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235 Cards in this Set

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What are some factors affecting pain?
previous experience with pain
fear of having pain
knowledge of pain/how to control pain
anxiety related to fear of experiencing pain
Morphine Sulfate
Narcotic
opiod agonist analgesic
controlled substance C-II

given IM: rapid onset, peaks at 30-60 minutes, 4-5 hr duration

given IV: immediate onset, peaks at 20 minutes, 4-5 hr duration
Percoset
Narcotic
5 mg oxycodone, opiod agonist analgesic
controlled substance C-II
+500 or 325 mg acetaminophen

given PO: peaks at 60 min
given PO: lasts 3-6 hours

Has faster onset and higher peak effects than most po narcotics.

patient should stay on schedule with meds to prevent pain getting out of control. Med may make her sleepy and she should not drive. She may have N/V as a side effect. Could cause constipation. Do not take alcoho; do not take other meds unless prescribed. Report any side effects to physician.
What parameters should the nurse assess when making decisions about interventions to control a client's pain?
Characteristics of Pain:
Old Dogs Like It Quiet,
Please Relieve Symptoms Effectively
Onset
Duration
Location
Intensity
Quality
Patterns (precipitating or aggravating factors)
Relief measures
Symptoms (other than pain, like N/V)
Effects of pain on the client
What are other considerations about controlling a client's pain?
-giving analgesics before pain occurs or increases gives clients confidence in the certainty of pain relief:
-client spends less time in pain
-smaller doses and less pain med overall
-smaller doses=fewer side effects
-reduce client's fear and anxiety pain will return
-client will be more physically active and avoid immobility
Characteristics of Pain:
Onset and Duration
When did it start?
How long does it last?
Is there a pattern to when it comes?
How often does it occur?
Characteristics of Pain:
Location
-point to location
-describe precisely
-classify: deep or visceral;
referred or radiating; or
superficial or cutaneous.
Characteristics of Pain:
Intensity
Use a descriptive scale, use the same one consistently for reassessment. Assist in evaluating change (improvement or worsening and response to interventions).
Characteristics of Pain:
Quality
-ask for description
-provide descriptors to help
-consider the characteristic descriptors for certain types of pain
Characteristics of Pain:
Pattern
what aggravates or precipitates the pain?
-have client demonstrate
consider the common patterns for specific types of pain
Sample interview questions for pain assessment:
-tell me when your pain started.
-does it come and go or is it there all the time?
-is there anything you do that makes it worse or better?
-can yo show me exactly where the pain is?
-does it stay right there or does it go anywhere else?
-what is the pain like: sharp, burning, stabbing, dull?
-on a scale of 1-10 how severe is the pain?
-are you having any other symptoms like dizziness or N/V?
-can you work/go to school or has the pain kept you from your usual activity?
What is pain?
Whatever a person experiencing it says it is, existing whenever the person says it does.

-subjective response to physical and pyschological stressors

-individual, distinct, personal experience influenced by physiologic, pyschologic, cognitive, socio-cultural, and spiritual factors.
What is the point of nurse advocacy in the treatment of a client's pain?
Addressing signs and symptoms
Achieve prompt treatment of all symptoms, including pain.
Where is pain modulated?
Peripheral modulation (skin level)
Spinal Cord Modulation
Spinal Reflexes
Is the pain threshold the same for everyone?
Yes - what varies is a person's pain tolerance: the amount of pain a person can endure before outwardly responding to it.
The neural pathway of pain:
-Cutaneous nociceptors perceive pain
-they generate pain impulses which travel fast and slow fibers to dorsal horn
-impulse travels the anterior and lateral spinothalamic tracts
-impulse passes through medulla and midbrain to thalamus
-in the thalamus and cerebral cortex, pain is perceived, described, localized, interpreted and a response is formulated.
-response impulse is returned down the cortico-spinal tracts.
What is acute pain?
temporary, localized, with sudden onset. It lasts less than 6 months and has an identifiable cause. It most often results from tissue injury from trauma, surgery, or inflammation.
ex: post-op, heart attack, injury.
What is referred pain?
-perceived in an area distant from the site of the stimuli.
ex: heart attack (left arm, jaw)
What is somatic pain?
-arising from nerve receptors originating in the skin or close to the surface of the body.
What is visceral pain?
-arising from body organs, dull and poorly localized because of the low numbers of noociceptors.
ex: appendicitis
Acute pain can lead to...
a state of stress in which clients develop manifestation sassicated with stimulation of the SNS.
-increased HR
-increased resp
-increased BP
What is chronic pain?
Prolonged, usually lasting longer than 6 months. Not always associated with an identifiable cause. Often unresponsive to conventional medical treatment.
What are the 4 categories of chronic pain?
1. recurrent acute pain
2. ongoing time-limited pain
3. chronic nonmalignant pain
4. chronic intractable nonmalignant pain
What is recurrent acute pain?
A type of chronic pain characterized by well-defined episodes of pain interspersed with pain-free episodes. Ex: migraines, sickle cell crisis.
What is ongoing time-limited pain?
A type of chronic pain characterized identified by a defined time period. Ex: cancer, burns.
What is chronic nonmalignant pain?
A type of chronic pain that is nonlife-threatening that persists beyond the expected time for healing. Ex: chronic lower back pain.
What is chronic intractable nonmalignant pain syndrome?
A type of chronic pain that is similar to chronic nonmalignant pain along with a person's inability to cope and other physical, psychological, and social disability resulting from the pain.
What are some common chronic pain conditions?
1. Neuralgias
2. Dystrophies
3. Hyperesthesias
4. Phantom Pain
5. Psychogenic pain
What is neuralgia?
pain from peripheral nerve damage
What is a dystrophy?
pain from peripheral nerve damage characterized by continuous burning pain.
What are hyperesthesias?
a state of oversensitivity to touch and painful stimuli.
What is phantom pain?
occurs post amputation, the person experiences sensations and pain in the missing body part.
Sensations are identified by the brain for location on the skin by the homunculus in the sensory cortex.
What is pyschogenic pain?
experienced in the absence of a physical cause or event.
What is central pain?
related to a lesion in the brain that may spontaneously produce high-frequency bursts of impulses that are perceived as pain (because of the homunculus - pain in hands, feet, ears).
What are factors affecting responses to pain?
-threshold
-tolerance
-age
-sociocultural
-emotional status
-past experiences
-source and meaning
-knowledge
What are some myths about pain?
-pain is a result, not a cause
-chronic pain is a masked form of depression
-narcotics are too risky for chronic pain
-wait until a person has pain before treating it
-clients lie about pain
-post-op pain is best treated with IM
Is post-op pain best treated with IM?
No- it is best treated with PCA; client ends up using less med overall and prevents inadequate or irregular absorption of med.
What does collaborative treatment medication mean?
a combination of meds to interrupt pain at different levels:
local anesthetics: work on peripheral nociceptors and peripheral nerves
NSAIDS: antiinflammatory at local nociceptors
Nonnarcotic: acetaminophin work at brain, spinal nerves, nociceptors
Narcotics: opiods work at brain, spinal level.
How can nurses deal with clients in pain who are reluctant to take pain medication?
Find out why - cultural, personal beliefs, side effects. Help them think through the process to decide why or why not.
What are some reasons why clients would refuse medication for pain or even deny they have pain?
cultural, social factors. Personal beliefs. Side effects. Fear of addiction.
What information could the nurse give the client that would motivate the client to take medicatio to relieve pain?
Explain med is not addictive when used properly, help the client with other comfort measures.
What are some surgeries to relieve pain?
1. cordotomy
2. neuroectomy
3. sympathectomy
4. rhizotomy
What is a cordotomy?
An incision into the anteriolateral tracts of the spinal cord to interrupt the transmission of pain. Ex: used for abdominal pain and legs, in terminal cancer.
What is neuroectomy?
The removal of a nerve.
What is a sympathectomy?
destruction by injection or incision of the ganglia of sympathetic nerves, usually in the lumbar region or cervi-cordorsal region at the base of the neck.
What is a rhizotomy?
surgical severing of dorsal spine roots, usually performed to relieve cancer of the head, neck, or lungs.
What are endorphines?
Endogenous morphines - natually occuring opiod peptides present in neurons in the brain, spinal cord, and GI tract. They bind with opiate receptors on the neurons to inhibit pain transmission.
Endorphins in the brain are released in response to afferent noxious stimuli.
Endorphins in the spinal tract are released in response to efferent impulses.
What can elicit endorphin release?
exercise
sex
deep breathing
things that give comfort and joy
What are some complementary therapies for pain treatment?
-acupuncture
-biofeedback
-hypnotism
-relaxation
-distraction
-cutaneous stimulation (massage, vibration, heat, cold)
-therapeutic touch
Nursing process: Assessment:
4 aspects of pain:
1. client's perception of pain pain rating scale (see characteristics of pain)
2. physiologic reponse to acute pain
3.behavioral response to acute pain
4. client's management of pain and its effectiveness

Denial of pain due to fear, misconceptions
Nursing Process: Diagnosis
acute or chronic
Nursing Process: Interventions
1. acknowledges and documents pain
2. Administers prescribed analgesics
3. Utilizes non-pharmacologic methods and comfort measures
4. Teaches clients and family about pain, medications, comfort measures
5. Suggests referrals as necessary
Nursing Process: Evaluation
utilizes client perception and pain rating scale to document changes in pain
What are 10 common cognitive distortions?
1. all or nothing thinking
2. overgeneralization
3. mental filter
4. disqualifying the positive
5. jumping to conclusions
6. magnification (catastrophizing) and minimization
7. emotional reasoning
8. should statements
9. labeling and mislabeling
10. personalization

Also
mind reading
fortune teller error (self-fulfilling prophecy)
What are defense mechanisms?
They help avoid coping. Ways to protect ourselves by distancing ourselves from awareness of our undesired and feared impulses. Some common ones are:
compartmentalization
compensation
denial
displacement
fantasy
intellectualization
projection
rationalization
reaction formation
regression
repression
sublimation
undoing
supression
What is compartmentalization?
a process of separating parts of the self from awareness of other parts and begaving as if one had separate sets of values. Keep two value systems separate and unintegrated and remain inconscious of the cognitive dissonance.
What is compensation?
process of psychologicall counterbalancing perceived weaknesses by emphasizing strength in other arenas.
What is denial?
the refusal to accept reality and to act as if a painful even, thought, or feeling did not exist. Primitive; characteristic of very early childhood development.
What is displacement?
redirecting thoughts, feelings, and impulses from an object that gives rise to anxiety to a safer, more acceptable one.
What is fantasy?
the channeling of unacceptable or unattainable desires into imagination to protect self-edteem as when educational ,vocational or social expectations are not being met; one imagines success.
What is intellectualization?
the use of a cognitive approach without the attendant emotions to suppress and attempt to gain mastery over the perceived disorderly and potentially overwhelming impulses.
What is projection?
cognitive reframing of ones perceptions to protect the ego in the fact of changing realities.
What is reaction formation?
the converting of wishes or impulses that are perceived to be dangerous into their opposites.
What is regression?
the blocking of unacceptable impulses from consciousness.
What is sublimation?
channeling of unacceptable impulses into more acceptable outlets.
What is undoing?
attempt to take back behavior or thoughts that are unacceptable.
What is suppression?
pushing into the unconscious; trying to forget something that causes you anxiety.
What is anxiety disorder?
a serious medical illness that fills people's lives with fear.
What are some anxiety disorders?
panic disorder
obsessive compulsive disorder
post-traumatic stress disorder
social phobia
specific phobias
generalized anxiety disorder
What is post-traumatic stress disorder?
can develop after exposure to a terrifying event in which grave physical or emotional harm occurred or was threatened. Usually people are initially numb, crash later.
*witnessing - common in children
PTSD 2x a prevalent in women as men
How does coping differ from defense mechanisms?
Coping is dealing with the problem while defense mechanisms are for avoiding the problem.
What are characteristics of PTSD?
flashbacks
dreams & nightmares
What are some treatments for PTSD?
-cognitive-behavioral therapy, group therapy, exposure therapy
-selective serotonin reuptake inhibitors and other antidepressants
-debriefinf people very soon after a catastrophic event - the sooner, the better
What is a phobia?
something a person fears to the point that they feel they have to change how they behave.
What is a specific phobia?
fear of an object or situation that poses little or no danger.
-irrational
Ex: fear of elevators, heights, blood
*facing the fear, or even just thinking about it can bring on a panic attack or severe anxiety.
What is a social phobia?
fear of being embarrassed, looked at, or made fun of in social or work situations.
-everything is about me
-everyone is criticizing me
-worry for days or weeks before meeting new people
-blushing, sweating, N/V, tremors
-avoid social situations
-alcohol to feel better
What are some treatments for phobias?
Cognitive-behavioral therapy, desensitization or exposure therapy (VR), relaxation, breathing exercises, support group, antidepressants
What is generalized anxiety disorder?
person worries all the time, even when nothing is "wrong"; they expect the worst, can't relax, they feel tense; have aches & pains, feel tired alot.
-source of worry is hard to pinpoint; hard to get through the day.
What are some symptoms of GAD?
-constant worry
-aches, pains
-trembling
-feeling tired
-trouble staying focused
-irritability
-trouble falling or staying asleep
-sweating or hot flashes
-having a lump in the throat, N/V
What are some treatments for GAD?
-cognitive-behavioral therapy
-biofeedback
-family and support group
-complementary therapies
-antidepressants
What is Obsessive-compulsive disorder?
recurring, upsetting thoughts (obsessions); repeat doing the same thing over and over again (compulsions) to make the thoughts go away; feels like you can't control or stop these thoughts or actions.
#men = #women
What is an obsession?
ruminating on upsetting thoughts, including fear of germs, being hurt, hurting others, and disturbed religious or sexual thoughts.
What is a compulsion?
actions you repeat to make the thoughts go away; counting, cleaning, hand washing, checking on things. Only provides short-lived relief; NOT doing them increase anxiety.
What are symptoms of OCD?
-upsetting thoughts
-feeling you can't stop the thoughts
-cannot stop yourself from doing things again and again; ex: collecting useless objects
-worrying about terrible things that could happen if you're not careful
-unwanted urges to hurt someone, but knowing you never would.
What are some treatments for OCD?
-cognitive-behavioral therapy
-exposure and response prevention
-social support
-stress release: areobic exercise, relaxation, avoid alcohol, caffeine, illegal drugs
What is panic disorder?
illness in which a person can feel frequent and sudden intense fear for no reason - "panic attacks"
-during a panic attack - scary physical signs - racing heart, trouble breathing, dizzy.
ex: agoraphobia - fear of leaving home.
What are some symptoms of PD?
-chest pain
-racing heart
-difficulting breathing
-dizzy
sweating
-chills or hot flashes
-stomach problems, N/V
-shaking, tingling in parts of body
-feeling out of control
-feeling unreal, detached
-fear of death or going crazy
When a person has a panic attack they can...
-think they are going to die
-have urge to run away, escape
-think they are having a heart attack
-worry alot that the attack will happen again so they avoid places, situations that may trigger an attack
What are some treatments for PD?
cognitive-behavioral therapy (CBT)
social support
pharmacology
What is a dissociative disorder?
-multiple personality disorder - have another "person" to take all the pain - personality dissociates, can see body from another place.
-a cognitive, spiritual process to protect against pain
-severe abuse in childhood

a lack of connection in a person's thoughts, memories, feelings, actions, or sense of identity.
What are some symptoms of dissociative disorder?
-depressed
-mood swings
-suicidal
-sleep disorders
-panic attacks and phobias
-alcohol and drug abuse
-compulsions and rituals
-psychotic-like symptoms
-eating disorders
-headaches, amnesias, time loss, trances, out of body experiences
-tend toward self-persecution
What are types of dissociation?
amnesia
fugue
dissociative identity disorder
depersonalization disorder
What is dissociative amnesia?
person is unable to remember important personal information, which is usually associated with a traumatic event in his/her life. Memory gaps in personal history.
What is dissociative fugue?
person impulsively wanders or travels away from home and upon arival in the new location is unable to remember the past.
-loss of personal id
-travel follows a stressful event
-person appears functional to others
-after the fugue person cannot recall what happened
-Dx occurs when relatives find the lost person living under a new id
What is dissociative identity disorder?
multiple personality disorder; intermittent experiences of two or more identities; that personality takes control and other personalities get repressed. Each personality has its own Hx and a totally separate name.
What is depersonalization disorder?
-feelings of detachment or estrangement from one's self
-feelings are difficult for person to describe
-feeling like in a dream watching themselves, like on TV
-feel like they are going crazy and frequently become anxious or depressed
What are some treatments for dissociation?
-individual psychotherapy
-hypnotherapy
-adjunctive therapies - art, movement
-long-term Tx for DID that helps person merge his/her multiple personalities

*people need to feel safe, respected, and heard.
Stages of chemical dependence:
I. Learning Phase
II. Seeking Phase
III. Harmful Dependence Phase
IV. Using-to-Feel-Normal Phase
Nature of addiction as a disease:
Can be diagnosed
Is a primary disorder
Causes other health problems
Predictable & Progressive
Treatable
Early signs of alcoholism are
tolerance and blackouts
Dysfunctional behavior patterns are a consequence of any substance addiction:
denial
manipulation
impulsiveness
anger
avoidance
grandiosity
codependence
contradependence

Others:
projection
rationalization
all or nothing thinking
conflict minimization
ego-centric
What are the CAGE questions?
have you felt the need to cut down?
have you ever been annoyed at criticism of your...?
have you ever felt guilty about something you've done when ....?
have you even had an eye-opener first thing in the morning?

Yes to 2, indicates risk for addiction
When dealing with a person with addiction the nurse needs to be...
matter of fact
nonjudgmental
nonthreatening
accepting
What are cognitive deficits associated with addiction?
abstract reasoning
perception and space
memory and learning
What are common signs of relapse?
denial
adamant commitment to sobriety
tunnel vision
progressive loss of daily structure
irregular attendance at Tx meetings
develop "I don't care" attitude
self-pity
unreasonable resentments
To prevent relapse, a nurse needs to...
-help client recognize warning signs of relapse;
-minimize the effects of euphoria recall - remembering only the positive expereinces with substance
-promote the acceptance of powerlessness and loss of control
-encourage avoidance of situations
-teach new methods to cope with dysphoric symptoms & drug craving
-12 step groups (AA started in 1930s)

*relapse is common - it takes 7-10 tries to quit.
A good recovery is...
being IN recovery (no past tense).
addiction is a chronic disease
Classic family aspects of substance abuse:
-don't trust, talk, feel
-guilt and shameful feelings
Classic family roles in regards to substance abuse:
chief enabler
family hero - codependent
scapegoat - contradependent
mascot - contradependent
lost child - contradependent
*all are enablers
What is codependence?
A dysfunctional behavior characterized by extreme social, emotional, or physical FOCUS on another person to the extent that individuals modify their behaviors in response to that other.
What does enabling do?
prevents person from experiencing the consequences of his/her behavior.
Codependent behaviors:
martyrdom
fusion
intrusion
perfection
addiction
What are female external reproductive organs?
mons pubis
labia majora
labia minora
clitoris
urethral meatus
paraurethral glands
vaginal vestibule
perineal body
What are femalie internal reproductive organs?
vagina
cervix
uterus
fallopian tubes
ovaries
bony pelvis
Follicle Stimulating Hormone
responsible for the production of the ovum
released from anterior pituitary -->production of egg
Estrogen
released from ovary --> stimulates release of egg
Lutenizing Hormone
released from anterior pituitary --> responsible for release of egg
Progesterone
responsible for maintaining pregnant state
If an ovum is fertilized during its trip through the fallopain tube, how long until implantation?
9-10 days
ova + sperm =
zygote --> morula (looks like a mulberry)
lifespan of ova
12-24 hrs
lifespan of sperm
72 hrs
How does estrogen effect conception?
During ovulation, high estrogen levels increases the contractility of fallopian tubes and make cervican mucus more readily penetrated by spermatozoa.
When does the morula enter uterus?
60 hr after fertilization
--> now a blastocyst
Blastocyst
embryo with a trophoblast layer (the chorion)
fertilization
ova + sperm = zygote --> morula -->blastocyst --> trophoblast
nidation
implantation
occurs 7-10 days after fertilization; the blastocyst attaches and buries into upper portion of uterine wall
cells of the trophoblast form CHORIONIC VILLI
After implantation the endometrium is called
the decidua
what is the rest of the uterus called
decidua vera
what is the uterus that encapsulates the embryo called
decidua capsularis
what is the part of the uterus under th embryo called
decidua basalis - becomes maternal portion of placenta
what is the chorion?
1st membrane to form, encloses the amnion
what is the amnion?
contains fluid and amnio; it grows until it contacts the chorion
together the chorion and amnion form the
amniotic sac
the chorionic villi form the ...
they protrude from the chorion and form the placenta
the amniotic fluid functions to...
-maintain temp
-prevent adherence
-allows for movement
-symmetric baby growth
-sound amplifier
-contains particles from meconium
-looks like coconut milk w/white flecks (vernix)
the yolk sac functions to...
produce RBCs until hematopoiesis begins, then becomes part of the umbilical cord
the chorionic villi contains
fetal blood
the intervillous spaces contain
maternal blood
What are cotyledons?
groups of villi (12-15)
What hormones does the placenta produce?
HCG - human chorionic gonadotropin
HPL - human placental lactogen estrogen
progesterone
What does HCG do?
maintains corpus luteum during pregnancy (test for it)
What does HPL do?
like growth hormone, aids in glucose transport + regulates maternal metabolism
What does estrogen do?
increases uterine blood flow via vasodilation
What does progesterone do?
maintains endometrium, increases uterine growth, decreases uterine contractility - maintains myometrial relaxation, increases breast development
The maternal portion of the placenta is...
red, fleshy, has cotyledons
"dirty duncan"
The fetal portion of the placenta is...
covered by amnion, shiny & gray
"shiny shultz"
The umbilical cord...
-55 cm long
-has 2 arteris (deoxygenated blood)
-has 1 vein (oxygenated blood)
-is surrounded by wharton's jelly which protects vessels from constriction
-attaches fetus to placenta
What is meconium stain?
when amniotic fluid is yellow or green - baby has been in stress, anal sphincter has relaxed - bm
What is amniotic infusion?
process to float baby off cord
fetal circulation
placenta --> fetal umbilical vein --> ductus venosus --> vena cava --> right atrium --> foramen ovale --> left atrium --> left ventricle --> ductus arteriosus --> aorta --> umbilical arteries --> placenta
What are 3 fetal structures that change at birth?
ductus venosus
foramen ovale
ductus arteriosus
What are the 3 cell layers?
ectoderm
mesoderm
endoderm
* all tissues, organs, and organ systems arise from these three layers
What are the 3 stages of development?
pre-embryonic
embryonic
fetal
The pre-embryonic stage consists of...
-stage of the ovum: 1st 14 days; rapid growth & cell differentiation
The embryonic stage consists of...
- stage of the embryo: wks 3-8; by end of this stage all major systems started, remainder of prenatal period is for refinement of structures & practice of function
The fetal stage consists of...
wk 9 to birth; viability: fetus can do functions of like but may not sustain life
What is point of viability of fetus in Ohio?
20 weeks
* used for determining live births
pregnancy test
BhCG
-serum test is more sensitive
*if mother at risk for miscarriage, test q 1-2 hrs.
What is the length of pregnancy?
10 lunar months
9 calendar months
280 days

preterm - before complete of week 37
term 38-42 weeks
postterm after 42 weeks
GPTAL
gravida = "pregnancy"
para - if woman carries past 20 weeks (viability)
then,
-preterm
-term
-abortions
-living

ex: gravida 1, para2, living 2 = twins
EDD
Estimated Date of Delivery
Nagele's Rule
use last day of menstrual period
day-3
month+7
year+1
Timing of prenatal visits:
5-27 weeks - q mo.
28-36 weeks - q 2 wks.
37-40 weeks - q wk

*vary according to risk
*measure fundal height
listen to FHT
special tests/labs
teaching done PRN
Total weight gain:
low (BMI<19.8) 28-40 lbs
Normal (BMI 19.8 - 26) 25-35 lbs
High (BMI> 26-29) 15-25 lbs
Presumptive signs of pregnancy
amenorrhea
breat tenderness & enlargement
Chadwick's sign (vagina --> violet)
fatigue
hyperpigmentation
cholasma
linea nigra
quickening
urinary frequency
N/V
Probable signs of pregnancy
abdominal enlargement
Ballottement
Braxton-Hicks
Goodell's sign (soft cervix)
Hegar's sign - (soft lower uterine segment)
palpate fetus
+preg. test
uterine enlargement
Positive signs of pregnancy
auscultate FHR
palpate fetal movements
USN verification
What happens at the 1st prenatal visit?
1. BhCG urine test (if neg do RIA BhCG)
2. Hx - LMP, cycle, contraceptives, gynecologic (diseases), sexual, reproductive, med-surg, psycho-social, family
3.Pelvic Exam - VS, head to toe, pelvic (pelvimetry), cervical status
4. Labs
5. prenatal ed
What is pelvimetry?
inlet - diagonal conjugate > 12.5 cm
midpelvis - ischial spines - 10.5 cm
outlet - ischial tuberosities 11.0 cm
sacrum
public arch
What is cervical status?
3-4 cm long, closed, firm, mid-posterio position
*in lithotomy position, most cervices point to floor.
Labs at 1st prenatal visit.
blood type
Rh antibody screen
CBC (looking for anemia)
rubella, varicella titer (give AFTER birth if not immune)
syphyllis screen
HIV, cyctic fibrosis, HEP
PPD
UA
chlamydia, gonorrhea
GBS - Tx during labor w/AB
pap
Considerations of drug use during pregnancy...
Classification (A through X)
Duration of exposure to drug
Amount of drug crossing placenta
Rate of drug transfer to fetus
Properties and effects of drug
Stage of fetal development:
day 1-15 most susceptible period
days 18-60 period of organogenesis
first 3 months most critical for malformations
2-9 months drug effects on brain may produce functional/behavioral defects
What is fetal fibronectin?
test to predict preterm delivery; vaginal swab for presence
A biological glue attaching fetal sac to uterine lining
Up to 22 weeks, FFn is normally present in cervical/vaginal secretions
After 22 weeks, is not normally secreted, so it should be gone
If it is still there, correlates to preterm delivery

Negative test result - risk is low for the next 2 weeks
What are preterm risk factors?
Major:
multiple gestation
DES exposure
hydramnios
uterine anomaly
cervix dilated >1cm or < 1cm long @ 32 wks
2-2nd trimester AB’s
previous preterm birth
previous preterm labor
abd surgery during preg
hx of cone biopsy
uterine irritability
cocaine abuse

Minor:
febrile illness
bleeding p 12 wks
hx of pylonephritis
smoking > 10 / day
2nd trimester AB
> 2-1st trimester AB’s
Pregnancy is a risk factor for abuse - what are some assessment questions?
1. Have you ever been emotionally or physically abused by your partner or someone important to you?
2. Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?
3. Since you’ve been pregnant, were you hit, slapped, kicked, or otherwise physically hurt by someone?
4. Within the last year, has anyone forced you to have sexual activities?
5. Are you afraid of your partner or anyone you listed above?
What are some warning signs during pregnancy of serious problems?
Severe headache that does not go away with Tylenol or associated with swelling or blurred vision
Fever of l0l degrees or more
Inability to take fluids by mouth for more than 12 hours or solid food for more than 24 hours
Decreased fetal movement after 26 weeks
Contractions of the uterus that occur more than 3-4 times an hour at less than 37 weeks gestation
Backache that comes and goes
Blurred vision or spots
Epigastric pain
Vaginal bleeding
Facial/hand edema
Sudden weight gain (>2lbs/week)
Leakage of fluid
Urinary pain/burning
TORCH infections
What are TORCH infections?
Group of infections that can affect a pregnant woman and her fetus
These have organisms that can cross the placenta and adversely affect the development of the fetus
-Toxoplasmosis - miscarriage
-Rubella - defects, death
-Cytomegalovirus - microcephaly
-Herpes - retardation - no Tx, C/S for active lesions
Special consideration for mothers with HIV?
early access to prenatal care
nutrition
social support
therapy for prevention of transmission
Hepatitis A
*Fecal-oral route by ingestion of contaminated food.
Possible fetal effects of first trimester exposure:
fetal anomalies
preterm birth
fetal or neonatal hepatitis
intrauterine fetal death
Gamma globulin given to infected mothers and exposed neonates.
Hepatitis B
major concern in pregnancy, most transmitted during birth.
Sexually transmitted
Virus most threatening to fetus and neonate
At risk women – history of multiple sex partners, STD’s, IV drug use, blood contact
50 to 100 times more contagious than HIV
Disease of the liver with outcome fatal
*First prenatal visit for all women and third trimester for women at risk
*Breastfeeding okay if baby immunized
What are some sexually transmitted diseases
Gonorrhea
Chlamydia
Human Papilloma Virus
Syphilis
Hepatitis
Herpes
Group B Strep
Recommended treatment is penicillin G 5 million units IV loading dose and then 2.5 million units IV q 4 hours during labor. Ampicillin is an alternative therapy.
Is there a Vaccine Available for Hepatitis A and hepatitis B?
yes
considerations of UTI?
Presence of bacteria in urine is significant if a clean-catch specimen contains > 50,000 bacteria of the same species
Contamination of a specimen is indicated and woman should not be treated, when culture results are
Up to 100,000 nonpathogenic organisms/ml
>100,000 if mixed species bacteria/ml
What happens at subsequent prenatal visits?
Wt
BP
urine (blood, protein, ketones, nitrites, glucose)
evaluate complaints of HA, visual disturbances, dizziness, fever/chills, n&v, abd pain, back pain, dysuria, CVA tenderness, vag discharge/bleeding, constipation/hemorrhoids, varicosities, leg cramps, edema, exposure to any infectious diseases, use of any meds
review nutrition/use of PNV’s
Things to do at prenatal visits afet 35 weeks...
Leopold’s (after 35 wks)
assess for quickening/fetal movement (16 weeks is detectable)
fundal height
FHR
include partner/siblings
assess relationship changes (increase/initiation of abuse)
teaching re any concerns, complaints, questions, problems
Prenatal visits - weeks 12-15:
review labs
follow up screening
Prenatal visits, weeks 15-18:
Maternal serum Alpha-fetoprotein screen (MSAFP) or quad screen.
Screening versus diagnostic testing.
Quad screen (MSAFP, hCG, estradiol, possible NTD), improved identification of chromosomal anomalies over MSAFP alone.
Normal values based on gestational age, maternal age, weight, race, diabetes (if present), multiple gestation.

NTD - spina bifida, microcephaly, anencephaly, down’s syndrome - (4 things)
Prenatal visits, weeks 16-20:
assess for quickening
USN for confirmation of gestational age
AFP quad screen: BhCG, MSAFP, unconjugated estriol
Prenatal visits, weeks 24-28:
Diabetes screen (week 28) - 1 hr GTT
Coombs’ test/antibody titer (for Rh neg women)
administer Rhogam if indicated
retest H & H
evaluate risk of PTL
Prenatal visits, weeks 29-32:
counsel re health care provider for infant
counsel re infant feeding method
discuss importance of fetal movement, give FMC card
Prenatal visits, weeks 33-34:
reassess for PTL and assess cervix as indicated
only check cervix for S&S of labor
Prenatal visits, weeks 35-36:
Discuss S&S of labor
GC culture (if necessary)
Chlamydia culture
GBS culture
Prenatal visits, weeks 37-40:
Assess fetal position/presentation
review birth plan/expectations
copy and forward records to place of birth
initiate fetal surveillance as indicated
examine cervix as indicated
review alternative methods for cervical ripening/induction of labor
discuss plans for contraception
review prep for breastfeeding
Prenatal visits, weeks 40+:
prepare client for postdate pregnancy protocol
assess cervical readiness
institute fetal surveillance: USN, NST, AFI, BPP
biweekly office visits
USCR: AIR
Modified throughout pregnancy
15-20% ^ on O2 consumption between 16-40 weeks to meet ^ needs of woman, placenta, fetus
Diaphragm is elevated from enlarging uterus
Breathing changes from abdominal to thoracic
Nasal stuffiness due to estrogen-induced edema & vascular congestion
Heart is laterally displaced
Blood volume ^ 45% due to ^ in plasma & erythrocytes
Pulse rate ^ 10-15 BPM
BP decreases then increases 3rd trimester
Femoral venous pressure rises due to uterine pressure on return blood flow, creates stagnation of blood in lower vessels leading to varicosities & dependent edema
Vena Cava Syndrome (supine hypotension)-enlarging uterus pressure on inferior vena cava interferes with returning blood flow producing drop in BP, dizziness, pallor, clamminess
Total RBC volume ^ 18-30%, necessary to transport additional O2 required
Physiologic anemia-from plasma ^ that is > erythrocyte ^
Leukocyte production > increase in blood volume
Fibrin & fibrinogen levels ^ 40-50% which ^ risk for venous thrombosis (DVT)
USCR:FOOD
Many discomforts of pregnancy from changes in GI system
N&V from HCG secreted by ovum and CHO metabolism changes
Peculiar tastes & smells
PICA - argo starch, nonfood substances, clay
Bleeding gums
Ptyalism
^ gastrin levels cause more acidic gastric contents
GI symptoms from growing uterus increase during 2nd trimester
^ progesterone causes smooth muscle relaxation
Heartburn from reflux of acidic secretions
Gastric emptying & intestinal motility delayed causing bloating & constipation
Average wt gain = 25-35 lbs
Weight may decrease due to N&V, then ^ of 3, 12, & 12 the 1st, 2nd, & 3rd trimesters
Fats more completely absorbed leading to ^ cholesterol & serum lipids
Demand for CHO ^ although oral GTT remains the same
Demand for iron is ^, iron is transferred to fetus and sustains need in neonate for 4 months
Vitamin metabolism does not change-PNV’s or Flintstones (two), taken at hs
USCR: WATER
^ water retention is basic alteration, caused from ^ hormones affecting Na & fluid retention, lower serum protein, & ^ intracapillary pressure & permeability
3.5L from fetus, placenta, amniotic fluid
3.5L from mother’s organs, blood volume, & interstitial fluids
^ in water intake creates flushing effect which aids in reducing retention
USCR:ELIMINATION
Uterus
Phenomenal changes: 8x5x2.5 nonpregnant to 28x24x21 at full term, weighs 1000 gms
Hypertrophy under influence of estrogen, then distension from growing fetus
Thickened musculature to thinning at term (5mm)
Vascularity ^ to 1/6 of total blood volume
Fundal height from symphysis to fundus, cms correlate with gestation weeks 20-31, 20 weeks = 20 cms (umbilicus)
Braxton-Hicks occur throughout pregnancy moving blood through placenta, toning muscle until term
Hyperactive cervical glands secrete thick mucous which forms plug preventing ascent of bacteria
Estrogen induced hypertrophy of vaginal mucosa occurs along with loosening of connective tissue, & ^ vaginal secretions
Highly acidic vaginal secretions prevent infections but favor growth of yeast -candidiasis
USCR:ELIMINATION
Breasts
Estrogen & progesterone changes mammary glands
^ in size and nodules from hypertorphy & hyperplasia for lactation
Veins prominent, nipples erect, pigmantation enhanced, on areola-Montgomery’s follicles ^, striae
Colostrum-thick, yellow secretion high in antibodies expressed by 12th week
USCR:ELIMINATION
Skin
^ estrogen & progesterone cause ^ in melanocyte-stimulating hormone causing changes in pigmentation of areola, nipples, vulva, perianal area, linea nigra, chloasma
Hyperactivity of sweat & sebaceous glands
^ adrenal steroid levels cause reduced connective tissue leading to striae
Vascular spider nevi
Hair growth decreased from estrogen but sudden growth after birth
USCR:ELIMINATION
Urinary tract
Bladder becomes irritated from pressure or uterus early in pregnancy, then at term making it more susceptible to infection
Dilation of ureters & kidneys
GFR & RPF ^
Glycosuria common but R/O DM
Renal fx ^ & urea & creatinine ^ (creatinine clearance test)
USCR:ELIMINATION
Bowel
Hemorrhoids common especially if constipation a problem
GI motility delayed, therefore constipation
Smooth muscle is relaxed, electrolyte & water reabsorption ^, plus weight of growing fetus & uterus all can cause problems
USCR: Activity & Rest
Sacroiliac, sacrococcygeal, & pubic joints relax in latter part of pregnancy from hormones
Center of gravity changes, lumbodorsal curve is accentuated, compensates for growing uterus ‡ frequent backaches
Diastasis recti-separation of rectus abdominis
Exercise-moderate routine involving large muscle groups (swimming, cycling, walking, cc skiing), intensity decreased as pregnancy progresses (no competitive sports, prevent hyperthermia, supportive clothing, ^ fluids, avoid lying flat
Sleeping-positioning important with pillows for support, interrupted late in pregnancy from urinary frequency
travel
USCR: Solitude & Social Interaction
Life-style changes
Relationship with partner may take on new meaning, roles are changed
Woman is no longer a separate individual, she must now consider needs of another being who is totally dependent on her
Woman often reestablishes stronger ties with own mother/grandmother
Attachment to fetus is evident in fantasy, USN
Sexual activity
USCR: Hazards
Warning signs
Gush of fluid from vagina
Vaginal bleeding
Abdominal pain
Temp > 38.3 C
Dizziness
Blurred vision
Persistent vomiting
Severe HA
Edema of face & hands
Epigastric pain
Oliguria/dysuria
Decreased fetal movement
Teratogens-substances that adversely affect growth & development of fetus, ie, medications, smoking, alcohol, caffeine, recreational drugs, environmental hazards, chemicals, etc
USCR: Normalcy
Several hormones required to maintain pregnancy, produced by corpus luteum initially then by the placenta
HCG-secreted by trophoblast, stimulates estrogen & progesterone production
HPL-produced by syncytiotrophoblast, increases free fatty acids and decreases maternal metabolism of glucose, is an insulin antagonist
Estrogen-stimulates uterine development & ductal development of breasts in preparation for lactation
Progesterone-plays greatest role in maintaining pregnancy, maintains endometrium, decreases uterine contractility, aids in preparing breasts for lactation
Relaxin-inhibits uterine activity, aids in softening the cervix
Psychological Tasks of Pregnancy
Nonstress Test
NST - Reactive:
2 accelerations in 20 minutes, (increase by 15 beats)
Begin use at 30-32 weeks
Adequate oxygenation and intact CNS
Fetal Movement Counts
same time each day
note the time it takes for 10 fetal movements
if takes longer than usual or decreased movements, contact care provider
Ultrasound can measure
Fetal gestational age, well-being, weight, multiple gestation, confirm pregnancy, placenta location, fetal position, amniotic fluid levels, fetal death
Biophysical Profile
Fetal muscle tone
fetal movement
fetal breathing movements
fetal heart rate activity (NST)
amniotic fluid volume (AFI)


Score of 8-10 is normal, otherwise delivery is considered
Childbirth preparation:
Lamaze:psychoprophylaxis
fear-tension-pain
Read: progressive relaxation
Bradley: abdominal breathing
partner-coached methods
abstaining from meds
Kitzinger: sensory memory
acting for relaxation
hypnosis: conditioned reflexes
theories of initiation of labor
oxytocin-stimulation theory
progesterone-deprivation theory
estrogen-stimulation theory
fetal-cortisol theory
PG theory
uterine distention theory
premonitory signs of labor
Lightening-baby has dropped
Braxton-Hicks contractions
cervical changes
bloody show
rupture of membranes (ROM)
energy surge
others: weight loss, flu, backache
only definitive difference between true and false labor
dilation of cervix
True & False Labor
True
progressive dilation, effacement, & descent
regular
increase in intensity, frequency, & duration
discomfort in back
worsen with activity

False
no progressive dilation, effacement, & descent
irregular
discomfort in abdomen & groin
relieved with activity or sedation
Factors affecting Labor 5 P’s
passage (pelvis)
passenger (fetus)
powers
Position - book does not include
psyche
What is the female pelvis type good for giving birth?
gynecoid
Progression through pelvis:
90 degree inlet --> 90 degree rotation
passenger
fetal head
sutures: frontal, sagittal, coronal, & lambdoidal
fontanels: anterior - diamond shape & posterior -triangle shape
landmarks of fetal skull:
sinciput
bregma
vertex
occiput
mentum
fetal lie
relationship of cephalo-caudal axis of fetus to mother
fetal presentation
fetal presentation - body part entering pelvis first
cephalic: vertex, sinciput, brow, face
breech: complete, frank, incomplete
Both of these have longitudinal lie
Shoulder - have a transverse lie
What is the most common position?
LOA is most common position
left occiputanterior
powers
primary powers - uterine contraction
Frequency - minutes
duration - seconds
intensity - pain scale of 1 to 10
secondary powers - abdominal muscles added to primary powers in Stage 2 of labor
Friedman Curve
not an actual curve: and ideal composite of the "average" labor
factors associated with a positive birth experience:
motivation for pregnancy
childbirth preparation
sense of competency/mastery
self-confidence, self-esteem
positive relationship with partner
control during labor
Presence - of support person, not being alone
support during labor
trust in health care professionals
Stages of Labor
Stage 1 Stage of Dilation and Effacement
latent phase 0-3 cms
active phase 4-7 cms
transition 8-10 cms

Stage 2 Stage of Expulsion
Stage 3 Placental Expulsion
Stage 4 Recovery
Why should you never pull on the cord to remove placenta?
-could pull cord off placenta or invert the uterus, let contractions do the work
USCR: AIR, FOOD, WATER
cardiovascular
contrx cause increase BP & P (will decrease on L side)
vena cava syndrome
Hgb is 12-16 gm/100 ml
increased leukocytes to 25-35,000 (=strenuous exercise)
bearing down causes c.o. to increase 40%
c.vol. decreases after delivery by 500cc (over 500cc hemorrhage)
fluid & electrolytes
fluid and electrolytes
temp remains normal (q 2 hours if ROM)
altered by diaphoresis and hyperventilation
diaphoresis from increase muscular activity
dehydration from increase respiratory rate
edema monitored (ankle vs facial)
oral fluids
IV fluids (lactated ringers)
respiratory
respiratory
rate = strenuous exercise
breathing techniques maintain oxygenation therefore decreasing ischemia
GI
GI
motility & absorption decrease
last intake
calories needed for energy expenditure
USCR: Elmination
bladder
trace of protein common due to muscular exercise (not > +2)
atony leads to distention and inability to void (from progesterone and physical compression)
glucose negative
ketones negative
specimen contaminated from vaginal secretions

bowel
enema rarely used but can cleanse, increase room for fetal descent, stimulate contrx
stool can create embarrassment causing woman to hold back, not push effectively

amniotic fluid
may rupture prior to or during labor
clear (coconut milk) and odorless
green - meconium from fetal distress
odor - from amnionitis
nitrazine test - pH of 6.5 or > indicates ROM - rupture of membrane
FHR indicates potential prolapse of cord
Uterine involution process
contraction of uterus to shrink back down
What is uterine subinvolution
when a uterus does not contract down
Lochia - color (rubra) --> cirrhosa (bluish) --> alba (white, tan)