Week 1 Learning outcomes-study guide Flashcards
- Describe the physiological changes that occur during pregnancy and their etiologies.
listed on the following cards
Uterus , Cervix and Vagina
increased levels of estrogen and progesterone -hypertrophie of uterine wall , softening of vaginal muscle and connective tissue and preparation for expansion of tissue , uterus contract ability increases in response to increased estrogen levels leading to Braxton Hicks contractions , hypertrophie of cervical glands leads to formation of mucus plug(protective barrier between uterus fetus and vagina) , increased vascularity and hypertrophy of vaginal and cervical glands leads to increase in Leukorrhea, cessation of menstrual cycle (amenorrhea) and ovulation.
•enlargement and stretching of uterus to accommodate developing fetus and placenta -increase uterine size 20 times that of non pregnant uterus , weight of uterus increases from 70 grams to 1100 grams , capacity increases from 10 milliliters to 5000 milliliters 80% of that to uteroplacental
.•expanded circulatory volume leads to increased vascular congestion -blood flow to uterus is 500 to 600 milliliters per minute at term ,
goodells sign- softening of cervix ,
hagars sign-softening of lower uterine segment , chadwicks sign blueish coloration of cervix vaginal mucosa and vulva
• acid pH of vagina -acid environment inhibits growth of bacteria , acid environment allows growth of candida Albicans leading to increased risk of candidiasis- yeast infection
Cardiovascular System
• Decrease in peripheral vascular resistance -decrease in blood pressure
• increase in blood volume by 40% to 45% -hypervolemia of pregnancy
• increasing cardiac output by 40% -increased heart rate Of 15 to 20 beats per minute
• BMR increased 10% to 20% by 3rd trimester -increased stroke volume of 25% to 30%
• increase in peripheral dilation -systolic murmurs , load and wide S1 split , load S2 , obvious S3 , increase in heart size
• increase in RBC count by 30% -In response to increased oxygen requirements of pregnancy RBC volume increases up to 33% with iron supplementations up to 18% without supplementation -physiological anemia of pregnancy
• Increase in plasma volume by 50%-Peaking at 32 to 34 weeks staying until term
-hemodilution is caused by increase in plasma volume being relatively larger than the increase in RBCS which results in decreased hemoglobin and hematocrit values=anemia ;
• Cardiac work is eased as the decrease in blood viscosity facilitates placental perfusion
• iron deficiency anemia=hemoglobin less than 11 grams per deciliter and hematocrit less than 33% maternal iron stores are insufficient to meet demands for iron in fetal development blood volume increases by 1500 milliliters to support uteroplacental demands and maintenance of pregnancy this is referred to as hypervolemia of pregnancy heart enlarges do too these factors
• hypercoagulation occurs during pregnancy to decrease risk of postpartum hemorrhage changes place women at risk for thrombosis and coagulopathies -Plasma fibrin increase of 40% fibrinogen increase of 50% coagulation inhibiting factors decrease
• increase in WBC count -values up to 16,000 mm3 in the absence of infection
• increase demand for iron and fetal development -iron deficiency anemia hemoglobin less than 11 grams per deciliter and hematocrit less than 33%
• plasma fibrin increase of 40% ,fibrinogen increase of 50% , decreasing coagulation inhibiting factors , protective of inevitable blood loss during birth - hypercoagulability
• Blood pressure decrease in first trimester due to a decrease in peripheral vascular resistance blood pressure returns to normal by term
• a systolic heart murmur or a third heart sound Gallup may be heard by mid pregnancy
• peripheral dilation increased
• increased Venous pressure and decreased blood flow to extremities due to compression of iliac veins and inferior vena cava -edema of lower extremities varicosities and legs and vulva hemorrhoids
•
• Cardiac output increases 30 to 50% peaks at 25 to 30 weeks
supine hypotensive syndrome
• supine hypotensive syndrome supine hypotensive syndrome is a hypotensive condition resulting from a woman lying on her back in mid to late pregnancy in superimposition enlarged uterus compresses inferior vena cava causing reduced blood flow back to right atrium and a drop in cardiac output and blood pressure that results in the woman feeling dizzy and faint
Respiratory System
- hormones of pregnancy stimulate respiratory center and act on lung tissue to increase and enhance respiratory function , increase of oxygen consumption by 15% to 20% - increase in title volume by 35% to 50% , slight increase in respiratory rate , increase in inspiratory capacity , decrease in expiratory volume , slight hyperventilation , slight respiratory alkalosis .
- estrogen progesterone and prostaglandins cause vascular engorgement and smooth muscle relaxation -dyspnea , nasal and sinus congestion , epistaxis (nose bleeds)
- upward displacement of diaphragm by enlarging uterus -shift from abdominals to thoracic breathing
- estrogen causes a relaxation of the ligaments and joints of the ribs , slight decrease in lung capacity -chest and thorax expand to accommodate thoracic breathing and upward displacement of diaphragm
- Increased oxygen demand is due to 15% increase in metabolic rate and 20% increased consumption of oxygen there is a 40 to 50% increase in minute ventillation mostly due to increase in title volume rather than in respiratory rate pulmonary function is not compromised in a normal pregnancy
- slight respiratory alkalosis -decrease in PCO 2 leads to increase in pH more alkaline and decrease in bicarbonate this change promotes transport of CO2 away from the fetus
- Diaphragm is displaced upward about four centimeters , increased chest circumference of 6 centimeters increase in kostal angle of greater than 90 degrees , these changes may contribute to physiological dyspnea that is common during pregnancy .
Renal System
• increased cardiac output an increased blood and plasma-increased renal blood flow of 50 to 80% in first trimester and then decreases ,
-increased progesterone cause a relaxation of smooth muscles -urinary frequency and incontinence and increased risk of UTI
• dilation of renal pelvis and ureters , ureters become elongated with decreased motility , decreased bladder tone with increased bladder capacity -increased risk of UTI
• pressure of enlarging uterus on renal structures , displacement of bladder and 3rd trimester
• increased glomerular filtration rate -increased urinary output
• increased renal excretion of glucose and protein -glucosuria and proteinuria(small amounts) exceeded tubal reabsorption threshold of protein and glucose due to increased volume small amount of protein area and glucosuria can be normal important to assess and monitor for pathology
• shift in fluid and electrolyte balance the need that’s increased
• In supine and upright maternal position blood pools lower body decrease in cardiac output GFR and urine output causing excess sodium and fluid retention
• a left lateral recumbent maternal position can maximize cardiac output renal plasma volume and urine output stabilize fluid and electrolyte balance minimize dependent edema maintain optimal blood pressure
• renal system secretes both maternal and fetal waste products
• Bladder capacity increases bladder tone decreases due to progesterone effect on smooth muscle relaxation and stretching
• urinary stasis -progesterone reduces tone of renal structures allowing pooling of urine stasis promotes bacterial growth and increases the woman’s risk for your UTI’s and pyelonephritis
• Urinary frequency urgency an nocturia begin early pregnancy continue varying degrees through pregnancy
UTI’s are common in pregnancy and may be asymptomatic symptoms of UTI urinary frequency discaria urgency sometimes pus or blood in urine if left untreated it can lead to pyelonephritis or premature labor
• decreased renal flow in 3rd trimester -dependent edema
• increased vascularity -hyperemia of Bladder and urethra
Gastrointestinal System
- nausea and vomiting- NVP
• increased levels of HCG and altered carbohydrate metabolism -nausea and vomiting during early pregnancy
• Uterine enlargement displaces stomach liver and intestines as pregnancy progresses -GI tract relaxation and slowing of processes =heartburn bloating and Constipation
• hemorrhoids varicosities and ** canal common due to increased venous pressure are exacerbated by Constipation puritis (itching)
-gallstones-relaxation of smooth muscle results distention of Gallbladder slows emptying of bile-
• pruritis-Abdominal Pruritis maybe early sign of Cholestasis(reduced bile flow from liver)
• ptyalism-Increase in saliva
• bleeding gums periodontal disease increased vascularity of gums can result in gingivitis
• increased heartburn
• increase progesterone slow the digestive process and movement of stool -bloating flatulence and Constipation
• increased progesterone levels decreased muscle tone of Gallbladder and result in prolonged emptying time -increased risk of gallstone formation and Cholestasis
• changes in sense of taste and smell -increased or decrease in appetite , nausea , -pica:abnormal craving for and ingestion of non food substances such as clay or starch
• displacement of intestines by uterus -flatulence abdominal distention abdominal cramping and pelvic heaviness
• increased levels of estrogen=gingivitis bleeding gums increased risk of periodontal disease
Musculoskeletal system
• increased progesterone and relaxin- lead to –softening of joints
increased joint mobility
widening and increased mobility of the sacroiliac and symphysis pubis -altered gate waddle gate , facilitates birthing process , low back pain or pelvic discomfort , pelvis tilts forward leading to shifting of center of gravity- change in posture and walking style increasing lordosis(Abnormal curvature anterior curvature of lumbar spine) , increased risk of falls
•
• Diastasis recti separation of rectus abdominis muscle in the midline caused by the abdominal distention at benign condition that can occur in 3rd trimester
• distension of abdomen related to expanding uterus reduced abdominal tone and increased breast size -round ligament spasm
• increased estrogen and relaxing levels lead to increased elasticity relaxation of ligaments -increased risk of joint pain and injury
• abdominal muscles stretched due to enlarging uterus -diastasis recti
Integumentary system
- estrogen and progesterone levels stimulate increased melanin= light Brown to dark Brown pigmentation -linea nigra , melasma (chloasma), increased pigmentation of nipples areola vulva scars and moles
- Melasma or mask of pregnancy brownish pigmentation of skin appears over cheeks nose and forehead more common and darker skinned women- after 16th week and is exacerbated by stretch marks due to growth plus estrogen relaxing an adreno corticoids =tearing of subcutaneous connective tissue/ collagen
- increased blood flow & BMR progesterone induced increase body temperature and vasomotor instability -hot flashes facial flushing alternating sensation of hot and cold , increased perspiration -increased thyroid activity
- increased action of adrenocorticosteroids Leads to cutaneous elastic tissues becoming fragile -striae gravidarum(stretch marks) On abdomen thighs breast and buttocks
- increased estrogen levels lead to color and vascular changes -angiomas (spider nevi), Palmar erythema: pinkish red modeling over palms of hands and redness of fingers
- increased androgens lead to increase in sebaceous gland secretions -increased oiliness of skin an increase of acne
Endocrine system
- alterations in pituitary adrenal thyroid parathyroid and pancreatic functioning
• Placenta after full development produces most hormones of pregnancy-estrogen progesterone human placental lactogen, relaxin
hormones play role in Physiology of pregnancy causing specific alterations in nearly all body systems to support maternal needs maintenance and progression of pregnancy and fetal growth and development
• decreased follicle stimulating hormone -amenorrhea
• increased progesterone -maintains pregnancy by relaxation of smooth muscles leading to decreased uterine activity which results in decreased risk of spontaneous abortions , decreases gastrointestinal motility and slows digestive processes
• increased estrogen-uterine and breast development , facilitates increase in vascularity , hyperpigmentation , alters metabolic processes and fluid and electrolyte balance
• increased prolactin -lactation
• increased oxytocin -stimulates uterine contractions , stimulates the milk let down or ejection reflex in response to breastfeeding
• increased HCG -maintenance of corpus luteum until placenta becomes fully functional
• human placental lactogen /human chorionic somatomammotropin- breast development , alters carbohydrate protein and fat metabolism , facilitates fetal growth by altering maternal metabolism ;acts as an insulin antagonist
• hyperplasia an increased vascularity of thyroid -enlargement of thyroid , heat intolerance and fatigue
• increased BMR related to fetal metabolic activity -depletion of maternal glucose stores leads to increased risk of maternal hypoglycemia
• increased need for glucose
increased production of insulin
• increase in circulating cortisol
-increase in maternal resistance to insulin leads to increase risk of hyperglycemia
Neurological System
Headache, Syncope
Generalized or multisystem
Fatigue (first and third trimesters)
Reassure the woman of the normalcy of her response.
Encourage the woman to plan for extra rest during the day and at night; focus on “work” of growing a healthy baby.
Enlist support and assistance from friends and family.
Encourage the woman to eat an optimal diet with adequate caloric intake and iron-rich foods and iron supplementation if anemic.
2 Identify nursing measures to relieve the discomforts caused by physiological changes during pregnancy.
As follows
Emotional lability (throughout pregnancy)
Reassure the woman of the normalcy of response.
Encourage adequate rest and optimal nutrition.
Encourage communication with partner/significant support people.
Refer to pregnancy support group.
Breasts
*Tenderness, enlargement, upper back pain (throughout pregnancy; tenderness mostly in the first trimester)
Encourage the woman to wear a well-fitting, supportive bra.
Instruct woman in correct use of good body mechanics.
*Leaking of colostrum from nipples (starting second trimester onward)
Reassure the woman of the normalcy.
Recommend soft cotton breast pads if leaking is troublesome.
Uterus
Braxton-Hicks contractions (mid-pregnancy onward)
Reassure the woman that occasional contractions are normal.
Instruct the woman to call her provider if contractions become regular and persist before 37 weeks.
Ensure adequate fluid intake.
Recommend a maternity girdle for uterus support.
Cervix/vagina
Increased secretions
Yeast infections (throughout pregnancy)
Encourage daily bathing.
Recommend cotton underwear.
Recommend wearing panty liner, changing pad frequently.
Instruct the woman to avoid douching or using feminine hygiene sprays.
Inform provider if discharge changes in color or is accompanied by foul odor or pruritus.
Dyspareunia(pain before during or after intercourse)(throughout pregnancy)
Reassure the woman/couple of normalcy of response, provide information.
Suggest alternative positions for sexual intercourse and alternative sexual activity to sexual intercourse.
Cardiovascular
Supine hypotension (mid-pregnancy onward) Instruct the woman to avoid supine position from mid-pregnancy onward.
Advise her to lie on her side and rise slowly to decrease the risk of a hypotensive event.
Orthostatic hypotension
Advise woman to keep feet moving when standing and avoid standing for prolonged periods.
Instruct to rise slowly from a lying position to sitting or standing to decrease the risk of a hypotensive event.
Anemia (throughout pregnancy; more common in late second trimester)
Encourage the woman to include iron-rich foods in daily dietary intake and take iron supplementation.
Dependent edema lower extremities and/or vulva (late pregnancy)
Instruct the woman to:
- Wear loose clothing
- Use a maternity girdle (abdominal support), which may help reduce venous pressure in pelvis/lower extremities and enhance circulation
- Avoid prolonged standing or sitting
- Dorsiflex feet periodically when standing or sitting
- Elevate legs when sitting
- Position on side when lying down
Varicosities (later pregnancy)
Instruct woman in all measures for dependent edema (see above).
Suggest the woman wear support hose (put on before rising in the morning, before legs have been in dependent position).
Instruct the woman to lie on her back with legs propped against a wall in an approximately 45-degree angle to spine periodically throughout the day.
Instruct the woman to avoid crossing legs when sitting.
Respiratory
Hyperventilation and dyspnea (throughout pregnancy; may worsen in later pregnancy)
Reassure the woman of the normalcy of her response and provide information.
Instruct the woman to slow down respiration rate and depth when hyperventilating.
Encourage good posture.
Instruct the woman to stand and stretch, taking a deep breath periodically throughout the day; stretch and take a deep breath periodically throughout the night.
Suggest sleeping semi-sitting with additional pillows for support.
Nasal and sinus congestion/epistaxis (throughout pregnancy)
Suggest the woman try a cool-air humidifier.
Instruct the woman to avoid use of decongestants and nasal sprays and instead to use normal saline drops.
Renal-Frequency and urgency/nocturia (may be throughout pregnancy; most common in first and third trimesters)
Reassure the woman of normalcy of response.
Encourage the woman to empty her bladder frequently, always wiping front to back.
Stress the importance of maintaining adequate hydration, reducing fluid intake only near bedtime.
Instruct her to urinate after intercourse.
Teach the woman to notify her provider if there is pain or blood with urination.
Encourage Kegel exercises; wear perineal pad if needed.
Gastrointestinal
Nausea and/or vomiting in pregnancy (NVP) (first trimester and sometimes into the second trimester)
Reassure the woman of normalcy and self-limiting nature of response.
Avoid strong odors and causative factors (e.g., spicy foods, greasy foods, large meals, stuffy rooms, hot places, or loud noises).
Encourage women to experiment with alleviating factors:
- Eating small, frequent meals as soon as, or before, feeling hungry
- Eat at a slow pace
- Eat crackers or dry toast before rising or whenever nauseous
- Drink cold, clear carbonated beverages such as ginger ale, or sour beverages such as lemonade
- Avoid fluid intake with meals
- Eat ginger-flavored lollipops or peppermint candies
- Brush teeth after eating
- Wear P6 acupressure wrist bands
- Take vitamins at bedtime with a snack (not in the morning)
- Suggest vitamin B6, 25 mg by mouth three times daily or ginger, 250 mg by mouth four times daily
Oral or rectal medications may be prescribed for management of troublesome symptoms.
Identify, acknowledge, and support women with significant NVP to offer additional treatment options.
Increase or sense of increase in salivation (mostly first trimester if associated with nausea)
Suggest use of gum or hard candy or use astringent mouthwash.
Bleeding gums (throughout pregnancy)
Encourage the woman to maintain good oral hygiene (brush gently with soft toothbrush, daily flossing).
Maintain optimal nutrition.
Flatulence (throughout pregnancy)
Encourage the woman to:
- Maintain regular bowel habits
- Engage in regular exercise
- Avoid gas-producing foods
- Chew food slowly and thoroughly
- Use the knee-chest position during periods of discomfort
Heartburn (later pregnancy)
Suggest:
- Small, frequent meals
- Maintain good posture
- Maintain adequate fluid intake but avoid fluid intake with meals
- Avoid fatty or fried foods
- Remain upright for 30–45 minutes after eating
- Refrain from eating at least 3 hours prior to bedtime
Constipation (throughout pregnancy; see Concept Map feature)
Encourage the woman to:
- Maintain adequate fluid intake
- Engage in regular exercise such as walking
- Increase fiber in diet through vegetables, fruits, and whole grains
- Maintain regular bowel habits
- Maintain good posture and body mechanics
Hemorrhoids (later pregnancy)
Avoid constipation (see above).
Instruct the woman to avoid bearing down with bowel movements.
Instruct the woman in comfort measures (e.g., ice packs, warm baths or sitz baths, witch hazel compresses).
Elevate the hips and lower extremities during rest periods throughout the day.
Gently reinsert hemorrhoid into the rectum while doing Kegel exercises.
Musculoskeletal
Low back pain/joint discomfort/difficulty walking (later pregnancy)
Instruct the woman to:
- Utilize proper body mechanics (e.g., stoop using knees vs. bend for lifting)
- Maintain good posture
- Do pelvic rock/pelvic tilt exercises
- Wear supportive shoes with low heels
- Apply warmth or ice to painful area
- Use of maternity girdle
- Use massage
- Use relaxation techniques
- Sleep on a firm mattress with pillows for additional support of extremities, abdomen, and back