ch 28 + 30: hemorrhagic disorders Flashcards
3 most common reasons for bleeding during early pregnancy
-miscarriage (spontaneous abortion)
-incompetent cervix
-ectopic pregnancy
types spontaneous abortions (7)
-threatened
-inevitable
-incomplete
-complete
-missed
-septic
recurrent
risks with missed spontaneous abortion
-DIC
-infection (leads to septic)
Tx for threatened miscarriage (mom might lose baby)
-bed rest 1-2 days
-pelvic rest 2 weeks (“nothing in the vagina”)
Tx inevitable/incomplete miscarriage
-allow spontaneous resolution (expectant management, up to 2 weeks)
-meds: prostaglandin (cytotec induces labor)
-suction curettage
Tx missed miscarriage
-expectant, meds, or surgical management
-monitor clotting factors (with expectant management)
D&C
dilation and curettage
Tx complete miscarriage
-no intervention
-as long as adequate uterine contractions after to prevent hemorrhage
Tx septic miscarriage
-immediate D&C
-cervical C&S
-Abx therapy
-monitor for septic shock
woman who has had 3+ miscarriages
recurrent miscarriage
1 priority with nursing care of miscarriage
physiologic stabilization
ASSESS:
-EGA
-type miscarriage
-bleeding
-pain
-emotional status
-VS
-labs (CBC, blood type, indirect coombs)
how often do you do VS with miscarriage
q15 mins - 1 hr (depending on severity of situation)
what is identified in type and screen blood test
ABO
Rh
major antibodies
what is identified in type and cross blood test
minor antibodies
(evaluate pt blood with blood bank sample)
test for Rh antibodies in blood
indirect coombs
*negative result = receives RhoGAM
minimum IV gauge for miscarriage stabilization
18 G
Interventions for miscarriage stabilization
-IV access
-monitor for complications (VS, bleeding, DIC, infection)
-administer RhoGAM if indicated
-manage medical Tx side effects
top 4 nursing priorities with miscarriage
- physiologic stabilization
- pain management
- psychosocial-spiritual
- discharge teaching
side effects prostaglandins
N/V/D
fever
psychosocial spiritual assessment for post-miscarriage
-current state
-meaning of loss to pt/family
-religion/spirituality
-support person
-effectiveness of current coping mechanisms
psychosocial spiritual interventions for post- miscarriage
-grief protocol
-cry with them
-pray with them
-contact support persons
-therapeutic response/touch
-active listening
-teach/explain
-offer option of seeing/holding fetus
-control environment
-memory packet
-explain grief process and refer to community resources
S+S complications to report to teach pt post-miscarriage
-fever (>100.4)
-foul smelling discharge
-bright red bleeding and clots bigger than a dime
discharge teaching post-miscarriage
-S+S complications
-peri care
-pelvic rest (two weeks, no tub baths)
-diet: increase iron and protein
-physical, psychosocial, and spiritual recovery
-support group/community resources
-recurrent (3+x) premature dilation of cervix
-passive, painless dilation during 2nd tri
-short cervix (<25 mm)
cervical insufficiency (incompetent cervix)
2 options Tx for cervical insufficiency
-cerclage (suture)
-progesterone (vaginal suppository, IM, PO)
when is cerclage suture removed
-in labor with vaginal bleeding
-36 weeks EGA
S+S to teach pt to report after cerclage
-fever
-contractions/back pain
-leakage of fluid
-vaginal bleeding
risk factors ectopic pregnancy (4)
-risk of tube obstruction (h/o tubal surgery, h/o of tubal infection STI or PID)
-smoking
-assisted reproductive technologies
-IUD use
classic S+S ectopic pregnancy
-abdominal pain
-missed period
-abnormal vaginal bleeding (spotting)
-positive pregnancy test
S+S acute rupture ectopic pregnancy
-vaginal bleeding (dark red, brown, “prune juice”)
-lower abdominal/pelvic mass
-sharp pelvic pain
-*referred shoulder pain
-fainting, shock
indicates bleeding into abdomen: bruising around belly button
cullens sign
interventions for ectopic pregnancy
-IV access (large bore)
-notify hcp
-explain procedures
-prepare pt for abdominal sonogram
-prepare for laparotomy (pre+post op instruction, conset)
-type and crossmatch
med for ectopic pregnancy if rupture has not occurred
methotrexate (attacks rapidly providing cells)
removal of products of conception from fallopian tube
salpingectomy
removal of fallopian tube
salpingostomy
what should you suspect in any woman of childbearing age who presents with sharp unilateral or bilateral abdominal pain
ectopic pregnancy (often misdiagnosed as appendicitis)
3 causes bleeding in mid to late pregnancy
-gestational trophoblastic disease
-placenta previa
-placental abruption
“molar pregnancy”
gestational trophoblastic disease/
hydatidiform mole
S+S gestational trophoblastic disease
-increased fundal height (bigger than expected)
-vaginal bleeding (dark or bright red)
-anemia
-S+S preeclampsia prior to 24 weeks (HTN, proteinuria)
-excessive N/V (bc excessive HCG levels)
-abdominal cramping
nursing interventions for hydatidiform mole
-diagnosed with HCG levels and sonogram (“snow storm pattern”)
-most abort spontaneously
-suction curettage
-RhoGAM prn
HESI hint: what is often masked by pregnancy and should be suspected if hCG levels do not diminish (molar pregnancy)
choriocarcinoma
discharge teaching molar pregnancy
-prevent pregnancy for 1 year
-follow up hCG levels for 1 year
-S+S complications to report (fever, bright red bleeding, foul smelling discharge)
low implantation of the placenta - complete or marginal (within 1 inch of cervix)
placenta previa
risk factors placenta previa
-previous uterine scars/surgery (C/S)
-uterine fibroids
-advanced maternal age (>35-40 yo)
-multiparity
-h/o suction curettage
-smoking
-multiple gestations
-previous placenta previa
1 risk factor for placenta previa
uterine scar (C/S)
-greater risk with multiple C/S
S+S placenta previa
-PAINLESS bright red bleeding 2nd/3rd tri
-*soft, relaxed, nontender uterus
-VS normal until shock
-decreased urinary output
-normal FHR until major detachment
-abnormal fetal position
why do you always assume pregnant woman with painless vaginal bleeding at 20+ weeks EGA have a placenta previa until proven otherwise
could rupture placenta with SVE
Tx placenta previa for 36+ weeks EGA, excessive blood loss, or unstable fetus
immediate birth through C/S
Tx placenta previa for <36 wk stable mom and fetus (expectant management)
-steroids if <34 wks EGA
-fetal and maternal monitoring
when could mom with placenta previa be put on home care
-<36 wks
-stable mom and fetus
-no bleeding for 48+ hrs
-compliant
-understands risk
-constant access to transportation
-lives close to hospital
nursing care: active management of placenta previa
-NO VAGINAL EXAMS
-lateral position, bed rest
-VS q15mins
-IV, labs
-continued FHR and UA monitor
-quantify blood loss
-Foley, I&O
-oxygen prn
-monitor for PPH
3 types placental abruption
-concealed (edges are still attached, forms hematoma)
-partial
-complete
risk factors placental abruption
-maternal HTN
-high gravity (G5+)
-cocaine
-previous abruption
-blunt external abdominal trauma
-smoking
-malnutrition
-twin gestation
-short umbilical cord
S+S placental abruption
-dark or bright red vaginal bleeding
-persistant severe abdominal pain
-uterine tenderness
-**rigid abdomen
-contractions with increased resting tone
-FHR abnormalities
-enlarging uterus
-shock out of proportion to blood loss
-coagulopathies (DIC)
Tx placental abruption for 36+ wks EGA, excessive blood loss, or unstable fetus
-immediate birth: vag or C/S
Tx placental abruption for <36 wks EGA stable mom and fetus
expectant management
-stay in hospital
-corticosteroids
S+S DIC
-bleeding gums, nose, injection sites, IV site
-altered clotting studies
-ecchymosis
nursing interventions DIC
-ensure patent IV
-pad side rails
-notify NICU
-notify hcp
normal cardiovascular changes of pregnancy
-increased intravascular volume
-decreased systemic vascular resistance (vasodilation and placenta)
-fluctuations in cardiac output during L&D
-intravascular volume changes just after birth
common cardiac diseases seen in pregnant women
-congenital defect
-valve disease (mitral valve disease, valve prolapse/stenosis due to rheumatic heart disease)
-myocardial disease (higher obesity rates)
classifications of cardiac disease in pregnancy and how they affect maternal physical activity
-class 1: unrestricted physical activity
-class 2: limited physical activity
-class 3: moderate to marked limitation of activity
-class 4: no activity allowed
management of cardiac disease in pregnancy
-limit physical activity to remain free of symptoms
-avoid excess weight gain
-prevent anemia (iron and folic acid supplements)
-prevent infections (get flu, DPT, pneumonia vaccines)
-monitor for CHF
-meds: anticoagulants, antidysrhythmics prn, antibiotics
can pregnant women receive coumadin for cardiac disease
no, teratogenic
heparin instead
antepartum teaching for woman with cardiac disease
-S+S to report
-need 8-10 hrs sleep
-self admin of heparin prn
-diet plan (increased iron, increased protein, adequate calories)
highest risk times antepartum for mom with cardiac disease (2)
-28-32 wks (reaches max blood volume)
-3rd stage of labor (placenta delivered, 1000 mL blood shunted back throughout body)
nursing care intrapartum for mom with cardiac disease
-calm environment
-maintain cardiac perfusion: lateral semifowler position, prevent valsalva, avoid hypoTN, avoid use of stirrups)
-careful management IV fluids to avoid fluid overload
-O2
-pain relief
nursing care postpartum for mom with cardiac disease
-watch for S+S fluid overload
-tailor care to functional classification
-positioning (head elevated, lateral)
-progress ambulation
-stool softeners
-monitor S+S UTI/infections
-report cardiac decompensation
S+S cardiac decompensation
-tachycardia
-tachypnea
-dry cough
-rales in bases
S+S cardiac disease in newborn
-weak cry
-cyanosis (worsens with crying)
-lethargy, hypotonia, flaccidity
-persistent brady/tachycardia
-tachypnea/resp distress
-decreased/absent pulses
nursing interventions newborn with cardiac disease
-thermoregulation
-no nippling (pacifiers, nursing, stimulation)
-transfer to NICU
meds for seizure control that are associated with increased risk fetal anomalies
-carbamazepine (tegretol)
-valproate (depakote)
fetal anomalies associated with use of antiseizure meds
-cleft lip/palate
-congenital heart disease
-NTDs
surgical considerations in pregnant women
-you have 2 pts
-monitor FHR and UA before, during, and after
-she has altered lab values
-preop: antacids, increased emptying time of stomach
-intraop: positioning (tilted)
-postop: tocolysis to stop Cxs if preterm labor
risks that are increased in obese women perinatally
-pregnancy associated HTN disorders
-gestational diabetes
-postterm birth
-induction of labor
-C/S and emergency C/S
-thromboembolism
-wound dehiscence and infection
