Postpartum Nursing Final Review PDF

FINAL EXAM Post-Partum Nursing Postpartum = placenta delivery → 6 weeks postpartum. The body undergoes retrogressive changes (things regress to where it was pre-pregnancy, like uterus size and location) and progressive changes (things that progress to take care of the infant, like milk production)....

FINAL EXAM Post-Partum Nursing Postpartum = placenta delivery → 6 weeks postpartum. The body undergoes retrogressive changes (things regress to where it was pre-pregnancy, like uterus size and location) and progressive changes (things that progress to take care of the infant, like milk production). Biggest focus is teaching/education, as we’re primarily working with healthy people. Changes in the: 1) Reproductive system: a) involution of the uterus, returning it to pre-pregnancy size by contraction of the muscle fibers. The uterus is one of the biggest muscles in the body. The site of placental detachment leaves many open, bleeding blood vessels. Contractions squeeze those vessels shut. One of the most important ways to keep the mother from bleeding is to have the uterus contract. b) regeneration of the uterine epithelium, which sloughs off after birth c) the cervix is formless and flabby like a balloon directly after birth. It’s wide open and may be edematous or have tears and lacerations. It has a permanent change after birth: a nulliparous cervix has a round os, and a parous cervix has a slit os. → one week postpartum, the cervix should be firm with a closed internal os and a slightly dilated external os. d) the vagina could be edematous after birth, with possible lacerations and/or few rugae folds. → it takes 6-10 weeks postpartum for the uterus to fully involute → the vaginal mucosa becomes atrophic due to estrogen present, so it could cause vaginal dryness. e) the perineum is the stretch between the base of the vagina and the anus. After birth, it could be bruised, edematous, or have hemorrhoids or an episiotomy or laceration (which typically take 4-6 months to heal). → hemorrhoids are painful nerve endings that have extended out of the anus → an episiotomy is a purposeful cut along the medio-lateral line or midline to enlarge the vulva for childbirth. → a laceration is a rip/tear in the vulvar area. Four degrees: i. 1st degree — superficial mucosa and/or skin ii. 2nd degree — deeper tissue and/or muscle iii. 3rd degree — involves the anal sphincter iv. 4th degree — extends into the rectal mucosa - Nursing actions after birth: assess uterus for location, position, and tone of fundus (top of uterus, feels like a ball) q15 mins for 1st hour, q30 mins for 2nd hour, q4 hours for 22 hours, q shift after 24 hours; or more frequently if abnormal. The uterus moves down 1 cm per day postpartum in a progressive, slow movement. → full bladder can shift the uterus, so keep the bladder empty for muscles to contract → blood clots in the uterus can shift the uterus, also preventing it from contracting → when assessing the uterus, keep one hand on the base of the uterus to keep it from involuting - afterpains are contractions after the baby is born as the uterus returns back to its prepregnancy size. They are more intense in multiparas, multifetals, macrosomia, and in women with polihydraminos (low fluid), and retained blood clots → nursing considerations: analgesia (Motrin and Percocet are safe for breastfeeding), repositioning, and heat — but heat should be used carefully, as it could dilate vessels that are trying to constrict, or cause burns - lochia is postpartum vaginal discharge, characterized by color and amount (scant, light, moderate, and heavy): i. lochia rubra = blood red, first 3-4 days ii. lochia serosa = pinkish, up to 3 weeks postpartum iii. lochia alba = white or brownish, up to 6 weeks postpartum → assess for amounts, clots, patterns, and odor. “Heavy” will fully saturate a pad in 1 hr, “excessive” will fully saturate a pad in 15 minutes and is cause for concern → focus on educating parents on what is concerning and when to call the healthcare practitioner: larger-thanquarter-sized clots, feeling the bleeding, or excessive bleeding ***REEDA = Redness, Edema, Ecchymosis (bruising), Discharge and Approximation of edges  assess vagina and perineum for*** 2) Breasts: a) primary engorgement occurs and subsides within the first 24-48 hours postpartum, due to an increase in the vascular and lymphatic systems (so it’s not all caused by milk). The breasts will become large, firm, warm and tender. b) subsequent engorgement occurs 3+ days after delivery with the distention of milk glands. 3) Cardiovascular system: - during pregnancy, the woman’s blood volume (hypervolemia) increases by 30-50%. The average woman loses 500mL of blood during a vaginal birth and 1000mL of blood during a cesarean birth. Anything over those numbers is considered a hemorrhage. - after birth, the cardiac output (stroke volume x heart rate) increases, and there’s an increase in blood flow from the uteroplacental unit. Extracellular fluid is mobilized into the vascular system, blood pressure can lower because there’s less pressure on vessels, and the woman can experience bradycardia. This peaks 10-15 minutes after birth, remains for 48 1 - hours, and is back to normal within 6-12 weeks postpartum. → to get rid of fluid, the woman can experience diuresis, diaphoresis, and thirst. white blood cell count can increase (potentially due to trauma to tissues), while hemoglobin and hematocrit decrease initially (due to hemodilution from extracellular fluid) and then stabilize. Mom needs to pee every 2 hours to maintain empty bladder. during pregnancy, plasma fibrinogen (clotting factors) increase, while fibrinolytic (breaks down clots) decreases. Pregnant women are at a higher risk for thrombus, especially after birth — get them moving OOB quickly! Hemostasis returns within 2-4 weeks. VITAL SIGNS: → temp: hard labor increases. If goes above 100.4, could be an amniotic fluid infection; assess odor & discharge → blood pressure: watch for orthostatic hypotension due to a lowered BP → pulse bradycardia may occur due to higher CO. Tachycardia could mean infections or bleeding → respirations should be normal (12-20) 4) GI system: - after birth, digestion begins — so mothers are very hungry and thirsty (from panting). They may have constipation. 5) Urinary system: - the bladder could have an increased capacity, or be edematous, with a diminished sensation (body protects it by numbing it). The woman could experience diuresis, as the bladder fills more quickly, or overdistention or incomplete emptying (because of numbness). The woman could have some stress incontinance while coughing, sneezing or laughing. Have her *empty her bladder Q2*, and feel for the bladder when doing palpations. Keep an eye out for UTIs or postpartum hemorrhages. 6) Musculoskeletal system: -pregnancy loosens ligaments to expand the birth canal. The mother may feel some fatigues and aches (especially in her hips) as the ligaments and cartilage start returning to their prepregnancy status. - in her abdomen, the uterine ligaments and abdominal wall split to make room for the baby. With diastasis recti abdominus, you can feel the “hole” in between the ligaments. 7) Integumentary system: - mother’s hormone levels decrease as soon as the placenta is delivered. Hyperpigmentation decreases rapidly (like melasma masks and linea nigras) and stretch marks change to a silvery color. - hair loss is common, and typically begins 4-20 weeks postpartum. 8) Neurological system: - depends on whether the mother had anesthesia or analgesia, which cause temporary neurological changes (lack of sensation in legs, dizziness, fatigue, headaches, pain, and *blurred vision* — which can be a danger sign for pre-eclampsia) 9) Endocrine system: - with placental delivery, there is a rapid decrease in placental hormones hCG, estrogen and progesterone. - there’s a resumption of ovulation and menstruation in non-lactating women by 7-9 weeks & lactating women by 18 months. - dopamine triggers the release of prolactin, which is necessary for lactation (it also causes weight loss) Postpartum assessment: initially, check vitals, skin color, location and firmness of fundus*, amount and color of lochia*, perineum, pain, IV sites, urinary output*, abdominal incision (if necessary), sensory assessment (especially if patient had an epidural), and neurological assessment (if the woman pushes incorrectly, she can “push into her head” and pop blood vessels) a) check perineum/vagina for REEDA and excessive lochia or pain b) assess the bladder for signs of distention, location/displacement of the fundus, bulge of the bladder above the symphysis (a danger sign b/c it’s not fully emptying), or frequent/small voids. c) assess the breasts/nipples for size, tenderness, and sores d) assess the lower extremities for edema (the baby pushes on mother’s blood vessels, which causes sluggish blood flow back to the heart) and thrombophlebitis, especially unilateral. Assist the mother in ambulation. e) assess nutritional status: is she hungry or thirsty? f) assess comfort and rest. She needs lots of sleep in the puerperium period, so enforce the “sleep when baby sleeps” rule. She may feel postpartum chills, which are hormonal and normal. g) assess psychosocial status for: i. bonding = initial attraction felt by parents ii. attachment = process of a enduring bond developing through the pleasurable and satisfying interaction with baby iii. maternal touch = discovering the infant, touching/counting toes, looking at every part iv. verbal behaviors = cooing, talking to, calling by name, holding en face - maternal role adaptation goes through three phases as she heads toward a new normal: 1) “taking in phase” — she is dependent, needs help, is very self-absorbed, focuses on her own comfort 2 and healing, and is in survival mode, speaks about her birth, and has difficulty making decisions 2) “taking hold phase” — she is more independent, her focus goes back to the infant, she is eager to learn and make decisions. She can be overwhelmed and fatigued and feel a bit blue. 3) “letting go phase” — the baby becomes a separate entity, she gives up the fantasy of what could have been. People focus on the baby, and she experiences guilt, grief, anxiety, and accepting the newborn for what it is. She may reconnect and grow with her partner, and may go back to work and leave her baby with others. - she redefines her new roles — mom does what, partner does what, which may lead to a bit of role conflict. She experiences maternal concerns about body image and may feel the postpartum blues from 3+ days on. - the whole family must adapt to new roles: father, siblings, grandparents…it’s not helpful for people to take the baby or older kids away. Leave them, and do necessary chores (laundry, cooking, cleaning) → things like discomfort and fatigue, knowledge of infant needs (babies cry to tell us they need something), previous experience, maternal age and temperament, infant temperament, support system (let mother take care of baby except when she sleeps), and labor and recovery (especially if it didn’t go well) all affect family adaptation. Postpartum complications: 1) Hemorrhage = uncontrolled bleeding. The most common and dangerous complication. Types: a) early PPH (24-36 hrs) b) late PPH (2-4 weeks, usually because bits of placenta/membranes are left behind) Hemorrhages can be caused by uterine atony = lack of muscle tone so uterus can’t contract properly, or trauma (lacerations, hematomas, or internal bleeding, which could be caused by large babies, rapid deliveries, augmentation, or assistive deliveries with forceps or vacuums) to the birth canal. The uterus MUST be empty (no placenta or clots) to contract well. Clots can block the exit, allowing blood to pool behind. Risk factors for uterine atony: a) bladder overdistention b) multiparity c) prolonged labor (the uterus is continually contracting and is exhausted) d) precipitate labor (a quick labor can send the uterus into shock) e) augmentation (like with pitocin, cranks up contractions) f) retention of placenta parts/blood clots g) large babies or twins h) lots of amniotic fluid i) tocolytic drugs (stop labor, like mag sulfate) - Uterine atony can cause difficulty locating the fundus (when it’s contracted, it’s a nice, tight ball), a soft or boggy fundus, the uterus loses firmness when the practitioner stops massaging it, the fundus is above the expected level, or there are excessive lochia or clots expelled. Hemorrhages can be managed by massage, bimanual compression of the uterus, expressing clots, emptying the bladder, replacing fluids lost (first by normal saline then by blood transfusions), or even ligation = cauterizing blood vessels. Pharmacological agents include: i. Pitocin, which causes the uterus to contract during and after labor ii. Methergine (IM injection), which raises blood pressure *DO NOT give in HTN pts iii. Misoprostol (rectal), which is a prostaglandin to stop bleeding iv. Hemabate, which is very expensive, and used to stop bleeding EARLY SIGNS FOR HEMORRHAGE: uterine atony, a large gush of blood OR a slow trickle/seeping (which could indicate a blood clot and blood is seeping out the side), saturation of more than one peripad in 15 mins, severe/unrelieved perineal or rectal pain, or pressure/feeling of needing to have a BM, severe cramping, or tachycardia. → Risk factors: manual removal of the placenta, uterine inversion, previous PPHs, general anesthesia, placenta previa/accreta or low placental implantation, drugs to initiate labor, or magnesium sulfate (given in pre-e pts to prevent them from seizing; also causes vasodilation which increases blood loss) → Other risk factors: advanced maternal age (everything gets tired), grandmultiparity; chorioamnionitis = infection of the amniotic fluid or uterus; clotting disorders; fibroids = non-cancerous masses in the uterine lining that prevent it from contracting properly, or disseminated intravascular clotting (DIC) = pre-eclampsia causes fluid to seep through the walls and damage the vascular system, so clotting factors try to save the vascular walls, and get used up. Give Heparin. → Medications used to treat PPHs: Pitocin/oxytocin and methergine 2) Retained placental fragments can cause hypovolemic shock, because the uterus contracts so hard trying to push them out it goes into shock. Must give adequate volume & blood. 3) Subinvolution of the uterus = the uterus doesn’t get smaller or descends into the pelvis; it remains soft and large postpartum, the lochia returns back to rubra (dark red), and the woman has back pain. Caused by fibroids, metritis (an infection), or retained placental fragments, leading to the need for a dilate & curate (D&C) wherein the woman is dilated and doctors “scrape” the insides of the uterus. Subinvolution can also be treated by methergine and antibiotics, depending on what it’s caused by. 3 4) Lacerations, either cervical or vaginal. Cervical lacerations can really bleed with a steady trickle of blood. When stitching, use dissolvable sutures. ***DO NOT LET PATIENT GET CONSTIPATED.*** Typically with 1st, 2nd, or 3rd degree lacs, will give stool softeners or suppositories, EXCEPT for 4th degree — nothing goes in the rectum! 5) Hematoma = blood collects within connective tissue. Women might say “I have pressure in my bottom,” or frequently feel the need to have a BM with no results. Can be surgically excised or have sitz baths/comfort care. Takes time to reabsorb. 6) Thrombophlebitis = thrombus due to increased clotting factor, edema, being bedbound, and dehydration. Do NOT do Homan’s or a calf massage; keep it elevated and still. Give Heparin. 7) Endometritis (puerperal infection) = infection of the endometrium. Risk factors: C-section, PROMs and prolonged labor (b/c of more vaginal/cervical exams), internal monitoring, mec-stained fluid, and obesity. Signs and symptoms: a) elevated maternal temperature b) lower abdominal pain c) tachycardia d) subinvolution e) malaise f) lochia changes To prevent, reduce risk factors by being sterile/clean! Typically treat with antibiotics. 8) Cystitis = infection of the bladder, with low grade fever, burning with urination, suprapubic pain, urgency to void and offensive urinal smell (like fish) presenting. Risk factors: epidurals, overdistended bladder, foley catheters, macrosomnia (baby’s head blocks urine from emptying fully), assistive deliveries (vacuums, forceps), and intrapartal vaginal exams. Management: - check CBC (white count) - do a urine culture and analysis — looking for WBCs, blood and protein in urine. PP pts can have lochia, so can’t have a clean catch with urine. Must do a straight cath. - do discharge teaching, as cystitis often starts post-discharge 9) Mastitis = infection/inflammation of the breast (localized or whole breast). Educate women on cleaning their breasts, and allowing them to air-dry after a feeding! Risk factors: previous history of mastitis, cracked nipples, and anti-fungal creams. Assessing for: a) hard, tender masses b) redness c) pain d) fever e) tachycardia f) malaise g) purulent drainage Treat with antibiotics, and encourage the mother to continue breastfeeding but wipe off antibiotics prior to nursing. → a breast abscess is a localized blocked duct. Try to hand express. 10) Affective disorders, like: a) postpartum blues = normal tearfulness, starts about day 3 as hormones bottom out. Causes anxiety and mood fluctuation. b) postpartum depression = severe depression 6-12 months postpartum. Causes extreme guilt, anxiety, personality changes, hogging the baby or pushing the baby away, insomnia, appetite changes, baby cries and mom won’t respond quickly, fidgety or restless, not showering, thoughts of harming infant or self. Needs psychotherapy and antidepressants, sometimes ECT. c) postpartum psychosis = a serious variant of bipolar disorder. Causes hallucinations and loss of contact with reality. Risk factors include a history of depression, depression or anxiety during pregnancy, inadequate support, problems with partner, life and childcare stresses (including finances), and complications of pregnancy or childbirth. → signs/symptoms: paranoia, bizarre delusions, mood swings, extreme agitation, distraught feelings, confusion, strange beliefs about baby, or disorganized behavior. → needs hospitalization and a psychiatric evaluation, meds, therapy, ECT. → review charts for risk factors, and keep an eye on everything. Educate family so they can watch too. Postpartum loss: provide support for the family, acknowledge the loss — don’t avoid the family. Allow them to see or hold the infant, and wrap/dress the baby and keep it warm. Provide memories like pictures, locks of hair, nail clippings, and hand/foot prints. Nursing Assessment of the Neonate Neonate = birth to 4 weeks old (newborn) 4 Flexed posture = because babies have little body fat, they keep a flexed posture to decrease surface area to stay warmer (arms bent back, legs bent back). Breech posture is like flexed, but they are a bit flatter (look like a frog). Newborns typically weigh 7-7.5 lbs; 70-75% of that weight is water. We expect a 5-10% drop in weight due to fluid shifts, losing feces, and not taking in much after birth, but babies do end up gaining about ½ lb per week. In the hospital, babies are weighed at birth and then QD nightly. Newborns are measured only at birth, and are typically 18-22”. They grow about 1” per month. A baby’s head circumference is measured at the eyebrow line; it should be roughly ¼ the size of the total body. We look for the outer campus of the eyes and ears to be even, as unevenness can be an indicator for Down syndrome. Molding = the bones of the head overlap so the baby can fit through the birth canal; often comes with caput (fluid). → to find the anterior fontanel: start at the bridge of the nose and go straight back. It’s a diamond shape, typically 3-4cm long, 2-3cm wide. The baby’s “soft spot” (don’t poke it). Closes around 18 months. → to find the posterior fontanel: go straight back from the anterior fontanel; it’s just a dimple. Closes between 8-12 weeks. - Some institutions measure a newborn’s chest circumference (at the nipple line). Sometimes newborns have engorged breasts due to mother’s hormones; those will go away. Other newborns can have an accessory nipple that won’t grow or lactate. - The abdomen’s circumference should be the same size as the chest; it’s measured right at the umbilical stump. - A newborn’s spine won’t develop normal curvature until the baby is walking. It’ll be straight until then. Only take a newborn’s temperature via axillary (their rectal mucosa is too fragile for a rectal temp). Push down well and hold their arm. If the temperature is below 97.9*, alert the instructor and encourage skin-to-skin with the mother. Assess a newborn’s apical pulse for 1 full minute, as babies often have murmurs that we need to pick up on. Any little movement affects their pulse, which typically runs from 100 bpm (sleep) to 180 bpm (crying). A newborn’s respirations are very irregular, anywhere between 30-60 breaths per minute. Crying can raise it higher. There can be a long span with no respirations, followed by rapid respirations. Babies also often have ronchi (fluid) in their lungs. To assess, feel their abdomens (babies are diaphragmatic respirators) or listen for air exchange for 1 minute. → babies are also nose breathers, and if they’re clogged up, use normal saline to help clear them. → **nasal flaring indicates respiratory distress** → also, intercostal (skin dips in between ribs) or subcostal (skin balloons above ribs) retractions indicates respiratory distress → see-saw respirations = abdomen rises, chest falls; or chest rises, abdomen falls → respiratory distress, along with tachypnea >60 bpm or grunting A newborn’s cry should be strong, lusty, and medium-pitched. If it’s shrill, or “meowing,” it could indicate a neuro problem. Accrocynaosis = a newborn’s body sends blood to its vital organs before its extremities, so newborns’ hands and feet can be pale, cool and cyanotic. Part of the APGAR score. → peri-oral cyanosis = blueness around lips is different. TAKE SERIOUSLY. Mottling (marbling) indicates respiratory or circulatory problems, a cold baby, or apneic episodes. Harlequin color change = the newborn’s circulation is not well-established, so blood pools on one side of the baby. Flip the baby over to reverse it! Jaundice (yellowing) develops at the head and works its way down. Jaundice seen on the chest is much scarier than on the head. Erythema Toxicum (newborn rash/flea bite rash) = pink rash with little vesicles on the belly, face or back. It’s totally benign and should be left alone! It’ll go away in a few days. Milia = tiny white dots on the cheek, nose & chin that are distended sebaceous glands. Leave alone & they’ll go away in a few weeks. Vernix = creamy, cheese-like covering on a newborn that acts as a barrier against amniotic fluid in the womb, and a moisturizer. Preemies have it, postmature babies don’t. Washes off. Overdue babies can have cracked or peeling skin; use lotion or Vaseline without any odor. Desquamation = skin so dry it’s peeling. Newborns typically have edema of the eyelids, face, and scrotum/labia. Breech babies are also susceptible to edema and bruising of the perineum. Ecchymosis = bruising; can be from delivery if vacuum or forceps used. Facial bruising can be due to the baby’s position in utero. → cephalohematoma = collection of blood between the parietal bone and the periosteum. It doesn’t cross the suture line, is unilateral or bilateral, and will disappear on its own between 2-3 months. → caput succedaneum = edema under the periosteum due to prolonged pushing or vacuum extraction. It feels “squishy” 5 and pitts when pushed on and will go away on its own. Lanugo = fine, downy hairs all over the baby’s body (especially Hispanic babies). Don’t shave it, it’ll fall off on its own. Telangiectatic Nevi (stork bite) = area that’s pink and can grow darker or lighter depending on if the baby’s crying. Typically on the nose, eyelids, or nape of neck. Usually goes away by age 2. Mongolian spot = bluish/purple irregularity in the sacral area; looks like a bruise. IMPORTANT to document so providers know it’s there and don’t assume it’s a bruise later on! Nevus Flammeus (port wine stain) = usually on face, a red or purple dense area of capillaries. On dark skin, it looks black. Can be removed or treated. Nevus Vasculosus (strawberry mark) = raised, rough, sharply demarcated raspberry-looking area. Goes away by school age. A newborn’s eyes may have transient strabismus, meaning the eye muscles haven’t strengthened yet. They’ll have tearless crying until about 2 months old due to underdeveloped lacrimal ducts. They can see shapes and colors of things 9-12 inches away, but see black and white the best. Newborns may have a subconjunctival hemorrhage (blood under sclera) due to pressure with delivery. Ankyloglossia (tongue tie) = short frenulum that is easily snipped. If left intact, may inhibit breastfeeding. To assess a newborn’s hard palate, put a gloved finger in the baby’s mouth to ensure that it’s intact. Some babies are born with precocious (natal) teeth, which are usually loose and can be pulled. A well-formed pinna of the ear indicates a full-term baby. When assessing a newborn’s abdomen, listen for bowel sounds in all four quadrants. An infant’s stomach can hold 1.5-2 oz at a time. The umbilical cord has two arteries and one vein. The vein carries oxygenated blood; the arteries carry deoxygenated blood. At birth, if you squeeze near the base of the cord, you can feel a pulse. After the cord is clamped and cut, watch for infection (it’ll turn red) — baby can get sepsis. It should be dry and hardened vs. white and moist; don’t put baby submerged in the bathtub. → an umbilical hernia usually resolves by the time the baby is sitting up and using its abdominal muscles Female genitalia: when the labia majora covers the labia minora, it indicates a full-term baby. Baby girls can have a pseudomenstruation = false period from maternal hormones. Male genitalia: check where the urinary meatus is placed, especially before circumcision! Should be at the tip! - hypospadius = urinary meatus is on the underside of the penis - epispadius = urinary meatus is on top of the penis (far less common) Assess the scrotum — gently press on both sides; the testes feel like little peas floating around in water. Sometimes one or both testes don’t descend. Hydrocele = one or both testes is edematous. By 1 week, newborns should be voiding 6x/day. Their urine should be a pale straw color. Sometimes, they can have “brick stain urine” that’s an orange color, due to the accumulation of uric acid crystals. When assessing the anus, assess the sacral/pilonidal dimple above the anus to make sure it’s closed. It can indicate spina bifida. With the anus, assess patency and ensure that it is open. An imperforate anus = no hole, which needs surgery within 24 hours for a colostomy (the colon doesn’t stretch all the way down). Stool patterns: 1) meconium = blackish green, sticky, tar-like, almost odorless feces excreted within the first 24 hours 2) transitional stools = lighter, greenish, keeps lightening - breastfed stool is pale yellow to golden mustard. Nursing newborns typically make stool every time they nurse. It’s relatively non-irritating to the baby’s skin with a distinct non-fecal odor. - formula-fed stool looks like feces with a fecal odor. Polydactyly = extra digits (they’re usually cartilage and can be tied off or removed). Syndactyly = webbed digits (they’re surgically repaired). Polydactyly and syndactyly are usually genetic. Palmar crease = single transverse crease across the palm; an indicator of Down syndrome. Brachial plexus palsy (Erb Duchenne) = the arm is limp, the elbow is extended and pronated. The baby can’t move it independently. It’s from a difficult/traumatic birth, and the prognosis depends on the nerve damage in the brachial plexus. 6 All babies are born bowlegged with flat feet. When assessing for congenital dislocation of the hip, hold the baby’s knees and hips and touch the femur. Feel for a click of the hips as you abduct the baby’s hips. → look for a symmetrical gluteal fold (lie baby on belly). If not present, then congenital dislocation. Club feet = baby can’t move its feet to the midline; they’re turned in. Must be casted and have surgery. Neurological reflexes: 1) Tonic neck/fencer = baby turns head in one direction → arm and leg on that side will extend and will flex on the other 2) Palmar grasp = put fingers on palm, baby will strongly grasp. 3) Plantar grasp = touch ball of baby’s foot and toes will curl under 4) Moro/startle = baby gets startled → arms and legs move outward, knees will flex, and fingers form a “C.” To assess, do palmar grasp first and then let go (gently). 5) Babinski = touch up the side of the baby’s foot and then over the ball. The toes will fan out (opposite of adults). 6) Stepping = put baby on firm surface, baby’s legs will go up and down 7) Swim reflex = if hold baby by its abdomen with arms and legs dangling in water, baby makes swimming motions. Eating reflexes: 1) Rooting = touch baby’s cheek → baby will turn in that direction and look for the breast. Cues to look for with nursing. 2) Sucking = baby will suck on anything in its mouth. If baby is having trouble sucking, put a gloved finger in the baby’s mouth and stroke the roof of the baby’s mouth to stimulate the suck reflex. 3) Extrusion = protective reflex. If try to put something like food in baby’s mouth, they will push it out with their tongue. Protective reflexes: blinking, coughing, sneezing and yawning. Babies develop in a cephalo-caudal manner — meaning the hold their head up before they sit up, they sit up before they stand up, they stand up before they walk. They develop from the center to the periphery, so they have gross motor skills before fine motor skills. → pincer grasp comes around 9 months Nutritional needs in the postpartum period: Mother and infant Assessing the breasts: - are the nipples and areola sore, reddened, bruised, flat, erect, or inverted? - palpate breasts to determine degree of firmness. Breastmilk comes in on the under portion of the breast. The breasts’ softness depends on how many babies the mother has had and breastfed. The more babies the mother has nursed, the quicker her milk will come in, but in general, the first 24-48 hours the breasts should be soft but starting to fill. By day 3, they should be firm, warm and full. → a mother can have engorgement (full, tender, hot to touch, throbbing pain; vessels/veins are visible) whether or not she is nursing. If she is formula-feeding, decrease stimulation to the breasts (no baby on the breasts, or hot water with shower). Wear a tight pre-pregnancy bra (no binder), apply ice/frozen peas, take Motrin or pain meds around the clock. Lasts 24-36 hours. If she is breastfeeding, nurse just until she feels relief, not til empty breast. The non-breastfeeding mother needs 2200-2300 calories per day; a high-protein, high vitamin/mineral diet for tissue repair and to return the body to its pre-pregnancy state. She needs a lot of roughage (fruits, veggies, whole grains) to help with peristalsis, which slows down with labor and c-section deliveries. She should keep taking her prenatal vitamins at home and push fluids to make sure her kidneys are functioning. - formula can be milk- or soy-based or non-lactose (smelly) in a powder, condensed liquid, ready-to-pour, or independent 3oz sterile nippled bottle form. Toss what is left after first use; keep only for an hour. Powder is most economical. The ratio of formula to water is important so the formula is constituted in the most nutritional way. - formula can be warmed in a bowl of hot water (NOT in a microwave — hot spots). It will keep for 48 hours in the fridge or freezer. When feeding, hold the bottle at an angle so the whole nipple is filled with milk so the baby doesn’t get much air. The baby is sucking if you see bubbles rise. - babies will take bottles every 3-4 hours or on demand, eating 30-45 mls at a time initially. - to burp, use fingers on face/weight of belly on hand (better for nurses b/c don’t want baby in nurse’s hair) or lay baby on belly on lap to burp The breastfeeding mother needs 500 extra calories per day, as well as 500 ml of fluid to make high-quality milk. She should sit down with non-caffeinated, non-alcoholic fluid to drink each nursing session. Benefits of breastfeeding: → for the baby, it enhances the immune system, is perfect for digestion (so much easier for the baby’s body than formula). It leaves the stomach more quickly, so the baby eats more often. It contributes to rapid brain growth. It’s made of less protein than cow’s milk so it’s easier on the kidneys and less likely to cause an allergic reaction. → for the mother, it’s protective against female cancers, it helps with uterine involution (b/c of oxytocin release; the mother may feel cramps/after pains while nursing), and it releases the hormone relaxin. It’s empowering — she’s the only one who 7 can feed her baby, and it reduces prep-time. It’s cost-effective. → Disadvantages: the partner can’t be involved in feeding; the woman must be comfortable with her own body and view breastfeeding as non-sexual. Medications can go through milk. Estrogen and progesterone prepare the breasts for lactation during pregnancy. At delivery, progesterone drops, and baby’s sucking stimulates the production of prolactin (which makes milk) by the anterior pituitary gland. The posterior pituitary gland releases oxytocin, which allows milk to collect and flow (let down). Oxytocin also causes uterine involution. The baby lives because of milk, the mother lives because it decreases her risk of PPH. *note: baby needs to be sucking on the areola, chin touching breast. Types of milk: 1) colostrum = clear yellowish first milk. Develops early in pregnancy and is excreted for 2-4 days postpartum (experienced BFers may get it sooner). Contains lots of protein and fat-soluble vitamins, minerals, antibodies and immunoglobulins. 2) transitional milk = first two weeks. High fat, lactose, and water-soluble vitamins and calories. 3) mature milk = looks like skim milk (white-blue). Two types: a) foremilk = first milk release when begin nursing session; it’s constantly formed and available. It has less fat and flows more quickly than hindmilk. b) hindmilk = formed after let down reflex (after several minutes). It’s higher fat, whiter, has more water and carbs and less nitrogen wastes. It’s more satisfying for the baby! Nurse as long as needed each session. Don’t remove the baby if it’s doing well. Nurse on demand, but usually every 2-3 hours (8-12x per day at first). Sometimes the baby will cluster feed for a few hours and then go a longer stretch without. Look for cues: rooting, moving hands to mouth, alert. Get to baby before crying! Position baby with chin, cheeks, and nose flush with breast. Mom should hold baby at the level of her breast (with pillows), belly to belly with mom: a) cradle position = abdomen flush with mom’s, in crook of arm, other arm free b) cross-cradle = use opposite hand to hold baby’s head, other hold baby in arm, abdomen to abdomen c) football = pillow under baby, good for c-sections d) side-lying = good for c-sections Hold the breast like a C, with thumb on top and forefingers below, above areola. Aim the nipple to the roof of baby’s mouth. Express colostrum onto nipple, and tickle the baby’s lower lip with the nipple. When the baby’s mouth is open, bring baby to mother’s breast. Make sure the baby’s bottom lip is curled out and chin, nose and cheek are flush with breast. The tongue should be below the nipple and areola, pressing the areola between the tongue and hard palate. One inch of the areola (where ducts are) should be in the baby’s mouth. If baby is just on the nipple, put a finger inside baby’s mouth and pull the mouth to the side. Here a “chick” noise to break suction. Babies suck hardest on the first breast, so switch first breasts every other feeding. → nipple shields help with sore nipples → use vitamin E, gel pads or lanolin or other products on cracked nipples → let nipples air-dry after nursing, and wear cloth breast pads to prevent leaking Problem-solving: sucking stimulates let-down. Get baby nursing more frequently (every 1.5-2 hrs) to help engorgement. If too engorged, take a hot shower with hot water beating on breasts, and hand express till breasts are softer. If edema, use cool compresses or cabbage leaves (with veins crushed) in bra — it decreases milk production and helps with pain. Motrin is also okay. Encourage the baby to nurse on both sides. Wear a well-fitting bra. Supplementation is not recommended by the AAP because of nipple confusion. Sore nipples are caused by an incorrect latch, so break the suction and reattach. Urine output should be 1 void per day of life for first 6 days. Stooling increases in amount to 4+ stools per day by day 6. Check baby’s weight gain after 1st week, listen to baby swallow, and evaluate to see if baby is happy and satiated to make sure baby is getting enough to eat. It’s important to encourage and give mothers information that will help them. Hispanics tend to nurse and supplement with formula. The AAP recommends breastfeeding for at least 1 year for the most nutrition. Nursing after that provides comfort and closeness. Tandem nursing during pregnancy can cause contractions and pregnancy may change the flavor of milk. It IS legal to breastfeed in public in Connecticut. Nursing care of the normal neonate The transition to extrauterine life begins when the umbilical cord is cut and the neonate takes its first breath. The respiratory system is the most critical and physiological change in the transition from fetus to neonate, initiated by the compression of the thorax, expansion of the lungs, air going into the alveoli, and the vasodilation of pulmonary vessels. → when the cord is clamped, the oxygenated blood the baby had initially been receiving discontinues. The baby’s oxygen levels dip down, carbon dioxide is not exchanged and its levels begin to rise, the pH turns acidotic, and this stimulates chemoreceptors in baby’s brain to contract the diaphragm. → when baby is born vaginally, the squeeze through the birth canal forces fluid out of the baby’s nose and mouth. Once the baby is pulled it, its chest expands for it to take its first breath (via negative pressure). Skin exposed to cold air also influences the impulses to take a breath. The neonate, cries, providing positive intrathoracic pressure and keeping the 8 alveoli open. Meanwhile, superfluous lung fluid is reabsorbed via the lymphatic system. → when baby is born via c-section, it doesn’t get rid of extra fluid, so it must be suctioned or coughed up. The first breath increases alveolar oxygen tension and decreases the arterial pH (which rebounds as the baby breathes). Pulmonary arteries dilate, which lowers pulmonary vascular resistance, and increases the blood flow throughout the pulmonary vessels (so baby can clear out its own CO2 and deliver O2 to the rest of its body). This results in an increase in O2 and CO2 exchange in the lungs. - Surfactant = a phospholipid that coats the alveoli, keeping them open at the end of expiration and decreasing the pressure and energy needed for inspiration. The first signs of respiratory distress are cyanosis (blue-ing), abnormal respiratory patterns (babies normally have abnormal patterns; really abnormal means retraction, grunting due to air pushing against the vocal cord, noises, struggling, etc.), nostril flaring and hypotonia — flaccid body. *Note: bruising is not cyanosis; to confirm, look at the tongue/rest of the body. It is normal to hear ronchi due to fluid that hasn’t been absorbed in baby’s lungs yet. The circulatory system comes in the transition from fetal to neonatal circulation, starting with cord clamping, and strongly influenced by the respiratory status. Three major structural changes: 1) ductus venosus — connects the umbilical vein to the inferior vena cava; when the cord is clamped, it eliminates this circulation. By day 3, it’s closed and become a ligament. 2) foramen ovale — the opening between the right and left atrium, which closes when the left arterial pressure is higher than the right arterial pressure (prior to that, pressure in the right atrium is higher because of resistance in the lungs before the baby starts breathing). Lowered pulmonary pressure → higher pulmonary blood flow → increased pressure in the left atrium, which closes the flap. ~ respiratory distress can re-open the foramen ovale, needing a shunt to fix it. 3) Ductus arteriosus — connects the pulmonary artery with the descending aorta. When blood stops shunting through it, it collapses and closes within 15 hours post-birth. *Note: it will remain open if lungs don’t expand The thermoregulatory system is transient — it changes constantly. It’s important to watch out for, since babies can’t shiver to tell us they’re cold. Babies have much larger surface areas and less brown fat (good fat), so it’s crucial to keep the baby warm (especially during bath time). Newborns are moist, and need to be kept dry and warm. They lose most heat through their head, so they need hats. The neonatal response to cold is to: a) increase metabolic rate, which depletes glucose stores b) increase muscular activity — babies don’t shiver, they get rigid c) constrict peripheral vessels, so baby’s fingers/toes get blue, its body gets mottled d) deplete stores of brown adipose tissue (babies have IF born at full-term). Brown fat is found in the neck and thorax, is intrascapular and around the adrenal glands and kidneys. It promotes an increase in metabolism, heat production, and heat transfer to peripheral systems. It’s also known as nonshivering thermoregulation. → put baby in a neutral thermal environment! High risk infants have more difficulty with thermoregulatory systems, because they have a higher body surface area-to-mass ratio (SGA babies); a higher metabolic rate; and limited reserves — especially premature babies. Babies lose heat through: - conduction (putting baby on a cold surface, heat transfers to surface) - convection (cool air moving over baby takes heat away) - evaporation (especially on a wet baby; fluid evaporates, cooling the baby down) - radiation (normal heat leaving the baby’s body; will radiate more heat in a cooler area) Cold stress = excessive heat loss leading to hypothermia (lowered core temp). - Risk factors: prematurity, because don’t have nonshivering thermoregulation; SGA; hypoglycemia, because low metabolism; prolonged resuscitation, because heat isn’t given to baby during the process; sepsis; and other neurological, endocrine or cardiorespiratory problems - S/SX: low temp/cool skin, lethargy, pallor, tachycardia, grunting (which goes away when baby warms up), hypoglycemia, jitteriness, and a weak suck. - To prevent: keep the baby dry with its head covered, skin-to-skin, pre-warmed blankets and swaddling, pre-warmed radiating warmers, and delaying the initial bath (baby loses heat when bathing) - To cure: cover head, skin-to-skin, warmed blankets, pre-heated radiating warmers, monitoring temp, and checking for/treating hypoglycemia (b/c body is working to keep warm and using up glucose stores). ~ hypoglycemia = blood sugars 24h and can’t keep anything down, dysuria, foul vaginal odor, abdominal cramping or pain, or vaginal spotting/bleeding. TORCH = infectious diseases. Toxoplasmosis = she should not be cleaning the litter box if she has a cat! Other (Hepatitis B), Rubella, Cytomegalovirus (a virus that can cause complications in the newborn), and Herpes simplex. SECOND TRIMESTER Physiological adaptations to the pregnancy become much more physical: - the areolas of the breast enlarge and darken, the nipples become more erect and darken, and there may be prominent veins and striae (stretch marks) possible as the ducts start to fill. - the uterus grows straight up in the abdomen until 20 weeks, and after 20 weeks the belly “pops” out. At EGA 12 weeks, the uterine fundus is at the level of the pubic symphysis. At EGA 16 weeks, it’s halfway between the pubic symphysis and the umbilicus. At EGA 20 weeks, it’s at the level of the umbilicus. → at this point, we begin to measure the belly with a tape measure (in cms). Measure from the top of the pubic symphysis to the fundus, which should be the same number of EGA weeks she is +/- 2 cms. (If she is not measuring correctly, re-measure in a week. If still not, send her for an ultrasound. → by EGA 40 weeks, the head descends into the pelvic cavity, so measurement may decrease a few cms. - the heart is pushed upward and to the left as the diaphragm is pushed up, which can cause a systolic murmur in 90% of pregnant women. Also: ~ RBC mass increases up to 33%, and plasma volume increases 40-50%. So HGB and HCT decrease because of hemodilution (called the physiologic anemia of pregnancy). After the 2nd trimester, plasma turns into swelling, which is retained for labor and birth. ~ Peripheral vascular resistance decreases, which leads to a decrease in BP during the 2nd trimester (which does level out in the 3rd trimester) ~ A hypercoagulable state — there are tons of blood gushing through the placenta 24/7. This uses lots of platelets and clotting factors to make clots, causing low platelets (in the 200s). ~ We do another CBC at 28 weeks to see the RBC, plasma, HGB & HCT levels at their lowest point. We need a baseline for birth 12 weeks later. - in the respiratory system, tidal volume increases 35-50% to meet the 15-20% in O2 demand/consumption, and to increase the excretion of CO2 (to have more receptor sites to be able to take CO2 from the baby). Causes a more alkaline environment (7.45), so we need it to become a bit more acidic. There’s a shift from abdominal to thoracic breathing, due to the difficulty in breathing through several pounds of baby weight, and the elevated diaphragm gives room for the fetus to grow. - in the genitourinary system, the growing uterus puts pressure on the ureters, causing them to dilate, which also causes the kidneys to enlarge. This increases the glomerular filtration rate by 50%, but the tubules can’t handle that increased rate, leading to decreased absorption, which leads to proteinuria and glucosuria (okay in trace or 1+ amounts). ~ BUN and Cr decrease because of glomerular dilution (6-10 is normal in pregnancy) ~ UTI risk increases due to urinary stagnation, causing a higher risk of kidney infection - early in pregnancy, the increased vascularity of gums leads to gingivitis. The woman may also experience ptyalism = very increased saliva production (ginger/cardamom help). Heartburn worsens as the esophageal sphincter tone decreases, and constipation worsens as GI muscle tone/motility decrease. - in mid to late pregnancy, decreased muscle tone of the gall bladder and increased retention of bile places the woman at an increased risk of gallstones (upper right quadrant pain). - in late pregnancy, the intestines are laterally and posteriorly displaced, and the stomach is displaced superiorly, causing more heartburn. - changes in the integumentary system: a) hyperpigmentation = skin darkens b) linea negra = dark longitudinal line on the stomach c) chloasma/melasma = mask of pregnancy d) striae = stretch marks e) vascular spider nevi/angiomas = spider veins f) palmar erythema = reddened palms g) hair growth increases (and then falls out postpartum) - the immune system ramps DOWN, because the baby is a foreign object that we don’t want to get rid of For the fetus, movement for a primip comes between 18-20 weeks. For a multip, it’s usually 14-16 weeks as the abdominal wall is so stretched. The kidneys begin secreting amniotic fluid, and bones solidify by 28 weeks (so calcium is important!). In the second trimester, the psychosocial adaptations of the mother should have the fetus as the primary focus, alongside concern about the changes in her body and her sexuality. Her task is to accept the baby by saying, “I’m having a baby,” which usually comes at the time of movement. The partner is going through the moratorium phase, saying, “She’s having a baby,” and his/her task is to establish 15 a relationship with the fetus. To promote family adaptations to the pregnancy, siblings at certain ages can come to the prenatal visit or attend sibling classes. Generally, toddlers/preschoolers need changes introduced early (like moving to big kid beds) so that there’s no connection with the baby. School age children tend to be very interested. Adolescents are usually excited or ambivalent. - abnormal acceptances of pregnancy include strong, intense resistance to the pregnancy; disabling physical symptoms; movement perceived as unpleasant; denial of need for any changes in the couple’s relationship; avoidance of weight gain; denial of fears about childbirth; and unrealistic expectations about birth and the infant. Second trimester testing includes: 1) CBC — it’s at the lowest level during pregnancy and establishes a baseline (esp. for iron) for delivery 2) One hour glucose challenge test (GCT) — make her drink sugar, wait 1 hr, check blood sugar. If >140, need to take: 3) Three hour glucose tolerance test (GTT) — must fast for 8 hrs, gets fasting levels drawn, drink HUGE amount of sugar and take the blood sugar at 1 hr, 2 hrs and 3 hrs. If two of those numbers are elevated, she has gestational diabetes. 4) If the mother is high risk, repeat the antibody screen (indirect Coomb’s) in Rh- moms, VDRL/RPR, Hepatitis B, HIV, and cervical cultures. Those are needed in women with a history of STDs, or multiple partners. In the second trimester, expect to counsel the mother on nutrition (calcium and iron are very important), clothing (wear white cotton panties), and exercise (she can do what she was doing pre-pregnancy, but with moderations/limitations. She can always walk). She may experience: - syncope = fainting, due to lower peripheral vascular resistance, which lowers the BP; and due to supine hypotension (from vena cava syndrome). Have her lie in a tilt, and slowly get up. - round ligament pain = the round ligaments attach the pubic symphysis to the fundus, and as the uterus expands, it pulls up and out — causing sharp pain in the right and left sides. Warm compresses and pulling her legs up may help Counsel the woman to call if she experiences: fever, chills, persistent vomiting >24h, foul vaginal odor, abdominal or pelvic pain, vaginal bleeding, s/sx of UTI, pregnancy induced hypertension or preterm labor, or changes in fetal movement (especially at the end of the 2nd trimester and all through the 3rd trimester). Fetuses are most active at night, because moms spend all day walking around and rocking them to sleep! THIRD TRIMESTER Physical adaptations in the third trimester include: - in the breasts, the ducts mature and fill with milk - the uterus measures the same number of weeks as EGA, but at the end slightly decreases when the head descends - in the musculoskeletal system, relaxin softens cartilage especially in the pubic bones. This, combined with center of gravity changes, affects the woman’s gait (pregnancy waddle). Lordosis = spinal curve to accommodate weight. Diastasis recti are muscles that run longitudinal on either side of the abdomen and stretch out during pregnancy. With the fetus, it has distinct movement patterns that the mother knows best. The fetus may take practice breaths in utero. From 28+ weeks, we watch fetal heart rate reactivity — making sure the rate is 110-160, there is good variability, and good accelerations and decelerations. Maternal psychosocial response is typically vulnerability, fear, increasing dependence, and acceptance that the fetus is separate but completely dependent. She must prepare for birth and motherhood, saying “I’m going to be a mother.” Her partner is in the focusing phase, identifying with the parent role, and saying, “I’m going to be a parent.” Anticipate counseling the mother on clothing (including comfortable shoes for her swollen feet), exercise (she can continue! Swimming is excellent), sleep/rest (can be difficult due to “baby gymnastics” and urinary frequency. NO sleeping pills!). Sexual activity is okay, but may require creative positioning. Employment may be difficult if she’s not sleeping or feeling well, but providers must have a documented problem to prescribe an absence. She can travel, but should stay close to home, remembering that her body is in a hypercoagulable state and sitting for a long time could lead to clots. She should stay well hydrated! She may be experiencing: - heartburn with a vengeance - urinary frequency - syncope - constipation (take stool softeners, fluids, fiber, prune juice, and be active) - hemorrhoids (can use ointment) - varicosities = poor venus return; use compression stockings - backache (good posture helps) - leg cramps (due to dorsiflexion. DO NOT point toes; make feet flat! Especially in labor.) Going back to TORCH — Herpes simplex and Group B strep are concerning around the time of delivery. Herpes simplex is a viral infection; if it’s in the genitalia at the time of delivery, we must do a c-section. But suppressive therapy should be started at 36 weeks to try to prevent an outbreak. For Group B Strep, which is a bacteria most people harbor that’s not harmful for us (but life-threatening to 16 the fetus). A test is done at 36 weeks by swabbing the vagina and then the rectum with the same swab. If it’s positive, she’s colonized with GBS, and as long as the baby is in its amniotic sac it’s protected. Counsel the woman that if her water breaks, to go to the hospital so we can treat her with penicillin before, during and after labor. (*NOTE: make sure she’s not allergic to penicillin! If she is, we need to do a sensitivity report.) If she doesn’t get 2 doses before her water breaks, the provider must put a hold on the baby and watch the baby in the nursery for 6 hours. Again, counsel the woman to call if she experiences: fever, chills, persistent vomiting >24h, foul vaginal odor, abdominal or pelvic pain, vaginal bleeding, s/sx of UTI, pregnancy induced hypertension or preterm labor, or changes in fetal movement. Antepartal nursing: testing and complications As with all testing, the role of the nurse is to provide information regarding how the test is performed, what to expect, and what the test measures. She should provide comfort, psychological support and reassurance, documenting and reporting responses and scheduling follow-ups. Note: 20-25% of pregnancies end in loss. Once a heartbeat of 100+ bpm is heard, the odds of a loss go down to 1 in 20. There are two types of genetic testing, which can be done preconception or during the first visit (EGA 8-10 weeks): 1) screenings, done by maternal blood testing, which calculate risk — the likelihood the baby might have… 2) diagnostic, done by fetal cell testing, which gives a definitive diagnosis Some of the most common things to test for are sickle cell anemia, cystic fibrosis, Tay-Sach’s, Trisomy 18 and Trisomy 21. All of those are autosomal recessive, so in order for the fetus to have it, it must have gotten recessive genes from both mom & dad. Chorionic villus sampling is a diagnostic test, done transcervically in the 1 st trimester (EGA 10-13 weeks). The nurse should know any necessary lab results (STDs? Mom’s Rh status?), and assist the pt with positioning and relaxing. Monitor maternal VS and FHR during procedure, give rhoGAM if mom is Rh-, and counsel the mother to report any cramping, rupture of membranes, bleeding, fever or chills. Risks of CVS include fetal loss, excessive bleeding, and fetal limb loss. Need to know Gonorrhea and chlamydia results. Ultrasonography can be done transvaginally or transabdominally to help test; looking for different things in different trimesters: ~ 1st trimester = FHR, # of fetuses, EDD, making sure the sac is implanted in the correct place, and placental location ~ 2nd trimester = sex of baby, fetal anatomy and growth ~ 3rd trimester = amniotic fluid status, fetal presentation, size, growth and anatomy The nurse must first assess any allergies, as transvaginal ultrasounds use condoms and gel (latex allergy alert). If the tests are being done in the 1st or early 2nd trimester, the pt should have a full bladder to push the uterus up, and she can lie supine. In the late 2 nd or through the 3rd trimester, her bladder should be empty, and she should be in semi-Fowler’s or tilted position. Between 15-20 weeks, the woman can undergo the MSAFP/Multiple marker screening (not diagnostic!), which looks for Trisomy 18, Trisomy 21, and open neural tube defects. Depending on the result, help pt understand what the results mean and the risks/benefits of further testing (like amniocentesis). Amniocentesis can be performed in the 2nd trimester for diagnostic testing or 3rd trimester for maternal infection and fetal lung maturity. (It can’t be performed in the 1st trimester because there’s no amniotic fluid yet.) The bladder should be empty, and rhoGAM given if the mother is Rh- (which lasts 14 weeks). Counsel the mother to report decreased fetal movement, cramping, ROM, bleeding, fever or chills. In the 3rd trimester only, the woman may undergo a Non-Stress Test to look at the FHR. It’s a 20 minute tracing test wherein the woman is put on external monitors for FHR and uterine activity. Its predictive value is good for 1 week, and looks for: 1) Is the FHR within 110-160 bpm? 2) Is there moderate variability throughout? 3) Have there been at least 2 accelerations with elevation of at least 15 beats, lasting at least 15 seconds, in that 20 minutes? Want this test to be REACTIVE. There’s also a Contraction Stress Test, which is also done only in the 3rd trimester. It’s rarely done on purpose because it decreases blood flow to the baby (but could be done/seen in labor if the FHR tracing isn’t great). Might have to do nipple stimulation or give pitocin to make this happen, but looks for: 1) at least 3 ctx lasting 40 seconds in 10 minutes 2) normal FHR with good variability and no decels. Want this test to be NEGATIVE. For both the NST and CST, the bladder should be empty, the woman in semi-Fowler’s or tilt position. Good results: reactive NST or negative CST. Bad results: Non-reactive NST or positive CST. If bad results, the woman is usually sent for a biophysical profile. 17 The Biophysical Profile looks at the NST, amniotic fluid level, fetal tone, breathing and movement. It gives either 0 pts or 2 pts for everything. 8-10/10 is reassuring, 2/10 requires immediate delivery. A variation on the biophysical profile is the Amniotic Fluid Index, which uses the NST results and an ultrasound that looks at all four quadrants of the uterus and the size of pockets of fluid in each. 8-24 cm is reassuring, 24 cm needs additional testing. The mother should begin daily fetal movement counts starting at 28 weeks. It’s the best indicator of fetal well-being, and the mother should eat, rest, and focus on fetal movements for one hour. 4 movements/hr is reassuring, call provider if it’s not. COMPLICATIONS An abortion/miscarriage is any pregnancy that ends before 20 weeks. There are five types: 1) missed = asymptomatic; mother has no idea. Discovered at a doctor’s visit. 2) incomplete = the cervix is partially open and starting to discard fetal contents. It can finish passing on its own (preferred, to avoid scar tissue that could affect the next implantation) or need to be cleaned out (D&C). 3) complete = everything passes on its own 4) septic = the uterus becomes infected (a risk with missed abortions). Can cause hemorrhaging. 5) recurrent = repetitive losses. After 2+ losses, we begin to look at genetics and clotting disorders. Nurses must be able to recognize the lack of probable/presumptive s/sx of pregnancy — i.e., the woman isn’t reporting any or much breast tenderness, urinary frequency or nausea — as well as the s/sx of infection. Be sure to offer discharge teaching if the woman needs a procedure done, like a D&C, so that a woman can know what to look out for (excessive bleeding). An ectopic pregnancy is a pregnancy that implants anywhere other than the uterine lining (typically in the fallopian tube). It’s imperative to catch an ectopic pregnancy early before it ruptures, or it could lead to a hemorrhage. S/sx: irregular bleeding and unilateral pelvic pain that gets increasingly worse. Women who have had a history of ectopic pregnancies, a history of PID, or a history of instrumentation (i.e., a D&C leading to scarring) are at a higher risk of ectopic pregnancies. It’s diagnosed via ultrasound if the pregnancy is far enough along to see it, but if not, you have to look for hCG levels that aren’t doubling. → Ideally, you would treat an ectopic pregnancy with methotrexate, which stops fetal development, loosens the contents and allows them to pass. If not, must do surgery to cut out the pregnancy. This can reduce future fertility because of scar tissue. → Nurses should recognize the risk factors for an ectopic pregnancy and highlight them in a woman’s chart! If the contents rupture, we must stabilize the cardiovascular system b/c hemorrhage. *Note: rupture can also manifest in shoulder pain. Gestational trophoblastic disease = molar pregnancy is a benign proliferating growth that hangs like grape-like cluster (without a fetus) beginning in the chorionic villi. S/sx: abnormally large uterus for EGA, abnormally high hCG levels, abnormally bad nausea and vomiting. The only risk factor is a history of molar pregnancy. This must be diagnosed by ultrasound, and medical management must include surgery to remove the mass — it must be very thorough and also take out a layer of the chorio. → Nurses must be ready to stabilize the cardiovascular system because the clusters are highly vascularized. They can pop and cause heavy bleeding. → Following the removal of a molar mass, the woman must keep coming back to the office to get her hCG levels checked. It may take months, but we have to make sure the level gets back down to 0. And she MUST be on reliable contraception during this period! Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) — required testing during the first trimester. If it’s positive, we have drugs that can lower the risk of transmitting it to the fetus from 25% to 2%! These babies are typically born via c-section, and usually aren’t allowed to breastfeed. We test babies 6 months after birth to see if they have it. Placenta previa occurs when the placenta implants close to or over the internal cervical os, exhibited by painless vaginal bleeding. Women who have had instrumentation (previous D&C or c-section), a history of PID, are of advanced maternal age or who smoke are at higher risk for placenta previa. Three kinds: 1) complete/total previa = entire os is covered 2) incomplete/partial previa = part of os is covered 3) marginal implantation/low-lying placenta = doesn’t cover the os, but comes within 2 cm of it. Practitioners can typically feel this beginning at the end of the 1 st trimester, but there’s always a chance the placenta will raise up as the uterus grows. So it’s diagnosed for sure by ultrasound in the 2nd trimester. The only medical management is bed rest (in the Trandelenberg position) and a c-section. During pregnancy, there should be NO cervical stimulation, orgasms, or anything in the vagina! → Typically women with placenta previa will end up on best rest in the hospital. Nurses must monitor maternal and fetal wellbeing with every episode of spotting. Watch CV status if she starts bleeding heavily. Incompetent cervix/recurrent spontaneous abortion occurs due to a repetitive defect in the cervix that results in multiple 2 nd trimester losses (with no contractions). Beginning s/sx include low pressure and excessive discharge, and women with histories of incompetent cervix or cervical trauma (i.e. D&C) are higher risk. Medical management includes sewing the cervix shut with a Cerclage. 18 After a Cerclage is placed, nurses must immediately monitor maternal & fetal well-being, monitor for uterine activity and administer tocolytics PRN, and monitor for heavy bleeding, ROM and s/sx of infection. (It’s normal to have some bleeding.) → Teach the woman warning signs to look for as well. Hyperemesis Gravidarum = severe nausea and vomiting that persists beyond the 1 st trimester, as exhibited by severe N/V and dehydration. It can be managed by IV fluids and anti-emetics (IV or suppository). Nurses should identify and promote/reduce alleviating and aggravating factors (have the woman keep a food/smells journal), and counsel the woman to minimize fluid intake with meals — because the fluid takes up space that should be filled with food to nourish the fetus. Also, offer comfort measures and oral hygiene care! → In the hospital, monitor Is & Os and electrolyte levels. During the 1st trimester and possibly again during the 3rd, a woman is given a blood test to determine Rh compatibility or incompatibility (indirect Coombs). Basically, RBCs contain antigens that determine blood type and Rh status. Rh status is determined by the presence of the D antigen (presence = Rh+). - If a mother is Rh- (doesn’t have the D antigen), and the fetus is Rh+ (does have the D antigen), AND if fetal RBCs cross the placenta, the mother’s body will begin making antibodies to the D antigen. Those anti-D antibodies can cross the placenta back and attack fetal RBCs, causing erythroblastosis fetalis = mother’s blood attacks baby’s blood and makes baby severely anemic. This is prevented by giving mother a rhoGAM shot, which provides her with temporary anti-D antibodies for 14 weeks so she doesn’t make her own. If the baby does have erythroblastosis fetalis, we can do fetal/newborn blood transfusions continually before and at delivery to help counteract the anemia. - Risks causing fetal and maternal cells to cross the placenta include bleeding, invasive tests, and delivery. Giving rhoGAM at 28 weeks covers her for delivery. *IF* the mother’s blood has been exposed to D antigens and has begun making the anti-D antibodies, she can’t have rhoGAM in a subsequent pregnancy. Fetal effects will be noted on the ultrasound, as it may be very difficult to have a healthy subsequent pregnancy. Nurses should confirm maternal Rh status at EACH interaction, and educate the mother about it. Nurses should also administer rhoGAM with any invasive uterine procedure or episodes of bleeding if not already received at 28 weeks. ABO incompatibility is far less severe than Rh incompatibility. Basically, if mother is type O, and fetus is A, B, or AB, AND if fetal RBCs cross the placenta, the mother will make antibodies to the A, B or AB antigen. Those anti-A, B or AB antibodies can cross the placenta back and attack fetal RBCs. This isn’t a big problem; it might cause jaundice in the fetus. This is diagnosed by the direct Coombs test, and a nurse should recognize s/sx of hyperbilirubinemia and be able to counsel the mother to provide frequent feedings to the baby to help pass the jaundice. The baby may need to go under light therapy. There are two types of diabetes in pregnancy: gestational diabetes (Class A), which includes diet-controlled (class A-1) and insulincontrolled (class A-2), and diabetes that the mother had prior to pregnancy — pregestational diabetes (any other class, determined by the likelihood/presence of vascular disease). Diabetes in pregnancy essentially means there has been a diagnosis of elevated blood sugars after 20 weeks’ gestation during the GTT. - Risk factors: family history of diabetes, macrosomic babies or a history of macrosomic babies, and obesity - S/sx: elevated maternal blood sugars, size-greater-than-dates babies, and polyhydraminios (baby has polyuria) - Diabetes in pregnancy can lead to diabetes later in life, pre-eclampsia, and possible c-section delivery in the mother, and macrosomia, shoulder dystocia, respiratory distress syndrome (elevated blood sugars impede lung maturity), and hypoglycemia in the fetus. - It can be managed by diet, exercise and insulin. - Nurses should offer nutritional/activity counseling, self-monitoring of blood glucose, and education about ketonuria (important! Monitor for ketonuria by dipping urine so that it doesn’t turn into ketoacidosis). The nurse should also monitor maternal and fetal well-being by offering weekly NSTs and amniotic fluid indexes. PIH/Pre-eclampsia/eclampsia/HELLP syndromes all have similar risk factors, risks, signs and symptoms, and medical/nursing care. Definitions: 1) Pregnancy-induced hypertension (PIH) = hypertension diagnosed after the 20th week of pregnancy 2) Pre-eclampsia = presence of PIH, proteinuria and edema 3) Eclampsia = seizures 4) Hemolysis, Elevated Liver Enzymes, and Low Platelets Syndrome (HELLP) = a variant of eclampsia; causes anemia and dangerously low platelets. - Risk factors: history of any of the conditions, women with gestational diabetes, obesity, primips and multiparips (their blood vessels go into vasospasm) - Risks to the mother: stroke, organ failure. Risks to the fetus: constricted blood flow to the placenta, hypoxia, IUGR - S/sx: HTN, severe headaches (due to blood vessels constricting), blurry vision (retinal vessels constricting), right upper quadrant pain (liver vessels constricting), being hyperflexic, heartburn, clonus = involuntary muscular contractions and relaxations. 19 - Medical management calls for rest in a lateral recline position, monitoring labs (especially BUN & Cr, which elevate), doing a 24-hr urinalysis looking for protein, and possibly putting the patient on mag sulfate. Usually, it ends up being a risk/benefit situation for delivery. - Nurses must correctly interpret lab results — remember, BUN & Cr should be lower in pregnancy, so when that elevates, it’s bad! Nurses should also enforce quiet and limiting visitors. *Note: Magnesium sulfate, when given IV, basically bogs everything down. It prevents seizures, causing a drugged effect. The patient must be on bed rest, have a Foley, and not eat. BP and RR will decrease, and it causes terrible headaches due to vasodilation. ALWAYS have the antidote available (calcium gluconate). → mag sulfate is excreted in the urine. If urine output increases, the mag sulfate level in the body decreases (and vice versa). Intrapartal nursing There are five factors that affect labor — the 5 Ps: Primary, Passage, Passenger, Psyche, and Position. Powers breaks down into primary powers = involuntary uterine contractions, and secondary powers = bearing down. * For primary powers, uterine contractions come in cycles with four stages: 1) Increment = no contraction to the height of a contraction 2) Acme/Peak = the most painful part of the contraction 3) Decrement = coming down from the peak; shorter than the increment 4) Relaxation = known as the interval between contractions, it allows the uterus to relax and profuse again * Contractions are measured in four ways: a. frequency — how often contractions come; timed in minutes from the start of one contraction to the start of a next contraction (includes the period of rest). In active labor, they’re every 3-4 minutes. b. duration — how long contractions last; timed in seconds from the beginning of one contraction to the end (does not include the period of rest). In active labor, they’re about 90 seconds long max. c. intensity — how strong the contractions are; measured at the peak of the contraction by putting fingers on the fundus to feel the uterus’ transition from soft → hard → soft. - mild contractions feel like you’re pressing on your nose - moderate contractions feel like you’re pressing on your chin - strong contractions feel like you’re pressing on your forehead *Note: the assessment of contractions can be subjective (how the woman deals with the pain) and objective (we palpate the fundus and time a contraction). d. regularity — the contraction pattern; usually starts irregularly and then becomes regular. * The power of contractions causes cervical changes. The cervix is like a tube, with an internal os (near the baby) and an external os (in the vagina). The cervical changes occur in two ways and don’t have to happen at the same time: 1) Effacement = the thinning/shortening of the internal os; described in percentages. (Like when you blow up a balloon and the balloon’s neck gets smaller and smaller til it disappears.) 2) Dilation = the gradual enlargement of the external os; measured in centimeters. * For secondary powers, bearing down is the maternal pushing effort, triggered by the fetus’ presenting part hitting the pelvic floor, that does not affect cervical effacement or dilation. It typically feels like the woman needs to have a BM. * Types of uterine and fetal monitors used during the powers stage: - External electronic monitoring of the uterus — by something like a tocotransducer, which is placed over the fundus and measures the firmness and softness of the belly, and frequency and duration of contractions, in graph form. It does not measure strength of contractions. - Internal electronic monitoring of the uterus — by an intrauterine pressure catheter (IUPC), which is placed as far up the cervix as it can go, and is the only real way to measure strength of contractions. *requires ROM and some dilation. - External electronic monitoring of the fetal heart — by a Doppler, periodically, or by an ultrasound transducer, that measures the fetal heart rate. - Internal electronic monitoring of the fetal heart — with a fetal scalp (spiral) electrode. A catheter with a little spring on it is screwed into the baby’s head, and gives extremely accurate information about the fetal heart. *requires ROM and some dilation. Passage is the second P, and it’s comprised the bony pelvis and soft tissues of the cervix, vagina and introitus (essentially, the tunnel the baby has to go through to be born). The pelvis is broken down into three planes: 1) the pelvic inlet = the upper portion of the pubic bones 2) the midpelvis = the center of the pelvis; the smallest place (it’s often where the baby gets stuck if it’s too big). It’s measured at the ischial spines and can be felt on a vaginal exam. 3) the pelvic outlet = the base of the ischial tuberosities, with the coccyx behind. * The baby’s location can be classified by using stations, which are the relationship between the fetus’ presenting part relative to the midpelvis. When the fetus hits the 0 station at the ischial spines (the smallest portion), the baby is engaged. 20 * Prior to pregnancy, soft tissues are comprised of the uterus and cervix. But labor causes the fundus to differentiate from the lower uterine segment. The fundus (upper part) works/contracts; the lower part passes the baby down. Passenger is the third P, and it’s comprised of the fetus and the placenta. - The fetal head is the most concerning part, because it’s relatively rigid and the biggest part of the baby. The fetal head can have bones that overlap (molding), so the head can get smaller. A woman dilates to 10 cm; the biparietal diameter of a fetal head is 9.25 cm. - The passenger’s attitude = the relationship of different parts of the fetus to itself. We want flexed (compact) with the head tucked down. - The fetal lie = the relationship of the mother’s spine to the fetal spine; it’s usually longitudinal (head or bottom first; it can be transverse, which requires a c-section). - Presentation = the general part of the fetus that enters the cervical os first. Most common: vertex or cephalic (headfirst). Breech = something else presenting. - Presenting part: * O = occiput; baby is born looking down at the floor; most common * S = sacrum (buttocks); breech position * SC = scapula (shoulder) * M = mentum (face) * BR = brown (eyebrows) - The position = where the fetus is in relation to the mother’s body. Described in three letters: first is Right or Left (which side the spine is on); second is the presenting part; third is whether the baby is anterior = facing the sacrum, or posterior = facing the sky (sunny side up). Posterior babies cause back labor due to where the fetal head is pressing! → the most common is LOA — spine is on the left side, occiput presenting, fetus is looking at the sacrum → to determine the fetus’ position, use Leopold’s Maneuver: 1) feel the top of the fundus; if you feel something mushy, it’s a tushy 2) feel the right and left side of the abdomen; the smooth side is the spine (bumpy is other side) 3) feel right above the symphysis pubis; if it’s hard, it’s a head - The placenta is a passenger, but rarely impacts the ability of labor to progress. Psyche is the fourth P. Women who view birth as an illness tend to have complicated births; people who view labor as normal and healthy tend to have smoother labors. Nurses are there to support women and their families. Assess the women’s support people (family and doulas) and make sure they’re who the mother wants and that they’re being supportive! Protect a woman’s privacy even when she can’t — keep her covered, curtains drawn, doors closed. And be careful of culture. Orthodox Jew fathers can’t be involved in birth. Asian women are stoic, and drink boiling water in labor. Hispanic cultures tend to be very verbal. Indian and Pakistani women don’t take care of their babies postpartum except to feed them. Positioning is the fifth P — the maternal position during labor and birth. Walking, sitting, kneeling, squatting, or a lateral position is encouraged during the first stage of labor, as they decrease the compression of the maternal descending aorta/ascending vena cava which can lead to decreased placental perfusion; the upright position helps the fetus descend and results in a shorter labor. During the second stage of labor, the upright position increases the pelvic outlet and better aligns the fetus with the fetal inlet. → Note: the lithotomy position is the most popular in the United States. During labor, several bodily systems undergo changes: 1) In the circulatory system, maternal blood pressure rises during contractions but returns to pre-labor levels between contractions. Very strong contractions, especially without adequate rest periods, can stop blood flow to the uterine arteries (if the woman lies on her back, it can lead to vena cava syndrome — so have her lie on her left side so the blood flow returns). Changes in bodily fluid volume slows down pulse. 2) In the respiratory system, there is an increased consumption of O2 during labor. Women can breathe so quickly they hyperventilate, so have them breathe into a paper bag. 3) In the gastrointestinal system, labor causes reduced gastric (stomach) motility and reduced absorption of food. Vomiting is common. Women need energy during labor, but are typically only allowed to eat jello, ice pops, or broth, because doctors don’t want them to aspirate if they need a c-section. It’s common for a woman to have a BM while pushing 21 4) during labor, as we tell them “push like you’re having a BM.” Hard stool in the colon can be a problem during labor, so try to make sure the woman is not constipated. In the genitourinary system, if the bladder is empty, the fetus can come down farther. Have the woman void q2-3hrs during labor. If she can’t void, straight-cath her. If she has an epidural, she’ll definitely have a catheter. Signs of impending labor: - lightening = when the baby “drops”, causing lower abdominal pressure (especially on the bladder), the woman can breathe more easily, there’s less pressure on her stomach so she can eat more, and there’s more pressure on her rectum so she could develop hemorrhoids. It can be gradual or sudden, and could cause leg cramping. Primips tend to deliver 10-14 days after baby drops. - Braxton-Hicks contractions = “dress rehearsal” for labor for both mom and fetus. Begins very early in pregnancy, but women don’t feel them. They get stronger as labor gets closer. They don’t cause cervical change (real labor = cervix starts to efface and dilate). Braxton-Hicks contractions start in the front and stay in the front; “real” contractions start in the back and go around in a wave. - cervical changes = pre-labor, the cervix is long, closed, firm, and facing posterior. As labor progresses, it gets softer as it effaces, and dilates (aka the “ripening” of the cervix”. It also swings anterior. Cervical changes = labor. - sudden burst of energy = “nesting instinct” — we don’t know why it happens, but manifests in most women as housecleaning, rearranging furniture, washing baby clothes, etc. - backache = the pelvic joints are loosening up. Women tend to get bad backaches right before labor. - Bloody show/mucous plug = during pregnancy, the body secrets mucous to fill up the column/hole in the cervix. It creates the operculum (mucous plug), which is hard at the bottom. Nothing can get into the cervix if it’s there. Just before labor, with cervical ripening, the mucous plug pulls away and causes bloody discharge (bloody show). The woman may loose the plug altogether. The mechanism of labor include moves the fetus has to make in order to be born. The fetus must make the right moves at the right time in order for the birth to be smooth. First comes engagement, when the baby is at 0 station and its head is level with the ischial spines. It descends and remains tightly flexed (the baby’s head hitting the pelvic floor promotes more flexion). The fetus begins internal rotation, during which the head turns slightly and tucks in. It starts to rotate to fit the diameter of the pelvic outlet. Once internal rotation is complete, it begins extension — when the head hits the perineum, the chin tucks out (neck pivots/extends) and the head comes under and out the symphysis pubis. Once extension is complete, external rotation begins with the head being born. The head turns either right or left, putting the shoulders in a better position to be born. The top/anterior shoulder is delivered first, and the bottom/posterior shoulder is delivered second. Finally, in expulsion, the shoulders are out and the baby is born. *Note: the time of birth is called when the whole body is out. In evaluating the fetal heart rate, you must first determine the baseline = the rate of the fetal heart rate BETWEEN contractions (during contractions, there may be expected changes to the FHR). Ignore accelerations; look at the baseline. Normal is 110-160. → fetal tachycardia = anytime the FHR is >160 for a 10 minute period. It’s an early sign of fetal distress, as the fetus is trying to get more blood out and is overcompensating. *Note: transient tachycardia is not uncommon. → fetal bradycardia = anytime the FHR is 20 ~ LOC: confused, restless (fight-or-flight response) ~ GU: decreased urine output (65 for tissue perfusion; BP stays low and requires compensatory meds (will stay low); erratic asystolic HR; respiratory failure even on mechanical ventilation. Everything is shutting down. ~ LOC: unconscious (though still talk to pt!) ~ GU: anuric, renal failure, requires dialysis (CVVH) ~ Skin: jaundiced Multiple organ dysfunction (doesn’t have to happen at the same time) → complete organ failure → imminent death. Medical management is the same as the progressive stage; vasoactive drugs, ventilator, dialysis. Diagnosis of irreversible can only be made on the basis of pt’s continued failure to respond to treatments (why documentation is so important). MD may attempte experimental strategies in this stage (ex. antibiotics). ~ Nursing management: continue to monitor pt, prevent injury, continue treatments; provide brief explanations and continued therapeutic touch/support to pt & family; arrange an informational family meeting; obtain copies of living wills/advanced directives; allow the family uninterrupted opportunities to see, touch, and talk with the pt (no visitation limitations). Managing shock requires collaboration among all members of the health care team to ensure that manifestations are quickly identified, and adequate and timely treatment is instituted, leading to the best possible outcome. The nurse is responsible for having all team members on board as soon as he/she notices anything abnormal. Things used: - fluid replacement, which is administered in all types of shock and helps improve cardiac and tissue oxygenation. The best fluid to use is controversial; usually it’s whatever is readily available EXCEPT Dextrose or D5. Start early to minimize fluid loss and to restore and maximize intravascular volume. Types used: a) crystalloid = isotonic fluid, contains the same concentration of electrolytes as the extracellular fluid (can be given without altering the concentration of plasma, and moves freely between intravascular and intracellular spaces). Types: NS & LR (electrolyte solutions). i. 3 parts of volume is lost to the interstitial space for every 1 part that remains intravascular (ex. if administer 1 L of IV fluid, pt gets ~250 ml and the other 750 ml is lost into tissues). ii. More fluid must be administered than lost; rapid infusion can lead to excessive edema (pulmonary). 36 - - b) colloid = large molecule IV solution, considered plasma proteins/molecules too large to pass through capillary membranes, they expand intravascular volume by exerting oncotic pressure pulling fluid into the intravascular space. Ex: albumin, blood products (packed RBCs, FFP, synthetic preparations like Hetastarch). i. colloids have a similar action as hypertonic crystalloid fluid, but requires less volume and has a longer duration of action ii. can still become edematous but not as rapidly as crystalloid boluses alone. The most common complication of fluid administration is cardiovascular overload and pulmonary edema, exhibited by adventitious lung sounds (crackles); this requires invasive monitoring, including: ~ arterial line (A-line) = a large catheter inserted into radial arteries, used for continuous BP monitoring, retrieval of arterial blood gases, routine blood draws, etc. ~ triple lumen catheter (TLC) = monitors central vascular pressures (CVPs), tells volume levels within the body ~ pulmonary artery catheter (swan ganz) = can read cardiac outputs and volume levels; only used in ICU. vasoactive medication therapy (ex. Levophed, Vasopressin) is administered throughout shock stages to improve the patient’s hemodynamic stability when fluid therapy alone cannot maintain an adequate MAP. It helps increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. → it must be administered via IV pump in a central line → requires vital signs Q15 mins until hemodynamically stable (i.e., all stable VS & volumes) → individual parameters are titrated by the nurse based on orders and patient response → physicians select drugs based on their actions in the sympathetic nervous system increased nutritional support: increased metabolic rates during shock increase energy requirements, which increase caloric requirements. These patients may require >3,000 calories daily. Parental or enteral nutrition should be initiated as soon as possible. *Enteral is preferred to protect the integrity of the GI system, b/c it depends on direct exposure to nutrients. The coating with enteral feeds helps prevent ulcers from forming. But if the pt is hemodynamically unstable (BP still dropping or VS abnormal), and is still titrating meds, then NO enteral nutrition — just parental (TPN). Hypovolemic shock is the most common type of shock, and occurs when there is a reduction in intravascular volume by 15-25% (depending on body size, can be as little as 750 ml). Can be caused by external fluid losses or internal fluid shifts, and medical management is to restore intravascular volume to reverse the sequence of events leading to inadequate tissue perfusion; redistribute fluid volume; and correct the underlying cause of the fluid loss ASAP. → If hemorrhaging, stop bleeding. If diarrhea/vomiting, med treatment until the source is identified (take sample) — provide antibiotics, hydrate, give anti-emetics or anti-diarrheals. Blood & fluid replacement is a primary concern; it’s priority to get two large-gauge peripheral IVs (minimum 18 gauge) for the simultaneous profusion of fluids, meds, and blood products. Infuse necessary crystalloids/colloids as ordered. Proper patient position helps redistribute fluids; place in modified Trandelenberg (head flat, feet elevated 20 degrees to promote venous blood return). Vasoactive meds improve cardiac contractility, decrease preload and afterload, and stabilize HR & rhythm. - essential nursing focus is prevention — close monitoring for fluid deficits and providing fluid replacements before the intravascular volume is depleted (blood and fluids safely). Obtain baseline blood counts, type and screens; anticipate need for blood transfusion; monitor pt for complications of CV overload and pulmonary edema; monitor hemodynamic pressures, vital signs, arterial blood gases, serum lactate, H&H, Is & Os, temperature, respiratory status; do a physical assessment (it’s a constant state of assessment). Anaphylactic shock is a severe allergic reaction, which is rapid onset and life-threatening. It can be prevented! Causative agents include plants, animals, pollen, latex, bee stings, medication, nuts/shellfish, dust, mold/mildew, etc. Patients are exposed to a foreign substance they have previously been exposed to and have developed antibodies toward. This provokes mast cells to release a vasoactive substance (histamine) that causes widespread vasodilation and capillary permeability (the capillary wall structure allows blood elements and/or waste products to pass through into tissue spaces). - Medical management includes removing forms of the causative agents; administering meds to restore vascular tone, reduce capillary permeability, and reverse bronchospasm (Epinephrine, Benadryl, Albuterol); and provide emergency support of basic life functions. If caught early, the person many not need to be intubated or resuscitated. - Nursing management includes preventing allergic reactions! If in the hospital, watch for known allergies and double check anything given to the pt (go back within 5 mins or stand and do something else); tell pt what s/sx to look out for. Assist with treatments/CPR if necessary; give IV fluids; and provide teaching to pt & family. - Teach pt: ID what they’re allergic to & get a med alert bracelet/necklace. If pt can’t vocalize, the team needs to know existing allergies. If pt has an epi-pen, tell them to fill the prescription and carry it with them at all times! (Dosing is different with kids & adults; keep them separate!). Have pt monitor their epi-pen for expiration dates! Anemia Anemia is a deficiency in either the number of erythrocytes (RBCs), the quantity of hemoglobin, or the volume/size of packed RBCs (hematocrit). Hemoglobin levels determine the severity of anemia, which may lead to tissue hypoxia. Levels: a) mild anemia → HGB 10-12; may not have symptoms unless there’s an underlying disease or heavy exercise (and then might see dyspnea, palpitations or fatigue) b) moderate anemia → HGB 6-10; cardiopulmonary symptoms occur even at rest but especially with activit 37 c) severe anemia → HGB 40 or 2+ comorbidities. Some people have to lose weight before surgery so surgery isn’t such a risk. They must also undergo preoperative care: - must see a nutritionist to figure out triggers for eating. They need to talk about lifelong dietary restrictions, and may be put on a ketosis diet for 3 days to see if they can stick with it. - see a psychologist to make sure they really understand themselves and what’s going on. 40 - the pt must be in the optimal physical health he/she can be in. No smoking, may go through an upper GI series to see if there are any problems, and pts cant be pregnant or hoping to become pregnant (surgery changes what you have to eat). Preoperative teaching includes preventing atelatasis (collapse of lung), because obese pts tend to breathe more shallowly. Give incentive spirometer, have them cough & deep breathe. Teach them to splint their incision, wear an abdominal binder, and use compression devices or do leg exercises to prevent DVTs. It may be difficult to get the pt on the OR table; someone may have to hold skin folds up during the surgical procedure. Types (all types make the stomach 15-30 ml): a) Gastric restrictive and Malabsorptive Surgery (Roux-en-Y gastric) is the only gastric restrictive and malabsorptive surgery; it’s a true gastric bypass (and the gold standard for weight loss, results in the greatest loss). The surgeon creates a small stomach pouch, takes the jejunum and attaches it to the pouch. It bypasses 90% of the stomach, duodenum, and part of the jejunum, decreasing absorption. It is NOT reversible, and the pouch does get bigger over time. It can be done laparoscopically, and the pt can lose their belly button when they have excessive skin taken off. *Note: it can cause longterm nutrient deficiences due to malabsorptive nature. b) Vertical Banded Gastroplasty is a gastric restrictive surgery that isn’t hugely popular in New England. The surgeon makes a vertical line of staples that creates a pouch in the stomach, and the rest of the stomach atrophies away. Stapes present risks, and it is not reversible. c) Adjustible Gastric Banding is a gastric restrictive surgery, and the ONLY bariatric surgery that is reversible. There’s a silicone band put around the top part of the stomach, with a catheter attached that goes to a port under the skin. Fluid can be put in through the port to make the stomach tighter (so pt loses more weight), or taken out to make the stomach looser. (When fluid comes out, it makes more space so the pt can eat more). - the band is set so the pt will lose 1-2 lbs per week originally; pt will eventually plateau, and the stomach can stretch out if the pt eats enough. The pt can also gain back their weight depending on what they eat! d) Gastric Sleeve Surgery is a gastric restrictive surgery, and the newest on the market. Surgeons remove 85% of the stomach, which becomes tube-shaped (sleeve-like), which is closed with staples. Postoperative care includes educating the pt that they may gain weight after surgery due to IV fluids, making sure they’re comfortable (sometimes they’ll sleep in chairs), and encouraging ambulation, respiratory and leg exercises. Postoperative eating: pts will be sent for swallow studies the next day to see if their staples are intact. Pts will get 15 ml of water at a time, and nurses must make sure there are bowel sounds before the pt can begin eating (especially with the Roux-en-Y surgery). Right after surgery, pt will be NPO, then on clears for a day, then on full liquids for 2 weeks, then on baby food purees, then on soft foods (soft boiled eggs, etc.), then on regular food. Pts should eat food in order: protein first, then things high in vitamins and minerals, then carbs. Pts should avoid high fat and sugar foods, carbonated beverages (bubbles fill up the stomach), and sometimes alcohol (don’t drink at the same time as the meal, and they can get drunk easily!). Educate pts to chew VERY slowly and thoroughly. Their initial goal is to eat 600-800 cals per day in 4-6 meals. Sip fluid throughout the day to try to get enough fluid (not with meals). Prior to surgery, the pt may feel that all his/her problems relate to weight. That can’t be an excuse once the pt loses weight, so depression and anxiety can set in. Have discussions pre & post op about what’s realistic. Support groups are important! And, once lose weight and have a lot of excess skin, can have skin reduction surgery (but is very painful). Surgical complications: - if belly gets very rigid post-op and H&H drop, could be internal bleeding - increased potassium levels - anastomotic leak (could make pt septic) - increased risk of dehiscence (wounds heal slowly b/c poor blood supply to areas with adipose tissue). High protein intake is important! - hypoventilation syndrome — post-op pts in pain, not taking deep breaths, and so much weight on diaphragm (can be made worse with narcotics for pain) - sleep apnea still, until pt loses weight - B12 anemia (pernicious anemia), especially with bypass because the stomach is gone (the stomach secretes B12). Will need B12 injections forever. - Dumpling syndrome = hyperglycemic reaction (exhibited by tremors, nausea, cramping, tachycardia, fatigue) when the pt eats high sugar or fat foods. Genitourinary conditions Urinary tract infections cause 8+ million office visits each year, and >100,000 people are hospitalized because of them annually. Urosepsis = a systemic infection from a urologic source; it needs prompt diagnosis and treatment or it can lead to septic shock and death. It’s important to treat lower tract infections before they can become upper tract infections, as recurring upper tract infections may lead to scarred, poorly functioning kidneys and chronic pyelonephritis (kidney stones). The urinary tract above the urethra is normally sterile, and has multiple defense mechanisms in place to maintain that sterility and prevent UTIs: the flow and acidity of urine, the valve to the bladder, rugae (folds) where the ureter meets the pelvic floor, and the 41 contractions the bladder does to push urine out. Alterations in any of those defense mechanisms increase the risk of contracting UTIs. Risk factors: - Factors increasing urinary stasis — anesthesia, prostate issues, tumors, neurological deficits - Foreign bodies — catheters, cystocopies (instrumentation allows bacteria to enter the urethra and bladder), stones - Anatomic factors — obesity, women’s shorter urethra - Compromising immune response factors — the immune response lowers with age, HIV/AIDS, diabetes - Functional disorders — reflex of the GU tract, constipation (stool bulks up near the rectum and puts pressure on/blocks the urethra) - Other factors — pregnancy, menopause, multiple sexual partners for women (introduces different bacteria), sex in general (intercourse promotes “milking” of bacteria from the perineum and vagina; may cause urethral trauma) Organisms originate in the perineum and are introduced via the ascending route from the urethra. (They can also less commonly come from the blood stream or lymphatic system, in a descending (hematogenous) route, and only if there is prior injury to the urinary tract.) The most common bacteria is gram-negative E. coli, or fungal/parasitic infections. Two classifications of UTIs: 1) Uncomplicated occurs in an otherwise normal urinary tract, and usually involves only the bladder 2) Complicated occurs with the coexisting presence of obstruction, s