N106

Nursing Care of the

Expanding Family

Outline

• Issues & Trends

• Menstrual Cycle

• Conception

• Fetal Development

Issues and Trends

• Family Centered

• Role of Nurse

• Legal and Ethical

• Cultural Influence

• Client Teaching

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Ovarian and Endometrial Cycles

Menstrual Cycle

Sperm penetration of an ovum

Conception

the fertilized ovum from conception to implantation

Fetal Development

• Ovum (pre-embryonic stage) – first 2 weekszygotemorulablastocyst

• Embryonic stage – weeks 3 to 8

• Fetal stage – 8 weeks to birth

Figure 3–12 The actual size of a human conceptus from fertilization to the early fetal stage. The embryonic stage begins in the third week after fertilization; the fetal stage begins in the ninth week. Source: Adapted from Marieb, E. N. (1998).

Figure 3–11 Fetal circulation. Blood leaves the placenta and enters the fetus through the umbilical vein. After circulating through the fetus, the blood returns to the placenta through the umbilical arteries. The ductus venosus, the foramen ovale, and the ductus arteriosus allow the blood to bypass the fetal liver and lungs.

Ductus Venosus

Foramen ovaleDuctus arteriosus

Outline

• Terminology

• Pregnancy dating

• Signs of Pregnancy

• Normal Physical Changes of Pregnancy

• Psychological Changes

• Nutrition

• Medication Admin

Terminology• Gravida - # of times a uterus has held a

pregnancy– Primigravida and Multigravida

• Para - # of times a uterus held a pregnancy past 20 wks – Primiparity and Multiparity

• Abortion – less than 20 weeks – miscarriage• Viability – past 24 weeks – Federal /State• Preterm – 20-37 weeks• Term – 38-42 weeks• Post term – after 42 wks• BOW – bag of waters• Bloody show – when cervix starts to dilate

Pregnancy dating

• Nagele’s rule – add 7 days to first day of LMP and count back 3 months

• McDonald’s rule – fundal height = week of gestation +/- 2-4 weeks

• Sonogram – early US at 7-13 weeks after LMP most accurate for dating pregnancy

McDonald’s method is used to assess fundal height.

The TPAL approach

Signs and symptoms of pregnancy

• Presumptive

• Probable

• Positive auscultation of FHTfetal movement felt by examinerfetus visualized by US

Physiologic changes with Common Discomforts

• Reproductive• Cardiac• Respiratory• Gastrointestinal• Renal• Integumentary• Endocrine• Musculoskeletal• Neurological

Reproductive and Cardiac

• uterus• cervix• vagina• ovaries• breast

• heart• heart sound• pulse• blood volume• cardiac output• peripheral

vasodilatation• B/P• blood components

Vena caval syndrome.

Respiratory and Gastrointestinal

• Thoracic circumference• Diaphragm• Oxygen consumption• Tidal volume

• Gingivitis and bleeding gums

• Heartburn• Nausea• Constipation• Gallstones

Endocrine/ hormones

• Human Chorionic Gonatropin (HCG)

• Human Placenta Lactogen (HPL)

• Relaxin

• Estrogen

• Progesterone

• Oxytocin

• Prolactin

Physiologic changes

• Renal• Integumentary

chloasmalinea nigrastriae gravidarum

• Musculoskeletallordosisdiastasis recti

• Neurological

Psychological changes

• First trimester – disbelief & ambivalence

focus: self-centered R/T physiologic changes

• Second trimester – introspective focus: baby; fetus becomes real

• Third trimester - pride and anxiety focus: labor / delivery & baby’s well-being

Nutrition

• Affects size of baby• Wt gain 3.5 lbs during 1st trimester than 1 lb/wk• Total 25-35 lbs• Folic acid – prevent neural tube defects• Iron supplements – 30 mg daily• Additional 300 cal/day• Lactating requires 2700-2800 cal/day and 3000cc of

fluids /day• Post partum 2200 to 2300 well balanced

Healthful eating Largest portion - grains, rice, bread, and pastaSmallest portion - fats, oils, and sweets,

Medication Administration

• Most medications cross placenta to fetus

• Medications during PG can harm fetus

• Pain meds in labor cross placenta

• Newborn meds are Vitamin K & Erythromycin

• PostPartum meds are oxytocics & analgesics

Prenatal Education

• Early pregnancy classes

• Childbirth Preparation classes

• Methods of childbirth

BradleyLamaze

Assessment during Pregnancy

• Prenatal appointmentsmonthly first 6 monthsq 2 weeks in 7 & 8 monthweekly last month

• Vag exam initial visit and 2-3 wks a EDC

• Assessment each visitwt, B/P, P, R, fundal ht, FHT

Danger Signs of Pregnancy

• Vaginal Bleeding • Rupture of membranes• Swelling of the fingers, face, eyes• Headache• Visual disturbances• Persistent abdominal pain• Chills and fever• Painful urination• Persistent vomiting• Change in fetal movements

Fetal Assessment

Ante-partal Fetal Assessment

• LabsAlpha-fetoprotein screening (MSAFP)

• Ultrasound• glucose tol test (GTT)

• AmniocentesisL/S ratio and PG

• Nonstress test (NST)• Contraction stress

test (CST)

Amniocentesis

Figure 14–5 Example of a reactive nonstress test (NST). Accelerations of 15 bpm lasting 15 seconds with each fetal movement (FM). Top of strip shows FHR; bottom of strip shows uterine activity tracing. Note that FHR increases (above the baseline) at least 15 beats and remains at that rate for at least 15 seconds before returning to the former baseline.

Reactive NST

Figure 14–6 Example of a nonreactive NST. There are no accelerations of FHR with FM. Baseline FHR is 130 bpm. The tracing of uterine activity is on the bottom of the strip.

Nonreactive NST

Figure 14–8 Example of a positive contraction stress test (CST). Repetitive late decelerations occur with each contraction. Note that there are no accelerations of FHR with three fetal movements (FM). The baseline FHR is 120 bpm. Uterine contractions (bottom half of strip) occurred four times in 12 minutes.

CST

Complications Antepartal• Gestational Diabetes• Hemorrhage - abortion• Hyperemesis Gravidarum• PROM – premature rupture of

membranes• Preterm labor• Pregnancy Induced Hypertension PIH• Substance abuse• Infections – TORCH

Gestational Diabetes

• Develops during pregnancy• Risk factors: obesity, <25 yrs, family

history, chronic hypertension, large birth wt, previous gestational diabetes

• Screening: between 24-28 weeks a 50 g, 1 hour glucose challenge test (GCT) if 140 or above recommend 3 hour oral glucose tolerance test (OGTT)

• Increased for PIH and fetal macrosomia

Therapeutic Management

• Diet – 2200 -2400 calories per day

• Exercise – Moderate exercise for active women, regular activity for sedentary women

• Blood glucose monitoring – if FBG >95 or PPBG >120 start on insulin

• Fetal surveillance – 28 weeks ultrasound, amniocentesis, NST, CST, BPP

Insulin Therapy

• First trimester – insulin needs lower

• Second and Third trimester – increased insulin due to placental hormones

• During labor – based on blood glucose levels

• Post Partum – insulin not needed due to abrupt cessation of placental hormones

Teaching Self-Care – S&S

• Hyperglycemia fatigueflushed hot skindry mouth, excessive thirstfrequent urinationrapid respheadachedepressed reflexes

• Hypoglycemiashakinesssweatingcold, clammy skinpallordisorientationirritabilityheadachehungerblurred vision

Spontaneous Abortion

• Incidence• Threatened• Inevitable/imminent• Complete• Incomplete• Missed • Recurrent

The cervix is not dilated, and the placenta is still attached to the uterine wall, but some bleeding occurs.

Threatened

The placenta has separated from the uterine wall, the cervix has dilated, and the amount of bleeding has increased.

Imminent

. The embryo or fetus has passed out of the uterus, but the placenta remains.

Incomplete

Ectopic Pregnancy

• Pregnancy outside the uterine cavity• S & S of PG• Rupture at 6-12 weeks• Severe pain• Vaginal tenderness and shock• Treatment – salpingectomy if ruptured

linear salpingostomy if tube is intact• Care – assess for bleeding and pain, prepare for

surgery, emotional support

Various implantation sites in ectopic pregnancy. The most common site is within the fallopian tube, hence the

name “tubal pregnancy.”

Complications of pregnancy

Hyperemesis gravidarum

Hyperemesis Gravidarum

• Persistent, uncontrolled vomiting• Cause unknown may be high hCG or

psychological problem – hydatidiform mole• S&S: Nausea and vomiting, weight loss,

fatigue, signs of dehydration, signs of starvation

• TX: antiemetics, IV fluids, quiet environment ,sedation, counseling

• Care: Allow to verbalize

Reducing nausea and vomiting

• 1) small portions q 2-3 hours• 2) attractively presented • 3) eliminate strong odors • 4) low-fat foods, • 5) easily digested carbohydrates, such as

fruit, breads, cereal, rice and pasta • 6) soups and liquids taken between meals• 7) sitting upright to reduce gastric reflex

Complications of Pregnancy

Premature Rupture of Membranes

Premature rupture of membranes (PROM)

• Diagnose – Nitrazine or fern test• Gestational age - more than 36 wks deliver

if – ripe cervix, abnormal FHT, meconium stained fluid, possible infection, abnormal presentation Tx – walking, Prostaglandin

• Gestational age between 32-35 weeksdeliver if – mature fetal pulmonary status, abnormal FHT, possible infection

• Strategies – tocolytics, steroids, antibiotics

Nursing Care for PROM

• Stay hospitalized until birth

• Frequent VS & FHT q 4 hours

• Frequent CBCs , mtr records “kick counts”

• Check vaginal bleeding

• No vag exams, restrict activity

• A & Z for 7 days

Complications of Pregnancy

Preterm Labor

Premature rupture of membranes (PROM)

• Diagnose – cramping and vag discharge prior to 20 and 37 weeks gestation

• Tocolytics act by depressing smooth muscle, glucocorticoids accelerate fetal lung maturity

• Nursing Care – monitor FHT & contractions, provide emotional support, manage side effects of tocolytics, teach what to do if occur at home

Complications of Pregnancy

Hypertensive Disorders

Pregnancy Induced Hypertension

• Incidence – 8% of all pregnant woman• Risk factors• Etiology - Preeclampsia is due to

generalized vasospasm• Cause remains unknown• Cardinal signs

1) hypertension2) proteinuria3) weight gain of 2 lbs in one week

Classification of hypertensive disorders of pregnancy

• Pregnancy-induced hypertension (PIH)

• Preeclampsia

• Eclampsia

• HELLP

PIH - HELLP syndrome – reflects severity of disease

• Signs and Symptomsheadachesvisual changesoliguriahyperreflexiaepigastric pain flu like symptomsgeneralized edemanausea and vomitingsevere elevated BPproteinuria

• Criteria of diagnosishemolysiselevated liver enzymes AST(SGOT)>72U/L ALT(SGPT)>50U/L serum LDH>600IU/Llow platelet<100,000/mm

PIH - management

• Dependent on severity of disease & gestational age of fetusActivity restriction / quiet environmentPharmacologic therapy

anticonvulsive therapy antihypertensive therapy stimulant for fetal surfactant

• Only cure – delivery of the fetus• Goal – prevent eclampsia & other severe

complications while allowing fetus to mature

PIH – eclampsia nursing interventions

• Reduce risk of aspiration• Prevent maternal injury• Ensure maternal oxygenation after seizure• Ensure fetal oxygenation after seizure• Establish seizure control with MgSO4• Treat severe hypertension• Correct maternal acidemia• Initiate process of delivery

Complications of pregnancy

Substance AbuseTypes of substanceRisk FactorsSigns and SymptomsNursing Management

Complications of Pregnancy

• Gestational Diabetes

Complications of Pregnancy

Infections during Pregnancy

TORCH

Infections

• T – toxoplasmosis

• O - other

• R – rubella

• C – cytomegalovirus

• H – herpes simplex virus