Exam 6 Lecture 1

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Exam 6 Lecture 1
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2014-04-27 14:47:53
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Exam 6 lecture 1
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  1. Abortion
    pregnancy lost prior to viability, can be spontaneous or induced

    before 20 weeks gestation or less than 500g
  2. Major cause of bleeding during 1st and 2nd trimester
    abortion
  3. Nursing interventions for threatened abortion
    bedrest and no intercourse

    there are prostaglandins in sperm....can cause contractions + nipple stimulation causes contractions
  4. Nursing interventions after all types of abortions
    • count and weigh pads to assess bleeding
    • save all clots
    • IV fluids for volume replacement
    • VS
    • Assess for FHT
    • O2 ready
    • observe for shock
    • Possible blood transfusion
    • assess coping and give emotional support
  5. RhoGam needs to be given when
    within 72 hours of delivery/abortion
  6. When and why does a spontaneous abortion occur?
    prior to 12 weeks

    baby problem/mom problem or a problem between the 2
  7. Maternal problems that can cause a spontaneous abortion
    • chronic disease
    • hypothyroid
    • DM or Lupus
    • Syphillis
  8. D&C
    used to expel or clean out the uterus when all parts don't get removed with spontaneous abortion

    it is a scraping with a curette (spoon shaped instrument) that removes the lining
  9. Threatened abortion
    vaginal bleeding with cramping and water bag has remained in tact
  10. How do you know a threatened abortion will more than likely change to an inevitable abortion?
    she will have a backache and pelvic pressure
  11. Spotting is always considered a
    threatened abortion.....the cervix is closed
  12. Inevitable abortion
    membranes have ruptured and there is cervical dilation
  13. Incomplete abortion
    some, but not all products of conception are expelled

    • bleeding
    • severe cramping
    • opened cervix
    • passage of tissue

    RISK FOR HEMORRHAGE
  14. If a woman comes in and has had an incomplete abortion
    <14 weeks
    >14 weeks
    book the OR

    • <14 weeks= D&C, transfusion (?), IV Pitocin or Methergine
    • >14 weeks=oxytocin/prostaglandin induction
  15. Complete Abortion
    • all products of conception are expelled
    • contractions and bleeding has stopped
    • cervix closes
    • pregnancy symptoms subside
    • pregnancy test is negative
  16. Missed abortion
    fetal death but it is retained in the uterus

    • signs of pregnancy have stopped
    • uterus decreases in size due to absorption of fluid
    • maceration of fetus
  17. Nursing considerations for a missed abortion
    • US to confirm death
    • serial pregnancy test to see decline in placental hormone production

    If spontaneous evacuation of uterus does not occur within 1 month, pregnancy is terminated by method appropriate to duration of pregnancy due to increased risk of DIC
  18. What lab do you monitor for a woman who has a missed abortion until the uterus is empty?
    clotting factors....risk for DIC
  19. Complication risks for a woman who is having a missed abortion
    • infection
    • DIC
  20. S/S of an vaginal infection
    • increased temp
    • foul vaginal discharge
    • abdominal pain
  21. What is DIC
    Disseminated Intravascular Coagulation

    It is an over-activation of clotting cascade and fibrinolytic system resulting in a depletion of platelets and clotting factors
  22. S/S of DIC
    • spontaneous bleeding from gums or nose
    • Petechiae
    • Excessive bleeding from venipuncture, IM or Sub Q injection....even shaving
    • tachy
    • diaphoresis
  23. If a person is having DIC a weird place you will see petechiae
    at the spot you put the BP cuff
  24. Abnormal lab findings for a person with DIC
    Decreased- RBC, fibrinogen, clotting factors

    Increased- PT/PTT and fibrin
  25. Nursing considerations for a woman who is having DIC
    • Correct underlying cause by removing the fetus/placenta
    • treatment of preeclampsia/eclampsia
    • provide volume replacement
    • blood component therapy
    • heparin
    • optimize O2
  26. Recurrent Spontaneous Abortion aka Habitual abortion
    when a woman has 3+ consecutive spontaneous abortions
  27. What makes a woman have recurrent spontaneous abortions?
    • bicornate uterus-cant hold pregnancy
    • incompetent cervix-opens prematurely
    • insufficient secretion of progesterone
    • immunologic factors
  28. How is an woman with an incompetent cervix treated?
    watch for the cervix to dilate around 15-20 weeks

    Cerclage operation to correct the weak cervix by suturing it closed to prevent dilation
  29. Position patient is placed in to perform cerclage
    trendelenberg
  30. Discharge teaching for the woman after a spontaneous abortion
    • advise her to report any heavy, profuse or bright red bleeding
    • Reassure that a scant, dark discharge may persist for 1-2 weeks
    • No SEX till bleeding stops
    • take antibiotics
    • ACKNOWLEDGE this is a loss and time will be required for recovery emotionally/physically
    • refer to support groups
  31. When can a woman who has had a spontaneous abortion get prego again?
    not till the doctor says...but usually 2 months later
  32. Ectopic Pregnancy
    implantation of fertilized ovum anywhere outside the uterus
  33. Where should the fertilized ovum implant?
    in the endometrium
  34. What is the primary cause of maternal mortality in the 1st trimester?
    ectopic pregnancy...it is a MEDICAL EMERGENCY
  35. What makes you at an increased risk for an ectopic pregnancy?
    • anything that decreases the tubal lumen in diameter OR
    • anything that alters the motility of an egg

    • any tubal damage/surgeries that have caused scar tissue PID/STD/GIFT
    • Congenital abnormality of tube/endometriosis
    • Presence of an IUD
    • multiple induced abortions
    • maternal age over 35
    • cigarette smoker
    • vaginal douching
  36. What two things change the environment of the fallopian tubes?
    cigarette smoking and vaginal douching
  37. S/S of ectopic pregnancy
    • acute illness
    • missed period
    • one sided lower abdominal pain OR
    • lower abdominal pelvic pain
    • light bleeding
    • cullens sign (bleeding around umbilicus)
    • fainting/dizzy
    • referred right shoulder pain
    • abdominal tenderness
  38. 2 types of bleeding with an ectopic pregnancy
    • hemorrhagic which will cause hypovolemic shock
    • or
    • slow bleeding which will be seen as a RIGID or tender abdomen
  39. How do you dx ectopic pregnancy?
    • HCG will be increased but not as high as it should be
    • transvaginal US
    • Laparscopy...to dx and remove
  40. 2 priorities when a woman comes in with an ectopic pregnancy?
    • #1 START AN IV
    • #2 put her NPO
  41. Nursing management of a woman who has come in with an ectopic pregnancy
    • US
    • Labs
    • Admin. Methotrexate IM
    • Prevent/ID hypovolemic shock
    • Control  pain
    • Control bleeding
    • Prep for surgery
    • Therapeutic communication
  42. A woman comes in to ED with lower abdominal pain....
    assume she may have an ectopic pregnancy until it has been R/O
  43. What does methotrexate IM do for a woman with an ectopic pregnancy?
    folic acid antagonis that will interfere with cell reproduction
  44. How do you prevent/ID hypovolemic shock?
    • VS
    • IV
  45. Surgeries for an ectopic pregnancy
    Intact tube to salvage it
    Removal of tube
    • Salpingostomy
    • Salpingectomy
  46. Hydatidiform Mole AKA Gestational Trophoblastic Disease
    abnormal pathologic proliferation of trophoblastic cells-embryo dies cuz the cells take over the uterus

    "Molar Pregnancy"
  47. Patient who had Hydatidiform Mole is at risk for......so.....
    choriocarcinoma

    will need to not get prego for 1 year to monitor HCG levels
  48. S/S of Hydatidiform Mole
    • increased HCG levels
    • vaginal bleeding (possible hemorrhage)
    • Large for dates uterus (cuz of prolif of cells)
    • No FHT or palpable parts
    • Excessive N/V due to HCG levels
    • Early PIH <24 weeks
  49. DX of Hydatidiform Mole
    US that will show no fetal skeleton
  50. Treatment of Hydatidiform Mole
    • Immediate evacuation of mole and curettage of uterus
    • F/U for malignancy by monitoring HCG for 1 year...if yes then chemo
  51. Nursing considerations of Hydatidiform Mole
    • *Watch for signs of hemorrhage
    • assess vaginal bleeding
    • monitor vs
    • admin o2
    • assess for anemia
    • BC for 1 year
  52. Main difference between placenta previa and abruptio
    abrevia is painless bleeding with normal contractions

    abruptia abdominal pain and contractions are hyperactive
  53. How do you know a woman is bleeding internally?
    abdomen will be rigid, board like and tender
  54. Dilation of cervix causes
    hemorrhage
  55. Placental location of previa vs. abruptio
    previa is a lower segment obstruction

    abruption is a normal implantation, but the placenta separates from the uterine wall
  56. Therapeutic management for a woman with placenta previa
    • bedrest
    • IV-prep for transfusion
    • NO vaginal exams
    • Monitoring of mom and fetus
  57. Therapeutic management for a woman with placenta abruptia
    • assess uterine tone
    • anticipate coagulation problems-DIC
    • prepare for emergency C section

    #1 IV in and prep mom for OR
  58. What increases a moms risk to have placenta previa/abruptia
    • PIH
    • Multiparas
    • Polyhydrammnios
  59. Hyperemesis Gravidarum....and what causes it....and  usually seen when?
    excessive vomiting/retching during pregnancy

    HCG levels....peak at 6 weeks and decline around 12 weeks, but symptoms can last for entire pregnancy
  60. Complication for hyperemesis gravidarum
    • dehydration
    • electrolyte imbalance
  61. Medical treatment for hyperemesis gravidarum
    • antiemetics
    • IV fluids to restore hydration and electrolyte imbalance (metabolic alkalosis)
    • look at potassium, thiamine, v. B12
    • NPO
    • TPN
  62. 2 antiemetics
    • Phenergan suppository
    • Zofran
  63. Nursing care for a woman with hyperemesis
    • assess amount and character of emesis
    • monitor I&O
    • dipstick for ketones
    • assess emotional state
    • provide relaxed/quiet environment
    • minimize food odors
    • provide oral hygiene
    • monitor weight
    • emotional support
    • refer to home health
  64. Diet for a person with hyperemesis
    • eat when hungry regardless of time
    • eat frequent and small meals
    • crackers in am
    • high protein snacks
    • avoid high fat foods
    • eat only bland foods
    • eliminate pills with iron
    • drink carbonated beverages
  65. If you have a problem with hyperemesis what can you do prior to getting pregnant to help with this?
    take prenatals prior to getting prego
  66. Specific foods to help with hyperemesis
    • herbal teas with peppermint/ginger
    • ginger beverages
    • broth
    • crackers
    • unbuttered toast
    • gelatin
    • frozen desserts
  67. Activity for person with hyperemesis
    some say decreased activity and rest help....while others say fresh outdoor air helps
  68. When does chronic hypertension occur?
    • prior to 20 weeks gestation
    • persists 42 days after birth

    can have superimposed preeclampsia with sudden increase in proteinuria or blood pressure and edema in upper body
  69. When does PIH/Gestational HTN occur
    • after 20 weeks gestation OR
    • up to 48 hours-1 week post partum
  70. Define PIH
    rise in BP during pregnancy without significant proteinuria

    140/90
  71. Define Preeclampsia
    • high blood pressure with renal involvement seen with proteinuria
    • +1 = mild
    • +3 or higher is severe
  72. Define Eclampsia
    most severe and is a progression of pre eclampsia with CNS involvement....seizures/coma
  73. Who is at risk for getting chronic hypertension
    • advanced maternal age
    • obese
    • DM
    • hereditary
  74. How does BP stay the same during pregnancy?
    there is an increase in vascular volume and CO, but BP is stable due to resistance to angiotensin II vasonconstrictors and presence of vasodilators that decrease peripheral vascular resistance
  75. What causes an increase in BP during pregnancy?
    a gradual loss of resistance to angiotensin II
  76. Classic triad of symptoms for preeclampsia
    • Edema/weight gain
    • HTN
    • Proteinuria
  77. The only way to cure preeclampsia and eclampsia...
    delivery the fetus
  78. HELLP...what is it
    • Hemolysis
    • Elevated Liver enzymes
    • Low Platelet count
  79. If a woman has HELLP she must have all symptoms present...but how will we see elevated liver enzymes in our assessment
    increased bilirubin and jaundice
  80. If a woman has HELLP she must have all symptoms present, but how will we see low platelets
    thrombocytopenia <100,000
  81. S/S of HELLP
    • N/V
    • Liver tenderness
    • Severe edema
    • Rt. upper quadrant pain-Liver
  82. Goal of fixing HELLP
    • control HTN
    • prevent seizures
  83. BP Mild vs. Severe Pre Eclampsia
    • mild 140/90
    • severe 160/110
  84. Proteinuria mild vs. severe pre eclampsia
    • mild trace to +1
    • severe 3-4
  85. Thrombocytopenia in mild vs. severe pre eclampsia
    • mild absent
    • severe present
  86. Hematocrit in mild vs. severe pre eclampsia
    • mild increased
    • sever is increased then decreased with hemolysis
  87. Urine output in mild vs. severe pre eclampsia
    • mild matches intake >= 30ml/hr
    • severe oliguria < 30ml/hr
  88. Edema in mild vs. severe pre eclampsia
    • mild- generalized
    • fingers/face
    • sudden weight gain

    • severe-generalized
    • noticeable in fingers and face
    • pulmonary crackles
    • sudden weight gain
  89. Reflexes in mild vs. severe pre eclampsia
    mild- hyperreflexia 3+

    severe 3+ or greater, ankle clonus
  90. Visual problems with mild vs. severe pre eclampsia
    mild absent

    severe blurred, photophobia, blind spots
  91. If a woman has severe pre eclampsia she will have these problems, and mild wont
    • epigastric or right upper quadrant pain
    • N/V
  92. Fetal S/S for mild pre eclampsia
    • reduced placental perfusion
    • but NO premature aging of the placenta
  93. Fetal S/S for severe pre eclampsia
    • reduced placental perfusion leading to
    • IUGR
    • oligohydramnios
    • late decels
  94. If a person has severe pre eclampsia what will the placenta look like at birth?
    small with many areas of infarcts
  95. Therapeutic management of pre eclampsia
    • bed rest
    • left side lying
    • pad side rails
    • diet with high protein and no sodium
    • monitor BP
    • daily weights
    • frequent UA
    • DTR's
    • Lung sounds and RR
    • watch for headaches/epigastric pain/visual problems
    • monitor LOC
    • teach fetal movement counting
  96. What meds are given to a woman with pre eclampsia?
    • Mag sulfate as an anti convulsant
    • Anti Hypertensives
  97. Labs to monitor on a woman with pre eclampsia
    • LFT
    • Kidney function
    • platelets
    • RBC's
    • Serum Magnesium levels
  98. Intrapartum management of woman who has pre eclampsia
    • continuous fetal monitor....NOTING decrease in variability
    • keep in lateral position
    • control pain
    • induction with pitocin
    • give mag sulfate to prevent convulsions
    • seizure precautions
    • airway, O2 and suction ready
    • crash cart nearby
    • Neonatologist at delivery
  99. Things to monitor when a woman is receiving mag sulfate
    • BP
    • RR >/= 12/min
    • DTR's
    • Urine output
    • recognize s/s of magnesium toxicity
  100. Antedote to magnesium sulfate
    Calcium Gluconate
  101. Therapeutic range for magnesium sulfate
    4-8mg/dl
  102. S/S of magnesium toxicity
    • nausea
    • muscle weakness
    • loss of reflexes
  103. Additional management for a woman with eclampsia
    • monitor seizures-noting time and sequence of convulsions
    • monitor for pulmonary edema, circulatory and renal failure
    • monitor ROM, onset of labor, fetal distress
    • Give O2 via mask at 8-10L/min
    • pulse ox
    • suction
    • **keep patient side lying
  104. Supportive meds for a woman with eclampsia
    • mag sulfate
    • furosemide/lasix
    • digitalis
    • crash cart meds-epi
  105. Leading cause of maternal morbidity for a woman with eclampsia?
    aspiration....keep her side lying
  106. How do you dx aspiration?
    • chest x ray
    • blood gases
  107. Post Partum management for a woman with pre eclampsia
    • BP return to normal
    • Urine output increase
    • Urine protein decrease
    • Labs back to WNL
    • Signs of shock for next 48 hrs (due to hypovolemia from pre eclampsia and delivery blood loss)
  108. When can eclampsia occur?
    • antepartum
    • intrapartum
    • postpartum
  109. Assessing Edema
    • +1 minimal lower extremity
    • +2 marked lower extremity
    • +3 edema lower extremity and face, hands and sacral area
    • +4 generalized edema with ascites
  110. Assessing Deep Tendon Reflexes
    • 0 absent
    • +1 present/hypoactive
    • +2 Normal
    • +3 brisker than average
    • +4 hyperactive with clonus
    • +5 brisk with sustained clonus
  111. What does hyper-reflexia indicate
    CNS irritability
  112. Pitting edema
    depression in skin after finger pressure is applied to edematous area....leaves a dent in the skin that will slowly fill back in
  113. Non pitting edema
    does not leave a dent with pressure is applied to a swollen area
  114. Define clonus and how you test for it
    muscle spasms or rhythmic jerking

    rapid forced dorsiflexion of the foot

    If positive means they are headed toward having seizures
  115. How do you treat DIC
    • replace blood volume
    • give heparin
    • sustain her VS and get to WNL
    • Get to ICU
  116. Ultimate result of DIC
    • organ damage
    • ischemia
    • acidosis
  117. Sum up DIC
    the process of coagulation and fibrinolysis lose control resulting in widespread clotting with resultant bleeding

    • clotting factors are used up
    • abnormal breakdown of fibrinogen occurs
    • thrombosis
    • infarcts causing impaired capillary perfusion and end organ damage
  118. Abnormal labs for DIC
  119. Cycle of violence
    • Tension building
    • Incident
    • Calm Stage
  120. Describe Tension building
    increased arguing, anger, blaming....person has a need for power and control

    victim feels the need to keep abuser calm....feels like they are walking on egg shells
  121. Describe Incident
    • the physical abuse
    • sexual abuse
    • verbal abuse and threats
    • one slap or punch for hours
  122. Describe calming stage
    • this stage may decrease/disappear over time
    • may deny violence every happened
    • may blame the woman for "causing" the incident
    • promises will never do again
    • gifts?
  123. Effects of domestic violence on pregnancy outcomes
    • risk for miscarriage
    • risk for low birth weight infant
    • increased risk of drug/alcohol abuse
    • associated homicide
    • PTL and delivery
  124. Second Hand abuse effects on fetus
    stress causes hormones to be released causing low birth weight and problems with the developing nervous system
  125. Second hand abuse effects on kids
    • trauma elevates stress hormones like cortisol....
    • makes kid jumpy and easily startled

    • emotional problems
    • illness
    • increased fears/anger
    • increased risk of abuse, injuries and death
    • repetition of abuse behavior
  126. Role of health care provider when there is abuse
    Our initial assessment when admitting  a patient should always include the question....

    Do you feel safe in your environment?

    Can I provide you with any referrals to help you in your home environment
  127. If you suspect abuse always as broad questions like
    • How are things at home?
    • How are you and your partner relating?
    • Is there anything else happening that may be affecting your health?
  128. If a person is telling you they are being abused and scared....always
    listen and communicate that you believe them and validate their feelings
  129. #1 priority when there is abuse
    Help them make an emergency plan....

    • Where to go
    • How to get there
    • What to take
    • Who can she contact for support
  130. My obligations of reporting abuse
    Must be within 2 days and in writing

    if I don't it is a misdemeanor with 6 months of jail and/or $1000 fine

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