ch 20, 21, 22 CORNELL NOTES

nvm theyre goated apparently

Left sided HF presentation

Respiratory

pulm edema & pulm HTN

profound SOB, orthopnea

Cardiovascular

↓BP

irregular pulse

chest pain on exertion

Also systemic edema (beyond feet/ankles)

L sided HF management

• Elevate chest and head when sleeping to prev orthopnea

• Prev thrombus formation

  • LMWH anticoagulant (preferred early pregnancy, doesn’t cross placenta = not teratogenic)

• Dec strain on aorta

  • antihypertensives, diuretics, beta-blockers.

Venous thrombosis disease What put’s a pt at risk for this:

• VIRCHOWS TRIAD:

  • Stasis – slow blood flow (uterus pressure)

  • Hypercoagulability – blood clots too easily (estrogen)

  • Endothelial injury – damaged vessel wall (baby head pressure)

• >30 y.o.
  

How to reduce the risk of thrombus formation:

Education

• avoid knee-high stockings

• leg crossing

• prolonged standing

Signs/Management of thrombus (DVT) assessment:

Presentation DVT

• calf pain/redness

Presentation P.E.

• dyspnea

• cough w hemoptysis

• tachy/missed beats

• dizziness

• EMERGENCY!!!

Management

• bed rest + IV heparin q1-2d

• then SQ heparin q12-24hr (arms/thighs; avoid abdomen)

• most occur postpartum

Assessment and Nursing care of pregnant patient with sickle-cell anemia:

Presentation

• vessel blockage with dehydration

• clump cells → dec organ perfusion

• hemolysis

• severe anemia

• placental circ compromised → low birth weight/fetal death

Risks

• altered blood flow to kidney → lose ability to concentrate urine/make acidic → alkalotic urine → bacteriuria

Assessment

screen at first prenatal visit

urine cultures

monitor nutrition/folic acid, daily 8+ glasses fluid

Management

• no iron supplement

• folic acid supplement (rep destroyed blood cells)

• periodic exchange transfusions

• crisis: pain control, oxygen, ↑ fluids

Therapeutic management of patient in sickle-cell crisis:

- Prevent sickle-cell crisis (periodic exchange / blood transfusion throughout preggo) 

- Exchange transfusion serves second fn of removing quantity of increased bilirubin from the breakdown of RBCs and restores hemoglobin level 

IN CRISIS 

1. Control pain 

2. Administer O2 PRN 

3. Increase fluid volume of circulatory system (lower viscosity) 

Nursing Care to prevent UTI:

Management

• ABx (amoxicillin, ampicillin, or cephalosporins)

Education

• void q2h

• washing hands

• empty bladder fully

• wipe front-to-back

• cotton underwear

• cranberry supplements

• void after intercourse

• drink 3-4 L/day if UTI present

Tuberculosis Assessment:

Presentation

• chronic cough

• weight loss

• hemoptysis

• low-grade fever, fatigue, night sweats

Diagnosis

• PPD → chest X-ray/sputum if positive (given protective shield over fetus for xray)

• Sputum smear test (confirms; AFB x 3 samples)

How to manage bleeding in pregnancy:

(always emergency; may hide true volume)

Emergency interventions

• side-lying

• large-bore IV

• O2 6-10 L

• external monitor uterine cxns & fetal HR

• NO vaginal exam

• type/cross 2 units blood

• weigh pads

• u/s

#1 concern: “Am I losing the baby?”

• listen & validate fears

How to prevent isoimmunization:

Management

Give Rh (D antigen) immunoglobulin (RhIG) to pts w Rh-negative blood type

• After miscarriage, pts w Rh- should get Rh (D antigen) Immunoglobulin (RhIG) to prev buildup of antibodies cuz child might have Rh+ blood 

Identify different types of miscarriage

Threatened: vag bleed, scant bright-red spotting, slight cramping, cervix closed

Imminent: vag bleed, cxns, early cervical dilation

Complete: all products expelled

Incomplete: partial expulsion → D&C to evac rest of preg

Missed: fetus dead in utero, no expulsion (fundal height stalls)

Signs/Management of placenta previa:

Presentation

painless bleeding with cervical dilatation

Management

bed rest side-lying; NO vaginal exam; cesarean birth

• placenta can move safely otw overtime

Signs of abruptio placenta:

Presentation

• sharp fundal pain (feels like peeling off scab too early)

• uterine tenderness

• heavy bleeding

• fetal distress, shock

Drugs to administer in Preterm labor and for what purpose:

Management

• terbutaline (off-label; as to Tocolytic agent to halt labor) 

• betamethasone for lung maturity (if cervix <4 cm, membranes intact)

Signs and symptoms of Gestational Hypertension and what meds to manage it:

Presentation
BP ≥140/90 after 20 weeks, no proteinuria/edema

• temp; returns to normal after birth

Management

• antihypertensives (hydralazine, labetalol, nifedipine)

Watch for progression to Preeclampsia

• Signs: BP changes + proteinuria, edema (UE/face), hyperreflexia, headache, visual changes, epigastric pain, oliguria

Adolescent pregnancy carries the increased incidence of which conditions:

Complications

• iron-deficiency anemia

• preterm labor

• postpartum hemorrhage

• preeclampsia

• cephalopelvic disproportion

What additional testing would you offer a pregnant patient over the age of 40 and why?

offer cfDNA at 10 weeks or genetic testing (Down syndrome risk ↑)

• non-invasive blood test