Maternal and Child Health Nursing Antepartal Complication

MATERNAL and CHILD HEALTH NURSING PREGNANCY COMPLICATION Lecturer: Mark Fredderick R. Abejo RN, MAN

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PREGNANCY COMPLICATIONS ( ANTEPARTAL ) A. Abortion - termination of pregnancy before the fetus is viable (20 weeks or a weight of 500 g)

TYPES 1. Threatened

DEFINITION The continuation of the pregnancy is in doubt

S/S Bleeding or spotting closed cervix

NURSING INTERVENTION Bedrest, Restrictive activity, Sedation, Avoid coitus for 2 weeks following last evidence of bleeding Rhogam indicated when a young patient has a threatened abortion in the first trimester and a laboratory studies reveal an Rh negative and the husband is Rh positive Save tissue fragments

2. Inevitable

3. Complete

4. Incomplete

Threatened loss that can be prevented; abortive process is going on Products of conception are totally expelled Some fragments are retained inside the uterine cavity

Bleeding and cervical dilation

Minimal bleeding Profuse bleeding

Continuous monitoring

5. Missed

6.Habitual / Recurrent

Retention of the products of conception after fetal death 3 spontaneous abortions occurring successively

Intermittent bleeding; absence of uterine growth

Dilatation & Curettage; Use of oxytocin: Oxytocin nasal spray should be administered while the client is sitting with her head in a vertical position. A nasal preparation must not be administered with the client lying down or the head tilted back because this could cause aspiration. Evacuation Evacuation, D & C

Provide IV, Monitor bleeding, Count perineal pads, psychological support NOTE:Because spontaneous abortion is threatening, all perineal pads must be inspected for the products of conception. Fluid replacement is necessary because of blood loss

B. Ectopic Pregnancy A pregnancy that occurs in another than uterine site, with implantation usually occurring in fallopian tubes A ruptured ectopic pregnancy is a medical emergency due to the large quantity of blood that may be lost in the pelvic and abdominal cavities. Shock may develop from blood loss, and large quantities of I.V. fluids are needed to restore intravascular volume until the bleeding is surgically controlled. Pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity.

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Causes Narrowing of tube Pelvic infection Endometriosis Smoking History of IUD usage .

Signs and Symptoms Vaginal Bleeding Knife-like abdominal pain Referred pain on the right shoulder Pelvic pressure of pelvic fullness Cullens sign Pain unilaterally, with cramping and tenderness Mass in the adnexal or culde-sac Slight, dark vaginal bleeding Profound shock if rupture occurs Symptoms of Shock: decreased BP increased RR, fast but thready pulse. This is the number 1 complication.

Diagnostic Tests Culdocentesis Culdoscopy Radioimmunoassay of elevated serum qualitative -Beta-HCG Abdominal Ultrasound Blood samples of Hgb and Hct; blood type and group

Management Monitor amount of bleeding Assess vital signs Assess abdominal pain Blood transfusion Surgery: Salpingostomy Administer Rhogam for Rh (-) client

C. Hydatidiform mole / Trophoblastic Disease / Molar Disease Gestational trophoblastic neoplasm that arise from the chorion; characterized by the proliferation and degeneration of the chorionic or trophoblastic villi.

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A patient with Hydatidiform mole has a positive signs of pregnancy but is not pregnant. The #1 Complication is Choriocarcinoma The Three H of H-mole 1.Hyper - emesis gravidarum 2. increase Hcg 3. increase incidence for piH

PREDISPOSING FACTORS Low socioeconomic status Women below 18 or above 35 Intake of Clomid (Clomiphene Citrate) Women of asian heritage

TYPES Complete/ classical parts of the villi are affected Incomplete/ partial- some parts are normal

MANIFESTATIONS Vaginal bleeding Excessive N/V Rapid enlargement of the uterus (+) Pregnancy test Possible PIH Abdominal cramps Absent FHR Elevated HCG titer: 1-2 million IU; Normal level: 400,000 IU

DIAGNOSTIC TESTS HCG titer determination Ultrasound X-ray of the abdomen

MANAGEMENT Molar evacuation / D&C Chemotherapy Monitor HCG levels Delay childbearing plans for a year Perineal pad counts Instruct the couple to have VAGINAL REST ( no sex) for 1 year.

The #1 Complication of H-mole is choriocarcinoma

D. Incompetent Cervix - Painless premature dilatation of the cervix (usually in the 16th to 20th week)

INCOMPETENT CERVIX Synonyms Predisposing/Contributing Factors: Dysfunctional cervix Repeated dilatation of the cervix, maternal DES ( Diethylstilbestrol) Exposure, Traumatic injuries to the cervix. Congenital anomaly Trauma to the cervix (surgery / birth) 1. Uterine anomaly 2. Habitual abortion 3. Pre-term labor Show (a pink-stained vaginal discharge) #1 Sign: Rupture of membranes and discharge of amniotic fluid Pressure or heaviness on the lower abdomen. The cervix dilates painlessly in the second trimester of pregnancy. Bloody show PROM Painless dilatation Birth of dead/non-viable fetus Ultrasound Ultrasonography Cervical Cerclage, McDonald Cerclage Sterility, rupture of the cervix premature delivery, pelvic bleeding and infection.

Initial Signs Late signs: Cardinal/Pathognomonic/maj or sign:

Screening or initial diagnostic test: Conformity test: Best major surgery: Possible surgical complication:

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Disease complication

#1 Hemorrhage, Ectopic pregnancy, birth defects, viruses and pregnancy diseases, diabetes in pregnancy, HPN Side lying position Prone position Suction Pre-op: Encourage patient to maintain bed rest Post-op: Check for excessive vaginal discharge and severe pain. Bed rest in trendelenburg position Administer tocolytic medications as ordered Eg; Ritodrine Hydrochloride (Yutopar): Terbutaline sulfate (Brethine): Magnesium Sulfate, Hydroxyzine hydrochloride (Vistaril) is a common drug ordered to counteract the effect of terbutaline (Brethine) Surgery: Cervical Cerclage Shirodkar-Barter Technique ( internal os) permanent suture: subsequent delivery by C/S. Mc Donald Procedure ( external os)-suture removed at term with vaginal delivery

Best position before and after surgery Best side equipment Nursing Intervention

Usually 4-6 weeks after vaginal delivery is the safe period for a patient to resume sexual activity, when the episiotomy has healed and the lochia had stopped - Monitor V/S and report HPN Monitor FHR Limit activities Observe for Ruptured BOW Avoid vaginal douche Avoid coitus

E. DIABETES MELLITUS Gestational diabetes mellitus (pregnancy induced) A pregnant, insulin-dependent diabetic is at risk for sudden hypoglycemia because insulin needs and metabolism are affected b pregnancy, making sudden hypoglycemic episodes more common for diabetics. Changes in the glucose-insulin mechanism: o Early in pregnancy: A. Increase production of insulin B. Maternal glucose is consumed by fetus o Late in pregnancy: A. Mother develops insulin resistance B. The presence of placental insulinase breaks down insulin rapidly B. Description of Diabetes in Pregnancy 1. 2. 3. 4. 5. Maternal glucose crosses the placenta but insulin does not During the first trimester, maternal insulin needs decrease The fetus produces its own insulin and pulls glucose from the mother, which predisposes the mother to hypoglycemic reactions During the second and third trimesters, increases in placental hormones cause an insulin-resistant state, requiring an increase in the client's insulin dose Diabetes mellitus is more difficult to control during pregnancy & occurs during the second or third trimester. Premature delivery is more frequent. The newborn infant of a diabetic mother may be large in size but will have functions related to gestational age rather than size. The newborn infant of a diabetic mother is subject to hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, and congenital anomalies. Stillborn and neonatal mortality rates are higher in pregnancies of a diabetic woman

NOTE: The greatest incidence of insulin coma during pregnancy occurs during the second and the third months, the incidence of the diabetic coma during pregnancy occurs around the sixth months.

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Definition

Synonyms Predisposing/Contributing Factors

Initial Signs

Late signs Cardinal/Pathognomenic/majo r sign Screening or initial diagnostic test Confirmative test

GESTATIONAL DIABETES A type of Diabetes where only pregnant women gets where her blood sugar rate elevates but never had a high blood sugar rate before pregnancy. Diabetes during Pregnancy Hyperglycemia develops during pregnancy because of the secretion of placenta hormones such as Prolactin, Progesterone& Corticosteroids Maternal age more than 35 Previous macrosomic infant Previous unexplained stillbirth Previous pregnancy with GDM Family history of DM Obesity Hypertension FBS more than 140 mg/dl 3-Ps: Polyuria, Polydipsia and Polyphagia MATERNAL SIGNS & SYMPTOMS: 1.Excessive thirst 2. Hunger 3. Weightless 4. Blurred vision 5. Frequent urination 6. Recurrent urinary tract infections and vaginal yeast infections 7. Glycosuria and ketonuria 8. Signs of pregnancy-induced hypertension 9. Polyhydramnios 10. Fetus large for gestational age Fatigue, weakness, sudden vision changes, tingling or numbness in hands Weight loss, fatigue, nausea, and vomiting excessive thirst, decrease urination 50 gms oral glucose challenge test 3- hour glucose tolerance test will be performed to confirm diabetes mellitus Glycosolated Hemoglobin less than 8% Strict Diabetic Diet Calories in diet should consist of 50% to 60% carbohydrates, 12% to 20% protein, and 20% to 30% fat NOTE: Because insulin does not pass into the breast milk, breastfeeding is not contraindicated for the mother with diabetes. Breastfeeding is encouraged; it decreases the insulin requirements for insulin-independent clients. Breastfeeding does not increase the risk of maternal infection; it leads to an increased caloric demand. Infants of diabetic mothers often display jitteriness in response to hypoglycemia after birth Well-balanced Caloric Diet Maternal Complications: PIH, Placental disorders, stillbirth, macrosomia, neural tube defects. Fetal Diabetic Complications: Macrosomia Pre-eclampsia Hydramnios Congenital anomalies NOTE: The incidence of congenital anomalies among infants of diabetic pregnancies is three to four times higher than that in general population and is related to the high maternal glucose levels during the third to sixth gestational weeks. Glucometer Insulin Equipment #1 Eternal Electronic Fetal Heart Rate monitoring

Best diet

Best diet for the disease: Disease complication

Best side equipment

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Best drug Nature of the drug Nursing Diagnosis

Nursing Intervention

Insulin therapy ( dont use Oral hypoglycemics, they are Teratogenic) Insulin #1 High Risk for fluid volume deficit related to polyuria and dehydration Imbalanced nutrition related to imbalanced of insulin, food and physical activity Potential heath care deficit related to physical improvements or social factors.. MANAGEMENT Screen clients between the 24th and 28th weeks of pregnancy Prenatal visits bimonthly for 6 months and weekly thereafter. Calories in diet should consist of 50% to 60% carbohydrates, 12% to 20% protein, and 20% to 30% fat Observe client closely for an insulin since a precipitous drop in insulin required is usual Monitor for signs of infection or post hemorrhage If a pregnant diabetic is in labor, her blood glucose should be monitored hourly. The preferred method of administration if insulin is required during labor is intravenous OTHER IMPORTANT MANAGEMENT: Urine testing Blood glucose determination Insulin administration Dietary management Exercise Fetal surveillance: (* Non-stress test * contraction stress test * amniocentesis)

F. CARDIAC DISEASE

CLASSIFICATION Class I Asymptomatic Class II Asymptomatic at rest; symptomatic with heavy physical activity Class III Asymptomatic at rest; symptomatic with ordinary activity Class IV Symptomatic with all activity; symptomatic at rest a. Class I: no limitation of activities. No symptoms of cardiac insufficiency. Class II: slight limitation of activity, Asymptomatic at rest. Ordinary activities causes fatigue, palpitations and dyspnea

EFFECTS Retarded growth Fetal distress To relieve fetal distress let the patient lie on her side Premature labor You dont have to notify the physician if the patient complains of a fluttering sensation in her chest because of taking terbutaline (Brethine) SQ for premature contractions because it is a common side effect unless vital signs indicate stress

MANAGEMENT Goal is to reduce workload of heart Promote rest Promote a healthy diet Educate regarding medication Educate regarding avoidance of infection Promote reduction of physiologic stress

b.

c. Class II: marked limitation of activities, comfortable at rest, less than ordinary activities causes discomforts d. Class IV: unable to perform any physical activity without discomfort. May have the symptoms during rest.

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PREGNANCY INDUCED HYPERTENSION (TOXEMIA OF PREGNANCY) NAME OF THE DISEASE Synonym Predisposing / Contributing factors PRE-ECLAMPSIA ECLAMPSIA

MILD SEVERE (PREGNANCY-INDUCED HYPERTENSION) Primiparas younger than age 20 years or older than 40 years women from low socioeconomic background because of poor nutrition women of color; women with heart disease diabetes with vessel or renal involvement essential hypertension poor calcium and magnesium intake hydatidiform mole multiple gestation polyhydramnios pre-existing vascular disease B140/90 mmGh on at least two occasion 6 hours apart proteinuria of 1-2+ on a random sample; weight gain over 2 lbs per week in second trimester and 1 lb per wk, third trimester mild edema in upper extremities or face BP160/110 mmHg or diastolic pressure110 mmHg on two occasions at least 6 hours apart with the patient on bedrest proteinuria 5 b/24 h or 3+ to 4+ on qualitative assessment (urine dipstick) extreme edema in hands and face/puffiness BP 160/110 mm Hg or above Epigastric pain Decreased urinary output Visual changes Headache Oligauria 400 to 500 ml/24h cerebral or visual disturbances (altered level of consciousness headache, scotomata, or blurred vision) epigastric pain or RUQ pain, pulmonary edema or cyanosis impaired liver function of unclear etiology thrombocytopenia (platelet count <150,000); development of eclampsia elevated serum creatinine > 1.2 mg/dl temperature rises sharply to 39.4C or 40C (103F to 104F) from increased cerebral edema; reflexes become hyperactive premonition that something is happening; epigastric pain and nausea; urinary output less than 30 ml/h

Initial Sign

Late Sign

Signs of Worsening PIH or Impending Seizures:

During pregnancy, blurred vision may be a danger sign of preeclampsia or eclampsia, complications that require immediate attention because they can cause severe maternal and fetal consequences.

Cardinal / Pathognomonic/ Major Sign

Hypertension and proteinuria are the most significant. Edema is significant only if hypertension and proteinuria or signs of multi-organ system involvement are present.

Nursing Diagnosis and Nursing Interventions

Fluid volume excess related to pathophysiologic changes of PIH and increased risk of fluid overload.

Maintaining Fluid Balance 1. Control IV intake using a continuous infusion pump. 2. Monitor input and output strictly; notify health care provider if urine output is <30 ml/h. 3. Monitor hematocrit levels to evaluate intravascular fluid status. 4. Monitor vital signs every hour.

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5. Auscultate breath sounds every 2 hours, and report signs of pulmonary edema (wheezing, crackles, shortness of breath, increased pulse rate, increased respiratory rate). Altered tissue perfusion, Fetal cardiac and cereral, related to altered placental blood flow caused by vasospasm and thombosis. Risk for injury related to convulsions. Decreased cardiac output related to decreased preload or antihypertensive therapy. Promoting Adequate Tissue Perfusion 1. Position on side, preferably the left side to promote placental perfusion. 2. Monitor fetal activity. 3. Evaluate NST to determine fetal status. 4. Increase protein intake to replace protein lost through kidneys. Preventing Injury 1. Instruct on the importance of reporting headaches, visual changes, dizziness, and epigastric pain. 2. Instruct to lie down on left side if symptoms are present. 3. Keep the environment quiet and as calm as possible. 4. If patient is hospitalized, side rails should be padded and remain up to prevent injury if seizure occurs. NOTE: The patient with a diagnosis of PIH should be close to the nurses station because she requires close observation. The patient also should be placed in a room with decreased stimuli. Maintaining Cardiac Output 1. Monitor IV intake using a continuous infusion pump. 2. Monitor input and output strictly; notify primary care provider if urine output is < 30 ml/h. 3. Monitor maternal vital signs; especially mean blood pressure and respirations. 4. Assess edema status, and report pitting edema of + 2 to primary care provider. 5. Monitor oxygenation saturation levels with pulse oximetry. Report oxygenation saturation rate of <90% to primary care provider.

Screening/Initial diagnostic test Confirmatory Test

Blood pressure over 140/90, or increase of 30 mm systolic, 15 mm diastolic over pre-pregnancy level. 24-hour urine for protein of 300 mg or greater; elevated serum BUN and creatinine; increased deep tendon reflexes and clonus; blood pressure changes meeting criteria for diagnosis The woman needs a moderate to high-protein, moderate-sodium diet to compensate for the protein she is losing. Abruptio placentae (Hypertension in PIH leads to vasopasm. This in turn causes the placenta to tear away from the uterine wall (abrupto placentae) disseminated intravascular coagulation; HELLP syndrome; prematurity; intrauterine growth restriction (IUGR) from decreased placental perfusion; maternal/fetal death; hypertensive crisis; acute renal failure; hemorrhage; cerebrovascular accident; blindness; hypoglycemia; hepatic rupture

Best Diet

Disease Complications

Best Position

SEVERE PRECLAMPSIA: Lateral recumbent position ECLAMPSIA: to prevent aspiration, turn the woman on her side to allow secretions to drain from her mouth. Infusion pump; pulse oximeter

Beside Equipment

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Best Drug

Mgnesium sulfate: 4-6 loading dose of 50% give IV over 15-30 mins followed by a maintenance dose (secondary infusion) of 1-4 g/h or IM injection or 10 g (5 g in each buttock) as a loading dose followed by 5 g every 4 hours Administer antihypertensives such as hydralazine (Apresoline) as prescribed, to prevent a cerebrovascular accident

Nature of the Drug

Best tocolytic agent; antihypertensive; anticonvulsant/eclampsia #1 Complication of MgSO4 is : Respiratory Depression Reflexes, respiration and urinary output are priority assessments during administration of magnesium sulfate therapy in patients with PIH. If the patients magnesium levels increase above the therapeutic range ( 4 to 8 mg/dl), the absence of reflexes is often the first indication of toxicity. Reflexes often disappear at serum magnesium levels of 8 to 10 mg/dl. Respiratory depression occurs at levels of 10 to 15 mg/dl, and cardiac conduction problems occur at levels of 15 mg/dl and higher. Urinary output of less than 30ml/hour may result in the accumulation of toxic levels of magnesium. Assessment Patellar Reflexes Position the client with legs dangling over the edge of the examining table or lying on back with legs slightly. Strike the patellar tendon just below the kneecap with the percussion hammer. Normal Response: Flexion of the arm at the elbow.

PRIORITY DRUG ASSESSMENT: SIDE EFFECT

Proper Assessment of Abnormal Reflexes

Clonus Position the client with legs dangling over the edge of the examining table. Support the leg with one hand and sharply dorsiflex the clients foot with the other hand. Maintain the dorsiflexed position for a few seconds; then release the foot. Normal Response: (Negative Clonus Response) Foot will remain steady in the dorsiflexed position. No rhythmic oscillation of jerking of the foot will be felt. When released, the foot will drop to a plantar flexed position with no oscillations. Abnormal Response: (Positive Clonus Response) Rhythmic oscillations when the foot is dorsiflexed. Similar oscillations will be noted when the foot drops to the plantar flexed position.

G. BLEEDING DISORDERS AFFECTING THE PLACENTA Placenta: contains 20 cotyledons, weighs 400-600 grams. Develops on the 3rd month. Form from Chorionic villi & deciduas basalis. Deciduas (meaning endometrial changes & growth) Functions: Main source of nourishment & acts a transfer organ for metabolic purposes for the fetus.

Placental Problem Placental separation is characterized by a sudden gush or trickle of blood from the vagina, further protrusion of the umbilical cord from the vagina, a globular-shaped uterus, and an increase in fundal height. With cervical or vaginal laceration, the nurse notes a consistent flow of bright red blood from the vagina. With postpartum hemorrhage, usually caused by uterine atony, the uterus isn't globular. Uterine involution can't begin until the placenta has been delivered.

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PLACENTA PREVIA

Definition

PLACENTA PREVIA Improperly implanted placenta in the lower uterine segment near or over the internal cervical os Total: the internal os is entirely covered by the placenta when cervix is fully dilated Marginal: only an edge of the placenta extends to the internal os Low-lying placenta: implanted in the lower uterine segment but does not reach the os Maternal age Parity (no. Of pregnancy) Previous uterine surgery . Painless . Heavy bleeding . Soft, non tender, relaxed uterus w/ normal tone . Shock in proportion to observed blood loss . Signs of fetal distress usually not present Anemia #1hemorrhage #2shock, renal failure #3 disseminated intravascular coagulation cerebral ischemia, maternal and fetal death > Ultrasonography to confirm the pressure of placenta previa. > Depends on location of placenta, amount of bleeding and status of the fetus. > Home monitoring with repeated ultrasounds may be possible with type Ilow lying > Control bleeding > Replace blood loss if excessive > Cesarean birth if necessary > Betamethasone is indicated to increase fetal lung maturity. #1 NURSING DIAGNOSIS: Potential fluid volume deficit Maintain bed rest > #1 Assessment - Monitor maternal vital signs, FHR, and fetal activity > Assess bleeding (amount and quality) > Monitor and treat signs of shock > Avoid vaginal examination if bleeding is occurring > Prepare for premature birth or cesarean section > Administer IV fluids as ordered > Administer iron supplements or blood transfusion as ordered (maintain hematocrit level) > Prepare to administer Rh immune globulin

Predisposing Factor

Assessment

Complication

Therapeutic Interventions

Nursing Diagnosis with Nursing Intervention

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BESTPOSITION

Confirmatory Test

Best Position

The patient with placenta previa should be maintained on bed rest, preferably in a side-lying position. Additional pressure from an upright position may cause further tearing of the placenta from the uterine lining. Ambulating would therefore be indicated for this patient. Performing a vaginal examination and applying internal scalp electrode could also cause the placenta to be further torn from the uterine lining . > Ultrasound for placenta localization NOTE: Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the third trimester unit a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus who is at risk for severe hypoxia. > Left lateral position

ABRUPTIO PLACENTAE

Definition

Synonyms Predisposing Factor

ABRUPTIO PLACENTAE Premature separation of the placenta from the uterine wall after the 20 th week of gestation and before the fetus is delivered (Saunders page 299300) > Placental abruption > Premature separation of placenta > Maternal age > Parity > Previous abruptio placentae, multifetal gestation > Hypertension NOTE: Abruptio placentae is associated with conditions characterized by poor uteroplacental circulation, such as hypertension, smoking and alcohol or cocaine abuse. It is also associated with physical and mechanical factors such as over distension of the uterus that occurs with multiple gestation or polyhydranions. In addition, a short umbilical cord, physical trauma, and increased maternal age and parity are risk factors.

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Pathophysiology

> Spontaneous rupture of blood vessels at the placental bed may due to lack of resiliency or to abnormal changes in uterine vasculature. > May be complicated by hypertension or by an enlarged uterus that cant contract sufficiently to seal off the torn vessels > Consequently, bleeding continues unchecked, possibly shearing off the placenta partially or completely. > Painful vaginal bleeding > Hypertonic to tetanic, enlarged uterus > Board-like rigidity of abdomen (Cullen Sign) > Abnormal/absent fetal heart tones > Pallor > Cool, moist skin > Bloody amniotic fluid > Rising fundal height from blood trapped behind the placenta > Signs of shock > Manifestation of coagulopathy NOTE: Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike upon palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding.

Manifestation

Complication

> Hemorrhage, shock, renal failure, disseminated intravascular coagulation, maternal death, fetal death(Nursing Alert p.4) > Replacement of blood loss. > With moderate or severe separation or maternal or fetal distress: emergency childbirth. NOTE: The goal of management in abruption placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choic if the fetus is at term gestation or if the bleeding is moderate to severe and mother or fetus is in jeopardy. > With mild separation without fetal distress and in the presence of some cervical effacement and dilatation: induction of labor may be attempted >Oxygen if necessary > Maintenance of fluid and electrolytes balance.

Therapeutic Interventions

Nursing Diagnosis with Intervention

#1 NURSING DIAGNOSIS: Risk for fluid volume deficit > #1 Assessment: Monitor and FHR > Assess for vaginal bleeding, abdominal pain, and increase in fundal height > Maintain bed rest > Administer oxygen as prescribed > Monitor and report any uterine activity > Administer IV fluid as prescribed > Monitor I & O > Administer blood products as prescribed > Monitor blood studies > Prepare for the delivery of the fetus as quickly as possible > Monitor for signs of disseminated intravascular coagulation in the postpartum period > Ultrasound detects retro-placental bleeding

Confirmatory Test

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VENA CAVA SYNDROME Definition Synonym Predisposing factors The venous return to the heart is impaired by the weight of uterus. Supine Hypotensive Syndrome Thrombophlebitis NOTE: Contribute to clot formation motion include inactivity,reduced cordiac output, compression of the viens in pelvis or legs The most likely cause of supine hypotension is feeling dizzy, short of breath and clammy when lying back for long periods of time in patients 6 th month of pregnancy. The cause of supine hypotension during pregnancy is the weight of the uterus compresses the inferior vena cava, decreasing the return of blood to the heart, thus decreasing cardiac output, which lowers the blood pressure Fatique proxymal nocturnal dyspnea orthopnea hypoxia cyanosis Reduce renal perfection, Decrease glomerular filtration Shock such as tachycardia NOTE: Caused by reduced cardiac output, respiratory distress, fatal distress FHT monitor NOTE: Above 160 or below 120 beats per minutes, Fetal PH below 7.5 Amniotomy: NOTE: Above keeping the significant other improved of the progress of care, the fatal status would he the priority Altered tissue perfection related to decrease blood circulation Risk for altered Health maintenance related to insufficient knowledge of treatments, drug therapies, home care management and prevention of future infection Altered comfort related to maladaptive coping Closely monitor for shock and decreasing blood. Pressure, tachycardia, coal, clammy Skin Maintain patient on bed rest to reduce Oxygen demands and risk for bleeding. Monitor prescribed medication given to preserve right Ventricular felling pressure and increase blood pressure Instruct patient in self care activities Provide information about anti smoking strategies and allow patient time to return demonstration of treatment to the done at home Assess physical complaints matters of facts without emphasizing concern. Use deep breathing, muscle relaxation, and imagery to relieve discomfort. Express a caring attitude Caesarian Section note if cervix is incomplete deleted. Food and fluid are withheld before invasive procedure is not resumed until the client is stable and free of nausea & vomiting. Hypoallergenic Ionic diet Calcium increased Interruption of vena cava, which reduce channel size. > Bleeding as a result of treatment NOTE: Observation of the fetal monitoring often reveal increase uterine rustling tone, caused by failure of the uterus to relax in an attempt to constrict blood vesicle and control bleeding > Respiratory failure. Sims Position NOTE: Turning to the left side to shift right of the fetus off the inferior vena cava. Oxygen obtain equipment for external electronic fetal heart rate monitoring Oxygen with Cannula Angina, myocardial infarction

Initial sign

Late Sign Cardinal sign

Initial / Screening test

Confirmatory test

Nursing Diagnosis

Nursing Intervention

Best major Surgery Best dirt for pre-operative Best diet for Disease Possible Surgical Complication Complication of Disease

Best position pre-operative

Bed Side Equipment History of Disease

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OTHER DISEASES AND CONDITION Name of the Disease Predisposing / Contributing Factors Disseminated Intravascular Coagulation Overwhelming infections particularly bacterial sepsis; #1 abruption placenta; eclampsia; amniotic fluid embolism; IUFD(Intra-uterine fetal death) or retention of dead fetus; burn; trauma; fractures; major surgery; fat embolism; sock; hemolytic transfusion reaction; malignancies particularly of lung, colon, stomach, and pancreas NOTE: Disseminated intravascular coagulation (DIC) is a state of diffuse clotting in which clotting factors are consumed. This leads to widespread bleeding. Platelet are decreased because they are consumed by the process, coagulation studies show no clot formation (and are thus normal to prolonged); and fibrin plugs may clog the microvasculature diffusely, oozing from injection sites, and presence of hematuria are signs associated with the presence of DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrompophlebitis. (Saunders Initial Sign Late Sign Nursing Diagnosis & Intervention Coolness and mottling of extremities; pain; dyspnea; abnormal bleeding Altered mental status; acute renal failure Minimizing Bleeding Risk for injury related 1. Institute Bleeding precautions to bleeding due to 2. Monitor pad count/amount of saturation during thrombocytopenia menses; administer or teach self-administration of hormones to suppress menstruation as prescribed. 3. Administer blood products as ordered. Monitor for signs and symptoms of allergic reactions, anaphylaxis, and volume overload. 4. Avoid dislodging costs. Apply pressure to sites of bleeding for at least 20 mins, use topical hemostatic agents. Use tape cautiously. 5. Maintain bed rest during bleeding episode. 6. If internal bleeding is suspected, assess bowel sounds and abdominal girth. 7. Evaluate fluid status and bleeding by frequent measurement fo vital signs, central venous pressure, intake and output. Promoting Tissue Perfusion 1. Keep patient warm 2. Avoid vasoconstrictive agents (systemic or topical). 3. Change patients position frequently and perform ROM exercises. 4. Monitor electrocardiogram and laboratory test for dysfunction of vital organs casued by ischemia arrhythmias, abnormal arterial blood gases, increased blood urea nitrogen and creatinine. 5. Monitor for signs of vascular occlusion and report immediately. a. Brain decreased level of consciousness, sensory and motor deficits, seizures, coma. b. Eyes Visual deficits. c. Bone Pain d. Pulmonary vasculature chest pain, shortness of breath, tachycardia. e. Extremities cold, mottling, numbness. f. Coronary arteries chest pain, arrhythmias. g. Bowel pain, tenderness, decreased bowel sounds.

Altered tissue perfusion (all tissues) related to ischemia due to microthrombi formation

Screening or Initial Diagnostic Test Confirmative Test Beside Equipment Best Drug Nature of the Drug

PT; PTT; Platelet count Decreased Fibrinogen level; increased fibrin split products; decreased anti-thrombin III level ECG; CVP Heparin inhibits clotting components of DIC Anticoagulant

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Name of the Disease Definition

Hyperemesis gravidarum Hyperemesis gravidarum is persistent, uncontrolled vomiting that begins in the first weeks of pregnancy and may continue throughout pregnancy. Unlike morning sickness, hyperemesis can have serious complications, including severe weight loss, dehydration, and electrolyte imbalance. NOTE: The defining factor for hyperemesis gravidarum should be the time of occurrence and that is the 2nd trimester, usually the 14 16th week. If this is on the 1st trimester, usually this is morning sickness.

Causes

Gonadotropine production Psychological factors Trophoblastic activity Continuous, severe nausea and vomiting Dehydration Dry skin and mucous membranes Electrolyte imbalance Metabolic acidosis Non-elastic skin turgor Oliguria Arterial blood gas and analysis reveals alkalosis. Hb level and HCT are elevated. Serum potassium level reveals hypokalemia Urine ketone levels are elevated. Urine specific gravity is increased. Fluid volume deficit Altered nutrition; less than body requirements Pain Total parenteral nutrition (TPN) Restoration of fluid and electrolyte balance Anti-emetics, as necessary for vomiting, for example Plasil , Hydroxyzine and Prochlorperazine Monitor vital signs and fluid intake and output to assess for fluid volume deficit. Obtain blood samples and urine specimens for laboratory tests, including Hb level, HCT, urinalysis, and electrolyte levels. Provide small frequent meals to maintain adequate nutrition. Maintain I.V. fluid replacement and TPN to reduce fluid deficit and pH imbalance. Provide em0otional support to help the patient cope with her condition. Teaching Topics Using salt on foods to replace sodium lost by vomiting.

Assessment Findings

Diagnostic Result

Nursing Diagnosis

Treatment

Nursing Intervention

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