KM Health Assess Pregnant Patient PDF

1 Pregnant Patient 3 Stages Embryo- day 15-8 weeks ○ Critical time for organogenesis occurs & at risk for abnormal development due to teratogens Zygote- fertilization to day 14 Fetus- week 8 til birth What do the two fetal mem...

1 Pregnant Patient 3 Stages Embryo- day 15-8 weeks ○ Critical time for organogenesis occurs & at risk for abnormal development due to teratogens Zygote- fertilization to day 14 Fetus- week 8 til birth What do the two fetal membranes form? Chorion- develops chorionic villi which become fetal side of placenta (outer) Amnion- surrounds embryo/fetus (inner) 3 Components of Prenatal Care Risk assessment Health promotion & education Therapeutic intervention When is the 1st prenatal visit and what’s done? Usually after amenorrhea(missed cycle) in 1st trimester up to 13 6/7 weeks Perform health history, physical exam, lab work Prenatal Care Demographic information Past obstetric history Menstrual & gynecologic history History of current pregnancy Personal medical history (including prescription, OTC, and herbal medication) Family medical history Past surgical history What age is considered an advanced age for pregnancy (geriatric pregnancy)? > or = 35 years What are the risks for advanced age pregnancy? Fetal aneuploidy, miscarriage, gestational diabetes, preeclampsia, stillbirth What are the risks for adolescent age pregnancy? Miscarriages, preterm babies, low birthweight, socioeconomic outcomes Past Obstetric History Past pregnancies (were births preterm,term, or post term), multiple gestation, terminations, ectopic pregnancy, living children  2 HIstory of previous: ectopic pregnancy, tubal surgery, IVF, endometriosis, pelvic inflammatory disease= ↑ risk for ectopic pregnancy Birth dates, gestational age at birth, weight/sex of newborn, spontaneous/induced, length, vaginal/cesarean, anesthesia used, formula/breastfed, complications How To Calculate Estimated DOB? EDB determined through ultrasonographic estimation done in 1st trimester Using the Naegele’s rule- subtract 3 for months, add 7 for days, check the year EDB (estimated date of birth) calculated based on LMP (last menstrual period) Trimester Dates 1 st: Up to 13 6/7 days 2 nd 14 weeks to 27 days 3 rd 28 weeks to 40-42 weeks GTPAL- acronym used to evaluate a women’s complete obstetric history G- gravida; # of pregnancies T- term ; # infants born at 37 weeks or after P- preterm ; # infants born between 20-36 weeks A- abortions; # of losses before 20 weeks L- living children ; # of living children Para- # of pregnancies that reach viability regardless if infant was alive Primigravida- women whose pregnant for the first time Primipara- women who gave birth to one child past age of viability Multigravida- women whose before pregnant before Grand multipara - women who has carried five or more pregnancies to viability Multipara - women who has carried two or more pregnancies to viability Nulligravida - woman who has never been and is not currently pregnant Presumptive Pregnancy- changes that make them think they might be pregnant Might be subjective or objective findings Could be due to physiological factors (peristalsis, infections, stress) Presumptive Pregnancy Signs: Amenorrhea Fatigue Nausea/ vomiting Urinary frequency Breast changes: darkened areolas, enlarged Montgomery’s glands Quickening- slight fluttering movements fetus, between 16- 20 weeks of gestation Uterine enlargement  3 Probable Pregnancy- changes that make the examiner suspect a client is pregnant primarily related to physical changes of the uterus (like pelvic congestion or tumors) Probable Pregnancy Signs Abdominal enlargement due to uterine size, shape, and position Hegar’s sign- softening/ compressibility of lower uterus Chadwick’s sign- cyanosis of cervix and vaginal mucosa Goodell’s sign- softening of cervical tip Ballottement- rebound of unengaged fetus Braxton Hicks- false contractions that are painless, irregular, and relieved by walking Positive pregnancy test Positive signs of pregnancy Fetal heart sounds Visualization of fetus by ultrasound Fetal movement palpated by an experienced examiner What hormone detects pregnancy? HCG (human chorionic gonadotropin) is the hormone that detects pregnancy Lower HCG might suggest a miscarriage or ectopic pregnancy Verifying pregnancy Blood and urine test accurate presence of HCG HCG begins with implantation, peak at 60 to 70 days of gestation, decrease around 100 to 130 days of pregnancy ○ Plasma levels remain at lower level Progesterone Maintains endometrium “hormone of pregnancy” decreases uterine contractility stimulates maternal metabolism prepares breasts for lactation (development of breast alveoli) Estrogen Stimulates uterine growth prepares breasts for lactation (proliferation of glandular tissue) Stimulates myometrial contractility ↑ in estrogen and ↓ of progesterone occur at beginning of labor Height of fundus at week of gestation Palpable at 20 weeks and use ultrasound Classified as- SGA (small for gestational age), AGA (average) or LGA (large) or IUGR (Intrauterine growth restriction)  4 McDonald’s Rule Cm = weeks of gestation Measure fundal height (cm) from symphysis pubis to the top of uterine fundus (between 18-30 weeks of gestation). Tells the gestational age, plus or minus 2 gestational weeks Cardiovascular Cardiac output ↑ (30% to 50%) blood volume ↑ (40% to 50%) Heart rate ↑ at week 5 and peaks to 10-15/min at 32 weeks Plasma volume ↑ which is > than blood cell mass: physiologic anemia Respiratory oxygen needs ↑. Respiratory rate ↑ total lung capacity ↓ O2 consumption ↑ 20% tidal volume ↑ 40 Musculoskeletal - body alter and weight increases an adjustment in posture. Pelvic joints relax Gastrointestinal - Nausea/vomiting begins 5-6 weeks, peak 9 weeks, subsides by 16-20 weeks ; Ptyalism (↑ saliva). Renal - Filtration rate ↑ due hormones ; ↑ blood volume. Endocrine - Placenta becomes endocrine organ to make hCG, progesterone, estrogen Vital Signs Blood pressure ○ Systolic: slight/no increase from pre-pregnancy levels ○ Diastolic: slight ↓ in 24-32 weeks return to pre-pregnancy level by the end of the pregnancy ○ 2nd trimester BP lower & more pronounced 20 weeks ○ 3rd trimester rises to pre-pregnancy levels ○ Supine position= BP lower due to weight of uterus on vena cava (↓ blood flow) Pulse- ↑ 10-15 beats about week 32, & stays ↑ for rest of pregnancy RR- Unchanged or slight ↑ Diaphragm ↑ up to 4cm Supine position, BP might may be lower due to weight pressure of uterus vena cava (decrease venous blood flow to the heart)  5 Supine hypotensive syndrome (supine vena cava syndrome) Maternal hypotension & fetal hypoxia Symptoms: dizziness, lightheadedness, pallor, clammy skin. Help by- Turn to left-lateral side, semi-fowler’s, or supine with wedge under one hip to alleviate pressure to the vena cava What is expected for fetal heart rate? Fetal heart tones 110 to 160/min with accelerations means intact fetal CNS Client heart changes in size and shape (cardiac hypertrophy), increase blood volume, increase cardiac output Heart sounds change more pronounced splitting of S1 and S2 ○ S3 around 20 weeks of gestation. By 36 weeks uterus & fundus reach the xiphoid process ○ Causes SOB as uterus pushes against diaphragm Breast changes occur due to hormones of pregnancy, increase size & areolas darkening Chloasma (melasma): an increase of pigmentation on the face Linea nigra: dark line of pigmentation from the umbilicus to pubic area Striae gravidarum: stretch marks on the abdomen and thighs Pyogenic granulomas: benign vascular tumors (tongue, gums, or lips) in the 1st five months When to start Prenatal visits & how often to go to Prenatal visits: Initial assessment in first 12 weeks & continues throughout pregnancy In uncomplicated pregnancy, prenatal visits are monthly for weeks 16-28, every 2 weeks from 29-36 weeks, and every week from 36 weeks until birth What to do in the Initial prenatal visit Determine estimated DOB based on the last period Obtain medical/nursing history to include social supports and review of systems Perform a physical assessment of baseline weight, vital signs, and pelvic examination Obtain initial laboratory tests What to do in the Ongoing prenatal visits Monitor weight, BP, glucose in urine, protein, and leukocytes, edema Monitor fetal heart rate in first trimester using doppler Measure fundal height in the second trimester ○ weeks 18-30 fundal height is the same as the number of gestation weeks Test fetal movement in 16-20 weeks of gestation Routine lab Tests: Blood type/ Rh factor CBC with differential Hepatitis B screen Vaginal/cervical culture  6 Common Findings Throughout Pregnancy UTI’s due to renal changes & vaginal flora becoming more alkaline Gingivitis, nasal stuffiness, and epistaxis (↑ estrogen levels ↑ vascularity) Gastroesophageal Reflux- like Pyrosis & heartburn Supine hypotension (when client lies on their back and the weight of the gravid uterus compresses vena cava; ↓blood supply to the fetus; client gets lightheaded and faint ○ side-lying or semi-sitting position with the knees slightly flexed Leg cramps 3rd trimester. (Compression of lower-extremity nerves & blood vessels by uterus; results in poor peripheral circulation, imbalance calcium/phosphorus ratio) ○ Extend affected leg, keeping knee straight, dorsiflex foot (toes toward head) ○ Heat affected muscle while the leg is extended to relieve cramping Common Finding in 1st Trimester: Nausea and vomiting Breast tenderness Common Finding in 1st & 3rd Trimester: Fatigue- Encourage client to have frequent rest periods Urinary frequency- do Kegel exercises (tighten & relax pubococcygeus muscle) Braxton Hicks- in 1st trimester onward, but ↑ intensity/ frequency in 3rd trimester Common Finding in 2nd & 3rd Trimester: Heartburn - due to stomach displaced by uterus, ↓ GI motility & digestion ○ Instruct client to eat small, frequent meals Constipation Hemorrhoids- Warm sitz bath, witch hazel pads, topical ointments to relieve discomfort Backaches- Exercise & pelvic tilt exercises & proper body mechanics Varicose veins & lower-extremity edema ○ Rest with legs/ hips elevated, avoid sitting/standing in a position, don't cross legs ○ exercise to stimulate venous return ○ Sleep in left-lateral position & exercise moderately with frequent walking to stimulate venous return Pregnancy Recommended Weight Gain from NAS 25 to 35 lb.. for women of normal weight. 28 to 40 lb.. for underweight women. 15 to 25 lb.. for overweight 11 to 20 lb.. for obese women.  7 Foods To Avoid When Pregnant Unpasteurized juice and dairy products Raw sprouts and dough premade meat or seafood salad Refrigerated smoked seafood, pate, or meat spreads Unheated deli meats, bologna, or hotdogs Caffeine (less than 200-300 mg/day) Certain types of fish due to high mercury Immunizations Tdap weeks 27 to 36 of each pregnancy. Reduces whooping cough in babies by 78% The flu vaccine, Covid vaccine, and Respiratory syncytial virus (RSV) is recommended Abrysvo is only RSV vaccine recommended during pregnancy