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ACUTE BIOLOGIC CRISIS f.

Neck – stiffness, masses


g. Breast – lumps, secretion, pain, tenderness
HIGH RISK PREGNANCY h. Respiratory – cough, wheezing, asthma, SOB
Definition: One in which a concurrent disorder, pregnancy- i. Cardiovascular – heart murmur, history of heart disease,
related complication, or external factor jeopardizes the health of HPN
the mother and/or fetus. j. G.I.T – pre-pregnant weight, diarrhea, constipation,
 Many factors enter into the categorization of high risk. hemorrhoids, ulcer
 No tool is perfect because the concept of high risk is a k. Genito-urinary – infection, STD’s
very individualized one l. Extremities – varicose veins, pain or stiffness of joints,
 The woman identified this way needs close fractures
observation during pregnancy to see that pregnancy is m. Skin – rashes, acne, psoriasis
progressing well
 The infant born of a woman identified this way needs
close observation in the neonatal period until it is I. Support Persons Role
confirmed that no anomalies exist  Questions asked to the support person : Current
 The failure to identify risk potential in pregnancy leads health status, feelings and concern about the
to increased perinatal mortality pregnancy, knowledge of pregnancy and childbirth
2. PHYSICAL EXAMINATION
ASSESSMENT FOR A FIRST PREGNANCY VISIT : A. Baseline Data : to establish a baseline for future
1. HEALTH HISTORY comparison
Purpose : - Weight, Height, BP, PR, RR
a. To establish rapport - FHR : 120-160 beats/min
b. To gain information about the woman’s physical and - 10-12 weeks (Doppler)
psychosocial health - 18-20 weeks (Stethoscope)
c. To obtain a basis for anticipatory guidance for the - Fundic height:
pregnancy 12-14 weeks – Symphysis pubis
20-22 weeks – Umbilicus
A. Demographic Data : Name, age, address, telephone 36 weeks - Xiphoid process
number, health insurance 40 weeks - Xiphoid process
B. Chief Concern – Reason why the woman has come to the
health care setting. B. System Assessment
1. Was the pregnancy planned? 1. General Appearance and Mental Status
2. Inquire date of last menstruation  Physical examination always begins with inspection of general
3. Ask if she has had a pregnancy test appearance to form a general impression of the woman’s health and
4. Elicit information about signs of early pregnancy well-being.
5. Observe for discomforts of pregnancy  A physical examination at a first prenatal visit typically includes
6. Has she been exposed to contagious diseases inspection of body systems, with emphasis on changes that occur
7. Has she taken any medicine that might be harmful to with pregnancy.
fetal growth  General appearance is important because it reveals how people
feel about themselves by the manner in which they dress, speak and
C. Family Profile – helps to know the woman earlier body posture they assume
1.Identify support persons, Family composition
2.What is her occupation, source of income, Nutrition, sleep 2. Head and Scalp
pattern, hobbies, living conditions  Examine head for symmetry, normal contour and tenderness
 Examine hair for distribution, thickness, excessive dryness or
D. Past Medical History – important because a past condition oiliness, cleanliness, or the use of hair dye.
may become active during or immediately following pregnancy.  Look for chloasma (extra pigment on the skin)
1. Any abdominal surgery, kidney, heart, etc.
3. Eyes
E. Gynecologic History – her past experience with her  Edema in the eyelids
reproductive system may have some influence on how well she  Spots before the eyes
accepts a pregnancy.  Diplopia (double vision)
1. When was her menarche - may indicate PIH
2. What is the length and duration of menstrual cycle 4. Nose
 Increased level of estrogen associated with pregnancy may
F. Obstetric History :
cause nasal congestion.
1. Review pregnancy briefly.
2. Determine woman’s status with respect to the number
5. Ears
of times she has been pregnant (gravida) and the
 The nasal stuffiness that accompanies pregnancy may lead to
number of children above the age of viability she has
blocked Eustachian tubes and therefore a feeling of fullness or
previously delivered (para).
dampening of sound during early pregnancy.
3. A more comprehensive system for classifying
pregnancy status (GTPAL or GTPALM) provides
6. Sinuses
greater detail on the pregnancy history. By this
system, the gravida classification remains the same,  Sinuses should feel nontender
but para is broken down into :
T : The # of full-term infants born (37 weeks or 7. Mouth, Teeth and Throat
after)  Pregnant woman is prone to vitamin deficiency because of the
P : The # of preterm infants born (infants born rapid growth of the fetus.
before 37 weeks)  Assess carefully for cracked corners of the mouth that would
A : The # of spontaneous or induced abortions reveal vitamin A deficiency.
L : The # of living children  Assess carefully for pinpoint lesions with an erythematous base
M : Multiple pregnancies on the lips; these suggest a herpes infection
 Gingival hypertrophy may result from estrogen stimulation
during pregnancy.
G. Typical Day History  Teach all women not to neglect good dental hygiene while
 Information about a woman’s current pregnant
nutrition, elimination, sleep, recreation and
interpersonal interactions can be elicited best by 8. Neck
asking the woman to describe a typical day of her  Slight thyroid hypertrophy may occur with pregnancy because
life. the overall metabolic rate is increased.
 Encourage a woman to continue to use iodized salt during
H. Review of Systems – Brief review of all body systems pregnancy and to eat seafood at least once weekly to supply enough
a. Head – Ask about headache, head injury, seizures, iodine for thyroxine production with this increased rate.
dizziness
b. Eyes – Inquire about vision, eyeglasses, eye diseases 9. Lymph Nodes
c. Ears – Infection, discharges, pain  No palpable lymph nodes should be present.
d. Nose – Bleeding, discharges, colds, allergy, sinuses
e. Mouth and pharynx –Dentures, teeth, toothache, 10. Breasts
bleeding, pain, surgery
 As pregnancy begins, the breast undergo the following :  Trichomoniasis – a protozoal infection, generally gives signs of
Breast areola darkens; Montgomery’s tubercles become redness; a profuse, whitish, bubbly discharge; and petechial
prominent; Breast size increases; breast tone affirms; secondary spots on the vaginal walls.
areola may develop surrounding the natural one; blue streaking  Candidal (Monilial) infection – presents with thick, white vaginal
of veins becomes prominent; colostrums may be expelled as patches that may bleed if scraped away.
early as the 16th week of pregnancy; any supernumerary nipple  A gonorrheal infection – presents with a thick, greenish-yellow
also may become darker. discharge and extreme inflammation.
 All women should be instructed on monthly breast self  Chlamydia infection – shows few symptoms.
examination.  Carcinoma of the cervix appears as an irregular, granular
growth at the os.
11. Heart  Cervical polyps (red, soft, pedunculated protrusions) also may
 Heart rate should range from 70 to 80 beats/minute. be seen occasionally at the os.
 No accessory sounds or murmurs should be present.
 Because of the breast size , it may be difficult to hear the c. PAPANICOLAOU SMEAR
woman’s heart beat during pregnancy  Weapon for detecting cervical cancer
 Many women notice occasional palpitations (heart skipping  American Cancer Society recommends a pap smear every 3
a beat) during pregnancy, especially when lying supine. Teach years in women who have had 2 consecutive negative tests.
pregnant woman to rest or sleep on their side (left side is best) to  Recommended more frequently to women who were exposed
avoid this problem. to diethylstilbestrol (DES) in utero, who have multiple sexual
partners, who have a history of human papillomavirus (HPV),
12. Lungs cigarette smokers, who were sexually active before age 21
 Late in pregnancy, diaphragmatic excursion is lessened
because the diaphragm cannot descend as fully as usual d. VAGINAL INSPECTION
because of the distended uterus.  A culture for gonorrhea, chlamydia or group B streptococcus
may be taken. All these organism can cause disease in the NB
13. Back so it is best if they can be eradicated during pregnancy
 Assess the spine for any abnormal curve that would  Any areas of inflammation, ulceration, lesions or discharge
suggest scoliosis. should be noted
 Vaginal examination is critical for a woman whose mother took
14. Rectum DES during her pregnancy. Female children of mothers who
 Assess the pregnant woman’s rectum closely for took DES are prone to develop adenosis or overgrowth of
hemorrhoidal tissue, which commonly occurs from pelvic cervical endothelium (which is possibly associated with vaginal
pressure preventing venous return. cancer).

15. Extremities and Skin e. EXAMINATION OF PELVIC ORGANS


 Assess the upper extremities. Many women develop palmar  A bimanual (two-handed) examination is performed to assess
erythema and itching early in pregnancy from a high estrogen the position, contour, consistency, and tenderness of pelvic
level and perhaps subclinical jaundice. organs
 Assess the lower extremities carefully for varicosities, filling  Abnormalities that can be noted by bimanual examination
time of the toenails (should be under 5 seconds) and edema. include ovarian cysts, enlarged fallopian tubes (perhaps from
 Assess the gait of pregnant women to see that they are pelvic Inflammatory Disease) and an enlarged uterus.
keeping their pelvis tucked under the weight of their abdomen.  An early sign of pregnancy (Hegar’s sign) is elicited on
bimanual examination.
MEASUREMENT OF FUNDAL HEIGHT AND FETAL HEART
SOUNDS f. RECTOVAGINAL EXAMINATION
 12-14 weeks of pregnancy – uterus is  To assess the strength and irregularity of the posterior vaginal
palpable over the symphysis pubis as a firm wall
globular sphere
 20-22 weeks – reaches umbilicus e. ESTIMATING PELVIC SIZE
 36 weeks – xiphoid process  It is hard to see from the outward appearance of a woman
 40 weeks – often return to 4 about 4 cm whether her pelvis is adequate for the passage of a fetus.
below the xiphoid due to lightening  Pelvic measurements should be taken if the woman is pregnant
 Auscultate for fetal heart sounds (120 to 160 and if she has never given birth vaginally
beats/minute. These can be heard at 10 to 12  In sonogram, estimations may be made by a combination of
weeks if Doppler is used. 18 to 20 weeks if regular pelvic pelvimetry and fetal sonogram
stethoscope is used.  Estimation of pelvic adequacy must be done at least by the 24 th
 Palpate for fetal outline and position after week of pregnancy, because by this time, there is danger that
the 28th week. the fetal head will reach a size that will interfere with safe
passage and birth if the pelvic measurements are small
PELVIC EXAMINATION  Once a woman has given birth vaginally, her pelvis has been
> Reveals information on the health of both internal and approved adequate, and it is not necessary to take pelvic
external reproductive organs measurements.
Types of Pelvis
a. EXTERNAL GENITALIA – note for : > Categorized into 4 groups :
1. Signs of inflammation • Gynecoid : normal female pelvis
2. Irritation • Anthropoid : Ape-like pelvis
3. Infection • Platypelloid : Flattened pelvis
4. Herpes simplex II virus infection • Android : Male pelvis
5. Rectocele
6. Cystocele PELVIC MEASUREMENTS
 Internal pelvic measurements give the actual diameters of the
b. INTERNAL GENITALIA inlet and outlet through which the fetus must pass. The
1. Cervix should be in the center and color should be almost following measurements are made most commonly :
purple when pregnant.
 Retroverted Uterus – cervix positioned anteriorly 1. The Diagonal Conjugate – The distance between the anterior
 Anteverted Uterus – cervix positioned posteriorly. surface of the sacral prominence and the anterior surface of the
1. Nulligravida – woman who is not or never has been inferior margin of the symphysis pubis. The most useful
pregnant, the cervical os is round and small. measurement for estimation of pelvic size, because it suggests the
2. A woman who has had a previous pregnancy, the cervical anteroposterior diameter of the pelvic inlet.
os has a slitlike appearance.
3. If the woman had a cervical tear during a previous birth, 2. The True Conjugate – Conjugate Vera.
the cervical os may appear as a transverse crease. The measurement between the anterior surface of the sacral
4. If a cervical infection is present, a mucus discharge prominence and the posterior surface of the inferior margin of the
maybe present. With infection, the epithelium of the symphysis pubis.
cervical canal often enlarges and spreads onto the area
surrounding the os. Giving the cervix a reddened 3. The Ischial Tuberosity – The distance between the ischial
appearance called erosion. This area bleeds easily if tuberosities, or the transverse diameter of the outlet. A diameter of
touched.
11 cm is considered adequate because it will allow the widest Topical clotrimazole instead of metronidazole because of its possible
diameter of the fetal head. teratogenic effects if used during the first trimester of pregnancy.

3. LABORATORY ASSESSMENT Etiology :


• Blood Studies  Probably associated with preterm labor, premature rupture of
• Urinalysis membranes and post cesarean section infection
• Tuberculosis Testing
• Ultrasound 3. THE WOMAN WITH BACTERIAL VAGINOSIS (GARDNERELLA
INFECTION)
IDENTIFYING THE HIGH-RISK PREGNANCY  Local infection of the vagina by the invasion, most commonly, of
 Some women enter pregnancy with a chronic illness that, Gardnerella organisms.
when superimposed on the pregnancy, makes it high risk.
 Other women enter pregnancy in good health but then Assessments :
develop a complication of pregnancy that causes it to 1. Discharge is gray and has a fishlike odor
become high risk. 2. Intense pruritus
 A combination of particular instances – poverty, lack of
support people, poor coping mechanisms, genetic Treatment :
inheritance, or past history of pregnancy complications can 1. Metronidazole for non pregnant women.
cause a pregnancy to be categorized as high risk. 2. Because Metronidazole is contraindicated during the first
trimester, women are usually treated with a topical cream

FACTORS THAT CATEGORIZE A PREGNANCY AS HIGH Complications :


RISK 1. Untreated bacterial infections are associated with amniotic fluid
A. Infections During Pregnancy infections, perhaps, preterm labor and premature rupture of
membranes.
• Maternal infections during pregnancy may
contribute significantly to fetal morbidity and
4. CHLAMYDIA TRACHOMATIS
mortality.
 One of the most common types of vaginal infections seen
• Infections in this category may be caused by
during pregnancy.
various viruses. Other organisms like bacteria,
> Infection is caused by a gram-negative intracellular parasite
spirochetes, protozoa, or yeast may also cause
maternal infections, which are harmful to the
Assessment :
developing fetus. Even though the infection in
1. Heavy gray-white vaginal discharge
the mother may be very mild, the effects on the
fetus may be catastrophic.
Dx: Diagnosis is made by culture of the organism from vaginal
• Most organisms cross the placenta and infect the secretions using a specific chlamydia culture kit.
fetus, causing birth anomalies. The fetus may
also acquire the organism as it travels the birth Treatment :
canal during labor, causing illness after birth. 1. Therapy is usually with tetracyclines but contraindicated during
SEXUALLY TRANSMITTED DISEASES AND PREGNANCY pregnancy because of possible long bone deformities; Erythromycin
 Spread through sexual contact with an infected partner. and Amoxicillin are used instead.
 All STD’s can be prevented to some extent by the use of  It is important that chlamydia infections be treated because they
safer sex practices. are associated with PROM, preterm labor and endometritis in
 Treatment begins with determining the causative organism the postpartal period.
so the appropriate antibiotic or antifungal medication can be  An infant who is born while a chlamydia infection is present in
prescribed. the vagina can suffer from conjunctivitis or pneumonia after
birth.
Nursing Diagnosis : Pain related to vulvar irritation secondary to
existence of STD 5.SYPHILIS
 A systemic disease caused by the spirochete Treponema
1. THE WOMAN WITH CANDIDIASIS pallidum.
 Candidiasis causes a vaginal infection spread by the fungus
Candida. Assessment :
Assessment :
1. The 1st stage results in a painless ulcer (chancre) on the
1. Thick, cream cheeselike vaginal discharge and extreme vulva or vagina.
pruritus. 2. Hepatic and splenic enlargement, headache, anorexia,
2. Vagina appears red and irritated and maculopapular rash on the palms of the hand and the
soles of the feet ( secondary syphilis; occurring about two
Etiology : months after initial infection
1. Occurs more frequently during pregnancy because of the
increased estrogen level present during pregnancy. Complications :
2. Occurs frequently to women being treated with an antibiotic 1. Spontaneous Abortion
for another infection. 2. Preterm Labor
3. Occurs frequently in women with gestational diabetes 3. Stillbirth
4. Mostly seen in women with HIV infection 4. Congenital anomalies in the NB

Dx : Diagnosed by microscopic analysis Dx: All pregnant women are screened for syphilis by VDRL, RPR or
FTA-ABS antibody reaction test.
Treatment : Local application of an antifungal cream such as
miconazole cream (Monistat) or oral fluconazole (Diflucan) Treatment :
1. One injection of Benzathine penicillin G is the drug of choice
during pregnancy
Complications :
1. If untreated during pregnancy, it may cause a candidal 6.THE WOMAN WITH GONORRHEA
infection, or thrush, in the NB.  A sexually transmitted disease caused by the gram-negative
coccus Neisseria gonorrhea.
2. THE WOMAN WITH TRICHOMONIASIS
 A single-cell protozoan spread by coitus. Assessments :
1. May not produce symptoms in some women
Assessment : 2. A yellow-green vaginal discharge may be present
1. A yellow-gray, frothy, odorous vaginal discharge.  Gonorrhea is associated with spontaneous abortion, preterm
2. Vulvar itching, edema, and redness birth, and endometritis in the postpartal period.
 Also a cause of pelvic infectious disease and infertility.
Dx: Diagnosed by examination of vaginal secretions on a wet
slide that has been treated with Potassium Hydoxide (KOH). Dx : Diagnosis is made by culture of the organism from the vagina,
rectum or urethra
Treatment :
Treatment :
1. Traditionally treated with amoxicillin and probenecid but the 3. Weight loss and fatigue (wasting syndrome)
incidence of penicillinase-producing strains has made this 4. Opportunistic infections and possible malignancies
therapy ineffective.
2. Oral Cefixime and Ceftriaxone sodium IM are now the drug of Complications :
choice. 1. It may invade cerebral spinal fluid and cause extreme neurologic
3. Sexual partner should also be treated to prevent infection. involvement
2. Higher risk for the development of toxoplasmosis and
cytomegalovirus infections.
3. Tuberculosis occurs at a higher rate with HIV people and may
Complications : grow worse during pregnancy
1. If untreated at time of birth, it can cause severe eye
infection that can lead to blindness in the NB Dx: ELISA antibody reaction. For confirmation a Western blot
(Ophthalmia neonatorum). analysis is required.
2. Major cause of pelvic infectious disease and infertility Complications :
1. HIV is associated with low birth weight and preterm birth.
7.THE WOMAN WITH HUMAN PAPILLOMA VIRUS 2. If the mother is untreated, 20% to 50% of infants born to HIV-
INFECTION positive women will develop AIDS in the first year of life.
 The Human papilloma virus (HPV) causes fibrous tissue
overgrowth on the external vulva (condyloma acuminatum) Therapeutic Management :
1. If Pneumocystis carinii pneumonia develops, the woman is treated
with trimethoprim with sulfamethoxazole. Trimethoprim may be
Etiology : teratogenic in early pregnancy; sulfamethoxazole may lead to
1. Women who have multiple sexual partners increased bilirubin in the newborn if administered late in pregnancy..

Assessments : 2. Pentamidine, the drug of choice for PCP in nonpregnant women,


1. Discrete papillary structures at first which spreads, enlarges maybe administered by aerosol.
and coalesce to form large, cauliflower-like lesions
2. Tend to increase in size during pregnancy because of the high 3. Kaposi’s sarcoma, malignancy that tends to occur with AIDS, is
vascular flow in the pelvic area. normally treated with chemotherapy. Chemotherapy is
3. They may become secondarily ulcerated and infected; when contraindicated during early pregnancy because of the potential for
this occurs, a foul vulvar odor may develop fetal injury but is used later in pregnancy to halt malignant growths.

Treatment : 4. Thrombocytopenia (lowered platelet count) may be present which


1. Aimed at dissolving the lesions and also ending any may make the woman a poor candidate for an epidural injection for
secondary infection present. anesthesia during labor or for episiotomy. She may need a platelet
2. Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) transfusion to restore coagulation ability
applied to the lesions weekly 5. Newborns of HIV-positive mothers are treated with zidovudine for
3. Large lesions may be removed by laser therapy, cryocautery the 1st 6 weeks of life to try to prevent seroconversion and
or knife excision. trimethroprim-sulfamethoxazole to prevent P. carinii pneumonia
4. If present at time of birth and obstruct birth canal, a CS maybe
performed Nursing Diagnosis: Risk for opportunistic infections

Complications : TORCH infections


1. Associated with the development of cervical cancer later in The term TORCH was applied to perinatal infections (T,
life. toxoplasmosis; O, other; R, rubella; C, cytomagalovirus; H, herpes).
• Toxoplasmosis – caused by the protozoan organism
8.THE WOMAN WITH A GROUP B STREPTOCOCCI Toxoplasmosis gondii, which is contracted from oocytes in
INFECTION cat feces or by eating uncooked meat. When primary
infection, which is generally asymptomatic, occurs just
Etiology : before or during early pregnancy, congenital infection may
1. Occurs at a higher incidence during pregnancy result. This can lead to the birth of a child who is mentally
and physically retarded, and who suffers from
Assessment : chorioretinitis and microcephaly. Approximately 10% to
1. Patient usually experiences no symptoms. 15% of these babies die, and most of the survivors are
severely compromised. Sulfamethoxazole may reduce the
Complications : fetal impact.
1. Urinary Tract Infection (UTI) • Other – includes the STDs, hepatitis
2. Intra-amniotic Infection leading to preterm birth • Rubella – although most concerns are for infection in the
3. Postpartal endometritis first trimester, serious problem are known to occur when
4. 40 % to 70% of neonates whose mothers have an active the infection develops as late as the fifth month of
infection will become infected from placental transferal or from gestation, and later infections may be responsible for more
direct contact with the organisms at birth. subtle problems. Infections in the first trimester may result
5. Infected neonates may develop severe pneumonia, sepsis, in abortion in more than 33% of cases.
respiratory distress syndrome or meningitis
• Cytomegalovirus – most common of perinatal infections.
Congenital defects include bone lesions, anemia, low birth
Dx: Women are screened at 35 to 38 weeks of pregnancy by a
weight, hepatomegaly, splenomegaly, jaundice, petechiae,
vaginal culture.
heart disease, pneumonia, cataracts, chorioretinitis,
microcephaly, obstructive hydrocephaly, intracranial
Treatment :
calcifications, and encephalitis.
1. Broad spectrum penicillin such as ampicillin
2. Women who experience rupture of membranes at less than 37 • Herpes (HERPES SIMPLEX VIRUS TYPE 2)
weeks of pregnancy are treated with Ampicillin IV Genital herpes infection is a sexually transmitted disease
caused by the herpes simplex virus (HSV) type 2.
9.THE WOMAN WITH HUMAN IMMUNODEFICIENCY VIRUS Herpes can be transmitted across the placenta to cause
(HIV) INFECTION congenital infection in the NB
Herpes can be transmitted at birth if active lesions are
 The HIV virus, which leads to AIDS, is the most serious of
present at that time in the vagina or vulva.
the STD’s because it may be fatal to both mother and child.
When infection in the NB occurs, Congenital Herpes can
result.
Etiology :
To avoid transmission, CS may be scheduled. If no lesions
1. Multiple sexual partners of the individual or sexual partner
are present, a vaginal birth is preferable.
2. Bisexual partners
Dx : Appearance of lesions, PAP smear, enzyme
3. IV drug use by the individual or sexual partner
Immunosorbent Assay (ELISA)
4. Blood transfusions
Treatment :
1. Drug of choice is acyclovir (Zovirax) in an ointment or oral
Assessment :
form
1. Initial invasion of the virus, which may be accompanied by
2. Women can reduce the pain of infection by sitz baths or
mild, flu-like symptoms
applying warm. Moist tea bags to the lesions.
2. Seroconversion in which the woman converts from having no
Assessment :
HIV antibodies in blood serum to having antibodies positive for
Painful, small, pinpoint vesicles surrounded by erythema on
HIV.
the vulva or in the vagina 3-7 days after exposure.
carriers, chances are that one in four of their children will be
B.HEMATOLOGIC DISORDERS AND PREGNANCY affected.
 Hematologic disorders during pregnancy involve either  Infection, exposure to cold, high altitudes, overexertion or other
blood formation or coagulation disorders. situations that cause cellular oxygen deprivation may trigger a
sickle cell crisis. The deoxygenated, sickle-shaped red blood
Anemia And Pregnancy cells stick to the capillary wall and each other, blocking blood
 Because the blood volume expands during pregnancy, flow and causing cellular hypoxia. The crisis worsens as tissue
most women have a pseudoanemia of early pregnancy. hypoxia and acidic waste products cause more sickling and cell
This is normal and should not be confused with the true damage.
anemia that can occur as a complication of pregnancy.
Complications:
Nursing Diagnosis: Risk for altered tissue perfusion 1. Increased incidence of asymptomatic bacteriuria, resulting in an
increased incidence of pyelonephritis.
1. THE WOMAN WITH IRON DEFICIENCY ANEMIA 2. In pregnancy, blockage to the placental circulation can lead to
 Most common anemia of pregnancy direct fetal compromise with low birth weight and possibly death.
 Iron deficiency anemia is characteristically a microcytic 3. The anemia can threaten the pregnant woman’s life if vital blood
(small-sized red blood cell), hypochromic (less Hgb than the vessels as those to the liver, kidneys, heart, lungs, or brain become
average red blood cell) anemia, because when an blocked.
adequate supply of iron is not ingested, iron is unavailable
for incorporation into red blood cells and so cells are not as Assessment :
large or as rich in hemoglobin as normally. Both Hgb and 1. Hemolysis in a sickle cell crisis may occur so rapidly that a
Hct will be reduced. woman’s hemoglobin level can fall to 5 or 6 mg/100 ml in a few
Therapeutic Management : hours.
1. All women should take prenatal vitamins that contain an iron 2. Rise in indirect bilirubin level
supplement of 60 mg of elemental iron as prophylactic therapy. 3. Susceptible to bacteriuria, preeclampsia and UTI’s
2. Advise women to take iron supplements with orange juice or a 4. Assess for pooling of blood in the lower extremities
Vitamin C supplement. 5. Severe abdominal pain, muscle spasms, leg pains, painful and
3. They need to eat diet high in iron and vitamins swollen joints, fever, vomiting, hematuria, seizures, stiff neck, coma
3. For severe iron deficiency anemia, and patient is and paralysis.
noncompliant with oral iron therapy, Iron Dextran IM or IV can be
administered. Therapeutic Management :
Etiology : 1. Replace sickle cells with normal cells by exchange transfusion
1. Diet low in iron periodically throughout the pregnancy.
2. Heavy menstrual periods 2. If a crisis occurs, control pain, administer oxygen as needed
3. unwise weight-reducing programs 3. Increase fluid volume of the circulatory system to lower viscosity.
4. Low socio-economic status Fluid administered is often hypotonic(0,45 saline) to keep plasma
Complications : tension low
1. Low fetal birth weight 4. As a rule, women with sickle cell anemia should not be given iron
2. Preterm birth supplement because the woman’s cells can’t absorb iron in the usual
Assessment : manner; taking supplements can lead to iron overload.
1. Extreme fatigue and poor exercise tolerance. 5. Keep woman well hydrated during labor.
2. THE WOMAN WITH FOLIC ACID DEFICIENCY ANEMIA
 Folic acid or Folacin is necessary for both the normal COAGULATION DISORDERS AND PREGNANCY
formation of red blood cells in the mother.  Most coagulation disorders are sex linked, or only occurs in
 Associated with a decrease in neural tube defects in the males, so have little effect on pregnancies.
fetus.  Von Willebrand’s disease is a coagulation disorder inherited as
an autosomal dominant trait that does occur in women.
Etiology :
1. Occurs most often in multiple pregnancies because of the Signs/Symptoms :
increased fetal demand. 1. Menorrhagia
2. In women with a secondary hemolytic illness in which there is 2. Frequent episodes of epistaxis
rapid destruction and production of red blood cells 3. Prolonged bleeding time
3. In women who are taking hydantoin, a drug that interferes with
folate absorption. IDIOPATHIC THROMBOCYTOPENIC PURPURA :
4. Alcohol abuse – suppresses the metabolic effects of folic acid  A decrease number of platelets

Assessment: Etiology:
The main symptom of folic acid deficiency anemia is a history of - unknown but assumed to be autoimmune illness
severe, progressive fatigue. Associated findings include
shortness of breath, palpitations, diarrhea, nausea, anorexia, Signs/Symptoms :
headaches, forgetfulness, and irritability. The impaired oxygen- 1. Miniature petechiae or large ecchymoses appear on the woman’s
carrying capacity of the blood from lowered hemoglobin levels body.
may produce complaints of weakness and light-headedness. 2. Frequent nose bleeds may occur
3. Marked thrombocytopenia
Megaloblastic anemia (enlarged red blood cells) – anemia that
develops. Therapeutic Management :
 The mean corpuscular volume will be elevated. 1. Platelet transfusion to temporarily increase platelet count
 May be a factor in early abortion or abruptio placenta 2. Oral prednisone is effective

Therapeutic Management : C. RENAL AND URINARY DISORDERS AND PREGNANCY


1. Vitamin supplement of 400 ug of folic acid daily  Adequate kidney function is important to successful pregnancy
2. assist with planning a well balanced diet that includes outcome; any condition that interferes with kidney or urinary
meals and snacks that are high in folic acid (eg. function is therefore potentially serious.
Asparagus, beef liver, brocolli, green and leafy
vegetables, mushrooms, oatmeal, peanut butter, red 1. THE WOMAN WITH A URINARY TRACT INFECTION
beans, whole wheat bread)  The organism most commonly responsible for UTI is
3. Encourage to eat and drink a rich source of vitamin C Escherichia coli
at each meal to enhance absorption of folic acid
Causes :
3. THE WOMAN WITH SICKLE CELL ANEMIA 1. In pregnant woman, because of the dilated ureters from the effect
 Sickle cell anemia is a recessively inherited hemolytic of progesterone, stasis of urine occurs.
anemia caused by an abnormal amino acid in the beta 2. .Minimal glucosuria that occurs with pregnancy contributes to the
chain of hemoglobin. (The amino acid valine is substituted growth of organisms.
for glutamic acid in the sixth position of the beta chain 3. Women with known vesicoureteral reflux often develop UTI or
causing the hemoglobin structure to change.) It is a pyelonephritis.
congenital hematologic disease that causes impaired
circulation, chronic ill health, and premature death. Patients Complications :
who suffer from this disease inherit the sickling gene from 1. Asymptomatic infections can flame into pyelonephritis.
both parents, although some parents may only be carriers 2. Increased incidence of preterm labor, PROM and fetal loss may
and don’t experience the symptoms. If both parents are be associated with pyelonephritis
Assessments : 3. THE WOMAN WITH PNEUMONIA
1. Pain on urination  Pneumonia is the bacterial or viral invasion of lung tissue.
2. Frequency of urination  Pneumonia poses a serious complication of pregnancy because
3. Hematuria fluid collects in alveolar spaces causing limited oxygen-carbon
4. Bacterial count of more than 100,000 colonies per milliliter in a dioxide exchange in the lungs.
clean-catch specimen  After the invasion, an acute inflammatory response occurs with
exudates of red blood cells, fibrin, and polymorphonuclear
Therapeutic Management : leukocytes into the alveoli. This process confines the bacteria or
1. Urine for culture and sensitivity test to detect infection and to virus within segments of the lobes of the lungs.
determine which antibiotic to be used.
2. Amoxicillin, ampicillin and cephalosporins are effective against Treatment :
most organisms causing UTI. 1. Appropriate antibiotic
3. Sulfonamides can be used early in pregnancy but not near 2. Oxygen administration
term because they interfere with protein binding of bilirubin. 3. Ventilation support maybe necessary in severe cases.

Nursing Diagnosis: Risk for infection  There is tendency of preterm labor late in pregnancy
Common Measure to prevent UTI : 4. THE WOMAN WITH ASTHMA
1. Voiding frequently (at least every two hours)  Asthma is paroxysmal wheezing and dyspnea in response to an
2. Wiping front to back after bowel movements inhaled allergen.
3. Wearing cotton, not synthetic fiber underwear
 With inhalation of allergen, there is an immediate histamine
4. Voiding immediately after sexual intercourse
release from IgE immunoglobulin interaction. This results in
constriction of the bronchial smooth muscle, marked mucosal
swelling, and the production of thick bronchial secretions.
These 3 processes reduce the lumen of air passages markedly.
2. THE WOMAN WITH CHRONIC RENAL DISEASE
 Pregnancy increases the work load of the kidneys because Symptoms :
the woman’s kidneys must excrete waste products not only 1. Difficulty with air exchange; on exhalation, she makes a high
for herself but for the fetus for 40 weeks. pitched whistling sound (bronchial wheezing)
 Many women with renal disease take a corticosteroid at a  Asthma has the potential of reducing oxygen supply to the fetus
maintenance level. An effect that may occur is that the if a major attack should occur.
infant may be hyperglycemic at birth because of the
 Many women find their asthma improved during pregnancy by
suppression of insulin activity by corticosteroid.
the high circulating levels of corticosteroid.
 Infants of women with renal disease tend to have
 Women with asthma have a higher rate of preterm birth
intrauterine growth restriction from lessened placental
perfusion.
Treatment :
 Women may develop severe anemia because their 1. Beta-adrenergic agonists such as terbutaline and albuterol are the
diseased kidneys do not produce erythropoietin drugs of choice. If ineffective, theophylline, a corticosteroid or
 Many women with renal disease have elevated blood cromolyn sodium may be added to the regimen.
pressure.
 Women with kidney disease who normally have an elevated 5. THE WOMAN WITH TUBERCULOSIS
serum creatinine level more than 2.0 mg/dl may be advised  With TB, lung tissue is invaded by mycobacterium tuberculosis,
not to undertake a pregnancy or the increased strain on an acid-fast bacillus
already damaged kidneys could lead to kidney failure
 Women with kidney transplants should be considered Assessment:
individually to determine whether they will be able to carry a 1. Chronic cough
pregnancy to term before a pregnancy is initiated. 2. weight loss
 Women with severe renal disease may require dialysis to 3. Hemoptysis
aid kidney function during pregnancy. This is associated 4. Night sweats
with a risk of preterm labor because progesterone is 5. Low-grade fever
removed with the dialysis. To prevent this complication 6. Chronic fatigue
Progesterone IM may be administered before dialysis
Therapeutic Management :
D. RESPIRATORY DISORDERS AND PREGNANCY 1. Isoniazid (INH) and ethambutol Hcl are drugs of choice. INH may
 Chronic respiratory conditions may worsen in pregnancy result in a peripheral neuritis if the woman does not take
because the rising uterus compresses lung space. supplemental pyridoxine (vitamin B6). Ethambutol may cause optic
 Any respiratory disorder can pose serious hazards to the nerve involvement in the mother.
fetus if allowed to progress to the point where the mother’s 2. Maintain an adequate level of calcium
oxygen-carbon dioxide exchange is altered. 3. A woman is advised to wait 1 to 2 years after the infection
becomes inactive before attempting to conceive.
Nursing Diagnosis: Risk for ineffective breathing pattern
TB lesions never really disappear but are only “closed off” and made
1. THE WOMAN WITH ACUTE NASOPHARYNGITIS inactive.
 Acute nasopharyngitis (common colds) tends to be more  Recent inactive TB can become active during pregnancy,
severe during pregnancy because during this period because pressure on the diaphragm from below changes the
estrogen stimulation normally causes some degree of nasal shape of the lungs, and a sealed pocket may be broken in this
congestion. process.
 Recent inactive TB may also become active during the post-
2. THE WOMAN WITH INFLUENZA partal period, as the lung suddenly returns to its more vertical
 Influenza is caused by a virus that is identified as Type A, B pre-pregnant position and breaks open calcium deposits.
or C.  Although TB can be spread by the placenta to the fetus, it is
 Type A causes most infections. usually spread to the infant after birth
 A woman should have at least 3 negative sputum cultures
before she holds/cares for her infant. If negative, there is no
Assessment : need to isolate infant from mother; she can even breastfeed.
1. Disease spreads in epidemic form
2. High fever 6. THE WOMAN WITH CYSTIC FIBROSIS
3. Extreme prostration  Cystic Fibrosis is a recessively inherited disease in which there
4. Aching pains in the back and extremities is generalized dysfunction of the exocrine glands. This
5. A sore, raw throat. dysfunction leads to mucus secretions, particularly in the
pancreas and lungs, so thick that normal secretion is blocked.
 Correlate with preterm labor and abortion  Women may have lessened fertility from inability of sperm to
 Treated with antipyretic to control fever and perhaps a migrate through viscid cervical mucus.
prophylactic antibiotic to prevent a secondary infection such
as pneumonia. Symptoms :
 Exposure to influenza while in utero was associated with 1. Chronic respiratory
the development of schizophrenia in later life. Later studies 2. Over inflation of lungs from the thickened mucus
do not show this association.
3. Inability to digest fat and protein because the pancreas cannot F. GASTROINTESTINAL DISORDERS AND PREGNANCY
release amylase.  Minor gastrointestinal disorders are common in pregnancy
(nausea, heartburn, constipation). Acute abdominal pain or
Complications : vomiting are causes for concern
1. Increased risk for preterm labor  Women who have colostomies can complete pregnancy without
2. Risk for perinatal death difficulties.
3. High possibility of developing DM due to pancreas
involvement Nursing Diagnosis: Risk for altered nutrition, less than body
requirements

Treatment :
1. Pancrelipase – to supplement pancreatic enzymes 1. THE WOMAN WITH APPENDICITIS
2. Bronchodilator  Appendicitis is inflammation of the appendix.
3. Antibiotic
4. Postural drainage daily – to reduce a buildup of lung Assessment :
secretions 1. Nausea
5. Iron supplement – because panrelipase interferes with iron 2. Generalized abdominal discomfort
absorption 3. Vomiting
6. Monitor for serum glucose to detect development of 4.Sharp, peristaltic, lower right quadrant pain
gestational diabetes 5. Leukocytosis
6. Elevated temperature
 It is not usually recommended for postpartum women with 7. Ketones in the urine
cystic fibrosis to breastfeed because their breast milk  In the pregnant woman, the appendix is often displaced so far
contains more fatty acid. upward in the abdomen that the localized pain may be so high it
resembles pain of gallbladder disease.
E. RHEUMATIC DISORDERS AND PREGNANCY  Advise woman not to take food, liquid, or laxatives because
increasing peristalsis tends to cause an inflamed appendix to
Nursing Diagnosis : Pain related to rheumatic disorder during rupture.
pregnancy
Therapeutic Management :
1. THE WOMAN WITH JUVENILE RHEUMATOID ARTHRITIS 1. CS if fetus is near term, then remove appendix.
 Juvenile Rheumatoid Arthritis is a disease of connective 2. Laparoscopy – if condition occurs in early pregnancy
tissue with joint inflammation and contracture, probably the
result of an autoimmune response. 2. THE WOMAN WITH A HIATAL HERNIA
 Hiatal Hernia is a condition in which a portion of the stomach
Pathology : extends and protrudes up through the diaphragm into the chest
The disease pathology is synovial membrane destruction. cavity.
Inflammation with effusion, swelling, erythema, and painful
motionof the joints occurs. Overtime, formation of granulation Symptoms :
tissue can fill the joint space, resulting in permanent 1. Heartburn
disfigurement and loss of joint motion. 2. Gastric regurgitation
Treatment : 3. Indigestion
1. Corticosteroids and salicylate therapy – a danger of large 4. Dysphagia
amounts of salicylates is prolonged pregnancy (salicylates 5. Possible weight loss due to inability to eat
interferes with prostaglandin synthesis, so labor contractions are 6. Hematemesis in extreme cases
not initiated). The woman is asked to decrease salicylate intake
2 weeks before term to avoid the problem. Dx : Diagnosed by direct endoscopy or sonogram
2. THE WOMAN WITH SYSTEMIC LUPUS ERYTHEMATOSUS Therapeutic Management :
 SLE is a multisystem chronic disease of connective tissue 1. Antacids to relieve pain
that can occur in women of childbearing age. 2. Elevate head when sleeping
 Highest incidence is in women ages 20 to 40 years
 Widespread degeneration of connective tissue occurs with 3. THE WOMAN WITH CHOLECYSTITIS AND CHOLELITHIASIS
the onset of illness
Assessment : Etiology :
1. Marked skin change is erythematous “butterfly-shaped” rash 1. Associated with women older than 40 years
on the face. 2. Obesity
 Most serious of the kidney changes are fibrin deposits that 3. Multiparity
plug and block the glomeruli, leading to necrosis and 4. High fat diet
scarring. 5. Gallstones are formed from cholesterol
 The thickening of collagen tissue in the blood vessels
causes vessel obstruction, blood flow to the vital organs Symptoms :
become compromised and to the fetus if blood flow to the 1. Aching and pressure in the right epigastrium
placenta is obstructed 2. Jaundice
Treatment : Therapeutic Management :
1. Corticosteroid, NSAID’s and salicylate therapy to reduce 1. Lower fat intake. Low fat but fat free diet because of the
symptoms of joint pain and inflammation. importance of linoleic acid for fetal growth.
2. IVF for acute episodes to provide fluid and nutrients
Complication : 3. Analgesics
1. Acute nephritis with glomeruli destruction 4. Laparoscopy if cannot be controlled by conservative management
2. Higher incidence of abortion and preterm births.
3. Infants may be born with lupuslike rash, anemia and Dx : Sonogram
thrombocytopenia.
4. Congenital heart block can occur in the NB. 4. THE WOMAN WITH VIRAL HEPATITIS
 Hepatitis is liver disease that may occur from invasion of the A,
 With nephritis, BP will rise. Patient will develop hematuria B, C, or D virus.
and decreased urine output. Proteinuria and edema may  Hepatitis A is spread mainly by contact with another person or
begin. by ingestion of fecally contaminated water or shellfish
 Women will be monitored by frequent serum creatinine  Incubation period 2 to 6 weeks.
levels to assess kidney function. Dialysis or plasmapheresis  Prophylactic gamma globulin to prevent the disease after
may be necessary. exposure.
 Women are asked to reduce salicylate close to birth to  Hepatitis B (serum hepatitis) is spread by transfusion of
reduce possibility of bleeding in the NB contaminated blood or blood products; it can be spread by
 Hydrocortisone IV is administered during labor to help the semen or vaginal secretions and thus considered STD.
woman to adjust to the stress at this time.  Incubation period 6 weeks to 6 months
 Infants with woman who have SLE tends to be small for  Hepatitis B vaccine may be administered to those who are at
gestational age due to the decreased blood flow to high risk
placenta.
Assessment :
1.Nausea, vomiting  Woman is advised to inform health personnel that she has
2. Liver is tender to palpation recurrent seizures and the medications she is taking
3. Dark yellow urine
4. Light colored stools Nursing Diagnosis: Risk for altered parenting
5. Jaundice
6. On physical examination, liver is enlarged  A woman who has recurrent convulsions may worry that her
7. Elevated bilirubin child will have seizures as the child grows older.
8. Increased liver enzymes  If seizures are result of acquired disorder, assure the woman
that her child will have no tendency toward seizures.
Dx : Liver Biopsy
2. THE WOMAN WITH MYASTHENIA GRAVIS
 Myasthenia Gravis is an autoimmune disorder characterized by
Therapeutic Management : the presence of an IgG antibody against acetylcholine receptors
1. Bed rest in striated muscle.
2. High calorie diet  It produces sporadic but progressive weakness and abnormal
3. Contact precautions when giving care fatigue in striated (skeletal) muscles. This weakness and fatigue
are exacerbated by exercise and repeated movement but
improved by anticholinesterase drugs. Usually, myasthenia
Complications : gravis affects muscles innervated by the cranial nerves (face,
1. Abortion and preterm labor lips, tongue, neck, and throat), but it can affect any muscle
2. Infants with mothers who have HB Ag-positive will develop group.
chronic hepatitis
 Other common signs of myasthenia gravis include weak eye
 After birth, infant should be washed well to remove any closure, ptosis and diplopia, blank masklike facial expression,
maternal blood. difficulty chewing and swallowing, a hanging jaw, bobbing
 Hepatitis B immune globulin (HBIG) and Hepa B motion of the head, and symptoms of respiratory failure if
immunization should be administered to the NB respiratory muscles are involved
 Infants should be observed for infection
 Mother should not breastfeed because HB Ag antigens can Treatment :
be recovered from breast milk. 1. Administration of anti-cholinesterase drugs such as neostigmine
and pyridostigmine counteract fatigue and muscle weakness and
5. THE WOMAN WITH INFLAMMATORY BOWEL DISEASE enable about 80% of normal muscle function
 Crohn’s Disease (inflammation of the terminal ileus) and 2. Plasmapheresis (withdrawal and replacement of plasma) to
ulcerative colitis (inflammation of the distal colon) remove immune complexes from the bloodstream
Etiology :
1. Occurs most often in young adults Between ages 12 and 30 Interventions:
years 1. Help the woman plan daily activities to coincide with energy
2. Cause is unknown but an autoimmune process may be peaks.
responsible 2. Teach the client how to recognize adverse effects and signs of
toxicity of anticholinesterase drugs (headaches, sweating, abdominal
Symptoms : cramps, nausea, vomiting, diarrhea, excessive salivation,
1. Shallow ulcers bronchospasm). Warn her to avoid strenuous exercise, stress,
2. Chronic diarrhea infection, and unnecessary exposure to the sun or cold weather.
3. weight loss Caution her to avoid taking other medications without consulting her
4. Occult blood in stool primary care giver.
5.Nausea and vomiting 3. Magnesium sulfate should be avoided because it can diminish the
6. Obstruction and fistula formation with peritonitis can occur in acetylcholine effect and therefore increase disease symptoms.
extreme conditions
> Malabsorption particularly of Vit B12 occurs 3. THE WOMAN WITH MULTIPLE SCLEROSIS
Complications :  Nerve fibers become demyelinated and lose function. Pregnant
1. Interferes with fetal growth women with this disorder grow increasingly fatigued as
Therapy : pregnancy progresses.
1. Total rest for GI tract by total parenteral nutrition  Other signs and symptoms include visual disturbances such as
2. Sulfasalazine, an anti inflammatory. Close to birth, dosage is optic neuritis, diplopia and blurred vision, sensory impairment
reduced because it may interfere with bilirubin binding sited and such as paresthesia, urinary disturbances such as
can cause neonatal jaundice. incontinence, frequency, urgency, and infections, emotional
lability such as mood swings, irritability and euphoria and other
G. NEUROLOGIC DISORDERS AND PREGNANCY associated signs like poorly articulated speech and dysphagia
 Any neurologic disease with symptoms of seizures must be
carefully managed during pregnancy because anoxia Etiology :
caused by severe seizures could deprive the fetus with 1. exact cause is unclear; however, current theories suggest that it
oxygen, with serious outcomes. may be caused by an autoimmune response to a slow-acting or
latent viral infection or by environmental or genetic factors
Nursing Diagnosis : Risk for Injury (maternal) 2. Predominant in women between 20-40 years old (childbearing
1. THE WOMAN WITH A SEIZURE DISORDER age)

Etiology : Treatment :
1. Head trauma 1. ACTH or a corticosteroid to strengthen nerve conduction
2. Meningitis 2. Plasmapheresis (withdrawal and replacement of plasma)
3. Cause of recurrent seizures are unknown (idiopathic)
Interventions:
Therapeutic Management : ⇒ Emphasize the need to avoid stress, infections, and
1. “Do not take medication during pregnancy” rule does not apply fatigue and to maintain independence by finding new ways
to seizure control medications. The risk of adverse maternal or to perform daily activities.
fetal outcome from seizures during pregnancy is greater than the ⇒ Explain the value of a well balanced nutritious diet that
risk of teratogenicity from taking anticonvulsant drugs. contains sufficient fiber.
Complications : ⇒ Evaluate the need for bowel and bladder training
1. Infants may have an increased danger of neural tube
disorders and childhood malignancies as a result of folic acid Complications :
displacement from maternal medication. 1. UTI
2. Infants are also prone to hemorrhagic disease because of 2. Painless precipitous birth if quadriplegia is present
decreased Vit K coagulation factors at birth. 3. Dysreflexia from the pain of labor which leads to HPN, headache,
diaphoresis and bradycardia
Nursing Diagnosis : Risk for altered placental perfusion
H. MUSCULOSKELETAL DISORDERS AND PREGNANCY
Tonic-clonic seizures (sustained full-body involvement) could
affect the fetus because of anoxia that can occur form spasms of 1. THE WOMAN WITH SCOLIOSIS
chest muscles.
 Scoliosis is lateral curvature of the spine
 Administer oxygen by mask is good prophylaxis to ensure
adequate fetal oxygenation Etiology :
1. Often in women approximately 12 years of age 5. Poor fetal heart tone variability from poor tissue perfusion
6. Decreased amniotic fluid from intrauterine growth retardation
Complications : 7. Edema from poor venous return
1. Cosmetic deformity 8. Irregular pulse
2. Because of chest compression, interferes with respiration and 9. Chest pain on exertion
heart action
3. Pelvic distortion Diagnostic Assessment : Chest x-ray, ECG

Therapeutic Management : Fetal Assessment :


1. Stainless steel rods (Harrington rods) implanted on both sides 1. Low birth weights
of spinal vertebrae to strengthen and straighten the spine. 2. Severe fetal distress
2. CS, if pelvis is distorted.
Nursing Diagnosis : Knowledge deficit regarding the effects of
I. CARDIOVASCULAR DISORDERS AND PREGNANCY maternal cardiovascular disease

1. THE WOMAN WITH LEFT-SIDED HEART FAILURE Nursing Interventions :


 Occurs with conditions such as mitral stenosis, mitral 1. Promote rest
insufficiency and aortic coarctation. 2. Promote healthy nutrition
 Occurs when the left ventricle is unable to move forward the 3. Educate regarding medication
volume of blood received by the left atrium from the 4. Educate regarding avoidance of Infection
pulmonary circulation
4. THE WOMAN WITH AN ARTIFICIAL VALVE PROSTHESIS
 Many women with valve prosthesis take oral anticoagulants to
Clinical Manifestations : prevent formation of blood clots at valve site. However, these
1. Productive cough of blood-speckled sputum medications increase the risk of congenital anomalies in infants
2. Fatigue, weakness, dizziness  Women are placed on heparin therapy before becoming
3. Orthopnea pregnant
4. Paroxysmal nocturnal dyspnea - suddenly waking at night  Observe for signs of premature separation of the placenta
short of breath during pregnancy and labor because anticoagulant in the
mother may cause placental dislodgement.
Complications :
1. High risk for Abortion 5. THE WOMAN WITH CHRONIC HYPERTENSIVE VASCULAR
2. preterm labor DISEASE
3. Maternal death  Women with chronic hypertensive vascular disease come into
pregnancy with elevated BP. This kind of HPN is usually
Therapeutic Management : associated with arteriosclerosis or renal disease
1. Anti-hypertensives  Fetal well-being is compromised by poor placental perfusion
2. Beta-blockers to decrease the force of myocardial during pregnancy
contractions  Management is similar with PIH
2. THE WOMAN WITH RIGHT-SIDED FAILURE 6. THE WOMAN WITH VENOUS THROMBOEMBOLIC DISEASE
 Congenital heart defects such as pulmonary valve stenosis  Incidence increases during pregnancy due to acombination of
and atrial and ventricular septal defects may result in right- stasis of blood in the lower extremities from uterine pressure
sided heart failure. and hypercoagulability (effect of increased estrogen)
 Occurs when the output of the right ventricle is less than the
blood volume the heart receives at the right atrium from the Signs/symptoms :
vena cava or venous circulation. Back pressure from this 1. Chest pain
results in congestion of the systemic venous circulation and 2. Sudden onset of dyspnea
decreases cardiac output to the lungs. 3. Cough with hemoptysis
 Blood pressure falls in the aorta because less blood is 4. Tachycardia or missed beats
reaching it ; 5. Severe dizziness or fainting from lowered blood pressure
 Pressure is high in the vena cava
 Both jugular venous distention and increased portal
circulation occur. Therapeutic Management :
 Both the liver and spleen become distended 1. Avoid use of constrictive knee-high stockings,
 Distention of abdominal vessels can lead to exudates of 2. Do not cross legs
fluid from the vessels into the peritoneal cavity (ascites). 3. Bed rest
Fluid moves from the systemic circulation into interstitial 4. Heparin IV administration
spaces (peripheral edema).
 Liver enlargement can cause extreme dyspnea and pain J. ENDOCRINE DISORDERS AND PREGNANCY
because it will put extreme pressure on the diaphragm.
 Eisenmenger’s syndrome – congenital anomaly most apt to 1. THE WOMAN WITH A THYROID DYSFUNCTION
cause right-sided failure (A right-to-left atrial or ventricular  Thyroid gland enlarges slightly due to increased vascularity, as
septal defect with accompanying pulmonary stenosis). They a normal effect of pregnancy
need oxygen administration and frequent arterial gases to
ensure fetal growth. Nursing Diagnosis: Risk for maternal and fetal injury

3. THE WOMAN WITH PERIPARTAL HEART DISEASE 2. THE WOMAN WITH HYPOTHYROIDISM
 A rare condition in pregnancy because women with symptoms
Peripartal cardiomyopathy – extremely rare condition that of untreated hypothyroidism are anovulatory and often unable
originate late in pregnancy. Due to the effect of pregnancy on the to conceive
circulatory system.
 Cause is unknown. May occur from previously undetected Signs/symptoms :
heart disease 1. Easy fatigability
Signs/symptoms : 2. Obese
1. Late in pregnancy, woman develops signs of myocardial 3. dry skin
failure : Shortness of breath, chest pain, and edema 4. Little tolerance for cold
2. Cardiomegaly (enlargement of the heart) 5. Extreme nausea and vomiting
Therapeutic Management :
1. Reduced activity Therapeutic Management :
2. Diuretic and digitalis therapy 1. Thyroxine – to supplement lack of thyroid hormone. As a rule, her
3. Low dose heparin to decrease the risk of thromboembolism. dose of thyroxine will be increased for the duration of pregnancy to
4. Immunosuppressive therapy simulate the effect that would normally occur in pregnancy

Assessment Of The Woman With Cardiac Disease : 3. THE WOMAN WITH HYPERTHYROIDISM
1.Fatigue
2. Cough Symptoms :
3. Increased respiratory rate 1. Rapid heart rate
4. tachycardia 2. Exophthalmos
3. Heat Intolerance
4. Nervousness • The pancreatic beta cell functions are impaired in
5. Heart palpitation response to the increased pancreatic stimulation and
6. Weight loss induced insulin resistance.
 If undiagnosed, woman may develop heart failure during • Pregnancy complicated by diabetes pits the mother at high
pregnancy because her rapid heart rate cannot adjust to the risk for the development of complications such as
increasing serum volume occurring with pregnancy. spontaneous abortion, hypertensive disorders, preterm
labor, infection, and birth complications.
Complications : • The effects of diabetes on the fetus include hypoglycemia,
1. PIH hyperglycemia, and ketoacidosis. Hyperglycemic effects
2. Fetal growth restriction can include
3. preterm labor a. congenital defects
b. macrosomia
c. intrauterine growth restriction
d. intrauterine fetal death
Therapeutic Management : e. delayed lung maturity
1. Thiomides to reduce thyroid activity. Unfortunately, these f. neonatal hypoglycemia
drugs are teratogens and possibly enlarges thyroid gland of the g. neonatal hyperbilirubinemia
fetus. Woman should be regulated on the lowest dose possible Assessment :
 Women on anti-thyroid drugs may be advised not to 1. Dizziness
breastfeed because these drugs are excreted in breast 2. Confusion if hyperglycemic
milk. 3. Thirst
4. Increased risk of PIH
4. THE WOMAN WITH DIABETES MELLITUS 5. Congenital anomalies
 DM is an endocrine disorder in which the pancreas is 6. Macrosomia
unable to produce adequate insulin to regulate body 7. Poor fetal heart tone variability and rate from poor tissue perfusion
glucose 8. Hydramnios
9. Glycosuria, polyuria
Pathophysiology : 10. Possibility of increased monilial infection
 The pancreas has both endocrine and exocrine types of
tissue. The Islets of Langerhans form the endocrine portion. Nursing Interventions
Alpha islet cells secrete glucagons; beta islet cells secrete • Teach the client the effects and interactions of diabetes
insulin. and pregnancy and signs of hyper and hypoglycemia
 Insulin is essential for carbohydrate metabolism and is • Teach client how to control diabetes in pregnancy, advise
important to the metabolism of fats and protein. The actual changes that need to be made in nutrition and activity
amount of insulin produced is regulated by serum glucose patterns to promote normal glucose levels and prevent
levels. When serum glucose exceeds 100 mg/dl, beta cells complications.
immediately increase insulin production. When blood serum • Advise client of increased risk of infection and how to
levels are lowered, production decreases. Both the ability to avoid it.
secrete additional insulin and the action to decrease • Observe and report any signs of pre-eclampsia.
production are immediate responses. • Monitor fetal status throughout pregnancy
• Assess status of mother and baby frequently
The primary problem of any woman with DM is control of the - carefully monitor fluid, calories, glucose and insulin during
balance between insulin and blood glucose to prevent labor and delivery
hyperglycemia or hypoglycemia - continue careful observation in postdelivery period

 Glomerular filtration of glucose is increased causing slight 6.HYPERGLYCEMIA


glycosuria. The rate of insulin secretion is increased, and
the fasting blood sugar is lowered. Nursing Diagnoses :
 All women appear to develop insulin resistance as 1. Risk for altered tissue perfusion
pregnancy progresses, a phenomenon that is probably 2. Altered nutrition less than body requirements r/t inability to use
caused by the presence of the hormone human placental glucose
lactogen and high levels of cortisol, estrogen, progesterone 3. Risk for ineffective individual coping
and catecholamines. 4. Risk for infection
 If the pancreas cannot respond by producing additional 5. Fluid volume deficit r/t polyuria accompanying disorder
insulin, excess glucose moves across placenta to fetus 6. Knowledge deficit r/t difficult and complex health problem
where fetal insulin metabolizes it, and acts as growth 7. Health-seeking behaviors r/t to voiced need to learn home glucose
hormone, promoting macrosomia monitoring
 The continued use of glucose by the fetus may lead to 8. Noncompliance r/t discouragement, misunderstanding or fear of
hypoglycemia. therapeutic measures
 There is a high incidence of congenital anomaly, abortion,
and stillbirth in infants. Nursing Interventions :
 At birth, infants are more prone to hypoglycemia, 1. Education regarding nutrition
respiratory distress syndrome, hypocalcemia, and 2. Education regarding exercise
hyperbilirubinemia.
Amanuel/Pslidasan/Ksjuliano Therapeutic Management :
NCM 104 1. Insulin
1st sem S.Y. 2006-2007 2. monitor fetal well-being
5. THE WOMAN WITH GESTATIONAL DIABETES
 Pregnant woman becomes diabetic usually at the midpoint K. MENTAL ILLNESS AND PREGNANCY
of pregnancy when insulin resistance become noticeable –  Mental illness may precede or occur with pregnancy.
Gestational Diabetes Mellitus Depression is the most common mental illness seen.
 Lithium, a mainstay of therapy for bipolar disorders is a known
Risk Factors for gestational diabetes : teratogen.
1. Obesity
2. Age over 30 years
3. History of large babies L. TRAUMA AND PREGNANCY
4. History of unexplained fetal loss  Trauma occurs at high incidence in childbearing years because
5. History of congenital anomalies in previous pregnancies for this age group, automobile accidents, homicide, and suicide
6. History of unexplained perinatal loss are among the three leading causes of death.
7. Family history of diabetes  High incidence occurs during the last trimester due to
clumsiness, fainting and hyperventilation.
Pathophysiology  Orthopedic injuries occur because the pregnant woman’s sense
• In gestational diabetes mellitus, insulin antagonism by of balance is altered
placental hormones, human placental lactogen,
progesterone, cortisol, and prolactin leads to increased PHYSIOLOGIC CHANGES IN PREGNANCY THAT AFFECT
blood glucose levels. The effect of these hormones TRAUMA CARE
peaks at about 26 weeks gestation. This is called the  After a traumatic injury, a woman’s body will maintain her own
diabetogenic effect of pregnancy. homeostasis at the expense of the fetus.
 The woman’s total plasma volume increases during  > If the woman did not have tetanus immunization within 10
pregnancy at term. This increase serves as a safeguard tot years, tetanus toxoid plus immune tetanus globulin is
the woman if trauma with bleeding should occur. administered.
 Fluid replacement volume would be high in case of injury  Knife wounds cause deep penetration and are often directed
because pregnant woman needs more fluid to restore fully into the abdomen. Most stab wounds of the abdomen, however,
her circulatory volume. occur in the upper quadrants of the abdomen above the height
 Peripheral venous pressure in pregnant woman is of the uterus.
unchanged, it tends to be higher in the lower extremities  To determine the depth and extent of the wound, a fistulogram
because of the compression of the vena cava and back may be done.
pressure. This causes lacerations of the legs or perineum to  If there is suspicion that there is bleeding in the abdomen, a
bleed much more profusely than usual. celiotomy or an exploratory surgical procedure into the
 During pregnancy, leucocyte count rises so it is difficult to abdominal cavity may be performed
use this determination as a sign of infection after an open  After surgical repair of an injured diaphragm, CS may be
wound. planned to avoid strain on a newly repaired diaphragm during
 Serum albumin level decreases during pregnancy, making labor
the large loss that normally occurs with burns a more
serious than usual response. 3. ANIMAL BITES
 Serum liver enzyme levels remain the same during  If the rabies immunization status of the dog is known, the
pregnancy, so if these are elevated during trauma, liver wound is washed and treated as a puncture wound.
trauma can be detected.  If the dog is questionable, the woman must be administered
 Bleeding into the abdominal cavity with an abdominal injury rabies immune globulin vaccine.
is apt to be forceful and extreme because of the increased  Pregnancy is not contraindicated to rabies immunization
pressure in the pelvic vessels. because contracting the disease would be so much more
 Paracentesis is dangerous because the bowel, dislocated serious
from its usual position, can be easily punctured. 4. BLUNT ABDOMINAL TRAUMA
 Culdocentesis may be done  No visible break is present on the skin.
 Peritoneal lavage may reveal bleeding or bladder rupture  After injury, underlying tissues becomes edematous; broken
best. underlying blood vessels may ooze and form ecchymosis or
 Bladder of pregnant woman is susceptible to rupture hematoma at the site.
because it is the most anterior organ and is elevated  To assess for abdominal bleeding, a diagnostic peritoneal
abnormally. lavage may be done, UTZ may also be done.
 After abdominal trauma, an indwelling bladder catheter is  Traumatic blow to the abdomen could cause dislodgement of
inserted to assess for blood in the urine. the placenta (abruptio placentae) or preterm labor.
 Palpate the uterus for any bleeding and count fetal heart tones
Emotional Considerations : using Doppler instrument.
 A feeling of guilt lowers self-esteem and increases the level  Sonogram may be used to show that the placenta and uterus
of stress. are intact
 People under stress do not process well and so may not  A pelvic examination is performed to assess for vaginal
perceive correctly the information given to them. bleeding or seepage of clear water that would suggest the
amniotic membranes were ruptured from the force of an
Initial Assessments After Trauma During Pregnancy abdominal blow.
> With multiple trauma, a nasogastric tube is usually passed to  If there is a uterine contraction, a uterine and fetal monitor
empty the stomach. A foley catheter is inserted to assess for should be placed to estimate the strength and effect on the fetal
urine output and to rule out ruptured bladder. heart rate and the possibility that preterm labor has begun.
 To prevent supine hypotension syndrome, be sure the  Magnesium sulfate is usually selected to halt preterm labor after
woman does not lie supine for an examination. If it is trauma.
necessary for her to lie supine, manually displace the  The possibility that placental blood will enter the maternal
uterus from the vena cava by placing rolled towels or a circulation with uterine trauma is a threat to the Rh negative
blanket under her right side to tip her body approximately woman. Rh (-) woman are therefore, administered Rh immune
15o to the side globulin (RHIG) after trauma.

Nursing Diagnosis : 5. GUNSHOT WOUNDS


1. Fear related to threat of injury to the fetus  Assessment of the wound includes inspection of the entry and
2. Risk for fetal injury exit point of the bullet.
3. Altered tissue perfusion r/t to severed artery  Uterine wall is so thick that it may trap a bullet; thus there may
4. Ineffective breathing pattern related to lung lacerated by be no exit point if the uterus is punctured.
gunshot wound  Gunshot wounds are surgically cleaned and debrided, and is
5. Risk for infection treated with a high concentration of antibiotics
6. Situational low self-esteem r/t occurrence of accident
7. Powerlessness r/t seriousness of the injury sustained or 6. POISONING
inability to prevent accident from occurring.  Syrup of Ipecac is the best emetic to cause vomiting and
discharge the poison from the body and is safe during
Therapeutic Management : pregnancy.
1. Immediate Care  Remember, some poisons can be more harmful if vomited than
 Interventions in emergency situations must be quick yet if allowed to remain in the body.
always remember that the woman’s primary health
condition is that she is pregnant. 7. CHOKING
 Cardiopulmonary resuscitation (CPR)  It is difficult to use a Heimlich maneuver because of a lack of
 If there is blood loss, a central venous pressure line may be space between the uterus and the sternum and because the
inserted. person can not reach from the rear around the woman’s
 If hypotension is present, it must be corrected quickly to enlarged abdomen.
maintain a pressure gradient across the placenta. Epedrine  Late in pregnancy, a rescuer must use successive chest
is the drug of choice for a pregnant woman because it has a thrusts. P. 362 Nursing procedure 14.2
minimal peripheral vasoconstriction effect.
8. ORTHOPEDIC INJURIES
Nursing Diagnosis : Risk for altered tissue perfusion  A woman has poor balance late in pregnancy, she may trip
more readily than usual
OPEN WOUNDS:  The extra weight pregnant woman carries puts a high
proportion of weight on the wrist, a serious wrist injury can
1. LACERATIONS occur
 Bleeding should be halted by pressure on the edge of the  Applying ice to the area decreases swelling
laceration
 X-ray may be done to determine a fracture.
 Encourage high calcium intake if woman has fracture so both
2. PUNCTURE WOUNDS
she and the fetus can have adequate calcium for new bone
 If the woman has had tetanus immunization within the past
growth
10 years, tetanus toxoid is administered.
9. BURNS
 Burns are dangerous to the pregnant woman because of 5. Knowledge deficit r/t signs and symptoms of possible
the thermal injury that occurs and the inhalation of carbon complications
monoxide gases which can lead to extreme fetal hypoxia as
carbon monoxide crosses the placenta in place of the BLEEDING DURING PREGNANCY
oxygen.  Vaginal bleeding is a deviation from the normal that may occur
 Smoke is irritating to the lung tissue and can result in at anytime during the pregnancy
extensive lung edema; this can cause additional fetal  Primary causes of bleeding during pregnancy
hypoxia due to the lack of oxygen-carbon dioxide exchange
space. 1. BLEEDING AND THE DEVELOPMENT OF SHOCK
 Because the fluid and electrolyte loss can be great with  A woman with any degree of bleeding needs to be evaluated for
burns, hypotension from hypovolemia or an electrolyte hypovolemic shock.
imbalance can occur.
 A body response to a harsh trauma such as burn is the Process of shock due to blood loss
production of prostaglandins, which may cause preterm
labor. Therapeutic Management
 Maternal and fetal prognosis are poor if burns cover more
than 50% of body surface area. Assessment :
 Interestingly, burn tissue heals more quickly than normal 1. Confusion
during pregnancy. This is probably related to the increased 2. Pallor
metabolism and to the increased corticosteroid serum level 3. Increased Pulse
that keeps inflammation and damage to tissue from the 4. Tachypnea
pressure of edema from occurring. 5. Decreased BP
6. Decreased cardiac output
THE BATTERED WOMAN 7. Fetal bradycardia
 Abused women may be pregnant because they were 8. Peripheral vasoconstriction
unable to resist sexual advances from their abusive partner. 9. Decreased urinary output
 Beatings may increase during pregnancy because stress is 10. Cold extremities
often a “trigger” to beatings, and pregnancy can increase Nursing Diagnosis : Risk for fluid volume deficit
the stress.
CONDITIONS ASSOCIATED WITH FIRST TRIMESTER
Assessment : BLEEDING
 A battered woman may come for care late in pregnancy
1. ABORTION
because her partner may control her transportation or
A. SPONTANEOUS ABORTION
money; she may fear that a health care provider will report
the abuse; pretending that the pregnancy does not exist to  Abortion-any interruption of a pregnancy before the fetus is
reduce stress in her home. viable. A non-viable fetus is usually defined as a fetus of 20 to
24 weeks’ gestation or weighing 500 gms. A fetus born at this
 She may be noticeable that she purchases no maternity
point would be considered a premature or immature birth
clothes.
1. Early abortion - occurs before week 16 of pregnancy
 She may decline laboratory tests if it involves transportation 2. Late abortion - occurs between weeks 16-24.
or money Causes:
 Battered woman may have difficulty following 1. Abnormal fetal formation due either to a teratogenic factor
recommended pregnancy nutrition. or to a chromosomal aberration.
 She may leave before health personnel sees her at prenatal 2. Immunologic factors
setting 3. Implantation abnormalities – placental circulation will not
 She may grow anxious if her prenatal appointment is be well established and fetal formation will be inadequate.
running late 4. Corpus luteum fails to produce enough progesterone to
 She may call and cancel appointments frequently. maintain the deciduas basalis
 She may dress inappropriately. 5. Infection
 Obvious bruises or lacerations, neck may reveal linear Assessment:
bruises from strangulation. 1. Vaginal spotting
 Battered woman may be anxious to hear baby’s heartbeat 2. History taking
because her partner recently punched or kicked her
abdomen and she is worried that fetus might have been B. THREATENED ABORTION
hurt. Minimal placental infarcts from blunt abdominal trauma S/Sx:
may lead to poor placental perfusion and low birth weight. - Vaginal bleeding, starts as scant bleeding usually bright red.
 A sonogram may be done for suspected abdominal trauma. - Slight cramping but no cervical dilatation
 Fetal heart tones and fundal height should be recorded. Intervention:
Nursing Diagnoses: - Limit activity to no strenuous activity for 24-48 hours is the
1. Powerlessness r/t perception that she is impossible to break key intervention.
away from abusing partner - Coitus is restricted for 2 weeks to prevent infection and to
2. Fear r/t constant threats of beatings avoid inducing further bleeding.
3. Social isolation r/t client’s need to hide evidence of abuse
3. Ineffective denial r/t inability to face the fact that spouse is C. IMMINENT (INEVITABLE) ABORTION
abusive  A threatened abortion becomes an imminent or inevitable
4. Ineffective family coping; compromised r/t dysfunctional abortion if uterine contractions and cervical dilatation occur.
relationship between client and abusive spouse. Symptoms :
1. Cramping or uterine contractions

Tasks the woman could accomplish to meet goals of care : Dx: UTZ
1. Client carries phone number for home for abused women with
her. Tx:
2. Client and abusive partner continue to attend counseling 1. D & C – to ensure all products of conception are removed.
sessions. 2. Suction Curettage
3. Client states she has filed restraining order against abusive 3. Any tissue fragments should be saved to be examined for possible
partner abnormalities such as gestational trophoblastic disease (H mole).
4. Client states she feels secure living at safe house
D. COMPLETE ABORTION
COMPLICATIONS OF PREGNANCY > Entire products of conception (fetus, membrane, and placenta) are
 Most women enter pregnancy in apparent good health and expelled spontaneously without any assistance.
achieve normal pregnancy and birth without complications.
In a few women, however, for reasons are usually unclear, E. INCOMPLETE ABORTION
unexpected deviations or complications from the course of  Part of the conception is expelled but the membranes or
pregnancy occurs. placenta is retained in the uterus.
 There is a danger of maternal hemorrhage as long as part of
Nursing Diagnosis : the conceptus is retained in the uterus.
1. Anxiety r/t guarded pregnancy outcome
2. Fluid volume deficit r/t third-trimester bleeding Treatment :
3. Risk for infection 1. Dilatation and Curettage
4. Altered tissue perfusion r/t hypertension of pregnancy 2. Suction Curettage
1. Women with Rh(-) blood should receive Rho (D antigen) immune
F. MISSED ABORTION globulin (RHIG) to prevent the build up of antibodies in the event the
 Fetus dies in uterus but is not expelled. conceptus was Rh (+)

S/Sx: 5. POWERLESSNESS
1. no increase in fundic height > A feeling of grief and sadness over the loss or that they have lost
2. no fetal heart sounds heard control of their lives is to expected.
3. painless vaginal bleeding
2. ECTOPIC PREGNANCY
Dx: UTZ  Second most frequent cause of bleeding early in pregnancy.
 Implantation occurs outside the uterine cavity.
Treatment :  Fertilization occurs normally in the distal third of the fallopian
1. D & C tube.
2 .If beyond 14 weeks maybe induced by prostaglandin
suppository to dilate the cervix followed by oxytocin stimulation. Causes :
a. Obstructions
Cx: DIC (Disseminated Intravascular Coagulation) b. Congenital malformations
c. Scars from tubal surgery
G. RECURRENT ABORTION d. Tumors
 3 spontaneous abortion that occurred in same gestational e. Progestin-only Oral contraceptives, post conceptual estrogen,
age. ovarian induction drugs
f. IUD
Possible Causes :
1. defective spermatozoa or ova Signs & Symptoms :
2.endocrine factors a. Bleeding – growing zygote ruptures the site of implantation which
3.deviations of uterus results to tearing & destruction of blood vessels which results to
4.infection bleeding
5.autoimmune disorders b. Sharp, stabbing pain
COMPLICATION OF ABORTION c. Vaginal spotting – placental detachment, uterine deciduas sloughs
thus bleeding occurs
1. HEMORRHAGE d. Severe shock – evidenced by rapid pulse, rapid respirations and
 With complete spontaneous abortion, serious or fatal falling blood pressure
hemorrhage is rare. e. Leucocytosis due to trauma
 With an incomplete abortion or DIC, major hemorrhage is a f. Rigid abdomen due to peritoneal irritation
possibility. g. positive Cullen’s Sign
h. Pain in the shoulders from blood in the peritoneal cavity causing
Therapeutic Management : irritation to the phrenic nerve.
 Immediately position the woman flat on bed & massage the i. On vaginal examination, a tender mass is usually palpable in
uterine fundus to aid contraction Douglas’ cul-de-sac
 D&C j. Extensive or dull vaginal and abdominal pain
 Monitor VS to detect hypovolemic shock k. Excruciating pain on the cervix during pelvic examination
 Start blood transfusion
Therapeutic Management :
 Direct replacement of fibrinogen
1. Laboratories : Hgb, Blood typing and Xmatching, HCG level for
immediate pregnancy testing
2. INFECTION
2. IVF using a large gauge catheter to restore intravascular volume
 Observe for fever, abdominal pain, tenderness, foul vaginal 3. Blood Transfusion if necessary
discharges 4. Laparotomy – to ligate the bleeding vessels and to remove or
 Usually caused by E. Coli repair the damaged fallopian tube.
 Endometritis (Infection of the uterine lining) – is the infection 5. Women with Rh (-) blood should receive Rho (D) immune globulin
that usually occurs after abortion (RHIG)
6. Methotrexate – if tube is not yet ruptured
3. SEPTIC ABORTION 7. Leucovorin
> An abortion complicated by infection due to use of nonsterile
instruments Nursing Diagnosis: Powerlessness r/t early loss of pregnancy
S/S : Fever, crampy abdominal pain, uterine tenderness secondary to ectopic pregnancy.
Complications :
1. Toxic Shock Syndrome Abdominal Pregnancy
2. Septicemia > Very rarely after ectopic pregnancy, the product of conception is
3. Kidney Failure expelled into the pelvic cavity. The placenta continues to grow in the
4. Infertility fallopian tube, spreading perhaps into the uterus or it may escape
into the pelvic cavity and successfully implant on an organ such as
Laboratories : an intestine. The fetus will grow in the pelvic cavity (an abdominal
1. CBC, Serum Electrolytes, pregnancy).
2. BT, Xmatching
3. Cultures of vaginal, cervical & urine specimen History :
1. Previous uterine surgery
2. Sudden pain of ectopic pregnancy earlier in the pregnancy
Treatment :
1. Hydration Complications :
2. Antibiotic 1. Hemorrhage
3. D&C 2. Bowel perforation and Peritonitis
4. TT or HTIG for Tetanus

 A CVP or pulmonary artery catheter may be inserted to


monitor left atrial filling pressure and hemodynamic status. CONDITIONS ASSOCIATED WITH SECOND TRIMESTER
 Dopamine and digitalis may be necessary to maintain BLEEDING
sufficient cardiac output.
 Oxygen and perhaps ventilatory support may be necessary 1. GESTATIONAL TROPHOBLASTIC DISEASE (HYDATIDIFORM
to maintain respiratory functions. MOLE)
> Proliferation and degeneration of the trophoblastic villi. As the cells
4. ISOIMMNUNIZATION degenerate, they become filled with fluid, appearing as fluid-filled,
 Some blood from placental villi may enter maternal grape-sized vesicles. Embryo dies.
circulation, either by spontaneous birth or by D&C. If the
woman is Rh (-), enough Rh (+) fetal blood may enter her Etiology :
circulation to cause Isoimmunization. 1. Occur most often in women from low socioeconomic groups who
 Isoimmunization – the production by her immunologic system have a low protein intake.
of antibodies against Rh(+) blood. 2. In young women (under age 18 years). In women older than 35
years
Treatment : 3. Women of Asian heritage
- cause essentially unknown 6. Monitor urine output frequently as an indicator of blood volume
adequacy
Assessment : 7. Monitor fetal heart sounds and uterine contraction
1. Uterus expands faster than normal; disproportionate to the 8. Hgb, Hct. PT,PTT, fibrinogen, platelet count, type and xmatch or
length of pregnancy antibody screen should be assessed to establish baselines, detect a
2. No fetal heart sounds nor palpable fetal parts possible clotting disorder
3. A blood or urine test of HCG for pregnancy will be strongly 9. Prepare BT if necessary
positive 10. Prepare oxygen equipment in case of fetal distress.
4. Excessive nausea and vomiting
5. A sonogram will show dense growth (a snowflake pattern) Complications :
6. Vaginal bleeding starting with spotting of dark brown blood or 1. Postpartal Hemorrhage – because the placental site is in the lower
as a profuse fresh flow, accompanied by discharge of the clear uterine segment which does not contract as efficiently as the upper
fluid-filled vesicles. segment
2. Endometritis – because the placental site is close to the cervix, the
Therapeutic Management : portal of entry for pathogens.
1. Suction curettage – to evacuate the mole
2. Every woman who had history of GTD should have a blood 2. PREMATURE SEPARATION OF THE PLACENTA (ABRUPTIO
test for HCG every 2 to 4 weeks along with pelvic examination PLACENTAE)
3. Thereafter, HCG levels and possibly chest xray are done once
a month for a full year. Predisposing Factors :
4. Instruct woman to use a reliable contraceptive method during 1. High parity
the year so that a positive pregnancy test will not be confused 2. Chronic hypertensive disease
with increasing levels and developing malignancy. 3. Hypertension of pregnancy
5. Prophylactic course of Methotrexate, the drug of choice for 4. Direct trauma
choriocarcinoma. Malignancy can be treated effectively with 5. Vasoconstriction from cocaine use
methotrexate. 6. Cigarette smoking

2. INCOMPETENT CERVIX Assessment :


> A cervix that dilates prematurely and therefore cannot hold a 1. Sharp, stabbing pain high in the uterine fundus
fetus until term. 2. Tenderness on uterine palpation
3. Heavy bleeding
Signs/Symptoms : 4. Hard, board-like uterus in cases of couvelaire uterus (Blood
1. A pink-stained vaginal discharged infiltrates uterine musculature
2. Increased pelvic pressure which maybe followed by rupture of 5. Signs of shock
the membranes and discharge of the amniotic fluid 6. Uterus becomes tense and rigid to the touch
3. Uterine contractions
Therapeutic Management :
Etiology : 1. Initial blood works – Hgb, typing and crossmatching
1. Associated with increased maternal age 2. Start IVF with a large-gauge catheter
2. Trauma to the cervix 3. Administer oxygen by mask to limit fetal anoxia.
3. Repeated D&C’s 4. Monitor fetal heart sounds
5. Monitor and record maternal vital signs every 5 to 15 minutes to
Therapeutic Management establish baselines
1. Cervical Cerclage – after one pregnancy loss due to an 6. Keep in lateral position to prevent pressure on the vena cava and
incompetent cervix to prevent from happening again additional compromising of fetal circulation.
2. McDonald or Shirodkar procedure – purse string sutures 7. Do not perform any vaginal or pelvic examination or give an
placed in the cervix to strengthen it and prevent from dilating. enema
3. Emergent cerclage – sutures placed in the cervix as
prophylaxis against pretem birth. DISSEMINATED INTRAVASCULAR COAGULATION (DIC)
 Acquired disorder of blood clotting.
CONDITIONS ASSOCIATED WITH THIRD-TRIMESTER  Also known as consumptive coagulopathy
BLEEDING  A diffuse, pathologic form of clotting, secondary to underlying
disease/pathology
1. PLACENTA PREVIA: Low implantation of the placenta.  Occurs in critical maternity problems such as abruptio placenta,
intrauterine fetal death, amniotic fluid embolism, pre-
Occurs in 4 Degrees : eclampsia/eclampsia, hydatidiform mole and hemorrhagic
(1) Implantation in the lower rather than in the upper portion of shock
the uterus (Low-lying placenta)
(2) Marginal implantation (the placenta edge approaches that of Pathophysiology
the cervical os) - precoagulant substances released in the blood trigger
(3) Implantation that occludes a portion of the cervical os (partial microthrombosis in peripheral vessels and paradoxical
placenta previa) consumption of circulating clotting factors
(4) Implantation that totally obstructs the cervical os (total - fibrin-split products accumulate, further interfering with the
placenta previa) clotting process
- platelet and fibrinogen levels drop
Assessment :
1. Vaginal bleeding – abrupt, painless, bright red Symptoms :
1. Easy bruising or bleeding from an IV site. Bleeding may
Etiology : range from massive, unanticipated blood loss to localized
1. Increased parity bleeding.
2. Advanced maternal age 2. Presence of special maternity problems
3. Past cesarean births 3. Prolonged prothrombin and partial thromboplastin time
4. Past uterine curettage
5. Multiple gestation Therapeutic Management :
1. Prompt recognition and adequate management of the underlying
problem ( eg. delivery of the dead fetus and the placenta)
Therapeutic Management: 2. IV administration of heparin to halt the clotting
3. Institute nursing measures for severe bleeding/shock if needed.
Immediate Care Measures : BT maybe necessary to replace blood loss
1. Place woman immediately on bed rest in a side-lying position 4. Anti-thrombin III factor, fibrinogen, or cryoprecipitate can be used
to ensure an adequate blood supply to the woman and fetus. to restore blood clotting
2. Determine vaginal blood loss 5. Fresh frozen plasma can also aid in restoring clotting function
3. Never attempt a pelvic or rectal examination with painless
bleeding late in pregnancy because any agitation of the cervix PRETERM LABOR
may initiate a massive hemorrhage. > Labor that occurs before the end of week 37 of gestation
3. Obtain baseline vital signs to determine whether symptoms of
shock are present Etiology :
4. Monitor BP every 5 to 15 minutes 1. HPN, UTI
5. IVF therapy using a large gauge catheter 2. Occurs more frequently in adolescent
3. Dehydration
4. Urinary Tract Infection 5. Blood is drawn for white blood count and C – reactive protein.
5. Chorioamnionitis
6. Continuous strenuous jobs during pregnancy that leads to Therapeutic Management :
fatigue 1. Bed rest
2. Prophylactic administration of broad-spectrum antibiotics may
Signs/Symptoms : delay onset of labor and reduce infection in the newborn.
1.Persistent, dull, low backache 3. Women positive for streptococcus B need IV administration of
2. Vaginal spotting penicillin or ampicillin to reduce the possibility of this infection in the
3. Feeling of pelvic pressure or abdominal tightening newborn.
4. Menstrual-like cramping
Health Education :
Therapeutic Management : 1. If at home, instruct to take temperature twice a day and to report a
1. Bed rest – to relieve pressure of the fetus on the cervix fever, uterine tenderness, or odorous vaginal discharge.
2. IVF therapy – hydration may have an influence on stopping 2. Refrain from tub bathing, coitus, and douching because of the
contractions danger of introducing infection.
White cell count needs to be assessed daily. A count of more than
Drug Administration : 18,000/mm3 to 20,000/mm3 is suggestive of infection.
1.Corticosteroid to the fetus – to accelerate the formation of lung
surfactant PREGNANCY-INDUCED HYPERTENSION (PIH)
2. Tocolytic agent – drug used to halt labor  A condition in which vasospasm occurs during pregnancy. The
3. Magnesium sulfate – first drug used to halt contractions. Also vasospasm may be caused by the action of prostaglandins
has CNS depressant action that slows and halts uterine (notably decreased prostacyclin and increased thromboxane).
contractions. Increased cardiac output may injure endothelial cells of the
arteries, leading to spasm. Normally, blood vessels during
Fetal Assessment : pregnancy are resistant to the effects of pressor substances
To evaluate fetal movement the woman lies down on her left such as angiotensin and norepinephrine so blood pressure
side and times the number of minutes it takes for her to feel 10 remains normal during pregnancy. With PIH, this reduced
fetal movements (about an hour) or counts the number of fetal responsiveness to BP changes appears to be lost.
movements she feels in 1 hour (10 to 12). If the time it takes to Vasoconstriction occurs, and BP increases dramatically.
feel 10 fetal movements is twice what it was the day before or  The cardiac system is overwhelmed because the heart is forced
she feels fewer than 5 movements during half an hour, she to pump against rising peripheral resistance. This reduces the
monitors again for second hour. If at the end of this second hour blood supply to organs esp. the kidney, pancreas, liver, brain
fetal activity has not increased, she should report it immediately and placenta. Tissue hypoxia may follow in the maternal vital
organs; poor placental perfusion may reduce the fetal nutrient
Labor That Cannot Be Halted and oxygen supply. Ischemia in the pancreas may result to
> Labor is too far advanced that it cannot be halted. epigastric pain and an elevated amylase-creatinine ratio.
1. The rupturing of membranes is a point of no return in stopping
 Spasm of the arteries in the retina leads to vision changes.
or delaying labor because of the increased risk of infection.
2. If the cervix is more than 50% effaced and 3-4 cm dilated  Vasospasm in the kidney increases blood flow resistance.
Degenerative changes develop in kidney glomeruli because of
Management : the back pressure. This leads to increased permeability of the
1. If the fetus is very immature, a CS maybe planned to reduce glomerular membrane allowing the serum proteins, albumin and
pressure on the fetal head and reduce the possibility of subdural globulin to escape into the urine (proteinuria). The degenerative
or intraventricular hemorrhage changes also result in decreased glomerular filtration so there is
2. As a rule, artificial rupture of membranes should not be done lowered urine output and clearance of creatinine. Increased
due to possibility of prolapse of the cord around a small head tubular reabsorption of sodium occurs. Because sodium retains
until the fetal head is firmly engaged. fluid, edema results.
3. Administer analgesic agents with caution during preterm labor.
4. Monitor uterine contractions and fetal heart sounds during Changes associated with PIH:
labor
5. Explain to the patient that an episiotomy may be made larger
than usual, although the head of preterm maybe smaller it is Vasospasm
more fragile and excessive pressure might result in subdural or
intraventricular hemorrhage that could be fatal.
6. Forceps may be used at delivery to reduce pressure on the
fetal head. Effects on the vascular Effects on the renal Effects on the
7. Clamp cord immediately after birth, an immature infant has a system system intrstitial
difficulty excreting large amount of bilirubin that will be formed if
this extra blood is added to the circulation. The extra amount of
blood may also burden the circulatory system.
Reduced glomerular filtration
PRETERM RUPTURE OF MEMBRANES (PROM) Rate; Increased glomerular
 A spontaneous rupture of fetal membranes with loss of membrane permeability
amniotic fluid before onset of regular contractions that
results in progressive cervical dilation. vasoconstriction Fluid diffusion from
vascular space into
Etiology :
1. Although cause is unknown, malpresentation and a contracted interstitial space.
pelvis commonly accompany the rupture Increased serum blood
2. Associated with infection of the membranes Impaired organ urea nitrogen
(chorioamnionitis). perfusion
Edema
Complications :
1. Uterine and fetal infection
2. Increased pressure on the umbilical cord inhibiting the fetal Oliguria and proteinuria
nutrient supply, or cord prolapse Hypertension
3. Development of Potter – like syndrome of distorted facial
features and pulmonary hypoplasia
4. Preterm labor Etiology :
1. Occurs more frequently in primiparas younger than age 20 years
or older than 40 years
Assessment : 2. Low socio-economic background
1. A sudden gush of clear fluid from the vagina with continued 3. Five or more pregnancies
minimal leak 4. Women of color
2. Sterile vaginal speculum examination is done to observe for 5. Multiple pregnancies
vaginal pooling of fluid. The fluid is tested with nitrazine paper 6. Hx of hydramnios
(appears blue). The fluid can also be tested for ferning. 7. Heart disease, DM with renal involvement
3. A sonogram may be done to assess amniotic fluid index. 8. Essential hypertension
4. Cultures for Neisseria gonorrhea and Chlamydia are usually 9. Associated with poor calcium or magnesium intake
taken.
Pathophysiologic Events - instruct client about appropriate diet
- continue monitoring for up to 48
Assessment : hours post delivery
1. HPN, proteinuria and edema are classic signs of PIH - administer medications as ordered,
vasodilator of choice is usually hydralazine (apresoline)
Symptoms of PIH :
ECLAMPSIA
GESTATIONAL HYPERTENSION  The most severe classification of hypertension of pregnancy
 An elevated blood pressure but has no proteinuria or edema. Assessment:
- increased hypertension precedes
MILD PREECLAMPSIA convulsion followed by hypotension, seizure may recur
 BP rises 30 mm Hg or more systolic or 15 mm Hg or more - coma may ensue
diastolic above her prepregnancy level, taken on two - labor may begin, putting fetus in
occasions at least 6 hours apart great jeopardy
 With proteinuria (1+ or 2+ on a reagent strip on a random
sample). Complications :
 Edema maybe present. This develops because of the protein 1. Cerebral hemorrhage
loss, sodium retention and lowered glomerular filtration rate. 2. Circulatory collapse
Interventions: 3. Renal failure
- Promote bed rest as long as
signs of edema or proteinuria are minimal, preferably Interventions
left-side lying to promote uterine and placental perfusion - minimize all stimuli
- Provide well balanced diet with adequate protein and - monitor vital signs
roughage, no sodium restriction - have airway, oxygen, and suction
equipment available
SEVERE PREECLAMPSIA - administer medications as ordered
 Blood pressure has risen to 160 mm Hg systolic and 110 mm - prepare for caesarian section when
Hg diastolic or above on at least two occasions 6 hours seizures stabilize
apart at bed rest or her diastolic pressure is 30 mm Hg - continue observations 48 hours
above prepregnancy level. post delivery
Assessment :
1. Extreme edema is noticeable in the woman’s face and hands HELLP SYNDROME
as puffiness.  is a category of PIH that involves changes in blood components
Nonpitting edema – If there is swelling or puffiness but the and liver functions. It is an acronym that help identify the
swelling cannot be indented with finger pressure. underlying signs associated with the syndrome :
Slight indentation – 1+ pitting edema 1. Hemolysis
Moderate indentation – 2+ pitting edema 2. Elevated Liver enzymes
Deep indentation – 3+ pitting edema 3. Low Platelets
4+ pitting edema – indentation is so deep it remains after HELLP syndrome develops in 12% of women with PIH. It can
removal of fingers occur in primigravidas and multigravidas. When it occurs, maternal
and fetal mortality is high; approximately one-fourth of women and
2. Severe epigastric pain and nausea and vomiting possibly due one-third of infants die from this disorder. However, after birth,
to abdominal edema or ischemia to the pancreas and liver. laboratory results return to normal usually within 1 week and the
3. Pulmonary edema may cause them to feel short of breath mother experiences no further problems.
4. Cerebral edema will result in visual disturbances. May also Etiology
produce symptoms of severe headache and marked hyperflexia Although the exact cause of HELLP is unknown, theories have
and perhaps muscle clonus been proposed about the development of its signs and symptoms.
Hemolysis is believed to result because RBCs are damaged by their
Medical Management: Magnesium Sulfate travel through small, impaired blood vessels. Elevated liver enzymes
- Magnesium sulfate acts upon are believed to result from obstruction in liver flow by fibrin deposits.
the myoneural junction, diminishing neuromuscular Low platelets are believed to be the result of vascular damage
transmission secondary to vasospasm.
- It promotes maternal Intervention
vasodilation, better tissue perfusion, and has - monitor maternal and fetal vital
anticonvulsant effect. Keep in mind that for magnesium signs
to be effective as an anticonvulsant, serum magnesium - maintain a quiet, calm, dimly lit
levels should be between 5 and 8 mg/dl. Levels above environment to reduce the risk of seizures
8 mg/dl indicate toxicity and place the patient at risk for - institute bleeding precautions
respiratory depression, cardiac arrhythmias, and cardiac - prepare patient for delivery
arrest. MULTIPLE PREGNANCY
- Monitor client’s respirations,  Considered a complication of pregnancy because the woman’s
blood pressure, and reflexes, as well as urinary output body must adjust to the effects of more than one fetus.
frequently.  Incidence has increased dramatically due to use of fertility drugs
- Assess the client’s patellar
reflex. If the client has received epidural anesthesia, Assessment :
test the biceps or triceps reflex. Diminished or 1. Uterus begins to increase in size faster than usual
hypoactive reflexes suggest magnesium toxicity. 2. Alpha-fetoprotein levels will be elevated
- Assess for ankle clonus 3. A sonogram will reveal multiple gestation sacs
( alternating contractions and relaxations of the 4. At the time of quickening, flurries of action at different portions of
muscles) by rapidly dorsiflexing the client’s ankle three her abdomen are noted
times, then removing your hand and observing the foot’s 5. On auscultation, multiple sets of fetal heart sounds may be heard
movement. If no further motion is noted, ankle clonus is
absent; if the foot continues to move involuntarily, POLYHYDRAMNIOS
clonus is present. Moderate (3-5 movements) or severe  An excessive amniotic fluid formation.
(6 or more movements) suggests possible magnesium  Usually, amniotic fluid is between 500 and 1000 ml in amount at
toxicity. term. An amount of more than 2000 ml or an amniotic fluid
- Antidote for excess levels of index above 24 cm is considered hydramnios.
magnesium sulfate is calcium gluconate or calcium
chloride Complications :
1. Fetal malpresentation because of the extra uterine space
Interventions 2. Premature rupture of membranes followed by preterm labor from
- promote complete bedrest, left the increased pressure and possibly prostaglandin release
side lying 3. Preterm rupture of membranes adds additional risks of both
- carefully monitor maternal/fetal infection and prolapsed cord
vital signs
- monitor intake and output Assessment :
- take daily weights 1. Unusual rapid enlargement of uterus
- institute seizure precautions 2. Small parts of the fetus are difficult to palpate because the uterus
( restrict visitors, minimize all stimuli, monitor for is unusually tense
hyperreflexia, administer sedatives as ordered)
3. Extreme shortness of breath because of the overly distended 3. Blood for coagulation studies to detect DIC
uterus that pushes up against her diaphragm.
4. Lower extremity varicosities and hemorrhoids because of poor Nursing Diagnosis : Powerlessness related to fetal death
venous return from the extensive uterine pressure
5. Increased weight gain

Nursing Intervention :
Therapeutic Management : A. Healthy process of grieving
1. Bed rest 1. Give woman opportunities to express feelings
2. Encourage to eat a high fiber diet to avoid constipation 2. Encourage support person to stay with the woman during labor
3. Assess vital signs and lower extremity edema 3. Present the baby if parents wished to in a manner like she were a
4. Amniocentesis – to give relief from the increasing pressure well newborn
5. A non steroidal anti inflammatory agent such as Indomethacin 4. Encourage parents to give name to the child to make him/her
therapy may be effective in reducing the amount of fluid formed more normal
6. If contractions begins, tocolysis with magnesium sulfate may 5. Explain how the anomaly affected the child
be begun to prevent or halt preterm labor 6. Explain hospital procedures regarding discharged
7. Ask about their desire for clergy or religious rites
POST-TERM PREGNANCY
A pregnancy that exceeds 42 weeks
HIGH RISK NEWBORN
Etiology :
1. Occurs in approximately 10% of all pregnancies  A neonate is considered to be high risk if he has an increased
2. Women who have long menstrual cycles (40 to 45 days) chance of dying during or shortly after birth or has a congenital
3. Women on high dose of salicylates interferes with the or perinatal problem that requires prompt intervention
synthesis of prostaglandins  Being able to predict that an infant is high risk allows for
4. Myometrial quiescence or a uterus that does not respond to advanced preparation
normal labor stimulation
Assessment :
Complications :  All infants should be assessed for obvious congenital anomalies
1. Macrosomia will create a delivery problem and gestational age. Assessments are made under prewarmed
2. Lack of growth radiant heat warmer to safeguard against heat loss.
3. Oligohydramnios leading to variable decelerations may occur  Assessment involves use of instrumentation such as cardiac,
4. Fetus may suffer from lack of oxygen, fluid and nutrients apnea and blood pressure monitoring.
Therapeutic Management : Nursing Diagnosis :
1. A nonstress test and/ or biophysical profile may be done to 1. Ineffective airway clearance r/t presence of mucus or amniotic
document the state of placental perfusion fluid in airway.
2. Prostaglandin gel applied to the cervix to initiate ripening or 2. Risk for fluid volume deficit 3. Ineffective thermoregulation r/t
stripping of membranes newborn status and stress from birth weight variation.
3. Oxytocin infusion is a common method to induce labor. 4. Risk for altered nutrition; less than body requirements
4. CS if oxytocin is ineffective 5. Risk for infection
6. Risk for altered parenting
7. Diversional activity deficit (lack of stimulation) r/t illness at birth
PSEUDOCYESIS Implementation :
 False pregnancy 1. Care should focus on conserving baby’s energy and providing a
thermoneutral environment to prevent exhaustion and chilling.
Assessment : 2. Painful procedures should be kept to a minimum
1. Nausea and vomiting 3. Parent teaching and participation with care such as bathing or
2. Amenorrhea feeding
3. Enlargement of the abdomen
Outcome Evaluation :
Etiology : 1. Infant maintains patent airway
1. Woman’s desire to be pregnant actually causes physiologic 2. Infant tolerates all procedures without accompanying apnea
changes 3. Infant demonstrates growth and development appropriate for
gestational age, birth weight, and condition
ISOIMMUNIZATION (RH INCOMPATIBILITY) 4. Infant maintains body temperature at 37oC in open crib with one
 Occurs when an Rh (-) mother is carrying a fetus with an Rh added blanket.
(+) blood 5. Parents visits at least once a week and make three telephone
calls to neonatal nursery weekly
Therapeutic Management : 6. Parents demonstrate positive coping skills and behaviors in
1. RHIG – administered to women at 28 weeks of pregnancy response to NB’s condition
2. Intrauterine transfusion – to restore fetal red blood cells. Done
by injecting red blood cells directly into a vessel in the fetal cord Neonatal Assessment
or depositing them in the fetal abdomen using amniocentesis
technique APGAR SCORE
During the initial examination of a neonate, expect to calculate an
FETAL DEATH Apgar score and make general observations about the neonate’s
 Obviously, one of the most severe complications of appearance and behavior. Developed by anesthesiologist Dr.
pregnancy. Virginia Apgar in 1952, Apgar scoring evaluates neonatal heart rate,
respiratory effort, muscle tone, reflex irritability, and color.
Causes : Evaluation of each category is performed 1 minute after birth and
1. Chromosomal Abnormalities again at 5 minutes after birth. Each item has a maximum score of 2
2. Congenital malformations and a minimum score of 0. The final Apgar score is the sum total of
3. Infections such as hepatitis B the five items; a maximum score is ten.
4. Immunologic causes Evaluation at 1 minute quickly indicates the neonate’s initial
5.Complications of maternal disease adaptation to extrauterine life and whether resuscitation is
necessary. The 5-minute score gives a more accurate picture of his
Symptoms : over-all status.
1. No fetal movements
2. No fetal heart tones Heart Rate. If the umbilical cord still pulsates, you can palpate the
3. Painless spotting neonate’s heart by placing your fingertips at the junction
4. Uterine contractions with cervical effacement and dilatation of the umbilical cord and the skin. The neonate’s cord
stump continues to pulsate for several hours and is a
Therapeutic Management : good, easy place to check heart rate. You can also place
1. Sonogram to confirm death of fetus to fingers or a stethoscope over the neonate’s chest at
2. If labor does not begin spontaneously, it will be induced the fifth intercostal space to obtain an apical pulse. For
through combination of prostaglandin gel application to the accuracy, the heart rate should be counted for 1 full
cervix to effect cervical ripening and oxytocin or prostaglandin minute.
administration to begin uterine contractions
Respiratory Effort. Assess the neonate’s cry, noting its volume He may have transient episodes of cyanosis when crying. Cutis
and vigor. Then auscultate his lungs, using a marmorata is transient mottling when the neonate is exposed to
stethoscope. Assess his respirations for depth and cooler temperatures.
regularity. If the neonate exhibits abnormal Palpate the skin to assess skin turgor. To do this, roll a fold of skin
respiratory responses, begin neonatal resuscitation on the neonate’s abdomen between your thumb and forefinger.
then use the Apgar score to judge the progress and Assess consistency, amount of subcutaneous tissue, and degree of
success of resuscitation efforts. hydration. A well-hydrated infant’s skin returns to normal
immediately upon release.
Muscle Tone. Determine by evaluating the degree of flexion in
the neonate’s arms and legs and their resistance to Head.
straightening. This can be done by extending the The neonate’s head is about ¼ of its body size. Six bones make up
limbs and observing their rapid return to flexion – the the cranium:
neonate’s normal state. • the frontal bone
• the occipital bone
Reflex Irritability. Evaluate neonate’s cry. Initially, he may not • two parietal bones
cry but you should be able to elicit a cry by flicking his • two temporal bones
soles. The usual response is a loud, angry cry. A Bands of connective tissue, called sutures, lie between the junctures
high-pitched or shrill cry is abnormal. A newborn of these bones. At the juncture of the sutures are wider spaces of
whose mother was heavily sedated tend to have a membranous tissues, called fontanels.
low score on this aspect. Fontanels.
The neonatal skull has two fontanels. The anterior fontanel is
Color. Observe skin color for cyanosis. A neonate usually has a diamond-shaped and located at the juncture of the frontal and
pink body and blue extremities. This condition called parietal bones. It measures 1 1/8 to 1 5/8” (3-4cm) long and ¾”
acrocyanosis appears in about 85% of normal (2cm) to 1 1/8” wide. The anterior fontanel closes in about 18
neonates 1 minute after birth. Acrocyanosis results months. The posterior fontanel is triangle-shaped. It is located at the
from decreased peripheral oxygenation caused by juncture of the occipital and parietal bones and measures about ¾”
the transition from fetal to independent circulation. across. The posterior fontanel closes in 8-12 weeks.
The fontanels should feel soft to touch but shouldn’t be depressed.
Sign Apgar Score A depressed fontanel indicates dehydration. In addition, fontanels
0 1 2 shouldn’t bulge. Bulging fontanels require immediate attention
Heart Rate Absent Less than 100 More than 100 because they may indicate increased intracranial pressure.
beats/min beats/min Pulsations in the fontanels reflect the peripheral pulse.
Respiratory Absent Slow, irregular Good crying
Effort Molding refers to asymmetry of the cranial sutures due to difficulties
Muscle tone Flaccid/Limp Some flexion and Active motion during vaginal delivery; it isn’t seen in neonates born by cesarean
resistance to delivery. There are two types of cranial abnormalities:
extension of • Cephalhematoma occurs when blood collects between a
extremities skull bone and the periosteum. It is caused by pressure
Reflex No response Grimace or weak Vigorous cry during delivery and tends to spontaneously resolve in 3-6
Irritability cry weeks. A cephalhematoma doesn’t cross cranial suture
Color Pallor, Pink body, blue Completely lines.
Cyanosis extremities pink • Caput succedaneum is a localized edematous area of the
presenting scalp. It is also caused by pressure during
A total score of 7-10 indicates that the neonate is in good delivery, but disappears spontaneously in 3-4 days and
condition; 4-6, fair condition (the neonate may have moderate can cross cranial suture lines
central nervous system depression, muscle flaccidity, cyanosis,
and poor respirations); 0-3, danger (the neonate needs Craniotabes is localized softening of the cranial bones. It can be so
immediate resuscitation, as ordered). soft it can be indented by the pressure of the examining finger. The
bone returns to its normal contour when he pressure is removed.
HEAD TO TOE ASSESSMENT This is probably caused by the pressure of the fetal skull against the
mother’s pelvic bone in utero.The condition corrects itself without
The neonate should receive a thorough physical examination of treatment after a matter of months
each body part. However, before each body part is examined, The degree of head control the neonate has should also be
assess the general appearance and posture of the neonate. evaluated during this part of the examination. If neonates are
Neonates usually lie in a symmetrical, flexed position – the placed down on a firm surface, they’ll turn their heads to the side to
characteristic “fetal position” – as a result of their position while maintain an open airway. They also attempt to keep their heads in
in utero. line with their body when raised by their arms. Although head lag is
normal in the neonate, marked head lag is seen in neonates with
Skin. Down syndrome or brain damage and hypoxic infants.
Common findings in a neonatal assessment may include:
Acrocyanosis – caused by vasomotor instability, Eyes.
capillary stasis, and high hemoglobin level for the first 24 Neonates tend to keep their eyes tightly shut. Observe the lids for
hours after birth. edema, which is normally present for the first few days of life. The
Milia- clogged sebaceous glands on the nose or chin eyes should also be assessed for symmetry in size and shape.
Lanugo- fine, downy hair appearing after 20 weeks of Here are some common findings of neonatal eye examination:
gestation on the entire body, except the palms and soles  The neonate’s eyes are usually blue or gray because of
scleral thinness. Permanent eye color is established
vernix caseosa – a white cheesy protective coating
within 3-12 months.
composed of desquamated epithelial cells and sebum
 Lacrimal glands are immature at birth, resulting in
erythema toxicum neonatorum – a transient tearless crying for up to 2 months.
maculopapular rash
 Neonate may demonstrate transient strabismus.
telangiectasia – flat reddened vascular areas  The Doll’s eye reflex (when the head is rotated laterally,
appearing on the neck, upper eyelid or upper lip the eyes deviate in the opposite direction or remain
port-wine stain (nevus flammeus) – a capillary stationary) may persist for up to 10 days.
angioma located below the dermis and commonly found on  Subconjunctival hemorrhages may appear from vascular
the face tension changes during birth.
strawberry hemangioma (nevus vasculosus) – a  The corneal reflex is present but generally isn’t elicited
capillary angioma located in the dermal and subdermal skin unless a problem is suspected.
layers indicated by a rough, raised, sharply demarcated
birthmark Nose.
sudamina or miliaria (distended sweat glands)- cause Observe the neonate’s nose for shape, placement, patency and
minute vesicles on the skin surface, especially on the face bridge configuration.
Because neonates are obligatory nose breathers for the first few
Mongolian spots – bluish black areas of pigmentation
months of life, nasal passages must be kept clear to ensure
more commonly noted on the back and buttocks of dark-
adequate respiration. Neonates instinctively sneeze to remove
skinned neonates (regardless of race)
obstruction. Test the patency of the nasal passages by occluding
Make general observations about the appearance of the
each nares alternately while holding the neonate’s mouth closed.
neonate’s skin in relationship to his activity, position, and
temperature. Usually, the neonate is redder when crying or hot.
Mouth and Pharynx.
The neonate’s mouth usually has scant saliva and pink lips. urinary bladder. The neonate should void within the first 24 hours of
Inspect the mouth for its existing structures. The palate is birth.
usually narrow and highly arched. Inspect the hard and soft Femoral pulses should also be palpated at this point in the
palates for clefts. examination. Inability to palpate femoral pulses should signify
coarctation of the aorta.
Epstein pearls (pin-head sized, white or yellow, rounded
elevations) may be found on the gums or hard palate. These are Anogenital Area.
caused by retained secretions and disappear within a few weeks The anus of the newborn must be inspected to be certain that it is
or months. The frenulum of the upper lip may be quite thick. present, patent and is not covered by a membrane (imperforate
Precocious teeth may also be apparent. The pharynx can be anus). The time after birth that the infant first passes meconium
best assessed when the neonate is crying. Tonsillar tissue should be noted. If the newborn does not do so in the first 24 hours,
generally isn’t visible. the suspicion of imperforate anus or meconium ileus is aroused.

Ears. Characteristics of a male neonate’s genitalia include rugae on the


Assess the neonate’s ears for placement on the head, amount of scrotum and testes descended into the scrotum. Scrotal edema may
cartilage, open auditory canal, and hearing. be present for several days after birth due to the effects of maternal
The neonate’s ears are characterized by incurving of the pinna hormones. It may be deeply pigmented in dark-skinned newborns.
and cartilage deposition. The pinna is usually flattened against Both testes should be present in the scrotum. Males with one or
the side of the head from pressure in utero. The top of the ear both undescended testicles (cryptorchidism) need further referral to
should be above or parallel to an imaginary line from the inner to establish the extent of the problem. It could be due to agenesis
the outer canthus of the eye. Low-set ears are associated with ( absence of an organ), ectopic testes (the testes cannot enter the
several syndromes, including chromosomal abnormalities. scrotum because the opening of the scrotal sac is closed), or
undescended testes (the vas deferens or artery is too short to allow
Neck. the testes to descend).
The neonate’s neck is typically short and weak with deep folds of The urinary meatus is located in one of three places:
skin. Observe for range of motion, shape, and abnormal  At the penile tip (normal)
masses. Also, palpate each clavicle and sternocleidomastoid  On the dorsal surface (epispadias)
muscle. Note the position of the trachea. The thyroid gland
generally isn’t palpable.  On the ventral surface (hypospadias)
In the female neonate, the labia majora cover the labia minora and
Chest. clitoris. These structures may be prominent due to maternal
Inspect and palpate the chest, noting shape, clavicles, ribs, hormones. Mucoid vaginal discharge which may be blood-tinged
nipples, breast tissue, respiratory movement, and amount of (pseudomenstruation) may also occur and the hymenal tag is
cartilage in rib cage. The neonatal chest is characterized by a present.
cylindrical thorax (because the anteroposterior and lateral
diameters are equal) and flexible ribs. Slight intercostals Extremities.
retractions are usually seen on inspiration. The sternum is The extremities should be assessed for range-of-motion, symmetry,
raised and slightly rounded, and the xiphoid process is usually and signs of trauma. All neonates are bowlegged and have flat feet.
visible as a small protrusion at the end of the sternum. The hips should be assessed for dislocation. With the newborn in a
Breast engorgement from maternal hormones may be apparent, supine position, both legs can be flexed and abducted to such an
and the secretion of “witch’s milk” may occur. Supernumerary extent (180 degrees) that they touch or nearly touch the surface of
nipples may be located below and medial to the true nipples. the bed. If the hip joints seem to lock short of this distance, hip
subluxation (a shallow and poorly formed acetabulum) is suggested.
If subluxation is present, when the infant’s leg is held with the fingers
Lungs. on the greater and lesser trochanters and the hip then abducted, a
Normal respirations of the neonate are abdominal with a rate “clunk” of the femur head striking the shallow acetabulum can be
between 30 and 50 breaths/minute. After the first breaths to heard (Ortolani’s sign). If the hip can be felt to actually slip in the
initiate respiration, subsequent breaths should be easy and fairly socket, this is Barlow’s sign.
regular. Occasional irregularities may occur with crying, A neonate who was born in a frank breech position will tend to
sleeping, and feeding. straighten the legs at the knee and bring them up to the face.
It’s easiest to auscultate the lung fields when the neonate is The fingertips, when arms are held down by the sides, should cover
quiet. Bilateral bronchial breath sounds should be heard. the proximal thigh. Unusually short arms may signify
Crackles soon after birth represent the transition of the lungs to achondroplastic dwarfism.
extrauterine life. Hyperflexibility of joints is characteristic of Down syndrome.
Some neonates may have abnormal extremities. They may be
Heart. polydactyl (more than 5 digits on an extremity) or syndactyl (two or
The neonate’s heart rate is normally between 110 and 160 more digits fused together).
beats/minute. Because neonates have a fast heart rate, it’s The nailbeds should be pink, although they may appear slightly blue
difficult to auscultate the specific components of the cardiac due to acrocyanosis. Persistent cyanosis indicates hypoxia or
cycle. Heart sounds during the neonatal period are generally of vasoconstriction.
higher pitch, shorter duration, and greater intensity than in later The palms should have the usual creases. A single, tranverse
life. The first sound is usually louder and duller than the second, palmar crease in contrast to the three creases normally seen in a
which is sharp in quality. Murmurs are commonly heard, palm, called a Simian crease, suggests Down syndrome.
especially over the base of the heart or at the third or fourth
intercostals space at the left sternal border, due to incomplete Spine.
functional closure of the fetal shunts. The neonatal spine should be straight and flat. The base of the
The apical impulse (point of maximal impulse) is at the fourth spine should be inspected carefully to e certain there is no pinpoint
intercostals space and to the left of the midclavicular line. opening or dimpling which may suggest spina bifida occulta.
The position of a baby presenting with a face presentation
Abdomen. sometimes simulates opisthotonos (back arched acutely with a deep
The neonatal abdominal assessment should include: concave appearance, and the head is bent back on the neck.
 Inspection and palpation of the umbilical cord
 Evaluation of the size and contour of the abdomen NEUROLOGIC ASSESSMENT
 Auscultation of bowel sounds An examination of the reflexes provides useful information about the
 Assessment of skin color neonate’s nervous system and his state of neurologic maturation.
 Observation of movement with respirations Some reflexive behaviors in the neonate are necessary for survival
 Palpation of internal organs whereas other reflexive behaviors act as safety mechanisms.
The neonatal abdomen is usually cylindrical with some Normal neonates display several types of reflexes. Abnormalities
protrusion. Bowel sounds are heard a few hours after birth. A are indicated by absence, asymmetry, persistence, or weakness
scaphoid (sunken anterior wall) appearance indicates a in these reflexes:
diaphragmatic hernia. The umbilical cord is white and gelatinous  Sucking – begins when a nipple is placed in the neonate’s
with two arteries and one vein and begins to dry within 1-2 hours mouth
after delivery.  Moro reflex – when the neonate is lifted above the crib
The liver is normally palpable 1” (2.5 cm) below the right costal and suddenly lowered; the arms and legs symmetrically
margin. Sometimes the tip of the spleen can be felt, but a extend and then abduct while the fingers spread to form a
spleen that’s palpable more than 1/3” (1cm) below the left costal “C”.
margin warrants further investigation. Both kidneys should be  Rooting – when the neonate’s cheek is stroked, the
palpable; this is easiest done soon after delivery, when muscle neonate turns the head in the direction of the stroke
tone is lowest. The suprapubic area is palpated for a distended  Tonic neck (fencing position) – when the neonate’s head
is turned while he is lying in a supine position, the
extremities on the same side straighten and those on Assessment :
the opposite side flex A. Prenatal Assessment
 Babinski reflex – the sole on the side of the 1. Fundal height during pregnancy is less than what is expected.
neonate’s small toe is stroked and the toes fan upward Dx Procedures :
 Grasping - when a finger is placed in each of the 1. Sonogram
neonate’s hands, the neonates fingers grasp tightly 2. Biophysical profile including nonstress test, placental grading ,
enough to be pulled to a sitting position UTZ add information on placental function
 Stepping – when the neonate is held upright with the
feet touching a flat surface, he responds with dancing Appearance :
or stepping movements 1. Below average in weight, length, and head circumference
 Startle – a loud noise such as a hand clap elicits 2. May have a small liver
neonatal arm abduction and elbow flexion and the 3. Poor skin turgor
neonate’s hands stay clenched 4. Appears to have a large head because the rest of the body is
 Trunk incurvature – when a finger is run laterally small
down the neonate’s spine, the trunk flexes and the 5. Skull sutures widely separated
pelvis swings toward the stimulated side 6. Hair is dull and lusterless
7. Sunken abdomen
 Blinking – the neonate’s eyelids close in response to
8. Cord appears dry and may be stained yellow
bright light
- SGA neonates are prone to meconium aspiration because fetal
 Acoustic Blinking – both eyes of the neonate blink in hypoxia allows meconium to pass through a relaxed anal sphincter,
response to a loud noise thus causing the neonate to experience reflexive gasping
 Perez reflex – when the neonate is suspended prone
in one of the examiner’s hands and the thumb of the  In contrast, the child may have :
other hand is moved firmly up he neonate’s spine from 1. Better developed neurologic responses, sole creases, and ear
the sacrum, the neonate’s head and spine extend, the cartilage
knees flex, the neonate cries, and he may empty his 2. Skull may be firmer
bladder 3. Unusually active and alert for that weight that could be attributed
to prolonged prenatal hypoxia
Eight (8) Priorities In First Days Of Life :
1. Initiating and maintaining respirations
 SGA infant needs careful assessment for possible congenital
 Resuscitation anomalies
 Establishing an airway
 Expanding the lungs Laboratory Findings :
 Drug Therapy 1. High hematocrit level at birth
 Maintaining effective ventilation 2. Increase in total number of red blood cells
3. Decrease serum glucose
2. Establishing intrauterine circulation
3. Fluid and Electrolyte Balance Nursing Diagnosis : Ineffective breathing pattern related to
4. Thermometer Regulation underdeveloped body system
 Radiant heat sources
 Isolettes  Birth asphyxia is a common problem for SGA because they have
 Kangaroo Care underdeveloped chest muscles and because they are at risk for
developing meconium aspiration syndrome due to anoxia
during labor

5. Preventing Infection Nursing Diagnosis :


6. Establishing Parent-Infant Bonding Risk for ineffective thermoregulation
 Following High-Risk Infants At Home Risk for altered parenting
 High-Risk Infants and Child Abuse
 Providing for Growth and Development  Mental development may have been impaired because of lack of
7. Intake of adequate nourishment oxygen and nourishment in utero
8. Developmental care or care that balances physiologic  SGA infants may always be below normal on standard growths
needs and stimulation for mental development chart and this inability to reach normal levels of growth and
development may interfere with bonding because the child does
Whether they are preterm, term, or postterm, neonates are not meet the parents expectations and eventually affects the
classified by weight in three ways child’s self-esteem
 Large for gestational age (LGA)
neonates Nursing Intervention :
 Appropriate for gestational age 1. Discuss ways parents can promote the infants development once
(AGA) neonates they are at home
 Small for gestational age (SGA) 2. Adequate stimulation during the infant period to reach normal
neonates growth and development
3. Encourage parents to provide toys that are suitable for their child’s
THE SMALL-FOR-GESTATIONAL-AGE INFANT chronologic age
4. Play periods must be spaced with rest periods or hypoglycemia or
 Birth weight is below the 10th percentile on an intrauterine apnea may occur
growth curve for that age (based on a postnatal growth
chart). THE LARGE-FOR-GESTATIONAL-AGE INFANT
 Infant may be born preterm, post term or term.  An infant is large for gestational age (Macrosomia) if the birth
 They are small for their age because they have experienced weight is above the 90% percentile on an intrauterine growth
intrauterine growth restriction (IUGR) or failed to grow at the chart for that gestational age
expected rate in utero
Causes :
Causes : 1. Mothers with diabetes mellitus
1. Lack of adequate nutrition 2. Multiparous women
2. Pregnant adolescents 3. Transposition of the great vessels
3. Placental anomaly 4. Beckwith’s Syndrome, a rare condition characterized by
overgrowth
 Placenta is unable to obtain sufficient nutrients from the 5. Congenital anomalies such as omphalocele
uterine arteries or it is inefficient at transporting nutrients to
the fetus Assessment :
 Size of the uterus measures unusually large for the date of
4. Placental damage pregnancy. A sonogram can confirm suspicion.
5. Women with systemic diseases that decrease blood flow to  A nonstress test to assess the placenta’s ability to sustain the
the placenta large fetus during labor
6. Smoking or use of narcotics  Infant’s lung maturity may be assessed by amniocentesis
7. Infants with intrauterine infections such as rubella or  Baby is unable to descend through the pelvic rim during labor
toxoplasmosis
 CS may be necessary because of cephalopelvic disproportion or
8. Infants with chromosomal abnormalities
shoulder dystocia.
THE PRE TERM INFANT
Appearance :
1. At birth, LGA infants may show immature reflexes and low  A preterm infant is usually defined as a live-born infant born
scores on gestational age examinations in relation to their size. before the end of week 37 of gestation
2. Infant may have extensive bruising or a birth injury such as  Weighs less than 2500 g (5 lb, 8 oz) at birth
broken clavicle  Infants born weighing 1500-2500g are considered low-birth
3. Erb-Duchenne paralysis from trauma to the cervical nerves if weight (LBW)
the infant was delivered vaginally  Infants born weighing 1000-1500 g are considered very-low-birth
4. Prominent caput succedaneum, cephalohematoma, or weight (VLBW)
molding  Infants born 500-1000 g are considered extremely-very-low-birth
weight (EVLBW)
Specific Criteria For Initial Or Continuing Assessment
 A lack of lung surfactant makes them extremely vulnerable to
respiratory disease syndrome
CARDIOVASCULAR DYSFUNCTION
 Preterm babies of every weight need to be differentiated at birth
 Heart rate should be carefully observed.
from small-for-gestational-age babies (who also may have low
 Cyanosis may be a sign of transposition of the great vessels, birth weights)
a serious heart anomaly
 A preterm infant is immature and small but well proportioned for
 Polycythemia is caused by the infant’s system attempting to age
fully oxygenate all body tissues
 Observe for signs of hyperbilirubinemia which may result DIFFERENTIATING CHARACTERISTICS OF SGA INFANTS AND
from bruising and polycythemia PRETERM INFANTS :
HYPOGLYCEMIA
 Infants should be carefully assessed for hypoglycemia in the Causes :
early hours of life because the infants use up nutritional 1. Low socio-economic level
stores readily to sustain weight. 2. Inadequate nutrition before and during pregnancy
 If mother has poor glucose control, the infant will have an 3. Lack of prenatal care
increased blood glucose level in utero, which causes the 4. Multiple pregnancy
infant to produce elevated levels of insulin. 5. Prior previous early birth
 After birth, increased insulin levels will continue up to 24 6. Race ( nonwhites have higher percentage than whites)
hours of life, possibly causing rebound hypoglycemia 7. Cigarette smoking
8. Age of mother (highest incidence is mothers younger than 20
Nursing Diagnosis : Ineffective breathing pattern r/t possible birth years old)
trauma 9. Order of birth (early termination is highest in first pregnancies and
in those beyond the fourth)
Outcome Identification : Newborn will initiate and maintain 10. Closely spaced pregnancies
respirations at birth 11. Abnormalities of the reproductive system such as intrauterine
septum
Outcome Evaluation : NB initiates breathing at birth; maintains 12. Infections (esp. UTI)
normal NB respiratory rate at 30 to 60 breaths per minute 13.Obstetric complications such as PROM or premature separation
of placenta
 SGA infants have difficulty establishing respirations because 14. Early induction of labor
of birth trauma 15.Elective CS
 Increase intracranial pressure from birth may lead to 16.Chronic Diseases – DM, renal, cardiovascular, respiratory
pressure on the respiratory center, in turn, causes a
decrease in respiratory function Appearance :
 A diaphragmatic paralysis may occur due to cervical nerve 1. Appears small and underdeveloped
trauma as the head is bent laterally to allow for birth of the 2. Head is large (3 cm or more grater than chest size)
large shoulders. This prevents active lung motion on the 3. Skin is unusually ruddy because of little subcutaneous fat
affected side. 4. Veins are noticeable
 During CS, transient fluid can remain in the lungs and 5. High degree of acrocyanosis may be present
interfere with effective gas exchange 6. Neonate is covered with vernix caseosa. However, very preterm
NB, less than 25 weeks gestation, vernix is absent
Nursing Diagnosis : Risk for altered nutrition; less than body 7. Lanugo is extensive
requirements r/t additional nutrients needed to maintain weight 8. Anterior and posterior fontanels are small
and prevent hypoglycemia 9. There are few creases on the soles of the feet.
10. Small eyes. Pupillary reaction is present.
Outcome Identification : Infant will ingest adequate fluid and 11. Ear cartilage is immature and allows the pinna to fall forward.
nutrients for growth during neonatal period The ears appear large
12. Reflexes are absent if infant’s age is below 33 weeks
Outcome Evaluation : Infant’s weight loss follows percentile 13. Much less active and rarely cries. Cry is weak and high pitched
growth curve; skin turgor is good; specific gravity of urine 1.003 14. (+) Scarf sign – elbow reaches midline
to 1.030; serum glucose is above 45 mg/dl 15. When the heel is drawn as near to the ear as possible, little
resistance is met
 As a rule, the LGA infants need to be breastfeed immediately 16. Barely visible areola and nipple
to prevent hypoglycemia 17. Males- testes are high in the inguinal canal with the presence of
 Infant may need supplemental feeding after breastfeeding to minimal rugae on the scrotum
supply enough fluid and glucose for the larger than normal Female – prominent clitoris, small widely separated labia majora
size for the first few days.
Potential Complications :
Nursing Diagnosis : Risk for altered parenting 1. Anemia or prematurity
2. Kernicterus (destruction of brain cells by invasion of indirect
Outcome Identification : Parents demonstrate adequate bonding bilirubin)
behavior during neonatal period 3. Persistent patent ductus arteriosus
4. Periventricular/Intraventricular Hemorrhage
Outcome Evaluation : Parents hold infant; speak of the child in 5. Respiratory disease syndrome
positive terms; state accurately why the infant needs to be 6. Apnea
closely observed in postnatal period 7. Retinopathy of prematurity
8. Necrotizing enterocolitis
 Educate parents regarding status of infant
Nursing Diagnosis : Impaired gas exchange related to immature
 Allow mother to express resentments or fear she may feel pulmonary functioning
toward the infant
 Preterm infants have difficulty initiating respirations at birth
 A LGA infant needs the same developmental care as normal because the pulmonary capillary bed is immature
infants do. Infant stimulation are important for infant’s
 A fetus usually turns to a vertex position late in pregnancy, the
development
preterm infant may still be in a breech position at birth
 Encourage parents to treat their baby as a fragile NB who
needs warm nurturing Interventions :
 Remind parents that infants birth weight is not a correlation of 1. Giving the mother oxygen by mask during birth will provide the
the child’s projected adult size. infant with optimal oxygen saturation at birth
2. Maternal analgesia and anesthesia to a minimum offers the  Preterm infant needs rest to conserve energy for growth and
infant best chance of initiating effective respirations respiratory function, to combat hypoglycemia and infection, to
3. CS has the advantage of reducing pressure on the immature stabilize temperature and to develop inner balance and
head but may lead to additional respiratory complications attentiveness
because of retained lung fluid  Infant needs planned periods of pleasing sensory stimulation
4. Resuscitate infant within 2 minutes to avoid irreversible
acidosis.
5. Prepare preterm size laryngoscopes, endotracheal tubes, THE POST TERM INFANT
suction catheters and synthetic surfactant
6. Infant must be kept warm during resuscitation
 Infant born after the 42nd week of a pregnancy
7. Continued oxygen administration  Infant who stays in utero past week 42 of pregnancy is at special
risk because a placenta appears to only function effectively for
Nursing Diagnosis : Risk for fluid volume deficit 40 weeks. Fetus may die or develop post term syndrome
 Preterm babies have a high insensible loss due to the large
Pathophysiology
body surface as compared with total body weight.
- If the placenta continuous to function well, the fetus will continue
 The infant is unable to concentrate urine well because of to grow, which results in an LGA infant who may manifest
immature kidney function and thus excretes a high problems such as birth trauma and hypoglycemia
proportion of fluid from the body. - If placental function decreases, the fetus may not receive
 It is important that the preterm baby receive up to 160 to 200 adequate nutrition. The fetus will utilize its subcutaneous fat
ml of fluid/kg of body weight daily stores for energy. Wasting of subcutaneous fat occurs, resulting
in fetal dysmaturity syndrome.
Interventions :
1. IVF administration within hours after birth to fulfill fluid Stages of Fetal Dysmaturity Syndrome
replacement and provide glucose to oprevent hypoglycemia 1. Stage 1 – Chronic Placental Insufficiency
2. Monitor baby’s weight, specific gravity and amount of urine,  Dry, cracked, peeling, loose, and
and serum electrolytes to ensure adequate fluid intake wrinkled skin
3. Blood glucose determinations to help determine hypoglycemia
 Malnourished appearance
or hyperglycemia.
4. Record all blood drawn  Open-eyed and alert
5. Check for blood in the stools to determine bleeding from
intestinal tract. 2. Stage 2 – Acute Placental Insufficiency
 Dry, cracked, peeling, loose, and wrinkled skin
Nursing Diagnosis : Risk for altered nutrition; less than body  Malnourished appearance
requirement  Meconium staining
 Nutrition problem arise with the preterm infant because the  Perinatal depression
body is attempting to continue to maintain the rapid rate of 3. Stage 3 – Subacute Placental Insufficiency
intrauterine growth. Therefore, the NB requires a larger  Dry, cracked, peeling, loose, and wrinkled skin
amount of nutrients in the diet than the mature infant..  Malnourished appearance
 If nutrients are not supplied, Hypocalcemia or azotemia  Meconium staining
develops.  Green staining of skin, nails, cord, and placental
 Delayed feeding may also add to hyperbilirubinemia membrane
 Nutrition problem is compounded with infant’s immature  A higher risk of intrapartum and neonatal death
reflexes, which makes swallowing and sucking difficult
 Small stomach capacity may affect nutrition, because a -The newborn is at increased risk for developing complications
distended stomach may cause respiratory distress related to compromised uteroplacental perfusion and hypoxia (eg.
 Increased activity due to ineffective sucking may increase Meconium aspiration syndrome [MAS])
metabolic rate and oxygen requirements, therefore, - Chronic intrauterine hypoxia causes increased fetal erythropoietin
increases caloric requirements even more and red blood cell production resulting in polycythemia
 Immature cardiac sphincter allows regurgitation to occur - Post-term infants are susceptible to hypoglycemia because of the
readily. rapid use of glycogen stores
 Lack of cough reflex may lead the infant to aspirate
regurgitated formula. Nursing Management
 Digestion and absorption of nutrients in the stomach and 1. Manage Meconium Aspiration Syndrome
intestine may also be immature. - suction the infant’s mouth and
nares while the head is in the
Nursing Diagnosis : Ineffective thermoregulation r/t immaturity perineum and before the first breath
is taken to prevent aspiration of
 A preterm baby has difficulty maintaining body temperature
meconium that is in the airway
because of the large surface area per pound of body weight
- once the infant is dry and in the
 Rapid cooling from evaporation occurs due to extended warmer, intubate and do direct
position tracheal suctioning
 The preterm infant has little subcutaneous fat for insulation - perform chest physiotherapy with
and because of poor muscular development the child does suctioning to remove excess
not move actively to produce body heat. meconium and secretions
 The preterm infant has limited amount of brown fat, the - provide supplemental oxygen and
special tissue present in NB’s to maintain body temperature respiratory support as needed.
 Because of an immature central nervous system and 2. Obtain serial blood glucose measurements
hypothalamic control, the child is unable to sweat thereby 3. If not contraindicated by respiratory status, provide early
reducing body temperature and unable to shiver , a useful feeding to prevent hypoglycemia
mechanism to increase body temperature 4. Maintain skin integrity
- keep the skin clean and dry
Nursing Management : - avoid the use of powders, creams
1.The infant must be kept under a radiant heat warmer and lotions
-
Nursing Diagnosis : Risk for infection
 The skin of preterm infant is easily traumatized therefore has ILLNESS IN THE NEWBORN
less resistance to infection
 Preterm infant has lowered resistance to infection 1. RESPIRATORY DISTRESS SYNDROME
 The infant has difficulty producing phagocytes to localize  RDS most often occurs in preterm infants, infants of diabetic
infection and has a deficiency of IgM antibodies mothers, infants born by CS, those who have decreased blood
perfusion of the lungs
Nursing Management :
1. Linen and equipment used with the preterm infant must be Pathologic Feature: A hyaline-like (fibrous) membrane comprised of
clean to reduce the chances of infection products formed from an exudates of the infant’s blood that lines the
2. Hospital staff must be free of infection, and hand washing and terminal bronchioles, alveolar ducts, and alveoli. This membrane
gowning regulations must be strictly enforced prevents exchange of oxygen and carbon dioxide at the alveolar-
capillary membrane.
Nursing Diagnosis : Diversional activity deficit (lack of
stimulation) r/t preterm infant’s rest needs
Cause of RDS: A low level or absence of surfactant, the 1. Close observation is the priority
phospholipid that normally lines the alveoli and resists surface 2. Oxygen administration
tension on expiration to keep alveoli from collapsing on
expiration. 3. MECONIUM ASPIRATION SYNDROME
Meconium is a thick, sticky, greenish black substance that
Pathophysiology : constitutes the neonate’s first feces. It is present in the bowels of the
 High pressure is required to fill the lungs with air for the first fetus as early as 10 weeks gestation. Meconium aspiration
time and overcome the pressure of lung fluid. It takes a syndrome results when the neonate inhales meconium that is mixed
pressure between 40 cm H2O and 70 cm H2O, to inspire a with amniotic fluid. It typically occurs while the neonate is in utero or
first breath, but only 15 cm H2O to 20 cm H2O to maintain with the neonate’s first breath. The meconium partially or completely
quiet, continued breathing. If alveoli collapse with each blocks the neonate’s airways so that air becomes trapped during
expiration, as happens when surfactant is deficient, exhalation. Also, the meconium irritates the neonate’s airways,
however, it continues to take forceful inspiration to inflate making breathing difficult.
them. With deficient surfactant, areas of hypoinflation occur The severity of meconium aspiration syndrome depends on the
and pulmonary resistance is increased. Blood then shunts amount of meconium aspirated and the consistency of the
through the foramen ovale and the ductus arteriosus. The meconium. Thicker meconium generally causes more damage.
lungs are poorly perfused, thus affecting gas exchange. As Neonates with meconium aspiration syndrome increase their
a result, the production of surfactant decrease even further. respiratory efforts to create greater negative intrathoracis pressures
The poor oxygen exchange leads to tissue hypoxia. Tissue and improve air flow to the lungs. Hyperinflation, hypoxemia, and
hypoxia causes the release of lactic acid. This, combined academia cause increased peripheral vascular resistance. Right to
with an increasing carbon dioxide level resulting from the left shunting often follows.
formation of the hyaline membrane on the alveolar surface,
leads to severe acidosis. Acidosis causes vasoconstriction, Pathophysiology:
and decreased pulmonary perfusion from vasoconstriction Meconium aspiration syndrome is commonly related to fetal distress
further limits surfactant production. With decreased during labor. When a neonate becomes hypoxic, peristalsis
surfactant production, the ability to stop alveoli from increases and the anal sphincter relaxes. Occasionally, healthy
collapsing with each expiration becomes impaired. This neonates pass meconium before birth. In either case, if the neonate
vicious cycle continuous until the oxygen-carbon dioxide gasps or inhales the meconium, meconium aspiration can develop.
exchange in the alveoli is no longer adequate to sustain life The resulting lack of oxygen may lead to brain damage.
without ventilator support.
Risk factors for meconium aspiration syndrome include:
Assessment :  Maternal diabetes
1. Difficulty initiating respirations at birth  Maternal hypertension
2. Low body temperature  Difficult delivery
3. Nasal flaring  Fetal distress
4. Sternal and subcostal retractions  Intrauterine hypoxia
5. Tachypnea  Advanced gestational age (greater than 40 weeks)
6. Expiratory grunting  Poor intrauterine growth
7. On auscultation, fine rales and diminished breath sounds
8.Seesaw respirations
9. Heart failure evidenced by decreased urine output and edema Signs and symptoms of meconium aspiration syndrome include:
of the extremities  Dark greenish staining or streaking of the
10. Pale gray skin color amniotic fluid
11. Periods of apnea  Obvious presence of meconium in the amniotic
12. Bradycardia fluid
 Skin with a greenish stain (if the meconium was
Therapeutic Management :
passed long before delivery)
1. Surfactant Replacement and Rescue
 Limp appearance at birth
2. Oxygen administration
3. Ventilation  Cyanosis
4. Use of muscle relaxants  Rapid and labored breathing. retractions
5. Extracorpeal Membrane Oxygenation  Low heart rate before birth
6. Liquid ventilation  Low APGAR score

Prevention : Nursing Interventions :


1. Preventing preterm labor by using tocolytic agents 1. Infant should be suctioned with a bulb syringe while at the
2. Administer 2 injections of a glucocorticosteroid to the mother perineum to avoid meconium aspiration
at 12 and 24 hours before birth. Steroids quickens the formation 2. Infant should be intubated and meconium should be suctioned
of lecithin production pathways from the trachea and bronchi as soon as the infant is born

Nursing Diagnosis : Impaired gas exchange r/t immaturity of the Therapeutic Management :
NB’s lungs and diminished surfactant 1. Amniotransfusion may be used to dilute the amount of meconium
in amniotic fluid and reduce risk of aspiration
Interventions : 2. Oxygen adminitration
1. Assess NB’s status and note signs of increasing respiratory 3. Antibiotic Therapy
distress 4. Maintain a thermal neutral environment
2. Maintain endotracheal tube, mechanical ventilation and 5. Chest physiotherapy with clapping and vibration to facilitate
supplemental warm humidified oxygen removal of remnants of meconium from the lungs
3. Prepare to administer surfactant rescue
4. Change the NB’s position during administration and refrain 4. APNEA
from suctioning the ET tube for up to 1 hour following  A pause in respirations longer than 20 seconds with
administration accompanying bradycardia
5. Anticipate administration of indomethacin and pancuronium  Many preterm infants have periods of apnea as a result of fatigue
6. Maintain a neutral thermal environment and minimize physical or the immaturity of their respiratory functions
activity  Babies with secondary stresses, such as infection,
7. Plan nursing care to allow for frequent rest periods and hyperbilirubinemia, hypoglycemia or hypothermia tend to have
attempt to anticipate the NB’s needs high incidence of apnea

2. TRANSIENT TACHYPNEA OF THE NEWBORN Tx Management :


1. Gently shake or flick the sole of the foot to stimulate the baby
Signs and Symptoms : 2. Apnea monitors to detect failing respiration
1. Mild retractions but not marked cyanosis 3. Ventilator to provide respiratory coordination
2. Mild hypoxia and hypercapnia 4. Maintain a neutral thermal environment
3. Feeding is difficult because infant cannot suck and breathe 5. Always suction gently
this rapidly at the same time 6. Careful burping after feeding
4. Chest x-ray reveals fluid in the lungs 7. Theophylline or caffeine sodium benzoate may be administered to
stimulate respirations
 Transient tachypnea results from slow absorption of lung fluid
5. SUDDEN INFANT DEATH SYNDROME (SIDS)
Intervention :  SID is the sudden unexplained death in infancy
Pathologic hyperbilirubinemia
Etiology : -May appear anytime after the first day of life and persists beyond 7
 Occur usually in infants of adolescent mothers, infants of days with serum bilirubin levels greater than 12mg/100ml in a term
closely spaced pregnancies and underweight and preterm neonate, 15mg/100ml in a preterm neonate, or increasing more than
infants. 5mg/100ml in 24 hours.
 Also prone to SIDS are infants with bronchopulmonary
dysplacia, twins, siblings of another child with SIDS Treatment:
 Infants of narcotic-dependent mothers Depending on the underlying cause, treatment may include:
 Peak ages of incidence are between 2 weeks and 1 year of *exchange transfusion – replaces the neonate’s blood with fresh
age blood (blood that is less than 48 hours old), thus removing some of
 Viral respiratory or botulism infection the
unconjugated bilirubin in serum
 Distorted familial breathing patterns
*phototherapy - uses fluorescent light to decompose bilirubin
 Possible lack of surfactant in alveoli in the skin by oxidation. Implemented after the initial exchange
 Sleeping prone rather than on the side or back transfusion, phototherapy is usually
discontinued after bilirubin levels fll below 10mg/100ml and continue
Apparent Life-Threatening Event (ALTE) to decrease for 24 hours and albumin infusion -(1g/kg of 25%
 Infants discovered cyanotic and limp in their beds but have salt-poor albumin) which provides additional albumin for binding
survived after mouth-to-mouth resuscitation by parents unconjugated bilirubin.

6. PERIVENTRICULAR LEUCOMALACIA (PVL) Performing Phototherapy


 PVL is abnormal formation of the white matter of the brain
 Occurs most frequently in preterm infants who experience  Set up the phototherapy unit about 18” above the
cerebral ischemia neonate’s crib and verify the placement of the light-bulb
 Ischemic episode interferes with circulation to a portion of the shield. If the neonate is in the incubator, place the
brain. Phagocytes and macrophages invade the area to phototherapy unit at least 3” above the incubator and turn
clear away necrotic tissue, what is left is an area in the on the light. Place a photometer probe in the middle of
white matter of the brain that is revealed on sonogram as a the crib to measure the energy emitted by the lights.
hollow space.  Explain the procedure to the parents.
 No therapy is identified.  Record the neonate’s initial bilirubin level and his axillary
 Infants may die from the original insult; thay may be left with temperature.
long term effects such as learning disabilities.  Place the opaque eye mask over the neonate’s closed
eyes and fasten securely.
7. HYPERBILIRUBINEMIA  Undress the neonate and place a diaper under him.
Cover male genitalia with a surgical mask or small diaper
Hyperbilirubinemia is an excess of bilirubin in the blood that to catch urine and prevent possible testicular damage
results in elevated serum bilirubin levels and mild jaundice. from the heat and light waves.
Hyperbilirubinemia can be physiologic (with jaundice being the  Take the neonate’s axillary temperature every 2 hours
only symptom) or pathologic (resulting from an underlying and provide additional warmth by adjusting the warming
disease). unit’s thermostat
Physiologic hyperbilirubinemia is self-limiting. It usually resolves  Monitor elimination and weigh the neonate twice daily.
in 7-10 days. Prognosis for pathologic hyperbilirubinemia varies, Watch for signs of dehydration (dry skin, poor turgor,
depending on the cause. If left untreated, hyperbilirubinemia depressed fontanels) and check urine specific gravity with
may result in kernicterus, a neurologic syndrome caused by a urinometer to gauge hydration status.
unconjugated bilirubin depositing in the brain cells. Survivors
 Take the neonate out of the crib, turn off the phototherapy
may develop cerebral palsy, epilepsy, or mental retardation, or
lights, and unmask his eyes at least every 3-4 hours with
they may have only minor effects, such as perceptual-motor
feedings. Assess his eyes for inflammation and injury.
disabilities and learning disorders.
 Reposition the neonate every 2 hours to expose all body
Pathophysiology: surfaces to the light and to prevent head molding and skin
As erythrocytes break down at the end of their neonatal life breakdown from pressure.
cycle, hemoglobin separates into globin (protein) and heme (iron  Check the bilirubin level at least once every 24 hours –
and protoporphyrin) fragments. more often if levels rise significantly. Turn off the
Heme fragments (protoporphyrin component) form unconjugated phototherapy unit before drawing venous blood for testing
bilirubin. Unconjugated bilirubin is fat soluble and cannot be because the lights may degrade bilirubin in the blood.
excreted by the kidneys in this state. Instead unconjugated Notify the doctor if the bilirubin level nears 20mg/dl in full-
bilirubin binds with albumin and is transported to the liver. In the term neonates or 15mg/dl in premature.
liver, it is converted by the liver enzyme glucuronyl transferase
into direct bilirubin, which is water soluble and is incorporated
into stool and then excreted in the feces. 8. HEMOLYTIC DISEASE OF THE NEWBORN (Erythroblastosis
Many newborns have such immature liver function that indirect Fetalis)
bilirubin can not be converted into direct form and, therefore, A. General Information
remains indirect. Other factors include: - characterized by RBC destruction in
- certain drugs (such as aspirin, tranquilizers and the newborn, with resultant anemia and hyperbilirubinemia
sulfonamides) or conditions ( such as hypothermia, anoxia, - possibly caused by Rh or ABO
hypoglycemia, and hypoalbuminemia) can disrupt conjugation incompatibility between the mother and the fetus (antigen-
and usurp albumin-binding sites antibody reaction)
-Increased erythrocyte production or breakdown (like in the - mechanisms of Rh incompatibility
resolution of cephalhematoma), or Rh or ABO incompatibility sensitization of Rh-negative woman by transfusion of Rh-
-Maternal enzymes and hormones (pregnanediol) present in positive blood
breast milk can inhibit the neonate’s glucuronyltransferase sensitization of Rh-negative woman by presence of Rh-
conjugating activity positive RBCs from her fetus conceived with Rh-positive man
approximately 65% of infants conceived by this
combination of parents will be Rh-positive
Manifestations:
The predominant sign of hyperbilirubinemia is jaundice in which mother is sensitized by passage of fetal Rh-positive
the usual pattern of progression is from head to feet. Blanch RBCs through placenta either during pregnancy
skin over bony prominence or look at conjunctiva and buccal (break/leak in the membrane) or at the time of separation
membranes in dark-skinned infants. Jaundice doesn’t become of placenta after delivery
clinically apparent until serum bilirubin levels reach about this stimulates the mother’s immune response system to
7mg/100ml. Around this serumlevel, unconjugated bilirubin produce anti-Rh positive antibodies that attack fetal RBCs
escape to the extravascular tissues. and cause hemolysis
if this sensitization occurs during pregnancy, the fetus is
Physiologic hyperbilirubinemia affected in utero; if sensitization occurs at the time of
- Typically develops within 2-3 days after birth in 50% of term delivery, subsequent pregnancies may be affected.
neonates and within 3-5 days after birth in 80% of preterm - ABO incompatibility
neonates. It generally disappears by day 7 in term neonates and same underlying mechanism
by day 9 or 10 in preterm neonates. Throughout physiologic mother is blood type O; infant A, B, or AB
jaundice, the serum unconjugated bilirubin level doesn’t exceed reaction in ABO incompatibility is less severe compared
12mg/100ml. to Rh-incompatibility
B. Rh- Incompatibility 3. May vomit fresh blood or pass black, tarry stools because of
first pregnancy, mother may become sensitized, baby bleeding into the GIT
rarely affected
Indirect Coomb’s test (tests for anti-Rh positive Therapeutic Management :
antibodies in mother’s circulation) performed during 1. Hemorrhagic disease of the NB can be prevented by Vit K 1 mg
pregnancy at first visit and again at 28 weeks IM immediately after birth
gestation. If indirect Coomb’s test is negative at 28 2. Blood transfusion of fresh whole blood in severe bleeding to
weeks, a small dose (Mic Rhogam) is given increase the prothrombin level
prophylactically to prevent sensitization in the third
trimester ( Rhogam may also be given after the 2nd 10. TWIN-TO-TWIN TRANSFUSION
trimester amniocentesis)  A phenomenon that can occur if twins are monozygotic (identical;
If positive, levels are titrated to determine extent of share the same placenta) and if abnormal arteriovenous shunts
maternal sensitization and potential effect on the occur that direct more blood to one twin than the other
fetus  Can be identified through sonogram
Direct Coomb’s test is done on cord blood at delivery  One twin is larger than the other
to determine presence of anti-Rh positive antibodies
on fetal RBCs. 11. NECROTIZING ENTEROCOLITIS
A. General Information
If both direct and indirect Coomb’s tests are negative - an ischemic attack to the intestines resulting in thrombosis and
(no formation of anti-Rh positive antibodies) and infarction of affected bowel, mucosal ulcerations,,
infant is Rh-positive, then Rh-negative mother can be pseudomembrane formation, and inflammation
given Rhogam (Rho human immune globulin) to - bacterial actions (E. coli, Klebsiella) complicates the process,
prevent development of anti-positive antibodies as producing sepsis
the result of sensitization from present pregnancy - may be precipitated by any event in which blood is shunted away
from the intestines to more vital organs like the heart and brain (e.g.
In each pregnancy, an Rh-negative mother who fetal distress, low APGAR score, RDS, prematurity, neonatal shock,
carries an Rh-positive fetus can receive Rhogam to and asphyxia).
protect future pregnancies if the mother has had - average age of onset is 4 days
negative indirect Coomb’s test and the infant has had - now that severely ill infants are surviving, NEC is encountered more
a negative direct Coomb’s test frequently
If the mother has been sensitized (produced anti Rh- - may ultimately cause bowel perforation and death
positve antibodies), Rhogam is not indicated. She
may be given high doses of gamma globulin to help B. Medical Management
reduce fetal involvement, hoping to interfere with the - parenteral antibiotics
rapid destruction of fetal RBCs. The fetus may - gastric decompression
receive a blood transfusion in utero via an injection of - correction of acidosis and fluid and electrolyte imbalance
RBCs directly into a vessel in the fetal cord or - surgical removal of the diseased intestine
instillation in the fetal abdomen via amniocentesis.
After birth, the neonate may receive an axchange C. Assessment Findings
transfusion to remove hemolyzed RBCs and replace -history indicating high-risk group
them with healthy blood cells. -findings related to sepsis (temperature instability, apnea and
Rhogam may be injected (IM in the gluteal area) into labored respiration, cardiovascular collapse, lethargy or irritability)
unsensitized mother’s system within 72 hours of -gastrointestinal symptoms (abdominal distention and tenderness,
delivery of Rh-positive infant. vomiting and poor feeding, hematest positive stools, x-rays showing
C. ABO Incompatibility air in the bowel wall, adynamic ileus, and bowel wall thickening)
Reaction less severe than with RH incompatibility
First born may be affected because type O mother
may have anti-A and anti-B antibodies even before D. Nursing Interventions
pregnancy -carefully assess infants at risk for early recognition of symptoms
-discontinue oral feedings, insert nasogastric tube
Fetal RBCs with A, B, or AB antigens evoke less
-prevent trauma to abdomen by avoiding diapers and planning care
severe reaction on part of mother, thus fewer anti-A,
for minimal handling
anti-B, or anti-AB antibodies are produced
-maintain acid base balance by administering fluid and electrolytes
Clinical manifestations of ABO incompatibility are as ordered
milder and of shorter duration than those of Rh compatibility -administer antibiotics as ordered
D. Assessment Findings -inform parents of progress and support them in expressing their
jaundice and pallor within the first 24-36 hours fears and concerns
anemia and hyperbilirubinemia – due to RBC
destruction
erythropoiesis
enlarged placenta and enlarged fetal liver and spleen
– due to the attempt to produce and supply new red blood THE NEWBORN AT RISK BECAUSE OF MATERNAL INFECTION
cells OR ILLNESS
edema and ascites – resulting from fluid shift because
1. BETA-HEMOLYTIC, GROUP B STREPTOCOCCAL INFECTION
the blood in the intravacular space is hypotonic relative to
 Beta-hemolytic, group B streptococcal organism is the major
the interstitial
cause of infection in NB infants
* Hydrops fetalis – “fatal edema”, old term for the
appearance of a severely involved infant at birth
Assessment :
E. Nursing Interventions
1. Tachypnea
determine blood type and Rh early in pregnancy 2. Apnea
determine results of indirect Coomb’s test early in 3. Symptoms of shock such as decreased urine output, extreme
pregnancy and again at 28-32 weeks paleness, or hypotonia
determine results of direct Coomb’s test on cord blood 4. Lethargy
administer Rhogam IM to mother as ordered 5. Fever
do careful monitoring 6. Loss of appetite
implement phototherapy or exchange transfusion for 7. Bulging fontannels
any hyperbilirubinemia
Therapeutic Management :
9. HEMORRHAGIC DISEASE OF THE NEWBORN 1. Antibiotics. Gentamicin, ampicillin and penicillin.
2. Immunization of all childbearing age women against streptococcal
 Results from a deficiency of Vit. K
organisms
 Vit K is essential for the formation of prothrombin by the liver
 Babies born to mothers on anticonvulsive medication are at 2. CONGENITAL RUBELLA
high risk  Rubella virus is capable of causing extensive congenital fetal
malformations if the mother is infected during the first trimester
Symptoms : of pregnancy
1. Petechiae from superficial bleeding into the skin
 The greatest risk to an embryo from rubella virus is during weeks
2. Conjuntival, mucous membrane or retinal hemorrhage
2 to 6 of intrauterine life.
Assessment : Therapeutic Management :
1. Thrombocytopenia 1. Drugs that inhibit viral deoxyribonucleic acid synthesis (acyclovir
2. Cataracts and vidaribine) are effective in combating this infection
3. Heart Disease 2. Women with active herpetic vulvar lesions are often delivered by
4. Deafness caesarian to minimize the NB’s exposure
5. Microcephaly 3. Infants with this infection are separated from other infants
6. Motor and cognitive impairment 4. Women with lesions on their face should not feed or hold their
NB’s until lesions are crusted and no longer contagious
Therapeutic Management :
1. Treatment is symptomatic, depending on the congenital 6. THE INFANT OF A DIABETIC MOTHER
defects present
2. Contact precautions Assessment :
3. Susceptible pregnant women should avoid contacts with the 1. Infants of a diabetic mother whose illness was poorly controlled
NB still having the virus during pregnancy is typically longer and weighs more thatn other
4. Women with low rubella titers should be given rubella vaccine babies (macrosomia)
to ensure that rubella infection does not occur in future 2. Infant has a greater chance of having congenital anomaly
pregnancies 3. Caudal regression syndrome or hypoplasia of the lower
extremities is a syndrome that occurs almost exclusively in such
3. OPHTHALMIA NEONATORUM infants
 Ophthalmia neonatorum is eye infection at birth or during the 4. Cushingoid (fat and puffy) appearance
first month 5. Lethargic or limp in the first days of life, effects of hyperglycemia
 Most common causative organisms include Neisseria 6. Lungs may be immature
gonorrhea or Chlamydia trachomatis 7. RDS occurs frequently
 N. gonorrhea if left untreated could progress to corneal
ulceration and destruction, resulting in opacity of the cornea Complications :
and severe vision impairment 1.Greater chance of birth injury if infant is macrosomic
Assessment : 2. Infants tend to be hyperglycemic immediately after birth
1. Ophthalmia neonatorum is generally bilateral 3. Hyperbilirubinemia
2. Eye conjunctivae become fiery red, there is thick pus and the 4. Hypocalcemia
eyelids are edematous 5. Infants will be small for gestational age (SGA) because of poor
placental perfusion
Prevention :
1. Prophylactic instillation of erythromycin ointment into the eyes Therapeutic Management :
of NB’s 1. To prevent hypoglycemia, infants are fed early with formula or
administered a continuous infusion of glucose
Therapeutic Management : 2. It is important not to give bolus of glucose to avoid rebound
1. Therapy is individualized depending on the organism cultured hypoglycemia
from the exudate
2. If gonococci is identified, Ceftriaxone and penicillin IV are 7. THE INFANT OF A DRUG-DEPENDENT MOTHER
effective drugs
3. If chlamydia is identified, Erythromycin ophthalmic solution is Assessment :
used 1. Infants tend to be small for gestational age
4. The eyes are irrigated with sterile saline solution to clear the 2. Irritability
copious discharge 3. Disturbed sleep patterns
5. The mother of the infected infant needs treatment for Constant movement possibly leading to abrasions on their elbows,
gonorrhea or chlamydia knees or nose
4. Tremors
4. HEPATITIS B VIRUS INFECTION 5. Frequent sneezing
 The hepatitis B virus can be transmitted to the NB through 6. Shrill, high –pitched cry
contact with infected vaginal blood at birth 7. Possible hyperplasia and clonus (neuromuscular irritability)
 70 to 90% of infected infants become chronic carriers of the 8. Convulsions
virus. 9. Tachypnea
10. Vomiting and diarrhea leading to large fluid losses and
 A number of these NB’s will develop liver cancer later in life
secondary hydration
Prevention :
Therapeutic Management :
1. Routine vaccination of infants at birth
1. Infants are most comfortable when firmly swaddled.
2. If mother is identified as HbsAg+. The infant is administered
2. Infants should be kept in an environment free from excessive
immune serum globulin (HBIG) within 12 hours of birth to
stimuli
decrease possibility of infection
3. Infants must be gavage fed if infants have poor sucking ability and
3. The infant should be bathed immediately after birth to remove
may have difficulty getting enough fluid intake
HBV-infected blood and secretions
4. Maintenance of electrolyte and fluid balance is essential
4. Suctioning should be with gentle technique to avoid possible
5. IVF administration is necessary if infant has vomiting or diarrhea
trauma to the mucous membrane which could allow HBV
6. Drugs used to counteract withdrawal symptoms include paregoric,
invasion
Phenobarbital, methadone, chlorpromazine and diazepam
7. Infants should not be breastfeed to avoid passing narcotics to the
5. GENERALIZED HERPESVIRUS INFECTION
child
 A herpes simplex virus type 2 (HSV-2) infections can be
contracted by a fetus across the placenta if the mother has 8. THE INFANT WITH FETAL ALCOHOL SYNDROME (FAS)
a primary infection during pregnancy. - A cluster of birth defects that are caused by in utero exposure to
 Most often, the virus is contracted from the vaginal secretions alcohol referred to as FAS.
from the mother who has active herpetic vulvovaginitis at - Although prenatal alcohol exposure doesn’t always result in FAS,
the time of birth the safe level of alcohol consumption during pregnancy isn’t known.
- Alcohol crosses through the placenta and enters fetal blood supply,
Assessment : and it can interfere with the healthy development of the fetus. In fact,
1. Vesicles covering the skin if the infection was acquired during birth defects associated with prenatal alcohol exposure can occur in
pregnancy the first 3-8 weeks of pregnancy, before a woman even knows she is
2. Loss of appetite pregnant.
3. Low-grade fever Variables that affect the extent of damage caused by the fetus by
4. Lethargy alcohol include the amount of alcohol consumed, the timing of
5. Stomatitis (ulcers of the mouth) or a few vesicles in the skin consumption, and the pattern of alcohol use.
6. Herpes vesicles are always clustered, pinpoint in size and Characteristics :
surrounded by a reddened base 1. Pre and postnatal growth restriction
7. After vesicles appear, infants become extremely ill. They 2. Central nervous system involvement such as cognitive
develop dyspnea, jaundice, purpura, convulsions, and shock impairment, microcephaly and cerebral palsy
3. Facial features such as short palpebral fissures, thin upper lip,
Complications : strabismus, low nasal bridge, flat midface, flat or absent groove in
1. Death may occur within hours or days the upper lip, short nose and receding jaw
2. Some who survived the infection may have permanent central 4. Infant may be tremulous, fidgety, irritable, and may have a weak
nervous system sequelae sucking reflex during neonatal period
5. Sleep disturbances are common  The impulses arising in the respiratory center travel through
6. Behavior problems such as hyperactivity may occur in school- nerves that extend from the brain stem down the spinal cord to
age children receptors in the muscles of respiration. Thus, any disease of
7. Growth deficiencies may remain through life the nerves, spinal cord, muscles or neuromuscular junction
Supportive treatment is implemented. involved in respiration seriously affects ventilation and may lead
Emphasis on management of respiratory problems, nutrition, and to ARF
maternal-neonate bonding should be made.
Dysfunction Of Lung Parenchyma
 Pleural effusion, hemothorax, pneumothorax, and upper airway
HIGH RISK ADULT obstruction are conditions that interfere with ventilation by
RESPIRATORY DISORDERS preventing expansion of the lung. These conditions, which may
ACUTE RESPIRATORY DISTRESS SYNDROME cause respiratory failure, usually are produced by an underlying
 A clinical syndrome characterized by a sudden and lung disease, pleural disease, trauma and injury.
progressive pulmonary edema, increasing bilateral  Other diseases and conditions of the lung that lead to ARF
infiltrates, hypoxemia refractory to oxygen supplementation include pneumonia, status asthmaticus, lobar atelectasis,
and reduced lung compliance pulmonary embolism and pulmonary edema
Other Factors
Etiologic Factors Related to ARDS :  In the postoperative period, esp. after major thoracic or
1. Aspiration (gastric secretions, drowning, hydrocarbons) abdominal surgery, inadequate ventilation and respiratory
2. Drug ingestion and overdose failure may occur. Causes of ARF during this period include the
3. Hematologic disorders effects of anesthetic agents, analgesics, and sedatives; they
4. Prolonged inhalation of high concentrations of oxygen, smoke, may depress respiration and lead to hypoventilation
or corrosive substances
5. Localized infection (bacterial, fungal, viral pneumonia) Clinical Manifestations:
6. Metabolic disorders ( pancreatitis, uremia)  Early signs are those associated with impaired oxygenation
7. Shock (any cause)  Restlessness, fatigue, headache, dyspnea, air hunger,
8. Trauma ( pulmonary contusion, multiple fractures, head injury) tachycardia, tachypnea, central cyanosis, diaphoresis and
9. Fat or air embolism finally, respiratory arrest
10. Systemic sepsis
 Physical findings : use of accessory muscles, decreased breath
sounds
Pathophysiology
Medical Management:
Clinical Manifestations :
 Objectives of treatment are to correct the underlying cause and
1. Rapid onset of severe dyspnea
to restore adequate gas exchange in the lung
2. Anxiety
3. Labored breathing and tachypnea  Intubation and mechanical ventilation

Assessment : Intercostal retractions and crackles Nursing Management:


 Assist with intubation
Medical Management :  Assess respiratory status by monitoring patient’s level of
1. Primary focus of management includes identification and response, arterial blood gases, pulse oximetry and vital signs
treatment of the condition.  Implement strategies to prevent complications : turning schedule,
2. Supportive Therapy : Intubation and mechanical ventilation mouth care, skin care, ROM
3. Circulatory support, adequate fluid volume and nutritional
support CHRONIC RESPIRATORY FAILURE
4. Supplemental oxygen is used as the patient begins the initial  Defined as a deterioration in the gas exchange function of the
spiral of hypoxemia lung that has developed insidiously or has persisted for a long
5. Positive end-expiratory pressure (PEEP) period after an episode of ARF
6. Hypovolemia must be carefully treated  Patients develop a tolerance to the worsening hypoxemia and
7. Intravenous crystalloid solutions are administered hypercapnia
8. Pulmonary artery pressure catheters are used to monitor  Patient with chronic respiratory failure may develop Acute
patients fluid status respiratory failure – seen in COPD patients who develops an
exacerbation or infection that causes additional deterioration of
Nursing Management : the gas exchange mechanism
1. Positioning is important. Nurse should turn the patient
frequently to improve ventilation and perfusion in the lungs and 2 Causes of Chronic Respiratory Failure:
enhance secretion drainage 1. COPD
2. Nurse must closely monitor rapid changes in oxygenation with 2. Neuromuscular Diseases
changes in position
3. The nurse should explain all procedures and deliver care in a RESPIRATORY FAILURE
calm, reassuring manner  Respiratory failure is a sudden and life-threatening deterioration
4. Rest is essential to reduce oxygen consumption of the gas exchange function of the lung.
 Exists when the exchange of oxygen for carbon dioxide in the
Nursing Diagnosis : Impaired gas exchange r/t inadequate lungs can not keep up with the rate of oxygen consumption and
respiratory center activity, chest wall movement, airway carbon dioxide production by the cells of the body.
obstruction, fluids in the lungs
ENDOCRINE/METABOLIC DISORDERS
ACUTE RESPIRATORY FAILURE (ARF) DIABETIC KETOACIDOSIS
 Defined as a fall in arterial oxygen tension and a rise in  DKA is caused by an absence or markedly inadequate amount of
arterial carbon dioxide tension. insulin
 The ventilation and/or perfusion mechanisms in the lung are
impaired. Three Main Clinical Features of DKA :
 Respiratory system mechanisms leading to ARF include: 1. Hyperglycemia
1. Alveolar hypoventilation 2. Dehydration and electrolyte loss
2. Diffusion abnormalities 3. Acidosis
3. Ventilation-perfusion mismatching
4. Shunting Pathophysiology

Pathophysiology: Three Main Causes of DKA :


1. Decreased or missed dose of insulin
Common Causes of Acute Respiratory Failure : 2. Illness or infection
Decreased Respiratory Drive 3. Undiagnosed and untreated diabetes
 May occur with severe brain injury, large lesions of the brain
stem (multiple sclerosis), use of sedative medications, and Clinical Manifestations :
metabolic disorders such as hyperthyroidism. This 1. Acetone breath
disorders impair the normal response of chemoreceptors in 2. Poor appetite or anorexia
the brain to normal respiratory stimulation 3. Nausea and vomiting
4. Abdominal pain
Dysfunction Of The Chest Wall 5. Blurred vision
6. Weakness
7. Headache  Peak incidence is between ages 20 and 50 years old
8. Dehydration  The cause of high BP in 0.9% to 2.2% of patients with HPN
9. Thirst or polydipsia  One form of HPN that is usually cured by surgery
10. Orthostatic hypotension
11. Hyperventilation Clinical Manifestations:
12. Mental status changes in DKA vary from patient to patient  Typical triad of symptoms : Headache, Diaphoresis, Palpitations
Assessment and Diagnostic Findings :  HPN may be intermittent or persistent
1. Blood glucose levels may vary from300 to 800 mg/dl
 Tremor, flushing and anxiety
2. The severity of DKA is not necessarily related to the blood
glucose level  Hyperglycemia may result from conversion of liver and muscle
3. Evidence of DKA is reflected in low serum bicarbonate and glycogen to glucose
low pH values  Clinical picture is usually characterized by :
1. Acute, unpredictable attacks, lasting seconds or several
Prevention : hours
1. Patients must be taught “sick day “rules for maintaining their 2. Patient is anxious, tremulous and weak
diabetes when ill. 3. Headache, vertigo, blurring of vision, tinnitus, air hunger,
2. The most important issue is not to eliminate insulin doses and dyspnea
when nausea and vomiting occur and then attempt to consume 4. Polyuria, nausea, vomiting, diarrhea, abdominal pain
frequent small portions of carbohydrates 5. Feeling of impending doom
3. Drinking fluids every hour is important to prevent dehydration 6. Palpitations and tachycardia
4. Patients are taught to have available foods for use on sick 7. BP as high as 350/200 mm Hg
days.
5. Supply of urine test strips and blood glucose test strips should Assessment/Diagnostic Findings:
be available. Patients must know how to contact their physician  Signs of sympathetic nervous system over activity : 5 H’s (HPN,
headache, hyperhidorsis (excessive sweating),
Medical Management : hypermetabolism, and hyperglycemia
1. Rehydration is important for maintaining tissue perfusion and
enhancing the excretion of excessive glucose by the kidneys Medical Management:
2. The major electrolyte of concern during treatment of DKA is Pharmacologic Therapy
potassium. Potassium replacement is vital to avoid dysrhythmias  Close monitoring of ECG changes and careful administration of
that may occur with hypokalemia alpha-adrenergic blocking agents, muscle relaxants – to lower
3. Insulin is usually infused IV at a slow, continuous rate BP quickly
4. Dextrose is added to IVF, such as normal saline solution when  Long-acting alpha blocker to prepare patient for surgery
blood glucose level reach 250 to 300 mg/dl to avoid too rapid  Beta-adrenergic blocking agents for patients with cardiac
drop in the blood glucose level dysrhythmias

Nursing Management : Surgical Management:


1. Nursing care focuses on monitoring fluid and electrolyte  Adrenalectomy- surgical removal of the tumor
status, blood glucose levels, administering fluids, insulin and
other medications and preventing complications such as fluid HEPATIC FAILURE (Hepatic Coma)
overload.  An end stage of liver disease, usually arises as a complication of
2. Urine output is monitored to ensure adequate renal function conditions that cause liver dysfunction although it can be
3. ECG is monitored for dysrhythmias idiopathic
4. VS, arterial blood gases and other clinical findings are  Also called Hepatic coma because the patient’s neurologic
recorded on a flow sheet status gradually deteriorates
 Represents the most advanced stage of hepatic encephalopathy
THYROTOXIC CRISIS (THYROID STORM)  A life threatening crisis may occur if the serum ammonia level
 A severe form of hyperthyroidism marked by sudden release rises, causing cerebral ammonia intoxication
of thyroid hormone into the blood stream
Causes :
Precipitating Factors : 1. Cirrhosis
1. Stress such as injury, infection, thyroidal and non-thyroid 2. Hepatitis
surgery, tooth extraction, insulin reaction, diabetic acidosis, 3. Drug or toxin-induced damage
pregnancy, digitalis intoxication, abrupt withdrawal of anti-thyroid 4. Fatty liver
medications, extreme emotional stress, or vigorous palpation of 5. Portal HPN
the thyroid. 6. Surgically-created portal systemic shunts that bypass the liver and
allow toxins into the blood
Clinical Manifestations :
1. High fever Pathophysiology :
2. Diaphoresis Liver disease alters liver structure and compromises essential
3. Cardiopulmonary symptoms : extreme tachycardia, HPN, functions. This leads to impaired protein, fat and carbohydrate
arrhythmias, CHF, pulmonary edema metabolism, fluid and electrolyte imbalance, poor lymphatic
4. CNS symptoms : increasing feeling of tremulousness to drainage, reduced coagulation and impaired detoxification of
severe agitation, psychosis with developing apathy, irritability, ammonia and of the metabolites. Ammonia accumulation and
coma , heat intolerance intoxication is the primary pathogenesis of hepatic failure and the
5. GI disturbance : weight loss, diarrhea, abdominal pain ensuing encephalopathy. Ammonia accumulates because liver cells
6. Increased T3T4 and elevated BUN can not detoxify and convert to urea the ammonia that is in constant
supply in GI tract blood. Remaining liver functions may become
Medical Management : impaired and may be difficult to treat or control. Hepatic failure may
1. Immediate objectives are to reduced body temperature and progress insidiously to a comatose state from which the patient
heart rate and to prevent vascular collapse rarely recovers.
2. Humidified oxygen is administered to improve tissue Clinical Findings :
oxygenation and meet metabolic demands
3. Monitor respiratory status by arterial blood gas or pulse Stage 1
oximetry  Slight personality and mood changes, disorientation,
4. PTU or methimazole is administered to impede formation of forgetfulness, slurred speech, slight tremors, periods of lethargy
thyroid hormone and block conversion of T4 to T3, the more and euphoria, mild confusion, inability to concentrate,
active form of thyroid hormone hyperactive reflexes, sleep-wake patterns, handwriting starts to
5. Hydrocortisone is prescribed to treat shock or adrenal decline and mild asterixis (flapping tremors of the hand) may
insufficiency. appear
6. Iodine is administered to decrease output of T4 from the Stage 2
thyroid gland
 The patient grows more disoriented and drowsy. He may display
7. For cardiac problems, Sympatholytic agents may be
inappropriate behavior, mood swings, agitation, apraxia. His
administered. Propranolol in combination with digitalis, has been
hand writing becomes illegible and asterixes may become
effective in reducing severe cardiac problems
pronounced
Stage 3
ADRENAL CRISIS
The patient becomes severely confused and may become
Pheochromocytoma
combative, incoherent and hard to arouse. Sleeps most of the time.
 A tumor that originates from the chromaffin cells of the You may detect hyperactive deep tendon reflexes and rigid
adrenal medulla extremities
Stage 4 dehydration during this phase; if dehydration occurs, the uremic
The pupil is comatose and does not react to stimuli. Pupils are symptoms are likely to increase.
dilated and lack corneal and deep tendon reflexes. Extremities
are flaccid and may assume flexion or extension posturing, 4. Period of Recovery – signals the improvement of renal function.
decebrate rigidity. The EEG is markedly abnormal. Laboratory values return to the patient’s normal level.

Assessment and Diagnostic Findings : Clinical Manifestations :


1. Elevated arterial ammonia blood levels 1. May appear critically ill and lethargic
2. The encephalogram shows generalized slowing and an 2. Persistent nausea, vomiting and diarrhea
increase in amplitude of brain waves and the appearance of 3. The skin and mucous membranes are dry due to dehydration
characteristic triphasic waves 4. Uremic fetor – breath have the odor of urine
3. Occasionally, fetor hepaticus, a characteristic breath odor like 5. CNS manifestations : drowsiness, headache, muscle twitching,
freshly mowed grass, acetone, or old wine, may be noticed. and seizures
4. In a more advanced stage, there are gross disturbances of
consciousness and the patient is completely disoriented with Assessment and Diagnostic Findings :
respect to time and place 1. Changes in urine. The urinary output varies (from scanty to normal
5. With further progression of the disorder, the patient lapses into volume). Hematuria may be present and urine has low-specific
frank coma and may have seizures. gravity. Patients with prerenal azotemia have a decreased amount of
sodium. Those patients with intrarenal azotemia usually have urinary
Intervention : sodium levels greater than 40 mEq/L.
1. Anti-infective agents – to decrease bacterial action in the 2. Increased blood urea nitrogen and creatinine levels (Azotemia)
colon. 3. Hyperkalemia
2. Ammonia detoxicants – to reduce ammonia. Lactulose 4. Metabolic acidosis
(Duphulac) is administered 5. Calcium and Phosphorus Abnormalities
3. Cleansing enemas with diluted acetic acid or neomycin 6. Anemia – due to reduced erythropoietin production, uremic
4. Discontinuation of any precipitating substance : Dietary gastrointestinal lesions, reduced Rbc lifespan, and blood loss
proteins, sedatives, diuretic therapy, analgesics
5. IV administration of glucose to minimize protein breakdown Prevention:
6. Oxygen administration 1. Renal function must be monitored closely if patient has been
7. Correction of any electrolyte imbalance taking nephrotoxic antibiotic agents or has been exposed to
8. Promote rest, comfort and quiet environment environmental toxins. Blood should be drawn for determining
baseline and monitoring serum BUN and creatinine levels by 24
Nursing Diagnosis : hours after initiation of medication therapy
1. Altered thought process
2. Potential impaired skin integrity Medical Management:
3. Impaired skin integrity 1. Prerenal azotemia is treated by optimizing renal perfusion.
2. Postrenal failure is treated by relieving the obstruction
3. Overall, medical management includes maintaining fluid balance,
RENAL DISORDER avoiding fluid excesses, or performing dialysis
RENAL FAILURE 4. The elevated potassium levels may be reduced by administering
 Renal Failure is a systemic disease and is a final common ion-exchange resins ( sodium polystyrene sulfonate “kayexalate”)
pathway of many different kidney and urinary tract 5. Diuretics are used for management of volume status
diseases. 6. Low-dose dopamine is often used to dilate the renal arteries
 Results when the kidneys are unable to remove the body’s 7. Atrial natriuretic peptide – inhibits sodium and water absorption
metabolic wastes or perform their regulatory functions and dilates the afferent arteriole, thus improving blood flow to the
 The substances normally eliminated in the urine accumulate glomerulus
in the body fluids as a result of impaired renal excretion and 8. Correction of acidosis and elevated phosphate levels. When
lead to a disruption in endocrine and metabolic functions severe acidosis is present, the arterial blood gases or serum
and fluid and electrolyte, an acid-base disturbances. bicarbonate levels must be monitored because patient may require
sodium bicarbonate therapy or dialysis. Patient’s elevated phosphate
ACUTE RENAL FAILURE level may be controlled with phophate-binding agents (aluminum
 Acute renal failure is a sudden and almost complete loss of hydroxide).
kidney function over a period of hours to days. 9. Nutritional Therapy. Dietary proteins are limited to about 1 g/kg
during the oliguric phase. High-carbohydrate meals to meet caloric
Categories of Acute Renal Failure : requirements. Foods and fluids containing potassium and
1. Prerenal Condition (hypoperfusion of kidney). Occurs as a phosphorus are restricted.
result of impaired blood flow that leads to hypoperfusion of the
kidney and a drop in the GFR. Common clinical situations are Nursing Management :
volume-depletion states(hemorrhage or gastrointestinal losses), 1. Monitoring fluid and electrolyte balance. Hyperkalemia is the most
impaired cardiac performance and vasodilation (sepsis or immediate life-threatening imbalance seen in acute renal failure.
anaphylaxis) 2. Reducing metabolic rate. To reduce catabolism and the
subsequent release of potassium and accumulation of endogenous
2. Intrarenal. Intrarenal causes of acute renal failure are the waste products. Bed rest is indicated and fever and infection are
result of actual parenchymal damage to the glomeruli or kidney prevented or treated promptly.
tubules. Conditions such as burns crush injuries, and infections, 3. Promoting pulmonary function. Patient is assisted to turn, cough
as well as nephrotoxic agents, may lead to acute tubular and take deep breaths frequently to prevent atelectasis and
necrosis and cessation of renal function. Severe transfusion respiratory infection.
reaction may also cause intrarenal failure. Medications may also 4. Preventing Infection. Asepsis is essential with invasive lines and
predispose a patient to intrarenal damage, esp. nonsteroidal catheters
anti-inflammatory drugs and ACE inhibitors 5. Providing skin care. Meticulous skin care is important. Massaging
bony prominences, turning the patient frequently, and bathing the
3. Post renal conditions. Postrenal causes of acute renal patient with cool water are comforting and prevent skin breakdown
failure are usually the result of an obstruction somewhere distal 6. Providing support. The patient and family will need assistance,
to the kidney. explanation and support during this time.

PHASES OF ACUTE RENAL FAILURE : CHRONIC RENAL FAILURE (End-Stage Renal Disease) ESRD
1. Initiation period – begins with the initial insult and ends when  CRF is a progressive, irreversible deterioration in renal function in
oliguria develops. which the body’s ability to maintain metabolic and fluid and
electrolyte balance fails, resulting in uremia or azotemia
2. Period of Oliguria – accompanied by a rise in the serum (retention of urea and other nitrogenous wastes in the blood)
concentration of substances usually excreted by the kidney
(urea, creatinine, uric acid, organic acids and the intracellular Pathophysiology:
cations – potassium and magnesium As renal function declines, the end products of protein metabolism
(which are normally excreted in urine) accumulate in the blood.
3. Period of diuresis – The patient experiences a gradual Uremia develops and adversely affects every system in the body.
increase in urinary output, which signals that glomerular filtration
has started to recover. Laboratory values start rising and 3 Stages of Chronic Renal Disease :
eventually begin a downward trend.Uremic symptoms may still
be present. The patient must be closely monitored for Stage 1
Reduced renal reserve. Characterized by a 40 to 75% loss of 5. Bone disease and metastatic calcifications. Due to retention of
nephron function. The patient usually does not have symptoms phosphorus, low serum calcium levels, abnormal vitamin D
because the remaining nephrons are able to carry out the normal metabolism, and elevated aluminum levels
functions of the kidney.
Medical Management:
1. Pharmacologic Therapy

Stage 2 a. Antacids. Hyperphosphatemia and hypocalcemia are treated with


Renal Insufficiency. Occurs when 75 to 90% of nephron function aluminum based antacids that bind dietary
is lost. At this point, the serum creatinine and blood urea phophorus in the GIT
nitrogen rise, the kidney loses its ability to concentrate urine and
anemia develops. The patient may report polyuria and nocturia. b. Antihypertensive and Cardiovascular agents. HPN is managed by
intravascular control and a variety of hypertensive medications. CHF
Stage 3 and pulmonary edema may require treatment with fluid restriction,
End-stage renal Disease (ESRD). The final stage of CRF occurs low sodium diets, diuretics, inotropic agents such as digitalis, or
when there is less than 10% nephron function remaining. All of dobutamine, and dialysis.
the normal regulatory, excretory, and hormonal functions of the
kidney are severely impaired. ESRD is evidenced by elevated c. Anticonvulsants. If seizures occurs. The onset of seizure is
creatinine and blood urea nitrogen levels as well as electrolyte recorded along with the type, duration and general effect on the
imbalances. Once the patient reaches this point, dialysis is patient. Intravenous Diazepam or phenytoin is usually administered
usually indicated. to control seizures. The side rails must be padded to protect the
patient
Signs And Symptoms Of CRF :
1. Neurologic d. Erythropoietin. Anemia associated with CRF is treated with
Weakness and fatigue; confusion; inability to concentrate; recombinant human erythropoietin (Epogen)
disorientation; tremors; seizures; asterixis; restlessness of legs;
burning of soles of feet; behavior changes. 2. Nutritional Therapy
2. Integumentary > Includes careful regulation of protein intake, fluid intake to balance
Gray-bronze skin color; dry, flaky skin; pruritus; ecchymosis; fluid losses, sodium intake to balance sodium losses and some
purpura; thin, brittle nails; coarse, thinning hair restriction of potassium
3. Cardiovascular
HPN; pitting edema(feet , hands, sacrum), periorbital edema; 3. Dialysis
pericardial friction rub; engorged neck veins; pericarditis; > Hyperkalemia is usually prevented by ensuring adequate dialysis
pericardial effusion; pericardial tamponade; hyperkalemia; treatments with potassium removal and careful monitoring of all
hyperlipidemia medications for their potassium intake
4. Pulmonary
Crackles; thick, tenacious sputum; depressed cough reflex; Nursing Management
pleuritic pain; shortness of breath; tachypnea; kussmaul-type
respirations; uremic pneumonitis; “ uremic lung Nursing Diagnoses :
5. Gastrointestinal 1. Fluid volume excess r/t decreased urine output, dietary excesses,
Ammonia odor to breath (uremic fetor); metallic taste; mouth and retention of sodium and water
ulcerations and bleeding; anorexia; nausea and vomiting; 2. Altered nutrition; less than body requirements r/t anorexia, nausea
hiccups; constipation or diarrhea; bleeding from GIT and vomiting, dietary restrictions, and altered oral mucous
6. Hematologic membranes
Anemia; thrombocytopenia 3. Knowledge deficit regarding condition and treatment regimen
7. Reproductive 4. Activity intolerance r/t fatigue, anemia, retention of waste products,
Amenorrhea; testicular atrophy; infertility; decreased libido and dialysis procedure
8. Musculoskeletal 5. Self-esteem disturbance r/t dependency, role changes, changes in
Muscle cramps; loss of muscle strength; renal osteodystrophy; body image, and sexual dysfunction
bone pain; bone fractures; foot drop
Nursing Care :
Assessment And Diagnostic Findings : 1. Directed toward assessing fluid status and identifying potential
1. Glomerular Filtration Rate. Decreased GFR can be detected sources of imbalance
by obtaining a 24-hour urine analysis for creatinine clearance. As 2. Implementing a dietary program to ensure proper nutritional intake
GFR decreases, the creatinine clearance value decreases, within the limits of the treatment regimen
whereas the serum creatinine and BUN levels increase. 3. Promoting positive feelings by encouraging increased self-care
and greater independence
2. Sodium and Water Retention. The kidney is unable to
concentrate or dilute the urine normally in ESRD. Some patients CARDIOVASCULAR DISORDERS
retain sodium and water, increasing the risk for edema, CHF,
and HPN. CARDIAC FAILURE
CONGESTIVE HEART FAILURE (CHF)
3. Acidosis. With advanced renal disease, metabolic acidosis  Often referred to as cardiac failure, is the inability of the heart to
occurs because the kidney is unable to excrete increased loads pump sufficient blood to meet the needs of the tissues for
of acid. oxygenation and nutrients.
 CHF is most commonly used when referring to left-sided and
4. Anemia. Anemia develops as a result of inadequate right-sided failure
erythoropoietin production, the shortened life span of RBC’s,  The incidence of CHF increases with age
nutritional deficiencies, and the patient’s tendency to bleed,
particularly from GIT Pathophysiology:
Cardiac failure most commonly occurs with disorders of cardiac
5. Calcium and Phosphorus Imbalance. The body’s serum muscles that result in decreased contractile properties of the heart.
calcium and phosphate levels have a reciprocal relationship in Common underlying conditions that lead to decreased myocardial
the body; as one rises, the other decreases. contractility include myocardial dysfunction, arterial hypertension,
and valvular dysfunction.
Myocardial dysfunction may be due to coronary artery disease,
Complications: dilated cardiomyopathy, or inflammatory and degenerative diseases
1. Hyperkalemia. Due to decreased excretion, metabolic of the myocardium. Atherosclerosis of the coronary arteries is the
acidosis, catabolism, and excessive intake (diet, medications, primary cause of heart failure. Ischemia causes myocardial
fluids) dysfunction because of resulting hypoxia and acidosis (from
accumulation of lactic acid). Myocardial infarction causes focal
2. Pericarditis. Due to retention of uremic waste products and myocellular necrosis, the death of myocardial cells, and a loss of
inadequate analysis contractility; the extent of the infarction is prognostic of the severity of
CHF.
3. Hypertension. Due to sodium and water retention and Dilated cardiomyopathy causes diffuse cellular necrosis, leading to
malfunction of the rennin-angiotensin-aldosterone system decreased contractility. Inflammatory and degenerative diseases of
the myocardium, such as myocarditis, may also damage myocardial
4. Anemia. Due to decrease erythropoietin, decreased RBC life fibers, with a resultant decrease in contractility.
span, GIT bleeding and blood loss during dialysis. Systemic or pulmonary HPN increases afterload which increases the
workload of the heart and in turn leads to hypertrophy of myocardial
muscle fibers; this can be considered a compensatory promotes vasodilation, causing a decrease in preload and afterload
mechanism because it increases contractility. and decreasing the workload of the heart.
Valvular heart disease is also a cause of cardiac failure. The
valves ensure that blood flows in one direction. With valvular Other medications. Anticoagulants may be prescribed. Beta-
dysfunction, valve has increasing difficulty moving forward. This adrenergic blockers maybe indicated in patients with mild or
decreases the amount of blood being ejected, increases moderate failure.
pressure within the heart, and eventually leads to pulmonary and
venous congestion. Nutritional Therapy:
1. A low-sodium diet
Etiologic Factors : 2. Avoidance of excessive amount of fluids
1. Increased metabolic rate (eg. fever, thyrotoxicosis)
2. Hypoxia Nursing Management:
3. Anemia 1. Record intake and output to identify a negative balance (more
output than input)
2. Weigh patient daily at the same time
VENTRICULAR FAILURE 3. Auscultate lung sounds daily to detect a decrease or an absence
of pulmonary crackles
LEFT-SIDED CARDIAC FAILURE 4. Determine the degree of jugular distention
 Pulmonary congestion occurs when the left ventricle cannot 5. Identify and evaluate severity of dependent edema
pump the blood out of the chamber. This increases 6. Monitor pulse rate and BP, and make sure the patient does not
pressure in the left ventricle and decreases the blood flow become hypotensive from dehydration
from the left atrium. The pressure in the left atrium 7. Examine skin turgor and mucous membranes for signs of
increases, which decreases the blood flow coming from the dehydration
pulmonary vessels. The resultant increase in pressure in 8. Assess for symptoms of fluid overload (orthopnea, paroxysmal
the pulmonary circulation forces fluid into the pulmonary nocturnal dyspnea, and dyspnea on exertion)
tissues and alveoli; which impairs gas exchange

Clinical Manifestations : Nursing Process : The Patient With Cardiac Failure


1. Dyspnea on exertion
2. Cough Assessment
3. Adventitious breath sounds  The focus of the nursing assessment for the patient with cardiac
4. Restless and anxious failure is directed toward observing for signs and symptoms of
5. Skin appears pale and ashen and feels cool and clammy pulmonary and systemic fluid overload.
6. Tachycardia and palpitations
7. Weak, thready pulse Health History
8. Easy fatigability and decreased activity tolerance  The nurse explores sleep disturbances, particularly sleep
suddenly interrupted by shortness of breath.
RIGHT-SIDED CARDIAC FAILURE  The nurse finds out about the number of pillows needed for sleep
 When the right ventricle fails, congestion of the viscera and (indication of dyspnea)
the peripheral tissues predominates. This occurs because  Find out also the activities of daily living and the activities that
the right side of the heart cannot eject blood and thus causes shortness of breath
cannot accommodate all the blood that normally returns to it
from the venous circulation. Physical Examination
 The lungs are auscultated at frequent intervals to detect crackles
Clinical Manifestations : and wheezes or their absence. The rate and depth of
1. Edema of the lower extremities (dependent edema) respiration are also noted.
2. Weight gain
3. Hepatomegaly (enlargement of the liver)
 The heart is auscultated for an S3 heart sound, a sign that the
4. Distended neck veins heart pump is beginning to fail and that increased blood volume
5. Ascites (accumulation of fluid in the peritoneal cavity) remains in the ventricle with each beat. HR and rhythm are also
6. Anorexia and nausea noted.
7. Nocturia (need to urinate at night)  Jugular vein distention is also assessed. Distention greater than
8. Weakness 3 cm above the sternal angle is considered abnormal.
 Sensorium and level of consciousness must be evaluated
Medical Management  Dependent parts of the patient’s body are assessed for perfusion
and edema.
The basic objectives in CHF management are the following :  The liver is examined for hepatojugular reflux.
1. Reducing the workload on the heart  Output is measured carefully to establish a baseline against
2. Increasing the force and efficiency of myocardial contraction which to measure the effectiveness of diuretic therapy. Intake
3. Eliminating the excessive accumulation of body water by and output record are maintained
avoiding excess fluid, controlling the diet, and monitoring diuretic
and angiotensin-converting enzyme (ACE) inhibitor therapy Nursing Diagnoses :
1. Activity intolerance r/t imbalance between oxygen supply and
Pharmacologic Therapy: demand secondary to decreased CO
If the patient is in mild failure, usually an ACE inhibitor is 2. Excess fluid volume r/t excess fluid/sodium intake or retention
prescribed. A diuretic is added if there is no improvement or if secondary to CHF and its medical therapy
there are signs of fluid overload. Next, digitalis is added if the 3. Anxiety r/t breathlessness and restlessness secondary to
symptoms continue. If symptoms are severe, all three inadequate oxygenation
medications are usually started immediately. 4. Non-compliance r/t to lack of knowledge
5. Powerlessness r/t inability to perform role responsibilities
ACE Inhibitors. Promote vasodilation and diuresis by decreasing secondary to chronic illness and hospitalization.
afterload and preload eventually decreasing the workload of the
heart. Potential Complications :
1. Cardiogenic shock
Diuretic Therapy. A diuretic is one of the first medications 2. Dysrhythmias
prescribed to a patient with CHF. Diuretics promote the excretion 3. Thromboembolism
of sodium and water through the kidneys. 4. Pericardial effusion and pericardial tamponade

Digitalis. This medication increases the force of myocardial Planning And Goals :
contraction and slows conduction through the AV node. It 1. Promoting activity while maintaining vital signs within identified
improves contractility thus, increasing left ventricular output. range
2. Reducing fatigue
Dobutamine.(Dobutrex) is an intravenous medication given to 3. Relieving fluid overload symptoms
patients with significant left ventricular dysfunction. A 4. Decreasing the incidence of anxiety or increasing patient’s ability
catecholamine, it stimulates the beta1-adrenergic receptors. Its to manage anxiety
major action is to increase cardiac contractility. 5. Teaching the patient about the self-care program.
6. Encouraging the patient to verbalize his ability to make decisions
Milrinone (Primacor). A phosphodiesterase inhibitor that prolongs and influence outcomes.
the release and prevents the uptake of calcium. This in turn,
Nursing Interventions :
1. Promoting Activity Tolerance wedge pressure is elevated and the CO is decreased as the left
 The patient is encouraged to perform an activity more slowly ventricle loses its ability to pump.
than usual, for a shorter duration, or with assistance initially.
 Barriers that could limit abilities to perform an activity are 2. The systemic vascular resistance is elevated due to the
identified sympathetic nervous system stimulation that occurs as a
 Pacing and prioritizing activities will maintain the patient’s compensatory response to the decrease in blood pressure.
energy to allow participation in regular exercise.
 Vital signs should be taken before, during and immediately 3. The decreased blood flow to the kidneys causes a hormonal
after an activity to identify whether they are within the response that causes fluid retention and further vasoconstriction.
predetermined range.
4. The increases in HR, circulating volume, and vasoconstriction
2. Reducing Fatigue occur to maintain circulation to the brain, heart and lungs, however,
 The nurse and patient can collaborate to develop a schedule the workload of the heart is increased.
that promotes pacing and prioritization of activities. The
schedule should alternate activities with periods of rest and 5. Continued cellular hypoperfusion eventually results in organ
avoid having two significant energy-consuming activities failure. The patient becomes unresponsive, severe hypotension
occur on the same day or in immediate succession. occurs, and the patient develops shallow respirations, cold, cyanotic
or mottled skin, and absent bowel sounds.
3. Managing Fluid Volume
6. Arterial blood gas analysis shows metabolic acidosis
 The nurse monitors the patient’s fluid status closely.
Auscultating the lungs, comparing daily body weights,
7. All laboratory results indicate organ dysfunction.
monitoring intake and output and assisting the patient to
adhere to a low-sodium diet.
Medical Management :
 The nurse needs to position the patient or teach the patient 1. Reduce any further demand on the heart
how to assume a position that shifts fluid away from the 2. Improve oxygenation and restore tissue perfusion
heart. 3. Diuretics, vasodilators, and mechanical devices (filtration and
 The nurse needs to assess for skin breakdown and institute dialysis)
preventive measures 4. Intravenous volume expanders (normal saline, lactated Ringer’s
solution, and albumin) are given for hypovolemia or low intravascular
4. Controlling Anxiety volume.
 The nurse should take steps to promote physical comfort and 5. Strict bed rest to conserve energy
psychological support. A family member’s presence 6. Oxygen administration is increased for hypoxemia
provides reassurance. Speaking in a slow, calm, and 7. Intubation and sedation may be necessary to maintain
confident manner is helpful. Stating specific, brief directions oxygenation balance.
for an activity is helpful in decreasing anxiety.
Pharmacologic Therapy:
5. Minimizing Powerlessness  Most medication are administered IV because of the decreased
 Patients need to recognize that they are not helpless and that perfusion to the gastrointestinal system
they can influence their direction, their lives, and their
outcomes. 1. Pressor agents are medications used to raise BP and increase
 The nurse needs to assess for factors contributing to a CO. Many pressor medications are catecholamines ( norepinephrine
perception of powerlessness and intervene accordingly. and high-dose dopamine) to promote perfusion to the heart and
Contributing factors may include lack of knowledge, hospital brain.
policies, and lack of opportunities to make decisions. 2. Diuretics and vasodilators may be administered to reduce the
 Taking time to listen to patient encourages them to express workload of the heart.
their concerns and questions 3. Positive inotropic medications are given to increase myocardial
 Provide the patient with decision-making opportunities contractility
 Provide encouragement and praise 4. Circulatory assist devices: Intra-aortic balloon pump – to augment
the pumping action of the heart. The device inflates during diastole,
Expected Outcomes : increasing the pressure in the aorta and therefore increasing
1. Demonstrates tolerance for increased activity perfusion. It deflates just before systole, lessening the pressure
2. Has less fatigue and dyspnea within the aorta before ventricular contraction, decreasing the
3. Maintains fluid balance amount of resistance the heart has to overcome to eject blood and
4. Is less anxious therefore decreasing the amount of work the heart must complete to
5. Adheres to self-care regimen eject blood.
6. Makes decisions regarding care and treatment
7. Absence of complications Nursing Management:
1. Nurse must carefully assess the patient, observe the cardiac
CARDIOGENIC SHOCK rhythm, measure hemodynamic parameters, and record fluid intake
 Occurs when the heart cannot pump enough blood to supply and urinary output.
the amount of oxygen needed by the tissues. 2. The patient must be closely monitored for responses to the
medical interventions and for the development of complications
Pathophysiology: 3. The patient is always treated in intensive care environment
The heart muscle loses its contractile power, resulting in a because of the frequency of nursing interventions and the technology
marked reduction in SV and CO, sometimes called “forward required for effective medical management.
failure”. The damage to myocardium results in a decrease in CO,
which in turn reduces arterial blood pressure and tissue THROMBOEMBOLISM
perfusion in the vital organs (heart, brain, kidneys). Flow to the  The decreased mobility of the patient with cardiac diseases and
coronary artery is reduced, resulting in decreased oxygen supply the impaired circulation that accompany these disorders
to the myocardium, which in turn increases ischemia and further contribute to the development of intracardiac and intravascular
reduces the heart’s ability to pump. The inadequate emptying of thrombosis.
the ventricle also leads to increased pulmonary pressures, Intracardiac Thrombus
pulmonary congestion, and pulmonary edema, exacerbating the  Detected by an echocardiogram and treated with anticoagulants,
hypoxia and resulting ischemia of vital organs. such as warfarin.
 A part of the thrombus may become detached and may be
Clinical Manifestations : carried to the brain, kidneys, intestines, or lungs
1. Tissue hypoperfusion – classic signs of cardiogenic shock  The most common problem is pulmonary embolism. The
manifested as cerebral hypoxia (restlessness, confusion, symptoms of pulmonary embolism include chest pain, cyanosis,
agitation), low blood pressure, rapid and weak pulse, cold and and shortness of breath, rapid respirations and hemoptysis.
clammy skin, increased respiratory crackles, hypoactive bowel  The pulmonary embolus may block the circulation to a part of the
sounds, and decreased urinary output. lung, producing an area of pulmonary infarction
2. Initially, arterial blood gas analysis may show respiratory  Systemic embolism may present as cerebral, mesenteric, or renal
alkalosis. infarction
3. Dysrhythmias are common  An embolism can also compromise the blood supply to an
extremity
Assessment and Diagnostic Findings :
1. The use of a Pulmonary Artery catheter to measure left PERICARDIAL EFFUSION AND CARDIAC TAMPONADE
ventricular pressures and CO is important in assessing the Pathophysiology:
severity of the problem and planning management. The PA
Pericardial effusion refers to the escape of fluid into the electrocardiographic monitoring and frequent BP assessment are
pericardial sac. Normally, the pericardial sac contains less than essential until hemodynamic stability is reestablished.
50 ml of fluid, which the heart needs to decrease friction for the
beating heart. An increase in pericardial fluid raises the pressure
within the pericardial sac and compresses the heart. This results DYSRHYTHMIAS
in :  Disorders of the formation and/or conduction of the electrical
 Increased right and left ventricular-end diastolic pressures impulse within the heart. This can cause disturbances of the
 Decreased venous return heart rate, the heart rhythm, or both.
 Inability of the ventricles to distend adequately
Pericardial fluid may accumulate slowly without causing Normal Electrical Conduction
noticeable symptoms. A rapidly developing effusion, however, The electrical impulse that stimulates and paces the cardiac muscle
can stretch the pericardium to its maximum size and, because of normally originates in the sinus node, located near the vena cava in
increased pericardial pressure, and reduce venous return to the the right atrium. Normally, the impulse occurs at a rate between 60
heart, and decrease cardiac output. The result is cardiac and 100 times a minute in the adult. The impulse quickly travels from
tamponade. the sinus node through the atria to the atrioventricular (AV) node
Clinical Manifestations : causing the atria to contract. The structure of the AV node slows the
1. The patient may complain of a feeling of fullness within the impulse, which allows time for the atria to contract and the ventricles
chest. The feeling of pressure may result from stretching of the to fill with blood. From the AV node, the impulse travels quickly along
pericardial sac the right and left bundle branches and the Purkinje fibers, located in
2. Engorged neck veins the ventricular muscle. The electrical stimulation of the ventricles, in
3. Shortness of breath turn, causes the ventricles to contract (systole). Then the
4. A drop and fluctuation in BP electromechanical impulse completes the circuit and the cycle begins
again. In this way, sinus rhythm promotes cardiovascular circulation.
Assessment and Diagnostic Findings : The electrical stimulus causes the mechanical event of the heart.
1. Pericardial effusion is detected by percussing the chest and
noting an extension of flatness across the anterior aspect of the  Depolarization. The electrical stimulation: the mechanical
chest contraction is called systole.
2. Echocardiogram to confirm diagnosis  Repolarization. The electrical relaxation and mechanical
relaxation is called diastole.
Medical Management :
1. Pericardial Fluid Aspiration (pericardiocentesis) – performed to Influences on Heart Rate and Contractility
remove fluid from the pericardial sac  Heart rate is influenced by the autonomic nervous system, which
2. Pericardiotomy. A portion of pericardium is sliced to permit the consists of sympathetic and parasympathetic fibers.
pericardial fluid to drain into the lymphatic system.  Stimulation of the sympathetic system increases heart rate.
 Sympathetic stimulation also causes the constriction of peripheral
CARDIAC ARREST blood vessels and, therefore, an increase in BP
 Occurs when the heart ceases to produce an effective pulse  Parasympathetic stimulation slows the heart rate
and blood circulation. It may be due to a cardiac electrical  Manipulation of the autonomic nervous system may increase or
event, as when the HR is too fast or too slow or when there decrease the incidence of dysrhythmias
is no heart rate at all.
Types of Dysrhythmias
Clinical Manifestations :
1. Loss of consciousness, pulse and BP 1. Sinus Node Dysrhythmias
2. Ineffective respiratory gasping
3. The pupils of the eyes dilate within 45 seconds. A. Sinus Bradycardia
4. Seizures may or may not occur
 Occurs when the sinus node creates an impulse at a slower –
Emergency Management : than-normal rate.
Cardiopulmonary Resuscitation
1. Airway – maintain open airway Etiology :
2. Breathing – provide artificial circulation by rescue breathing 1. Slower metabolic needs (sleep, athletic training, hypothyroidism)
3. Circulation – promoting artificial circulation by external cardiac 2. Vagal stimulation (vomiting, suctioning, severe pain, extreme
compression emotions)
4. Defibrillation – restoring the heart beat 3. Medications
4. Increased intracranial pressure and MI
Maintaining Airway and Breathing
 The first step in CPR is to obtain an open airway. Any Treatment :
obvious material in the mouth and throat should be 1. Atropine 0.5 to 1.0 mg given quickly and IV as bolus – medication
removed. The chin is directed up and back or the jaw of choice
(mandible) is lifted forward. The rescuer “looks, listen. and 2. Catecholamines and emergency transcutaneous pacing
feels” for air movement. An oropharyngeal airway is
inserted if available. Two rescue ventilations over 3 to 4 B. Sinus Tachycardia
seconds are provided using a bag or mouth-mask device. If
the first rescue ventilation entered easily, then the patient is  Occurs when the sinus node creates an impulse at a faster-than-
ventilated with 12 breaths per minute and the open airway normal rate.
is maintained. Endotracheal intubation is performed to
 It may be caused by acute blood loss, anemia shock,
ensure an adequate airway and ventilation.
hypovolemia, hypervolemia, CHF, pain, hypermetabolic state,
fever, exercise, anxiety or sympathomimetic medications.
Restoring Circulation
 After performing ventilation, the carotid pulse is assessed Treatment :
and external cardiac compressions are provided when no 1. Calcium channel blockers (ex. Diltiazem)
pulse is detected. 2. Beta-blockers (ex. Propranolol)
 1. Compressions are performed with the patient on a firm
surface (Cardiac board, floor) C. Sinus Arrhythmia
 2. The rescuer (facing the patient’s head) places the heel of  Occurs when the sinus node creates an impulse at an irregular
one hand on the lower half of the sternum, two fingerwidths rhythm; the rate increases with inspiration and decreases with
from the tip of the xiphoid and positions the other hand on expiration
top of the first hand. The fingers should not touch the chest
wall. 2. Atrial Dysrhythmias
 3. Using the body weight while keeping the elbows straight,
the rescuer presses quickly downward from the shoulder A. Premature Atrial Complex (PAC)
area to deliver a forceful compression to the victim’s lower  This is a single ECG complex that occurs when an electrical
sternum toward the spine. impulse starts in the atrium before the next normal impulse of
 4. The chest compression rate is 80 to 100 times/minute the SA node.
 The PAC may be caused by caffeine, alcohol, nicotine, stretched
Follow-up Monitoring atrial myocardium
1. After successful resuscitation, the patient is transferred to an  PAC’s are common in normal hearts. The patient may say “My
intensive care unit for close monitoring. Continuous heart skipped a beat.” A pulse deficit may exist.
 If PAC’s are infrequent, no treatment is necessary.
4. Intravenous adenosine may be prescribed to cause a conversion
B. Paroxysmal Atrial Tachycardia to sinus rhythm.
 A term used to indicate a tachycardia characterized by abrupt
onset and abrupt cessation and a QRS of normal duration. 4. Ventricular Dysrhythmias
 Now called AV nodal reentry tachycardia
A. Premature Ventricular Complex (PVC)
C. Atrial Flutter  PVC is an impulse that starts in a ventricle before the next normal
 Occurs in the atrium and creates impulses at an atrial rate sinus impulse.
between 250 and 400 times per minute  PVC’s can occur in healthy people, esp. with the use of caffeine,
 May cause serious signs and symptoms: chest pain, nicotine, and alcohol.
shortness of breath, and low blood pressure.  Also caused by cardiac ischemia or infarction, increased
workload on the heart (ex. Exercise, fever. Hypervolemia, CHF,
Treatment : and tachycardia), digitalis toxicity, hypoxia, acidosis, and
1. If patient is unstable, electrical cardioversion is indicated electrolyte imbalances, esp. hypokalemia
2. If patient is stable, diltiazem, verapamil, beta-blockers or  In the absence of disease, PVC’s are not serious. In the patient
digitalis may be administered IV to slow the ventricular rate. with acute MI, PVC’s may indicate the need for more
aggressive therapy.
 The following are warning or complex PVC’s (precursors of
D. Atrial Fibrillation ventricular tachycardia) : (1) more than 6/minute (2) multifocal
 Causes a rapid, disorganized, and uncoordinated twitching of (having different shapes), (3) two in a row (pair), and (4)
atrial musculature. occurring on the T wave (the vulnerable period of ventricular
 The most common dysrhythmias depolarization)
 Usually associated with advanced age, valvular heart
disease, cardiomyopathy, hyperthyroidism, pulmonary Treatment :
disease, moderate to heavy ingestion of alcohol and the 1. Lidocaine is the medication most commonly used for immediate
aftermath of open heart surgery short-term therapy

Treatment : B. Ventricular Tachycardia


 Treatment depends on its cause and duration and the  Defined as three or more PVC’s in a row, occurring at a rate
patient’s symptoms and instability exceeding 100 beats/minute.
 In some cases, AF converts to sinus rhythm within 24 hours  Ventricular tachycardia is usually associated with coronary artery
without treatment disease and may precede ventricular fibrillation.
 Both stable and unstable AF of short duration are treated the  Ventricular tachycardia is an emergency because the patient is
same as stable and unstable atrial flutter usually unresponsive and pulseless.
 To prevent recurrence and to promote heart rate control over
a long period, quinidine, procainnamide, flecainide, sotalol,
or amiodatone may be prescribed Treatment :
 Anti-coagulation therapy is indicated if patient is elderly or 1. Lidocaine is the initial choice
has hypertension, heart failure or a history of stroke. 2. Cardioversion maybe indicated if the medications are ineffective or
 Pacemaker or surgery is sometimes indicated for patients if the patient becomes unstable
who are unresponsive to medications 3. Immediate defibrillation

3. Junctional Dysrhythmias  Ventricular tachycardia in a patient who is unconscious and


without pulse is treated in the same manner as ventricular
A. Premature Junctional Complex fibrillation.
 An impulse that starts in the AV nodal area before the next
normal sinus impulse. C. Ventricular Fibrillation
 Causes include : digitalis toxicity, congestive heart failure,  A rapid but disorganized ventricular rhythm that causes
and coronary artery disease ineffective quivering of the ventricles.
 Rarely produce any significant symptoms  This dysrhythmias is always characterized by the absence of an
audible heartbeat, a palpable pulse, and respirations.
 Treatment is the same as for frequent PAC’s
 Cardiac arrest and death are imminent if VF is uncorrected
B. Junctional Rhythm
Treatment :
 Occurs when the AV node, instead of the SA node, becomes
1. Immediate defibrillation and activation of emergency services.
the pacemaker of the heart.
Placing a call for emergency assistance takes precedence over
 Junctional rhythm may produce signs and symptoms of initiating CPR
reduced cardiac output. If so, the treatment is the same as 2. After a successful defibrillation, eradicating causes and
for sinus bradycardia. administering anti dysrhythmics medication are treatments to prevent
the recurrence of VF.
C. AV Nodal Reentry Tachycardia
 Occurs when an impulse is conducted to an area in the AV D. Idioventricular Rhythm
node that causes the impulse to be rerouted back into the  Also called ventricular rhythm, occurs when the impulse starts in
same area over and over again at a very fast rate. the conduction system below the AV node
 Factors associated with the development of AV nodal reentry  Commonly causes the patient to lose consciousness and
tachycardia include caffeine, nicotine, hypoxemia, and experience other signs and symptoms of reduced cardiac
stress output. In such cases, treatment is the same as for any
 Signs and symptoms vary with the rate and duration of the bradycardia, including identifying the underlying etiology,
tachycardia and the patient’s underlying condition. Usually administering IV atropine, and initiating emergency
of short duration, resulting only in palpitations. A fast rate transcutaneous pacing.
may reduce cardiac output, resulting in significant signs and  Bed rest is prescribed so as not to increase cardiac workload
symptoms such as restlessness, chest pain, shortness of E. Ventricular Asystole
breath, pallor, hypotension and loss of consciousness
 Commonly called flatline, ventricular asystole is characterized by
absent QRS complexes, although P waves may be apparent for
a short duration.
Treatment :
 There is no heart beat, no palpable pulse, and no respiration.
 Treatment is aimed at breaking the reentry of the impulse.
 Without treatment, ventricular asystole is fatal.
1. Vagal maneuvers, such as carotid sinus massage, gag reflex,
breath holding, and immersing the face in ice water – increase Treatment :
parasympathetic stimulation, causing slower conduction through 1. CPR
the AV node and blocking the reentry of the rerouted impulse. 2. Rapid assessment to identify possible causes
3. Intubation and establishment of IV access are the first
 Because of the risk of a cerebral embolic event, carotid sinus
recommended actions
massage is contraindicated in patients with carotid bruits.
4. Bolus of IV epinephrine and to be repeated at 3-5 minutes
intervals
2. If vagal maneuvers are ineffective, the patient may then
5. Sodium bicarbonate maybe administered IV
receive a bolus of adenosine, verapamil, or diltiazem.
3. Cardioversion is the treatment of choice if the patient is
Nursing Process: The Patient With A Dysrhythmia
unstable or does not respond to the medications.
Assessment 3. Hemothorax from puncture of the subclavian vein or internal
 Major areas of assessment include possible causes of the mammary artery
dysrhythmias and the dysrhythmia’s effect on the heart’s 4. Ventricular ectopy and tachycardia from irritation of the ventricular
ability to pump an adequate blood volume wall by the endocardial electrode
 When cardiac output is reduced, the amount of oxygen 5. Movement or dislocation of the lead placed transvenously
reaching the tissues and vital organs is diminished. This (perforation of the myocardium)
diminished oxygen produces the signs and symptoms 6. Phrenic nerve, diaphragmatic (hiccupping) or skeletal muscle
associated with dysrhythmias. stimulation may occur if the lead is dislocated or if the delivered
 A health history is obtained to identify possible causes and energy is set high
past incidences of syncope (fainting), lightheadedness, 7. Rarely, cardiac tamponade occurs after removal of epicardial
dizziness, fatigue, chest discomfort, and palpitations. wires
 Psychosocial assessment is also performed to identify the 8. Dislodgement of the pacing electrode – most common
possible effects of dysrhythmia complication. Minimizing patient activities can help to prevent this
 Physical assessment is conducted to confirm the data complication.
obtained from the history and to observe for signs of
diminished cardiac output during the dysrhythmic event, BURNS
esp. changes in level of consciousness. Skin may be pale
and cool. Signs of fluid retention, such as neck vein There are 4 major goals relating to burns :
distention, crackles and wheezes in the lungs may be 1. Prevention
detected during auscultation. 2. Institution of lifesaving measures for the severely burned person
3. Prevention of disability and disfigurement through early,
 The rate and rhythm of apical and peripheral pulses are
specialized, individual treatment
assessed and any pulse deficit is noted.
4. Rehabilitation through reconstructive surgery and rehabilitative
 The chest is auscultated for extra heart sounds, esp. S3 and programs
S4, measures BP and determines pulse pressures. A
declining pulse pressure indicates reduced cardiac output. Pathophysiology:
Burns are caused by a transfer of energy from a heat source to the
Diagnosis: body. Heat maybe transferred through conduction or electromagnetic
1. Potential/actual decrease in cardiac output radiation. Burns are categorized as thermal (including electrical
2. Anxiety related to fear of the unknown burns), radiation or chemical. Tissue destruction results from
3. Lack of knowledge about the dysrhythmias and its treatment. coagulation, protein denaturation, or ionization of cellular contents.
The skin and the mucosa of the upper airways are the sires of tissue
Potential Complications : Ischemic Heart Disease destruction. Deep tissues, including the viscera, can be damaged by
electrical burns or through prolonged contact.
Nursing Interventions : The depth of the injury depends on the temperature of the burning
1. Monitoring and Managing the Dysrhythmias agent and the duration of contact with the agent.
 Controlling the incidence or effect of dysrhythmias is often
achieved by the use of ant-idysrhythmic medications Classification of Burns
 A constant serum blood level of the medication is maintained  Burn injuries are described according to the depth of the injury
to maximize beneficial effects and minimize adverse effects and the extent of body surface area (BSA) injured.
 If the patient is hospitalized, an ECG is initiated and rhythm
strips are analyzed to track dysrhythmias Characteristics of Burns according to Depth
 BP, rate and depth of respirations, pulse rate and rhythm are
evaluated regularly to determine the hemodynamic effect of Factors to consider in the determination of depth :
the dysrhythmias 1. History of how the injury occurred
2. Causative agent, such as flame or scalding liquid
2. Minimizing Anxiety 3. Temperature of the burning agent
 Nurse must maintain a calm and reassuring attitude 4. Duration of contact with the agent
 Maximize the patient’s control and to make the unknown less 5. Thickness of the skin
threatening
Extent of Body Surface Area Injured
Evaluation
Rule of Nines
Expected Outcomes :  An estimation of the total BSA involved in a burn is simplified
1. Cardiac output is maintained using the rule of nines
2. Anxiety is minimized
3. The patient knows about dysrhythmias and its treatment Lund and Browder Method
 A more precise method of estimating the extent of a burn
 Recognizes that the percentage of BSA of various anatomic
Adjunctive Modalities and Management parts, especially the head and legs, changes with growth.
1. Cardioversion and Defibrillation  By dividing the body into very small areas and providing an
 Treatment for tachydysrhythmias. estimate of the proportion of BSA accounted for by such body
 Used to deliver an electrical current to stimulate a critical parts, one can obtain a reliable estimate of the total BSA
mass of myocardial cells. This allows the sinus node to burned.
recapture its role as the heart’s pacemaker.  The initial evaluation is made on the patient’s arrival at the
 One major difference between cardioversion and defibrillation hospital.
has to do with the timing of the delivery of electrical current.
 Defibrillation is usually performed as an emergency Palm Method
treatment, whereas cardioversion is usually a planned  A method to estimate the percentage of scattered burns.
procedure  The size of the patient’s palm is approximately 1% of BSA. The
 Cardioversion involves the delivery of a “timed” electrical size of the palm can be used to assess the extent of burn injury.
current to terminate a tachydysrhythmia.
 Defibrillation is the treatment of choice for ventricular Local and Systemic Responses to Burns
fibrillation and pulseless ventricular tachycardia.  Burns that do not exceed 25% of the total BSA produce a
primarily local response
2. Pacemaker Therapy  Burns that exceed 25% BSA may produce both a local and a
 An electronic device that provides electrical stimuli to the systemic response, which is considered a major burn injury.
heart muscle.
 Usually used when a patient has a slower-than-normal
impulse formation Overview of physiologic changes after a major burn injury
 May also be used to control tachydysrhythmias that do not
respond to medication therapy Cardiovascular Response
 Cardiac output decreases before any significant change in blood
Complications of Pacemakers : volume is evident. As fluid loss continuous and vascular volume
1. Local infection at the entry site of the leads or at the decreases, cardiac output continuous to fall and blood pressure
subcutaneous site drops. This is the onset of burn shock. In response, the
2. Bleeding and hematoma at the lead-entry sites or at the sympathetic nervous system releases catecholamines, resulting
subcutaneous sites for permanent generator placement in an increase in peripheral resistance (vasoconstriction) and an
increase in pulse rate. Peripheral vasoconstriction further  Treatment usually consists of early intubation and mechanical
decreases cardiac output. ventilation with 100% oxygen. Using 100% oxygen is essential
 Prompt fluid resuscitation maintains the blood pressure in the to accelerate the removal of carbon monoxide from the
low-normal range and improves cardiac output. Despite hemoglobin molecule.
adequate fluid resuscitation, cardiac filling pressures remain
low during the burn-shock period. If inadequate fluid
resuscitation occurs, distributive shock will occur. Indicators of possible pulmonary damage :
 Generally, the greatest volume of fluid leak occurs in the first 1. History indicating hat the burn occurred in an enclosed area
24 to 36 hours after the burn, peaking by 6 to 8 hours. 2. Burns of the face or neck
 As the capillaries begin to regain their integrity, burn shock 3. Singed nasal hair
resolves and fluid returns to the vascular compartment. 4. Hoarseness, voice change, dry cough, stridor, sooty sputum
 As fluid is reabsorbed from the interstitial tissue into the 5. Bloody sputum
vascular compartment, blood volume increases. 6. Labored breathing or tachypnea (rapid breathing) and other signs
 If renal and cardiac function is adequate, urinary output of reduced oxygen levels (hypoxemia).
increases. 7. Erythema and blistering of the oral or pharyngeal mucosa
 Patients with severe burns develop massive systemic
edema. As edema increases in circumferential burns, Pulmonary Complications secondary to Inhalation Injury :
pressure on small blood vessels and nerves in distal
extremities causes an obstruction of blood flow and 1. Acute respiratory failure
consequent ischemia. This complication is known as  Occurs when impairment of ventilation and gas exchange is life-
compartment syndrome. The physician may need to threatening.
perform an esharotomy, a surgical incision into the eschar  The immediate intervention is intubation and mechanical
(devitalized tissue resulting from a burn), to relieve the ventilation.
constricting effect of the burned tissue.  If ventilation is impaired by restricted chest excursion, immediate
escharotomy is needed.
Effects on Fluids, Electrolytes, and Blood Volume
 Circulating blood volume decreases dramatically during burn 2. Acute respiratory distress syndrome
shock. Evaporative fluid loss through the burn may reach 3 > May develop in the first few days after injury secondary to systemic
to 5 L or more over a period of 24 hours until the burn and pulmonary responses to the burn and inhalation injury.
surfaces are covered.
 During the shock, serum sodium levels vary in response to Other Systemic Responses
fluid resuscitation. Usually hyponatremia (sodium depletion)  Renal function may be altered as a result of decreased blood
is present, as water shifts from the interstitial to the vascular volume. If there is inadequate blood flow through the kidney,
space. the hemoglobin and myoglobin occlude the renal tubules,
 Immediately after burn injury, hyperkalemia (excessive K) resulting in acute tubular necrosis and renal failure.
results from massive cell destruction. Hypokalemia may  The immunologic defenses of the body are greatly altered by
occur later with fluid shifts and inadequate potassium burn injury. The loss of skin integrity is compounded by the
intake. release of abnormal inflammatory factors. Immunosuppression
 At the time of burn injury, some red blood cells may be places the patient at high risk for sepsis.
destroyed and/or damaged resulting in anemia. Despite  Loss of skin also results in an inability to regulate body
this, patient’s hematocrit may be elevated due to plasma temperature. Burn patients may therefore exhibit low body
loss temperature in the early hours after burn injury, but as
 Blood transfusions are required periodically to maintain hypermetabolism resets core temperatures, burn patients
adequate hemoglobin levels for oxygen delivery. becomes hyperthermic for most of the postburn period, even in
 Abnormalities in coagulation, including a decrease in the absence of infection.
platelets (thrombocytopenia) and prolonged clotting and  Two potential gastrointestinal complications may occur: paralytic
prothrombin time, also occur with burn injury. ileus (absence of intestinal peristalsis) and Curling’s ulcer.
Decreased peristalsis and bowel sounds are manifestations of
Pulmonary Response paralytic ileus resulting from burn trauma. Gastric distention and
 Inhalation injury is the leading cause of death in fire victims. nausea may lead to vomiting unless gastric decompression is
initiated.
 One third of all burn injuries have a pulmonary problem
related to the burn injury.
Management Of The Patient With A Burn Injury
 Even without pulmonary injury, hypoxemia may be present.
Early in the post burn period, catecholamine release in A. Emergent/Resuscitative Phase of Burn Care
response to the stress of the burn injury alters peripheral
 The first priority in on-the-scene care for a burn victim is to
blood flow, thereby reducing oxygen delivery to the
prevent injury to the rescuer.
periphery. Later, hypermetabolism and continued
catecholamine release lead to increased tissue oxygen
Airway, Breathing, Circulation
consumption, which can lead to hypoxemia.
 It is important to remember the ABC’s of all trauma care because
Categories of Pulmonary Injury : the systemic effects pose a greater threat to life.

1. Upper Airway Injury 1. Airway


2. Breathing
 Results from direct heat or edema.
3. Circulation; Cervical spine immobilization for all high voltage
 Manifested by mechanical obstruction of the upper airway, electrical injury; Cardiac monitoring for all electrical injuries for at
including the pharynx and larynx least 24 hours after cessation of dysrhythmias.
 Because of the cooling effect of rapid vaporization in the
pulmonary tract, direct heat injury does not normally occur  Breathing must be assessed and a patent airway established
below the level of the bronchus. immediately during the initial minutes of emergency care.
 Treated by early nasotracheal or endotracheal intubation. Immediate therapy is directed toward establishing an airway
and administering humidified 100% oxygen.
2. Inhalation below the glottis  The circulatory system must also be assessed quickly. Apical
 Results from inhaling the products of incomplete combustion pulse and blood pressure are monitored frequently
or noxious gases. These products include carbon
monoside, sulfur oxides, nitrogen oxides, aldehydes, Management of Fluid Loss and Shock
cyanide, ammonia, chlorine, phosgene, benzene, and  Next to respiratory difficulties, the most important is preventing
halogens. irreversible shock by replacing lost fluids and electrolytes.
 The injury results directly from chemical irritation of the Survival of burn victims depends on adequate fluid
pulmonary tissues at the alveolar level. resuscitation.
 Inhalation injuries below the glottis cause loss of ciliary
action, hypersecretion, severe mucosal edema, and 1. Fluid Replacement
possibly bronchospasm.  Some combination of fluid categories may be used : Colloids
 The pulmonary surfactant is reduced, resulting in atelectasis ( whole blood, plasma, and plasma expanders) and
(collapse of alveoli). Expectoration of carbon particles in the crystalloids/electrolytes (physiologic sodium chloride or lactated
sputum is the cardinal sign of this injury. Ringer’s solution)
 Carbon monoxide is the most common cause of inhalation  Formulas have been developed for estimating fluid loss based on
injury because it is a byproduct of the combustion of the estimated percentage of burns BSA and the weight of the
organic materials and is therefore present in smoke.
patient. Length of time is also very important in calculating  Assessment should include the time of injury, mechanism of
estimated fluid needs. burn, whether the burn occurred in closed space.
 The formulas are individualized to meet the requirements of  The neurologic assessment focuses on the client’s level of
each patient consciousness, psychological status, pain and anxiety levels,
 The NIH Consensus Development Conference on Supportive and behavior
Therapy in Burn Care established that salt and water are
required in burn patients, but that colloid may or may not be Acute or Intermediate Phase of Burn Care
useful during the first 24 to 48 postburn hours  Begins 48 to 72 hours after the burn injury.
 The consensus formula provides for the volume of balanced  Attention is directed toward continued assessment and
saline solution to be administered in the first 24 hours in a maintenance of respiratory and circulatory status, fluid and
range of 2 to 4 mL/kg per percent burn. electrolyte balance, and gastrointestinal function.
 Generally, 2 mL/kg/ percent burn of lactated Ringer’s solution  Airway obstruction caused by upper airway edema can take as
may be used initially for adults. This is the most common long as 48 hours to develop. Changes may occur as the effects
fluid replacement in use today. of resuscitative fluid and the chemical reaction of smoke
 Studies show that with large burn, there is a failure of the ingredients with lung tissues become apparent. The patient’s
sodium-potassium pump at the cellular level. Thus, patients arterial blood gas values and other parameters determine the
with very large burns may need proportionately more need for intubation and mechanical ventilation.
milliliters of fluid per percent of burn than those with smaller  If cardiac or renal function is inadequate, fluid overload occurs
burns and symptoms of congestive heart failure may result.
 Most fluid replacement formulas use isotonic electrolyte Vasoactive medications, diuretics, and fluid restriction may be
solutions. used to support circulatory function and prevent congestive
 Another fluid replacement method requires hypertonic heart failure and pulmonary edema
electrolyte solutions. This method uses concentrated  Cautious administration of fluids and electrolytes continuous
solutions of sodium chloride and lactate (a balanced salt because of the shifts in fluid from the interstitial to intravascular
solution). The rationale for this replacement method is that compartments. Blood components are administered as needed
by increasing serum osmolality, fluid will be pulled back into to treat blood loss and anemia
the vascular space from the interstitial space. Reduced  A resetting of the core body temperature in severely burned
systemic and pulmonary edema results from administering patients results in a body temperature slightly higher than
hypertonic solutions. normal for several weeks after the burn injury. Bacteremia and
septicemia also causes fever in many patients.. Acetaminophen
Goals of Fluid Replacement Therapy: A systolic blood pressure and hypothermia blankets may be required to maintain body
exceeding 100 mm Hg, pulse rate less than 110/minute, and temperature to reduce metabolic stress and tissue oxygen
urine output of 30 to 50 ml/hour. demand.
 Central venous, peripheral arterial or pulmonary artery
 Another gauge for fluid requirements and response to fluid thermodilution catheters may be required for monitoring venous
resuscitation include hematocrit and hemoglobin and serum and arterial pressures. However, invasive vascular lines are
sodium levels. avoided because they provide an additional port for infection.
 Infection progressing to septic shock is the major cause of death
Nursing Process : Care during the Emergent/Resuscitative in patients who have survived the first few days after a major
Phase burn injury. The immunosuppression place the patient at high
 Nursing assessment in the emergent phase of burn injury risk for sepsis. The infection that begins within the burn site
focuses on the major priorities for any trauma patient; the may spread to the bloodstream.
burn wound is a secondary consideration.
 Aseptic management of the burn wounds and invasive line Infection Prevention
continues.  Burn wound is an excellent medium for bacterial growth and
 The nurse checks vital signs frequently. Respiratory status is proliferation.
monitored closely. Apical, carotid, and femoral pulses are  Bacteria such as Staphylococcus, Proteus, Pseudomonas,
evaluated Escherichia coli, and Klebsiella find optimal conditions for
 Cardiac monitoring for patients with cardiac problems, growth within the burn wound. The burn eschar is a non-viable
electrical injury or respiratory problems or if the pulse is crust, no blood supply; therefore, neither polymorphonuclear
dysrhythmic or the rate is abnormally slow or rapid. leucocytes or antibodies nor systemic antibiotics can reach the
 Determining BP is a problem if all extremities are burned. A area.
sterile dressing under the BP cuff will protect the wound  Phenominal numbers of bacteria- 1 billion per gram of tissue-
from contamination. A Doppler UTZ or a non-invasive may appear and spread to the blood stream or release their
electronic BP may be helpful. toxins, which reach distant sites.
 In severe burns, an arterial catheter is used for BP  Fungi such as Candida albicans also grow easily in burn wounds
measurement and for collecting blood specimen  The primary source of bacterial infection appears to be the
 Peripheral pulses of burned extremities are checked hourly. patient’s intestinal tract.
Doppler is used.  Major secondary source is the environment.
 Elevation of burned extremities is crucial to decrease edema.  Cap, gown, mask and gloves are worn while caring for patient’s
 Elevation of the lower extremities on pillows and of the upper with open burn wounds. Clean technique is used when caring
extremities on pillows or by suspension using intravenous directly for burn wounds.
poles may be helpful.  Antibiotics are seldom given prophylactically because of the risk
 Large-bore IV lines and Indwelling urinary catheter are of promoting resistant strains of bacteria.
inserted.  Tissue specimens are taken for culture regularly to monitor
 Assessment includes monitoring of fluid intake and output. colonization of the wound by microbial organisms.
 Urine output, an excellent indicator of circulatory status, is  Systemic antibiotics are administered when there is
monitored carefully. documentation of burn wound sepsis or other positive cultures
 The amount of urine first recorded may assist in determining such as urine, sputum, or blood.
the extent of preburn renal function and fluid status.
 Burgundy-colored urine suggests the presence of Wound Cleaning
hemochromogen and myoglobin resulting from muscle  Hydrotherapy in the form of shower carts, individual showers and
damage. This is associated with deep burns caused by bed baths.
electrical injury.  Because of the high risk of infection and sepsis, the use of plastic
 Glucosuria results from the release of stored glucose from liners and thorough decontamination of hydrotherapy
the liver in response to stress. equipment and wound care areas are necessary to prevent
 Infusion pumps and rate controllers are used to deliver a cross-contamination.
prescribed IV fluids  Tap water alone can be used for burn wound cleansing.
 Monitoring IV therapy is a major nursing responsibility.  Hydrotherapy in any form should be limited to 20 to 30 minute
 Body temperature, body weight, preburn weight, and history period to prevent chilling and additional metabolic stress.
of allergies, tetanus immunization, past medical and  Hydrotherapy provides an excellent opportunity for exercising the
surgical problems, current illnesses, and use of medication extremities and cleaning the entire body.
are assessed.  At the time of wound cleaning, all skin is inspected for any hints
 A head-to-toe assessment is performed, focusing on of redness, breakdown, or local infection.
signs/symptoms of concomitant illness, injury, or developing  Hair in and around burn area, except the eyebrows, should be
complications. clipped short.
 Patients with facial burns should have eye examination for  Intact blisters may be left, but the fluid should be aspirated with a
potential injuries to the cornea needle and syringe
 Wound cleaning is usually performed daily. 1. To remove contaminated tissue, thereby protecting the
 When the eschar begins to separate from the viable tissue patient from invasion of bacteria
beneath, more frequent cleaning and debridement may be 2. To remove devitalized tissue or burn eschar in preparation
necessary for grafting and wound healing.
 After burn wounds are cleaned, they are gently patted with
towel and the prescribed method of wound care is Natural Debridement
performed.  The dead tissue separates from the underlying viable tissue
 Whatever is the method of wound care, the goal is to protect spontaneously. After partial and full- thickness burns occur,
the wound from overwhelming proliferation of pathogenic bacteria that are present at the interface of the burned tissue
organisms. Patient comfort and ability to participate are also and the viable tissue underneath gradually liquefy the fibrils of
important considerations. collagen that hold the eschar in place for the first or second
postburn week.
Topical Antibacterial Therapy  Using antibacterial topical agents tends to slow down this natural
 Topical antibacterial therapy does not sterilize the burn process of eschar separation
wound; it simply reduces the number of bacteria so that the
overall microbial population can be controlled by the body’s Mechanical Debridement
host defense mechanisms  Involves using surgical scissors and forceps to separate and
 The three most commonly used topical agents are Silver remove the eschar.
sulfadiazine (Silvadene), silver nitrate, and Mafenide  This is carried out to the point of pain and bleeding
acetate (Sulfamylon)  Dressings are also helpful debriding agents. Coarse-mesh
 No single agent is universally effective. Using different dressings applied dry or wet-to-dry (applied wet and allowed to
agents at different times in the postburn period may be dry) will slowly debride the wound of exudates and eschar when
necessary. Prudent use and alternation of antimicrobial they are removed.
agents results in less-resistant strains of bacteria, greater
effectiveness of the agents.
 Before a topical agent is applied, the previously applied
topical agent must be thoroughly removed. Surgical Debridement
Wound Dressing  An operative procedure involving either primary excision (surgical
 After the wound is cleaned, patted dry and applied topical removal of tissue) of the full thickness of the skin or shaving the
agent; the wound is then covered with several layers of burned skin layers gradually down to freely bleeding, viable
dressings. tissue.
 A light dressing is used over joints to allow for motion, light  Surgical excision is initiated early in burn wound management.
dressing is also applied over areas for which a splint has This may be performed a few days after or as soon as the
been designed to conform to the body contour for proper patient is hemodynamically stable and edema has decreased.
positioning  Ideally, the wound is then covered immediately with a skin graft
 Circumferential dressings should be applied distally to and an occlusive dressing.
proximal.  The use of surgical excision carries with it risks and
 If the hand or foot is burned, the fingers and toes should be complications, especially with large burns. The procedure
individually wrapped to promote adequate healing. creates a high risk for extensive bleeding (as much as 100 to
125 ml of blood per percent BSA excised).
Exposure Method
 Occasionally, a wound is treated by exposing it to air. Wound Grafting the Burn Wound
care proceeds in the same manner and a topical agent is  If wounds are deep (full thickness) reepitheliazation is not
applied, but no dressings are applied. possible. Therefore coverage of the burn wound is necessary
 The success of exposure method depends on keeping the until coverage with a graft of the patient’s own skin (autograft) is
immediate environment free of organisms. Everything possible.
coming in contact with the patient must be sterile. Those  The purpose of wound coverage is to decrease the risk for
who come in direct contact must wear masks, caps, sterile infection; prevent loss of protein, fluid, and electrolytes through
gowns and gloves; visitors are instructed to wear protective the wound; and minimize heat loss through evaporation.
garb and not to touch the bed or hand anything to the  The main areas for skin grafting include the face, for cosmetic
patient. and psychological reasons; the hands and other functional
 The room must be maintained at warm temperature with 40 areas such as the feet; and areas that involve joints.
to 50% humidity to prevent excessive evaporative fluid  Grafting permits earlier functional ability and reduces
losses. contractures (shrinkage of burn scar through collagen
 A cradle may be placed over the patient to prevent sheets maturation).
from coming in contact with the burn area, to minimize the  When burns are extensive, the chest and abdomen maybe
effects of air currents (to which burn patient is sensitive) grafted first to reduce the burn surface.
 During wound healing, granulation tissue develops. It fills the
Occlusive Method space created by the wound, creates a barrier to bacteria, and
 An occlusive dressing is a thin gauze that is either serves as a bed for epithelial cell growth.
impregnated with a topical antimicrobial or that is applied  Richly vascular tissue is pink, firm, shiny, and free of exudates
after topical antimicrobial application and debris. It should have a bacterial count of less than
 Occlusive dressing are most often used over areas with new 100,000 per gram of tissue to optimize graft take.
skin grafts. These are applied under sterile conditions in the  A preoperative culture is mandatory before grafting, because
operating room. enzymes of bacteria can dissolve a graft and lead to its failure.
 Their purpose is to protect the graft, promoting an optimal Beta hemolytic streptococci are a major factor in graft failure.
condition for its adherence to the recipient site.
 Ideally, these dressings remain in place for 3 to 5 days. Biologic Dressings (Homografts And Heterografts)
 Precautions are taken to prevent two body surfaces from  In extensive burns, biologic dressings can be lifesaving by
touching, such as fingers or toes, ear and scalp, areas providing temporary wound closure and protecting the
under the breasts, any point of flexion, or between the granulation tissue until autografting is possible.
genital folds.  Biologic dressing may also be used to debride untidy wounds
after eschar separation.
Dressing Changes  With each biologic dressing change, debridement occurs.
> Dressings are changed approximately 20 minutes after an  Once the biologic dressing appears to be taking or adhering to
analgesic is administered. the granulating surface with minimal underlying exudation, the
> A mask, hair cover, disposable plastic apron or cover gown, patient is ready for an autograft.
and gloves are worn by health care personnel.  Biologic dressing also provides immediate coverage for clean,
 Dressings that adhere to the wound can be removed more superficial burns and decreases the wound’s evaporative water
easily if they are moistened with saline solution or if the and protein loss.
patient is allowed to soak for a few moments in the tub.  Biologic dressing decrease pain by protecting nerve endings and
 The patient may participate, providing some degree of control are an effective barrier against water loss and entry of bacteria.
over this painful procedure.  When applied to superficial partial-thickness wounds, they seem
to speed healing.
Wound Debridement  Biologic dressings consist of homografts (or allografts) and
heterografts(or xenografts).
Debridement has two goals :
 Homografts are skin obtained from living or recently  Using expanded grafts may be necessary in large wounds but
deceased humans. The amniotic membrane (amnion) from should be viewed as a compromise in terms of cosmetics.
the human placenta may also be used as a biologic
dressing. Care of the Patient with an Autograft
 Heterografts consist of skin taken from animals (usually  Occlusive dressings are commonly used initially after grafting to
pigs). immobilize the graft.
 Most biologic dressings are used as temporary coverings of  Occupational therapists may be helpful in constructing splints to
burn wounds and are eventually rejected because of the immobilize newly grafted areas to prevent dislodging the graft
body’s immune reaction to them as foreign.  If the graft is dislodged, sterile saline compresses will help
 Homografts tend to be the most expensive biologic prevent drying of the graft until the physician reapplies it.
dressings. They are available from skin banks in fresh and  The patient is positioned and turned carefully to avoid disturbing
cryopreserved (frozen) forms. the graft or putting pressure on the graft site.
 Homografts are thought to provide the best infection control.  If an extremity has been grafted, it is elevated to minimize
Of all the biologic and bio synthetic dressings available. edema.
Revascularization occurs within 48 hours, and the graft may  The patient begins exercising the area 5 to 7 days after grafting.
be left place for several weeks.
 Amnion is low in cost, however, amnion grafts do not become Care of Donor site
vascularized by the patient’s vessels and can be left in  Moist gauze is applied at the time of surgery to maintain pressure
place only briefly. and to stop any oozing.
 Pigskin is available from commercial suppliers. Pigskin  A thrombostatic agent such as thrombin or epinephrine may be
impregnated with a topical antibacterial such as silver applied directly to the site.
nitrate is also available.  The donor site may be applied with a single-layer gauze
 One new biologic dressing that has shown promise for impregnated with petrolatum, scarlet red, or bismuth to new
permanent burn wound coverage is Alloderm. biosynthetic dressings such as Biobrane.
 Alloderm is processed dermis from human cadaver skin.  Donor site must remain clean, dry, and free from pressure.
When a donor site is taken for an autologous skin graft,  Because a donor site is usually a partial-thickness wound, it will
both the epidermal and dermal layers of skin are removed heal spontaneously within 7 to 14 days with proper care
from the donor site. However, Alloderm provides a
permanent dermal layer replacement. Pain Management
 Use of alloderm allows the surgeon to take a thinner skin  Pain management is the most difficult challenges facing the burn
graft consisting of the epidermal layer only. The patient’s team.
epidermal layer is placed directly over the dermal base  Many factors contribute to the patient’s burn pain experience:
(Alloderm). severity of the pain, health provider’s pain assessment, the
 Use of Alloderm has resulted in less scarring and appropriateness and adequacy of pharmacologic treatment of
contractures with healed grafts; donor sites heal much more pain, the multiple procedures involved and assessment of the
quickly than conventional donor sites because only the effectiveness of pain relief measures.
epidermal layer has been taken.  The outstanding features of burn pain are its intensity and long
duration.
Biosynthetic And Synthetic Dressings  Wound care carries with it anticipation of pain and anxiety.
 Currently, the most widely used synthetic dressing is  In partial-thickness burn, the nerve endings are exposed,
Biobrane, which is composed of nylon. Silastic membrane resulting to excruciating pain with exposure to air currents.
combined with a collagen derivative.
 Although, nerve endings are destroyed in full-thickness burns,
 Less costly than homograft or pigskin. there is deep pain and pain in adjacent structures.
 Biobrane dressings adhere to donor sites and meticulously  The primary pain is intense in the initial acute post burn phase.
clean debrided partial-thickness wounds; they will remain This pain gradually subsides. However, until the skin heals or
until spontaneous epitheliazation and wound healing occur. graft are applied and taken, the pain level remains high
 Like biologic dressing, Biobrane protects the wound from because of treatment-induced pain. Wound cleaning, dressing
fluid loss and bacterial invasion. changes, debridement, and physical therapy inflict intense pain.
 Biobrane is also useful for intermediate or long-term closure Discomforts related to tissue healing, such as itching, tingling,
of a surgically excised wound until an autograft becomes and tightness of contracting skin and joints adds to the duration
available. and intensity of pain.
 Like Biologic dressing, Biobrane should not be used over  Because pain can not be eliminated short of anesthesia, the goal
grossly contaminated or necrotic wounds. is to minimize the pain with analgesics before the patien faces
 Several other synthetic dressings are available: Op-site, a wound care procedures.
thin, transparent, polyurethane elastic film, can be used to  Bolus doses of opioids, usually morphine, are often provided.
cover clean partial-thickness wounds and donor sites. This Ketamine anesthesia administered IV are also used.
dressing is occlusive and waterproof but permeable to  Sedation with anti-anxiety agents such as lorazepam (Ativan) or
water vapor and air; this permeability provides protection midazolam(Versed) may be indicated in addition to analgesia.
from microbial contamination and allows for the exchange  Patient-controlled analgesia, using both continuous and bolus
of gases. Other synthetic dressings are Tegaderm, N- morphine infusions, and sustained release oral morphine, given
Terface, and Duoderm. every 12 hours have helped burn patients.
 Artificial skin (Integra) is the newest type of synthetic  Self-administered nitrous oxide also helps to make dressing
dressing. A dermal analogue, Integra is composed of two changes tolerable to those patients who have sufficient hand
main layers. The epidermal layer, consisting of Silastic, acts function to hold a mask to their faces intermittently during
as a bacterial barrier and prevents water loss from the dressing changes.
dermis. The dermal layer is composed of animal collagen. It
 Early surgical excision with grafting under anesthesia may be the
interfaces with the open wound surface and allows
best way to reduce the overall pain experience for burn
migration of fibroblasts and capillaries into the material.
patients.
Autografts
Nutritional Support
 The ideal means of covering burn wounds because they
 Hypermetabolism persist after burn injury until wounds are
come from the patient’s own skin and thus are not rejected
closed, thereby increasing the basal metabolic need by as
by the patient’s immune system.
much as 100%.
 They can be split-thickness, full-thickness, pedicle flaps, or
 The goal of nutritional support is to promote a state of positive
cultured epithelium. Full-thickness and pedicle flaps are
nitrogen balance.
commonly used for reconstructive surgery, months or years
 The nutritional support required is based on the patient’s preburn
after the initial injury.
status and the extent of total BSA burned.
 Split-thickness autografts can be applied in sheets or in
postage stamp-like pieces, or they can be expanded by  Several formulas exist for estimating the daily metabolic
meshing so that they can cover 1.5 to 9 times more than a expenditure and caloric requirements of burn patients.
given donor site area. Skin meshers enable the surgeon to  Protein requirements may range from 1.5 to 4 g of protein per kg
cut tiny slits into a sheet of donor skin, making it possible to of body weight every 24 hours
cover large areas with smaller amounts of donor skin.  Lipids are included in the nutritional support because of their
These expanded grafts cling to the recipient site more importance for wound healing, cellular integrity, and absorption
easily than sheet grafts and prevent the accumulation of of fat-soluble vitamins.
blood, serum, air, or purulent material under the graft.  Carbohydrates are included to meet caloric requirements as high
as 5,000 cal per day
 Adequate vitamins and minerals are also needed.
 The proportions of fat, protein, and carbohydrate are planned  Assessment on pain and psychosocial responses, daily body
for maximal use. weights, caloric intake, general hydration, and serum electrolyte
 Overfeeding can be detrimental. Therefore, a dietitian familiar and hemoglobin levels and hematocrit
with current concepts in nutrition for burn patients is  Assessment for excessive bleeding from blood vessels adjacent
necessary. to areas of surgical site and debridement
 As soon as GIT function resumes, nutritional support begins.
The enteral route is preferred. In patients with extensive Potential Complications :
burns, tube feedings may be indicated to ensure daily 1. Congestive heart failure and pulmonary edema
calories needed. 2. Sepsis
 Indications for Total parenteral nutrition (TPN) include weight 3. Acute Respiratory Failure
loss greater than 10% of normal body weight, inadequate 4. Visceral Damage
intake of enteral nutrition prolonged wound exposure, and
malnutrition or debilitated condition before injury. Planning and Goals :
The major goals :
 restoration of normal fluid balance,
 absence of infection,
 attainment of anabolic state and normal weight,
 improved skin integrity,
DISORDERS OF WOUND HEALING  reduction of pain and discomfort
 optimal physical mobility
SCARS  adequate patient and family coping
 Results from excessive abnormal healing or inadequate new  adequate patient and family knowledge of burn treatment
tissue formation.
 absence of complications
 Hypertrophic scars and wound contractures are more likely to
occur if the initial burn injury extends below the level of the Nursing Interventions:
deep dermis. Healing of such deep wounds result in the
replacement of normal integument Restoring Normal Fluid Balance
 Compression measures are instituted early in the burn  Monitor IV and oral intake to reduce risk for fluid overload and
wound treatment to prevent scar formation. Ace wraps are consequent CHF
used to promote adequate circulation, used as the first form 1. Use IV infusion pumps
of compression. 2. Daily weights are obtained
 Scar management occurs mainly in the rehabilitative phase,  Low-dose dopamine to increase renal perfusion
after the wounds are closed.
 Diuretics to increase urine output
KELOIDS
Preventing Infection
 A large, heaped-up mass of scar tissue.
 A clean and safe environment
 Keloids tend to be found in darkly pigmented people, grow
 Detect early signs of infection – culture results and WBC counts
outside of wound margins, and recur after surgical excision.
are monitored
FAILURE TO HEAL  Aseptic technique for wound care procedures. Hand washing
before and after each patient contact
 Failure to heal may be due to many factors, including
 Fresh flowers, plants or fresh fruit baskets should not be allowed
infection and inadequate nutrition
inside the room because of the risk of microorganism growth
 A serum albumin level of less than 2g/dL is a usual factor
 Visitors are screened to avoid exposing the immunocompromised
CONTRACTURES patient to pathogens
 The burn wound tissue shortens because of the force exerted
Maintaining Adequate Nutrition
by the fibroblasts and the flexion in natural wound healing.
 Oral fluids should be initiated slowly when bowel sounds
 An opposing force provided by splints, traction, and
resumes. If vomiting and abdominal distention do not occur,
purposeful movement and positioning must be used to
fluids may be gradually increased
counteract deformity in burns affecting joints.
 The nurse collaborates with the dietitian to plan a protein-and
Nursing Process : Burn Care During The Acute Phase calorie-rich diet
Assessment  If caloric goals can not be met by oral feeding, a feeding tube is
inserted
 Continued assessment focuses on hemodynamic alterations,
wound healing, pain and psychosocial responses, and early
Promoting Skin Integrity
detection of complications.
 Nurse assess VS frequently  Assess and record changes or progress in wound healing
 Wound care
 Continued assessment of peripheral pulses is essential for
the first few post burn days while edema continuous to  Topical antibacterial agents
increase, potentially damaging peripheral nerves and
restricting blood flow. Relieving Pain and Discomfort
 Observation of the electrocardiogram may give clues to  Pain is more severe in partial-thickness burns than in full-
cardiac dysrhythmias resulting from potassium imbalance, thickness burns because the nerve endings are not destroyed.
preexisting cardiac disease, or the effects of electrical injury Cover exposed nerve endings to help reduce pain
or burn shock  Analgesics and anti-anxiety medications
 Assessment focuses on hemodynamic alterations, wound  Teach relaxation techniques
healing, pain and psychosocial responses, and early  Give patient control over wound care
detection of complications.  Pain-relieving distractions : video programs/games, hypnosis
 Assessment of respiratory and fluid status is the highest  Complete treatments and dressings quickly. Analgesics before
priority for detection of complications. any painful procedures
 Assess VS  Oral anti-pruritic agents, cool environment, frequent lubrication of
 Assessment of peripheral pulses while edema continuous to skin with water or silica-based lotion – to reduce discomfort in
increase, damaging peripheral nerves and restricting blood itching
flow  Exercise and splinting to prevent skin contracture
 ECG may give clues to cardiac dysrhythmias resulting from
potassium imbalance, preexisting cardiac disease, or the Promoting Physical Mobility
effects of electrical injury or burn shock  Early priority is to prevent complications resulting from immobility
 Assessment of residual gastric volumes and pH in the patient  Deep breathing, turning, and proper positioning to prevent
with a NGT- gives clues to early sepsis or the need for atelectasis and pneumonia, control edema and to prevent
antacid therapy. Blood in the gastric fluid or stools must pressure ulcers and contractures.
also be reported  Early sitting and ambulation
 Important wound assessment include size, color, odor,  When lower extremities are burned elastic bandage are applied
eschar, exudates, abscess formation under the eschar, before the patient is placed in an upright position. This
epithelial buds (small pearl-like clusters of cells on the bandages promote venous return and minimize swelling
wound surface), bleeding, granulation tissue appearance,  Passive and active ROM to prevent contracture
progress of grafts and donor sites, and quality of  Splints or other functional devices are used for contracture
surrounding skin control. Monitor splinted areas for signs of vascular insufficiency
and nerve compression
Strengthening Coping Strategies Choice of Article 5pts
 The patient is facing the reality of burn trauma and is grieving Comprehensiveness 10pts
over obvious loss. Depression, regression and manipulative Neatness & organization 5pts
disorders are common problems ================================
 Develop effective coping strategies by : Total 20pts for each reading
1. Setting specific expectations for behavior
2. Promoting truthful communications to build trust REFERENCE MATERIALS:
 Patient always ventilates feelings of anger – enlist someone 1. Books
to whom patient can vent feelings without fear of retaliation a. The Lippincott Manual of Nursing Practice, 7th edition,
2001.
Monitoring and Managing Potential Complications : b. Luckmann and Sorensen Medical and Surgical Nursing:
A Psychophysiologic Approach, 4th edition, 1992
Congestive Heart Failure and Pulmonary Edema c. Maternal and Child Health Nursing: Care of the
 Patient is assessed for pulmonary overload – may occur as Childbearing and Childrearing Family. Adele Pilliteri.1999.
fluid is mobilized from the interstitial compartment back into d. Maternal and Child Health Nursing. Koniak.
the intravascular compartment. If the cardiac and renal e. Maternal and Neonatal Nursing Made Incredibly Easy.
system cannot compensate for the excess vascular volume, 2004
CHF and pulmonary edema may result. f. Medical-Surgical Nursing books
 Crackles in the lungs and increased difficulty with respiration
may indicate a fluid buildup in the lungs. 2. Websites
1. Patient is positioned comfortably with the head of the a. google.com
bed raised to promote lung expansion and gas b. eMedicines.com
exchange c. yahoo.com
2. Provide supplemental oxygen
3. Administer IV diuretics

Sepsis
 Early signs are increased in temperature, increased pulse
rate, flushed dry skin, increased pulse rate, widened pulse
pressure, and flushed dry skin in unburned areas
 Wound and blood cultures
 Antibiotics

Acute Respiratory Failure and Acute Respiratory Distress


Syndrome
 Patient is assessed for increased difficulty in breathing,
change in respiratory pattern, onset of adventitious
(abnormal) sounds
 Signs of hypoxia (decreased O2 to the tissues), decreased
breath sounds, wheezing, tachypnea, stridor
 Patients receiving mechanical ventilation must be assessed
for a decrease in tidal volume and lung compliance
 Key sign of ARDS is hypoxemia while receiving 100%
oxygen, decreased lung compliance and significant
shunting
 Management includes intubation and mechanical ventilation

Visceral Damage
 Assess for signs of necrosis of visceral organs due to
electrical injury. Tissues affected are usually between the
entrance and exit wounds of the electrical burn
 All patients with electrical burns should undergo
electrocardiographic monitoring
 Assess for pain relate to deep muscle ischemia
 Fasciotomies are performed to relieve the swelling and
ischemia in the muscles

Rehabilitation Phase Of Burn Care


 Rehabilitation begins immediately after the burn has occurred
 Wound healing, psychosocial support, and restoring maximal
functional activity remain priorities
 Continued focus on maintaining fluid and electrolyte balance
and improving nutritional status
 Reconstructive surgery to improve body appearance and
function
 Psychological and vocational counseling and referral to
support groups

COURSE REQUIREMENTS:
1. Quizzes – after each topic, a quiz will be
administered.
2. Readings – current issues (2003-present) on High
risk pregnancy, High risk newborn and High risk adult.
One reading for each of the High risk conditions.
Provide cover sheet, photocopy or print out of the
issue, one page summary, and one page reaction
(staple the pages properly). Include the date and
reference (book, article, website). Computer
encoded/typewritten (short size coupon bond, 1.5 line
spacing, and font size 12). Deadline of submission will
be on the first day of class.

GRADING POLICY:
Reguirement (3 Readings - High risk pregnancy,
newborn and adult):