210 Final Study Guide PDF

Intrapartum Stages of Labor First stage Latent phase (0-5cm) o Onset of labor; Irregular contractions o Frequency: 5-30 min; Duration: 30-45 seconds o Mucus plug expels (scant brown, pale pink) o Mother talkative and calm and easily follows directi...

Intrapartum Stages of Labor First stage Latent phase (0-5cm) o Onset of labor; Irregular contractions o Frequency: 5-30 min; Duration: 30-45 seconds o Mucus plug expels (scant brown, pale pink) o Mother talkative and calm and easily follows directions Active Phase (6-10cm) o Strength: mod-strong; Frequency: 3-5 min; Duration: 40-90 seconds o Mother feels more anxious and helpless (pain more severe) Interventions o Encourage voiding, teach expectations of labor, relaxation techniques Second stage 100% dilated & 10 cm effaced; fetal decent occurs AVOID pushing until 10 cm dilated NSG Care o Monitor VS and FHR o Coach w/pushing and position changes (High Fowlers, Lithotomy, side- lying) o Warm compress (perineum) and cold compress (neck/head) o Promote skin-skin after birth **golden hour** Third stage Delivery of placenta; should be completed w/in 30 min of birth NSG Care o Monitor: BP, HR, and RR q15min o Instruct pt to push once 10cm dilated; admin oxytocin o After birth: Gently cleanse perineum w/warm water, blot, and apply ice pack Fourth stage Occurs 1-4 hrs after birth; maternal stabilization of VS Normal blood loss: 500 for vaginal, 1,000 for c/s NSG Care: ‘fundus first” o Assess fundus, monitor lochia q15min for 1st hr & q30min next ▪ Fundus should be firm; massage if boggy o Monitor maternal VS q15min for first 1-2 hr True vs False Labor True labor Changes in cervix (dilation) Blood show Stronger and longer contractions; pain in lower back False labor  Irregular contractions; no pain No changes in cervix Pain stops w/ walking NO bloody show Factors Affecting Labor Passenger (fetus and placenta) Presentation: presenting part of fetus o Ex: cephalic, breech, or shoulder Lie: relationship of maternal spine to fetal spine o Longitudinal (vertical) best for vag delivery Attitude: relationship of fetal body parts to one another o Flexion or extension Fetal position: position of fetal head to maternal pelvis o ROA and LOA most desirable… “OA is AOkay” Station: degree of fetal decent into pelvis (-1 to +5) Fetal Assessment during Labor Leopold’s Maneuvers External palpation to determine presenting part, fetal lie, and altitude o Should be done laying supine and empty bladder Post maneuvers ALWAYS assess FHR FHR Auscultation and Contraction Monitoring Indications for continuous monitoring o Oxytocin infusion, abnormal NST, maternal complications, fetal growth restriction, meconium-stained amniotic fluid, suspected or actual abruptio placentae, placenta previa Guidelines for auscultation o Latent phase: at least hourly o Active phase: every 15-30 min o Second phase: every 5-15 min Category 1: Normal Baseline FHR of 110-160 BPM w/moderate variability Accelerations present or absent Early decels present or absent; NO LATE DECELS Category 2: indeterminate Baseline FHR tachycardic or bradycardic; marked variability Prolonged FHR decels, recurrent late decels, and variable decels Category 3: Abnormal Sinusoidal pattern, absent baseline variability, recurrent variable or late decels FHR Patterns Acceleration Transitory increase in FHR above baseline  Causes: healthy fetal/placental exchange, spontaneous movement, contractions No interventions required; indicative of Reactive NST Early deceleration Slowing of FHR at start of contraction & returns to baseline at end of contraction Causes: fetal head compression No interventions needed Late deceleration Slowing of FHR after contraction has started w/return to baseline well after contraction ends Causes: placental insufficiency Interventions: Put mom in side-lying position, admin IV bolus, d/c oxytocin o Elevate legs if maternal BP is decreased Variable Deceleration Transitory, abrupt slowing of FHR by >15 BPM BELOW baseline for 15 sec Causes: umbilical cord compression Intervention: Reposition to side-lying or hands/knees, d/c oxytocin Absent variability Associated w/ fetal hypoxia Induction of Labor Indications Post-term pregnancy, dystocia (prolonged labor), FGR, maternal complications, fetal demise, chorioamnionitis (insuff. Amniotic fluid) Cervical ripening Promotes cervical softening, dilation, and effacement o when cervix is unfavorable (3L/day normal), size of bladder for possible distention o Distended bladder= excessive lochia, fundus displaced from midline, bladder bulges above symphysis pubis, tenderness over bladder area Discharge Teaching Perineal care Clean w/ warm water in Peri-bottle front to back after void and BM; Blot perineal area Topical anesthetic ointments, witch hazel pads (tucks, ice pack, dermoplast) Sitz baths Breast care Hand hygiene, well-fitting wire-free bra Nurse newborn on demand (q2-3hr) until breast is soft; alternate breasts Activity, Nutrition, Sexual activity & Contraception Activity: No strenuous activity for first 6-8 weeks, Kegel exercises Nutrition: o Breastfeeding pt must increase caloric intake, calcium foods (1,000mg/day), protein, and fluids Sexual activity: May resume once bleeding as stopped Contraception: o Don’t take if milk production isn’t established o Menses for lactating pt may not resume until cessation of breastfeeding Postpartum disorders DVT Nursing Care: Prevention: SCD’s, stockings, early ambulation, avoid leg crossing During: do NOT massage, elevate leg, foot pumps, no walking Anticoagulants if DVT Heparin and Warfarin; watch for bleeding and monitor coag studies Coagulopathies Types Idiopathic thrombocytopenic purpura (ITP): o autoimmune disorder characterized by decreased platelet count ▪ can result in severe hemorrhage following c/s or lacerations Disseminated intravascular coagulation (DIC): o Life-threatening disorder, widespread blood clotting throughout body Postpartum Hemorrhage Bleeding >1,000 mL for vaginal & >500mL for c/s Causes: Uterine atony, multiparity, retained uterine segments, uterine rupture, trauma Manifestations Excessive BRIGHT RED bleeding, blood clots, boggy fundus, fundal height higher than expected, ↑ HR, ↓ BP, pallor of skin, loss of turgor Nursing Monitor VS; watch for hypovolemic shock Assess fundal height, lochia, & trauma sites Firmly massage the fundus q15, empty bladder Medications Uterine stimulants: o Oxytocin, Misoprostol, Methylergonovine, Carboprost Antifibrinolytics: Tranexamic acid (TXA) Uterine atony Physiologic factors Inability of uterine muscle to contract adequately after birth Manifestations: ↑ vaginal bleeding, boggy uterus, prolonged lochia Nursing: Ensure bladder is empty; perform fundal massage Monitor: Fundal height and location, lochia (color, quantity, consistency) Postpartum infections Complications that occur up to 28 days following childbirth, or spontaneous or induced abortion o Fever of ≥100.4°F after the first 24hr or first 2 days of PP period Uterine infections (endometritis) o Foul smelling lochia, fever, abd pain, cramping, chills, malaise, anorexia Wound infections o Site of C/S incisions, episiotomies, lacerations Mastitis o Infection of breast involving CT; usually occurs 6 weeks after breastfeeding UTI o Occurs secondary to bladder trauma during delivery Postpartum mental health Postpartum Blues Occurs during first few days after labor; resolves naturally in 10-14 days  Sx: Mood swings, episodic tearfulness, decreased appetite, sleep disturbances Postpartum Depression (PPD) Major depression occurring first 4 weeks following birth; can be present ≤ 12 months Sx: Depression, anhedonia, sleep or appetite disturbances, impaired concentration, feelings of guilt or worthlessness, SI Postpartum psychosis PP mood episodes w/ psychotic features; EMERGENCY Sx: Delusions, hallucinations, agitation, irrational guilt, mood lability o Prompt treatment necessary to prevent suicide and infanticide Pharm therapy Antidepressants, antipsychotics, benzos, mood stabilizers Nursing care Assess s/s of depression (note duration and severity), level of anxiety IMMEDIATELY report any s/s of self-harm or harm to baby Postpartum Medications Uterine Stimulants Oxytocin o Main use for induction of labor; other use to control bleeding after birth of placenta Methylergonovine o Use: prevent and treat PP or post-abortion hemorrhage o NSG Actions: monitor VS (BP, HR), watch for bleeding or s/s of HTN crisis Carboprost (Hembate) o Use: treat PP hemorrhage ; C/I: Asthma, HTN o Actions: Admin antiemetic or antidiarrheal w/med, monitor for fever Antifibrinolytics Tranexamic acid (TXA) o improves clotting, emergency tx for PP hemorrhage o C/I: hx of thrombosis, use of contraception Newborn Care Adaptations to Extrauterine Life Respiratory Normal: initial functioning: 30-66 RR, diaphragmatic breathing, & irreg depth and rhythm ABNORMAL: RR 60 at rest, nasal flaring, expiratory grunting, increased use of intercostal muscles Cardiovascular Normal: Average resting HR: 110–160 bpm; possible murmur ABNORMAL: arrythmias, HR 180, central cyanosis Hepatic  Normal o Normal rise in bilirubin 1st few days of life and decrease clotting factors ▪ Reduction in hepatic activity ↑ susceptibility to jaundice Hyperbilirubinemia o Aka jaundice; yellow discoloration of skin due to excess bilirubin o Pathological Jaundice ▪ Seen w/in first 24hrs of birth and can persist for 2 weeks ▪ Due to structural defects of liver → buildup of bilirubin o Physiologic Jaundice ▪ Due to RBC’s destruction, which leads to ↑ amounts of bilirubin ▪ Arises >24hr after birth and disappears naturally o Nursing Care ▪ Assess for jaundice by pressing on forehead or nose w/ finger ▪ Maintain temperature >97.8°F; monitor BM characteristic & amount ▪ Treatment: phototherapy Gastrointestinal Normal: bowel sounds may be absent or hypoactive until 1st feed, meconium passed w/in first 8-24 hr, regurgitation common ABNORMAL: no voiding in >24 hr, abd distention, bulging, hernias, distention Urinary Tract Normal: voiding immediately, cloudy urine following 1st void, pseudomenstruation Reflexes Rooting Elicited by touching infant’s check, causes infant to turn head and open mouth in direction of stimulus Sucking Instantly suck when touching top of mouth Moro (Startle Reflex) Elicited by making a sudden loud noise or quickly lowering head backward Infant will extend arms & legs, then bring them toward their body Grasping When placing finger inside palm or under toes, they will curl Tonic neck or “fencing reflex” Elicited by turning head to one side; arm & leg on that side extends & opposite arm & leg flex Stepping When baby’s feet touch a flat surface, they will make movements like they’re walking Babinski  When outer edge of sole is stroked, their toes should fan out and curl upward Plantar or toe - grasping Elicited by pressing ball of infant’s foot; toes will curl Initial Care of Newborn Apgar scoring Scoring of 0, 1, or 2 for each of following: Appearance, pulse, grimace, and activity Total 7-10= adequate; 4-6= moderate distress; 0-3= severe distress (0.5) o Indicates presence of clot in body Doppler ultrasound Pharmacologic Therapy Heparin o Used for short-term therapy; fast onset o Monitor: aPTT and signs of bleeding o Antidote: protamine sulfate Warfarin o long-term therapy, slow onset; NOT safe during pregnancy o Monitor: PT/INR and signs of bleeding o Antidote: Vit K Nursing Care Prevention: calf exercises, ambulation, SCD’s, no prolonged sitting During: bed rest, elevate, NO MASSAGE Monitor for s/s of PE: SOB, diff. breathing, chest pain, ↑RR, ↑HR, ↓BP DIC Patho MED EMERGENCY; massive systemic coagulation Blood clots eventually lead to organ infarct, necrosis or ischemia Etiology Most common: sepsis, cancer, serious trauma, obstetric complications Manifestations Moderate Bleeding from nose, gums, mouth, or puncture sites; petechiae and purpura Blood in stool (melena) or urine (hematuria) Severe Altered mental status, chest pain, dyspnea, palpitations, shock, cyanosis VTE, stroke (CVA), heart attack, DVT, multiorgan failure Arterial thrombosis → ischemia and necrosis Collaboration Diagnostic Tests CBC w/ diff: ↓ clotting factors, platelets Coag studies: ↓ fibrinogen, prolonged PT and PTT D-dimer: ↑↑ Treatment IV/blood products, anticoags, ventilator support if severe Nursing Care BLEEDING PRECAUTIONS Monitor: CBC and coag studies, pulses, pain, LOC Insert indwelling and monitor I&O Fractures Types of Fractures Closed: doesn’t break skin surface Open: breaks skin surface Impacted/compression: +2 bones crushed together Comminuted: bone broken in at least +2 places Oblique: broken at an angle (slanted) Greenstick: partial, only broken on one side o common in children Compression: occur in the spine and result of bone loss or injury Spiral: caused by twisting motion o HIGH suspicion for abuse Complications Osteomyelitis (bone infection), VTE Fat embolism: petechiae, confusion and restlessness, dyspnea and chest pain, low SpO2 Compartment Syndrome MEDICAL EMERGENCY Increased pressure in muscle compartment, which impairs circulation to extremity 5 P’s: intense pain, paresthesia (pins and needles), paralysis, pallor, pulselessness o Affected extremity will be hard and swollen Do NOT elevate extremity or apply cold packs Treatment: fasciotomy (to release pressure) or amputation Collaboration Diagnostic Tests Imaging: x-ray, CT, MRI Pharmacologic Therapy Analgesics for pain, ABX for open fractures, muscle relaxants Nursing Care Emergency Care: cut clothing, remove jewelry, controlling bleeding, immobilize fracture by splinting Neurovascular check o Assess pain, sensation to area, monitor color and temp of skin, check cap refill, check pulses, mobility of extremity RICE (rest, ice, compression, elevation) Osteoporosis Patho Bones broken down more than being rebuilt & loss of Ca+ and phosphorus Bone density and mass gradually decrease Risk Factors Family hx, older adults, menopause, smoking, prolonged steroid use Manifestations Back pain, decreased height, balance issues, kyphosis, arthralgia Common fractures: wrist, spine, & hips (intracapsular) Collaboration Diagnostic Tests Imaging: DEXA bone scan, x-ray, CT Labs: Ca+, Vitamin D, alkaline phosphate, PTH Pharmacologic Therapy Biophosphate o Inhibits bone reabsorption; adverse sx: esophagitis, GI upset o Ex: alendronate Selective Estrogen Receptor Modulators o Prevents bone loss after menopause; increases risk for blood clots o Ex: tamoxifen Phosphate Binders o Binds w/ phosphate in GI tract to be excreted in feces; helps ↓ phosphate o Ex: sevelamer Muscle relaxants o Reliefs discomfort associated w/ musculoskeletal conditions o Ex: cyclobenzaprine Nursing Care Interventions Monitor height, encourage weight-bearing exercise Safety checks, assist w/ ADL’s Teach: limit caffeine & alcohol, diet high in Ca+ and vit D; avoid strenuous exercise Multiple Sclerosis Patho Autoimmune disorder; body attacks myelin sheath around nerves & causes inflamm o Can eventually lead to impaired nerve transmission Risk Factors Women (ages 20-40), family hx, smoking, infections, vitamin D deficiency Types (least to most severe) Relapsing-Remitting Clearly define flare-ups w/partial or complete remission Secondary-Progressive Relapsing and remitting course w/ steady progression of symptoms Primary-Progressive Steady neuro deterioration w/ NO relapses or remissions Progressive-Relapsing Worsening acute relapses w/partial recovery (no remission) Manifestations Flare up: muscle spasticity, ataxia, muscle hyperreflexia, urinary retention Cognitive: short-term memory loss, impaired judgement, depression Motor: weakness, intention tremors, unsteady gait, Sensory: blurred vision, hearing loss, vertigo, diminished sense of temp Collaboration Diagnostic Tests MRI & CSF analysis (increased antibodies) Pharmacologic Therapy Corticosteroids, immunosuppressants, muscle relaxants, monoclonal antibodies Nonpharmacologic Therapy PT/OT, speech therapy, mild exercise program, vocational therapy Nursing Care Initiate fall precautions and aspiration precautions Assess neuromuscular function Q2h turns, monitor for constipation and urinary retention Promote independence; bowel training Low fat, high fiber diet; remind to drink fluids Adrenocortical Dysfunction Addison’s Disease (Adrenal Insufficiency) Patho Insuff secretion of mineralocorticoids (ex: aldosterone), glucocorticoids (ex: cortisol), and androgens (ex: testosterone) Types Primary o Hyposecretion of adrenal cortex hormones o Cause: adrenalectomy, autoimmune diseases, TB, cancer, trauma Secondary o Hyposecretion of ACTH from pituitary gland o Cause: abrupt d/c of corticosteroids, pituitary tumor or trauma Manifestations Hyperpigmentation (bronze), weight LOSS, hypotension, fatigue ↓ Na+, ↓ blood sugar, ↑↑ K+ Addisonian Crisis Life-threatening disorder caused by ACUTE adrenal insuff. Cause: abrupt d/c of steroids, infection, stress, trauma Manifestations: “think shock” o SEVERELY low BP, sudden pain in abd/legs/back, severe vomiting & diarrhea, syncope, loss of consciousness o ↓ Na+, ↓ blood sugar, ↑↑ K+ Treatment: high dose hydrocortisone, fluids w/ dextrose Collaboration Diagnostic Tests o Lab: Elevated K+, calcium, BUN; Decreased cortisol, sodium, glucose o ACTH Stimulation Test: High = primary; low= secondary Medications o Cortisone or mineralocorticoid ▪ Taken for life; stopping causes adrenal crisis ▪ Monitor weight, I&O, growth, electrolytes, and glucose Nursing Care Interventions  o Monitor: I&O, LOC, VS, cardiac rhythm, electrolyte & glucose levels, and weight o Institute cardiac monitoring o Provide bed rest and quiet environment Teaching o Lifelong hormone replacement therapy is needed; do NOT stop o In periods of high stress, med adjustment may be necessary o Wear medical alert bracelet and carry emergency med kit o Teach emergency intramuscular injection Cushing’s Syndrome Patho Overproduction of cortisol by adrenal cortex Causes: prolonged steroid use, pituitary or adrenal tumor, lung cancer Manifestations Buffalo hump + moon face + truncal obesity Weight GAIN, fluid retention, bone loss, hirsutism, sensitive and thin skin, HTN, purple striae, muscle wasting & osteoporosis, hyperglycemia “When you have Cushing’s, you will look like a cushion” Collaboration Diagnostic Tests o ↑ glucose and Na+; ↓ K+ and Ca+; ↑ cortisol in saliva o Dexamethasone Suppression Test Treatment : Adenoma removal, hypophysectomy, adrenalectomy Medication: Ketoconazole- inhibits cortisol synthesis Nursing Care Restrict fluid + sodium & encourage intake of K+, Ca+, and protein Monitor for fluid volume overload and edema Meticulous skin care and ambulating as tolerated Assist w/ ambulation to decrease injury risk NEVER GIVE ASPIRIN OR NSAID Adequate hand hygiene due to decreased immune response Thyroid Disorders Hyperthyroidism Patho Overproduction of T3 & T4, leading to a hypermetabolic state Etiology  Grave’s disease, toxic nodular goiter, hyperfunctioning thyroid adenoma, damaged/inflamed thyroid, TSH secreting tumor Risk Factors Female sex, family hx, another autoimmune disorder, radiation therapy in neck Manifestations Increased appetite, weight LOSS, diarrhea, heat intolerance, diaphoresis, palpitations, amenorrhea, hand tremors high vitals (↑ HR and BP) Exophthalmos: bulging eyes due to fluid accumulation Complications Thyroid Storm o MED EMERGENCY; state of severe hypermetabolism o Occurs during periods of acute stress; ex: infections, trauma, surgery o Manifestations ▪ Agitation & confusion is an early sign ▪ Severe HTN, tachycardia, fever, increase RR, dysrhythmias o Tx: antithyroid rx, B-blockers, high-dose glucocorticoid Collaboration Diagnostic Tests o ↑ T3 and T4; ↓ TSH o Radioactive Iodine Uptake Test: ↑ o Other: Thyroid Scan, ECG Medications o B-blockers (propranolol): decreases cardiac symptoms o Corticosteroids (prednisolone): inhibits T4 to T3 conversion o Antithyroid medications (methimazole): decrease thyroid hormone synthesis; effects take up to several weeks (by blocking iodine) Surgery: thyroidectomy Nursing Care Interventions o Monitor: HR and rhythm, thyroid levels, daily weight, I&Os o For exophthalmos: Tape eyelids close for sleeping & provide eye lubricant Teaching o Contact MD: HR >120, dizziness, chest tightness, syncope o Encourage high calorie and protein diet o Diet: high calories, high protein & carbs, low fiber, no caffeine Hypothyroidism Patho  Decreased production of T3 & 4, which decreases metabolic processes Etiology Underactive thyroid gland, Hashimoto’s, tumor, trauma, low iodine Risk Factors Females, family hx, autoimmune disorders, radiation therapy in neck region, medications (lithium, amiodarone) Manifestations Decreased appetite, weight GAIN, constipation, cold sensitivity, amenorrhea, thin hair & dry skin, low VS (↓ BP and HR) Myxedema: swelling and thickness of skin (puffy appearance) Complications Myxedema coma: o severe and profound hypothyroidism o Triggered by severe stress; leads to cardiovascular collapse o Sx: Hypoxia, decreased CO, decreased LOC, low VS (↓ HR, BP, RR, temp), stupor, coma, stroke o Tx: IV levothyroxine or glucose, frequent assessment Collaboration Diagnostic Tests o ↓ T3 and T4; ↑ TSH Medications o Thyroid hormone replacement therapy: levothyroxine ▪ Take in morning & on empty stomach ▪ Monitor HR & rhythm (causes ↑ HR and dysrhythmias) Nursing Care Interventions o Assess: skin color and temp, energy levels, appetite changes, BM’s o Monitor: edema of eyes or extremities, weight, HR, thyroid levels o Encourage rest periods o Increase temp in room and provide warm blankets Teaching o Diet: low calories, high fiber, increase fluids Eating Disorders Patho Abnormal eating behaviors that negatively impact physical and mental health Common in young females w/ low self-esteem & social pressure  Possible disturbance in serotonin and neuropeptide systems Altered serotonin- dysregulates appetite, mood, & impulse control Risk Factors Women, teens/young adults, childhood abuse or trauma, family hx, comorbid mental condition (depression, anxiety, OCD, bipolar) Anorexia Nervosa Overview Restriction of calorie intake results in dangerously low body weight Typically begins in teens, ↑ in females; has HIGHEST mortality rate Pt severely limit food consumption & offset w/ purging Manifestations EXTREME thinness: 35 in females, post-menopausal women, genetic risk factors Modifiable Large waistline, high triglyceride levels, low HDL levels, HTN, ↑ fasting blood sugar, obesity, physical inactivity, smoking, poor diet Manifestations Angina CHEST PAIN: tightness, squeezing, heavy pressure, constricting sensation o classic sequence is activity-pain & rest-relief; lasts ~2-5min o typically begin beneath sternum & may radiate to jaw, neck, shoulder, or arm Atypical S/S: indigestion, N/V, upper back pain Other manifestations: dyspnea, pallor, tachycardia, anxiety, fear Acute Coronary Syndrome Substernal or epigastric chest pain; may radiate to neck, left shoulder or arm May be present w/ or activity, lasts ~10-20 minutes Other symptoms: dyspnea, diaphoresis, pallor, tachycardiac, hypotension, nausea Acute Myocardial Infarction Cardinal symptom- CHEST PAIN Crushing, severe, tightness, heavy pressure, or squeezing Start at center of chest (substernal) & may radiate to shoulders, neck, jaw, or arms Lasts more than 15-20 min and NOT relieved by rest or nitroglycerin Other S/S: tachypnea, anxiety, cool & clammy skin, ↑ temp Collaboration Diagnostic Tests Labs: serum cholesterol (↑ LDL, triglyceride; ↓HDL), CRP (↑) Angle-brachial BP intake: