stage of Labor: RECOVERY
- Begins with birth of placenta
- 1-4H
- Uterus should be fully contracted - Lochia rubra
- Perineal discomfort
What is the nursing care for the 4th stage of labor?
- 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)
What are the 5 essential factors of labor (5 p’s)?
- 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.
What is passenger?
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.)
What is passageway?
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
What is physiologic adaptation and psychological response of mother?
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
Terbutaline (Brethine)
- 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)
Magnesium Sulfate
- 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)
Oxytocin (Pitocin)
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.
Abortions and management and treatment options?
- 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.
what is the assessment for abortions?
- 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.
Nursing Interventions for abortions?
- 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.
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
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.
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.
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
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
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
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.
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.
S/S of postpartum hemorrhage?
- Drop in BP
- Increased HR
- Pale or clammy skin
- N/V
- Worsening of abdominal or pelvic pain
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.
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
UTI effects on baby?
low birth weight
treatment/management for UTI?
antibiotic = amoxicillin and cephalexin (Keflex)
inflammation (swelling) of the breast tissue that can be caused by infection or milk remaining in milk tissue (Milk stasis)
Mastitis
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
Mastitis effects on the baby?
breast unable to supply milk
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.
what is a DVT?
a blood clot, usually in the lower extremities.
