Mother Baby Final by Katrina Gero

Family Centered Care(1)

kgero — 2020-04-27 15:25:02 UTC

Focus:
Holistic focused on meeting physical and psychological needs

Patient might need to alter birth plan as labor progresses/changes.

Three principles

Childbirth is considered a norm, healthy event in the life of a family
Childbirth affects the entire family, and relationships will change
Families are capable of making decisions about their own care if given adequate information and professional support.

Family Centered Care Examples:

Providing comfort measures
Managing family dynamics
Respect birth plan
Include family in teaching
offer lactation consultant

Evidence Based Practice(1)

kgero — 2020-04-27 15:26:23 UTC

Review Class Notes

3 basic components:

reliance on viable/reliable literature
clinical expertise of physician
patient preference

Culture(1)

kgero — 2020-04-27 15:26:42 UTC

What are cultural influences?

Language
Family structure/roles
Social interaction: what is their cultures definition of it? ex breast exposure
Religion/Spirituality
Diet
Genetics (some cultures have a higher rate of certain genetic disorders)
Health beliefs and practices (ex blood transfusion, circumcision, birth control)

Health Promotion/ Disease Prevention(2)

kgero — 2020-04-27 15:27:07 UTC

1. Primary = Preventing the disease or illness from occurring

Examples: vaccines, wear a helmet when riding a bike, no smoking/drinking, pregnant woman not cleaning litter box

2. Secondary = Screening for occurrence of disorders

Examples: blood glucose, BP checks to screen for disease, mammograms/colonoscopies, belly measuring, CBC

3. Tertiary = Treatment of disorder to achieve the best outcome

Examples: Rehab and PT after a stroke, Taking BP meds for high BP, bed rest.

Genetics(2)

kgero — 2020-04-27 15:49:58 UTC

Types of Genetic Traits

Autosomal Dominant:

1 parent generally expresses phenotype
50% change offspring with express trait
Ex Huntington's disease, achondroplasia

Autosomal Recessive

Both parents must carry the trait to pass on to offspring
expressed in genotype in offspring, so offspring can carry gene but not show physical signs of it
In any pregnancy 25% will demonstrate trait, 50% are carriers of trait, and 25% are unaffected
Ex PKU, Sickle Cell Disease, Cystic Fibrosis

Sex Linked (X-linked)

X linked recessive- male offspring exhibit trait
X linked dominant- both male and female exhibit
Ex: Colorblindness, hemophilia, Duchene MD

Non-Mendelian Inheritance

Genetic defect is a result of deviation of normal 46 chromosomes – errors occurs during cell division.
Can be from transcription/translation/structural development issues of the chromosomes.
Ex: Down syndrome, Turners, Trisomy 13

Nursing Assessment and Teaching
Terms

Genotype – the gene pair inherited from parents
Phenotype – inherited observed characteristics

Genetic Counseling

Begin before pt is pregnant and discuss with both partners
Find out pts feelings/thoughts- might not be important to them to know ahead of time

Nursing Considerations

Folic acid/prenatal vitamins
Family hx
Support (emotional)
Like views on testing for both partners and what they want done if there was a genetic defect
Level of understanding/best way to teach them
Spiritual and cultural needs
Pedigree- family outline of risk factors
Ethical issues

Fetal Development(2)

kgero — 2020-04-27 15:50:44 UTC

Fetal Oxygenation

Placenta transmits O2 and nutrients to the fetus
Placenta removes waste and CO2 by diffusion
Chorion side of placenta attaches to uterine wall with finger like projections to help oxygenate baby
Mothers blood does NOT provide oxygen to fetus
Fetal lung development begins 21-24 weeks when alveoli are formed in lungs and surfactant production starts,

Fetal Circulation- Know the 4 fetal circulatory areas

Normal Fetal Circulation:
1. Umbilical Vein carries O2 blood to fetus

2. Ductus Venosus - Oxygenated blood from the umbilical vein enters the fetus travels to the liver where more where ½ of the O2 blood is shunted through the Ductus Venosus to the IVC and up to the right atrium. In fetal circulation, the vena cava system carries the oxygenated blood up to the heart for circulation to the baby. Much of fetal blood is mixed blood. Will have higher H&H levels bc they need to carry a lot of O2.

3 .Foramen Ovale - Blood enters the Right atrium and a small amount shunts via the Foramen Ovale to the left atrium and to the Left ventricle_for O2 of upper extremities and brain. The remainder of blood travels from the right ventricle and to the pulmonary artery

4.Ductus Arteriosus - From the pulmonary artery a small amount of blood enters the lungs. The remaining blood, from the Right ventricle, is shunted via the Ductus Arteriosus to the aorta to supply O2 blood to the rest of the body.

5.Umbilical Arteries - Deoxygenated blood leaves the fetal body through the umbilical arteries (2 arteries), which exit near the iliac veins, and are part of the umbilical cord returning deoxygenated blood and waste products to the placenta

Newborn Assessment(6)

kgero — 2020-04-27 15:52:49 UTC

Priority assessments:

First thing- dry them off. Want to warm baby off, also stimulates baby, hit feet, rub back- can make baby wake up and cry.
Put baby on dry towel, then start assessments.
Airway/breathing- is baby breathing? Do I have a HR? HR above 100, can just give breaths. Less than 100- need chest compression/CPR
Don’t need to give a lot of oxygen.
Pulse oximetry is vital on these babies. Will tell you how much O2 they will need.

NORMAL
Respiratory:

RR 30-60 w/short period of apnea in term newborn "periodic breathing"
Listen on right side if chest
cord clamping cuts off placental gas exchange
Neonates are obligatory nose breathers

Cardiovascular

HR 110-160
Acrocyanisis- bluing of hands and feet. should go away after 24 hrs after birth

Blood components :

increased number of RBCs
High affinity for O2
RBCs are large
Leukocytosis- small bump in white blood cells is a protective measurement in the first few days of life.

Temp

Assess axillary temperature (NOT rectal)
Normal Temp: 36.5-37.5 C or 97.9-99.7 F

Warmth - considered the fifth vital sign in the newborn. Any cold stress puts metabolic stress on neonate (ex hypoglycemia, hypoxia)

Four mechanisms that neonates can lose warmth:

Radiation- cold external process pulling heat away from neonate. That's why we put hats on babies.
Convection- lost temp through air going over the body
Evaporation- if they are wet. Mostly from moisture from intrauterine environment.
Conduction (they’re laying on a cold surface)

Newborn Thermoregulation

Brown Fat
- Helps to burn, stabilize and helps with metabolic needs. Needed because newborns have non-shivering thermoregulation
Which infants are at risk for cold stress because they lack brown fat?
- Premature, low birthweight, small for gestational age.

Neurological
Neonate’s neurological system is immature.

may be more jittery. May respond differently. Primitive reflexes. (look up those in text),
Development is rapid
Reflexes are important indicators of CNS health
Reflexes
- Rooting
- Sucking- doesn't need to be checked once you see them nurse
- Swallow/gag
- Blink
- Stepping- push up against their feet, or hold them up under arms and see if they moon walk
- Babinski- finger on foot, toes curl and fan
- Grasp – plantar/palmar
- Moro (startle)

Neurological/Sensory Assessment

Vision - can see objects close up (8-10 inches), prefers contrast, Sensitive to light
Hearing - Should be able to hear and respond to noises
Hearing screens are state mandated neonatal test
Smell - very well developed sense and can sense things through their olfactory sense better than most other sense system
Touch - should be comforting to newborns

Intake – Small stomach – Size of a cherry
In the first few days of life the stomach has amniotic fluid and mucus
Output - Meconium to Transitional to Normal newborn
Normal newborn stool consistency is dependent on whether the baby receives breastmilk or formula

1 wet diaper per day of life
- EX 3 day old baby should have 3 wet diapers in 24 hrs
This continues on until day 6, then this number remains the minimum moving forward

Weight

All newborns lose weight in the first few days of life
Maximum of 8-10 % of birth weight
Newborn will regain birth weight by 10-14 days

Why do all babies lose weight?

Meconium
fluids/mucus
burning brown fat
colostrum doesn't help them gain much weight- allows for more rapid emptying of the meconium

Definitions

Preterm = <37 complete weeks
Post term = > 42 weeks gestation
LBW = Low Birth Weight): < 2500 gm (5.5 lbs)
VLBW = Very low birth weight < 1500 gm SGA = Small for Gestational Age < 10thpercentile
IUGR = Intrauterine Growth Restricted
LGA/Macrosomia = Generally > 4000gmLarge for Gestational Age
Late Preterm Neonates = 35-37 weeks

Hepatic
Liver takes over the functions of the placenta:

Iron storage
Carbohydrate metabolism – Glycogen stores/maintains blood glucose
Bilirubin conjugation- if liver is immature, it can’t handle the break down of RBCs/bilirubin = jaundice.

Skin

Lanugo – fine hair that covers the baby in utero. The amount of lanugo diminishes with gestational age.
Milla– White pearly bumps seen on many newborns. Often seen on nose, chin, and forehead
Vernix – White thick waxy substance that covers the skin of a newborn. Vernix helps protect the fetal skin in the intrauterine environment. Vernix comes off in the amniotic fluid, and the closer the baby is to term the less vernix on the skin at delivery.
Nevus flammeus nuchae, also known as a stork bites, is a congenital capillary malformation present in 25%-50% of newborns – most common birth mark- often found on the back of the neck
Erythema toxicum - Baby acne
Congenital Dermal Melanocytosis – Mongolian Spots any of a number of dark-bluish or mulberry-colored rounded or oval spots on the sacral region – can occur elsewhere, generally seen in darker skinned individuals. Usually start to disappear around age four. Sometimes they don’t go away though.
Normal healing of umbilical stump. Take off clamp after 24 hours and the stump will dry out and fall off in 7-10 days.
Umbilical Cord Care - make sure it stays dry and diapers are pulled down under it.

Musculoskeletal

Normal fetal posture is flexed, should resist when try to straighten extremities in term newborn

Normal Behaviors of Newborn Reactive Responses after delivery

First Reactive Phase : first 24 hours of life. They’re wide awake. Good time to get them to try breastfeeding. Good bonding time.
Sleep phase: can last from a couple hours to the first 24 hours of life. Can be hard to wake them up to breastfeed. Normal transition.
Second Reactive Phase: happens whenever the sleep phase ends. Baby is wide awake/alert wants to interact w/ parents. Understands, hears, recognizes parent’s voices.

Abnormal
Respiratory:

RR below 30 or above 60
grunting
retraction
provide suction if RR is low
Respiratory Distress Syndrome (RDS)
- Caused by surfactant deficiency
- Signs are hypoxia, respiratory acidosis, and metabolic acidosis
TTN - Transient Tachypnea of the Newborn
- Usually seen in term infants by 6 hours of age, respiratory rate increases greatly, up to 100-140/min
- Happens often w/ C section babies bc the fluid doesn’t get squeezed out like it would w/ vaginal birth babies.
Meconium Aspiration
- Meconium aspirated into the neonates lung fields. Babies will need NICU.

Cardiovascular
HR below 110 or above 160

Skin
Pilonidal dimple – in crevice of baby’s back. Need to get seen bc want to make sure it isn’t a neural tube issue. Its an abnormal finding. You would not expect to see that in a newborn.

Musculoskeletal
Check for birth injury

Bruising
Skin tears
Clavicle fracture- assess for crepitus

Neonatal Abstinence Syndrome (NAS)

Set of symptoms experienced by a neonate as they experience withdrawals from addictive substances.

Symptoms can be seen from 8hrs to 8 days depending on the drug and the last exposure to it.
For our purposes, we are discussing 24hrs- that’s when you’ll really start seeing it in babies.

Symptoms:

Hyperactivity
Tachypnea
Tremors
Fever
Seizures
High-pitched/shrill cry
Vomiting/diarrhea, skin breakdown at diaper area due to diarrhea
Sneezing
Sweating
Disorganized sucking and swallowing

Sepsis Neonatorum

Generalized infection in newborn that occurs during or shortly after birth.
Leading cause of sepsis is Group Beta Strep.- this is a normal flora in the vagina so we want to know if mom has it and treat w/ antibiotics during labor to prevent transmission to baby.

Infant who have suffered hypoxia

Multiple causes- anything that causes a disruption of blood flow to the baby
Some will often have meconium stained amniotic fluid- this just means there was a stress event. The stress event causes the hypoxia, not the meconium. Those hypoxic episodes can lead to developmental delays and cerebral palsy
May need resuscitation measures at birth
Lead to developmental delays and cerebral palsy- studies show that most cases of cerebral palsy are due to in utero hypoxic episode to the brain as opposed to a birth injury.
Cold stress can cause hypoxia bc it increases oxygen demand on baby

Infant of an HIV Positive Mother

Transmission rate about 30% in untreated mothers (much lower in mothers who have been treated so it's very important they get treated and get tested for HIV)
Do not breastfeed- can be transmitted through milk to baby
All infants will have antibodies present at birth from the mother
Mother’s antibodies disappear at 8-15 months of age
Child will be retested at 12 and 18months for sero-conversion
Appearance of opportunistic infection between 3-6 months of age indicates HIV infection

Transition
24 hours and before discharge

Transition from fetal circulation and placental gas exchange

As soon as the cord is clamped the ductus venosus ceases to carry blood to the heart and it begins to constrict. (The ductus venosus closes within the first few days of life). Within the first few hours of life the very first thing that happens when the fetus is born is it takes its first breath the lungs expand. This causes the resistance or pressure in the lungs drop which promotes blood flow into the lung. The ductus arteriosus begins to constrict and is typically fully closed within 24 to 48 hours of life. The blood is now fully directed into the lung as the blood returns to the left side of the heart after traversing the pulmonary circulation and picking up oxygen. Pressure in the left atrium rises and the trap door of the foramen ovale, which was open before birth, now begins to close usually within the first few days of life

Apgar Score:

Score given at 1 and 5 minutes of life.
Rates respiration, crying, reflexes, irritability, pulse, HR, skin color of body and extremities, muscle tone.
Scores assigned 0, 1, or 2 for each criteria (0 is lowest score)
Normal is 7-9. Rare to get a 10. Less than 7 requires resuscitation

*See pic at bottom of this section for chart on apgar score**

Respiratory
How does a baby know to breath?

Physical Factors (Mechanical factors)- diaphragm drops, starts mechanism of breathing.
Could be hypoxic drive.
First breath causes an increase in pulmonary pressure, resulting in diaphragm descending
Cord clamping cuts off placental gas exchange

Feedings-
When to hold and when to feed?

respiratory difficulty because of aspiration risk
enterocolitis

Formula feeding

eat every 3-4 hours
No set time for starting, 4-5 hours
start small- .5 oz or 15 mL. Slowly start to increase as baby shows signs of wanting more
green pasty, smelly, more formed
amount of water, formula ratio. don’t warm in microwave

Breast feeding

eat every 2-3 hrs, or 9-12 times a day
Initiate within first hours of life
at least 20 minutes on 1st breast, then offer 2nd breast
watery, seedy, and yellow. harder to get constipated. no offensive odor
Signs of readiness to feed
- Rooting
- Protruding Tongue
- Making noises

Basic Care(2)

kgero — 2020-04-27 15:54:44 UTC

Bathing
First Bath - delayed up to 24 hours- flora in vaginal canal helps protect infants so we don’t want to wash that off.

Sponge bathe (will continue sponge baths until umbilical cord stump is healed)

Use wet warm washcloth

Start with eyes, then all of face

Wash hair last to prevent heat loss

Medications

Vitamin K IM injection (L thigh commonly). Vit K often deficient in neonate bc it’s produced by bacteria in the GI tract and babies don’t have any to start out w/. Takes about 24 hrs to start making their own vit K so it puts them at risk for hemorrhage if they don’t get the shot. Boys can’t get circumcised until after vit K
Eye Prophylaxis - ointment. Usually erythromycin. Goes from inner to outer canthus.
Hepatitis B Vaccine - Usually given in R thigh. Its a series.

Discharge Instructions
Safety

ID checks on babies. Make sure they stay w/ moms.
Safe sleeping habits
Put on backs to sleep, not sides, stomachs.
Nothing in crib.
Swaddle them.

Preterm Infant(2)

kgero — 2020-04-27 15:58:37 UTC

Associated risks with prematurity

Respiratory distress (primary problem)
Cerebral bleeding
Cerebral Palsy (outcome of hypoxic episode on the brain in utero, at delivery or shortly after delivery)
Sensory deficits- (cause of it is too much oxygen administration)
- Retinopathy
Patent Ductus Arteriosus (doesn’t close yet)
Infections- (immature immune system and skin is translucent and easily damaged)
Necrotizing Enterocolitis - Blood is shunted to vital organs leading to inflammation and death of bowel. Lack of perfusion to the gut. Big deal in NICUs. Can be prevented in the majority of cases.

Nursing Care/Assessment

Respiratory distress-

prevent resp distress in these babies w/ oxygenation. Give them just enough oxygen to keep them saturated. You want the lowest amount possible. Preterm can be given surfactant in the delivery room- given via a trach, goes into lungs. Mothers can also get steroid injections to help baby if we anticipate a preterm birth. Steroids can increase lung maturity in preterm babies.

Cerebral bleeding

Thermoregulation

Hypoglycemia

Test w/ heel sticks. Prevention is best.

Cerebral Palsy

Preventing is key. Possibly oxygenation. Often injury occurs pre-birth and is not preventable. Cerebral palsy is on a continuum. It could be just a gait issue or loss of control to the whole body.

Sensory deficits

Retinopathy- biggest sensory deficit in preterm baby. Abnormal vascular growth in retina in preterm babies. Tiny capillaries. They can rupture and bleed which then scar the retina
Increased oxygen can increase the pressure in the capillaries.

Patent Ductus Arteriosus-

give an NSAID called indomethacin

Necrotizing Enterocolitis
Blood is shunted to vital organs leading to inflammation and death of bowel

Assessments:

Bowel sounds.
Palpations, Inspect.
Belly will be distended. Monitor I&Os.
If there is a rupture, they won’t have bowel movements.
Preterm babies guts are too permeable.
Will need a GI tube or TPN.
Lab work may show elevated WBCs.

How to prevent?

Try to catch it ahead of time. Quiet the bowel. Stop feeding them. Let it heal. If you don’t catch it, risk of sepsis and death. Have mother provide milk. Lowers risk. Can happen in full term babies, but more common in preterm

Priority nursing intervention-

baby will be on antibiotics to try to fight off sepsis. Broad spectrum antibiotics (cephalosporins, amoxicillin)
Primary nursing intervention is NPO, monitoring, continuing abdominal assessments, can do abdominal girths and track them on a daily basis.

Hyperbilirubinemia (2)

kgero — 2020-04-27 16:00:25 UTC

Excessive bilirubin in the blood leading to jaundice in the newborn.
Immature liver cannot process the breakdown of RBCs. Bilirubin builds up

Assessment of Hyperbilirubinemia

Nursing assessment- Note jaundice descends and moves from central to distal and head to toe. Look at baby from head down and in to out.
Blanch test- press down and look for yellow
Transcutaneous Bilirubin Test (TCB)- put it on baby’s forehead, gives a number. Corresponds to how old they are. Not diagnostic. Just gives a baseline.

Lab work (total bilirubin)

Blood Work - Gold Standard (MUST KNOW THESE #s)
5mg/dl – You will see it on the face
7-8 mg/dl – moves down chest
12mg/dl- see more centrally and may indicate treatment
> 15mg/dl risk for kernicterus. (bilirubin is in the brain- you can’t get the bilirubin out of the brain)

Common Risk Factors for Hyperbilirubinemia

Rh and ABO incompatibilies -Mom and baby’s blood don’t mix generally so if they’re opposite types, there can be an incompatibility that develops. Mom develops antibodies to the babies RBCs, the antibodies cross through the placenta barrier and can go into fetus and break down fetal RBCs. Breakdown of RBCs = bilirubin = hyperbilirubinemia
Pre-maturity
Bruising/birth injury
Cold stress because it increases metabolic rate
Asphyxia
Breast feeding
Sibling with history of jaundice
Infection

Types

Physiologic Jaundice:

Normal Newborn Jaundice- Normal occurrence bc babies are born w/ higher levels of RBCs
Occurs after 24hrs of age
Bilirubin level generally does not exceed 12 mg/dl
Very common, doesn’t usually need treatment
Continue to breastfeed

Pathological Jaundice:

Occurs in the 24 hours of life
Bili level is 12mg/dl or higher
Causes
- Infection
- Hypothyroidism
- Metabolic Disorders
- Polycythemia
- Congenital Abnormalities
  - Biliary Atresia
  - Liver/Hepatic Malformations
Most common causes are:
- Rh
- ABO incompatibles

ABO Incompatibility

Hemolytic Disease

Mom with type “O”, fetus with type “A” or “B”

Maternal antibodies pass through placenta causing hemolysis of fetal RBCs

Type O blood doesn’t have any antigens. Sees other antigens on A or B and develops antibodies which will attack any blood cell that isn’t a type O. If mother has antibodies against the type A or B, will attack the fetal RBCs.
This increases likelihood for bilirubin in the blood.
Always needs to be watched and may need treatment but isn’t as big of a deal as the Rh compatibilities.

Rh incompatibilities Erythroblastosis Fetalis

Occurs when mother is Rh neg and baby is Rh positive
Rhogam at 28 weeks or at any bleed in pregnancy for Rh - moms
Rhogam after delivery if baby is Rh (+), 72 hours
Direct coombs/direct antibody titer on baby to see if maternal antibodies are present
If not detected and not treated can lead to Hydrops Fetalis = severe anemia due to RBC breakdown leading to heart failure and edema.

Breast Milk Jaundice

Two types
- Early breastfeeding jaundice
- Late breast milk jaundice

Can help by stopping BFing for a short period of time and then start back up again.

Jaundice Nursing Interventions

Early & Frequent Feeding (for term babies)- we want them to poop out the bilirubin
Early Detection.
Prevention of Cold Stress & other avoidable risk factors

Therapeutic Management

Hydration
Phototherapy- biggest problem they aren’t w/ mama. Not eating, skin to skin. Highest level of lighting you can get. Nursing assessments will be skin, thermoregulation. Can send them home w/ a bili-blanket.
Exchange Transfusion

Teaching the parents about care at home?

Encourage feeding every 2-3 hours
Monitor I&O – give only formula or breast milk unless otherwise indicated. No water.
Monitor stool
Notify the health care provider is the baby become lethargic or worsening of jaundice
Follow up with pediatrician as indicated

Hypoglycemia

kgero — 2020-04-27 16:02:19 UTC

placenta doesn’t filter sugar so mom’s high blood sugar goes to baby. Baby’s pancreas works fine so it puts out insulin to metabolize that glucose. They will gain weight. Once they’re born they don’t get exposed to mom’s high blood sugar so blood sugar will drop

Who's at risk?

Everyone but a term newborn who is in parameters for weight. Premies. Big babies. Diabetic mother.

Apply the nursing process:

Assessment including maternal history-
Low blood glucose 30-40mg/dl in the first 72 of life
May be lethargic and whiny, irritable, shkaky
Anything that increases the metabolic rate increases the risk.
Diagnoses:
Ineffective blood glucose regulation.
Risk for hypoglycemia.
Ineffective feeding.
Risk for birth injury r/t large size of baby

Interventions/implementation:

Assess BG. Baby needs 3 normal blood glucose readings in a row before we stop checking them.

Evaluation-

based on whatever the problem was.

Signs of Pregnancy(1)

kgero — 2020-04-27 17:23:54 UTC

Presumptive:

what mom is feeling/reports
- ex- fatigue, breast tenderness, amenorrhea, nausea

Probable:

Mainly signs the provider reports
- Braxton hicks
- Positive pregnancy test- Important to note- not a positive sign of pregnancy- it is a probable sign of pregnancy
- Chadwicks sign- blue vagina/cervix- highly vascular

Positive:

Identified on exam
- U/S verification of fetus
- Fetal movement felt by clinician
- Auscultation of heart

Abortion(1)

kgero — 2020-04-27 17:28:41 UTC

Nursing process

Preparing woman for treatment:
- Pain meds
- Close assessment of vitals
- Want to watch out for hypovolemic shock- could happen w/ tubal rupture.
Provide emotional support- encourage her to talk about her feelings.
Tell her she needs to follow up for several weeks to monitor hCG levels until they return to zero.

Pregnancy Discomforts(2)

kgero — 2020-04-27 17:29:03 UTC

Trimester and pt education:

First trimester:

Peeing a lot- drink a lot. At least 64 oz a day- not soda.
Tired- make sure she isn't anemic
N&V- small, frequent meals. Dry carbs. Ginger ale
Breast tenderness- wear bra if its comfy
Constipation- diet, fiber, exercise, water intake. Can take colace. Constipation can be bc of the iron supplement.
Nasal stuffiness
Bleeding gums- use soft bristle brush
Cravings
Leukorrhea- clear watery discharge from vagina- pantyliner
Mood swings
Ptyalism- excessive salivation

Second Trimester:

Gas- ask her what she is eating. Tell her not to hold it.
Leg cramps- lack of calcium. Stretch toes to nose- dorsiflex
Varicosities of the vulva and legs- elevate feet, compression stockings
Backache- walk. Heat on back okay. Not okay on tummy
Hemorrhoids- diet, exercise, fluids, don't strain with BM, use colace, don't try to push hemorrhoid back in.

Third Trimester:

SOB
Indigestion
Dependent edema
Braxton hicks contractions
Return of many of 1st trimester aches:
- Fatigue, urinary frequency, leukorrhea, constipation, mood swings

Hormones(1)

kgero — 2020-04-27 17:29:56 UTC

Estrogen:

Stimulates uterine growth and blood supply
Stimulates breast ductal system development
Hyperpigmentation, vascular changes
Increases vascularization

Progesterone:

Relaxes uterine/smooth muscle
Makes a bed for baby- maintains endometrium for implantation
Stimulates development of breast lobs
Helps mom store fat- P for Pudgy Progesterone.
Relaxes and dilates ureters= increased risk of UTI due to back flow of urine.

Placental Lactogen:

Insulin antagonist
AKA chorionic somatomammotropin
Can cause mom to be insulin resistant

Relaxin:

Causes increase in mobility of pelvic joints and ligaments
Causes ligaments to soften and feet to spread
Changes center of gravity= waddling.

Naegele's Rule/GPA(2)

kgero — 2020-04-27 17:33:13 UTC

You estimate the EDD using Naegele’s rule:
Subtract 3 months, add 7 days from LMP
Thirty days hath September, April, June, and November; All the rest have thirty-one, Excepting February alone, And that has twenty-eight days clear, and twenty-nine in each leap year.
30 days- ASNJ (April, Sept, Nov, June).
The rest have 31
Except Feb- 28

Nutrition in Pregnancy(3)

kgero — 2020-04-27 17:33:27 UTC

PICA- what should nurse do?

Pica: is eating substances without nutritional value and not normally eaten
Any examples? chalk, ice (most common pica), dirt
Usually due to iron deficiency anemia.

Weight gain- What is normal?

Weight gain should be 2-5 lbs during 1st trimester,
Then about 1 lb/wk in the 2nd and 3rd trimesters
Recommended wt gain is 25-35 lbs in healthy average weight client
Recommendations change if mother is over/underweight.
Most women today are gaining 40-50lbs with pregnancy

Supplements:

Add multiple vitamin with calcium (1200mg/day) and iron
Folic acid prevents – neural tube defects (neural tube defects happen very early in development- often before mom even knows she is pregnant)

Lab Values(3)

kgero — 2020-04-27 17:33:37 UTC

Which labs are done per visit?

First Visit

Complete Blood Count - CBC
- want to look at RBC, WBC, and H&H and platelets
Blood Type with Rh factor (T&S), Indirect Coombs (has to do with Rh factor- looking to see if mother has antibodies)
HIV (standard test for all first prenatal visit), VDRL (RPR- tests for syphilis), Hepatitis B
Rubella Titer (can pass through placenta barrier and cause significant fetal anomalies) If results come back as negative or equivocal- cannot vaccinate her bc it is a live virus. Teach mom to avoid places where there is a potential for measles.
Gonorrhea and Chlamydia (culture) tested at first visit and in third trimester if they engage in risky behavior.
PAP smear (they would get one if they were due for one)
Urinalysis (can tell if UTI, glucose. Full UA done on first visit)
Ultrasounds for dating (most accurate way to date a pregnancy in the first trimester) It would be a transvaginal.

Interventions done at every visit:

Urine dip stick for glucose (gestational diabetes?) and protein (protein associated with hypertensive disorders in pregnancy)
Weight checks
Vital sign
FHR obtained by doppler after 14 weeks
Fundal Height

Ultrasound at 18-20 weeks for morphology

One hour glucose at 26-28 weeks, if abnormal will need a 2 or 3 hour GTT

Quad or triple screen at 14-16 weeks

Labs that look for neural tube defects and genetic abnormalities:

AFP
hCG
Estriol
Inhibon A

Normal lab value changes in pregnancy

Katrina- haaaaalp!

Amnitoic Fluid (2)

kgero — 2020-04-27 17:36:03 UTC

Amniotic Fluid – What is its purpose?

keeps baby safe. Provides buoyant environment. Allows baby to practice breathing. Allows us to monitor urinary function. Prevents infection.
Oligohydramnios= not enough amniotic fluid
Polyhydramnios= too much amniotic fluid

Assessment of Fetal Well-being(3)

kgero — 2020-04-27 17:36:54 UTC

Understand why each test is performed and nursing care/education during

Non stress Test

Indirect measure of uteroplancental function
Reactive test is 2 FHR accelerations of 15 bpm from the baseline lasting for 15 seconds and occurring within 20 minutes
If the above doesn't happen- its nonreactive. Further testing needed

Fetal Kick Counts

Instruct mom to be still, but do not lie flat on back
Eat something to wake up baby
Put hand on belly and count big movements, not hiccups or flutters.
Good: 4-5 movements in 1 hr, 10 in 2 hr
Done in 2nd trimester during baby's wake time
Change/decrease in kick counts, call doc immediately

BPP

Tests 5 parameters:
- Non stress test- 2 pts
- Fetal Breathing- 2 pts
- Gross Fetal Movement- 2 pts
- Fetal tone(fine movement-limbs/hands/suck)- 2 pts
- Amniotic Fluid Index- 2 pts
Results of 8-10 are normal
Results of 6 pts will need careful monitoring
Results under 4- delivery is considered

Contraction Stress Test

Contractions are stimulated to add stress to the baby.
FHR is evaluated under stress of contractions
Negative: no deceleration w/contractions. Good
Positive: deceleration with contractions. sign of fetal compromise

Chorionic Villus Sampling

Done early in pregnancy, wk 8-10
Ultrasound guides speculum through cervix to grab piece of chorion.
Chorion is side of placenta attached to uterine wall
Used for genetic testing
Risks- loss of pregnancy, bleeding, cramping

Amniocentesis

Early in pregnancy to check for chromosomal abnormality.
Large needle inserted through abdomen, into amniotic sac
Risks- preterm labor, loss of pregnancy, ROM.

Ultrasound

Date pregnancy early on
Not definitive but can show congenital heart defects, neural tube defects

Percutaneous umbilical blood sampling - Aka PUBS.

Ultrasound on abdomen, needle in abdomen, access umbilical vessels to draw out blood.
Test baby for issues w/ blood. Blood transfusion for fetus.
Not done very often.

Triple or quad screens-

looks for markers for defects
High false positives
Based on gestational age
Screening tool, If you get a positive, you have to go back for more testing.

Cell-free fetal DNA

Draws maternal blood and can detract fetal blood from that to see any fetal defects
Looking at plasma, not RNA

Fetal nuchal translucency: ultrasound to look at the thickness of the nuchal ridge.

Large ridge associated with certain fetal anomalies.

Signs of Labor (1)

kgero — 2020-04-27 17:57:08 UTC

Ruptured membranes- generally does not break unless woman is in active or transitional labor
Increase in Braxton Hicks contractions- start at fundus- pts say “feels like baby is balling up”
Increased vaginal mucous secretions
passing mucus plug (its a barrier that plugs the cervix)- First time moms- can happen up to 2 weeks before labor.
Cervical ripens/thins/softens/more pliable so when contractions start, it can open up.
Lightening/Dropping- Lightens the load. Mom might have easier breathing.
Energy Burst- nesting

Pain Medications (1)

kgero — 2020-04-27 17:57:18 UTC

When to use:

Active phase

Contraindications:

Meperidine: takes a while to clear, baby will get some of this bc it crosses placenta barrier. Don’t want to give it close to delivery.

Nubain: synthetic narcotic. Can have an agonist antagonist effect = works like an opioid. Can’t give to someone on opioids bc it will reverse the effect and they will go into withdrawals

Butorphanol: Synthetic narcotic, works a agonist/antagonist. Can’t give to someone on opiods for the same reason as Nubain. A problem w/ this med is you can see fetal HR changes

Epidural(2)

kgero — 2020-04-27 17:57:51 UTC

An injection of an anesthetic drug into the space between the wall of the spinal canal and the covering of the span cord.
Regional anesthetic.

Nursing Care/Assessment:

During epidural- pt needs to have pulse ox and B/P cuff on her. The reason for the pulse ox- tachycardia is a sign the medication has been taken up in the vascular system
Nursing Considerations (#1 side effect of epidural- lower extremity vasodilation distal to injection site. leads to pooling of blood and lowering B/P.
- B/P checks -need continuing blood pressures while the epidural is working. Every 2-3 mins for the first 15 mins and every 15 mins until baby is born.
- FHR monitoring- If Mom’s BP drops, you’ll see it in FHR bc placenta perfusion will be affected.
- Positioning Other side effects: nausea, lightheaded/dizzy. Get mom in lateral position or at least tilted. After epidural NEVER lay mom on back. Epidural meds work w/ gravity so we don’t want her tipped to one side right away.
- Safety- side rails up so she doesn’t fall
- Bladder distention
- Pruritus- happens when they add a narcotic to the epidural (usually fentanyl)
- Effective Labor- if given too early, can slow it down. Give during active labor- should be good.

Fetal Heart Rate(2)

kgero — 2020-04-27 17:58:16 UTC

Types of Deceleration: what do do as a nurse and what causes them?

Early: caused bye fetal head compression. No indication of distress and do not require intervention.

Late: caused by uterine placental insufficiency- this is the one that is most concerning bc that means baby isn't being perfused adequately.

Intervention:

Discontinue oxytocin
Position change- Left side
IV fluids- bolus
Oxygen 8-10L/min via nonrebreather face mask
Prepare for surgical birth if pattern isn't corrected w/in 30 mins

Variable: caused by cord compression. Usually transient and correctable

Intervention:

Position change to relieve pressure from cord.
Give IV fluids to increase pressure so blood is getting to placenta.
Give O2 if they are persistent variables.

Stages/Phases of Labor(3)

kgero — 2020-04-27 17:59:51 UTC

Know when they occur, nursing care, and maternal response

Stage 1
Stage 2
Stage 3
Stage 4

Early labor: takes the longest, especially for first time moms. Can take up to 8-10 hrs. Moms are feeling good. Early labor is a good one for moms to do at home. We want her to walk around, shower, rest, if she has broken her water, she needs to come in. Want to get a monitor on her to check out baby. Unless there is a problem, mom doesn’t need to be hooked up on monitors all the time. She can get up and move around.

Active phase: Contractions are coming about every 3-5 mins, mom is getting more focused. Encourage breathing techniques/relaxation. Check fetal heart tones about every 30 mins. Listen to baby’s HR through an entire contraction cycle to make sure they’re tolerating them okay. This is a time when pt come into hosp to be admitted. Good time to get pain meds.

Transition labor: Mom is starting to lose her confidence. Contractions are coming about every 2 mins. Rise to peak quickly, stay at their peak and then drop. Only has about a min before it starts again. Fastest phase in the First stage. This is when mom’s often say “I can’t do it anymore” If pt wanted a non medicated birth and she is close to delivery, we prob don’t want to do a lot of pain meds Can get out of bed. Can use labor/peanut ball. Position changes. Massage/heat for lower back. Transition phase- mom may say mean things to family. This is normal. Help family through. Caution w/ IV meds when close to delivery, passes through to baby and can make baby sleepy.

Second stage labor: 10 cm to delivery. Pt will start pushing when 10 cm and has urge to push. Don’t leave room if mom is pushing. Fetal heart tones every 5 to 10 mins if not on monitor. We do not want mom to do “Closed glottis pushing”- pushing without grunting/exhaling. We want that exhale while pushing = most effective. Open glottis = increased perfusion to baby. Can last a few minutes to a few hours

Third stage of labor: Delivery of baby to delivery of placenta.

Fourth stage: Recovery. 1-4 hrs after delivery.

Leopold Maneuver(1)

kgero — 2020-04-27 18:00:42 UTC

What does it tell you?

Tells us the reference point of fetal presenting part to maternal pelvis and if baby is engaged.
Tells us presentation, position and lie of the fetus

When?

First stage of labor? Honestly not sure. Couldn't find an answer.
One of the main times she mentioned this in class was for placing the fetal heart rate monitor

Oxytocin (1)

kgero — 2020-04-27 18:01:15 UTC

Proper administration:

IV titrated, second bag. On infusion pump. Inserted into most proximal access site on her IV.

Nursing care:

How is Oxytocin dosing (titration) accomplished?

Start lowest dose possible, every 15-30 minutes assess contraction pattern and increase dose, goal is to get mom to level of oxytocin where she will have three good contractions w/ in a 10min period. Once you’re there, keep that level.

Special Precautions with Oxytocin Administration in Labor

Prolonged or excessive administration can lead to water intoxication
Only given titrated IV drip, never IV push. Never give Pitocin via IM route when patient is still pregnant. (This is done for postpartum bleeding)

Goal?

Hormone used to induce or augment labor. Used w/ hypotonic contractions. Also used post-delivery to prevent mother from heavy bleeding

Induction of Labor(1)

kgero — 2020-04-27 18:02:18 UTC

Types of Inductions
Bishops Score:
Lower the Bishop score, the higher chance the mother will need cervical ripening before starting true induction procedures (oxytocin)

High Bishop score= cervix is ripe.

Cervical Ripening
Cervical ripening alternative to medication:

Mechanical:

Foley bulb- goes inside the os into the uterus, balloon inflated w/ sterile saline, pull on it slightly to create tension and tape it down. Creates added pressure.
Hygroscopic dilators- laminaria. Put into the cervical os. The fluid in the vagina and uterus inflates it and it helps to dilate the cervix.

Facilitate contractions:

Amniotomy- rupture the amniotic sac. Irritates uterus and causes mother to go in labor.

Stripping membranes- strip membranes away from the cervix. Causes uterus to be irritated and contract.

Postpartum Nursing Care(3)

kgero — 2020-04-27 18:04:13 UTC

Involution= Body’s return to pre-pregnancy state (6 weeks)
Bonding= Initial family infant attachment process
Lochia= Vaginal bleeding after childbirth
Fundus= Top portion of uterus
Dyspareunia= Painful intercourse
BUBBLE= Focused PP assessment (Breast Uterus Bowel Bladder Lower Extremities)

Postpartum Terms to Know: Match these:

Afterpains= Pain of contracting uterus after delivery
Colostrum= First fluid in breast
Puerperal Infection= Infection during the first six weeks postpartum
Subinvolution= Delay of uterus to non-pregnant state
Puerperium= First 6 weeks after delivery
Catabolism= Process of converting living cells to simpler components
Atony= Lack of muscle tone

Rubella

Given to rubella non-immune mothers
Route SC
Live, attenuated virus
Client should avoid pregnancy w/in 28 days of vaccination.
Crosses placenta. We give it at the hospital after baby bc we know she is not pregnant

Anemia

Maternal role adaptation: Rubin’s 3 Puerperal Phases

Taking-In

Mother focuses on bodily needs
Focused on L and D experience
Integrating birth experience into reality
Passive behaviors exhibited
Taking everything in but allowing others to care for her and the baby

Taking-Hold

Takes responsibility for care
Focuses more on the baby
Voices anxiety over ability to mother
Mother is anxious to learn
Nurses need to allow parents to assume care!
GREAT PHASE FOR TEACHING

Letting-Go

First time parents accept role transition
Give up idealized expectations of both delivery and baby.
- Gender disappointment
- Something wrong with baby
- Birth plan didn't go the way they wanted

Post Operative Nursing Care(1)

kgero — 2020-04-27 18:04:48 UTC

NOT SURE WHAT TO PUT HERE. POST OP CSECTION??

Rhogam (1)

kgero — 2020-04-27 18:04:58 UTC

What mothers should receive this?
When?

Given prenatal at 28 weeks, within 72 hrs of delivery.
Can give IM or IV.
Given postpartum to moms who are Rh negative only if the baby is Rh positive

Maternal Assessment (5)

kgero — 2020-04-27 18:05:24 UTC

Know what is abnormal/normal and appropriate interventions

PP Reproductive System Changes

Uterus Involution process
Described as firm or boggy
Decreases 1 cm per day
Unable to palpate by 10-14 days PP because it should have decreased and dropped back into the pelvis
as the bladder fills, it pushes the uterus up to the right or left, displacement of the fundus relaxes the muscle and leads to bleeding

Lochia Assessment

Lochia: Amount of blood noted on the peri-pad in 1 hour time frame

Scoggin estimated method:

Scant - 2.5 cm (1 in)
Light - 2.5-10 cm (1-4 in)
Mod - 10-15 cm (4-6 in)
Large: sat in 1 hour

Excessive bleeding

In the 4th stage it is defined as saturating pad in 15 minutes

After recovery period it is defined as saturating pad in one hour

What is the most accurate way to measure blood loss?

Weight

1g=1mL

Lochia - Color
Lochia rubra

Bright to dark red, may have dicidua tissue present, small clots
less than 1 cm. Present for 3 days PP

Lochia serosa

pink serous exudate and cells. Present in light to scant amt of
days -4-11. Mom should not get to this stage and then return to rubra. this would be sign of sub-involution.

Lochia alba

light yellow discharge, cells, and mucus Present for 3-6 weeks PP
Normal Lochia odor: earthy
Menstrual flow odor. earthy
Foul odor may indicate infection or ineffective, perineal care.

Lochia flow –
May be influenced by:

Breastfeeding- when the baby latch-oxytocin-contraction-pushes out blood
Full bladder
Maternal activity- moms should rest when they get home, overdo it
Other uterine factors- tumors, uterine fibroids, shapes, infection
Uterine stretching during pregnancy

Cervix:

Resumes round form immediately but is “floppy”
Initial appearance is edematous and purple
Slit like appearance to os
If lacerations are present, see as excessive vaginal bleeding with firm fundus
cervix has no muslces to help stop bleeding
By one week PP the cervix has regained tone

Vagina

Vaginal walls edematous
Initially rugae absent, regain by 3 weeks but it may take a full 6 weeks to involute.
Never again the same nulliparous size.
Dyspareunia may be present due to injury to vaginal wall, decrease in estrogen

Perineum –

part between bottom of vagina and where the anus is
can be torn and need an episiotomy
even if not torn, it does stretch so can be very edematous
Assess for Hemorrhoids, REEDA

R Redness

E Edema

E Ecchymosis

D Drainage

A Approximation

PP Breast Changes –

In pregnancy breast development was regulated by estrogen and progesterone
When the placenta delivers, estrogen and progesterone quickly diminish. Colostrum is present
Prolactin is then released from anterior pituitary; needed for milk production
Oxytocin is released from posterior pituitary needed for Milk ejection reflex
Milk day 3-5
Engorgement- pathological
Avila- fill up

PP Vital Sign Changes

Temperature

Normal slight increase to 100.4 normal in first 24 hours
Due to dehydration(vascular) and PP leukocytosis
If temp is elevated longer than 24 hours PP or greater than 100.4, suspect infection

Pulse

Slight decrease in pulse
50-90 bpm due to increased blood to maternal central circulation leads to increased stroke volume
r/t uterus has dropped down inside, no placenta needing blood supply so now the extra blood has nowhere to go, so the mom's body system has to readjust
When might you see tachycardia? postpartum hemorrhage, pain

Blood pressure

should remain close to pre-delivery normal parameters
Increase means: pain, underlying hypertension
Decrease means bleeding
S/S Hypotension
Light headed/dizzy, nausea, feeling faint, tingling

Respiratory rate:
no change from norm

Pain –

Assess with other VS

Where would the pain be?

PP Cardio-vascular System Changes

Increase in blood plasma/volume (hypervolemia) is a protective mechanism against blood loss
Leukocytosis – up to 25,000 ,normal is 5-10k
Returns to normal in 4-7 day PP
PP H&H should decline over admission levels r/t dilution and blood loss
Return to pre-preg in 4-6 weeks PP
Increased volume leaves body through:
- Diuresis – urine output
- Diaphoresis- sweating

Coagulation Changes

Fibrinogen and other clotting factors increase with pregnancy and initial PP
good protective mechanism, but increases risk of DVT
Check homans sign- toes to their nose, dorsiflex their foot with pain in calf=DVT
Return to pre-preg Hemostasis 3-4 wks PP

PP GI System Changes

Vaginal delivery? Evacuate bowels during labor
C-Section delivery? risk for injury to bowel, anethseia slows bowel
Initially hypoactive decreased motility
Diet:healthy, protein, complex carbs, fruits/vegetables, lots of water
First BM is expected day 2-3
Hemorrhoids
- Varicose veins of rectum
- Goal of care: Prevent further damage and promote comfortable Elimination
- Do not push them back in
Help pts have BM w/ stool soft- bowel regimen with stool softner, increase fluid intake, dietary, creams to promote comfort

PP GU system changes

Bladder factors:

Increased capacity and output related to diuresis and IV fluids
Decreased tone
Use of urinary catheter
Trauman and edema
All of these factors can lead to over-distention of the bladder and urinary retention which can lead to: Risk for Infection and PP hemorrhage
increase in leukocyte esterase and nitrates
The GU system is part of the Focused Assessment!
How much time does a client have to void until intervention may be necessary?
6 hours, or csection 6 hours from catheter removal
Educate:
Pelvic floor exercises – Kegels

PP Joints/Muscle Changes/Assessment

Relaxin decreases within a few days PP
Aches and Pain
- Back pain- epidural
- hip- positioning
- muscle pain
Diastasis Recti - Separation of the rectus abdominis muscle
PP Abdominal Exercises and Support
- splint pillow with c section
- 6 weeks start exercise
- support bands

PP Lower Extremity Assessment

Edema
Peripheral pulses
Skin temp
Calf pain – Homan’s sign
Reflexes/Clonus

PP Lower Extremity Changes

Varicose Veins

PP Integumentary Changes and Assessment

Incisions
Access sites
Abrasions, small lacerations
Nipple damage when breast feeding

PP Neurological System Changes and Assessment

Post epidural or spinal assessment

PP Endocrine System Changes and Assessment

Begins with placenta delivering
Progesterone and Estrogen decreasing with prolactin and oxytocin incresing
Oxytocin and Prolactin increase mood
Ovulation/Menses resumes:
- Non breast feeding mom- 6-8 weeks
- Breastfeeding- can take up to a year or more
- ovulation always occurs before menses, so you ovulate 14 days before menstrual cycle so without cycle you dont know when youre ovualting and you could end up pregnant.

Contraception (1)

kgero — 2020-04-27 18:08:42 UTC

Natural Family Planning Pt Teaching

Natural Method - Rhythm method

Couple abstains from intercourse 3 days before and after days after ovulation
May use basal body temperature chart to pinpoint time of ovulation, body temp will drop when ovulating
Ovulation kits also available
can monitor Spandeccken mucus

Comfort Measures (1)

kgero — 2020-04-27 18:12:59 UTC

Ice vs Heat
Dermablast
How to make mom comfortable following birth
KAREN- Do you have more notes for her? this is all i have

Non-medication Intervention for Pain

Ice pads – when? first 24 hours
Sitz bath – when? after 24 hours
Position changes
Adequate peri care
Comfortable, calm, environment

PP Pain Medications

Topical
- Witch Hazel, “Caine Sprays”
PO
- NSAIDS, Acetaminophen, Narcotic
Parenteral
- IM/IV- Ketorolac (Toradol, can damage kidneys), Narcotic
PCA
- Epidural/Spinal meds
- Morphine, preservative free

Breastfeeding (1)

kgero — 2020-04-27 18:15:20 UTC

Advantages vs Disadvantages

Maternal physiological response during feeding

Breastfeeding Assessment

visualizing a breastfeeding event

Breast feeding Support

Encourage first feed during 4 stage of labor
Encourage frequent feeding
Encourage rooming-in
Give encouragement
Give accurate and consistent information
Help with positioning at the breast

Nursing considerations for PP breast assessment

Engorgement- swollen/edematous
- Give ibuprofen and breastfeed!
Nipple damage or breakdown- use lanolin or breast milk
Previous breast surgery
Hypertrophy or underdevelopment of the breast tissue
Flat/inverted nipples
Clogged ducts
Mastitis

Breast care (1)

kgero — 2020-04-27 18:16:11 UTC

Breastfeeding:

Nipple damage or breakdown- use lanolin or breast milk

Formula- how to comfortably dry up supply:

Wear a tight supportive bra 24 hrs a day. Apply ice to breasts for approx 15-20 mins every other hour. Avoid stimulation (squeezing). Avoid hot showers. Takes about 2-3 days for engorgement to subside.

TOLAC/VBAC(1)

kgero — 2020-04-27 18:24:55 UTC

Uterine rupture risk:

Risks for Uterine Rupture:
- Previous uterine surgery
- Abdominal trauma
- Over distention uterus
- Hypertonic uterus
- Use of contraction stimulating drugs
- Multiparity

How does nurse manage/prevent this?

Never give a med that would cause uterus to be hypertonic or tachysystolic.
Want to monitor for increased pain, fetal distress (dropped HR), change mom’s position, give IV fluids, give O2, check cervix (presenting part may not be there anymore)- it will have moved up and through the uterus. Emergent situation. You have minutes to get baby out.

ROM (1)

kgero — 2020-04-27 18:26:23 UTC

Nursing Assessment

Physical findings and assessments- how do we tell if its amniotic fluid?

Pooling- mother is laid down. Look for pooling of fluid in vaginal canal
Damp perineum
Just a FYI- amniotic fluid has a particular odor
Fern test- look at it under a microscope- looks like a fern
Nitrazine- pH checker- amniotic fluid is alkaline so it will turn bright blue. Not definitive but suggestive. Some women can have alkaline urine.
Amnisure- very definitive to amniotic fluid. Qtip in vagina, twirl for 1 full minute. Put in reagent, twirl for another full minute. Send to lab or do the test yourself. Positive = membranes have ruptured.

Risks:

Infection

Placental Disorders(2)

kgero — 2020-04-27 18:29:16 UTC

Placenta Previa

Placental implantation in lower uterine segment over or near the cervical os
Normal attachment is close to fundal level of the uterus. If it implants low, can cover up the os.

Risks and Why

Previous uterine scar- embryo doesn’t implant into scar tissue well so if there is a scar in the upper uterus, can cause implantation to occur lower.
Multi-parity
Multi-gestation (multiple babies
AMA (advanced maternal age)
Short interval pregnancies (had a baby and got pregnant right away- less than 2-3 years between pregnancies)

Classic symptom – Painless vaginal bleeding – why?

Placenta is right on top of cervix. Cervix is super vascular. If cervix is disturbed at all, can pull at placenta and can bleed. Placenta doesn’t hurt though so you won’t feel pain.

Management

Conservative if preterm and there is minimal to no bleeding
If active bleeding, mom needs to be in hospital.

Placental Abruption:

Premature separation of the placenta from the uterine wall before delivery of the infant Placenta should separate after but if it does before, can be a problem.

Risk Factors
- Multiple Gestations- more placentas
- Multiparity- if mom has had babies before = faster transitional labor
- Polyhydramnios- over expansion of uterus= tension and pressure inside uterus
- Diabetes- vascular issues.
- HTN- vasoconstriction of vessels, increased pressure placenta can pull away
- Pre/Eclampsia
- Cocaine abuse- bc of vasoconstriction
- Uterine hyper-stimulation- tachysystole bc uterus is contracting so much it pushes the placenta right off the uterine wall.

Symptoms

Classic –PAINFUL vaginal bleeding
Board like abdomen
No relaxation of abdomen between frequent uterine ctx- when assessing pt who is contracting, put your hand on their belly- should relax and tense up.
Hypertonic Uterus (Tachysystole)
Fetal distress possible

PP Affective Disorders(1)

kgero — 2020-04-27 18:36:56 UTC

Postpartum Affective Disorders:

due to plummeting levels of estrogen and progesterone immediately after birth increase the chance of developing a mood disorder
Types:
- Baby blues
- PPD (postpartum depression)
- Postpartum Psychosis

Baby Blues

Normal – affects 60-80% of PP women
Feeling of being “let-down” or overwhelmed
Begins 2-3 days PP and can last 2 weeks
Self-limiting
Can get worse with every pregnancy

Postpartum Depression (PPD)

Affects 12-15% of new mother’s
Cause unknown
Diagnosis is made if feelings of depression persist past 2 weeks PP. Can occur and last up to 1-year PP
Risk:
- Hormone changes, Hx of depression, Low self esteem, Chronic stressors
- High risk for impaired maternal infant bonding
Characteristics a person with PPD might exhibit
- Fatigue
- Sense of worthlessness
- Shame, Guilt
- Obsessive thoughts
- Panic attacks
- Thoughts of suicide
Treatment for PPD
- Early intervention = better outcomes
- Treatment is based on severity of symptoms
- Treatment mirrors treatment for psychiatric depression disorders
  - Psychotherapy
  - Support
  - Antidepressants, Anti-anxiety meds – should continue in the postpartum period
  - Electroconvulsive therapy (ECT)
Nurse’s role in PP mood disorders
- Screening tools – PP specific tools or MSE
- Who should be screened?
  - everyone
- Provide a supportive environment
- Ensure safety of mother and baby

PP Psychosis

Effects 1% of PP women
Can occur immediate PP and is usually seen within 3 months after delivery
Risk factors:
- History bipolar disorder
- Other psychiatric disorders
PP Psychosis is a medical emergency and immediate treatment is necessary before the mother hurts herself or the baby
Symptoms of PP psychosis
- Poor judgment
- Manic Activity
- Confusion
- Delusions
- Persecution complex
- Severe depression
- Hallucinations
Treatment for PP Psychosis
- In-patient treatment if immediate danger is present
- Treatment mirrors treatment for psychiatric psychotic disorders
- Psychotherapy
- Medications may include:
  - Antidepressants, Antipsychotic, Lithium

Attachment Disorder

Occurs when a child does not develop a meaningful attachment to a primary care giver.
The child may exhibit a number of social, chronic health, and emotional problems, and learning disabilities.

Hypertensive(7)

kgero — 2020-04-27 18:38:02 UTC

Types of Hypertensive Disorders:

Chronic-

Development of hypertension that is present in a pregnant woman before 20 weeks gestation.

Gestational

Hypertension noted AFTER 20 weeks gestation but no other signs (ex protein in urine)

Pre-eclampsia

Past 20 weeks hypertension AND proteinuria. (THIS IS THE DEFINITION OF PRE-ECLAMPSIA)
Severe features of pre-eclampsia: headache, blurred vision, epigastric pain, generalized edema.

Eclampsia

Hypertension is accompanied by grand mal seizure. We want to avoid this.

HELLP

Hemolysis
Elevated Liver enzymes
Low Platelets.

Has to do w/ liver disorder. 50% of people w/ HELLP have severe preeclampsia. You can have HELLP w/out having preeclampsia though.

Nursing Assessment

Maternal well being:

Pt w/ preeclampsia may be in a fluid volume deficit state bc vascular system has allowed fluid to go outside of vascular bed and is instead in the third space.

BP- elevated BP has to do w/ vasospasms, not fluid overload.

Weight- her fluid is sitting in interstitial space so she is gaining weight.

Edema- generalized, need to be turning pt over, assess edema everywhere. Can be accompanying factor but is NOT a dx factor.

Reflexes- will be hyperreflexive bc of central nervous involvement. We need to be assessing patients about this all the time so we have a baseline. We need to have something to compare to if the patient does become preeclamptic, we will know. Also checking clonus

Headache- Central nervous side effect. Persistent HA that won’t go away

Epigastric pain- assoc w/ edema around liver capsule and pain w/ in the liver

Visual changes- assoc w/ central nervous system

Assessing Reflexes and Clonus

Patella reflex- hold leg up so its resting. Bop under patella.
Clonus- dorsiflex foot and pull hand away. If pt’s foot falls back immediately and is still= good. If you take your hand away and it wiggles = clonus. If you bring the foot up to dorsiflex and it wiggles continuously- could be a sign they are close to seizing. Don’t keep checking clonus. Tone down the environment to make it less likely she will be overstimulated and seize. Decrease risk of seizure.

Therapeutic Management- Varies depending severity of disease

Activity – Limited to bedrest.
Fetal Surveillance
Maternal medications
- Anti-hypertensive medications
- Anticonvulsant – Magnesium Sulfate (also lowers BP but it is NOT given as antihypertensive med)

S/S
Nursing Assessment
Treatments

Magnesium Sulfate

Always start this one first before antihypertensive- it will lower BP
not used for preterm labor but is given to pts in preterm labor for neuroprotection of fetus
Titrated through an IV. Needs to be run as a secondary IV. Need another line going into the same site.
Pt will be on seizure precautions
Can become toxic
Will need catheter
Hourly I&Os

Safety

Diabetes (4)

kgero — 2020-04-27 18:38:42 UTC

Screening Tests:

Test one: Glucose Challenge Test (GCT) - Also known as the Glucola

Just a screening test
Preformed between 24 and 28 weeks
Does not require fasting, doesn’t need to be at a certain time of day
Pt is given 75 gm of CHO (high carbohydrates), waits an hour
Normal results- 140mg/dl or less
Abnormal results lead to diagnostic test
3 hour GTT or 2 hour GTT
- Two abnormal values on that test diagnoses gestational diabetes

Patient Teaching
Gestational Diabetes:

Diabetes that develops during the second half of pregnancy, after 20 weeks gestation.

Pre-Gestational Diabetes

Diabetes is present before 20 weeks, or the client has a diagnosis prior to pregnancy

Nursing Assessment:

Fetal Assessment

Ultrasound eval at 16-18 weeks (called morphology scan- looks for abnormalities in growing fetus) Most preg women have this one. This would be specific to pregestational diabetic moms bc gestational diabetes isn’t dx until after 20 weeks. Usually between 24-28weeks)

Maternal serum AFP (alpha fetal protein)- indicator of fetal malformation specifically neural tube defects. Drawn around 16 weeks. More indicative for pregestational diabetic.

Fetal echocardiogram at 20 wks - pregestational. Maternal diabetes is assoc with fetal cardiac anomalies.

Weekly non stress test (NST) after 28 weeks- pregestational diabetics. Gest. diabetics will start weekly around 32-34 weeks bc diabetes can affect vascular system in the placenta. Will give a good idea how the baby is doing.

Twice weekly NST after 34 weeks

Use kick counts for home monitoring

Can use BPP (ultrasound study for fetal well being) in third trimester

U/S in third trimester for estimated fetal weight and AFI (amniotic fluid index)

Risks r/t pregnancy, labor, postpartum

Hypertension,
Polyhydramnios
Preterm labor/PROM
Hypoglycemia (one of the biggest risk factors)
Increased risk of infections – UTI, Yeast
Difficult birth (bc baby grows so big)
Increased risk of developing type 2 diabetes later
Malformation in pre-gestational diabetes
Macrosomia
Fetal mal-presentation- baby is too big to fit down into pelvis
Birth trauma- ex shoulder dystocia, bruising
Hypoglycemia
Preterm birth
IUGR
RDS (resp distress syndrome)- can occur bc mom’s blood glucose is high so baby’s is. Delays surfactant development in fetus. They don’t have as much surfactant so they have problems.
Risk for Perinatal death

PP Hemorrhage

kgero — 2020-04-27 18:40:18 UTC

Normal blood loss following delivery is 500ml and following csection 1000ml
Risks

Maternal Issues
- History of PP hemorrhage
- Clotting disorders (idiopathic thrombocytopenia, HELLP syndrome- has low platelets)
Chorioamnionitis
Placenta issues
- Previa
- Accreta
- Retained
Medications
- Oxytocin (when its been used for a long time)
- General anesthesia
- Magnesium sulfate (relaxes uterine muscle)
Birth Trauma
- Forceps/Vacuum extractor (cervical lacerations and vaginal wall tears)
Precipitate or prolonged labor
Over-distended uterus
- Polyhydramnios
- Macrosomia
- Multiple gestations

Major causes of early ( first 24 hours) PP Hemorrhage

Uterine Atony/boggy uterus = will see increased lochia flow
Birth trauma
Clotting disorders and surgical complications

What to do about uterine atony:

#1 Fundal Massage
#2 Assess bladder- may need a foley
Care provider intervention = may put hand inside and see if there are any placenta fragments, may include bimanual compression

LABS for PPH
Decrease

H&H (make sure you have predelivery labs available for comparison)
Platelets
Fibrinogen

Increase

FSP/FDP (Fibrin Split Products and Fibrin Degradation Products) These are associated with DIC
D-Dimer
APTT/PTT

Medications for PPH
Oxytocin(Pitocin)

Route: IM, IV drip
Rapid IV with hemorrhage
Dose:10-40 units in 1000ml IV fluid Increased use increases risk of atony if overused
H20 intoxication

Carboprost(Hemabate)

Route: IM, Dose: 250mcg
Diarrhea, N&V, fever, H/A
Contraindicated for pts w/ asthma

Methyl- ergonovine(Methergine) |

Route:PO, IM, IV
Dose: IM, IV - 0.2 mg
PO - 0.2mg
Vasoconstrictor: Contraindicated/Caution for pts w/ hypertension
Check BP prior to giving it- for all pts, no matter if hx of hypertension
H/A, Cramping

Misoprostol(Cytotec)

PO (buccal mucosa)
PR (per rectum)
Not vaginally with PP hem. (will come right back out) 200-1000mcg*****Wants us to notice the difference between dosage for this vs for induction of labor (25-50mcgs)MAKE SURE YOU HAVE THE RIGHT DOSE WHEN YOU’RE GRABBING THIS MED
Nausea, cramping, H/A

Intimate Partner Violence(1)

kgero — 2020-04-27 18:52:01 UTC

(physical, emotional,financial, sexual)

What does IPV look like?

Yelling
Screaming
Isolation
Putting trackers on their phone
Silencing
Physical, sexual, financial

Why is pregnancy such a high time of risk for IPV?

Vulnerable time in woman’s life
Stressful time
Financial burden
Violence in family of origin
Lack of father role model
Resentment towards the growing fetus
- Questions of paternity
- Baby will be a competitor

Outcomes of IPV in pregnancy:

Miscarriage or stillbirth
Premature labor & birth
Inadequate prenatal care
STIs
Substance abuse
Maternal or fetal injury or death

Assessment:

Missing appointments
Mental health issues
- Anxiety
- Depression
Injury
STI’s or PID
Hovering partner

Interventions:

Isolate client if possible -- Have a direct/indirect (open- ended questions)

Example: get her alone in the bathroom and ask questions like:

Do you feel safe at home?
Is there anything you want to tell me?
Provide resources
- Hotlines for domestic violence
- Availability
- Put contact numbers in their pockets/bottom of their shoes

Women's Health Issues(3)

kgero — 2020-04-27 18:52:13 UTC

Polyps

Non cancerous tissue growth
Clinical manifestations
- Often asymptomatic
- Menorrhagia -- Abnormal bleeding originating from the uterus
Treatments- Removal of polyps, can be an in house treatment unless there are many. Will be sent for biopsy to rule out malignancy.
Risks for Polyps
- Cancer
- Blood loss

Fibroids

Composed of smooth muscle and fibrous tissue. Can also be called Myomas or Leiomyomas.
Clinical manifestations
- Pelvic and back pain
- Bloating
- Infertility
- Risk of miscarriage
- Dysmenorrhea/Metrorrhagia and Menorrhagia
- Anemia
Complications
- Risk for miscarriage and premature birth
- Fibroids continue to grow during pregnancy, which could lead to preterm labor
- Dysmenorrhea
- Menorrhagia
- Anemia

Treatment

Hormones therapy
- Advantages: non-invasive, helps provide relief for fibroid symptoms such as heavy bleeding and pain, helps with conditions such as hot flashes, night sweats, vaginal dryness
- Disadvantages: should not use for longer than 6 months, does not allow ovulation to occur, risk for osteopenia/osteoporosis
Uterine artery embolization
- Advantages: minimally invasive
- Disadvantages: can affect fertility, abdominal pain, uncomfortable procedure
Myomectomy-
- Advantages: maintains fertility
- Disadvantages: risk factors associated with abdominal surgery (blood loss, infection, pain, and longer recovery)can cause scarring and result in uterine rupture or placenta previa
Laser surgery
- Advantages: minimally invasive
- Disadvantages: can cause tissue scarring, which could cause fertility issues
Hysterectomy
- Advantages: no new uterine fibroid growths, eases abnormal bleeding, prevents possibility of future uterine cancer. CURES
- Disadvantages: it is permanent, may need to take hormone replacements. You don’t maintain fertility. Cultural considerations of taking away a woman's uterus.

Menstrual Cycle

Menarche (Onset of menstruation)- When does it start?
Between 12-13 years old
Range from 8 to 18 years old- need to investigate if not occurred by 16
Menstrual bleeding average of 3 to 7 days
Women have between 400-500 menstrual cycles in their reproductive years
Average age of cessation of menstruation, 50 years of age

28 Day Cycle

2 Phases of menstruation, follicular phase and luteal phase
Day 1 of menstruation starts the follicular phase
Mature follicle ruptures when hormone levels rise, causing ovulation
the follicular stage is the stage that changes time
Ovulation takes place 14 days Before 1st first day of next cycle (menstruation)
Luteal phase begins at ovulation and corpus luteum releases hormone progesterone to prepare the uterus, endometrial lining, for a fertilized egg.
When fertilization does not occur, the shedding of the endometrium, lining of the uterus produces menstruation.

Perimenopause

Definition- Change in ovarian function, transition from a woman’s reproductive phase of life to final menstrual period.
Some women have symptoms, other women do not.
As menopause approaches, more and more menstrual cycles become anovulatory, usually 2-8 years before cessation of menstruation.
Body systems affected
Brain-hot flashes, disturbed sleep, mood and memory
Cardiovascular-lower HDL, increased risk for CVD.
Skeletal- rapid loss of bone density
Breasts-atrophy, fat replaces duct and glandular tissues
Genitourinary- vaginal dryness, sexual incontinence, cystitis
GI-less absorption of calcium from food, increased risk for fractures
Integumentary-dry, thin skin
Body-increased abdominal fat, waist swells relative to hip size

Causative factors

Ovaries begin to fail, estrogen (estradiol) drops by 90%, and estrone produced in fat cells becomes the body’s main source of estrogen.
Testosterone and progesterone levels drop

Therapy

Managed individually.
Metabolic changes increase risk for metabolic disease (HTN, increased blood sugar, abnormal cholesterol, excess body fat around waist, increased risk for heart disease, stroke, and diabetes)
Lifestyle changes
Hormone therapy
Diet
Exercise

Nursing Considerations

Education about changes to body
Lifestyle education, nutrition, exercise, smoking cessation, maintain healthy weight
Hormone replacement, risk versus benefits

Menopause

Definition-
- Cessation of menstruation, one year without menses.
- Average age 50-51
- Atrophy of breast, uterus, fallopian tubes, ovaries, vagina
- Vaginal spotting can occur after intercourse, dry, unlubricated vagina
  - Can lead to dyspareunia
- Bleeding after menopause should be reported to primary care provider, evaluated for disease process, infection, cancer
- Hormone replacement controversial
  - Synthetic versus bioidentical/human identical hormones
Estrogen hormone replacement: Pills, vaginal creams, transdermal patches
Relief of vaginal symptoms and prevention of osteoporosis
May be beneficial for preventing diabetes, improving mood, avoiding urinary tract problems

Endometriosis

One of the most common gynecological diseases
Functioning endometrial tissue is located outside the uterine cavity.
Endometrial tissue attaches to ovaries, fallopian tubes, outer surfaces of the uterus, area between vagina and rectum (rectovaginal septum), pelvic sidewall, and more.
Where tissue attaches is called implants or lesions.
The tissues respond to hormones released in the menstrual cycle and when menstruation bleeding begins, the implants bleed also.
“Mini-periods” throughout the abdomen, wherever the tissue exists.
Two common symptoms, infertility and pain
Painful and debilitating condition, but also can be asymptomatic
Chronic and progressive
Causative factors
- Family history of endometriosis in a first degree relative
- Shorter menstrual cycle (less than 28 days)
- Long menstrual flow (more than one week)
- High dietary fat consumption
- Young age at menarche, less than 12

Therapy

Pelvic exam -- nodular masses are found, sometimes is the only way for definitive diagnosis with surgery and biopsy
Surgical interventions
Removal of implants, cautery, reduces pain and allows pregnancy in the future. -- maintains fertility
Hysterectomy – does not maintain fertility

Medication therapy

NSAIDs -- first line of treatment to reduce pain
Oral contraceptive -- suppresses cyclic hormonal response of endometrial tissue
Progestogens -- cast off endometrial cells and destroy them
GnRH agonist -- Suppresses endometriosis and creating temporary pseudo-menopause

Nursing Considerations

Ask about pain, when? How often? Pain during/after intercourse, pain with urination, pain with bowel movements, chronic pelvic pain?
Ask about pregnancy, difficulties with conception.
Explain procedures, why tests are needed for diagnosis.
Healthy lifestyle habits
Support groups

Infertility(2)

kgero — 2020-04-27 18:55:18 UTC

Infertility occurs in approximately 15% of the childbearing population

Types of Infertility
- Primary infertility -- woman is unable to get pregnant after a year
- Secondary infertility -- infertility that occurs after a pregnancy
Causes – shared between the sexes
- Important concept -- both parents must be evaluated for causes of infertility
- Men are easier to evaluate -- less invasive
- 19-20% of causes are unknown
Evaluation: Male
- Past medical history -- high fevers as a child, mumps
- Pattern of intercourse -- too much, too little
- Semen analysis -- visualizing sperm under microscope
- Blood work -- testosterone levels
- Testicular biopsy
Evaluation: Female
- Ovulation Prediction Test -- commercially available test
- Blood work for hormone levels -- estrogen, progesterone, follicle stimulating hormone
- Hysterosalpingogram -- radiology test, checks patency of fallopian tubes
- Hysteroscopy -- visualizes interior of uterus
- Laparoscopy -- visualizes the inside of abdominal cavity
- Endometrial Biopsy
Treatment -- Focus is treating the underlying cause
- Ovulation Prediction -- checking for spanndecken mucus within vagina, basal body temperature
- Ovulation Induction -- clomid, speeds up maturation of eggs allowing ovulation to occur
  - Risk for ovarian hyperstimulation -- more eggs mature than needed
  - Engorged ovaries or multiple gestations
- Artificial Insemination: IUI
  - Sperm injected into the uterus
  - Used for sperm donation
- Assisted Reproductive Techniques
  - IVF – In Vitro Fertilization
    - Woman given ovulation stimulating drugs, eggs are harvested, mixed with semen, fertilization occurs, fertilized ovum are injected back into uterus to implant
  - GIFT – Gamete Intrafallopian Transfer
    - Fertilized gamete is placed into fallopian tube to transition down into the ovary
    - Not as common as IVF
  - ZIFT – Zygote Intrafallopian Transfer
  - ICSI - Intracytoplasmic Sperm Injection
    - Sperm is injected into egg to ensure fertilization
    - Done in case of male infertility or with genetic testing
- Surrogacy and Adoption
Nurse’s Role
- Assessments -- female and male reproductive assessment, cultural, spiritual, what is the couple willing to do for treatment of fertility
- Patient education -- regarding procedures, treatments, factors that contribute to infertility etc
- stress management and anxiety reduction, possibly a referral to a support group

STDs (3)

kgero — 2020-04-27 18:55:38 UTC

Know S/S, teaching, reporting

Spread and Control:

STIs are infections of the reproductive tract caused by microorganisms, transmitted by vaginal, anal or oral intercourse.

Risk Factors:

Adolescents at high risk.
Risk taking behavior
Obstacles to health care system
Inadequate knowledge of STIs
Insufficient screening
- Screening should occur when they become sexually active and when there is a change in partners
Confidentiality concerns
- Don't want to disclose their sexual behavior with provider due to feeling ashamed or they don’t trust confidentiality
Biology
- Young women are more susceptible to STDs than older women
- Epithelial cells are more susceptible to penetration by gonorrhea and chlamydia
Lack of access to health care
Lack of insurance or they are on their parents plan
Multiple sex partners
Multiple or new partners
Risk of exposure
Illicit drug use, alcohol use
Trading sex for money or drugs
Age less than 25
Not in a stable relationship with one person
Experimenting
Unprotected sex
Abstinence is not protective due to resorting to anal or oral sex
Not using condoms (best protection)
- Inappropriate use of condoms
- Wrong size
- Slippage/breakage

Specific Infections:

Yeast – Candida albicans (fungus)

Yeast is normal flora in the vaginal canal
When pH gets off balance the environment becomes more alkaline and yeast proliferates
Antibiotics can also cause it
Show up in 10-14 days if related to antibiotic treatment
White cottage cheese discharge in the vaginal area that comes out onto the vulva
Itchy, burn, odor of yeast
Tx: antifungal
- Miconazole-Cream or suppository inserted in the vagina.Over the counter
- Fluconazole (Diflucan)-Pill one time

Bacterial Vaginosis - (BV), causative agent Gardnerella vaginalis

Clue cells
Sniff test -- stale fishy odor from discharge
Tx: Metronidazole
Trichomoniasis (protozoan)
Classified as not an STD because you can get it from a toilet seat or damp bathing suit someone else has worn
Mostly seen with sexual activity
Protozoa
Partner needs to be treated as well

Human Papilloma Virus (HPV) (cannot be cured)

Causes – Condyloma/Genital Warts –
Caused by HPV
However only a few types of HPV cause condyloma
Most types of HPV are asymptomatic
Cancer can occur from HPV
- This does not cause warts
Preventable (vaccine)
- Not against all HPV)

Herpes Simplex Virus (HSV Type II)

Causes very painful blisters, very raw area
Virus then goes back into the body and lies dormant up against the nerve cells
Pts don’t complain normally but it is very painful
Females may have the lesions up in their vagina and cannot see them
Highly infectious
If they have an active lesion when they are term pregnant or in labor, they have to have a C-section
The babies can pick up this infection and it becomes systemic and cause mortality
Caused by
Transmitted through – Sporadic outbreaks
Not curable but focus on treating the symptoms
Diagnosis made on symptoms and culture of the open lesion
Treatment with antiviral medications

Human Immunodeficiency Virus(HIV) and Hepatitis (Hep B)

Considered STD
Can get from other sources
Drug use
Contaminated blood and body fluids

Pubic Lice – Pediculosis

Like head lice, but different
Not necessary STD
Can pick up from close contact
- Bed sheets, Bathing suit sharing, Wet towels
Don’t always see
Itching, lay eggs on hair shaft
Treated like head lice
Anti Louse medication
Need to be careful in mucus membrane area
Can shave hair to help but still need medication
Need to treat the environment

Zika Virus

Transmitted through aedes species mosquito
Can also be transmitted through sexual contact and blood transfusions
Virus is linked to development issues with fetus – microcephaly
80% of people have no symptoms
Usually get symptoms around 2-7 days
Don’t feel good, Fever, Rash, Pain in joints
Common in the Caribbean and Africa
Avoid pregnancy during infectious period

Pelvic Inflammatory Disease - PID

Inflammation of pelvis usually caused by infectious agent
Risk factors:
- Multiple partners, STD, IUD, recent childbirth or pelvic surgery
Cause:
- Bacteria go up into the uterus and if they can get a pathway into the fallopian tube and come out of the ovary and drop into the peritoneum and cause pelvic infection
- Infection and inflammation lead to scarring which leads to infertility
S&S
- Fever, severe pelvic pain, N&V, peritonitis
- May wall off and create abscesses
Treatment
- Antibiotics, surgery only if necessary (if abscess)
- Pain control

Syphilis

Bacterial infection- spirochete
Bores down into the tissue
Mucus membranes are very susceptible
Treatment: antibiotics (can be cured)
- Penicillin
Has 4 phases

Primary

- Chancre appears within first week of intercourse
- Will disappear in 1-6 weeks after intercourse
- Infectious stage
- When the open sore is weeping or has a little discharge DO NOT HAVE SEX

Secondary

- No longer infectious
- Appears 2-6 months after initial infection
- If patient has not been treated yet it is hard to trace it back to syphilis b/c the complaints are very general
- Feel like they have the flu
- Little malaise
- Fever, chills
- Upset stomach
- Rash palmar or plantar of the hands or the feet (typical)
- Lasts up to 2 years

Early and late latent

- Can last up to 20 years
- Patient feels better
- Not infectious
- May or may not progress to tertiary stage

Tertiary

- Now affected the body systems
- Heart, bones, liver and brain
- Can be terminal

Gonorrhea

Women tend to be asymptomatic
Men have worse symptoms
Bacterial/Neisseria gonorrhoeae
If not treated can lead to PID
Diagnosed with genital culture
Reportable
- When a test comes back positive, the lab needs to notify the health department and provider
Treatment
- Dual therapy
- Ceftriaxone IM (one time) + azithromycin PO (one time) or doxycycline PO (7 days)
Babies born to mom with gonorrhea are at risk for conjunctivitis
- All babies are treated with erythromycin ophthalmic ointment

Chlamydia (curable)

Diagnostic: Culture
Female Symptoms:
- Asymptomatic
- Dysuria
- Vaginal discharge
- Can cause inflammation of rectum or lining of eye
Male symptoms:
- Asymptomatic
- Dysuria
- Penile discharge
- Can cause inflammation of rectum or lining of eye
Treatment
- Azithromycin
- Sexual Partners need evaluation and treatment as well

Benign Breast Disease(1)

kgero — 2020-04-27 18:56:34 UTC

Types and changes they cause
Fibrocystic Benign breast disease (BBD)

Overgrowth of fibrous tissue, have dense breasts
cannot get rid of all of the cysts
May be accompanied by fluid filled cyst
Manage with self care
Education
- Extra supportive bra, oral contraceptives, low-fat diet rich in fruits & veggies & grains, apply heat, take diuretics, reduce salt intake, take aspirin/ibuprofen, thiamine & vit E, discuss possibility of aspiration, avoid caffeinated drinks

Fibroadenomas

Benign solid tumor
Growth is stimulated by hormones, preg, and lactation
- Tumor recedes after pregnancy is over or breastfeeding has stopped
Smooth, rubbery and mobile
Nursing management
- Urge the client to be re-eval in 6 mos
- Perform monthly SBE
Diagnostic
- Mammography -- distinguishing fibrocystic changes from breast cancer
- US -- adjunct to ^^, helps differentiate cystic mass from a solid one
- Fine-needle aspiration -- differentiate solid tumor, cyst, or malignancy
- ↑↑↑All of these are assessments and mainly secondary interventions. To get a DX- you need a biopsy → Bennett, mentioned in video at 9:55
Nurse Role:
- TEACH—SBE & importance of **Breast Awareness**
- EDUCATE about potential screenings & about differences between malignant vs. benign, when to get a CBE/other screening done,

Breast Cancer (2)

kgero — 2020-04-27 18:56:57 UTC

Malignant tumors of the breast

Tumors are classified as to where they occur in the breast

Ductal- carry the milk out into the nipple. transporting system
Lobular- stores milk
Other invasive tumors
- Inflammatory breast cancer
- Pagets disease- nipple, areola

Staging

Size
Lymph node involvement
Evidence of metastasis
common metastatic sites: lungs, liver, bones, brain

Stage 0: insitu, very early stages, small place. less than a couple cm.
Stage 1: when the tumor is less than 1 inch. very localized
Stage 2:axilla, 1-2 inches, still localized but spreading to some lymph nodes
Stage 3: other lymph nodes
Stage 4: distal organ, metastatic breast cancer

Educate
Risks:

Biggest risk of having breast cancer is having breasts.
Family hx. Go back to grandma. Look for both breast cancer and ovarian cancer. Gynecological hx.
Genetic predisposition w/ BRACA 1 and BRACA 2 genes
obesity
unopposed estrogen (never been pregnant, breastfed, no hormonal depression of cycling years). Ethnicity- Caucasian women get it more often but AA tend to have poorer outcomes/cancers are found at later stages.

Holistic approach to care-

Nutrition- Stay away from soy, hormone products- meat products that have hormones in animal feed. More organic is important
CAM- acupuncture, aromatherapy, massage, yoga
Stay away from estrogen products. Some cancers aren’t dependent on estrogen for growth.

Self breast exams (SBE) teaching

Women should look in the mirror, stand with hands on the hips to see the symmetry of the breasts
- Inform patient that one breast may be slightly different, for example one areola maybe a little different from the other→ this is okay
While standing in front of the mirror raise arms above the head→ this pulls the breast tissue and will show if there is any dimpling or tugging of the breast tissue→ this is not what you want to see
The self-breast exam itself
- either lying down with one hand above the head or if in the shower with the arm raised
  - instruct the patient to use the soft pads of the fingers and palpate each breast by either doing the wedge pattern, circular motion pattern, or lines pattern (all are acceptable)
- the wedge pattern: going from the areola out
- circular motion: palpating around the breast in a circular motion
- Ensure the patient does not forget to check the areola
  - they should compress the areola to check for any discharge out of the nipple-you should not have any discharge from the nipple
- Ensure that the patient does not forget to check/palpate the tail of spence (lymph nodes that extend all the way up the axilla), which is under the arms
Teach the patient what they should be looking for during the exam
- Looking for any lumps: do you see any or feel any
- any pulling at the nipple especially when raising their hands above their heads
- Any dripping- out of the nipple when it is compressed or expressed
- any redness
- Any rashes
- Any skin changes at all

Screenings
Mammograms for screenings

Recommended to start at age 40 for average risk
if high risk it will usually be younger than 40

CBE: (Clinical breast exams) this is done by providers: MD, PA, NP, Midwife

is a systematic exam of the breast
should be done on annual health exams
Is a gross screening
- does not tell us a whole lot but if anything appears abnormal the provider will then send the patient for further testing such as a diagnostic mammogram and/or ultrasound

Pelvic Floor Dysfunction(2)

kgero — 2020-04-27 18:57:25 UTC

Pelvic Floor Dysfunction

Weakening of pelvic floor muscles leads to:
Pelvic organ prolapse
Urinary and fecal incontinence

What are predisposing factors?

Pregnancy history
- large babies, traumatic delivery, many
Age
Obesity
Smoking
Excessive straining

Types of Pelvic Floor Dysfunction

Rectocele
- constipation, trouble pooping. rectum bulges into vagina
Cystocele
- urinary frequency, difficulty voiding, pelvic pressure. bladder bulges into vagina
Enterocele
- when the small intestines comes down to pelvic floor. pain, constipation, assess bowel habits
Prolapse uterus and vagina
- pelvic muscles are very droopy, impacts sex life, lots of pressure in vagina, pain with sex

Management of Pelvic floor dysfunction

Weight loss
Pelvic floor muscle exercises – otherwise known as Kegels
Lifestyle changes
- exercise, dietary changes, prevent constipation, fluids, use bathroom for urination frequent to keep bladder empty
Hormone replacement therapy
- Estrogen therapy helps support vagina and pelvis to be more healthy and support the pelvic floor better.
Pessaries
- insert in vsagina to push up against the cervix and vaginal wall and support the entire pelvic floor muscles.
- low cost
- doesnt cure it
- estrogen creams, lubricate
- can stay in all the time but need to be removed to clean or can use disposable

Surgery-

Anterior colporrhaphy for cystoceles
posterior colporrhaphy for rectocele or enterocele
Vaginal hysterectomy – for vaginal prolapse

Provide 5 instructions the nurse should provide the patient undergoing surgery for pelvic floor disorder

Teach foley care and instructions when going home- (if they have an anterior colporrhaphy will be sent home w/indwelling foley. Pt will get a leg bag.) soap and water everyday, reporting pain
Teach infection control, washing hands, proper hygiene
Teach keeping stool soft (fiber, increase fluids) and instructions about stool softener (if given)
Complete pelvic rest for at least 6 weeks- no sex!
Report signs and symptoms of infection to a provider.

Cancer(1)

kgero — 2020-04-27 18:58:25 UTC

Cervical Cancer

Slow growing cancer
HPV predisposes to cervical cancer
Screening test = Papanicolaou test (Pap) – can have false negative results
Every 3 years ages 21-30
Every 3-5 years ages 30-65
If screen identifies dysplasia – treatment prevents cancer
Risks
- older age
- early age at first intercourse
- unsafe sexual practices
- family history
- smoking
- lower socioeconomical status
- HIV
- HPV
- Birth control use
- most common hispanic women
Symptoms – vaginal discharge and bleeding

Ovarian Cancer

Poorest prognosis of all cancers of the female reproductive tract
Early diagnosis is essential for better survival
Genetic counseling for women with family history, BRAC1 and BRAC2
Risks
- nulliparity
- early menarche
- late menopause
- increasing age after menopause
- obesity
- high fat diet
- first degree relative with ovarian cancer
- BRCA1 and BRCA2
- HRT for more than 10 years
- infertility
- Increased incidence with exposure to estrogen over time
Symptoms
- Increase urinary frequency
- Trouble eating
- Feeling of filling up very quickly
- Pelvic fullness
- Pelvic pain
- Feeling of bloating
- these symptoms are considered vague, which adds to making it harder to catch early
No standard screening
CA- 125 cancer marker – problem with this?
- Is nonspecific, can elevate with other cancers that increase it

Math(3)

kgero — 2020-04-27 18:58:46 UTC