exam 2 management of discomfort

Question 1

What are components of physiologic pain?

Answer 1

dilation and stretching of cervix
distention of the lower uterine segment
uterine muscle cell ischemia
pressure by presenting part on abdominal structures
referred pain –> near by structures

Question 2

what are the factors influencing pain response?

Answer 2

culture
anxiety
previous experience and learned coping skills
childbirth preparation
support and environment

Question 3

what are strategies of pain management?

Answer 3

relaxation: relax selected muscle groups
distraction techniques, focal imagery
touch and massage
effleurage and counter pressure
- Effleurage is light stroking of abdomen or back in rhythm with the patient’s breathing during a contraction.
-Counter-pressure is steady pressure applied to sacral area…Especially helpful when back pain is caused by the baby in the occiput posterior position…
- Lifts the occiput off the nerves –> some relief.
music
water therapy (hydrotherapy)

Question 4

what are the controlled breathing techniques?

Answer 4

Provides distraction and reduces the perception of pain during UC

1st stage of labor _ relaxation _ increases size of abdominal cavity _ promotes fetal descent

2nd stage of labor _ used to increase abdominal pressure and assist in bearing down (pushing) with UC

Question 5

what is a cleansing breath?

Answer 5

All breathing patterns begin and end with relaxing cleansing breath…in through nose…out through mouth

Question 6

what are the breathing techniques?

Answer 6

slow paced breathing
modified paced breathing
pant blow: Used during transition to help control urge to push. SE: hyperventilation and respiratory alkalosis

The most difficult time to maintain control is transition phase of first stage of labor when cervix is dilating 8-10 cm. The pant-blow technique is suggested during this time.

Symptoms of respiratory alkalosis are:
Lightheaded
Dizzy
Tingling of fingers
Circumoral numbness or blueness

Blow into paper bag or cupped hands helps to rebreathe the CO2 and eliminate the bicarbonate ion

Be pattern that is no more than 2X the normal rate helps reduce chance of resp. alkalosis

Question 7

what are the pharm pain management considerations?

Answer 7

effects on the fetus:
Drugs may cross placenta to fetus
Drugs –> maternal hypotension and reduce placental perfusion

effects on the course of labor
may slow progress if given too early
may impair natural urge to push

Question 8

What are the systemic analgesia?

Answer 8

Goal is adequate pain relief without increasing maternal or fetal risk
Pain relief without affecting the progress of labor
Stage/phase and progress of labor determines type of analgesia or anesthesia

Question 9

What do you need to know about barbiturates?

Answer 9

Examples: Secobarbital (Seconal) * or Pentobarbital (Nembutal)
relieve anxiety and induce sleep
may be administered in early labor to alter a dysfunctional pattern
are not used in active labor because of CNS depression in newborns

Question 10

what do you need to know about Ataractics?

Answer 10

reduces anxiety apprehension and N/S
increases sedation
thought to potentiate opioid analgesic meds effects (actually impairs efficacy of opioids)
antiemetic effect
may contribute to maternal hypotension and neonatal depression
Examples: Promethazine (Phenergan) and Hydroxyzine (Vistaril)

Question 11

Administration of Systemic Medications During Labor?

Answer 11

IV preferred over IM because onset of action is faster and duration more predictable

IV medication injected slowly through the distal port (nearest the IV insertion site) in small doses.

or an epidural pump (discussed later)

Question 12

Opioid (Narcotic) Agonist Narcotic Analgesics –> ex of pure opioids include?

Answer 12

dilaudid
demerol (meperidine)
fentanyl (sublimaze)
sufenta (sufentanil)

Question 13

what are agonists?

Answer 13

Agonist = agent that stimulates a receptor to act

These drugs decrease gastric emptying and increase N/V
May cause inhibition of bladder

Question 14

what do you need to know about demerol?

Answer 14

onset of action for IV administration almost immediate. 10-20 minutes IM.

Duration of action: 1.5 to 2.0 hours… (NOT used as much because of undesirable effects on the neonate – prolonged sedation & neurobehavioral changes and can las for up to 2-3 days in the neonate)

Question 15

what do you need to know about fentanyl and sufenta?

Answer 15

Fentanyl and Sufenta most commonly administered by epidural catheter.

Sufenta…newer drug …more potent than fentanyl. Does not cross the placenta as readily so less fetal exposure to drug.

Onset 3-5 minutes…duration of action about 60 minutes.

Question 16

what are antagonists?

Answer 16

Antagonist = agent that blocks a receptor

A med may be injected over a period of three-five consecutive contractions if needed to complete the dose

Question 17

what is the nursing alert for narcan?

Answer 17

Narcan (Naloxone Hydrochloride)is antidote/antagonist to narcotic analgesic _ reverses CNS depressant effects of the narcotic

Narcan contraindicated for narcotic addicted patients because may precipitate withdrawal symptoms

Question 18

What are Mixed Opioid Agonist-Antagonist Analgesics and what do they do?

Answer 18

Stadol (Butorphanol Tartrate) and Nubain (Nalbuphine Hydrochloride)

Provides adequate analgesia without respiratory depression in mom or baby

Used more in labor than narcotic analgesics

May precipitate withdrawal symptoms in narcotic dependent women and baby

Question 19

what are Regional Anesthesia/Anesthesia?

Answer 19

epidural block
in some area 90% of pts laboring receive an epidural.

Question 20

what are the epidural advantages?

Answer 20

pt remains alert
good relaxation techniques are achieved
only partial motor paralysis occurs
airway reflexes reamin intact
gastric emptying is not delayed
blood loss is not excessive

Question 21

what are the epidural disadvantages?

Answer 21

limited mobility
may increase duration of second stage labor
not effective for some pts/ and a 2nd form of analgesia is required
urinary retention
pruritus (itching)
high or total anesthesia

Question 22

what are the epidural meds?

Answer 22

usually a combo of a “caine” drug and a opioid analgesic

Bupivacaine (sensorcaine)
ropivacine (naropin)

Drug concentrations have been lowered…

Fentanyl, sufenta or preservative-free morphine may be added…opioid analgesics

Continuous infusion pumps are used to administer…gives woman control

Question 23

What is a nerve block analgesia: epidural?

Answer 23

Administered after labor is well established _ dilated 5-7 cm (typical)

Injection of medication or combination of meds through a catheter inserted into epidural space

Meds administered by continuous infusion or intermittent injections

Patient controlled epidural anesthesia allows the patient to control the dosing

Question 24

What are the structures of the spinal column and what do you need to know for an epidural?

Answer 24

Spinal cord (ends at L1 in adults) this may be a question which arises. The epidural is placed between L2 to L5 so therefore the epidural needle does not go near the spinal cord.

Question 25

what are the insertion techniques?

Answer 25

Preload with IV fluids _ volume expansion to prevent maternal hypotension

Position in modified Sims or upright with back curved and legs dangling from bedside

After insertion assist to alternate side lying positions (Prevents supine hypotension and Helps distribute medication evenly)

Question 26

what are the Post Epidural Block Nursing Interventions?

Answer 26

Assess maternal VS and FHR and O2 sat (protocol)

Assist woman to change position using pillows to prop if necessary

observe for bladder distention

protect from injury

record the response

monitor for adverse or allergic reactions

Preloaded with IV fluid for blood volume expansion to prevent maternal hypotension
Assist client to assume and maintain position (sitting or side-lying) during the procedure
Monitor for bladder distention and measure urinary output to ensure bladder is completely emptied

Question 27

what are the epidural complications?

Answer 27

accidental injection of epidural dose in the subarachnoid space –> “high spinal”
Watch for Maternal hypotension –> decreased placental perfusion –> non-reassuring FHR pattern

Significant maternal hypotension –> to newborn endangerment

post dural puncture HA

infection

A test dose will be given to assess for intravascular injection.

S/s include increased heart rate, numbness tingling of mouth, ringing in ears, disorientation, excitation, and bizarre behavior
-High Spinals can lead to respiratory arrest
-fever can be related to thermoregulatory changes and or infection

Question 28

what is the Nursing Care for Hypotensive Episode c Epidural Block?

Answer 28

turn to lateral position or wedge hip
increase IV infusion rate
O2 by face mask at 10-12 L/M
evaluate clients legs (10-20 degrees)
alert DR
be prepared to admin vasoconstrictor drugs (ephedrine) per order

(ex: systolic BP falls below 100)

Question 29

What is a post-dural puncture HA?

Answer 29

May be seen within 2 days of puncture but may continue for days to weeks

• Assuming an upright position intensifies headache
• Lying flat for 30 minutes or less results in relief of headache
  -Headache can be accompanied by blurred vision, ringing in the ears, and/or light sensitivity

Question 30

What is an epidural block patch?

Answer 30

The most rapid, beneficial, and reliable relief measure for PDP headache

The woman’s blood is injected into the epidural space which creates a clot that patches the tear or hole

Pain relief can be almost instantaneous

Other treatment options can be bedrest, lying flat, increased caffeine intake, some practitioners use Mountain Dew and Excedrin Migraine, which has a high caffeine level. Oral or IV fluids can also be administered. 10 to 20 ml of blood is injected into the lumbar space and patches the hole in the dura mater.

Question 31

what are the Pain pathways and sites of pharmacologic nerve blocks?

Answer 31

A. Pudendal block; suitable during second and third stages of labor and for repair of episiotomy

B. Epidural block; suitable during all stages of labor and for repair of episiotomy

Question 32

what is a pudendal block?

Answer 32

blockage of pudendal nerve
used for birth and post delivery repairs, NOT LABOR
doesn’t depress fetus
no relief from uterine contractions; only from perineum distention.

Question 33

how is a spinal block done and what are the advantages of it?

Answer 33

Injection of medication into the CSF in spinal canal

Advantages:
Rapid pain relief without sedation (useful for urgent cesarean births) and Low incidence of adverse effects

Small gauge needle can reduce likelihood of post spinal headache
Position flat X 8 hours

Question 33

how is a spinal block done and what are the advantages of it?

Answer 33

Injection of medication into the CSF in spinal canal

Advantages:
Rapid pain relief without sedation (useful for urgent cesarean births) and Low incidence of adverse effects

Small gauge needle can reduce likelihood of post spinal headache
Position flat X 8 hours

Question 34

what are the Disadvantages of Spinal Block?

Answer 34

short duration of action
post spinal HA r/t leakage of CSF
increased incidence and degree of hypotension
urine retention

Question 35

what is Local Infiltration of Perineum?

Answer 35

used frequently for episiotomy
epi added to “caine” drug to prevent excessive bleeding by constricting blood vessels
does not affect pain of uterine contractions
no adverse fetal, newborn, or maternal effects.

Local anesthetic (i.e.. Lidocaine) injected into the skin and then SQ into region to be anesthetized (episiotomy or repair of laceration)

Question 36

What is important to know about general anesthesia?

Answer 36

Used only if regional anesthesia is contraindicated or if an emergency situation develops suddenly

Inhaled anesthetics include nitrous oxide, Halothane, and Fluothane

Fetal adverse reactions include respiratory depression, hypotonia and lethargy

Oral antacid given if time (Alka-Seltzer Gold or Bicetra) neutralizes the gastric acids in the stomach. Anesthesia may also give Reglan, Pepcid or Zantac IV
Tilt the patient – displaces the uterus keeping the Aorta & vena cava from being compressed = good placental flow & cardiac output