Maternal and Child Care at Risk - NCM 109 PDF

NCM 109 Less educated, poor rural are more likely to become fathers early CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND Husbands prefer more children than their CHRON...

NCM 109 Less educated, poor rural are more likely to become fathers early CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND Husbands prefer more children than their CHRONIC) wives Introduction On the average, women want 3 children Why do we need to study diff HOW ARE OUR MOTHERS? complications either from antepartum, intrapartum and postpartum? 360,000 pregnancies experienced obstetrical complications that require hospitalization Because of death and disabilities from pregnancy (can be prevented or Treated) Less severe cases that does not need admission: severe Vomiting, IDA These can be achieved by a combination of interventions -Roughly, 10 women die every 24 hours from causes related to pregnancy and childbirth Ex. Prenatal Consultations for status monitoring of the baby and also the -3650 maternal deaths/yr… most are in the mother rural areas Ultrasound -7 out of 10 deaths occur during labor or Vaginal Ultrasound – have it between within 1 day after delivery 10-12 weeks to determine if there is heartbeat Postpartum assessment: check temp for Abdominal ultrasound possible infection; check lochia; BP Family planning can help avoid and prevent -473000 unsafe abortions take place every unplanned too early, too late, too close, year? (due to sepsis) too sickly and too many pregnancies particularly among very high-risk women. WHY DO WOMEN DIE Quality prenatal, delivery and postpartum Complications related to pregnancy occurring services can prevent complications, detect in the onset of labor, delivery, and puerperium problems early and management, mobilizing communities and local Hypertension complicating pregnancy, government will help improve the status of childbirth, and puerperium women who needed care. Postpartum hemorrhage due to uterine atony, retained placenta BASIC DATA Pregnancy related to abortive outcome Poor women have 3x more children (mostly rural areas) Hemorrhage related to pregnancy Poor women are more likely to start sexual Ectopic pregnancy ( 1st Most two activity, get married, and have children the trimester/ last 8-12 weeks or common earliest else will rupture ) cause of Placenta Previa (occur during hemorrhage 3rd tri) Closely spaced pregnancies higher among young mother (Papi) GLOBAL SITUATION 529000 women die annually from pregnancy- Ways for identifying client’s at Risk: related causes ❖ Physiological 95% of maternal deaths in 2000 occurred in ❖ Psychological Africa and Asia; 4% in Latin America; and ❖ Social 1% in developed regions Factors that categorize a pregnancy as Direct Causes – Hemorrhage; Causes of High risk hypertension; severe infection; maternal obstructed labor PRE-PREGNANCY Death Indirect Causes – malaria; PSYCHOLOGICAL Severe anemia; other medical causes History of drug dependent More than 1 million of children are orphaned History of mental illness Children who have lost their mothers are 10x History of poor coping mechanism more likely to die early SOCIAL PHILIPPINE SITUATION Occupation handling of toxic 3.1 million pregnancies occur each year. Half substances of these are unintended and one-third ends in abortion. Environmental About 473000 abortions annually with Contaminants at home (smoking) abortions as leading cause of maternal deaths Isolated CENTRAL VISAYAS Lower economic level Only 4 in 10 births occur in health facility Poor access to transportation for care 70% of birth were delivered at home; Poor housing 27% at hospital; 3% others Lack support people HIGH RISK PREGNANCY PHYSICAL Is defined as one in which a concurrent disorder, pregnancy related complication Visual or hearing challenges or external factor jeopardizes the health of the mother, fetus, or both. Pelvic inadequacy HIGH RISK PREGNANCY CAN BE GROUP Secondary major illness (heart disease, INTO TWO: DM, kidney disease, hypertension etc.) Women with pre existing or newly acquired illness Poor gynecologic or obstetric history Women who develop complications of pregnancy History of pregnancy outcome CHAPTER 20 ( miscarriage, stillbirth, intrauterine fetal death) Nursing Care of a Family Experiencing a Pregnancy Complication From a Pelvic inflammatory disease Preexisting or Newly Acquired Illness SIGNS INDICATING POSSIBLE Obesity COMPLICATIONS OF PREGNANCY: Small stature Severe Pain: Severe abdominal pain [ectopic pregnancy], cramping, or Younger than age 18 years or older contractions Than 35 years Bleeding: Heavy bleeding or unusual vaginal discharge [miscarriage, Cigarette smoker placenta previa] (sudden escape of clear fluid from the vagina) [preterm Substance abuse labor] Dizziness: Fainting spells or dizziness LABOR & DELIVERY [anemia] Vision Changes: Blurred vision or PSYCHOLOGICAL spots before your eyes [preeclampsia] Chills & Fever: Fever higher than Severely frightened by labor and delivery experience 100.4 degrees Fahrenheit [UTI/Infection] Inability to participate due to anesthesia Vomiting and Diarrhea: Persistent vomiting [hyperemesis] and/or diarrhea Lack of preparation for labor [severe dehydration] Swelling: Swelling in your hands, Birth of infant who is disappointing in some fingers, face, or legs [eclampsia] way Chest Pain: Chest pain or fast-beating heart [rheumatic heart disease, deep SOCIAL vein thrombosis] Shortness of breath: Trouble Lack of support person breathing or shortness of breath – Unplanned CS related to chest pain [asthma] Thoughts of self-harm: Thoughts Lack of access to continued health care about hurting yourself or your baby [mental disorders prior to pregnancy] Lack of access to emergency personnel or equipment DEFINITION OF A HIGH-RISK PREGNANCY PHYSICAL A high-risk pregnancy is one in which a concurrent disorder, pregnancy- Hemorrhage related complication, or external factor Infection jeopardizes the health of the pregnant person, the fetus, or both. Dystocia Causes: low socio-economic status; lack of support; lack of knowledge; poor coping mechanism; poverty ASSESSMENT THAT MIGHT CATEGORIZE A PREGNANCY AS AT RISK:  Obstetric History (No. of preg, Infection LMP…) Hypertension of pregnancy Past Illness (Prev. hospitalization) Ectopic pregnancy Current Obstetric Status (3 min. NURSING PROCESS RELATED TO CARE Ultrasound - every trimester; at 3rd tri OF A PERSON WITH A HIGH-RISK monthly; at 8th month every 2 weeks; at PREGNANCY 9th month every week) Psychosocial Factors (support Assessment system) - Objective data (Observation) Demographic Factors (genogram, - Subjective data environment) Nursing diagnosis Lifestyle (hours of sleeping, diet, Outcome identification and planning exercise, relaxation, type of work) Implementation and planning Outcome evaluation A PREGNANT PATIENT WITH INFLUENZA ESTABLISHING A BASELINE WHEN Is caused by a virus CARING FOR A PERSON WITH A HIGH- High fever, back pains and pain at the RISK PREGNANCY lower extremities, sore throat Antipyretic (Tylenol) – to decrease Healthy People 2030 Goals Related to fever Complications of Pregnancy Oseltamivir (Tamiflu) – should be Reduce the rate of fetal deaths to 5.7 given (teratogenic) per 1,000 live births from a baseline of Influenza vaccine – can still be given 5.9 per 1,000 live births. to pregnancy Reduce the rate of maternal deaths A PREGNANT PATIENT WITH COVID-19 to 15.7 per 100,000 live births from a baseline of 17.4 per 100,000 live births. Covid-19 is an illness that affects the Reduce the rate of severe maternal lungs and breathing complications during delivery It is caused by a coronavirus. hospitalizations to 61.8 per 10,000 births from a baseline of 68.7 per Symptoms may include fever, cough, sore 10,000 births. throat, and congestion HIGH-RISK PREGNANCY: - Symptoms may occur 2-14 days after CARDIOVASCULAR SYSTEM being exposed by the virus Cardiovascular disease complicates Risk of having covid-19 during the first only 1% of pregnancies but accounts trimester of pregnancy: Abortion, for 5% of maternal deaths. hemorrhage, preterm, increase risk of - Heart put extra workload (ma death to the baby overwhelm ang heart) - Vaccine for pregnant: Pfizer - System needs to be increased cause 2 ang nag need (the baby is LEADING COMPLICATIONS OF dependent to the mother) PREGNANCY Blood volume and cardiac output increase up to 50% during pregnancy Hemorrhage (Abortion and ectopic (peaks at 28 to 32 weeks), which pregnancy) places stress on a comprised heart. Thromboembolism – life threatening - 5 to 10 mins after delivery heart is condition that could lead to DVT (deep the most at risk cause the body of vein thrombosis) and pulmonary the mother compensates to put into embolism balance  New York Heart Association criteria is - Ascites (accumulation of fluid in commonly used to categorize severity the peritoneal cavity) of heart disease. - Peripheral edema (swelling at the legs because of the unrepaired CARDIOVASCULAR SYSTEM: MATERNAL congenital heart defect) ASSESSMENT Fatigue Layers of abdomen Cough Skin – Subcutaneous – Fascia – Muscle – Increase respiratory rate Peritoneum – Organ Poor fetal heart tone HIGH-RISK PREGNANCY: Decrease amniotic fluid from CARDIOVASCULAR SYSTEM NURSING intrauterine growth restriction DIAGNOSIS (Example) Edema Based on the discussion: Ineffective CARDIOVASCULAR SYSTEM: FETAL tissue perfusion related to poor ASSESSMENT heart function as evidenced by (can Low birth weigh or SGA be get from the objective cues or from If the placenta is not filling well, a fetus the lab results) edema may not respond well to labor Deficient knowledge regarding (evidenced by late deceleration steps to take to reduce the effects of patterns on a fetal heart monitor) maternal cardiovascular disease on - Early decelerations cause is head the pregnancy and fetus compression so change position HIGH-RISK PREGNANCY: - Cause of late deceleration is CARDIOVASCULAR SYSTEM uteroplacental insufficiency; ASSESSMENT suggest for cesarean delivery if less than 100bpm ang baby Level of exercise (what can she do - Variable deceleration cause is cord without getting difficulty breathing and coil cyanosis) Presence of cough and edema HIGH-RISK PREGNANCY: COMMON (assess if there is rapid or difficult CARDIOVACULAR CLINICAL FINDINGS respiration) Left-sided heart failure (left ventricle Comparison of baseline vital signs cannot move the large volume of (check the prenatal card) blood) Signs: Liver size (right sided heart failure - Pulmonary edema (shortness of involvement) breath with blood) ECG/echocardiogram - Orthopnea (shortness of breath Fetal size (small for gestational age) when lying flat) and poor response to labor (FHR - Paroxysmal nocturnal dyspnea decelerations) (shortness of breath when HIGH-RISK PREGNANCY: sleeping) CARDIOVASCULAR SYSTEM NURSING INTERVENTIONS DURING ANTEPARTAL PERIOD Promote rest (save baby until 36 Right-sided heart failure (right weeks) ventricle is overwhelmed) Signs: Promote healthy nutrition (prevent - Distended liver and spleen anemia; encourage high fiber and low (abdominal pain and difficulty sodium diet and intake of breathing)  multivitamins) Educate regarding medication Educate regarding avoidance of infection MEDICATIONS: Digitalis (digoxin) Iron preparations Classes III & IV Caudal Anesthesia (type of epidural anesthesia) pt need ur instruction cause pt. don’t feel the pain - Not allowed to push because of Vasalva Maneuver Valsalva Maneuver - ↑workload of the heart - ↑increase venous return – causes weakening and damage of the heart that’s they use anesthesia Adults w/ heart diseases should refrain from straining when defecating – put ↑pressure to the heart – lead to RUPTRD ANEURYSM – can be to brain (can be save) and abdomen (once rupture liver will be affected mag bleeding) CARDIOVASCULAR SYSTEM NURSING INTERVENTIONS DURING INTRAPARTUM AND POSTPARTUM PERIODS ❖ Intrapartum period - Positioning (semi sitting) - Epidural anesthesia (caudal) and assisted vaginal delivery (forceps assisted) ❖ Postpartum period - Assess for heart failure - Anticoagulant and digoxin therapy - Intermittent pneumatic compression boots A PREGNANT PATIENT WITH VENOUS THROMBOEMBOLIC DISSEASE Advise the mother - Perform case resuscitation is required. Then primary differences in performing CPR in pregnant woman is the avoid inferior vena cava just above the xiphoid process in Antenatal interventions: Ensure the woman has at least two rest periods in a day and a full night's sleep. When resting, the woman should be in left lateral recumbent position versus supine hypotension Left lateral recumbent position in pregnancy is the most comfortable position for it allows maximum blood flow to the fetus, uterus, and kidneys) Enforce a rest program with specifications concerning degree of work the pregnant woman may perform Ensure that the woman will gain adequate weight Instruct that prenatal vitamins must be taken, especially iron supplementation, to avoid increasing the workload of the heart for oxygen delivery Advise on following the therapeutic regimen strictly DIABETES MELLITUS  Diabetes Mellitus (DM) Is an endocrine disorder where the pancreas cannot  produce adequate insulin to regulate glucose levels A1  Hyperglycemia – insulin  Abnormal glucose tolerance without other Hypoglycemia – insulin symptoms and fasting glucose is normal TYPE 1 Diabetes  Management: diet  autoimmune A2  insulin cannot produce adequate insulin  abnormal glucose tolerance test and elevated fasting glucose TYPE 2 Diabetes  Management: insulin  Has enough production of insulin but the body cannot sustain PATHOPHYSIOLOGY: GESTATIONAL DIABETES MELLITUS (GDM) Primary concern: controlling the balance between Insulin and blood glucose to  Higher risk for mothers to have this prevent hyper and/or hypoglycemia. problem if they are diagnosed with DM before pregnancy Infants of women with unregulated diabetes are 5x more apt to be born large for  DM during pregnancy gestational age or with anomalies Oral Glucose Tolerance Test When insulin is insufficient, glucose cannot (26-32 weeks) get into body cells. The liver thinks the body needs more glucose, so It Increases the blood levels even more, once blood RISK FACTORS: glucose reaches 150 mg, the kidneys star to dump glucose in the urine (glycosuria).  Obesity/overweight Fat is broken down to create energy, which  Over 25 years old releases ketones into blood – stream/urine  Fetal loss COMPLICATIONS  Large babies – 10 lbs RISKS:  Polycystic ovarian syndrome Macrosomia: more than 10 pounds can cause:  Hispanic and Asian  cephalopelvic disproportion (CPD)  Shoulder dystocia Total weight gain during pregnancy: Caudal regression syndrome – lower 25-35 pounds extremities fall to develop Miscarriage, Stillbirth, Hypoglycemia, Respiratory  distress syndrome, Hypocalcemia, results throughout the pregnancy. Hyperbilirubinemia Provide client and family teaching.  Assess the client’ s understanding of Mc Roberts Manuever GDM and its implications for daily life.  pushing the legs of the mother towards her  As needed, explain the effects of gestational diabetes on the mother and Variable deceleration: side lying fetus. DIAGNOSTICS  Point out the need for frequent laboratory testing and follow- up for mother and SCREENING TEST (OGPT) fetus, for example, to prevent infection and assess other potential complications. Giving the pt 50 grams of glucose to drink and the blood sugar be check 1 hour after  Discuss and demonstrate insulin self- and It should be 135 – 140 mg/dl, if injection elevated then check 3 hours after, same process, if elevated the doctor will do HYPOGLYCEMIA Glycosylated hemoglobin (GbA 1c) – 4 to 8 weeks before the test performed  Sweating HbA1c more than 6 – insulin ta dapat  Shakiness FBS = fasting blood sugar  Dizziness FETUS:  Hunger  Maternal serum alpha fetoprotein level  Headache  Ultrasound  Fainting  Non-stress test (as early as 30 weeks)  Fatigue = preterm birth  Weakness  Contraction stress test HYPERGLYCEMIA  Fatigue  Lung maturity studies (amniocentesis)  Flushed hot Skin Best location for insulin injection: stomach  Depressed Reflexes  Drowsiness  Headache NURSING MANAGEMENT  Frequent Urination  Establish an initial database, and maintain serial documentation of test  Dry mouth  Excessive thirst  Hygiene DIABETES MELLITUS  Voiding frequently and after sexual intercourse  Occurs in pregnancy and is caused by pregnancy hormones  Cranberry juice intake (alkaline)  Insulin is not working effectively 25-30 ml/hr of urine  Usually goes away when the baby is born 4 criteria:  Increases the risk of type 2 diabetes for  Urine output must be less than 25 cc the mother later in life  Blood pressure  Mothers are advised to see the doctor yearly for diabetes test  Respiratory Rate  High blood glucose levels in mother  Deep Tendon Reflex (DTR) – to determine the toxicity of magnesium to  Brings extra glucose to baby stop magnesium infusion Adverse effects: RR depression  Causes baby to put on weight HIV/AIDS URINARY  Acquired Immune Deficiency Syndrome HIGH RISK PREGNANCY: INTERVENTION (AIDS) is caused by the Human RELATED TO PREVENTION OF RENAL Immunodeficiency Virus (HIV) AND URINARY TRACT DISORDERS  HIV attacks and destroys while blood Monitoring of fluid cells, causing a defect in the bodies Hygiene  immune system Voiding frequently after coitus  Infected persons becomes so weakened that it cannot protect itself from serious Cranberry juice intake infections. When it happens, the person clinically has AIDS POSTPARTUM UTI:  AIDS my manifest as early as 2 years or Compression of uterus to the bladder tone as late as 10 years after infection with HIV = distended Initiate voiding – bed pan Interventions: MODES OF TRANSMISSION  Nutritional consults and monitoring fluid  Sexual intercourse intake  Accidental exposure to blood, shared Proper disposal of placental and other items needles, contaminated instruments  MOTHER TO CHILD: MODE OF DELIVERY – VAGINAL Pregnancy Artificial rupture of membranes should be avoided Birth Rupture of membranes past 4 hours should Breastfeeding be avoided ANTENATAL Fetal scalp sampling and the use of scalp electrodes should be avoided In utero by trans placental passage INTRANATAL MODE OF DELIVERY – CESARIAN BIRTH Exposure to maternal blood and vaginal HIV infected women should be counseled- secretions during labor or delivery about elective C/S POSTNATAL Vertical transmission is reduced to 2% with patch 076 therapy and elective C/S During breastfeeding To avoid from & onset of labor elective c-s is HIV CANNOT BE TRANSMITTED BY: performed at 38 weeks Casual person to person contact After from op onset of labor 0-5 is less protective Food, Air, Water To avoid c-s morbidity, antibiotic prophylaxis Insect/mosquito bites should be considered Coughing, sneezing, spitting IRON DEFICIENCY ANEMIA Shaking hands, touching, dry kissing or  Is a disorder in which hemoglobin hugging synthesis is deficient and the body’ s capacity to transport oxygen is impaired. PRECAUTIONS DURING LABOR: Iron deficiency anemia during pregnancy is associated with low fetal birth weight Protection from blood and amniotic fluids and preterm birth. Protection from sharp instruments  Hemoglobin – carries blood oxygen in the body Growth restriction RESUSCITATION OF BABY: No mouth to mouth suction  Preterm delivery No mouth to mouth breathing  Abortion PREACUTION FOLLOWING LABOR:  Most common anemia during pregnancy Proper disinfection of instruments  Risk: mother who were pregnant less  Less than 10g/dl of hemoglobin than 2 years: low socio-economic levels  Less than 33% of hematocrit  Causes: diet low in iron, heavy menstrual flow, reduction of wait  Less than 30 mcg/dl of serum iron  Less than 100 mg/dl of serum ferritin 2 TYPES OF IRON ANEMIA  Low RBC count with microcytic and Microcytic anemia – hypochromic cells Hypochromic anemia –  mean corpuscular hemoglobin (less than 30g/dl) ASSESSMENT FINDINGS  Absent iron stores and hyperplasia of normal precursor cells  Fatigue Primary iron binding protein – transferrin  Lightheadedness NURSING MANAGEMENT  Pallor  Take prenatal vitamins as prescribed  Exercise intolerance  Oral supplements of iron with vit. C  Pica (ferrous sulfate & ferrous gluconate) SIGNS AND SYMPTOMS  Monitor patients CBC and serum iron and ferritin levels  Dyspnea on exertion  IM (ventrogluteal/Z-track TO PREVENT  Susceptibility to infection SKIN DISCOLORTION) or IV (monitor for possible allergy reaction  Tachycardia  Assess FHR every 4 hours  Coarsely, ridged, spoon shaped, brittle thin nails  If anemia is severe, expect to administer oxygen as ordered to reduce chances of  Sore, red burning tongue hypoxia  Sore, dry skin in the corners of the mouth  Fiber  Tell pt. stool can be black and tarry  Possible constipation DIAGNOSTIC TESTS BEST TIME IN TAKING IRON: WITH MEAL (DURING) MANAGEMENT: FOLLIC ACID ANEMIA 400 microgram per day FOLIC ACID or FOLACIN is a water soluble Liver B9 vitamin that’ s necessary for RBC formation Green leafy vegetables FOLLIC ACID ANEMIA Neural tube defect DIAGNOSTICS: Hydantoin- anticonvulsant drug Woman with poor gastric absorption – gastric bypass  Macrocytic RBCs surgery  Decreased reticulocyte count Hormonal contraceptives may play a great role COMPLICATIONS: EARLY SPONTANEOUS ABORTION PREMATURE SEPARATION OF THE PLACENTA FETAL NEURAL TUBE DEFECTS