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Tuesday, January 15, 2008

Introduction to Maternity and Pediatric Nursing

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Slideshow transcript
Slide 1: Introduction to Maternity and Pediatric Nursing, Fourth Edition

Slide 2: Nursing Care of Women with Complications During Pregnancy

Slide 3: High Risk Pregnancy Causes Relate to the pregnancy itself Occurs because the woman has a medical condition Results from environmental hazards Arise from maternal behavior or lifestyle

Slide 4: Assessment of Fetal Health Nurses responsibility – Preparing patient properly for test – Explaining reason for test – Clarifying and interpreting results in collaboration with other HCPs – Providing support to patient

Slide 5: US Images

Slide 6: 4D US Images

Slide 7: AFI

Slide 8: Kick Count Assessment Tool

Slide 9: Doppler Ultrasound Blood Flow Assessment

Slide 10: AFP

Slide 11: Amniocentesis

Slide 12: NST

Slide 13: Percutaneous Blood Sampling

Slide 14: Danger Signs in Pregnancy Sudden gush of fluid from vagina Vaginal bleeding Abdominal pain Persistent vomiting Epigastric pain Swelling of face and hands Severe, persistent headache

Slide 15: Danger Signs in Pregnancy – Cont’d Blurred vision or dizziness Chills with fever > 100.4 degrees Painful urination or reduced urine output

Slide 16: Pregnancy-Related Complications Hyperemesis Gravidarum – Manifestations Persisitent N/V Significant weight loss Dehydration: dry tongue and mucous membranes, decreased turgor, scant concentrated urine, high hematocrit Electrolyte and acid-base imbalance Unusual stress, emotional immaturity, passivity, ambivalence

Slide 17: Pregnancy-Related Complications – Treatment Correct electrolyte imbalances and acid-base imbalances with oral or IV fluids Antiemetic drugs Possibly parenteral nutrition

Slide 18: Pregnancy-Related Complications – Nursing Care Focus is on teaching Avoid foods that trigger N/V Eat small, frequent meals Teach about intake and output Provide support to the mother

Slide 19: Bleeding Disorders of Early Pregnancy Abortion – Specific care depends on whether abortion induced or spontaneous – Treatment Cervical cerclage – Suturing of cervix – to help maintain threatened pregnancy Counseling Administration of oxytocin to help control blood loss Rhogam given if mother Rh negative

Slide 20: Bleeding Disorders of Early Pregnancy – Nursing Care for Abortion Physical care – Documents amount of bleeding – Pad count – Vital signs – Instruct pt. To remain NPO if actively bleeding – Instructions Report increased bleeding Monitor temp every 8 hours x 3 days Take iron supplement Resume sex as prescribed by HCP Appointment with HCP at assigned date and time

Slide 21: Bleeding Disorders of Early Pregnancy Emotional Care for Abortion – Acknowledge grief – Provide for spiritual support

Slide 23: Bleeding Disorders of Early Pregnancy Ectopic Pregnancy – Occurs when fertilized egg is implanted outside uterine cavity 95% in fallopian tube – May result from Hormonal abnormalities Inflammation Infection Adhesions Congenital defects Endometriosis Use of intrauterine contraception – due to inflammation Failed tubal ligation

Slide 24: Bleeding Disorders of Early Pregnancy – Zygote cannot survive for long May die and be reabsorbed May rupture tube creating a surgical emergency – Manifestations Lower abdominal pain Light vaginal bleeding If rupture occurs – Sudden, severe abdominal pain, vaginal bleeding and hypovolemic shock – Referred shoulder pain

Slide 25: Bleeding Disorders of Early Pregnancy – Treatment for Ectopic Pregnancy Test for hCG Transvaginal US Laparoscopic exam Medical treatment – No action if being reabsorbed – Methotrexate (if tube not ruptured) – inhibits cell division – Sugery to remove pregnancy from tube or entire tube if damage is severe

Slide 26: Bleeding Disorders of Early Pregnancy – Nursing Care for Ectopic Pregnancy Vital signs Assessment of lung and bowel sounds IV fluids Blood replacement as necessary Antibiotics Pain management NPO Indwelling catheter Bed rest Emotional support

Slide 28: Bleeding Disorders of Early Pregnancy Hydatidiform Mole – Molar pregnancy Occurs when the chorionic villi abnormally increase and form vesicles May be complete (no fetus) or partial (only part of the placenta has vesicles) May cause – Hemorrhage – Clotting abnormalities – Hypertension – Later development of choriocarcinoma

Slide 29: Bleeding Disorders of Early Pregnancy – Chromosome abnormalities are common – May occur in women at ages of extreme reproductive life – Manifestations Bleeding Rapid uterine growth Failure to detect FHR activity Signs of hyperemesis gravidarum Unusually early PIH Snowstorm pattern on US with no evidence of fetus

Slide 30: Bleeding Disorders of Early Pregnancy – Treatment for Hydatidaform Mole Vacuum aspiration and D&C Level of hCG is tested until undetectable and levels followed for at least 1 year Women advised to delay conception until follow- up care complete Rhogam given if mother Rh negative

Slide 31: Bleeding Disorders of Early Pregnancy – Nursing Care for Hydatididaform Mole Observe for bleeding and shock Emotional support Education on reasons to delay pregnancy Contraception education

Slide 32: Bleeding Disorders of Late Pregnancy Placenta Previa – Placenta develops in the lower part of the uterus versus the upper part – There are 3 degrees of previa Marginal – reaches within 2-3 cm of cervical opening Partial – placenta partially covers the cervical opening Complete or Total – completely covers the opening

Slide 33: Bleeding Disorders of Late Pregnancy – A low-lying placenta is near the cervix Not a true placenta previa May or may not be accompanied by bleeding May be discovered during a routine exam

Slide 35: Bleeding Disorders of Late Pregnancy – Manifestations of Placenta Previa Bright red, painless vaginal bleeding Risk of hemorrhage increases with nearing of labor Fetus often in abnormal presentation Fetus may have anemia Mother may be more at risk postpartum for infection and hemorrhage – Vaginal organisms can easily reach placenta site – Lower portion of uterus has fewer muscles resulting in weaker contractions

Slide 36: Bleeding Disorders of Late Pregnancy – Treatment Depends on length of gestation and amount bleeding Goal is to maintain pregnancy as long as safely possible Mother encouraged to lie on side or with pelvic tilt to avoid supine hypotension Delivery by C-section if total or partial May deliver vaginally if low-lying or marginal

Slide 37: Bleeding Disorders of Late Pregnancy – Nursing Care Observe for vaginal blood loss Observe for S/S of shock Vital signs q 15 minutes if actively bleeding and oxygen administered NO VAGINAL EXAMS Continuos fetal monitoring Prepare for Cesarean if indicated Supportive Care

Slide 38: Bleeding Disorders of Late Pregnancy Abruptio Placentae – Permanent separation of placenta from implantation site – Predisposing factors include Hypertension Cocaine or Alcohol Use Smoking Poor Nutrition Abdominal Trauma Prior History of Abruption Placentae Folate deficiency

Slide 39: Hypertension During Pregnancy – Manifestations of Abruptio Placentae Bleeding with abdominal or low back pain Bleeding may be concealed at first Dark red vaginal bleeding when blood leaks past placenta Uterine tenderness and firm May have cramp-like contractions Fetus may or may not be in distress Fetus/Neonate may have anemia or hypovolemic shock

Slide 40: Hypertension During Pregnancy – Disseminated Intravascular Coagulation (DIC) May complicate abruptio placentae Large clot behind placenta consumes clotting factors which leaves mother deficient Clot formation and destruction occurs at the same time Mother may bleed from all orifices due to depletion of clotting factors Postpartum hemorrhage may occur Infection likely due to damaged tissue being susceptible to bacteria

Slide 41: Hypertension During Pregnancy – Treatment 1st Choice – Immediate Cesarean Blood and clotting factor replacement if necessary After delivery problem quickly resolves – Nursing Care Prepare for C-section Close, continuous monitoring of mother and baby Observe for S/S shock Prepare for compromised infant Prepare for grieving if infant dies

Slide 42: Hypertension During Pregnancy Hypertension During Pregnancy – High blood pressure in pregnancy (PIH) – Preeclampsia PIH + proteinuria – Eclampsia PIH + proteinuria + convulsions/seizures – Toxemia – old terminology

Slide 43: Hypertension During Pregnancy – Cause unknown – Birth only definitive cure – Usually develops after 20th week, but research has shown that it is determined at implantation – Vasospasm is main characteristic – May increase risks of further complications

Slide 44: Hypertension During Pregnancy – Risk Factors for PIH 1st pregnancy Obesity Family history of PIH >40 years or <19 years Multifetal pregnancy Chronic hypertension Chronic renal disease Diabetes mellitus

Slide 45: Hypertension During Pregnancy – If mild to moderate BP readings (systolic <160mm Hg and diastolic <110 mmHg) identified medications typically not used to treat Treated/Monitored with diet modification, daily weights, activity restriction, BP monitoring, fetal kick counts, frequent monitoring for proteinuria

Slide 46: Hypertension During Pregnancy – Medication is started if BP exceeds moderate range Drugs of Choice – Methyldopa (Aldomet) – Labetalol – Nifedipine (Procardia)

Slide 47: Hypertension During Pregnancy – Manifestations of PIH Vasospasm impede blood flow to mother and placenta resulting in: – Hypertension Typically should not occur in pregnancy due to hormonal changes which decrease resistance to blood flow – Edema Occurs when fluid leaves blood vessels and enters tissues – Proteinuria Develops as reduced blood flow damages kidneys

Slide 48: Hypertension During Pregnancy Other Manifestations of Preeclampsia – CNS – HA – Eyes – Visual disturbances – Urinary Tract – Decrease UOP – Respi9ratory – Pulmonary Edema – GI and Liver – Epigastric pain and N/V, elevated liver enzymes – Blood – HELLP – hemolysis, elevated liver enzymes, low platelets

Slide 49: Hypertension During Pregnancy Eclampsia – Woman has one or more generalized seizures Facial muscles twitch, then contraction of all muscles – Effects on Fetus Decreased oxygen availability which may result in fetal hypoxia Meconium IUGR Fetal Death

Slide 50: Hypertension During Pregnancy – Treatment of PIH Prevention Management – as discussed previously Drug Therapy – Magnesium Sulfate (anticonvulsant and antihypertensive) – Antihypertensive Drug Therapy if BP > 160/100 mg Hg

Slide 51: Hypertension During Pregnancy – Nursing Care Assist to obtain PNC Help cope with therapy Provide care/Monitor Administer meds Postpartum Care

Slide 52: Blood Incompatibility Rh and ABO Incompatibility – Rh blood factor = Rh+ – No Rh blood factor in erythrocytes = Rh- – Rh+ person can receive Rh- blood if all other factors compatible because factor is not present – Rh incompatibility only occurs if the mother is Rh- and fetus is Rh+

Slide 53: Blood Incompatibility – Rh- is autosomal recessive triat – both parents must pass on this gene to the fetus – Rh+ is dominate gene – Rh+ person can inherit two Rh+ genes or one Rh+ and one Rh- – Rh- mother does not have the factor and therefore if her fetus does her body may respond with antibody production as a defense mechanism (isoimmunization) Typically occurs at delivery and would therefore affect subsequent pregnancies

Slide 54: Blood Incompatibility – Manifestations If mother produces anti-Rh anitbodies no outward manifestation Labs reveal increased antibody titers When maternal anti-Rh antibodies cross the placenta fetal erythrocytes are destroyed (erythroblastocis fetalis)

Slide 55: Blood Incompatibility – Nursing Care Prevent antibody production – Rhogam at 28 weeks and w/in 72 hours of delivery if mother Rh- and baby Rh+ May also be given after amniocentesis as a precaution Not effective if sensitization has already occurred If antibody production occurs fetus is monitored carefully – Coomb’s test – Amniocentesis – Percutaneous umbilical sampling test – Intrauterine transfusion if severely anemic

Slide 56: Pregnancy Complicated by Medical Conditions Diabetes Mellitus – Preexisting (Type I or Type II with onset before pregnancy) – Gestational (GDM occurs only during pregnancy)

Slide 57: Pregnancy Complicated by Medical Conditions – Pathophysiology of DM Pancreas produces insufficient insulin or cells resist effect of insulin Cells cannot receive glucose Body metabolizes proteina and fat for energy – Ketones and acid accumulate – Person loses weight – Person experiences fatigue and lethargy – Fluid moves to tissues to dilute excess glucose leading to increased thirst resulting in tissue dehydration and glycosuria (glucose-bearing urine)

Slide 58: Pregnancy Complicated by Medical Conditions – Effect of Pregnancy on Glucose Metabolism Increased resistance of cells to insulin Increased speed of insulin breakdown – Gestational Diabetes Mellitus Maternal Links to GDM – Maternal Obesity (>198 lbs.) – Previous macrosomic infant – Maternal age > 25 years – Previous unexplained stillbirth or infant with congenital anomalies] – Family history of DM – Fasting glucose > 135 mg/dl or postmeal > 200 mg/dl

Slide 59: Pregnancy Complicated by Medical Conditions – Treatment of Diabetes During Pregnancy Identification Diet Modification Monitoring Ketone Monitoring PO antidiabetic agents Insulin Exercise Fetal monitoring May indicate early delivery

Slide 60: Pregnancy Complicated by Medical Conditions – Nursing Care for Diabetes During Pregnancy Self-care/Management Emotional Support Encourage Breastfeeding

Slide 61: Pregnancy Complicated by Medical Conditions Heart Disease – Affects small percentage of pregnant women – Manifestations Increased clotting causes predisposition to thrombosis – If cannot meet demand leads to CHF – Priority of care is limiting demands on heart throughout pregnancy, labor, delivery and postpartum period

Slide 62: Pregnancy Complicated by Medical Conditions – Nursing Care for Heart Disease Teach self-management to patient Teach S/S of CHF Diet modification Teach about eliminated stress

Slide 63: Pregnancy Complicated by Medical Conditions Anemia – Hgb levels < 10.5-11.0 g/dl in pregnancy – 4 types in pregnancy Iron-deficiency – RBCs small and pale Prevention – iron supplements Treatment – elemental iron supplements Folic acid-deficiency – Large, immature RBCs – Iron-deficiency anemia may also be present Prevention – folic acid supplement Treatment – 1mg/day supplement over the amount of preventative supplement

Slide 64: Pregnancy Complicated by Medical Conditions Sickle cell disease – Abnormal Hgb that causes erythrocytes to become sickle-shaped during hypoxia or acidosis – Autosommal recessive trait – Approx 1/12 African Americans has the trait – Pregnancy may cause crisis – Risk to fetus – occulsion of vessels leading to preterm birth, IUGR, fetal death Thalasemia – Genetic trait that causes abnormality in one of two chains of Hgb ,alpha or beta

Slide 65: Pregnancy Complicated by Medical Conditions – Nursing Care for Anemias During Pregnancy Nutrition education Education about changes in stool pattern and characteristics Taught to avoid dehydration

Slide 66: Pregnancy Complicated by Medical Conditions Infections – TORCH - Devestating infections for fetus T – toxoplasmosis O – other infections R – rubella C – cytomegalovirus H – herpes simplex virus

Slide 67: Pregnancy Complicated by Medical Conditions Viral Infections – Cytomegalovirus – May be asymptomatic in mother, but serious problem in infant Mental retardation Seizures Blindness Deafness Dental abnormalities Petechiae (blueberry muffin rash) No effective treatment, therapeutic abortion may be offered if early in pregnancy

Slide 68: Pregnancy Complicated by Medical Conditions – Rubella – mild virus with low fever and rash, but effects on fetus can be devastating Microcephaly MR Congenital cataracts Deafness Cardiac defects IUGR Treatment – Immunization prior to pregnancy

Slide 69: Pregnancy Complicated by Medical Conditions – Herpes virus – type 1 and type 2 – type 2 affects pregnancy Infection in infant can be localized or widespread, may cause death or neurological complications Treatment and Care – Avoid contact with lesions, if active outbreak Cesarean delivery

Slide 70: Pregnancy Complicated by Medical Conditions – Hepatitis B – transmitted by blood and body fluids, can also cross placenta Treatment and Care – screen during pregnancy, infants born to women who are Hepatitis B+ should be given Hepatitis B immune globulin (HbIG), followed by Hep B vaccine

Slide 71: Pregnancy Complicated by Medical Conditions – HIV – causitive organism of AIDS, cripples immune system Acquired one of three ways – Sexual contact with infected person – Parenteral or mucous membrane exposure to infected body fluids – Perinatal exposure (20% - 40% chance of infecting infant) Transplacentally Contact with infected maternal secretions at birth Breastmilk

Slide 72: Pregnancy Complicated by Medical Conditions Nonviral Infections – Toxoplasmosis – caused by Toxoplasma gondii, a parasite that may be in cat feces in raw meat and transmitted through the placenta Possible S/S in newborn – Low birth weight – Enlagred liver and spleen – Jaundice – Anemia – Inflammation of eye structures – Neurological damage

Slide 73: Pregnancy Complicated by Medical Conditions Treatment and Nursing Care – Cook all meats thoroughly – Wash hands after handling raw meat – Avoid litter boxes , soil and sand boxes – Wash fresh fruits and veggies well – Group B streptococcus – leading cause of perinatal infections. Organism found in woman’s rectum, vagina, cervix, throat or skin. Woman usually asymptomatic, but can be transmitted to baby at delivery. Diagnosis – + culture of woman’s vagina or rectum at 35-37 weeks gestation Treatment – Antibiotics to mother prior to delivery – Antibiotic therapy to infant after delivery

Slide 74: Pregnancy Complicated by Medical Conditions – TB S/S – fatigue – weakness – loss of appetite and weight – Fever – Night sweats Treatment and Nursing Care – Isoniazid and Rifampin to mother for 9 months – Infant may have preventative therapy for 3 months

Slide 75: Pregnancy Complicated by Medical Conditions Sexually Transmitted Diseases Prevention is by safe sex with protection of condom – Herpes – HIV – Syphilis – Gonorrhea – Chamydia – Trichomoniasis – Genital Warts

Slide 76: Pregnancy Complicated by Medical Conditions Urinary Tract Infections – More common in pregnancy due to pressure on urinary structures keeps bladder from emptying completely and because ureters dilate and lose motility under influence of relaxing effects of progesterone and relaxin – Cystitis – infection of bladder S/S – Burning with urination – Increased frequency and urgency – May have slightly elevated temp

Slide 77: Pregnancy Complicated by Medical Conditions – Pyelonephritis – infection of kidney(s) S/S – High fever – Chills – Flank pian – N/V – Treatment for UTIs Antibiotic therapy – Nursing Care Teach to wipe front to back Intake adequate fluid Urinate before and after intercourse Teach S/S

Slide 78: Pregnancy Complicated by Medical Conditions Substance Abuse – the use of illicit or recreational drugs during pregnancy . – Treatment and Nursing Care Identify substance abused Educate on potential effects of drug Use nonjudgmental approach

Slide 79: Pregnancy Complicated by Medical Conditions Trauma During Pregnancy – Manifestations of Battering May enter late to prenatal care May make up excuses – Treatment and Nursing Care Provide for privacy Be nonjudgmental Offer resources Assessment of maternal and fetal well-being

Slide 80: Effects of a High-Risk Pregnancy on the Family Disruption of Roles Financial Difficulties Delayed Attachment Loss of Expected Birth Experience

Slide 81: References Introduction to Maternity & Pediatric Nursing; Fourth Edition, 2003; Gloria Leifer, Ma, RN; Associate Professor Obstetrics, Pediatrics, and Trauma Nursing; Riverside Community College; Riverside, California; Saunders

Slide 82: The END!!!

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