ATI Real Life RN Case Study

Pre-class Assignment Week 5 Assignment:  ATI Real Life RN Case Study o Preterm labor Reading: Durham & Chapman, please read:  Chapter 7 ATI Review Chapters:  Ch 9-10  12-13  15-16 Pre-class Assignment: Create a template for the following concepts. Include definition/pathophysiology, manifestations, immediate interventions, medications (if applicable) and patient teaching for the following: Preterm labor - onset of labor after 20, before 37 weeks, spontaneous preterm labor - patho (multicausal) → 1. Uterine overdistention a. Prostaglandin can be producedTOO SOON , stimulating the uterus to contract when overdistended 2. Decidual activation a. From hemorrhage b. From fetal-decidual paracrine system c. From upper genital tract infection 3. Premature activation of the normal physiological initiators of labor, activation of the maternal-fetal HPA axis → prostaglandin → stress estrogen → vasocontriction 4. Inflammation/infection in decidua, fetal membranes, and amniotic fluid a. Inflammatory cytokines or bacterial endotoxins can stimulate prostaglandins -> cervical ripening, contractions, and weakening of rupture of membranes Dx → fetal febronectin (swab vaginal secretions for inflammation, cervical cultures (C&S infx organisms)+ shortened cervical LENGTH (shows UC’s), CBC, urinalysis + BPP and/or NST → fetal well-being How to test: biomarkers (decidual membrane separation “fetal fibronectin”, cervical length, bacterial vaginosis, STRESS X PTB - S/S: UC, pelvis pressure, mens cramping, low backache, GI cramping, diarrhea, urinary freq, vagina discharge, - increase change, odor, blood in vaginal discharge - change in cervical dilation reg uc, every 10 min, lasting 1 hr or longer premature ROM, discomfort → low abd, back pain, pelvic pressure, heaviness o Risk factors for PTL ▪ Prior preterm birth (single most important factor reoc- currence rates of up to 40%) ▪ History of second trimester loss ▪ History of incompetent cervix ▪ Cerclage ▪ IVF pregnancy ▪ Multiple gestation (50% of twins delivered preterm, ≥90% higher multiples delivered preterm) ▪ Uterine/cervical abnormalities, diethylstilbestrol (DES) exposure ▪ Hydramnios or oligohydramnios ▪ Infection, (amniotic sac) ▪ Premature rupture of membranes ▪ Short pregnancy interval (less than 9 months) ▪ Pregnancy associated problems such as hypertension, dia-betes, and vaginal bleeding ▪ Chronic health problems such as hypertension, diabetes, or clotÝng disorders ▪ Inadequate nutrition, low BMI, low pre-pregnancy weight, or poor weight gain ▪ Age younger than 17 or older than 35 years old ▪ Late or no prenatal care ▪ Obesity, high BMI, or excessive weight gain ▪ Low BMI ▪ Working long hours, long periods of standing ▪ Ancestry and ethnicity ● ● Preterm birth rates are highest for African American infants (17.8% vs. 12.2%) (March of Dimes, 2012). Maternal unmarried status is associated with an increased risk of preterm birth as well as low birth weight and small for gestational age (Shah, Zao, & Ali, 2011). Preterm birth is more likely in the presence of intimate partner violence (IPV), mental health issues, substance abuse, and other psychosocial stressors (March of Dimes, 2011) ○ Maternal exposure to domestic violence is associated with significantly increased risk of low birth weight and preterm birth. Inadequate ● ● ● prenatal care, higher incidences of high- risk behaviors, direct physical trauma, stress, and neglect are postulated mechanisms (Shah & Shah, 2010). Lack of social support Smoking, alcohol, and illicit drug use Lower education and socioeconomic status, poverty Incompetent cervix → mechanical defect in cervix that results in painless cervical dilation in 2nd trimester that can progress to ballooning of membranes into the vagina and delivery of premature fetus <2.5cm sutures and then removed → bed rest, pelvic rest, no intercourse s/s : rp pelvic pressure (urge to push), increased pink vaginal discharge, gush of fluid, UC + expulsion of fetus, shortened cervical length/funneling, obstet hx, live fetus and intact membranes Dx: ultrasound → short cervix less than 25 mm in length, beaking (cervical funneling), effacement of cervical os - prophylactic cervical cerclage → surgical reinforcement (12-14 wks) removed at 36 weeks ● Risks to woman ○ Repeated 2nd trimester or early 3rd trimester births → PTB ○ Recurrent pregnancy losses ○ Preterm delivery ○ ROM/infections ● Risks to fetus and newborn ○ Preterm birth and consequences of prematurity ● Medical management ○ Obtain transcervical ultrasound to evaluate cervix ○ Cervical cultures for chlamydia, gonorrhea, and other cervical infections ○ Cerclage: purse string suture placed cervically to reinforce a weak cervix (@ 12-14 weeks, removed at 36)  Administer antibiotics and tocolytics as indicated  Nursing actions post-op o Monitor for uterine activity with palpation o Monitor for vaginal bleeding and leaking of fluid/ROM o Monitor for infection (fever, uterine tenderness) o Admin tocolytics to suppress uterine activity o no excise, no movement, 5 or more contractions in 1 hr bad  eval support sys → activity rstx + bedrest  ↑ hydration = relaxed uterus,  no sex, o report: PTL, ROM, infx, contractions less than 5 minutes apart, severe perin pressure, urge to push Preeclampsia → hypertensive, multisystem disorder of pregnancy whose etiology remains unknown; reduced organ perfusion secondary to VASOSPASM/VASOCONSTRICTION and endothelial cell damage activation ONSET AFTER 20 WEEKS GESTATION DEFINING: GH with proteinuria (+1) s/s : transient headaches, nausea, blurring vision, irritability, edema, RIGHT UPPER QUADRANT PAIN - htn, proteinuria, periorbital edema, pitÝng edema, vomiting, oliguria, hyperreflexia, scotoma, epigastric pain, right upper quad pain, dyspnea, dimininishe dbreas=th sounds, seizures, jaundice, - worsening: liver, kidney, htn, cerebral involvement, developing coag Labs: liver enzymes, blood creatinine, VUN, uric acid, CBC, clotÝng, chemistry profile → dipstick proteinuria, 24 hr urine collection → protein anc creatinine clearance NST, contrsaction stress test, BPP, ultrasounds, → fetal status doppler bllood flow analysis, daily kick counts ● ● ● ● ●   Patho of preeclampsia: ○ Increase in microvascular fat deposition within the liver; can lead to periportal hemorrhagic necrosis in the liver -> subcapsular hematoma -> RUQ pain or epigastric pain ○ protienuria is 1+ or greater Risk factors ○ Nulliparity, < 19 years old, > 35 years old, Obesity, Multiple gestation, Family history of preeclampsia, Preexisting HTN or renal disease, RA, Previous preeclampsia or eclampsia, Diabetes mellitus, systemic lupus Risks for woman ○ Cerebral edema/hemorrhage/stroke, DIC, Pulm edema, Congestive HF, Hepatic/renal failure, Abruptio placenta Risks for fetus and newborn ○ Premature delivery may be indicated preterm related to deterioration of maternal status ○ IUGR -> decreased uteroplacental perfusion ○ Low birth weight ○ Fetal intolerance to labor -> decrease placental perfusion ○ Stillbirth Medical management ○ Woman and fetus monitored weekly ○ late in first trimester → low dose aspiring thearpy ○ Antihypertensive drugs ○ Use of magnesium sulfate during delivery to prevent seizures monitor mag levels: 4-7mg TOXICITY → absent DTR, RR <12, uo less than 30/hr o “Cure” = delivery of fetus and placenta MAG strict input -- 125 ml/hr → 75  Nursing actions o Measure blood pressure with woman seated and arm at heart level, pulse ox, UO, o Give antihypertensive drugs as ordered  methyldopa, nifedipine, hydralazine, labetalol o Admin magnesium sulfate as ordered (for 24 hours)  ↓ CNS and prevent seizures  tox - abs patellar deep tendon reflex, ↓ UO 30 ml, resp ↓ 12/min o ↓ LOC, cardiac dysrhythmias  stop infusion, admin calcium chloride, prevent resp/card arrest o Assess for CNS changes,LOC o Auscultate lung sounds and monitor RR o Assess for s/s of pulm edema o Assess for RUQ or epigastric pain o Assess weight daily and assess for edema o lateral positioning o Check urine for proteinuria o Check adequate intake of calories and protein o NST and BPP  ** SAFETY AND SEIZURE PRECAUTIONS  NST and daily kick counts, Placenta previa → 3RD TRIMESTER →PAINLESS VAGINAL BLEEDING placenta attaches to lower uterine segment of the uterus, near or over the internal cervical os instead of in the body or fundus of the uterus; 4 types: total, partial, marginal, and low-lying placenta painless hemorrhage, fetal malposition, BRIGHT bleeding near end of pregnancy, confirmed by US, vaginal exam contraindicated  Risk factors (endometrial scarring and impeded endometrial vascularization) o ENDOMETRIAL SCARRING → Previous placenta previa, Prior c-section, Abortion, Multiparity, o IMPEDED ENDOMETRIAL VASCULARIZATION → > 35 years old, Diabetes or HTN, Cigarette smoking, Uterine anomalies/fibroids/endometritis, o INCREASED PLACENTAL MASS (large mass, multiple gestation)  Risk for woman o Hemorrhagic and hypovolemic shock related to excessive blood loss o Unresolved bleeding -> maternal exsanguinations in 10 min o Anemia o Potential Rh-sensitization as Rh-negative woman can become sensitized during any antepartum bleeding episode  Risks for fetus and newborn o Disruption of uteroplacental blood flow →deteriorating fetal status o Blood loss, hypoxia, anoxia, and death related to maternal hemorrhage o Fetal anemia due to maternal blood loss o Neonatal morbidity and mortality → prematurity  Emergency medical management o C-section birth due to extensive hemorrhage o Vaginal delivery may be attempted with low-lying placenta o May be associated with placenta accreta, increta, or percreta o Blood is transfused as needed o After stabilization, prolonging pregnancy or delaying delivery is possible  Nursing actions o Perform initial assessment (COCA bleeding, US for location, fetal well being, gestational age, fetal lung maturity)  V/S → ↑ pulse and RR and falling BP every 5-15min o Notify physician o Assess ab pain, uterine tenderness, irritability, and contractions o Initiate bedrest with bathroom privileges o Maintain IV access with large-bore IV (blood replacement therapy) o Assess FHR and UCs o Monitor lab values  Anticipate c-section birth if patient is unstable  corticosteroids → fetal lung maturity  monitor labs → CBC, platelets, clotÝng  anticipate c/s if pt is unstable, Rhogam to RH- mother Placenta abruption (abruption placentae) → premature separation of normally implanted placenta; initiated by hemorrhage into decidua basalis S/S painful sharp abd pain, bright red blood bleeding, rigid uterus ● Risk factors ○ Previous abruption increases risk up to 15% ○ HTN disorders of pregnancy ○ Ab trauma ○ Cocaine, meth use, and/or smoking cigs ● ● ● ● ●     ○ PPROM ○ Thrombophilia ○ Uterine anomalies/fibroids Risks for the woman ○ Hemorrhagic shock ○ DIC of the release of thromboplastin into maternal venous system ○ Hypoxic damage to organs such as kidneys/liver ○ Postpartum hemorrhage Risks for fetus and newborn ○ Preterm birth ○ Hypoxia, anoxia, neuro injury, fetal death related to hemorrhage ○ Intrauterine growth restriction ○ Neonatal death Emergency medical management - cesarean indicated ○ Monitor maternal volume status ○ Restoring blood loss ○ Monitor fetal status ○ Monitor coagulation status ○ Correcting coagulation defects ○ Expediting delivery Medical management after stabilization ○ Hospitalization ○ Close monitoring of maternal/fetal status: FHR, maternal bleeding, uterine activity, ab pain, vaginal bleeding, and maternal lab and coag studies ○ Corticosteroids to accelerate fetal lung maturity ○ Possible tocolysis Nursing actions ○ Monitor vaginal bleeding, assess ab pain, Palpate uterus for contractions, tenderness, hypertonus, ○ increasing uterine distention, Manage n/v, Assess for decreased renal output, Monitor maternal ○ cardiovascular status for hypotension and tachycardia ○ Maintain IV access with large-bore needle ○ Admin oxygen at 8-10 L/min by mask ○ Assess FHR for baseline changes, variability, and periodic changes indicative of an abnormal FHR ○ Monitor lab values including CBC and clotÝng studies ○ emotional support / treatment plan, ○ monitor ultrasound + doppler results DIC: CLOTTING AND BLEEDING AT THE SAME TIME Placenta acreta invasion of trophoblast beyond normal boundary Substance abuse o o o Types: alcohol, smoking/tobacco ( ↓ uterine blood flow ), illicit drugs  carbon monoxide binds to hemoglobin ↓ oxygen carrying capacity of blood Risks to pregnancy and fetus: preterm labor, PPROM, poor weight gain and nutritional status, placental abnormalities. For fetus, stillbirth, low birth weight, preterm birth, IUGR, neonatal withdrawal syndrome, and SIDS. VASOCONSTRICTING → IUGR, fetal alcohol syndrome, withdrawal PTB