exam 2 management of discomfort Flashcards
What are components of physiologic pain?
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
what are the factors influencing pain response?
culture
anxiety
previous experience and learned coping skills
childbirth preparation
support and environment
what are strategies of pain management?
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)
what are the controlled breathing techniques?
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
what is a cleansing breath?
All breathing patterns begin and end with relaxing cleansing breath…in through nose…out through mouth
what are the breathing techniques?
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
what are the pharm pain management considerations?
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
What are the systemic analgesia?
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
What do you need to know about barbiturates?
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
what do you need to know about Ataractics?
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)
Administration of Systemic Medications During Labor?
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)
Opioid (Narcotic) Agonist Narcotic Analgesics –> ex of pure opioids include?
dilaudid
demerol (meperidine)
fentanyl (sublimaze)
sufenta (sufentanil)
what are agonists?
Agonist = agent that stimulates a receptor to act
These drugs decrease gastric emptying and increase N/V
May cause inhibition of bladder
what do you need to know about demerol?
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)
what do you need to know about fentanyl and sufenta?
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.
what are antagonists?
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
what is the nursing alert for narcan?
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
What are Mixed Opioid Agonist-Antagonist Analgesics and what do they do?
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
what are Regional Anesthesia/Anesthesia?
epidural block
in some area 90% of pts laboring receive an epidural.
what are the epidural advantages?
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
what are the epidural disadvantages?
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
what are the epidural meds?
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
What is a nerve block analgesia: epidural?
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
What are the structures of the spinal column and what do you need to know for an epidural?
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.
what are the insertion techniques?
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)
what are the Post Epidural Block Nursing Interventions?
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
what are the epidural complications?
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
what is the Nursing Care for Hypotensive Episode c Epidural Block?
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)
What is a post-dural puncture HA?
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
What is an epidural block patch?
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.
what are the Pain pathways and sites of pharmacologic nerve blocks?
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
what is a pudendal block?
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.
how is a spinal block done and what are the advantages of it?
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
how is a spinal block done and what are the advantages of it?
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
what are the Disadvantages of Spinal Block?
short duration of action
post spinal HA r/t leakage of CSF
increased incidence and degree of hypotension
urine retention
what is Local Infiltration of Perineum?
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)
What is important to know about general anesthesia?
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
