Module 3: Nursing care of high risk pregnant patient (medical complications)

Hyperemesis Gravidarum

Hyperemesis Gravidarum

persistent, excessive vomiting that causes dehydration and starvation

Causes of hyperemesis gravidarum

• psychological factor

• hormonal factors

• multiple pregnancy

• hydatidiform

Management of hyperemesis gravidarum

• fluid and electrolytes

• vitamins and mineral replacement

• bedrest in less stimulating environment

• strict hygiene

• close monitoring for fetal and maternal distress

Hypertension in pregnancy

• leading causes of infant and maternal morbidity and mortality worldwide

• second leading cause of maternal mortality which accounts for 26.92%

• etiology: increased vasoconstrictor tone, abnormal prostaglandin action

• main pathogenic factor is poor perfusion secondary to vasospasm

Predisposing factor of Hypertension in pregnancy

• large fetus

• older than 35, younger than 17

• primigravida

• multiple pregnancy or H mole

• poor nutrition

• Hx of DM, renal and vascular disease

• morbid obesity or weigh less than 100 lb

• family history

Assessment/ Cues of Hypertension in pregnancy

• facial edema

• blood pressure over 140/90 or increased of 30 mm systolic, 15 mm diastolic over prepregnancy level

• proteinuria

• hyperreflexia

• significant lower extremity edema

• weigh gain

Roll-Over test

assess the probability of developing toxemia when done between the 28th and 32nd week of pregnancy.

Procedure

1. patient in lateral recumbent position for 15 minutes until BP stable

2. rolls over to supine position

3. BP taken at 1 minute and 5 minutes after roll over

4. Interpretation: if diastolic pressure increases 20 mmHg or more, patient is prone to Toxemia

Eclampsia

• includes coma and convulsions

• possible life threatening complication: HELLP syndrome: Hemolysis, Elevated Liver Enzymes, Lowered Platelets)

• only known cure is delivery

Assessment/ Cues of Gestational Hypertension

• appearance of symptoms between 20th and 24th weeks of pregnancy

• blood pressure of 140/90 or +30/+15 mmHg on two consecutive occasions at least 6 hours apart

• No proteinuria

• No edema

Assessment/ Cues of Mild Preeclampsia

• appearance of symptoms between 20th and 24th week of pregnancy

• blood pressure of 140/90 or +30/+15 mmHg on two consecutive occasions at least 6 hours apart

• sudden weight gain (+3lb/month in second trimester; +1lb/week in third trimester; +4.5lb/week at any time)

• slight generalized edema, especially of hands and face (+1, +2)

• proteinuria of 300 mg/liter in a 24 hour specimen (+1)

Intervention of Mild Preeclampsia

• promote bed rest as long as signs of edema or proteinuria are minimal, preferably lying on the left side

• provide well-balanced diet with adequate protein and roughage

• explain need for close follow-up, weekly or twice-weekly visits to physician

Assessment/ Cues of Severe Preeclampsia

• headaches

• epigastric pains

• nausea and vomiting

• blurring of vision

• irritability

• dizziness

• pulmonary edema

• elevated liver enzymes

• blood pressure of 150 - 160 / 100 -110

• increased edema (+3,+4)

• weight gain (> 5lbs/week)

• proteinuria (>5 g/24 hours) or (+4)

• Oliguria <400-500 ml

Intervention to Severe Preeclampsia

• promote complete bed rest; lying on left side

• carefully monitor maternal/fetal vital signs

• monitor I & O, results of laboratory tests

• take daily weights

• do daily fundoscopic examination

• institute seizure precautions

• instruct client about appropriate diet

• continue to monitor 24-48 hours postdelivery

• administer medications as ordered; vasodilator of choice - hydralazine (apresoline)

Assessment/ Cues of Eclampsia

• increased hypertension precedes convulsion followed by hypotension and collapse

• coma may ensue

• labor may begin, putting fetus in great jeopardy

• convulsion may recur

Intervention to Eclampsia

• minimize all stimuli (darken room, limit visitors, used padded bedsides and bed rails)

• check vital signs and lab values frequently

• have airway, oxygen, and suction equipment available

• administer medications as ordered

• monitor fetal status

• type and cross match blood

• continue observations 24-48 hours postpartum

• prepare for possible delivery of fetus

management of Eclampsia

1. Digitalis (with heart failure)

   • increase the force of contraction of the heart - decrease heart rate

   • NC: check CR prior to administration ( do not give if CR <60/min)

2. potassium supplements - prevent arrhythmias

3. Barbiturates - sedation by CNS depression

4. Analgesics, antihypertensive, antibiotics, anticonvulsants, sedatives

5. magnesium sulfate - drug of choice

Magnesium sulfate

• 10 gms initially - either by slow push IV push over 5 -10 minutes or deep IM

• 5 gms/buttock, then an IV drip of 1 gm per hour (1 gm/ 100 ml D10W)

• Check first before administering

  • deep tendon reflexes are present

  • RR = 12/min

  • UO = at least 100 ml/6 hrs.

• Action: CNS depressant; vasodilator

• Antidote: Calcium Gluconate - Given 10% IV to maintain cardiac and vascular tone

  • Earliest sign of toxicity is disappearance of knee jerk/patellar reflex

Gestational hypertension

a woman who develops elevated blood pressure but has no proteinuria or edema. no drug therapy is necessary

Mild Pre-eclampsia

a woman who has proteinuria and blood pressure rises to 140/90 mmHg, taken two occasions at least 6 hours apart. systolic pressure id greater than 30 mmHg and diastolic pressure greater than 15 mmHg

Severe Pre-eclampsia

a woman showing blood pressure to 160 mmHg and 110 mmHg diastolic, taken two occasions at least 6 hours. marked proteinuria on a random urine sample or more than 5 g in 24 hours sample, and extensive edema are also present

3 phases of eclampsia

1. Tonic phase

2. Clonic stage

3. Postictal state

tonic phase

a phase of eclampsia where client felt the body contract, back aches, arms and legs stiffen, and jaw closes abruptly. the client may bite her tongue from the rapid closing of her jaw. respiration halt because her thoracic muscles are held in contraction. this phase last up to 20 seconds

Clonic stage

A phase in eclampsia where client’s bladder and bowel muscles contract and relax; incontinence of urine and feces may occur. although a woman begins to breathe during this stage, the breathing is not entirely effective. this seizure last for 1 minute

postictal state

a phase in eclampsia where the client is semicomatose and cannot be roused except by painful stimuli for 1 -4 hours

intervention for tonic and clonic state of eclampsia

• maintain patent airway

• administer oxygen by face mask to protect the fetus

• to prevent aspiration, turn a woman on her side to allow secretions to drain from her mouth.

• magnesium sulfate / diazepam (valium) may be administered intravenously as an emergency measure

• assess oxygen saturation via pulse oximetere

• apply an external fetal heart monitor if one is not already in place to assess the condition of the fetus

• check for vaginal bleeding to detect placental separation

Intervention for postictal phase

• extremely monitor for seizures causing premature separation of placenta, labor may begin during this period but a woman will be unable to report the sensation of contractions. painful stimulus of contractions may initiate another seizure'

• keep the client on her side so secretions can drain from her mouth

• maintain at nothing to eat or drink

• limit conversation as the client may be able to hear even though she does not respond

• continuously assess FHR and uterine contractions

• continue to check for vaginal bleeding every 15 minutes

Diabetes Mellitus

• an edrocine disorder in which the pancreas cannot produce adequate insulin to regulate body glucose levels

• this disorder affects 3% to 5% of all pregnancies

• becomes a threat to normal fetal growth. fetal born can have heart anomalies

glycosuria

when the level of blood sugar rises to 150 mg/100 mL (normal = 80 to 120 mg/dL), the kidney begins to excrete quantities of glucose in the urine

polyuria

the process of osmotic action, the increased amount of glucose in the urine reduces fluid absorption in kidney, and large quantities of fluids are lost in the urine

Diabetes in Pregnancy

• a phenomenon that is probably caused by the presence of the hormone human placental lactogen and high levels of cortisols, estrogen, progesterone, and catecholamines

• causes increased amniotic fluid and increased urine production

• can create a macrosomia infant causing birth problems

risk factors for gestational diabetes

• obesity

• age over 25 YO

• history of large babies

• history of unexplained fetal or perinatal loss

• history of congenital anomalies in previous pregnancy

• history of PCOS

• heredity and culture trait

Type 1 diabetes

• formerly known as insulin-dependent diabetes mellitus

• a state characterized by destruction of the beta cells in the pancreas that usually lead to absolute insulin deficiency

  1. immune-mediated DM results from autoimmune destruction of the beta cells

  2. idiopathic type 1refers to form that have no known cause

Type 2 diabetes

• formerly known as non insulin independent diabetes mellitus

• a state that usually arises because of insulin resistance combined with a relative deficiency in the production of insulin

Pregnancy risk of DM

• toxemia

• infection

• hemorrhage

• polyhydramnios

• spontaneous abortion - vascular complications which affect placental circulation

• acidosis - nausea and vomiting

• dystocia - due to large baby

DM risk factor

• overweight or obesity

• family history of type 2 diabetes

• racial/ethnic group with high prevalence of diabetes

• gestational diabetes

• large aby

• stillbirth

• PCOS

• hypertension

type 3 diabetes

• classification of DM formerly called gestational; onset during pregnancy; reversal after termination of pregnancy

type 4 diabetes

• classification of DM formerly call secondary occurs after pancreatic infections or endocrine disorder

Assessment/ Cues of DM

• polyuria

• polydipsia

• weight loss

• polyphagia

• elevated glucose levels in blood and urine

Maternal effects of DM

• uteroplacental insufficiency

• risk of dystocia

• polyhydramnios

• infection

Fetal effects of DM

• increase fetal mortality

• risk of congenital abnormalities

• increased hypoxia-delayed lung maturity

• LGA infants

• neonatal hypoglycemia

DM interventions/test

1. 1 hour glucose tolerance test

2. 3 hour glucose tolerance test

3. hbAlc

1 hour glucose tolerance test

usually done for screening on all pregnant women 24-28 weeks pregnant

3 hour glucose tolerance test

used where results from 1 hour GTT>140 mg/dl.

HbAlc

glycosylated hemoglobin; reflect past 4-12 week blood levels of serum glucose

DM management

• glycemic control

• monitoring

• lifestyle interventions

• pharmacologic interventions

Serum alpha-feto protein level

obtained at 15 - 17 weeks to assess for neural tube defects

signs and symptoms of diabetic babies

• shrill, high pitched cry

• listlessness/jitteriness/tremors

• lethargy/poor suck

• apnea/ cyanosis

• hypotonia/ hypothermia

Class 1 heart disease

• classification of heart disease where there is no physical limitation

• no symptoms of cardia insufficiency

Class 2 heart disease

• classification of heart disease where there is a slight limitation of physical activity

• asymptomatic at rest

• ordinary activity causes fatigue, palpitation, dyspnea, or angina

Class 3 heart disease

• classification of heart disease that shows moderate to marked limitation of physical activity

• less than ordinary activity causes discomfort

class 4 heart disease

• classification of heart disease that shows unable to carry on any activity without experiencing discomfort

• may have symptoms even at rest

signs and symptoms of heart disease

1. heart murmur due to increased total cardiac volume

2. heart palpitations on sudden exertion

3. edema and ascites

4. dyspnea, exhaustion, edema, pulse irregularities, chest pain on exertion and cyanosis of nailbeds

Implementation to heart disease

• report URI and coughing during pregnancy-as pulmonary edema is first manifested as cough

• edema

• irregular pulse, rapid, and difficult respiration

• chest pain on exertion

• jugular venous exertion

• ECG, chest x-ray, echocardiogram

Fetal effects of Heart disease

• IUGR

• fetal distress

• preterm labor

Interventions to heart disease

• promote rest

• promote healthy nutrition - not much weigh gain, iron supplementation, limit sodium intake

• educate regarding medication -

• educate regarding avoidance of infection

Blood incompatibility

an antigen-antibody reaction which causes excessive destruction of fetal red blood cells

Rh HDN

• frequency: Less common

• blood group

  • mother : Rh negative

  • fetus : Rh positive

• pregnancy affected: usually second

• severity: severe

• blood smear: erythroblastosis

• DCT: strongly positive

ABO HDN

• frequency: More common

• blood group

  • mother : O

  • fetus : A or B

• pregnancy affected: usually first

• severity: mild

• blood smear: spherocytosis

• DCT: weakly positive or negative

Urinary tract infection

• affects 10% of all pregnant women

• dilated, flaccid and displaced ureters are a frequent site

• E. coli is the usual cause

• may cause premature labor if severe, untreated or pyelonephritis develops

Assessment/ Cues of UTI

1. frequency and urgency of urination

2. suprapubic pain

3. flank pain - kidney punch test

4. hematuria

5. pyuria

6. fevers and chills

Interventions to UTI

1. encourage high fluid intake

2. provide warm baths to relive discomfort and promote perineal hygiene

3. administer and monitor intake of prescribed medications

4. stress good bladder-emptying schedule

5. monitor for signs of premature labor from severe or untreated infection

Anemia

• low red blood cell count may be underlying condition

• may or may not exacerbated by physiologic hemodilution of pregnancy

• most common medical disorder or pregnancy

Assessment/ Cues to anemia

1. client is pale, tired, short of breath, dizzy

2. Hgb is less than 11 g/dl; hct less than 37%

interventions to anemia

1. encourage intake of foods with high iron content

2. monitor iron supplementation

3. teach sequalae iron ingestion

4. assess need for parental iron

Physical signs of substance abuse in pregnancy

• slow weight gain

• dryness of mouth and conjunctivitis

• fetal growth retardation

• appetite affected

• increased activity level

• altered sleep pattern

• rhinitis and sinusitis

• Respiratory depression

• hypertension and tachycardia

• needle marks

• skin infections

• STI’s

fetal physical signs of substance use of mother

• slow growth

• prematurity

psychological sign of substance use in pregnancy

• euphoria

• depression

• rapid mood swings

• paranoia

• panic attacks

• psychosis

• lethargy

behavioral signs of substance use in pregnancy

• not keep appointments

• reluctant to submit to urine testing

• difficulty in keeping with instruction

drug effects on woman and fetus

• Fetal alcohol syndrome

• pregnancy loss

• spontaneous abortion

• stillbirth

• abruptio placenta

• elevation of body temp

• seizures

• intracerebral hemorrhage

• psychosis

• hypertension and tachycardia

• anorexia and malnutrition

narcotics effects on mother and fetus

• respiratory depression

• death

Marijuana effects on mother and fetus

• increases carbon monoxide level

• affects blood pressure decreasing uterine blood supply

• decreased fetal size

Intervention for substance abuse

• helping mother to stop using substance

• assist the woman have a good nutritional state

• decrease the effects on the fetus

• promote the establishment of the relationship with the infant

HIV

• is a virus that attacks the immune system

• invades and destroys certain white blood cells called CD4+ cells

Mode of transmission of HIV

• exposure to blood-borne pathogen

• semen

• vaginal fluids

• sexual contact

• sharing needles

• exposure to body fluids

• perinatal transmission

Stage 1 of HIV

disease is asymptomatic and not categorized as AIDS

stage 2 of HIV

includes minor mucocutaneous manifestation and recurrent upper respiratory tract infection

Stage 3 of HIV

includes unexplained chronic diarrhea for longer than a month, severe bacterial infection, and pulmonary tuberculosis

Stage IV of HIV

includes toxoplasmosis of the brain, candidiasis of the esophagus, trachea, bronchi, or lungs, and kaposi’s sarcoma; these diseases are indicators of AIDS

Enzyme linked immunosorbent assay

the first step of an HIV test. this test detect presence of HIV antibodies in the blood

Western blot

this test is used to confirm the positive elisa test results. detects specific protein bands that are present in an HOV infected individual. is 99.9% accurate in detecting that HIV have occurred

Radio Immuno precipitation assay

confirmatory test that is used when HIV antibody levels are low or difficult to detect

it can also be use when western blot test result are uncertain

HIV PCR

test that detects specific DNA and RNA sequences that indicate the presence of HIV in the genetic structure of anyone HIV infected

treatment for HIV

1. antiretroviral therapy or HAART

2. two nucleoside analogue reverse transcriptase inhibitors or either a protease inhibitor or a non-nucleoside reverse transcriptase inhibitors

reverse transcriptase inhibitors

• inhibit the enzymes called reverse transciptase which is needed to copy information for the virus to replicate

• drugs with -ine suffix

protease inhibitors

• they work by inhibiting the enzyme protease which are needed for the assembly of viral particles

• drugs with - Vir suffix

4 C’s management of AIDS

1. Compliance

2. counselling

3. contract tracing

4. condoms

compliance

giving of information and counselling the client which results to the client’s successful treatment, prevention, and recommendation.

counseling/ education

• giving instruction about the treatment

• disseminating information about the disease

• providing guidance on how to avoid contracting STD again

• sharing facts about HIV and AIDS

contract tracing

tracing out and providing treatment to partners

condoms

promoting the use of condom, giving instructions about its use, and giving away available condoms

ABC approach to lower AIDS acquisition

Abstain

Be monogamous

Condom use

avoid Drug use

Educate partners