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Self-fulfillment needs : Self - actualization Psychological needs: Esteem Love/Belonging Basic needs: Safety Physiological Chapter 8 – Lesson 10 Adaptations to pregnancy (what does mom/dad/siblings/grandparents go through, how can they prepare) Mom 1 st^ trimester = disbelief 2 nd^ trimester = quickening (16-20wk)
- Mom starts feeling baby move
- Seperates baby from self 3 rd^ trimester = anxious, nesting, tired of being preggo Adaptation to Pregnancy o Maternal adaptation Accepting pregnancy Identifying w/mother role Reordering personal relationships – mom is no longer # Establishing relationship w/fetus--Emotional attachment o Preparing for childbirth Attend Childbirth classes – approx. 7mo (28wk) of preggo 7th month of pregnancy → Empathy belly used for family memb’s Remb:
- Assess
- Intervention
- Maslow’s
- ABC’s
o Psychological Tasks of Mother Form foundation for mutual gratifying relationship w/infant Helps dev self-concept 1. Ensuring safe passage through pregnancy, labor, &birth Seek competent prenatal care → Concerned for herself &unborn child Read literature, observe/interact w/ new parents → View parenting differently Acute sense of environmental threats o Perform self-care activities → Diet, nutrition 3rd trimester, longs for birth though frightened 2. Seeking acceptance of child by others Alteration of 1° support group PRN → Network must meet needs of pregnancy Partner support & acceptance important → Work to encourage other children’s acceptance If no partner – seek family or friend’s support o Baby-Daddy drama can keep her from reaching this stage 3. Seeking commitment &acceptance of herself as mother to infant “Binding in” occurs o Binds to the role of being a mom o Occurs in 2nd^ trimester 1 st^ trimester – abstract idea 2 nd^ trimester – quickening, bonding &attachment begins Imagines baby images → Motivation to become competent in role of mother 4. Learning to give of oneself on behalf of one’s child Dad Paternal Adaptation to Pregnancy o Accepting pregnancy → Id’ing w/ father role o Reordering personal relationships → Est’ing relationship w/ fetus → Emotional attachment o Preparing for childbirth o Couvade – when dad becomes pregnant Unintentional dev of phys symptoms of preggo Sympathy pains, etc. Partner experiences Siblings Sibling Adaptation o Reactions manifested in behavioral ’s o New baby marks beg’ing of sibling rivalry → Attempt to minimize prob’s during pregnancy o Involvement in planning &care (age approp) → Take to prenatal visit, sibling class → Visit mom & baby in hospital o Consistency is important Same care, person, things remain same → Same parental attention Discuss handling regressive or aggressive behavior o ’s should be made several wks prior to childbirth → give sibling time to adjust Move from crib to bed Toilet training → May regress &wet bed Weaning → May want bottle or breast again
Chapter 9 – Lesson 9 Remb: Antepartum – period b/t conception to the onset of labor (during preggo) Intrapartum – period from labor to just before delivery Postpartum – period from afer delivery until 6 wk afer delivery Pregnancy hormones (estrogen, progesterone, relaxin, hCG, hpl): What does each one do? How do they help create or sustain pregnancy? o Physiological Changes of Pregnancy: Influence of hormones Body secretes hormones essential to pregnancy o Human chorionic gonadotropin (hCG) Source: Fertilized ovum & chorionic villi (trophoblastic cells) Stim’s prod of progesterone (pregnancy hormone) &estrogen Estrogen gets you preggo Progesterone keeps you preggo Preserves the corpus luteum (assumes role of placenta) Corpus luteum secretes progesterone until placenta b/g’s to secrete it – approx. 10wk hCG – basis for pregnancy test ELISA: Enzyme-linked immune-sorbent assays o Specific antibody(anti-hCG) bonds w/ hCG in urine o Take 1st thing in the morning: need fresh urine sample o hPL - Human placental lactogen Dev’s breasts for lactation ↓’s maternal insulin sensitivity Can interfere w/ production of insulin, can cause GDM o Estrogen ----Stim’s dev of uterine & breast tissue (2°^ female sex chara’s) Causes ↑ in cervical cells, resulting in mucus plug ↑ vaginal secretions Breasts enlarge & areola darken “Gets pregnancy started” o Progesterone ---Maintains endometrium, smooth muscle relaxant. Causes ↑ volume of air & ↓ air resistance Clotting factors ↑, cardiac output ↑, RBC ↑, blood pools in lower extremities ↓ peristalsis & delayed gastric emptying ↑ skin pigmentation & relaxed joints “keeps pregnancy going” o Relaxin ---Causes ’s in collagen, connective tissue - Can cause falling! Causes waddling
Signs of pregnancy (subjective, objective, &diagnostic): What are examples of each one? o Signs of Pregnancy ’s women experience during pregnancy; Used to diagnose the pregnancy itself o Subjective Changes—Presumptive ’s the woman experiences & reports → can be caused by other conditions Not considered proof of pregnancy Examples: An ↑ in urination tender breasts N/V Quickening – fluttering of fetal movement – could be gas o Objective Changes—Probable Reasonable to believe Examiner can perceive changes → More diagnostic than subjective -- Does not offer definite dx Examples: P. 190; Tbl 9- Pelvic organ changes o Hegar’s sign (Hay-gars) (pg 190, Figure 9-4) sofening of isthmus (lower portion) of the uterus determined by examiner by vaginal examination o abdominal enlargement o Goodell’s sign – sofening of the cervix o Chadwick’s – discoloration of the cervix McDonald’s – flexing of the body of the uterus if the cervix is pressed on Braxton Hick’s Contractions Skin pigmentation o Linea nigra o Nipples/areola Preggo tests – false +’s Uterine Souffle – whooping sound o Diagnostic Changes—Positive completely objective - cannot be confused w/pathologic states conclusive proof of pregnancy
- Palpation of fetal movement by the examiner afer 20 wks gestation
- Visualization of fetus (ultra sound)
- Listening to fetal heartbeat w/Doppler device Assess mom’s heart rate 1st o Average HR 120- o Must be at least 8 weeks Fetal scope (16-20 wks)
o Place pillow or wedge under right hip Blood Volume Changes Progressively ↑ ↑ most significantly during 2nd^ trimester ↑ slower during 3rd^ trimester stabilizes during last wks of pregnancy o 40 – 45% ↑ pre-preggo level – by last wk of preggo o due to ↑ in erythrocytes &plasma → blood is watery (plasma) & RBC’s of immature Blood Composition Changes ↑ level of RBCs to ↑ O2 delivery to cells - ↑ O2 in hemoglobin to baby Total erythrocyte (RBC) volume ↑ o 30% w/ iron supplementation o 18% w/out iron supplementation Plasma volume ↑50% o Hct measures conc. of RBC in plasma – a lot of plasma = ↑ water in blood o Hemodilution is manifested by a lower Hct - excessive plasma, diluting the blood Physiologic anemia of pregnancy (psuedoanemia) Not true anemia – is just a excess in plasma (water in blood) Leukocyte production ↑ White blood cells (WBCs) - ↑ during pregnancy o 5,000 – 12, o May reach 25,000 or higher by time of delivery o This is normal → helps fight infxn Clotting factors ↑ Factors VII, VIII, IX, &X – not exactly sure which ones Fibrin &plasma fibrinogen levels ↑ Hypercoagulable state → Risk for dev’ing venous thrombosis o ↑ coag = less bleeding during delivery Nursing Interventions: Monitor Homan’s sign o Respiratory ↑ in O2 needs between 16 – 40 wks → O2 consumption ↑↑ 15-20% - ↑ O2 for mom & baby Increasing levels of progesterone causes: remb: progesterone relaxes ↓ airway resistance → ↑ volume of air Tidal volume ↑steadily 30-40% rise from non-pregnant values – deeper respirations Uterus enlarges…. Diaphragm elevates, *****Ribs flare ↑ anterior-posterior diameter****Up to 6 cm greater Breathing ’s from abdominal to thoracic breathing S&S: Shortness of breath (SOB) → Hyperventilation → Thoracic breathing Nasal stuffiness (rhinitis) → Nosebleeds (epistaxis) o Due to estrogen
o Urinary (not on study guide) 1st trimester = uterus is a pelvic organ 2 nd^ trimester = uterus is an abdominal organ Cause: ↑ size of uterus Fxnal ’s: ↓ Bladder capacity → uterus is sitting on bladder - ↑ pressure Ureters elongate & dilate → glomerular filtration rate ↑ 50% & renal tubular reabsorp ↑ o Leading to ↑ voiding S&S: ↑ urination, glycosuria (glucose in urine) o GI - Bowels ↑ progesterone Smooth muscle relaxation Colon displaced S&S: Peristalsis ↓→ Delayed gastric motility & emptying Constipation → Hemorrhoids → Varicosities of rectum Appetite fluctuates, taste ’s N/V – hCG, metabolism o Integumentary Skin : ↑ estrogen, progesterone & melanocyte-stim’g hormone Pigmentation ’s: o Areolae, nipples, vulva → Linea nigra o Striae gravidarum – stretch marks 50-90% o Chloasma - Melasma gravidarum = Mask of pregnancy dark, irregular well demarcated hyperpigmented macules to patches commonly found on the upper cheek, nose, lips, upper lip, and forehead fades afer pregnancy Hair Rate of growth may ↓ o ↓ # hair follicle in resting or dormant phase Reports of Hirsutism common o unwanted, male-pattern hair growth in women o Fine hair growth ↑ Hyperactive sweat glands o Musculoskeletal Changes (not on study guide) Diastasis recti--Rectus abdominis muscle to separate Cause: Pressure on abdominal muscles --Enlarged uterus Nursing Interventions Teach about safe position ’s--Support joints Pregnancy belt, wrist supports--Wear support hose (knee or thigh-high)---Elevate lower extremities → ↑ BP, ↑ venous return, ↓ DVT’s Teach prenatal exercises Avoid muscle strain and overtiring----Perform according to comfort level Partial sit-ups---Knees flexed, feet flat on floor Stretch arms to knees---Head and shoulder off floor---5 reps
o Nonstress Test (NST) KNOW: RN interventions & how to read Fetal HR strips If fetus has adequate O2 & intact CNS = accelerations of fetal HR (FHR)with fetal movement (FM) Only done if prob: HTN, DM, hx of previous fetal demise Mom pushes button if she feels FM Reactive NST - normal 15 x 15: accelerations of 15 bpm lasting 15 sec’s w/each fetal movement (FM) 2 x 20: occurs 2 times in 20 minutes time frame – pt must stay on monitor for 20 min If 15 x 15 & 2 x 20 → RN int: document as reactive NST Nonreactive NST - abnormal No accelerations of FHR w/ FM If no rxn in 20min → RN interventions: o 1. Cracker, juice (↑ glucose) or vibroacoustic stimulation (sound & vibrations shake baby awake) o 2. Monitor for add’l 20 min – 40 min max o 3. If no rxn → notify MD o Contraction Stress Test (CST) Only done if it is suspected baby will not tolerate labor - done close to term mom given Pitocin to induce contractions Eval’s resp fxn of the placenta Negative CST: o Normal: healthy fetus will maintain a steady HR o 3 contractions last 40 sec + in 10 min - NO decelerations Rn int: Once this occurs STOP oxytoxin (Pitocin)!! Positive CST: Remb: we want…. NST + CST -
o Stress of uterine contraction shows repetitive late deceleration w/more the 50% of the uterine contractions o ↓ placental sufficiency o RN int: prep for C/S o Amniocentesis Needle inserted into uterine cavity to w/draw amniotic fluid Performed early (15-16wks) – genetic abnormalities Performed late (3rd^ trimester - 35-36 wk) – fetal lung maturity - L/S ratio L/S ratio 2:1 = 99% chance that lungs are fxn’ing (have adequate surfactant) If L/S ↓ →RN Int: Admin Celestone to mom →↑ baby’s production of surfactant RN int: admin RhoGAM afer procedure to all Rh – mom’s Risks: ↑ r/o bleeding, infxn o Biophysical Profile - 1st^ choice for follow up fetal evaluations!!! i.d’s compromised/healthy fetus assesses placental fxn each eval has possibility of 2 pnts A. Fetal Breathing Movements – 1 episode of 30 sec in 30 min B. Fetal Tone - at least 1 episode of extremity extension & flexion C. Body Movement – 3 episodes in 30 min D. Amniotic Fluid Volume – More than 1 pocket > 1 cm in 2 planes E. Reactive NST – FHR ↑ w/activity o A.L.O.N.E. A mniocentesis L /S ratio (2:1) O xytocin Test (CST) N on-stress Test (NST) E striol level – one of the 3 main Estrogens prod’d by the body (Remb: Estrogen keeps you preggo!) o Blood Tests Know specific values!!!! Hemoglobin/hematocrit o Detects anemia, iron or folic acid deficiency Anemia = Hgb < 10, Hct < 35% - usually Hct is 2x Hgb Remb: during preggo, ↓ Hgb b/x of ↓ blood vol on board in mom o Preggo N: Hgb 10-14g/dL, Hct 32-42% o Eliminate symptoms – pale mucus membranes, susceptible to infection, tachy, pallor… o Correct deficiency – PNV and Fe tab – w / O Sickle cell anemia o Abnormal hemoglobin molecule (hemoglobin S) in blood – causes sickle shape o Recessive hereditary, familial d/o o Mediterranean, Southeast Asians, or African-American descent o Monitor fetal well-being
o Tuberculin skin testing Assess exposure to tuberculosis – Mycobacterium tuberculosis Carried on droplets and spread by airborne transmission Those at risk: Immunocompromised (ie mom w/HIV), homeless, immigrants, injectable drug users Assessment findings Fatigue, fever or night sweats, nonproductive cough, slow wt loss, anemia Tine or PPD (purified protein derivative) tuberculin tests Intradermal, reddened induration within 72h Chest x-ray afer 20 wks, sputum cultures to confirm Treatment during pregnancy is the same as for general population Isoniazic, rifampin, ethambutol daily for up to 9 months. Fetal effects – minimal risks for congenital anomalies BF not contraindicated------------Teach not to cough, sneeze or talk directly into NB’s face Other tests o Pap test- all mom’s Screen for cervical neoplasia, Herpes simplex type 2, HPV Vaginal or rectal smear--------------------Exposure to STI, Neisseria gonorrhea-----Chlamydia, HPV o GBS – Group B Streptococcus Naturally occurring bacterium found on body Asymptomatic most ofen----------------------May have UTI, uterine infection(afer delivery) or chorioamnionitis Fetus/Newborn: Can be life-threatening to newborns-----------Pneumonia or sepsis, meningitis – if baby comes through vaginal canal; C/S = no risk CDC guidelines; Screen all 35-37 weeks----------Treat with PCN or Amp 4 h before birth Baby will have CBC & blood cultures Other tests cont’d. o Completion of TORCH panel o Urinalysis------------------------------------------------------------Infections o Renal disease----------------------------------------------------------------------------Unsuspected diabetes mellitus o Hematuria CLIENTS THAT need additional screening - not on study guide HAVE TYPE O BLOOD or Rh factor that is negative (D antigen absent) o ABO incompatibility or Rh incompatibility Maternal Serum Antibody Screening o IF Patient has O Blood Type Tests mother’s blood for anti-A, anti-B antibodies – IgM antibody Positive results – monitor newborn closely afer birth o IF Patient is RH negative (D antigen negative)
Tests for Rh antibodies (Indirect Coombs Test) – IgG antibody response o Positive results – monitor baby closely afer birth o *********Negative results (good)--- prevent isoimmunization********RhoGAM at 28wks Newborn/Fetal effects Fetuses at risk for developing erythroblastosis fetalis---------------Hyperbilirubinemia in neonatal period Review RhoGAM! o RhoGAM Immunoglonulin IM Injection at 28 wks PRN Temporary Passive Immunity o Rh incompatibility does not affect 1st pregnancy Must prevent antibodies o DO NOT GIVE IF: Baby’s Rh factor is - Ex: MOM – O- & BABY – O- = no RhoGAM Mother is sensitized---Indirect Coombs + ---Exposed to Rh + blood Direct or indirect Coomb’s is + b/c sensitivity has already occurred, can’t undo it o GIVE RhoGAM IM at 28 wks & w/in 72h afer delivery IF: Mother is not sensitized - indirect Coombs is - Baby’s Rh factor is + & direct Coombs Test is - Ex: MOM- O -, BABY – O + Direct or indirect Coombs is - TORCH panel: What is it? What does each letter stand for? o TORCH Infections To : toxoplasmosis - parasite infxn from handling cat litter, raw meat wash fruits & veggies therapeutic abortion if diagnosed < 20 weeks stillborns &neonatal death common Assessment o Usually asymptomatic to mother o Flu-like symptoms o Fetal affects depend when infections occurred R : rubella (German Measles) test mother for immunity, greatest risk 1st trimester C : cytomegalovirus most common viral infection spread by body fluids common cause of mental retardation H : herpes virus Type II Cesarean delivery to protect infant
o Documentation of OB Hx (pg 200-201) o Primigravida – preggo for 1st^ time o Primipara – woman delivered 1 potentially viable fetus o Multi – preggo many times o Nulli – never preggo o Term – born b/t 38-42wk o Premature – birth afer 20wk but b/f completion of 37wk → 20wk, 1 day – 37wk, 6 days o Post-term – afer 42wk o GP – Gravidity & Parity A two-digit system -documents # of pregnancies G_ P_ Gravida → # of pregnancies, including current pregnancy Para →pregnancies that have reached point of viability (viability = 20wk) If # of wk is unknown, weigh to determine if fetus is > 500g Ex: G1P0: 1 pregnancy, did not reach viability o Acronym GTPAL – documents the # of infants; more detail G -Gravida T -Term P -preterm (does NOT mean para) ; afer 20wk A - Abortions (Induced or spontaneous) ; b4 20wk L - living children (how many are alive TODAY) M - multiple gestations (twins, triplets, etc) o Critical Thinking Exercise: M.P has come to the clinic on Sept. 10th. Pregnancy test was +. States LMP was June 10th. Obstetrical HX: Had an abortion when she was 18. Had a miscarriage at 11 weeks last year. How would you document her obstetrical hx using the 2 method system? o G_3__ P_0__ o Critical Thinking Exercise: M.P has come to the clinic on Sept. 10th. Pregnancy test was +. States LMP was June 10th. She tells you: She had an abortion when she was 18. Had a miscarriage at 11 weeks last year. How would you document her obstetrical hx? Using GTPAL: G_3__T_0__P_0__A_2__L_0___ OR (G30020)
- Initial prenatal assessment (what happens to specific body systems?, what is normal?, what is abnormal?, what does nurse need to do?) o Initial exam to provide a baseline o Assess V/S, Height, Weight o Bladder should be emptied before pelvic exams o Head to toe by examiner - Review Assessment Guide (pgs 206-212) - Naegele's Rule: how do you determine due date? o LMP – 3mo’s + 7days + 1yr = due date o Critical Thinking Exercise: Determining Estimated Date of Birth o EDB using Naegele’s Rule: LMP:July 10,2013; Subtract 3 months__April 10,2013__; Add 7 days_April 17,2013__;Add 1 year (prn) April 17, 2014 o EX: July 10th ---------------EDB or EBC or due date: April 17, 2014 o Figure 10-2 (pg 213) EDB wheel. The EDB wheel can be used to calculate the due date. To use it, place the “last menses began” arrow on the date of the woman’s LMP. Then read the EDB at the arrow labeled 40. In this case the LMP is September 8, &the EDB is June 17_ - Subsequent prenatal assessment (after the first visit, what is assessed?) (pgs 217-220) Remb: G– preggo T,P,A,L – babies M - preggo
o q4wk = 1st^ 28wk (7mo) ; q2wk = 29 - 36wk ; q1wk = afer 37wk
- Fundal height measurements (what measurement equals what gestational age?) o Meas’d from the superior aspect of the symphysis pubis to the upper most part of the uterus = fundus o Correlate w/22-34 gestational wk o 22-24wk – fundus is level w/umbilicus o 38-40 wk – fundal height ↓ as lightening occurs - What is lightening? When does it normally occur? o Fetus drops & descends into the pelvis in preparation for birth Remb: lightening shoots to the ground o Occurs – 38-40wk **Chapter 11 – Lesson 11
- Discomforts in pregnancy (Table 11-2). What can nurse do for each one? What can Mom do for each one?** Education for each one? ****most complications of preggo can be relieved w/o meds!!!! o Pregnancy (pg 229-230, Table 11-2): o Morning Sickness - Nausea & vomiting (subjective info) Causes: diet 50-80% of pregnancies – Should subside by 12 weeks Helpful hints Small meals – GI tract has time to empty Crackers/toast b4 rising Avoid odors Ginger Avoid spicy/greasy food May lead to hyperemesis o Ptyalism (pronounced: tyalism) Excessive salivation Usually before 8 weeks Helpful hints Swallow frequently Good oral hygiene Mouthwash, hard candy, chewing gum Avoid starch intake – breaks down oral cavity o Altered taste Usually bitter or sour Helpful hints Brush teeth frequently Use mouthwash Use hard candy or chew gum o Bleeding gums Increased blood flow - ↑ ♥ output Good oral care (gum care) Will go away afer pregnancy McDonald’s method
Progesterone @ peak in 2nd trimester Slows smooth muscle of GI tract Helpful hints Small frequent meals Avoid fatty foods – takes longer to digest Drink milk prior to meals Antacids – TUMS (calcium) o No Rolaid’s - magnesium Avoid lying down afer meals o Constipation Progesterone Pressure &displacement of bowels Helpful hints Drink lots of water Increase roughage in diet Exercise - walking Use only laxatives prescribed by MD o Hemorrhoids 1st: Varicose veins of the rectum Straining w/ constipation (usually) 2nd: can be r/t pressure of uterus Painful itching symptoms Helpful hints Avoid straining by preventing constipation Warm baths, ice packs, Tucks pads (witch hazel) Creams or ointments prescribed by MD only → Prep H, ammusol o Faintness or Dizziness ↓ BP due to uterus compressing major arteries - supine position ↓ blood sugar ↓ iron Quickly ’ing positions Helpful hints Move slowly when changing positions – rise slowly, dangle @ edge of bed Avoid warm crowded areas – don’t lock knees Rest on either side (not supine) o Round ligament pain Maintains uterus in ante-flexed position Pelvic bone to pelvic bone As uterus grows, round ligament stretches = round ligament pain Pain in abd – usually when she moves & stands o If she lays down & rests it goes away Helpful hints Avoid sudden jerking movements
Turn on side when getting up Warm baths, heating pads (on low) - hydrotherapy Non-constricting clothing → no low-rider jeans – rest on round ligament o Edema Normal – below the hips Feet, ankles, & lower legs Abnormal Face, tibia, anywhere else Helpful hints Avoid remaining in one position → blood pooling Rest frequently w/ legs elevated - ↑ venous return o Nocturia ↑ urine production Affects sleep & rest needs of client Urinary freq – 1st & 3rd trimester is common Helpful hints Avoid caffeine Avoid drinking fluids late evening o Insomnia Large size of uterus Fetal activity Heartburn Nocturia Emotional factors Helpful hints Support uterus while sleeping - preggo pillow Semi-sitting to sleep (semi-folwers or high-fowlers) or L-Lateral preferred More frequent rest periods Elevate HOB o Varicose Veins Common- legs, vulva, & rectum (hemorrhoids) Dull, throbbing pain Caused by ↑ pressure on the legs & pelvic veins (by gravid uterus) & by ↑ blood volume Helpful hints Avoid constrictive clothing Avoid prolonged standing or sitting or crossing legs ofen Wear support hose o Lower backache Change in center of gravity Progressive lordosis - normal inward curvature of the lumbar and cervical regions of the spine Helpful hints Good body mechanics (pg 234, Figure 11-4) Good posture
