Medical conditions during pregnancy/Assessments/interventions

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dsherman
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Medical conditions during pregnancy/Assessments/interventions
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2011-11-29 16:33:19
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Medical conditions during pregnancy/Assessments/interventions
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  1. Unexpected medical conditions during pregnancy
    • incompetent cervix
    • hyperemesis gravidarum
    • anemia
    • gestational diabetes mellitus
    • gestational hypertension/pregnancy induced
    • hypertention
    • heart disease
  2. Incompetent Cervix Overview/Risk factors/Assessments
    • Overview:
    • painless dilation of the cervix in the absence of uterine contraction. The cervix is incapable of supportine the weight and pressure of the growing fetus and results in expulsion of the products of conception during the second trimester of pregnancy

    usually occurs around 20 weeks of gestation

    • Risk Factors:
    • *History of cervical trauma (previous laceratioms, excesive dilations, and curettage for biopsy)
    • *In utero, exposure to diethylstilbestrol (ingested by the patients mother during pregnancy)
    • *congenital structural defects
    • *increased maternal age

    • Assessment:
    • Subjective data:
    • *Increase in pelvic pressure
    • Objective data
    • *pink-stained vaginal discharge or bleeding
    • *possible gush of fluid (rupture of membranes)
    • *Uterine contractions with the expulsion of the fetus
    • *Postoperative (cerclage) monitoring for uterine contractions, rupture of membranes, and signs of infection

    • Diagnostic/Theropeutic procedures:
    • *an ultrasound showing a short cervix less then 20mm in length) indicates a reduced cervical competence
    • *Prophylactic cervical cerclage is the surgical reinforcement of the cervix with a heavy ligature that is placed submucosally around the cervix to strengthen it and prevent premature cervical dilation. The cerclage is removed at 37 weeks of gestation
  3. Collaborative care for patients with Incompetent Cervix
    • Nursing care:
    • *evaluate patients support systems and availability of assistance if activity restrictions and/or bed rest are prescribed
    • *assess vaginal discharge
    • *monitor patient reports of pressure and contractions
    • *check the patients vital signs and temperature

    • Medications:
    • administer tocolytics prophylactically to inhibit uterine contractions

    • Discharge instructiosn:
    • *place the patient on activity restriction/bed rest
    • *encourage hydration to promote a relaxed uterus (dehydration stimulates uterine contractions)
    • *advise the patient to refrain from intercourse, prolonged standing for more than 90min and heavy lifting

    • Patient education:
    • *signs and symptoms to report to the physician for preterm labor, rupture of membranes, infection, strong contractions less than 5 min apart, severe perineal pressure, and urge to push
    • *instruct the patient about using the hime uterine activity monitor to monitor for uterine contractions
    • *arrange for the patient to followup with a home-health agency for close observation and supervision
    • *remove the cerclage around 37 weeks of gestation

    • expected outcomes:
    • *patient will remain free of injury during pregnancy
    • *patient will maintain pregnancy until term
  4. Hyperemesis Gravidarum Overview/Risk factors/Assessments
    • Overview:
    • excessive nausea and vomiting (related to elevated hCG levels) that prolonged past 12 weeks of gestation and results in a 5% weight loss form prepregnancy weight, electrolyte imbalance, acetonuria, and ketosis
    • *May be accompanied with liver dysfunction
    • *there is a risk to the fetus for intrauterine growth restriction (IUGR) or preterm birth if the condition persists

    • Risk factors:
    • *maternal age younger than 20 years
    • *obesity
    • *first pregnancy
    • *multifetal gestation
    • *gestational trophoblastic disease
    • *women with a history of psychiatric disorders
    • *transient hyperthyroidism
    • *Vitamin B dificiencies
    • *high stress

    • Assessment:
    • Objective data:
    • *excessive vomiting for prolonged periods
    • *dehydration with possible electrolyte imbalance
    • *weight loss
    • *increased pulse rate
    • *decreased B/P
    • *poor skin turgor

    • Laboratory test:
    • *urinalysis for ketones and acetones (breakdown of protein and fat) is the most important initial laboratory test
    • *elevated specific gravity
    • Chemistry profile revealing electrolyte imbalances such as:
    • sodium, potassium, and chloride reduced from low intake
    • acidosis resulting from excessive vomiting
    • elevated liver enzymes
    • *Thyroid test indicating hyperthyroidism
    • *Hct concentration is elevated because inability to retain fluid results in hemoconcentration
  5. Collaborative care for patients experiencing Hyperemesis Gravidarum
    • Nursing care:
    • *monitor the patients I&O
    • *assess the patients skin turgor and mucus membranes
    • *monitor the patients vital signs
    • *monitor the patients weight
    • *have the patient reamin NPO for 24 hours
    • *give the patient IV fluids or Lactated Ringer's solution for hydration

    • Medications:
    • *give pyridoxine (Vitamen B6) and other vitamen supplements as tolerated
    • *use antiemetic medications cautiously for uncontrollable nausea and vomiting (promethazine [Phenergen], metoclopramide [Reglan])
    • *use corticosteroids to treat refractory hyperemesis gravidarum

    • Discharge instructions:
    • *advance the patient to clear liquids after 24 hr if no vomiting
    • *advance the patient's diet as tolerated, with frequent, small meals,start with dry toast, crackers, or cereal, then move to a soft diet, and finally to a normal diet as tolerated
    • *in severe cases, or if vomiting returns, enteral nutriton per feeding tube or total parental nutrition (TPN) may be considered

    • Expected outcomes:
    • patient will maintain fluid and electrolyte balance, stabilize weight, and retain meals
  6. Anemia during pregnancy Overview/Risk factors/Assessments
    • Overview:
    • Iron-deficiency anemia occurs during pregnancy due to inadequacy in maternal iron stores and consuming insufficient amounts of dietary iron

    • Risk factors:
    • *less then 2 years between pregnancies
    • *heavy mensis
    • *diet low in iron

    • Assessments:
    • Subjective:
    • *fatigue
    • *irritability
    • *headache
    • *shortness of breath with exertion
    • *palpitations
    • *craving unusual food (pica)
    • Objective:
    • *pallor
    • *brittle nails
    • *shortness of breath
    • Laboratory test:
    • Hgb: <12mg/dL
    • Hct: <33%
  7. Collaborative care for anemia during pregnancy
    • Nursing care:
    • *prophylactic treatment of prenatal supplements with 60 mg of iron is suggested
    • *Increase dietary intake of foods rich in iron (legumes, fruir, green, leafy vegetables, and meat)
    • *educate the patient about ways to minimize gastrointestinal side effects

    • Medications:
    • *Ferrous sulfate iron supplements
    • used to increase Hgb and Hct levels
    • *instruct the patient to take the supplement on an empty stomach
    • *encourage the intake of vitamin C to increase absorption of iron
    • *suggest tht the patient increase roughage in diet to sassist with discomforts of constipation
    • *Iron dextran (Imferon)
    • used in the treatment of iron-deficiency anemia when oral iron supplements cannot be tolerated by the patient who is pregnant

    • Expected outcomes:
    • the patients Hgb and Hct levels will increase during pregnancy
  8. Gestational Diabetes Mellitus Overview/Risk factors/Assessments
    • *impaired tolerance to glucose with the first onset or recognigion during pregnancy. The *ideal blood glucose level during pregnancy should fall between 70-110 mg/dL
    • *symptoms of diabetes mellitus may disappear a few weeks following delivery. however, approximately 50% of women will develop diabetes mellitus within 5 years

    • Risk factors:
    • *obesity
    • *maternal age older than 25 years
    • *family history of diabetes mellitus
    • *previous delivery of an infant that was large or still born

    • Assessments:
    • Subjective data:
    • *hypoglycemia (nervousness, headache, weakness, irritability, hunger, blurred vision, tingling of mouth or extremities)
    • *hyperglycemia (thirst, nausea, abdominal pain, frequent urination, flushed dry dkin, fruity breath)
    • Objective data:
    • hypoglycemia:
    • *shaking
    • *clammy pale skin
    • *shallow respirations
    • *rapid pulse
    • hyperglycemia:
    • *bomiting
    • *excessive weight gain during pregnancy

    • Laboratory test:
    • *Routine urinalysis with glycosuria
    • *glucose screening test/1 hr glucose tolerance test (50g oral glucose load, followed by plasma glucose analysis 1 hr later performed at 24-28 weeks of gestation- fasting is not necessary; a positive blood glucose screening is 140mg/dL or greater; additional testing with a 3-hr glucose test is indicated)
    • *3-hr glucose tolerance test (following overnight fasting, avoidance of caffeine, and abstinence form smoking for 12 hrs. prior to testing; a fasting glucose is obtained, a 100g glucose load is given, and serum glucose levels are determined at 1, 2, and 3 hr following glucose ingestion)
    • *Ketones tested to sddess the severity of ketoacidosis

    • Diagnostic procedures:
    • *Biophysical profile to ascertain fetal well-being
    • *Amniocentesis with alpha-fetoprotein
    • *Nonstress test to assess fetal well-being
  9. Increases to the fetus caused by Gestational Diabetes Mellitus
    • *Spontaneous abortion, which is related to poor glycemic control
    • *infections (urinary and vaginal) which are related to increased glucose in the urine and decreased resistance because of altered carbohydrate metabolism
    • *Hydramnios, which can cause overdistention of the uterus, premature rupture of membranes, preterm labor, and hemorrhage
    • *Ketoacidosis from diabetogenic effect of pregnancy (increased insulin resistance), untreated hyperglycemia, or inapppropriate insulin dosing
    • *Hypoglycemia, which is caused by overdosing in isulin, skipped or late meals, or increased exercise
    • *hyperglycemia, which can cause excessive fetal growth (macrosomia)
  10. Collaborative Care for Gestational Diabetes Mellitus
    • Nursing Care:
    • *monitor the patients blood glucose
    • *monitor the fetus
    • *instruct the patient to perform daily kick counts

    • Medications:
    • *Administer insulin prescribed
    • *Most oral hypoglycemic agents are contraindicated for gestational diabetes mellitus, but there is limited use of glyburide (DiaBeta) at this time. The physician will need to make the determination if these medications may be used

    • Patient education:
    • educate the patient about diet and exercise
    • instruct the patient about self-administration of insulin

    • Expected outcomes:
    • patient will effectively manage and contreol blood glucose level throughout her pregnancy to ensure maternal/fetal well-being
  11. Gestational Hypertensiion/Pregnancy- Induced Hypertension Overview
    Hypertensive disease in pregnancy is divided into clinical subsets of the disease based on end-organ effects and progresses along a continum.

    • 1) Gestational hypertension (GH)
    • *begins after the 20th week of pregnancy
    • *elevated B/P 140/90 or higher
    • *No proteinuria or edema
    • *B/P returns to baseline by 12 weeks post partum

    2) Mild preeclampsia is GH with the addition of proteinuria of 1-2+ and a weight gain of more than 2 kg (4.4lbs) per week in the second and third trimesters. Mild edema will also begin to appear in the upper extremities or face

    3) Severe preeclampsia consists of blood pressure that is 160/100 mm Hg or greater, preoeinuria 3-4+, oliguria, elevated serum creatinine greater than 1.2 mg/dL, cerebral or visual disurbances (headache, blurred vision), hyperreflexia with possible anlkle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and right upper-quadrent pain, and thrombocytopenia

    4) Eclampsia is severe preeclampsia symptoms along with the onset of seizure activity or coma. Eclampsia is usually preceded by headache, severe epigastric pain, hyperreflexia, and hemoconcentration, which are warning signs of probable convulsions

    • 5) HELLP syndrome is a variant of GH
    • *H-hemolysis resulting in anemia and jaundice
    • *EL-elevated liver enzumes resulting in elevated alanine aminotransferase (ALT) or aspartate transminase (AST), epigastric pain, and nausea and vomiting
    • *LP-low platelets (<100,000/mm3), resulting in thrombocytopenia, anormal bleeding and clotting time, bleeding gums, petechiae, and possibly DIC

    6) Gestational hypertensive disease and chronic hypertension may occur simultaneously

    7) Gestational hypertensive diseases are associated with placental abruption, acute renal failure, hepatic rupture, preterm birth, and fetal and maternal death
  12. Risk Factors for Gestational Hypertension/Pregnancy-Induced Hypertension
    • No single profile identifies risks for gestational hypertensive disorders, but some high risk include
    • *Maternal age younger than 20 or older than 40
    • *first pregnancy
    • *morbid obesity
    • *multifetal gestation
    • *chronic reanl disease
    • *chronic hypertension
    • *familiar history of preeclampsia
    • *diabetes mellitus
    • *Rh incompatibility
    • *molar pregnancy
    • *previous history of GH
  13. Assessments for Gestational Hypertension/Pregnancy-Induced Hypertension
    • Subjective data:
    • *severe continious headache
    • *nausea
    • *blurred vision
    • *flashes of lights or dots before the eyes

    • Objective data:
    • *hypertension
    • *proteinuria
    • *periorbital, facial, hand and abdominal edema
    • *pitting edema of lower extremities
    • *vomiting
    • *oliguria
    • *hyperreflexia
    • *scotoma (a blackened area in field of vision)
    • *epigastric pain
    • *right-upper quadrant pain
    • *dyspnea
    • *diminished breath sounds
    • *seizures
    • *jaundice
    • *Signs of progression of hypertensive disease with indications of worsening liver involvement, renal failure, worsening hypertension, cerbral involvement, and developing coagulopathies (HELLP)
    • *rapid weight gain (2kg[4.4lb]) per week in the second and third trimester
  14. Abnormal Laboratory findings for Gestational Hypertension/Pregnancy Induced Hypertension (Objective data)
    • *elevated liver enzymes (LDH, AST)
    • *incresed creatinine
    • *increased plasma uric acid
    • *thrombocytopenia
    • *decreased Hgb
    • *hyperbilirubinemia

    • Laboratory tests:
    • *Liver enzymes
    • *serum creatinine, BUN, uric acid, and magnesium increase as renal function decreases
    • *CBC
    • *clotting studies
    • *chemistry profile

    • Diagnostic Procedures
    • *dipstick testing of urine for proteinuria
    • *twenty-four hour urine collection for protein and creatinine clearance
    • *Nonstress test, contraction stress test, biophysical profile, and serial ultrasounds to assess fetal status
    • *doppler blood flow analysis to assess fetal well-being
  15. Collaborative care for Gestational Hypertension/Pregnancy Induced Hypertension
    • Nursing care:
    • assess the patient's level of consciousness
    • obtain pulse oximetry
    • Monitor the patients urine output and obtain a clean-catch urine sample to assess for proteinuria
    • obtain daily weight
    • monitor vital signs
    • discuss lateral positioning
    • perform NST and daily kick counts as prescribed
    • instruct the patient to monitor I&O
  16. Medications for Gestational Hypertension/Pregnancy Induced Hypertension
    • Magnesium sulfate:
    • administer IV magnesium sulfate
    • this is the medication of choice for prophylaxis or treatment of Hypertention

    use an infusion control device to maintain a regular flow rate

    • instruct patient that she may initially feel flushed, hot and sedated with magnesium sulfate bolus
    • Monitor the patient's B/P, pulse, respiratory rate, deep-tendon reflexes, level of consciousness, urinary output (indwelling urinary catheter for accuracy), presence of headache, visual disturbances, epigastric pain, uterine contractions, and FHR and activity

    • Monitor for signs of Magnesium sulfate toxicity:
    • *absence of patellar deep tendon reflexes
    • *urine output less than 30 mL/hr
    • *respirations less than 12/min
    • *decreased level of consciousness
    • *cardiac dsrhythmias

    • If magnesium toxicity is suspected:
    • *immediately discontinue infusion
    • *administer antidote calcium gluconate
    • *prepare for actions to prevent respiratory or cardiac arrest
  17. Health promotion and disease prevention; Gestational Hypertention/Pregnancy Induced Hypotention
    • Discharge instructions:
    • *maintain the patient on bed rest and encourage her to lie in a side-lying position
    • *promote diversional activities
    • *have the patient avoid foods that are high in sodium
    • *have the patient avoid alcohol and limit caffeine
    • *instruct the patient to increase her fluid intake to 8 glasses/day
    • *maintain a dark quiet environment to avoid stimuli that may precipitate a seizure
    • *maintain a patent airway in the event of a seizure
    • administer antihypertensive medications as prescribed

    • Expected outcomes:
    • patient will maintain blood pressure within acceptable parameters
    • patient and fetus will remain free of injury
  18. Heart Disease during pregnancy (Classifications)/Complications
    Class I: Patient exhibits no symptoms with activity, should have a normal pregnancy and delivery

    Class II: Patient has symptoms with ordinary exertion, should have a normal pregnancy and delivery

    Class III: Patient displays symptoms with minimal exertion, Total bed rest is indicated

    Class IV: Patient has symptoms at rest, are not good candidates for pregnancy and all risk factors should be discussed with these patients

    Patients will be revaluated at 3 and 7 months of gestation to determine appropriate treatment and interventions

    • Complications:
    • *right-sided heart failure
    • *hypertension
    • *arrhythmias
    • *pulmonary hypertension
    • *heart failure
    • *aneurysm
    • *aortic dissection
    • *maternal/fetal death
  19. Heart Disease during pregnancy Risk factors/Assessments
    • Risk Factors:
    • *preterm labor
    • *miscariage
    • *intrauterine growth restriction

    • Assessments:
    • Subjective data:
    • Dizziness, shortness of breath, weakness, fatigue, chest pain, anxiety
    • Objective data:
    • arhythmias, irregular heart rate, tachycardia, heart murmur, distended jugular veins, canosis of nails or lips, pallor, generalized edema, diaphoresis, increased respirations, cough, hemoptysis, intrauterine growth restriction, decreased amniotic fluid, FHR with decreased variability

    • Laboratory test:
    • Hgb, Hct, WBC, chemistry profile, sedimentation rate, maternal ABG's, clotting studies

    • Diagnostic test:
    • Echcardiogram, Holter monitoring, chest x-ray, ultrasound, pulse oximetry, NST, Biophysical profile

  20. Collaborative Care for Heart Disease during pregnancy
    • Nursing care:
    • *instruct the patient to adhere to bed rest
    • *provide the patient with education related to restricvtion dietary sodium and adhering to a cardiac diet
    • *instruct the patient to decrease physical activity
    • *monitor the patients vital signs
    • *monitor FHR and uterine contractions
    • *administer influenza and pneumococcus vaccines
    • *encourage the patient to take prenatal vitamins and iron supplements
    • *administer oxygen tot he patient as prescribed
    • *monitor the patient's daily weight and urinary output
    • *perform diagnostic procedures and laboratory studies as indicated
    • *instruct the patient to perform daily kick counts to assess fetal well-being
    • *perform NST as prescribed
  21. Medications for Heart Disease during pregnancy
    • Propranolol (Inderal)
    • *Beta-blocker
    • *used to treat tachyarrhythmias and to lower maternal blood pressure
    • Gentamicin (Garamycin)
    • *aminoglycoside antibiotic
    • *prophylaxis that is give to prevent endocarditis
    • Ampicillin (Polycillin)
    • *antibiotic
    • *prophylaxis that is given to prevent endocarditis
    • Heparin sodium
    • *anticoagulant
    • *used in treating patients with pulmonary embolus, deep vein thrombosis, prosthetic valves, cyanotic heart defects, and rheumatic heart disease
    • *educate the patient regarding self-administration of anticoagulants
    • *provide nutritional education regarding avoiding foods that are high in vitamin K
    • Digoxin (Lanoxin)
    • *cardiac glycoside
    • *used to increase cardiac output during pregnancy, and may be prescribed if fetal tachycardia is present
  22. Patient education/Expected outcomes Heart Disease During Pregnancy
    • *instruct the patient to notify the nurse of signs or symptoms of infection
    • *reinforce education related ot medication
    • *instruct the patient to perform daily kick counts

    • Expected Outcomes:
    • *patient will remain free of injury during pregnancy
    • *patient will be free of infection

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