Study Guide NURSING 306 Chapter 7 DURHAM: High Risk Antepartum Nursing Care Study Guide

West Coast University, Orange County Study Guide NURSING 306 Chapter 7 DURHAM: High Risk Antepartum Nursing Care Week 5 Pre WORK • Due @ 2359 on Sunday, Week 5 • Upload your copy under Journal Week 5 for Week 5 Pre work • Complete ATI N306F5 Practice Assessment and attach the report with a minimum score of 76%, with your prework Chapter 7 DURHAM: High Risk Antepartum Nursing Care Handwrite or type Define and explain: Medical management Nursing Actions/Interventions Patient education • PROM p 140 o Prolong rupture of membrane o Greater than 24 hours o Risk Factors for preterm PROM ▪ Previous preterm PROM or preterm delivery ▪ Bleeding during pregnancy ▪ Hydramnios ▪ Multiple gestation (up to 15% in twins, up to 20% in triples) ▪ Sexually transmitted infections (STIs) ▪ Cigarette smoking o Risk for the Woman ▪ Maternal infections (ex: chorioamnionitis) ▪ Preterm labor and birth ▪ Increase rates of cesarean birth o Risk for the Fetus and Newborn ▪ Fetal or neonatal sepsis • The earlier the fetal gestation at ROM, the greater the risk for infection • The membranes serve as a protective barrier that separates the sterile fetus and fluid from the bacteria-laden vaginal canal ▪ Preterm delivery and complications of prematurity ▪ Hypoxia or asphyxia because of umbilical cord compression due to decreased fluid ▪ Fetal deformities if preterm PROM before 26 weeks’ gestation o Assessment Findings ▪ Confirmed premature gestational age by prenatal history and ultrasound ▪ Confirmed rupture of membranes with speculum exam and positive ferning test ▪ Oligohydramnios on ultrasound may be seen but is not diagnostic o Medical Management Week 5 Pre WORK ▪ Pt with PROM between 34-36 wks should be managed as if they were term with induction of labor and treatment for group B streptococcal prophylaxis recommended ▪ Pt with PROM before 32 weeks of gestation should be cared for expectantly until 33 completed weeks of gestational if no maternal or fetal contraindications exist. ▪ All women with preterm PROM and viable fetus, GBS-should receive intrapartum chemoprophylaxis to prevent vertical transmission of group B streptococci ▪ Corticosteriods should be administered to women with preterm PROM before 32 weeks of gestation tor reduce risk of RDS, perinatal mortality, and other morbidities ▪ Delivery is recommended when preterm PROM occurs at or beyond 34 weeks of gestation ▪ With preterm PROM at 32-33 completed weeks of gestation labor induction may be considered if fetal pulmonary maturity has been documented ▪ Digital cervical exam should be avoided in pt with PROM unless they are in active labor or imminent delivery ▪ Monitor for infection, labor, and fetal compromise ▪ Assess for fetal lung maturity with LS ratio/ phosphatidyl glycerol (PG) ▪ Administer prophylactic antibiotic therapy to reduce maternal and fetal infection ▪ Antibiotic prophylactic therapy o Nursing Actions ▪ Assess FHR and uterine contractions ▪ Assess for signs of infection • Tachycardia • Fever 100.4 F or 38C • Uterine tenderness • Malodorous fluid or vaginal discharge ▪ Monitor for labor and for fetal compromise ▪ Provide antenatal testing including non stress test (NST) and (BPP) • PPROM p140 o Preterm premature rupture of membranes o Rupture of membrane with a premature gestation 37 weeks • Pregestational Diabetes p147 o Women with preexisting pregestational diabetes have a fivefold increase in the incidence of major fetal anomalies of the heart and central nervous system (CNS) o Risk for the woman ▪ Hypoglycemia or hyperglycemia ▪ DKA 1% especially in second trimester ▪ Hypertensive disorders and preeclampsia (10%-15% risk) Week 5 Pre WORK ▪ Metabolic disturbances related to hyperemesis, nausea, and vomiting of pregnancy ▪ Preterm labor (25%risk) ▪ Spontaneous abortion (30% risk) ▪ Polyhydramnios/ oligohydramnios ▪ CS delivery ▪ Exacerbation of chronic diabetes-related conditions such as: heart disease, retinopathy, nephropathy, and neuropathy ▪ Infection related to hyperglycemia 80% UTI, chorioamnionitis and postpartum endometritis ▪ Induction of labor o Risk for the Fetus and Newborn ▪ Congenital defects including cardiac, skeletal, neurological, genitourinary and gastrointestinal related to maternal hyperglycemia during organogenesis ▪ Growth disturbances, macrosomia related of feta hyperinsulinemia ▪ Hypoglycemia related to fetal hyperinsulinemia ▪ Hypocalcemia and hypomanesemia ▪ IUGR r/t maternal vasculopathy and decreased maternal perfusion ▪ Asphyxia r/t fetal hyperglycemia and hyperinsulinemia ▪ RDS r/t delayed fetal lung maturity ▪ Polycythemia (hct 65%) r/t increased fetal erythropoietin ▪ Hyperbilirubinemia r/t polycythemia and RBC breakdown ▪ Prematurity ▪ Cardiomyopathy r/t maternal hyperglycemia ▪ Birth injury r/t macrosomia ▪ Stillbirth in poorly controlled maternal diabetes esp 36wks o Assessment Findings ▪ Pregestational diabetes, history of type 1 or type 2 diabetes ▪ Abnormal blood glucose levels ▪ HbA1C test to determine the average blood glucose levels over the last 4-8 weeks ▪ Cardiac, renal, and ophthalmic function assessment and evaluation o Self management Week 5 Pre WORK ▪ Monitor blood glucose 4-8 times per day • AM fasting 90 • Premeal 105 • 1hr post pradial 140 • mean blood glucose 100 ▪ Monitor urine ketone • Moderate- large inadequate food intake o Report to provider ▪ Record keeping of BG levels, food intake, insulin, and activity ▪ Exercise 3-4 times a week for 20 minutes ▪ S/S of hypoglycemia for the prevention and management o Medical Management ▪ Achieving euglycemic control for 1-2 mo is recommended ▪ Achieving HbA1C less than 7% ▪ Multidisciplinary management ▪ Screening at diagnosis pregnancy • Kidney • Heart • Thyroid function • Eye exam • Ultrasound • Insulin tx o Nursing action ▪ Physiological changes- gestational diabetes ▪ Dietary counseling ▪ Self monitoring glucose/ urine ketones ▪ Importance of record keeping dietary intake ▪ Bring records of prenatal appointment ▪ Review sign and symptoms and treatment of hyperglycemia/hypoglycemia ▪ S/S of DKA ▪ Provide information when to call provider ▪ Management of N/V ▪ Provide an expected plan of prenatal care, antenatal test, fetal surveillance ▪ Provide expected plan for labor and delivery ▪ Arrange to meet with diabetic nurse educator ▪ Emphasize that changes in the management plan due to physiological changes ▪ Arrange for antenatal testing ▪ Antenatal testing generally starts at 28 weeks’ gestation includes NST and BPP • Gestational Diabetes o Define as any degree of glucose intolerance with the onset or first recognition in pregnancy o Pregnancy is a condition characterized by progressive insulin resistance that begins mid-pregnancy and progress throughout the gestation o Two main contributors to insulin resistant ▪ Increased maternal adiposity ▪ Insulin desensitizing hormones produced by the placenta o Risk factors for GDM ▪ No known risk factors are identified in 50% of patients with GDM ▪ History of fetal macrosomia ▪ Strong family history of diabetes ▪ Obesity o Risk factor for the woman ▪ Hypoglycemia and DKA ▪ Preeclampsia ▪ CS birth ▪ Development of non-gestational diabetes o Risk factor for the Fetus and Newborn ▪ Macrosomia-places fetus at risk for birth injuries such as brachial plexus injury ▪ Hypoglycemia during the first few hours post birth ▪ Hyperbilirubinemia ▪ Shoulder dystocia ▪ RDS ▪ The magnitude of fetal-neonatal complications is proportional to the severity of maternal hyperglycemia ▪ Risk of GDM for newborns are similar to risks with pregestational diabetes, except they are not at risk for congenital anomalies o Assessment Finding ▪ Abnormal glucose screening results o Medical Management ▪ GDM consultation and referral ▪ Diet and exercise ▪ Insulin management ▪ Oral medication ▪ CS birth is recommended for estimated fetal weight 4,5OO g ▪ Women with GDM need to monitor type 2 diabetes after birth o Nursing action ▪ Management of GDM is glycemic control ▪ Test glucose 4 times per day (1 fasting, 3 postprandial checks/day) • 95mg/ dL before meals • 120-135 mg/ dL after meals ▪ Effects of elevated glucose on developing fetus ▪ Encourage active participation in management and decision making ▪ Teach the woman to monitor fasting ketonuria levels in the morning ▪ Teach self administration of insulin ▪ Teach for s/s & treatment for hypoglycemia, hyperglycemia, DKA ▪ Diet management 33-40% complex CHO, 35-40% fat, 20% protein ▪ Exercise 10-15 minutes after meal is beneficial and 3 X per week for 30 mins • Preeclampsia p 152 Week 5 Pre WORK o Hypersensitive, multisystem disorder of pregnancy o Mild to severe hypertension o Pregnant specific syndrome of reduced organ perfusion secondary to vasospasm and endothelial activation o Risk Factors for preeclampsia/ Eclampsia ▪ Nulliparity ▪ Age younger than 19 or older than 35 years ▪ Obesity ▪ Multiple gestation ▪ Family history of preeclampsia ▪ Preexisting hypertension or renal diseas ▪ Previous preeclampsia or eclampsia ▪ Diabetes Mellitus o Risk for the woman ▪ Cerebral edema/ hemorrhage/stroke ▪ DIC ▪ Pulmonary edema ▪ CHF ▪ Hepatic failure ▪ Renal Failure ▪ Abruptio placenta o Risk for the Fetus and Newborn ▪ Prematurity delivery may be indicated preterm related to deterioration of maternal status ▪ Intrauterine growth restriction (IUGR) related to decrease uteroplacental perfusion ▪ Low birth weight ▪ Fetal intolerance to labor because of decrease placental perfusion ▪ Stillbirth o Assessment findings (accurate assessment) ▪ Elevated blood pressure- HTN 140mmHG, 90mmHg ▪ Proteinuria 1+ or greater ▪ Lab values (liver function, Kidney function, altered coagulopathy) o Medical management ▪ Magnesium Sulfate (IV)-CNS depressant tx for seizure ▪ Antihypertensive medications ▪ Management of preeclampsia- rest, frequent MD visit, Monitor BP ▪ Delivery for fetus and placenta- only CURE o Nursing action ▪ Early recognition and accurate assessment ▪ Accurate blood pressure measurement ▪ Administer hypertensive as per order BP 160/110mmHg ▪ Administer Magnesium sulfate ▪ Assess for CNS changes including HA, Visual changes, DTR and clonus Week 5 Pre WORK Auscultate lung s