Prelim Cardio-Respi PDF

I. CARDIOVASCULAR DISORDERS AND PREGNANCY The number of adult of childbearing age who output increases approximately 30% during have heart disease is diminishing as more and pregnancy. (up to as much as 50%) more congenital heart anomalies are corrected in Half...

I. CARDIOVASCULAR DISORDERS AND PREGNANCY The number of adult of childbearing age who output increases approximately 30% during have heart disease is diminishing as more and pregnancy. (up to as much as 50%) more congenital heart anomalies are corrected in Half of this increase occurs by 8 weeks and is infancy. maximized by midpregnancy. Rheumatic fever- actively prevented and treated The danger of pregnancy in woman with cardiac = cardiac damage reduced. disorder occurs primarily because of this Cardiovascular disease which was once a major increase in volume. threat to pregnancy, now complicates only 1% of The most dangerous time for her is in weeks 28 all pregnancies. to 32 just after the blood volume peaks. o Leads to serious complications. However, if heart disease is severe, symptoms o Responsible for 5% of deaths during can occur at the very beginning of pregnancy. pregnancy Towards the end of pregnancy her heart may The cardiovascular disorders that most become so overwhelmed by the increase in blood commonly cause difficulty during pregnancy are volume that her cardiac output falls to the point valve damage concerns caused by Rheumatic vital organs (including placenta) can no longer be fever or Kawasaki disease and congenital perfused adequately. anomalies such as atrial septal defect or Type and extent of the disease are needed for a uncorrected coarctation of the aorta. successful pregnancy for pt with pre-existing Aortic dilatation may occur from Marfan cardiovascular disease syndrome To predict a pregnancy outcome, heart disease is Coronary artery disease and varicosities divided into four categories based on criteria Peripartum heart disease – heart disease that established by the New York Heart Association. occurs w/ pregnancy – rarely occurs bc it is Class 1 – Uncompromised unrelated to age. o no discomfort A person with cardiovascular disease needs an o no symptoms of cardiac insufficiency interprofessional team approach to care during o no angina pain pregnancy. Class II – slightly compromised Ideally, she should visit her pregnancy care o Excessive fatigue provider for preconception care so her state of o Palpitation health and baseline data can be established. o Dyspnea or angina pain She should begin prenatal care as soon as she Class III- markedly compromised suspects she is pregnant (1 week after the first o Excessive fatigue missed menstrual period or as soon as she has a o Palpitations positive home pregnancy test) so her general o Dyspnea or angina pain condition and circulatory system can be Class IV – Severely compromised monitored from the beginning of the pregnancy. o Unable to carry any physical activity Pregnancy taxes the circulatory system of every without experiencing discomfort. woman, even those without cardiac disease, o At rest – symptoms of cardiac 1 because both the blood volume and cardiac insufficiency or anginal pain are present Page cpreapred  Class I and Class II – normal pregnancy and birth Class III – maintain special intervention; bed rest ▪ With this, interstitial fluid returns Class IV- avoid pregnancy, cardiac failure even to the circulation – overburdens at rest and when they are not pregnant. circulation= increases left-sided failure and pulmonary edema A PREGNANT PATIENT WITH CARDIAC If mitral stenosis is present, it will be so difficult DISEASE for blood to leave the left atrium that a Cardiac disease can affect pregnancy in different secondaryproblem of thrombus formation can ways depending on whether it involves the left or occur from non circulating blood. the right side of the heart. o to prevent thrombus formation, a woman may be prescribed anti-coagulants PREGNANT PATIENT WITH LEFT-SIDED o if anti-coagulant is required, low- HEART FAILURE molecular-weight heparin (LMWH) is Occurs in conditions such as mitral stenosis, the drug of choice for early pregnancy bc mitral insufficiency, and aortic coarctation. it doesn’t cross the placenta so does not The left ventricle cannot move the large volume have a teratogenic effects. of blood forward that it has received by the left if coarctation of the aorta is causing the atrium from the pulmonary circulation. - this difficulty, dissection of the aorta from High BP causes back pressure, left side of the heart from trying to push blood past the constriction becomes distended, systemic blood pressure can occur. decreases, pulmonary hypertension occurs. o To decrease strain on the aorta, When pressure of the pulmonary vein reaches 25 antihypertensives may be prescribed to mm Hg, fluid begins to pass from pulmonary control BP. capillary membranes-interstitial o Diuretics to reduce blood volume spaces(surrounds the lung and alveoli)-alveoli o Beta blockers to improve ventricular themselves. filling Pulmonary Edema- produces profound Pregnant pt will be scheduled for NST after shortness of breath as is interferes with oxygen- weeks 30-32 of pregnancy to monitor fetal cardon dioxide exchange. – health & rule out poor placental perfusion. o because of the limited oxygen exchange, a woman with left sided heart failure is at high risk for spontaneous miscarriage, PREGNANT PATIENT WITH RIGHT-SIDED preterm labor, or even maternal death. HEART FAILURE o as it become severe, a woman cannot Happens when the output of the right ventricle is sleep in any position except with her overwhelmed by the amount of blood received by the chest and head elevated (orthopnea) right atrium from the vena cava. o she may also notice paroxysmal Can be caused by unrepaired congenital heart nocturnal dyspnea, suddenly waking up defect; pulmonary valve stenosis at night with shortness of breath. Results in congestion of the systemic venous ▪ Heart action is more effective at circulation and also decrease in cardiac output. BP decreases in the aorta, bc less blood is able to 2 rest Page reach it. cpreapred  Pressure is high in vena cava, leading to jugular A PREGNANT PAATIENT WITH vein distention and increased portal circulation. PERIPARTUM HEART DISEASE Both jugular venous distension and increases Peripartum heart disease- a condition that portal circulation are evident. develops during pregnancy. Liver and spleen both become distended An extremely rare condition, peripartal Liver is enlarged, and this could cause extreme cardiomyopathy ( weakness of the heart dyspnea and pain in a pregnant woman. muscle) can originate in pregnancy in those with Eisenmenger syndrome is the congenital no previous history of heart disease. anomaly that would most likely cause right- Cause is unknown, this occurs bc of the stress of sided heart failure in women of reproductive pregnancy on the circulatory system. age. Mortality rate – as high as 50% o it is a right-left atrial or ventricular Occurs most in black multiparas in conjunction septal defect with pulmonary stenosis. with gestational hypertension. individuals who have uncorrected anomaly of Signs of myocardial failure; shortness of breath, this type are advised not become pregnant chest pain, nondependent edema. if they do plan a pregnancy then they can expect The heart increases size(cardiomegaly) to be hospitalized for days during the last part of Therapy: pt must sharply reduce their physical pregnancy. activity, most individual needs diuretic, During labor, may need pulmonary artery arrhythmia agents, digitalis therapy to maintain catheter inserted to monitor pulmonary pressure. heart function. Patients with this condition need closed LMWH may be administered to decrease the risk monitoring after epidural anesthesia to minimize of thromboembolism. risk of hypotension. Immunosuppressive therapy is yet another possibility to improve symptoms. If the cardiomegaly persists past the postpartum period, it is generally suggested that a patient not attempt any further pregnancies because the condition tends to recur or worsen in additional pregnancies. At the same time, oral contraceptives are contraindicated because of the danger of thromboembolism that these can create. In some cases, the disease progresses so much that following pregnancy, the patients may need a heart transplant. 3 Page cpreapred ASSESSMENT OF A PREGNANT PATIENT o because the enlarged uterus presses the WITH CARDIAC DISEASE liver upward under the ribs and makes it Continuous assessment of the health status, difficult to palpate. health education, and health-promotion activities For an additional cardiac status assessment, an Assessment begins with a thorough health electrocardiogram (ECG) or an echocardiogram history to document prepregnancy cardiac may be done at periodic points in pregnancy. status. Assure the patient that an ECG merely measures Document the patient’s level of performance cardiac electrical discharge and so cannot harm Ask if they normally have cough or edema the fetus in any way. o it's important that those with cardiac Echocardiography uses ultrasound and , likewise, disease always report coughing during will not harm the fetus. pregnancy because pulmonary edema FETAL ASSESSMENT from heart failure may first manifest itself as a simple cough. At the point that BP becomes insufficient to Documenting edema is also important because provide an adequate supply of blood and the usual innocent edema of pregnancy must be nutrients to the placenta, fetal health can be distinguished from the beginning of edema from compromised. heart failure (serious). For this reason, the infants of those with severe o An important difference is that the usual heart disease tend to have low birth weights or edema of pregnancy involves only the feet be small for gestational age because of acidosis, and ankles but becomes systemic with heart which develops due to poor oxygen-carbon failure. It can begin as early as the first dioxide exchange or not being furnished with trimester, and other symptoms such as enough nutrients. irregular pulse, rapid or difficult This can result in preterm labor, which exposes respirations, and chest pain on exertion the newborn to the hazards of immaturity as well will likely be present. as low birth weight. Be certain to record a baseline BP, pulse rate, If the placenta circulation is inadequate, a fetus and respiratory rate in either a sitting or lying may not respond well to labor (evidenced by late position at the first prenatal visit; deceleration patterns on a fetal heart monitor), o at future health visits, always obtain these and a cesarean birth may be necessary (an in the same position for the most accurate increased risk for both the patient and fetus). comparison. Making comparison assessments for nail bed Interventions during Labor and Birth filling (should be less than 5 seconds) Frequently assess BP, pulse, rr, monitor FHR and jugular venous distention can also be helpful uterine contraction for those with heart disease throughout pregnancy. Assume side-lying position to reduce possibility If a patient's heart disease involves right-sided of supine hypotension heart failure, assess liver size at prenatal visits. If patient have pulmonary edema, elevate head Keep in mind that liver assessments can become and chest (semi fowler position) 4 difficult and probably inaccurate late in Page pregnancy cpreapred  Many with heart disease should not push with A PREGNANT PATIENT WITH CHRONIC contractions VASCULALR DISEASE Bc of lack of pushing, low forceps of vacuum Patient’s with this disease enter pregnancy with extractor may be used for birth. elevated BP (140/90 mmHg or above) NURSING CARE PLAN USING ASSESSMENT Hypertension of this kind is usually associated with arteriosclerosis or renal disease, making it a ASSESSING A PREGNANT WOMAN WITH problem for older pregnant pt. COUGH DISEASE Chronic hypertension – can be serious and place Fatigue both the pt and infant at high risk due of poor Cough heart, kidney, and/ placental perfusion during Increased respiratory rate pregnancy. Tachycardia Management: prescription of beta-blockers and Decreased amniotic fluid from intrauterine calcium channel blockers to reduce BP. growth restriction Typical drugs prescribed: Labetalol (trandate) Poor FHT variability form poor perfusion nifedipine (Procardia) Edema from poor venous return. A PREGNANT PATIENT WITH AN A PREGNANT PATIENT WITH VENOUS ARTIFICIAL VALVE STENOSIS THROMBOEMBOLIC DISEASE In the past, pt with heart valve prostheses are The incidence of this disease increases during advised not to become pregnant for fear of pregnancy increased blood volume gained during o because of a combination of stasis of blood pregnancy. in the lower extremities from uterine Today, pt with valve prostheses can now become pressure and hypercoagulability (the effect pregnant. of elevated estrogen). When the pressure of One potential problem involves the use of oral the fetal head at birth puts additional anti-coagulant taken to prevent blood clot pressure on lower extremity veins, damage formation at the valve site. can occur to the walls of the veins. o Bc sodium warfarin (Coumadin), o With this triad of effects in place (stasis, increases risk of congenital anomalies in vessel damage, and hypercoagulation), infants the stage is set for thrombus formation in the o Pt are usually placed on LMWH therapy lower extremities. before and during pregnancy. The likelihood of deep vein thrombosis (DVT), Subclinical bleeding from continuous formation of a blood clot in the veins of the lower anticoagulant therapy has potential to cause extremities, leading to pulmonary emboli is placental dislodgment highest in those 30 years or older because Therefore, observe those on anticoagulant for increased age is yet another risk factor for signs of petechiae and premature separation of thrombosis formation 5 the placenta during labor and pregnancy. The risk can be reduced through common-sense Page measure; avoiding constricted knee-high cpreapred  stockings, not sitting with legs crossed at the knee, not standing in one position for a long o Corticosteroid – help reduce formation of time. antibodies Signs: (during pregnancy) pain and redness in o No oral contraceptives after pregnancy bc calf of leg they can increase blood coagulation and the DVT is diagnosed through a patient’s history and possibility of thrombi formation. Doppler ultrasonography. Treatment to keep thrombus form moving and becoming pulmonary embolus: o Bed rest o IV heparin for 24-48h o Subcutaneous heparin may be prescribed for injection every 12/24h for duration of the pregnancy. Lower abdomen recommended sight used for subcutaneous heparin injection. o For pregnancy, this site is avoided and injection sites are limited to the arms and thighs. Signs of pulmonary embolism o Chest pain, sudden onset of dyspnea, cough w/ hemoptysis, tachycardia or missed beats, dizziness, and fainting. Heparin or sodium warfarin is can be prescribed after birth if patient is not breastfeeding Coumadin should be used cautiously while breastfeeding. Majority of thrombosis occurs in postpartum period Additional measures for DVT o Heat, elevation, and bed rest PT more susceptible to thrombi formation; o Spontaneous miscarriage, fetal death, hypertension of pregnancy o This group consist of those with antiphospholipid antibodies (aPLAS) Those with aPLA positive o Prophylactic programs of aspirin or SUBQ 6 Page heparin during pregnancy cpreapred  II. HEMATOLOGIC DISORDERS AND PREGNANCY Involves blood formation or coagulation Mildly associated with low birth weight and disorders preterm birth, some developed pica, and restless Because the blood volume expands during leg syndrome. pregnancy slightly ahead of the red cell count, To prevent common anemia most individuals have a pseudoanemia in early o Pt must take prenatal vitamins 27mg of pregnancy. iron as prophylactic therapy o This condition is normal and of anemia that o Eat diets high in iron and vitamins occur should not be confused with true types For pt with anemia as complications of pregnancy. o Ferrous sulfate/ ferrous gluconate True anemia is typically considered to be present Iron is best absorbed in acidic medium. – vit c when the hemoglobin concentration is less than supplments -> ascorbic acid 11 g/dL (hematocrit less than 33%) in the first or Ferrous sulfate turns stool black third trimester of pregnancy or when the IV iron can be prescribed if oral iron therapy is hemoglobin con- centration is less than 10.5 g/dL contraindicated (hematocrit less than 32%) in the second A PREGNANT PATIENT WITH FOLIC ACID- trimester. DEFICIENCY ANEMIA A PREGNANT PATIENT WITH IRON- Folic acid, folacin, folate, one of B vitamins DEFICIENCY ANEMIA Necessary for normal formation of RBC and Most common anemia of pregnancy (15%-25%) preventing neural tube and abdominal wall Due to diet low in iron, heavy menstrual period. defects Unwise weight-reducing programs Occurs most often in Iron is low for: o multiple pregnancies o Those pregnant less than 2 years b4 o Secondary hemolytic illness – rapid current pregnancy destruction and production of new RBC o Low in iron-rich diets o In pt taking hydantoin (an o Undergo bariatric surgery- may suffer anticonvulsant that interferes with folic anemia absorption. Confirmed by relatively low serum iron level o Poor gastric absorption (