Nursing Care of a Family Experiencing a Pregnancy Complication PDF

Nursing Care of a Family Experiencing a Pregnancy Complication From a Preexisting or Newly Acquired Illness Definition of a 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, th...

Nursing Care of a Family Experiencing a Pregnancy Complication From a Preexisting or Newly Acquired Illness Definition of a 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. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Nursing Process Related to Care of a Woman With a High-Risk Pregnancy Assessment o Objective data-v/s o Subjective data-level of edema and exhaustion Nursing diagnoses o Impaired tissue perfusion related to poor heart function secondary to mitral valve prolapse during pregnancy o Pain related to pyelonephritis secondary to uterine pressure on ureters o Fear regarding pregnancy outcomes and related chronic illnesses Outcome identification and planning o Based on the pattern of life Implementation and Outcome Evaluation Copyright © 2018 Wolters Kluwer · All Rights Reserved Establishing a Baseline When Caring for a Woman With a High-Risk Pregnancy Copyright © 2018 Wolters Kluwer · All Rights Reserved 2020 National Health Goals Related to Complications of Pregnancy 01 02 03 Reduce the Reduce the rate Reduce the rate of of maternal rate of fetal maternal deaths to deaths to 5.6 illness and 11.4 per 100,000 complications per 1,000 live live births from a during births from a baseline of 12.7 pregnancy to 28 baseline of 6.2 per 100,000 live per 100 births per 1,000 live births. from a baseline births. of 31.1 per 100 births. Copyright © 2018 Wolters Kluwer · All Rights Reserved  High-Risk Pregnancy: Cardiovascular System  Cardiovascular disease complicates only 1% of pregnancies but accounts for 5% of maternal deaths.  Blood volume and cardiac output increase up to 50%% during pregnancy (peaks at 28 to 32 weeks), which places stress on a compromised heart.  New York Heart Association criteria are commonly used to categorize the severity of heart disease.  Most common are valve damaged caused by rheumatic fever or Kawasaki disease and congenital anomalies(coarctation of aorta, atrial septal defect) Copyright © 2018 Wolters Kluwer · All Rights Reserved Most dangerous time is 28-32 weeks just after the blood volume weeks The estimation of whether a patient with preexisting cardiovascular disease can complete pregnancy successfully depends on the type and extent of the disease Copyright © 2018 Wolters Kluwer · All Rights Reserved  High-Risk Pregnancy: Common Cardiovascular Clinical Findings Left-sided heart failure o Occurs in conditions such as mitral stenosis, mitral insufficiency, and aortic coarctation o Orthopnea-chest and head are elevated in sleep due to pulmonary edema o Paroxysmal nocturnal dyspnea-suddenly waking at night with shortness of breath Interventions- 1. Low-molecular-weight heparin will be given since it does not cross the placental barrier. 2. Antidiuretics, antihypertensives, beta/blockers 3. Patient will be scheduled for NST and serial UTZ to determine placental perfusion Copyright © 2018 Wolters Kluwer · All Rights Reserved Right-sided heart failure o Caused by unrepaired congenital heart defect such as pulmonary valve stenosis, Eisenmenger syndrome ( a right-to-left atrial or ventricular septal defect with accompanying pulmonary valve stenosis. o It will cause:  Distended liver and spleen  Ascites  Peripheral edema Copyright © 2018 Wolters Kluwer · All Rights Reserved Patients with uncorrected RSHF will not be allowed to get pregnant. They may need repeated ABG’s to ensure fetal growth. May need pulmonary artery catheter to monitor pulmonary pressure May need extremely close monitoring after epidural anesthesia to minimize the risk of hypotension. Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved  Classification of Heart Disease Class 1-Uncompromized.Ordinary physical activity causes no discomfort. No symptoms of cardiac insufficiency and no anginal pain. Class II- Slightly compromised. Ordinary physical activity causes excessive fatigue, palpitation and dyspnea or anginal pain. Class III- Markedly compromised. During less-than- ordinary activity, patient experiences excessive fatigue, palpitations and dyspnea, or anginal pain. Class IV- Severely compromised. Patient is unable to carry out any physical activity without experiencing discomfort. Even at rest, symptoms of cardiac insufficiency or anginal pain are present. Copyright © 2018 Wolters Kluwer · All Rights Reserved High-Risk Pregnancy: Cardiovascular Issues Valve damage with or without valve replacement Congenital anomalies Coronary artery disease (CAD) Chronic hypertensive vascular disease Venous thromboembolic disease Peripartum heart disease Copyright © 2018 Wolters Kluwer · All Rights Reserved  Peripartum Heart Disease called Peripartal Cardiomyopathy- an extremely rare condition that originates in pregnancy in those with NO previous history of heart disease Cause: Unknown Mortality rate: 50% Copyright © 2018 Wolters Kluwer · All Rights Reserved Occurs in black multiparas with Gestational Hypertension The patient develops myocardial failure signs such as shortness of breath, chest pain, and nondependent edema, and cardiomegaly. Immunosuppressive therapy may be given to improve symptoms. If it persists postpartum, the woman may be allowed to get pregnant No oral contraceptives, as they may lead to thromboembolism If with another pregnancy, a patient may need a heart transplantation Copyright © 2018 Wolters Kluwer · All Rights Reserved  High-Risk Pregnancy: Cardiovascular System Assessment Level of exercise Presence of cough or edema Comparison of baseline vital signs Liver size (right-sided heart failure involvement) ECG/echocardiogram Fetal size (small for gestational age) and poor response to labor (FHR decelerations) Copyright © 2018 Wolters Kluwer · All Rights Reserved High-Risk Pregnancy: Cardiovascular System Nursing Diagnosis (Example) Deficient knowledge regarding steps to take to reduce the effects of maternal cardiovascular disease on the pregnancy and fetus Copyright © 2018 Wolters Kluwer · All Rights Reserved High-Risk Pregnancy: Cardiovascular System Nursing Interventions During Antepartal Period Promote rest. Promote healthy nutrition. Educate regarding medication. Educate regarding avoidance of infection. Copyright © 2018 Wolters Kluwer · All Rights Reserved High-Risk Pregnancy: Cardiovascular System Nursing Interventions During Intrapartum and Postpartum Periods Intrapartum period o Positioning o Epidural anesthesia and assisted vaginal delivery Postpartum period o Assess for heart failure o Anticoagulant and digoxin therapy o Intermittent pneumatic compression boots Copyright © 2018 Wolters Kluwer · All Rights Reserved Quality & Safety Education for Nurses (QSEN) Patient-Centered Care Teamwork & Collaboration Evidence-Based Practice Quality Improvement Safety Informatics Copyright © 2018 Wolters Kluwer · All Rights Reserved Reducing Risk of Thromboembolic Disease Through QSEN Competencies Copyright © 2018 Wolters Kluwer · All Rights Reserved Venous Thromboembolic Disease increases during pregnancy due to combination of stasis of blood in the lower extremities and uterine pressure and hypercoagulability (an effect of elevated estrogen. Risk factors o DVT o More than 30 years old o Signs: chest pain o Sudden onset of dyspnea o Cough with hemoptysis o Tachycardia or missed beats o Dizziness or fainting Copyright © 2018 Wolters Kluwer · All Rights Reserved Interventions: Avoiding constrictive knee-high stockings No sitting with legs crossed at the knee Avoid standing in one position for a long time Heparin will be given Copyright © 2018 Wolters Kluwer · All Rights Reserved  Anemia and Pregnancy Pseudoanemia Complicates 15%-25% of pregnancy Causes: o Diet low in iron o Heavy menstrual periods o Unwise weight reducing programs Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved  High-Risk Pregnancy: Endocrine System #1 Diabetes mellitus o Pathophysiology and clinical manifestations o Classification o Gestational diabetes Diabetes during pregnancy o Decreased control of glucose regulation o Effect on fetal size, infant hypoglycemia, and increased incidence of congenital anomalies Copyright © 2018 Wolters Kluwer · All Rights Reserved A Pregnant Patient with Malaria Malaria is a protozoan infection that is transmitted by Anopheles mosquitoes. Incubation period is 12-14 days Signs: o Elevated liver enzymes o Fever o Malaise o Headache o Thrombocytopenia o Renal failure Copyright © 2018 Wolters Kluwer · All Rights Reserved  Prevention/Treatment o Wearing clothing that covers most of the body o Use insect repellent o Sleep with night mosquito net o Keep windows closed o Delay travel to endemic areas Copyright © 2018 Wolters Kluwer · All Rights Reserved  Combination of anti- malarial drugs o To reduce LBW and Pre- term birth. o Sulfadoxine/ Pyrimethamine-safe on third trimester o Chloroquine (DOC)-all trimesters o Teratogenic-Quinine, Atovaquone, Proguanil, Tetracyclines Copyright © 2018 Wolters Kluwer · All Rights Reserved A Pregnant Patient with UTI Progesterone dilates ureters during pregnancy so stasis of urine can occur. The minimal amount of glucose (Glycosuria), provides a medium for growth of bacteria Associated with preterm labor and PROM Caused by E.Coli Copyright © 2018 Wolters Kluwer · All Rights Reserved  Treatment (safe) o Amoxicillin o Ampicillins o Cephalosporins o Sulfonamides can be used early in Pregnancy but not near term because they can cause hyperbilirubinemia in NB. o Tetracyclines can cause bone growth retardation and staining of teeth Copyright © 2018 Wolters Kluwer · All Rights Reserved A Pregnant Patient with COVID-19 Copyright © 2018 Wolters Kluwer · All Rights Reserved  COVID-19 can cause severe respiratory and cardiovascular symptoms Pregnant woman susceptibility results in higher rates of pregnancy and fetal morbidity than in those not infected during pregnancy COVID vaccine can be given during pregnancy (Rasmussen et al., 2020) Copyright © 2018 Wolters Kluwer · All Rights Reserved High-Risk Pregnancy: Endocrine System #2 Diabetes during pregnancy—(cont.) o Screening during pregnancy o Monitoring during pregnancy Copyright © 2018 Wolters Kluwer · All Rights Reserved High-Risk Pregnancy: Endocrine System #3 Diabetes during pregnancy—(cont.) o Nursing diagnoses and related interventions  Nursing diagnosis: “Deficient knowledge related to a therapeutic regimen necessary during pregnancy”  Interventions:  Education regarding nutrition during pregnancy  Education regarding exercise during pregnancy Copyright © 2018 Wolters Kluwer · All Rights Reserved High-Risk Pregnancy: Endocrine System #4 Diabetes during pregnancy—(cont.) o Therapeutic management  Insulin needs and dosage adjustments  Education related to blood glucose monitoring  Insulin pump therapy  Education related to pump care and use  Tests for placental function and fetal well-being  Education related to recording fetal movement  Postpartum management of blood glucose Copyright © 2018 Wolters Kluwer · All Rights Reserved High-Risk Pregnancy: Renal and Urinary System Assessment Copyright © 2018 Wolters Kluwer · All Rights Reserved High-Risk Pregnancy: Interventions Related to Prevention of Renal and Urinary Tract Disorders3 Nutritional consults and monitoring fluid intake Hygiene Voiding frequently and after sexual intercourse Cranberry juice intake Copyright © 2018 Wolters Kluwer · All Rights Reserved Caring for Woman With Multiple Threats to Her Pregnancy #1 Copyright © 2018 Wolters Kluwer · All Rights Reserved Caring for Woman With Multiple Threats to Her Pregnancy #2 Copyright © 2018 Wolters Kluwer · All Rights Reserved Question #1 Which statement by a woman who is 8 weeks pregnant and has cardiac disease would you most likely follow up closely? A. “I have been really constipated for the last few weeks.” B. “I have gained 4 lb during the last week, but I’m not eating more than before.” C. “I have not felt any fetal movement as yet.” D. “I have had episodes in the morning when I have almost thrown up.” Copyright © 2018 Wolters Kluwer · All Rights Reserved Answer #1 B. “I have gained 4 lb during the last week, but I’m not eating more than before.” Rationale: Constipation and nausea are common during the first trimester. Fetal movement (quickening) is not usually felt until the second trimester. Weight gain of 4 lb within a week during the first 8 weeks of pregnancy without additional intake could signal increased circulatory fluid and impending heart failure. Copyright © 2018 Wolters Kluwer · All Rights Reserved Question #2 What is the most accurate statement regarding exercise and nutrition during pregnancy for a woman with diabetes? A. Extreme exercise may cause hypoglycemia; therefore, it should be avoided. B. During the last trimester, caloric intake should be decreased to less than 1,800 calories to control fetal weight gain. C. Exercise reduces the need for insulin; therefore, beginning an exercise regimen during pregnancy is recommended. D. Ideally, dietary calorie intake should be approximately 20% from protein, 40% to 50% from carbohydrates, and up to 30% from fats. Copyright © 2018 Wolters Kluwer · All Rights Reserved Answer #2 D. Ideally, dietary calorie intake should be approximately 20% from protein, 40% to 50% from carbohydrates, and up to 30% from fats. Rationale: This caloric balance allows for good glycemic control. Because exercise programs may cause glucose fluctuations, they need to be initiated before pregnancy. Extreme exercise can cause hyperglycemia because of glucose release by the liver to compensate for energy need and lack of insulin to metabolize it. Intake of less than 1,800 calories may result in fat breakdown and acidosis. Copyright © 2018 Wolters Kluwer · All Rights Reserved Question #3 Which is the most accurate and reliable outcome measure for evaluating an intervention? A.A fasting glucose level of 85 mg/dl B.An oral intake measurement of 720 ml of fluids within 8 hours C.An exercise diary indicating the pregnant woman walked 30 minutes every day for a week D.The statement by a pregnant woman, “I understand why folic acid is important for red blood cell formation.” Copyright © 2018 Wolters Kluwer · All Rights Reserved Answer #3 A. A fasting glucose level of 85 mg/dl Rationale: Fasting glucose level is the only measure of an outcome. The other three choices are evaluation of activities (processes), which may or may not result in a desired outcome. Copyright © 2018 Wolters Kluwer · All Rights Reserved Read: Page 513-520 for self-directed learning activity Copyright © 2018 Wolters Kluwer · All Rights Reserved