NURS 368 EXAM 2

Ethics

Ethics

descriptive ethics, metaethics, normative ethics.

Normative ethics

norms or standards

Morals

principles. Can be common or particular.

Common moral principles

do not kill, tell the truth, do not steal. Honesty, integrity, fairness, veracity.

Particular moral principles

cultural norms, family norms. Religious codes, professional codes. Organizations like hospitals.

Ethical dilemma

circumstance in which moral obligations demand or appear to demand that a person adopt each of two or more alternative but incompatible actions, such that the person cannot perform all the required actions

Deontological

right or wrong based on duty/obligation. Does not look at consequences of action. Individual has clear direction in how to act in all situations.

Teleological

humanistic origins. Outcome focused. Ends justify the means.

Principlism

based on common principles of autonomy, beneficience, non-maleficence, and justice.

Utilitarianism/consequentialism

what is best for most people, main emphasis is on the outcome/consequences.

Feminist ethics/ethics of care

requires context of the situation, takes into account variances in culture/societal norms. What is right for one group may not be right for another.

Situational

each situation creates own rules and principles. Emphasizes uniqueness of the situation and respect for person in that situation.

Casuistry

case based reasoning. Does not follow rules or theories, but practical decision making. May be combined with other models and theories.

Ethical principlism

prima facie - on the face of things. Based on moral principles.

Four principle clusters

respect for autonomy - informed consent, privacy and confidentiality. Beneficence - compassion, fidelity, veracity. Nonmaleficence - futile or pointless treatments. Justice - fairness, equitable distribution of benefits and burdens.

Respect for autonomy

freedom to act in self-determined manner, refers to right to make one's own decisions regarding tx options. Pt autonomy should be respected aslong as in doing so it does not pose greater harm to others. May be suspended if client incapable of self-rule such as infants and suicidal clients. Autonomy does not obligate providers to provide futile or useless treatments. Professional autonomy.

Informed consent

consists of pt understanding nature of procedure, alternatives to procedure, risk, benefit, uncertainty, being alert and cognitively able to understand, understanding he has a right to accept, decline, or terminate an intervention or procedure. Accepting procedure.

Beneficence

doing good, deeds of mercy, kindness and charity. Prventing or removing harm, promoting good. Advocacy. Nurses obligated to implement actions that benefit the patient while not ignoring his wishes. Usually overridden by respect for autonomy. Compassion - caring, fidelity - obligation to be faithful to promises. Veracity - truth telling. Altruism - deeds of mercy, kindness, charity.

Paternalism

healthcare professionals exercise of unilateral authority over a patient to make decisions, usually out of a perceived obligation of beneficence.

Nonmaleficence

do no harm. Prevent harm. Obligation to not cause intentional harm. Due diligence - care that a reasonable person exercises in a given situation to ensure that he/she does not harm another person. Rule of double effect - causing harm/pain for greater good. Futile or pointless treatments, slippery slope argument - typically against something because if we allow this behavior, it's easier to slip into worst behavior.

Justice

often referred to as an obligation to treat all people fairly, and for appropriate and equitable distribution of benefits (resources) and burdens. Respect for others - principle that all persons are of equal value and important. Equality, impartiality, veil of ignorance.

Four Topics Method

gather facts, define central dilemma, explore the specifics for the clinical case, discuss and come to resolution.

Ethics committees

write guidelines and policies for organization, provide education, counseling, support on ethical issues, provide guidance to competent client, an incompetent client family, or health care providers. Ensure relevant facts of a case are brought out. Forum in which diverse views can be expressed. Provide support for caregivers. Can reduce institution's legal risks.

PAIN

purposeful, anticipated, intermittent, normal. Sources of discomfort: pain receptors in uterus stimulated as decreased blood supply during contractions. Additional discomfort: cervical stretch, distention of lower uterine segment. Traction of supporting structures and stretching of the uterine floor.

Pain during first stage of labor

cramp like, originates in uterus and cervix - stretching. Distention of mechanoreceptors and ischemia of uterine/cervical tissue.

Early/latent phase

mild contractions 5-30 min apart; 30-40 sec. Similar to menstrual cramps.

Active phase

2-3 min contractions apart, 40-60 seconds each. Lower back/abd pain.

Transition phase

most difficult, intense contractions combined with perineum pressure by descending fetus. Intense pressure on rectum and lower floor. Pain may radiate to back/legs. Splitting or stretching of tissue felt even if no trauma.

Third stage of labor

stretching of cervix as placenta expelled.

Pharmacological pain relief considerations

may affect fetus, drug may slow labor if given too soon, drug may have effects with medications that mom is already taking.

Direct effects of medication on fetus

drug crosses placenta (decreased FHR).

Indirect effects of medication on fetus

mother's response to med causes secondary response in fetus like hypotension = reduced placenta blood flow. Fetal hypoxia/acidosis.

Systemic administration

sent to placenta. Opioids - severe to mod pain, small frequent doses through IV, timing important to reduce neonatal resp depression, so give at peak of contraction when placental blood flow is lowest. Resp depression, nausea, slow progress of labor esp when given during early phase. Tranquilizers, antiemetics (can also be tranquilizers), sedatives (not given routinely because barbituates - prolonged resp depression in neonate).

Regional medication administration

delivered to induce analgesia or anesthesia (loss of sensation). Physician must get informed consent. Mother does not have diminished LOC. Fetus usually less sequelae. Epidural - blocks nerve impulses leaving spinal cord. Contraindicated with coagulation defects, systemic infection, allergy to drug, uncorrected hypotension. Effects within 20-40 min.

Hyperventilation

can result in maternal hypoxemia, dizziness, loss of consciousness. Can cause uteroplacental vasoconstriction and decrease blood flow to uterus.

Adverse consequences of labor pain

pain increases catecholamine release and decreased blood flow to uterus. Studies of primates have shown that maternal pain lowered fetal oxygenation and slowed FHR. Unrelieved pain = can contribute to postpartum depression. Risk factor for PTSD.

Analgesia vs anesthesia

analgesia is pain relief whereas anesthesia is loss of sensation (local, regional, or general). Epidurals usually both, but walking epidurals are only analgesia (usually duramorph or fentanyl). Anesthesia is one of the caines.

Advantages of systemic analgesia

availability, ease of administration, cost. 20-30 min for an epidural to take effect but spinal is quick, within 5 minutes in the subarachnoid space. Duramorph is a preservative free morphine and can last up to 24 hours.

Systemic analgesics

opioids most commonly used. Morphine, fentanyl, Demerol (meperidine), nubain (nalbuphine), stadol (butorphanol) - no respiratory depression in mom,baby. Demerol not used in most places - avoid use when close to delivery time (1hr), prolonged half life in babies, max concentration in baby occurs 2-3 hours after administration.

Systemic analgesic side effects

mom - pain relief only slightly better than placebo, itching, nausea, vomiting, CNS depression/sedation. Fetal - decrease HR variability, respiratory depression.

PCA

rapid onset within 1 min, cause sedation and hypoxemia in mother, respiratory depression in baby

Narcan/Naloxone

antidote for opioids, administered IM, subq, IV. Must be administered under close supervision. Side effects - nausea, vomiting, tremors, tachycardia, hypo or hypertension, v-fib, seizures, cardiac arrest. Quick acting so wears off. Usually up to 10 mg or 3 doses can be given.

Promethazine/Phenergan

non opioid, used also for nausea and vomiting. When given with opioid, synergistic analgesic effect, must be mixed with normal saline and pushed slowly. Can cause a drowsy, fuzzy feeling.

Benzodiazepines

midazolam (versed), diazepam (valium). Both are anxiolytics. Not used often in moms. Impair memory and moms won't remember birth. Risk for aspiration. May result in neonatal depression.

Nitrous oxide

inhaled through hand held mask. Quickly eliminated through lungs and does not accumulate in mom. No resp depression in baby, but can cause sedation.

Non systemic analgesics

local injection, pudendal nerve block.

Pudendal nerve block

second stage of labor, alleviate pain from vaginal and perineal distention when pushing, risk for infection, risk for urinary retention. Not used often.

Epidural

anesthesiologist administered. Informed consent. Sterile procedure, need to check labs, esp plts. Pt usually able to feel touch and pressure but not cold and or cramping pain. Usually combo of analgesia and anesthesia. Local anesthetics like duramorph. Catheter and infusion pump to provide constant infusion of med into epidural space between 4th and 5th vertebrae. May have bolus setting for breakthrough pain. Directly affected by gravity. Nurses monitor but don't manage epidurals.

Epidural side effects

maternal hypotension number one side effect. Very gravity sensitive - windows. May be one sided or not work at all. Nausea, vomiting, bladder distention, pruritus, may prolong labor and pushing.

Spinal

regional anesthesia, subarachnoid space, no catheter involved. Onset faster than epidural - 5 min. Pain relief usually 90 min to 3 hours. Usually when there is c-section. Self limiting as far as the numbing.

Spinal side effects

spinal headaches - as soon as they lay up, will feel pain but not when supine. They will do a blood patch which seals the leaking CSF. Maternal hypotension, nausea, vomiting, bladder distention, pruritus, fetal bradycardia.

Contraindications for epidural or spinal

rash or infection on back, hx of back surgery, scoliosis, taking anticoagulants such as warfarin, thrombocytopenia.

Epidural/spinal nursing care

fluid bolus before procedure if ordered (500-1000). Time out. Assist with positioning. Assess for side effects, frequent VS, place a urinary catheter PRN.

Maternal hypotension

turn pt on left side, increase IV rate, administer O2, notify anesthetist/anesthesiologist.

Local anesthesia

usually lidocaine, injected into perineum for episiotomy and repair, may be used for laceration repair, risk of hematoma and infection.

Duramorph

usually in combo with anesthetic in epidural/spinal to extend pain relief w/o loss of motor, sensory or sympathetic function. Can last up to 24 hours. Can cause respiratory depression - should be checked hourly for first 24 hrs.

Emergency anesthesia

epidural (if already in place/working), general anesthesia - rapid uterine relaxation, possible retained placenta or uterine inversion, respiratory depression in baby.

General anesthesia

IV with large bore needle, place indwelling catheter, administer meds to decrease gastric acidity as ordered such as Protonix. Place wedge to prevent vena cava syndrome. Emegency c-section.

Childbirth pain

unique and time-limited; intensity of pain is variable and relative. Pain vs. suffering.

Gate control theory of pain

sensation of pain is transmitted from the periphery of the body along ascending nerve pathways to brain. Limited number of sensations that can travel along these pathways so alternate activity can replace pain sensation. Basis behind effleurage, etc.

Pharmacologic pain management

goal to eliminate pain

Non-pharmacologic pain management

goal is to prevent suffering, not eliminate pain. Generally no adverse effects for mom/baby. Very individualized. Multiple methods can be used together. Difficult to measure effectiveness from scientific perspective.

6 Healthy Birth Practices

patience, active, supported, individualized, upright, togetherness.

Doulas offer five types of support

physical, emotional, informational, advocacy, partner support

Childbirth education

classes which educate about labor, pain control, the birth process, clinical practices, caring for the newborn, and infant feeding. Assist women in identifying and developing coping skills.

Ideal birth environment

comfortable, private, home-like. Consider temperature of the room, guest presence, stimulation.

Support person

someone who can be with the patient throughout the labor and delivery. Should be supporting and help with anxiety and coping techniques. EXAMPLES: mom, spouse, doula mom.

Doula

means woman's servant in Greek. Professional labor support.

Positioning

allowing movement or position changes. Can accelerate labor and possibly correct concerns like maposition. Back labor is often associated with malposition of the baby. Changing position can assist baby in rotating and relieving discomfort in patient. Upright position - less painful labor. Birth balls and rocking chairs.

Rhythmic breathing patterns

used to promote relaxation, distraction from pain, and enhance woman's sense of control. Various birthing methods teach relaxation and breathing such as Lamaze and the Bradley method. Deep breathing at beginning of contraction and breath slowly during contraction. As labor increases, maybe more rapid and shallow. If hyperventilation, breathe into bag/cupped hands.

Water

immersion in ___ aids in relaxation and pain relief. Used primarily in first stage of labor but can be used in some facilities for birth as well. Always be cautious of the water temperature. Less medication needs, less anesthesia, faster labors, facilitation of fetal positions (which decreases instrumental deliveries), fewer episiotomies, decrease in BP, edema, promotes diuresis.

Massage and touch

used to promote relaxation. Promotes a feeling of reassurance and safety. Provide counter pressure or hip squeeze during contractions. Hand massage.

Acupuncture and acupressure

placing needles, fingers, or beads at specific points to relieve pain. In labor, placement depends on various factors such as location of pain, stage of labor, maternal fatigue and anxiety. Not a lot of data on this technique's use in labor.

Hypnosis

self ___ is most commonly used in labor. Partner or support person can also be taught to aid patient in this. Contraindicated in woman with hx of psychosis.

Transcutaneous electrical nerve stimulation (TENS)

low voltage electrical impulses are transmitted to the skin through electrodes placed on the skin. The woman controls the intensity, stimulation pattern, and frequency. Can be purchased in drug stores or medical equipment companies without a doctor's order.

Hot or cold

easy to use, inexpensive, minimal side effects. Care should be taken to protect against skin damage. Know facility policy! May need order before doing this. Policies may limit what can be used.

Music and audioanalgesia

can increase pain tolerance, improve mood, and aid in rhythmic breathing. Woman selects music that she wants, making it more personal and giving her a sense of control. Woman selects music that she wants, making it more personal and giving her a sense of control.

Aromatherapy

used often by midwives, used to reduce fear, nausea, headache, and pain. Lemon grass, lavender, rose, and frankincense often used. No burning candles or incense allowed in hospital. Lavender/jasmine promote relaxation and decrease pain perception, while peppermint may decrease nausea.

Rebozo

a long flat garment used mostly by women in Mexico. Used to carry babies and large bundles. Used before labor to support the abdomen. Helps drop baby into pelvis. Good for multiparous moms.

Other comfort measures

imagery, eating and drinking to comfort, urinating frequently, human touch, massage, effleurage.

Effleurage

cutaneous stimulation by lightly stroking abdomen.

Counter pressure

exerted to sacral area with heel of hand or fist to relieve pressure of fetal head. Often associated with posterior position of fetus during labor

Dick-Read method

advocates birth w/o fear by education and environmental control and relaxation.

Lamaze method

promotes psychoprophylaxis with conditioning and breathing.

Bradley method

husband coached childbirth and support by working with and managing the pain rather than being distracted from it

Early labor support

relax and tune in to her body. Try and go about her normal day if during the day. If at night, sleep if at all possible. Alternate activity with periods of rest. Pack bag for hospital or birth center. Encourage her to rest, eat, walk, whatever she feels like doing. Have someone rub her feet or back. Help her time contractions.

Active labor support

relax and don't fight contractions. Breathe - deep abdominal. Breathing helps to keep calm. Find a comfy position. Maintain mobility as long as possible. Gravity will speed labor. Remind her to urinate every hour. Aromatherapy may be helpful. Remind her to change positions.

Transition labor support

relax, go with the flow. Make sure she is not tensing with the contractions. Help her find a comfortable position. Move around and get comfortable, you may need to change position with every contraction or you may not want to move. Have her sit on the toilet. This is a great place if she is having trouble tensing her perineum. Remind her to breathe and listen to her body. Remind her to take one contraction at a time. Assure her this is almost over. Water is especially helpful during transition. Try a shower, a tub, or cloths. Lightly stroke her face or other part of the body if that feels good to her.

Support for back labor

the most common cause is a baby who is in the posterior position (their spine against mom's spine). Continue to stay relaxed. Encourage her to take one contraction at a time. Take a shower. Adopt positions that encourage the baby to turn - hands and knees, one foot up on a chair and lean into it, remain upright, going to bed will not encourage the baby to turn. Encourage her to pelvic rock. Counter pressure (counter sacral massage) on the back - use a tennis ball, rolling pin, soda can, or massager on her back. You may be asked to push for long periods very forcefully. Double hip squeeze.

Pushing support

usually have an urge to push - push to comfort. Find a comfortable position. Help her with positioning, she may need you to hold a leg or support as she squats. Squatting opens the pelvis by more than 10%. Open glottis pushing. Remember that the baby is almost here. Encourage her verbally or count for her and coach. Offer sips of water or juice. Cool washcloths to the face and neck might feel really good to her. Remind her to relax between contractions. If she is making noise, remind her to keep it low so that she doesn't tense her throat or bottom.

Terbutaline MOA

ß2 adrenergic agonist which causes relaxation of uterine smooth muscle which suppresses pre-term labor.

Terbutaline dose

0.25mg SQ; 2.5mg PO

Terbutaline route

SQ, IV, PO. Given IV initially to stop labor. PO dose begun 12 hrs after labor has stopped. Administered in titrated SQ doses to patients on outpatient basis.

Terbutaline side effects

Contraindicated in preeclampsia, hemorrhage, maternal cardiac disease, gestation less than 20 wks, hyperthyroidism, diabetics (causes hyperglycemia)

Terbutaline nursing actions

used for pregnancies between 20 and 34 weeks, pts must be instructed to return to hospital if on PO terbutaline and UCs resume. Usually causes maternal and fetal tachycardia. Monitor VS, UCs, FHR. ECG recommended if pt c/o chest pain, heaviness, SOB.

Dexamethasone/betamethasone MOA

Unlabeled use in obstetrics is to prevent hyaline membrane disease in premature infants.

Dexamethasone/betamethasone dose

Betamethasone 12 mg IM every 12 hours x 2 doses, Dexamethasone 6 mg IM every 12 hours x 4 doses

Dexamethasone/betamethasone route

IM

Dexamethasone/betamethasone side effects

insomnia, headache, vertigo, euphoria, congestive heart failure, hypertension, edema, hyperglycemia, nausea, increased appetite, heartburn, bruising, impaired wound healing

Dexamethasone/betamethasone nursing actions

report adverse reactions to physician. Monitor BG in pts with insulin dependent or gestational diabetes