Nursing Care of a Family Experiencing Pregnancy Complications PDF

NURSING CARE OF A FAMILY EXPERIENCING A PREGNANCY COMPLICATION FROM A PREEXISTING OR NEWLY-ACQUIRED ILLNESS Maebil Marie B. Go, MAN RN College of Nursing, Misamis University  At the end of the discussion, the students: 1.Define high-risk pregnancy, inc...

NURSING CARE OF A FAMILY EXPERIENCING A PREGNANCY COMPLICATION FROM A PREEXISTING OR NEWLY-ACQUIRED ILLNESS Maebil Marie B. Go, MAN RN College of Nursing, Misamis University  At the end of the discussion, the students: 1.Define high-risk pregnancy, including preexisting factors that contribute to its development such as diabetes mellitus or cardiovascular disease. Learning 2.Assess a woman with an illness during pregnancy. Outcomes 3.Plan nursing care using the nursing process. 4.Implement nursing care for a woman with illness that complicates pregnancy. HIGH RISK PREGNANCY A high-risk pregnancy is one in which a concurrent disorder, pregnancy-related complication, or external factor jeopardizes the health of the woman, the fetus, or both. Refers to not just one causative factor but includes psychological and social as well as physical aspects. CARDIOVASCULAR DISORDERS and PREGNANCY Cardiovascular disorders that most commonly cause difficulty during pregnancy are:  Valve damage concerns caused by rheumatic fever or Kawasaki disease  Congenital anomalies such as atrial septal defect or uncorrected coarctation of the aorta. Danger occurs primarily due to the increase in circulatory volume, especially in weeks 28 to 32, just after the blood volume peaks. A woman needs an interprofessional team approach to care during pregnancy. Ideally, she should visit her pregnancy care provider for prenatal care as soon as she suspects she is pregnant. Clinical features of KAWASAKI Disease  A Pregnant Client with Cardiac Disease Left Sided Right Sided  I. A WOMAN WITH LEFT-SIDED HEART FAILURE Occurs in conditions such as mitral stenosis, mitral insufficiency, and aortic coarctation. left ventricle cannot move the large volume of blood forward that it has received by the left atrium from the pulmonary circulation. Because of the limited oxygen exchange, a woman with left-sided heart failure is at an extremely high risk for spontaneous miscarriage, preterm labor, or even maternal death.  Paroxysmal Nocturnal Dyspnea – sudden waking at night with shortness of breath. II. A WOMAN WITH RIGHT-SIDED HEART FAILURE Occurs when the right ventricle is overwhelmed by the amount of blood received by the right atrium from the vena cava. Caused by an unrepaired congenital heart defect such as pulmonary valve stenosis, and commonly, Eisenmenger syndrome - right-to-left atrial or ventricular septal defect with an accompanying pulmonary valve stenosis. Women who have an uncorrected anomaly of this type may be advised not to become pregnant.  R-Sided Heart Failure Jugular venous distention Increase portal circulation (liver and spleen are distended) Distention of abdominal & lower extremities (ascites & peripheral edema) Extreme monitoring> may advised not to become pregnant.  III. A WOMAN WITH PERIPARTUM HEART DISEASE Peripartal cardiomyopathy - can originate in pregnancy in women with no previous history of heart disease cause is unknown – occurs due to stress in the circulatory system signs of myocardial failure such as shortness of breath, chest pain, and nondependent edema (eg.cardiomegaly)  WOMAN WITH PERIPARTUM HEART DISEASE Therapy; Reduce physical activity Diuretic, an arrhythmia agent, digitalis therapy (heart function) LMWH maybe administered - < risk of thromboembolism Immunosuppressive therapy If persist = no attempt for further pregnancies Assessment of Pregnant Patient with Cardiac Disease Continuous assessment Health education Health Promotion activities FETAL ASSESSMENT Low birth weights / small for gestational age (SGA) – due to acidosis which develops due to poor oxygen/carbon dioxide exchange or not being furnished with enough nutrients. Preterm labor exposes the newborn to the hazards of immaturity as well as low birth weight. CS birth may be necessary if fetal circulation is inadequate. NURSING INTERVENTIONS during L & B Assess maternal V/S and fetal HR. Monitor uterine contractions. Advise woman to assume a side-lying position. If dyspneic, position Semi-Fowler’s. Administer O2 inhalation as ordered. Continue hemodynamic monitoring as prescribed. Advised not to push with contractions (requires effort) > use EPIDURAL ANESTHESIA Be certain to point out that acrocyanosis is normal in newborns Administer meds (oxytocin, stool softener) as prescribed. Instruct patient not to begin postpartum exercises to improve abdominal tone until her primary care provider approves. Instruct importance of rest periods. IV. A WOMAN WITH ARTIFICIAL VALVE PROSTHESIS An artificial heart valve is a one-way valve implanted into a person's heart to replace a heart valve that is not functioning properly. Potential problem: use of oral anticoagulants taken to prevent the formation of blood clots at the valve site. Sodium Warfarin -increases the risk of congenital anomalies in infants. Observe a woman who is taking an anticoagulant for signs of petechiae and premature separation of the placenta during both pregnancy and labor. V. A WOMAN WITH CHRONIC HYPERTENSIVE VASCULAR DISEASE Elevated blood pressure (140/90 mmHg or above) Usually associated with arteriosclerosis or renal disease. Can be serious because it places both the woman and fetus at high risk because of poor heart, kidney, and/or placental perfusion during the pregnancy. Management: prescription of Beta blockers and calcium channel blockers to reduce BP ending in –lol (Beta-Blockers) eg. Labetalol (Trandate), ending in –dipine (Calcium Channel Blockers) eg. Nifedipine (Procardia) V. A WOMAN WITH VENOUS THROMBOEMBOLIC DISEASE Deep Vein Thrombosis (DVT) is the formation of a blood clot in the veins in the lower extremities. CAUSES: > stasis of blood in the lower extremities > hypercoagulability (effects of elevated estrogen), > vessel damage THROMBUS formation Deep Vein Thrombosis (DVT ) Pulmonary emboli  Risk may be reduced through:  Avoiding the use of constrictive knee-high stockings.  Not sitting with legs crossed at the knee.  Avoiding standing in one position for a long period Dx : patients history & Doppler Untrasonography Tx (to prevent pulmonary embolism) : Bed rest, IV Heparin for 24-48 hrs. for the duration of pregnancy, then SQ every 12 or 24 hrs. for the duration of pregnancy. SQ Heparin = lower abdomen (rotate sites) but with pregnancy lower abdomen is avoided , use arms & thigh.  S/Sx: Pain and redness usually in the calf of a leg S/Sx: Pulmonary embolism - chest pain, a sudden onset of dyspnea, a cough with hemoptysis, tachycardia or missed beats, or dizziness and fainting Caution for Heparin: not to take additional injections once labor begins to prevent hemorrhage at birth. HEMATOLOGIC DISORDERS AND PREGNANCY Hematologic disorders involve either blood formation or coagulation disorders. I. A WOMAN WITH IRON DEFICIENCY ANEMIA Most common anemia of pregnancy (15% - 25%) low serum iron level (under 30 μg/dl) May be microcytic (i.e., small red blood cell) and hypochromic (i.e., less hemoglobin than the average red cell) anemia. S/Sx: Extreme fatigue, poor exercise tolerance, pale skin, headache Associated with low birth weight and preterm birth May develop Pica, or cravings. Restless Leg Syndrome  Restless Leg Syndrome Uncontrollable urges to move the legs I. A WOMAN WITH IRON DEFICIENCY ANEMIA MANAGEMENT:  Take prenatal vitamins containing 27 mg of iron as prophylactic therapy during pregnancy  Eat a diet high in iron and vitamins.  Women who develop IDA will be prescribed therapeutic levels of medication (120 to 200 mg elemental iron per day), usually in the form of ferrous sulfate or ferrous gluconate.  IRON – best absorb in acid medium. I. A WOMAN WITH IRON DEFICIENCY ANEMIA NURSING INTERVENTIONS:  Advise to take iron supplements with orange juice or a vitamin C supplement.  Increasing roughage in the diet always taking the pills with food reduces constipation and gastric irritation.  Caution women that FeSO4 turns stools black to prevent them from worrying that they may be bleeding internally. II. A WOMAN WITH FOLIC ACID DEFICIENCY ANEMIA Folic acid, or folate or folacin, one of the B vitamins, is necessary for the normal formation of red blood cells in the woman as well as being associated with preventing neural tube and abdominal wall defects in the fetus. a megaloblastic anemia (enlarged red blood cells) – caused by Vit B12 & Folic Acid insufficiency Slow to progress; may take several weeks to develop or may not be apparent until the second trimester of pregnancy Full blown, it may be a contributory factor in early miscarriage or premature separation of the placenta. II. A WOMAN WITH FOLIC ACID DEFICIENCY ANEMIA MANAGEMENT Supplement of 400 μg folic acid daily in addition to eating folate-rich foods (e.g., green leafy vegetables, oranges, dried beans) Women who develop folic acid–deficiency anemia are prescribed even higher or therapeutic levels of folic acid III. A WOMAN WITH SICKLE CELL ANEMIA Recessively inherited hemolytic anemia caused by an abnormal amino acid in the beta chain of hemoglobin. Majority of red blood cells are irregular or sickle shaped III. A WOMAN WITH SICKLE CELL ANEMIA ASSESSMENT All patients who have not been previously tested should be screened for sickle cell anemia at a first prenatal visit. Hemoglobin levels for all women with sickle-cell disease should then be obtained throughout pregnancy. A woman with sickle-cell disease may normally have a hemoglobin level of 6 to 8 mg/100 ml. Assess for varicosities in the lower extremities Periodically, collect clean catch urine sample during pregnancy to detect asymptomatic bacteriuria. III. A WOMAN WITH SICKLE CELL ANEMIA NURSING INTERVENTIONS: Blood transfusions as ordered throughout pregnancy to replace sickled cells with non-sickled cells Control pain, Administer O2 as needed (if Sickle Cell Crisis occurs) Monitor nutritional intake (sufficient amount folic acid  to replace RBC that has been destroyed) Monitor that women should not take a routine iron supplement as sickled cells cannot incorporate iron in the same manner as non-sickled cells Ensure the woman is drinking at least eight glasses of fluid daily (guard against dehydration) III. A WOMAN WITH SICKLE CELL ANEMIA NURSING INTERVENTIONS: Advise to sit on a chair with the legs elevated Advise that lying on the side in a modified Sims position encourages venous return from the lower extremities. Help a woman plan her day so she has limited long periods of standing and adequate rest periods. Monitor fetal health through UTZ IV. A WOMAN WITH THALASSEMIA Autosomal recessive inherited blood disorders that lead to poor hemoglobin formation and severe anemia. Occur most frequently in Mediterranean, African, and Asian populations. Treatment focuses on combating anemia through such measures as folic acid supplementation and perhaps blood transfusion to infuse hemoglobin-rich red blood cells. Women do not usually take an iron supplement during pregnancy because they could receive an iron overload because iron is infused with blood transfusions V. A WOMAN WITH MALARIA Malaria is a protozoan infection that is transmitted to people by Anopheles mosquitoes. Causes red blood cells to stick to the surface of capillaries causing obstruction of these vessels and resulting in end-organ anoxia and blood not reaching organs effectively. Mother-to-fetus transmission Incubation period: 12 to 14 days Most noticeable S/Sx: elevated liver function tests with fever, malaise, headache, V. A WOMAN WITH MALARIA COMPLICATIONS: Thrombocytopenia (i.e., low platelet count) Anemia, Renal failure TX: Antimalarial drugs such as Sulfadoxine, Pyrimethamine, Chloroquine (drug of choice) V. A WOMAN WITH MALARIA PREVENTION: Wearing clothing that covers most of the body Using an insect repellent Sleeping at night with a mosquito net Keeping windows closed to prevent mosquitoes from entering Urge women to delay travel to endemic areas until after pregnancy if possible. HYPERTENSIVE DISORDERS IN PREGNANCY  Gestational Hypertension is a condition in which vasospasm in both small and large arteries during pregnancy, causing increased blood pressure. PREECLAMPSIA Pregnancy-related disease process evidenced by increased blood pressure and proteinuria. Cause: unknown Risk factors:  Women of color  Multiple pregnancy  Primipara younger than 20 years old or older than 40 years old  Low socioeconomic backgrounds (perhaps because of poor nutrition);  Five or more pregnancies  Polyhydramnios (i.e., overproduction of amniotic fluid)  Underlying disease such as heart disease, diabetes with vessel or renal involvement, and essential hypertension NURSING INTERVENTIONS (PREECLAMPSIA WITHOUT SEVERE FEATURES) Monitor antiplatelet therapy Promote bed rest Promote good nutrition Provide emotional support NURSING INTERVENTIONS (PREECLAMPSIA WITH SEVERE FEATURES) Support bed rest Monitor maternal well-being Monitor fetal well-being Support nutritious intake Administer meds to prevent eclampsia – (Hypotensive Drug) Hydralazine (Apresoline), Labetalol, Nifedipine (lowers BP & do not interfere w/ placental circulation) – Drug of choice: Signs and Symptoms of Magnesium Sulfate Toxicity MgSO4 Hypotension (Anticonvulsant) Bradycardia – The drug begins to act Respiratory depression almost immediately; < LOC unfortunately, the effect Decreased urine output (8 mg/dL: Loss of reflexes MsSO4 toxicity) >10 mg/dL: Respiratory depression >15 mg/dL: Cardiac arrest NURSING INTERVENTIONS (ECLAMPSIA) Seizures (tonic-clonic seizures) Maintain patent airway – Priority! – Turn to side Administer MgSO4 IV or Diazepam (Valium) Administer O2 (protect fetal oxygenation) Monitor O2 saturation Assess FHR Check for vaginal bleeding – to detect placental separation Safety Measures for Seizures Stay with the patient to monitor the seizure activity. Protect the head by placing a soft object/ pillows Loosen tight clothing Remove harmful objects from the area to prevent injury. Do not restrain the patient or restrict their movements. turn the patient onto their side to prevent aspiration and keep the airway clear. Do not place anything in the patient’s mouth. Ensure suction equipment is readily available in case of excessive secretions or vomiting.  COAGULATION DISORDERS AND PREGNANCY COAGULATION DISORDERS 1. Von Willebrand disease Inherited as an autosomal dominant trait, and so does occur in women. caused by a deficiency or dysfunction of von Willebrand factor (vWF), a protein that helps blood clot. Women will have normal platelet counts, but bleeding time is prolonged, may experienced menorrhagia or frequent episodes of epistaxis as a child. May lead to spontaneous miscarriage or postpartum hemorrhage Management = replacement of coagulation factor by infusion of cryoprecipitate or fresh frozen plasma before labor COAGULATION DISORDERS 2. Hemophilia B (Christmas disease/Factor IX deficiency) = caused by a deficiency or dysfunction of Factor IX, a clotting protein essential for blood coagulation sex-linked disorder, so the actual disease occurs only in males female carriers may have such a reduced level of factor IX, that hemorrhage with labor or a spontaneous miscarriage can be a serious complication COAGULATION DISORDERS COAGULATION DISORDERS 3. Idiopathic Thrombocytopenic Purpura (ITP) a decreased number of platelets in the blood.  COAGULATION DISORDERS Idiopathic thrombocytopenic purpura (ITP) Treatment: RENAL AND URINARY DISORDERS AND PREGNANCY I. A WOMAN WITH UTI During pregnancy, ureters dilate from the effect of progesterone and stasis of urine can occur. Glycosuria with pregnancy provides an ideal medium for growth for any organisms present. Asymptomatic infections are potentially dangerous because they can progress to pyelonephritis, are associated with preterm labor and premature rupture of membranes (PROM) Pyelonephritis Infection of the pelvis of the kidney. I. A WOMAN WITH UTI The organism most commonly responsible for UTI is Escherichia coli from an ascending infection. Can also occur as a descending infection or can begin in the kidneys from the filtration of organisms present from other body infections I. A WOMAN WITH UTI ASSESSMENT Common S/Sx of UTI : frequency and pain on urination With Pyelonephritis, pain in the lumbar region (usually on the right side) that radiates downward, costovertebral tenderness Accompanying nausea and vomiting, malaise, pain (dull & flank pain extending towards the umbilicus) and frequency of urination, Elevated temperature. Urine culture reveals bacteriuria  UTI Pyelonephri Signs and Symptoms: Dysuria: Painful or burning sensation tis Signs and Symptoms: High Fever: Often greater than 100.4°F (38°C), during urination. Frequency: Urinating more often than typically accompanied by chills. Flank Pain: Pain or tenderness on the side of usual, even with small amounts of urine. the body, usually near the lower back, where Urgency: A strong, persistent urge to the kidneys are located. urinate. Dysuria: Pain or burning sensation during Cloudy or foul-smelling urine: Often urination. indicates infection. Frequency and Urgency: Similar to a UTI, but Hematuria: Presence of blood in the more pronounced. Nausea and Vomiting: Common, due to the urine, making it appear pink or red. Suprapubic Pain: Discomfort or pain in severity of the infection. Cloudy or foul-smelling urine: May also be the lower abdomen (above the pubic present. bone). Hematuria: Blood in the urine, sometimes Mild Fever: Usually low-grade, if present. seen. No systemic symptoms: Generally, Systemic Symptoms: The patient may feel there are no systemic symptoms like chills generally unwell, with symptoms such as or significant pain beyond the lower fatigue, malaise, and chills. abdomen. Possible Dehydration: Due to vomiting and fever. I. A WOMAN WITH UTI MANAGEMENT Obtain a clean-catch urine sample for culture and sensitivity Meds: Amoxicillin, ampicillin, and cephalosporins are effective against most organisms causing UTIs and are safe antibiotics during pregnancy Pain Management: Over-the-counter pain relievers like acetaminophen or ibuprofen can help relieve pain and fever Hydration: Drinking plenty of fluids helps flush out bacteria from the urinary system. II. A WOMAN WITH HYPERACTIVE BLADDER Hyperactive bladder refers to a bladder that contracts more frequently than usual, causing symptoms of frequency, urgency, and incontinence (involuntary leakage of urine). Tx: Antispasmodic drug (Fesoterodine) should be used during pregnancy and breastfeeding only if the risk outweighs the benefit until it is proven not to be teratogenic III. A WOMAN WITH CHRONIC RENAL DISEASE Women with chronic renal disease and even women who have had renal transplants, can expect to have healthy pregnancies and healthy children with conscientious prenatal care Need to be monitored carefully during pregnancy because their diseased kidneys may not produce erythropoietin, a glycoprotein necessary for red cell formation and so they may develop a severe anemia. III. A WOMAN WITH CHRONIC RENAL DISEASE Many women with renal disease routinely take a corticosteroid such as oral prednisone at a maintenance level. Women with severe renal disease may require dialysis to aid kidney function during pregnancy With dialysis, there is a risk of preterm labor, perhaps because progesterone is removed with the dialysis. III. A WOMAN WITH CHRONIC RENAL DISEASE CRITERIA TO BE EVALUATED IN WOMEN WITH KIDNEY TRANSPLANTS:  LET’S REVIEW! Symptoms: Left-sided heart failure Symptoms: Right-sided heart failure SGA? Position: Dyspneic patient  LET’S REVIEW! DVT? Symptoms: DVT Types of Anemia? Prevention: Malaria  LET’S REVIEW! Menorrhagia? PROM? Common causative agent: UTI Nursing Interventions: UTI Nursing Interventions: Sickle Cell Anemia RESPIRATORY DISORDERS I. ACUTE NASOPHARYNGITIS (common cold) Caused by virus – no antibiotic except to prevent secondary infection Check with AP before taking OTC meds Simples measures to combat colds:  Get extra rest and sleep and eat a diet high in vitamin C  Take acetaminophen (Tylenol) every 4 hours for aches and pains. Do not take aspirin – interfere with blood clotting.  Use a room humidifier or apply a medicated vapor rub to the chest, especially at night, to moisten nasal secretions and help mucus drain.  Use cool or warm compresses to relieve sinus headaches II. INFLUENZA Caused by virus S/Sx: high fever, extreme prostration, aching pains in the back and extremities, and generally, a sore, raw throat. Tx:  Antipyretic (Acetaminophen/Tylenol)  Immunization  COVID -19 is a respiratory illness caused by the SARS- CoV-2 virus. It emerged in late 2019 and has since caused a global pandemic. Caused severe respi & cardiovascular symptoms S/S ; cough, fever, SOB, loss of taste & smell, fatigue, sore throat, congestion, & GI symptoms. III. PNEUMONIA Bacterial or viral invasion of lung tissue by pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, and Mycoplasma pneumoniae After the invasion, an acute inflammatory response occurs in the lung alveoli, causing an exudate of red blood cells, fibrin, and leukocytes to flood into the alveoli. MGT:  Antibiotic  O2 inhalation  Ventilation support in severe cases  PNEUMONIA DX : S/S: X-ray, Inc. WBC, + Low –pitched crackles Sputum Culture Cough (yellow sputum) Difficulty breathing Fever/chills Loss of appetite Pleuritic chest pain (sharp Associated with fetal chest pain upon inspiration) growth restriction & preterm birth (due to O2 deficit) IV. ASTHMA Marked by reversible airflow obstruction, airway hyperactivity, and airway inflammation. (Bronchoconstriction) Often triggered by an inhaled allergen (pollen, smoking), smoking, stress Constriction of the bronchial smooth muscle, marked mucosal inflammation and swelling, and the production of thick bronchial secretions has the potential of reducing the oxygen supply to a fetus leading to preterm birth or fetal growth restriction. MGT: β-Adrenergic agonists such as terbutaline and albuterol may be taken safely during pregnancy, but because they have the potential to reduce labor contractions, the dosage may be tapered close to term if possible S/S High- pitched wheezing SOB/ dyspnea Accessory muscle “paradoxical breathing’ Minimal diminished breath sounds V. TUBERCULOSIS Lung tissue is invaded by Mycobacterium tuberculosis. It is inhaled through respiratory droplets. The bacteria reach the lungs and settle in the alveoli. Alveolar macrophages engulf the bacteria. Mycobacterium tuberculosis resists destruction inside the macrophages, multiplying instead. This triggers an immune response, attracting more immune cells (lymphocytes and macrophages). The immune system walls off the bacteria, forming granulomas (tubercles). Inside the granuloma, some bacteria may remain dormant (latent TB). Antibodies produced – positive Mantoux test (purified protein derivative [PPD] test. V. TUBERCULOSIS ASSESSMENT Chronic cough, are substantial weight loss, hemoptysis (coughing blood), a low-grade fever, extreme fatigue, and waking at night with night sweats If (+) PPD – to undergo CXR (lead shielded) or a sputum culture V. TUBERCULOSIS THERAPEUTIC MGT Pregnant women with TB need tx: Isoniazid (INH), Rifampicin, Ethambutol - Drugs of Choice INTERVENTIONS Obtaining a negative sputum culture after birth rules out active tuberculosis Urge the woman to continue taking her tuberculosis medications as prescribed during breastfeeding as only small amounts of these are secreted in breast milk and so are safe for her infant.  Rifampicin Isoniazid (INH) - Causes - Causes hepatotoxicity (jaundice, vomiting, dark hepatotoxicity urine, n/v) & peripheral neuropathy (numbness, tingling) *avoid alcohol intake & Ethambutol hepatotoxic agent (acetaminophen) - Causes ethambutol-induced *take pyridoxine (vit. B6) to prevent neuropathy optic neuropathy (ION), loss *avoid aluminum containing of color green recognition antacid (within 1 hr. of taking INH) *report changes in vision (blurred, loss vision) Risk Factors TB treatment is long-term Close contact with someone and uses a combination of who has active TB. antibiotics to prevent Weakened immune system (e.g., HIV/AIDS, diabetes). resistance. Treatment is Malnutrition. divided into two phases: Smoking or substance abuse. Intensive Phase (2 Living or working in crowded conditions (e.g., months): prisons, shelters). – First-line drugs: Rifampin Travel or residence in areas (RIF), Isoniazid (INH), with high TB prevalence. Pyrazinamide (PZA), Ethambutol (EMB). VI. CHRONIC OBSTRUCTIVE PULMONARY DSE (COPD) Constriction of the airway associated most often with long-term cigarette smoking, exposure to respi. irritants Associated with fetal growth restriction and preterm birth Women may need additional rest during pregnancy Prescribed continuous positive airway pressure (CPAP) at night if with sleep apnea. Advised to have a cesarean birth. Pregnancy may be the time a woman with COPD realizes she needs to stop smoking Cystic Fibrosis Recessively inherited disease - generalized dysfunction of exocrine gland. Mucus secretions (pancreas & lungs) Show symptoms of chronic respi infection & overinflation of lungs (thickened mucus), difficulty digesting fat and protein (pancreas cannot release amylase) Inadequate O2 supply to the fetus - growth restriction, preterm labor, perinatal death. Administration of Pancrealipase - to supplement pancreatic enzyme Bronchodilator or antibiotics – reduce pulmonary symptoms. RHEUMATOIC DISORDERS I. RHEUMATOID ARTHRITIS aka Juvenile Rheumatoid Arthritis (JRA) or chronic rheumatoid arthritis marked by joint inflammation and contractures Meds: corticosteroids,hydroxychloroquine, and NSAIDs (prevent joint pain & loss of mobility) Some women may be taking oral aspirin therapy (salicylates) – lead to increased bleeding & may fetus may also experience premature closure of ductus arteriosus Those taking low dose methotrexate (a carcinogen) should stop taking this prepregnancy because of the danger of head and neck defects in the fetus. II. SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) is a multisystem chronic disease of connective tissue that occurs most frequently in woman 20 to 40 years of age Widespread degeneration of connective tissue (especially of the heart, kidneys, blood vessels, spleen, skin, and retroperitoneal tissue) occurs with onset of the illness. A marked skin change: erythematous butterfly-shaped rash on the face. Prepregnancy, a woman may be taking a combination of NSAIDs, low– molecular-weight heparin, salicylates, hydroxychloroquine, low-dose prednisone, or azathioprine (an immunosuppressant) to reduce Sx.  Can cont. to use these meds during pregnancy but with caution. Reduce dose of salicylates 2 weeks prior to labor to prevent bleeding in newborn and premature closure of the ductus arteriosus. GASTROINTESTINAL DISORDERS I. APPENDICITIS Inflammation of the appendix Pain in overstretched round Appendicitis - pain not only ligaments fades almost continues but grows more instantly intense. Ectopic pregnancy - woman may Appendicitis - nausea and experience morning sickness, and vomiting is much more intense the pain she feels is either diffuse and the pain is sharp and or sharp. localized at McBurney point I. APPENDICITIS THERAPEUTIC MANAGEMENT CS along with appendectomy (past 37 weeks pregnancy). If early in pregnancy, appendectomy by laparoscopy. If the appendix ruptures before surgery, the risk to both mother and fetus increases dramatically. II. ESOPHAGEAL REFLUX DISEASE (GERD) aka Hiatal hernia refers to the reflux of acid stomach secretions into the esophagus. S/Sx: Heartburn, which is particularly extreme when lying supine after a full meal Gastric regurgitation Dysphagia (difficulty swallowing) Possible weight loss because of the stomach pain Hematemesis II. ESOPHAGEAL REFLUX DISEASE (GERD) NURSING INTERVENTIONS: Administer medications as prescribed - antacid, proton pump inhibitor such as Esomeprazole Magnesium (Nexium) Advise a woman to wear clothing that is loose around her waist. Sleep with her head elevated on two or more pillows to help confine stomach secretions. III. PANCREATITIS Inflammation of the pancreas Rare disorder that tends to occur in late adolescents and so may occur during pregnancy. S/Sx: severe epigastric pain, nausea, vomiting, anorexia, and fever Tx:  Nasogastric suction  Bowel rest  Analgesia  Intravenous hydration through parenteral nutritional supplementation IV. HEPATITIS Liver disease that occurs from invasion of the hepatitis A, B, C, D, or E virus. Hep A – fecal-oral contact Hep B & C - exposure to contaminated blood or blood products or by contact with contaminated semen or vaginal secretions; transplacental Hep D & E - spread by the same methods as hepatitis B and C but are rarely seen in pregnant women. IV. HEPATITIS Women exposed to the virus receive immune globulin for prophylaxis; a hepatitis B vaccine can be administered to those who are at high risk, such as women who handle blood products, to prevent the illness. IV. HEPATITIS ASSESSMENT N/V Tender liver upon palpation Dark yellow urine Light-colored stools Jaundice (late symptom) Hepatomegaly Elevated liver enzymes Elevated serum bilirubin IV. HEPATITIS THERAPEUTIC MANAGEMENT Bed rest High caloric diet CS may be done to reduce the possibility of blood exchange between mother and fetus – follow standard precaution! IV. HEPATITIS NURSING INTERVENTIONS (after birth) Encourage breastfeeding. Infant should be washed well to remove any maternal blood hepatitis B immune globulin (HBIG) and the first dose of hepatitis B should be administered. The infant then needs to be observed carefully for symptoms of infection during the first few months of life and for chronic liver disease as he or she grows older. ENDOCRINE DISORDERS I. HYPOTHYROIDISM Underproduction of the thyroid hormone rare in pregnancy because women with symptoms of untreated hypothyroidism are often anovulatory and unable to conceive. S/Sx: fatigue easily, tend to be obese, their skin is dry (myxedema), and they have little tolerance for cold. It may be associated with an increased incidence of extreme nausea and vomiting (i.e., hyperemesis gravidarum). Drug: levothyroxine (Synthroid) II. HYPERTHYROIDISM Overproduction of thyroid hormone Aka Graves disease S/Sx: rapid heart rate, exophthalmos (i.e., protruding eyeballs), heat intolerance, heart palpitations, and weight loss If undiagnosed, a woman may develop heart failure because her heart, already stressed, cannot manage the increasing blood volume that occurs with pregnancy III. DIABETES MELLITUS Pancreas cannot produce adequate insulin to regulate body glucose levels. The primary concern for any woman with this disorder is controlling the balance between insulin and blood glucose levels to prevent hyperglycemia or hypoglycemia. III. DIABETES MELLITUS GESTATIONAL DM Develops during the second or third trimester The symptoms fade again at the completion of pregnancy, but the risk of developing type 2 diabetes later in life may be as high as 50% to 60%. III. DIABETES MELLITUS ASSESSMENT: Fasting plasma glucose greater than or equal to 126 mg/dl or a nonfasting plasma glucose greater than or equal to 200 mg/dl meets the threshold for the diagnosis of diabetes and does not need confirmation. Recommended that all pregnant women receive a 50-g glucose challenge test between 24 and 28 weeks gestation to determine if they are at risk for gestational diabetes. After a fasting glucose sample is obtained, the woman drinks an oral 100-g glucose solution; a venous blood sample is then taken for glucose determination at 1, 2, and 3 hours later. III. DIABETES MELLITUS III. DIABETES MELLITUS MONITORING A WOMAN WITH DM Glycosylated hemoglobin (HbA1c) - reflects the average blood glucose level over the past 4 to 6 weeks Urine culture done every semester Opthalmic exam at each trimester III. DIABETES MELLITUS THERAPEUTIC MGT Insulin therapy Blood glucose monitoring Insulin pump therapy III. DIABETES MELLITUS NURSING INTERVENTIONS Screening: 1 hour oral glucose tolerance test at 24 to 28 weeks. Screening: 3 hour oral glucose tolerance test (administer if 1 hr ogtt abnormal) Diet and exercise Test urine for glucose during prenatal visits Monitor blood glucose levels during and after labor Know risk factors for GDM: