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REPRODUCTIVE AND SEXUAL HEALTH Source: Maternal and Child Health Nursing by Pillitteri et al. NURSING PROCESS OVERVIEW
The primary role of the nurse concerning reproductive anatomy and physiology is education.
I. ASSESSMENT:
Sexual assessment is not a routine part of every health assessment. However it should be included when appropriate, such as when discussing: adolescent development before providing family information during pregnancy following childbirth
Teaching adolescent safer sex practices IV. OUTCOME EVALUATION: Examples of outcome criteria might be: Clients state he is no longer fearful of contacting STD Clients state she is better able to control symptoms of premenstrual syndrome Couple state they have achieved a mutually satisfying relationship Client states he is ready to tell family about homosexual gender identity
Week 7 or 8- in chromosomal males, gonadal tissue differentiated into primitive testes and begins the formation of testosterone: mesonephric (wolffian) ducts - develop to male reproductive organ paramesonephric (mullerian) ducts - regresses
Secondary sex characteristic of boys occurs in order: increase in weight growth of testes growth of face, axillary, and pubic hair voice changes penile growth increase in height spermatogenesis Secondary sex characteristic of girls occurs in order: 1. growth spurt 2. increase in the traverse diameter of the pelvis 3. breast development (thelarche) 4. growth of pubic hair (adrenarche) 5. onset of menstruation (menarche 12.5 y/o ave.) 6. Ovulation occurs 1 2 years after menarche 7. growth of axillary hair (adrenarche) 8. vaginal secretion
Placenta serves the ff purpose. Respiratory system (lungs) Renal system (kidneys) Gastrointestinal system (stomach and intestine) Circulatory system Endocrine system
Weeks:40, plus or minus 2 Months (lunar):10 Months (calendar):9 Trimesters:3 Estimated Due Date/Estimated Date of Confinement (Nageles rule); This calculation is an estimation only. Most women deliver: due date + or 2 week. a. Add 7 days to the first day of the LMP b. Subtract 3 months. c. Add 1 year Example: 1st day of LMP= September 16, 1998 Add 7 days= September 23 Add 1 year= June 23, 1999, will be EDD/EDC. Sonogram dating used to confirm dates.
Subtract 3 months= June 23
-is the period of differentiation of tissues into organs. 3 primary germ layers of the embryo: 1. Endoderm lining of the GIT, respiratory tract, tonsils, thyroids, bladder and urethra 2. Mesoderm (bones, dentin of teeth, connective tissue, cartilage, muscles and tendons), circulatory system, reproductive system, kidneys and ureters. 3. Ectoderm nervous system, skin, tooth enamel, hair, nails, mucus membrane of mouth and anus. C. Fetal stage from 5- 8 weeks to birth every structure is present that will be found in the full term neonate.
20 weeks Vernix caseosa and lanugo appear; movement usually felt by mother Quickening occurs; heart rate audible;bones hardening. Vernix caseosa appears Lt=16-18.5 cm.,wt300 g Lanugo covers entire body 24 weeks Body well proportioned; skin red and wrinkled; hearing established. Lt=23 cm., wt= 600 g. 28 weeks Infant viable, but immature if born at this time. Body less wrinkled; appearance of nails. Lt= 27 cm., wt= 1100g 32 weeks Subcutaneous fat begin to deposit; L/S ratio in lungs now 1.2 : 1 . Skin smooth and pink. Lt= 31 cm., wt =1800-2100 g. 36 weeks Lanugo disappearing; body usually plump; L/S ratio usually 2:1; definite sleep/wake cycle. Lt= 35 cm., wt= 2200-2900 g 40 weeks Full-term pregnancy; Baby is active, with good muscle tone; strong suck reflex; if male testes in scrotum; little lanugo. Length >40 cm., weight= 3200g or more
Development
- the site of waste excretion. Temporary Structures involved in fetal circulation: Placenta Umbilical cord Ductus venosus (vein to a vein) connects the umbilical vein to the inferior vena cava. Allows the oxygenated blood from the placenta to bypass the liver. Foramen ovale temporary opening between atria that allows the majority of blood entering form the IVC to pass across in to the left atrium. Ductus arteriosus (artery to an artery) channel between fetal aorta and main pulmonary artery. It closes during normal respiration. Allows the blood to bypass the fetal lungs. Hypogastric arteries They return the blood to the placenta.
Increased vascularity (Chadwicks sign) Estrogen-induced leukorrhea Change in pH (less acidic) may favor overgrowth of yeast like organisms Connective tissue loosens in preparation for distention of labor and delivery.
Shape of thorax shortens and widens to accommodate the growing fetus Slight increase in respiratory rate Dyspnea may occur at end of third trimester before engagement or lightening Increased respiratory volume by 40 to 50 %. Oxygen consumption increases by 15%.
Increased joint mobility as a result of action of ovarian hormone (relaxin) on connective tissue. Possible headache Occasional cramps in calf may occur with hypocalcemia.
Neurologic System
Few changes with a typical pregnancy Pressure on sciatic nerve may occur later in pregnancy due to fetal position.
Endocrine System
Pituitary: FSH and LH greatly decreased; oxytocin secreted during labor and after delivery; prolactin responsible for initiation and continuation of lactation. Progesterone secreted by corpus luteum until formation of placenta. Principal source of estrogen is placenta synthesized from fetal precursor. HPL produced by placenta; similar to growth hormone, it prepares breasts for lactation: also affects insulin/ glucose metabolism; may overstress maternal pancreas Ovaries secrete Relaxin during pregnancy Slight increase in thyroid activity and basal metabolic rate (BMR). Pancreas may be stressed due to complete interaction of glucose metabolism, HPL and cortisol, resulting in diminished effectiveness of insulin and demand for increased production.
B. Second trimester
Mother demonstrates growing realization of baby as separate and needing person. Fantasizes about unborn child.
C. Third trimester
Nesting activity appears as due date approaches Desire to be finished with pregnancy. Anxiety over safe passage for self and baby through labor and delivery. Reactions of father-to-be may parallel those of mother (e.g ambivalence, anxiety). COUVAGE SYNDROME 5. Preparation of siblings varies according to their age and experience.
Determination of Pregnancy Diagnosis of pregnancy is based on pregnancy-related physical and hormonal changes and are classified as presumptive, probable or positive A. Presumptive Signs and Symptoms (Subjective) These changes may be noticed by the mother/health care provider but are not conclusive for pregnancy. Amenorrhea (cessation of menstruation) Nausea and vomiting Urinary frequency Fatigue Breast changes Weight change Skin changes Vaginal changes including leukorrhea Quickening
B. Probable Signs and Symptoms (Objective) These changes are usually noted by the health care provider but are still not conclusive for pregnancy. Uterine enlargement Changes in the uterus and cervix from increase vascularity Ballottement: fetus rebounds against the examiners hand when pushed gently upwards. Braxton Hicks contractions: occurs early in pregnancy, although not usually sensed by the mother until the third trimester Laboratory test for pregnancy Most tests rely on the presence of HCG in the blood or urine of the woman Easy, inexpensive, but may give false readings with any handling error, medications or detergent residue in laboratory equipment.
Nursing diagnoses for the antepartal period may include: Knowledge deficit: information on the following topics needs to be given and reinforced Alteration in nutrition potential: individualized nutritional information will be needed Activity intolerance: need for additional rest and benefits of a moderate exercise program Anxiety Constipation, potential Body image disturbance Alteration in comfort Individual coping, ineffective Powerlessness
Interventions
Prenatal care A. Time frame First visit: may be made as soon as woman suspects she is pregnant; frequently after first missed period. Subsequent visit: Every mon. until the 8th mon., qo 2 wks during the 8th mon and wkly during the 9th mon more frequent visits are scheduled if problem arise
1. Extensive collection of data about client in all pertinent areas in order to form basis for comparison with data collected on subsequent visits and to screen for any high-risk factors. a. Menstrual history: menarche, regularity, frequency and duration of flow, last period. b. Obstetrical history: all pregnancy, outcome, complications, contraceptive use, sexual history. c. Medical history: include past illnesses, surgeries; current use of medication d. Family history/ psychosocial data e. Information about the father-to-be may also be significant f. Current concerns.
2. Complete physical examination, including internal gynecologic exam and bimanual exam 3. Laboratory work, including CBC, urinalysis, pap test, blood type and Rh, rubella titer, testing for sexually transmitted diseases (STD), other test as indicated (e.g. TB test, hepatitis viral studies, EKG, etc
Nutrition during Pregnancy A. Weight gain Variable, but 25 lb usually appropriate for average woman with single pregnancy Woman should have consistent, with only 2-3 lb in first trimester, then average 12 oz gain every week in second and third trimesters. Gain mostly reflect maternal tissue in second half of pregnancy B. Specific nutrient needs Calories: + 300 kcal/day. Never < 1800 kcal/day. Protein: + 30g/day to ensure intake of 74-76g/day Carbohydrates: Fats: Iron: Calcium: 1200mg/day Sodium: Vitamins:
Nutrition during Pregnancy C. Dietary supplements: many health care providers supplement the pregnant womans diet with an iron-fortified multivitamins to ensure essential levels
D. Special concerns religious, ethics, and cultural practices that influence selection and preparation of foods Pica (ingestion of non-edible or nonnutritive substances) Vegan vegetarians- no meat products, may need B12 supplement Adolescence Economic deprivation Heavy smoking, alcohol consumption, drugs Previous reproductive problems
A. Fetal diagnostic tests 2. Types continue Ultrasound: use of sound and returning echo patterns to identify intrabody structures. Useful early in pregnancy to identify gestational sac(s); later uses include assessment of fetal viability, growth patterns, anomalies and adnexal masses. Used as an adjunct to amniocentesis; safe for fetus (no ionizing radiation). Amniocentesis: location and aspiration of amniotic fluid for examination; possible after the 14th week when sufficient amount is present. Used to identify chromosomal aberrations, sex of fetus, levels of alpha-fetoprotein and other chemicals indicative of neural tube defects and inborn errors of metabolism, gestational age, Rh factor.
maturity
Fetal movement count: teach mother to count 2-3 times daily, 30-60 minutes each time, should feel 5-6 movements per counting time. Mother should notify care giver immediately of abrupt change or no movement
Nipple stimulated CST: massage or rolling of one or both nipples to stimulate uterine activity and check effect on FHR Oxytocin challenge test (OCT): infusion of calibrated dose of IV oxytocin piggy Backed to main IV line; controlled by infusion pump; amount infused increased every 15-20 minutes until three good uterine contractions are observed within 10-minute period. CST never done unless willing to deliver fetus
The so-called natural childbirth method. Underlying concept: knowledge diminishes the fear that is key to pain. Classes include information as well as practice in relaxation and abdominal breathing techniques for labor. Lamaze method Psychoprophylactic method based on utilization of Pavlovian conditioned respond theory. Classes teach replacement of usual response to pain with new, learned responses (breathing, effleurage. Relaxation) in order to block recognition of pain and promote positive sense of control in labor Bradley method Husband-coached childbirth. A modification of the Read method emphasizing working in harmony with the body.