Exam 4 Flashcards
Chronic HTN
SBP >140 or DBP >90.
Pts <20 wks OR hx HTN before pregnancy.
Gestational HTN
SBP >140 or DBP >90.
>20 wks
Absence of proteinuria or symptomatic.
Pre-eclampsia Definition and risk factors
SBP >140 or DBP >90.
>20 wks
Proteinuria w/ or w/o sx
OR s/s & lab abnormalities w/o proteinuria.
Risk Factors: Hx pre-eclampsia, multifetal gestation, chronic HTN, T1 or T2DM, renal disease, autoimmune disease, nulliparity, obesity, family hx, age > 35yrs, African American, IVF, previous adverse pregnancy outcome, >10yr pregnancy interval
HELLP Syndrome Def and risk factors
Assoc w/ pre-eclamptic mothers .
Hemolysis (Breakdown RBCs)
Elevated Liver enzymes
Low Platelet Count
Increased risk for: Cerebral hemorrhage, retinal detachment, liver rupture, DIC, placental abruption, eclampsia, renal failure, pulmonary edema, maternal death
Severe HTN/HTN Crisis;
- Definition
- Sx
SBP >160 and/or DBP >110 (repeat pressures) Thrombocytopenia (Plt <100) Impaired LFTs (RUQ pain, elevated LFTs) Renal insufficiency (Cr >1.1) Pulmonary edema HA unresponsive to tx Visual disturbances
Pre-eclampsia Mgmt (Outpatient vs inpatient)
Outpatient: OB visits 1-2x/wk, quiet environment, intermittent bedrest, hydrate, take BP/wt daily, urine dipstick, fetal kick count
Inpatient: Freq assessments, bedrest, seizure precautions, Betamethasone
Magnesium Sulfate;
- Indications
- Assessments
- S/s toxicity
Prevention/tx eclamptic seizures
Monitor mg levels
Assess DTRs, ankle clonus
Calcium Gluconate for mg toxicity
S/s toxicity: flushing, sweating, hypotension, cardiac/CNS depression
Hydralazine (Apresoline);
- Indications
- Adverse effects
Improve perfusion to renal, uterine, cerebral areas
Reduce BP
D/c slowly to prevent rebound HTN
Adverse effects: palpitations, HA, tachycardia, anorexia, n/v/d
Labetolol (Normodyne);
- Indications
- Adverse effects
Reduce BP, lowers BP w/o decreasing maternal HR, CO
Adverse effects: gastric pain, flatulence, constipation, dizziness, vertigo, fatigue
Nifedipine (Procardia);
- Indications
- Adverse effects
Reduces BP, stops pre-term labor
Adverse effects: Dizziness, peripheral edema, angina, diarrhea, nasal congestion, cough
Placental Abruption;
- Definition
- Causes, risks
MEDICAL EMERGENCY
- Early separation of placenta after 20w before birth
- Bleeding between decidua & placenta
- High mortality rate; fetal 40%, mother 5%
- Maternal vessels tear away from placenta & bleeding occurs between uterine lining & maternal side of placenta
- Blood accumulates & pushes uterine wall & placenta further apart
- Abruption continues, loss of placental function results in fetal hypoxia & eventually fetal death
Most causes: originate from maternal HTN & pre-eclampsia
Maternal risks: obstetric hemorrhage, blood transfusions, hysterectomy, DIC
Placenta Previa;
- Definition
- Causes
“Afterbirth first”
- Placenta inserted wholly or partly into lower uterine segment, partially or completely covering internal cervical opening
- Risk for prenatal & postpartum hemorrhage
- Increased risk after multiple c-sections
-Caused by: uterine endometrial scarring or damage into upper segment, incites placental growing in unscarred lower segment
Placenta Previa vs Placental Abruption;
- Onset
- Bleeding
- Pain/uterine tenderness
- FH tone
- Shock
- Delivery
Previa;
- Onset- 2nd trimester
- Bleeding- Mostly external, small to profuse amt, bright red
- Pain/uterine tenderness- Usually absent, uterus soft
- FH tone- Usually normal
- Shock- Not present unless excessive bleeding
- Delivery- May be delayed depending on size of fetus & amt of bleeding
Abruption;
- Onset- 3rd trimester
- Bleeding- Concealed, external dark hemorrhage, bloody amniotic fluid
- Pain/uterine tenderness- Usually present, irritable uterus
- FH tone- Irregular or absent
- Shock- Mod to severe depending on external hemorrhage
- Delivery- Immediate, by C-section
Postpartum Body Changes
- Blood from uterus/placenta returns to central circulation
- Extracellular fluid moves into vascular compartments
- CO increases
- Diuresis & diaphoresis occur
- Increased risk for clots
- WBC remain elevated
- HCT low but stable
- Tachycardia/low BP early sign postpartum hemorrhage, infection, dehydration
- BP increase w/ HA is pre-eclampsia postpartum
- Diastis recti abdominis: left/right abd muscles most outward layer separate
- Lactogensis: onset milk secretion, triggered by delivery of placenta d/t decreased estrogen/progesterone w/ prolactin
- Breast tissue larger, firmer, more tender before milk arrives
Postpartum Assessment
BUBBLE
Breasts Uterus Bowels Bladder Lochia (vaginal d/c after birth) Episiotomy/laceration/caesarean incision
Breast assessment;
- Engorgement
- Mastitis
Inspect size, symmetry, engorgement, redness
Check nipples cracks, redness, bleeding, d/c
Palpate nodules, masses, areas warmth
Feeding challenges?
Manually express milk to assist w/ latching
Breast feeding women-Engorgement relived by: freq emptying, warm showers/compresses before feeding, cold showers/compresses between feedings
Non breast feeding women-Engorgement: Wear tight supportive bras, ice, avoid breast stimulation
S/s mastitis: flu like sx, tender, hot, painful areas, inflamed breast tissue, tenderness, cracked skin around nipple, breast distention w/ milk, hx clogged ducts/poor feeding
Mastitis tx: breast emptying, massage breasts before feeds, ABX, cold/warm compresses
Uterus assessment
- HOB <30 degrees
- Fundal massage if boggy, should be midline/firm
- Empty bladder, can affect uterine location
- Quantified blood loss if still bleeding
- Fundus cont descend into pelvis approx 1cm or finger/day, should be nonpalpable by 14 days post partum
Bowel assessment
Bowel sounds Return of bowel function Flatus Color/consistency of stool High fiber, fluids, ambulation
Bladder assessment;
-S/s UTI
- Return of urination, within 6-8 hrs of delivery
- Approx 8 hours after delivery measure amt urine each void
- Minimum 150ml/void. Less = urine retention d/t decreased bladder tone post partum
- S/s UTI: freq urination, bladder spasm, cloudy urine, urgency, dysuria
- Bladder should be nonpalpable above pubis
Lochia assessment;
-Types of Lochia
- Saturating one pad <1 hr, constant trickle, large lochia/clots could indicate serious complications
- How often pad changed?
- Color, flow, clots present
- Quantified blood loss
Lochia Rubra: Bright red bleeding/clots 1-3 days
Lochia Serosa: Pink/brown bleeding for 4-10 days
Lochia Alba: Whitish/yellow d/c for 10-14, could last up to 6 weeks
Episiotomy;
- REEDA
- Interventions
Redness Edema Ecchymosis Discharge Approximation
- Redness normal
- Ice packs 12-24 hrs
- Sitz baths
- No d/c, wound edges approximated
- Kegel exercises, squeezing glutes w/ position changes
Postpartum hemorrhage;
- Causes
- Assesments
- Mgmt
Causes:
- Grand multiparity
- Overdistention uterus
- Rapid, precipitous, prolonged labor
- Retained placenta
- Placenta previa or abruption
- Meds (Tocolytics, oxytocin)
- OR procedures (C-sec, vacuum extraction)
- Coagulation defects
Assessments:
- Risk factors
- Uterine tone, vaginal bleeding
Mgmt:
- Fundal massage w/ HOB down
- Measure quantified blood loss
- Admin uterotonic
- Start 2nd 18G IV
- Fluid admin
- Monitor s/s of shock; ER measures of DIC occurs
Oxytocin
Begin or improve contractions during labor, reduce bleeding after childbirth
Methergine
- Prevent or treat bleeding from the uterus after childbirth
- Contraindicated HTN/toxemia
- Monitor BP, HR, uterine response, change in vitals, freq periods of uterine relaxation, character/amt of vaginal bleeding
- NOT safe breastfeeding
- DONT use IV reg d/t increased risk severe HTN/stroke
Misoprostol (Cytotec)
Increases uterine tone, decreases PP bleeding
Causes uterine contractions, induce labor
Carboprost
Treat bleeding after birth
Enhances uterine tone
Subinvolution;
- Definition
- Causes
- Complications
Incomplete involution of uterus after birth
Causes: retained placental fragments, distended bladder, uterine myoma, infection
Complications: hemorrhage, pelvic peritonitis, salpingitis, abscess formation
Thromboembolism;
- Causes
- Screening/assessment
- Causes: Stasis, altered coagulation, localized vascular damage
- Homan’s sign in calf
- Assess s/s thrombophlebitis
Puerpal Phases
Puerpal: During/relating to period of 6 wks after birth mother’s reproductive organs return to original condition
Taking-in: 1-2 Days
- Dependent passive role
- Focus: rest, food, fluids
- Recount labor experience
- Spend time claiming newborn, common features
Taking-hold: Day 3-several wks
- Concerned about own health, baby’s condition, her ability to care for baby
- Increased autonomy/independence by caring for self/baby
- Still requires assurance
Letting-go
- Assumes responsibility/care for baby w/ more confidence
- Relinquishes fantasy infant and accepts real one
Neonate Cold Stress;
- Definition
- Compensation
- Sx
- Newborns need higher environmental temp to maintain neural thermal environment
- Newborns tolerate narrower range of environmental temps, vulnerable to under heating and overheating
Compensation:
- Increase metabolic rate
- Increase flexion to maintain heat
- Increase peripheral vasoconstriction
- Increase glucose use
- Non-shivering thermogenesis- skin temp cool, metabolize “brown fat” to produce heat, converts chemical energy to heat, depleted fate stores leads to metabolic acidosis
Sx:
- Axillary temp < 36.5 C
- Cool skin temp, pale, mottled, acrocyanosis (blue skin)
- Lethargy, decreased muscle tone
- Irritability, weak cry or suck
- Poor feeding or intolerance
- Hypoglycemia
- Resp distress/hypoxia
- Poor wt gain
- Jaundice
Neonate Heat Loss;
- Factors
- Modes of heat loss
- Overheating
- Thin skin
- Cannot shiver
- Limited stores, glucose/glycogen/fat
- Large body surface r/t wt
- Lack subq tissue
- Cant conserve heat by position change
- Inability to communicate cold
Heat Loss:
1) Conduction- Transfer heat from one object to another w/ contact, ex metal scale
2) Convection- Flow of heat from body surface to cooler surrounding air or air circulating over body, ex drafty window
3) Evaporation- loss heat liquid converted to vapor
4) Radiation- loss body heat to colder, solid surface in proximity, ex next to cold window
Overheating: limited insulation and sweating ability, increases fluid loss, RR, metabolic rate
White fat vs Brown fat
White fat: Adipose tissue “bad fat.”
Accumulated from excess calories or lack of exercise
Brown fat: “Good fat.” Babies born with own fat, developed on fetus at 39 wks, only have it for 3-5 wks after birth
Burns calories and produces heat, on neck, chest, back, buttocks
Preterm Neonates;
- Complications
- Mgmt Nursery & NICU
Complications:
- Cold stress
- RDS
- Sepsis/infection
- Pain
- F&E imbalance
- Feeding difficulties
- Environmental overstimulation
- Hypoglycemia
- Hyperbilirubinemia
- Bronchopulmonary dysplasia
- Intracranial bleed
- Retinopathy of prematurity
- Necrotizing enterocolitis
- Cognitive delays
Mgmt Nursery 34-36w6d:
- VS q 4hrs
- Feeding q2 BF, q3 formula
- Blood sugar
- Neutral thermal environment
- Anticipatory guidance for parents
Mgmt NICU:
- Cont monitor VS, O2 sat
- Maintain hydration, assess for overload
- ABX for + blood cultures
- Cluster care
- Gavage (tube) and IV feedings
Premature Respiratory System
- Surfactant def resulting in RDS
- Unstable chest wall leading to atelectasis
- Immature resp control centers leading to apnea
- Inability to clear fluid leading to transient tachypnea
Premature F&E
- Most newborns after 34w feed normally
- Increased insensible water loss, Keratin keeps water in skin, developed 2-3 wks after delivery infants 30wk or more
- Difficulty maintaining fluid balance
- Kidneys DONT concentrate/dilute urine well, develop aat 35 wks, CANT regulate electrolytes
- Immature renal system, reduced ability to concentrate urine & slow GFR, risk fluid retention w/ subsequent F&E disturbances increases
- Limited ability to clear drugs from system = risk drug toxicity
Premature Risk for Infection
- Immature immune system; def IgG, transplacental transfer occurs at 34 wks
- Impaired ability to manufacture antibodies to fight infection if exposed to pathogens during birth
- Thin skin, fragile blood vessels limited protective barrier
- Lack passive antibodies from mom
- UA line, invasive procedures, do not cluster invasive procedures
- 3-10x > incidence of infections
- Feeding intolerance, early sign infection
- Monitor changes temp, tachycardia, tachypnea
Premature Overstimulation;
- Definition
- S/s
- Easily overstimulated
- Keep environment quiet, lights dimmed
- Environment caused stress
- O2 decreased
- Increase/decrease HR, RR
- BP instability
S/s:
- VS changes
- Cyanosis, pallor, mottling
- Flaring nares
- Sneezing, coughing, hiccupping
- Behavior changes
- Stiff, extended arms/legs
- Fisting of hands, splaying fingers
- Alert, worried expression
- Gaze aversion
- Regurgitation, gagging
- Yawning, fatigue
Premature Nutrition;
- Definition
- Readiness vs Nonreadiness Nipple feedings
- Working harder to breath = burning calories
- Lack coordination necessary for sufficient calorie and fluid intake to support growth, at risk malnutrition and wt loss
- Enteral feeds once resp system stabilizes
- DONT feed if baby not oxygenating, cause necrotic enterocolitis
- Enteral tube feedings conserve energy
- Gavage feedings used compromised newborns to allow rest. Use pacifier to train to suck then try bottle with tube feeds
Readiness for Nipple Feedings:
Rooting, sucking on gavage tubes/finger/pacifier, able tot tolerate holding, RR <60, presence of gag reflex
Nonreadiness: RR <60, No rooting, sucking, or gag reflex
Hyperbilirubinemia;
- Level
- Risk Factors
- Overproduction bilirubin from Hgb breakdown
- Serum bilirubin >5
- Jaundice
- Occurs from imbalance in rate of bilirubin production and bilirubin elimination
Risk Factors:
- Polycythemia (RBC)
- Fewer albumin sites after birth
- Liver immaturity
- Bruising, cephalohematoma
- Insufficient intake of milk
- Delayed BM
- Family ethnicity/background
- Intrauterine infections
- Maternal medication use
- Fetal-maternal blood group incompatibility
Increased ICP;
- Causes
- Interventions
- Result from head trauma, birth trauma, hydrocephalus, infection, brain tumors
- Measure head circumference in children <3 yrs; increases in circumference may indicate ICP
- Elevate HOB 15-30 degrees to facilitate venous return
- Minimize environmental stimuli/noise
- Have code cart available; resp/cardiovascular collapse
- Early intervention critical to prevent neuro damage/death
- Lumbar puncture to monitor spinal pressure
- ICP monitoring device placed in head to monitor pressure
Early signs of ICP
- HA
- Vomiting, projectile
- Blurred/double vision
- Dizziness
- Decreased HR, RR
- Increased BP, pulse pressure
- Pupil reaction time decreased/unequal
- Change in LOC, irritability
- Bulging, tense fontanel
- Wide sutures
- High pitched cry
Late signs of ICP
- Lowered LOC
- Decreased motor/sensory responses
- Bradycardia
- Irregular RR (Kussmals or Cheyne-Stokes)
- Decerebrate (outward flexion) or decorticate (toward the core) posturing
- Fixed/dilated pupils
Cushing’s Triad
3 primary signs that indicate increase ICP:
- Increased SBP
- Decreased HR
- Decreased RR
Hydrocephalus;
- Definition
- Congenital
- Acquired
- Obstructive
- Nonobstructive
- Disorder of nervous system
- CSF accumulates w/in ventricular system & causes ventricles to enlarge/increase in ICP occurs
- Congenital present at birth d/t genetic/environmental influences during fetal involvement (drugs, alcohol)
- Acquired develops at time of birth, results from injury or disease
- Obstructive occurs when flow of CSF blocked
- Nonobstructive occurs when CSF blocked after it exits ventricles
VP Shunts
- Placed for hydrocephalus
- Shunt revision surgery needed as child ages
- Inserted into brain & go into abdomen, allows fluid to be removed from brain & collect in peritoneal space & absorbed by digestive system
- Small amts of hydrocephalus - endoscopic 3rd ventriculostomy, perfusion made in 3rd ventricle to allow CSF to leave ventricle & go into subarachnoid space
- Un-dx present with irritability, lethargy, poor feeding, vomiting, HA, altered mental status
- Infants: palpate fontanels may reveal wide, budging fontanels
- Tests include: Skull Xray, CT, MRI
- Infection in shunt common 1-2 months after placement
Ischemic Stroke;
- Definition
- Embolism
- Thrombosis
- TIA
- Causes: large artery thrombosis, small penetrating artery thrombosis, cardiogenic embolic, cryptogenic
- Causes wide variety of neuro deficits depending on location of lesion
- Sx appear contra-lateral below neck to location of stroke
- TPA administered within 3 hours of onset
- FAST: facial drooping, arm weakness, slurred speech, time to call 911
- Embolism: clot left part of body, develops in heart and travels to brain, which stops blood flow
- Thrombosis: Clot forms w/in artery wall in neck/brain, seen in pt’s w/ HLD, atherosclerosis
- TIA (transient ischemic attack): “mini-stroke.” S/s stroke occurs only for a few mins-hours then resolved. Warning sign of impending stroke may occur
Left Side Stroke Sx
“Logical”
- Paralysis/weakness right side of body
- Right visual field deficit
- Aphasia (Expressive-inability to express self, Receptive-inability to understand language/communicate, Global-both)
- Altered intellectual ability
- Slow, cautious behavior
Right Side Stroke Sx
“Creative Side”
- Paralysis, weakness on left side of body
- Left visual field deficit
- Increased distractibility
- Impulsive behavior
- Lack of awareness of deficits (neglect)
- Left side weakness (hemiplegia)
- Impairment in creativity, arts, music
- Confused on date, time, place
- Cannot recognize faces or person’s name
- Loss of depth perception
- Trouble staying on topic when talking
- Trouble w/ maintaining proper grooming
- Emotionally: not thinking things through, impulsive
- Poor ability to make decisions/assessing spatial qualities/shapes
- Denial about limitations
- Not able to read nonverbal language/understand hidden meaning of things
- Very short attention span
TX Ischemic Stroke
TPA, Before giving it:
- CT Scan negative for hemorrhagic stroke
- SBP <185 and DBP ,<110
- No TIA
- No seizure at onset of stroke
- Not taking Warfarin
- No Heparin in last 48 hours
- No prior intracranial blood, neoplasm, aneurysm, AV malformation
- No major procedure in 14 days
- No stroke, head injury, intracranial surgery in last 3 months
- No GI bleed within 21 days
**Within 3 hours of sx onset, can be given 3-4.5 hrs in set criteria
Hemorrhagic Stroke;
- Definition
- Intracranial
- Subarachnoid
- TX
- SX
- Cause by IC or subarachnoid hemorrhage
- Caused by bleeding into brain tissue, ventricles, subarachnoid space
- IC hemorrhage; spontaneous rupture of small vessels accounts for 80% of hemorrhagic stroke, caused by uncontrolled HTN
- Subarachnoid hemorrhage results from ruptured IC aneurysm
- Increased ICP from sudden entry of blood into subarachnoid space compresses & injuries brain tissue
- SX: vomiting, early change in mental state, LOC, focal seizures
- CT to r/o bleed
- Lumbar puncture if no indication of increased ICP
- TX: Fresh frozen plasma and vitamin K, anticonvulsants, Craniotomy
Generalized Tonic Clonic
-AKA Grand Mal
-May experience AURA
-LOC
-Tonic phase: body stiffens, breathing stops
Clonic phase: recurrent jerking of extremities
-Usually lasts <3 mins
-At risk for status epilepticus
