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98 Cards in this Set

  • Front
  • Back
Types of IPV behavior
(Intimate partner violence)
Physical - person hurts or tries to hurt partner
Sexual violence - forcing sexual acts
Threats - re: finances; physical or sexual violence; words, gestures, weapons to intimidate
Emotional - threatening or his or her possesions or loved one. name calling, stalking, intimidation, isolating
Risk factors for becoming victim/perp of IPV
Individual factors: depression, hx of abuse, low income, emotional dependent, insecure, heavy alcohol or drug use.
Relationship factors: marital conflicts, marital instability, dominance/control by one over the other, economic stress, unhealthy family relationships.
Community factors: poverty, weak community sanctions (not intervening in violence)
Societal: traditional or gender norms
Nursing role in IPV
*Need to report to authorities
*remain non-judgmental
*gain trust
*tell them it's confidential
*need to screen at OB visit - screen mom in private
Consequences of IPV
Physical - depend on severity and frequency - broken bones, stds, gi disorders, cardiac disorders, preterm labor
Psychological - depression, anxiety, fear of intimacy, sleep disorders, suicidal thoughts
Social - restricted access to health services, strained relationships w/ family, friends, health providers, emoployers, isolation
Why do men abuse?
*Learned bx - observation, experience, culture
*believe they are entitled to control partner
*use stress, anger, drug/alchohol as reason why
*many other reasons
Screening for IPV
Screen ALL pts for IPV
For women who are not preg - screen at routine visits, family planning visits, preconception visits (may not do b/c no $)
Screening pregnant women for IPV
Screen at various times over course of preg. - new abuse may occur as dad gets jeolous. Woman may become more willing to confide as she builds relationhship w nurse.
Screen: at first prenatal visit, at least 1x per trimester, at postpartum
*interview mom alone, maintain confidentiality, remain nonjudgmental
Screening for IPV
3 questions
*W/in past year, or since you have been pg - have you been hit, slapped, kicked or otherwise physically hurt by SOMEONE (not necessarily partnter)?
*Are you in a relationship w/ a person who threatens or physically hurts you?
*Has anyone forced you to have sexual activities that made you feel uncomfortable?
+any "yes" answer indicator of abuse
3 phases of the cycle of violence
*Tension building
*Acute battering
*Honeymoon
Tension building phase of IPV
Tension builds over common domestic issue.
- verbal abuse
- victim tries to control situation by pleasing, giving in or avoidance
Acute battering episode of IPV
Triggered by an external event of abuser's emotional state.
Unpredictable and beyond victim's control
Honeymoon phase of IPV
Abuser ashamed of bx.
Expresses remorse, may exhibit loving, kind bx.
Followed by generosities, kindness, helpfulness.
Give victim false belief that everything will be alright.
Why do women stay in violent relationships?
Emotional factors: insecurity, loyalty, fear, love, shame/humiliation, material objects, lack of shelter, religious reasons
Situational factors: ties to home and belongings, economics, fear, lack of shelter
Predicting preterm labor - endocervical length
Done by endovaginal ultrasonography.
Ideally s/b more than 30mm (3cm)
Shortened cervix w/ positive fFN = ^risk preterm labor
Will usually keep mom in hosptial.
Fetal fibronectin (fFN)
*Extracellular matrix protein that is an adhesive "glue" produced by fetal membranes adn binds membranes and placental to decidua
*Presence normal in 1st 1/2 of preg. as sac attaches to inside of uterus and at end of 3rd trimester
*ABNORMAL after 22wks gestation - possilbe inflammatory or mechanical disruption of the fused membranes
Fetal fibronectin test:
*done during a vag. exam using a cotton swab to collect secretions. Results w/ in 24hr
*Postive - can occur w/ recent sexual intercourse, bacterial vaginosis, vag. bleeding, rupture of membranes.
Neg: - less than 1 in 100 chance of birth w/ in 2 weeks
*NOT ABSOLUTE*
Management of fFN results
Negative fFN w/ no cervical change: managed at home
Postive fFn w/ cervical change: hospital admission
Investigational study: Salivary Estriol
*collect maternal saliva
*estriol is produced by placenta. Close to birth (3-5wks) levels increase
*May indicate potential for labor if levels exceed 2.1 ng/ml
Lifestyle modifications in pre-term labor
*individualized.
*Activities taht cause s/s of PTL should be avoided
- no sexual intercourse
- modify job - sit
Bedrest and PTL
*No evidence to support that reduces pre term birth
*unknown effectiveness
*difficult on mother - mentally.
Keep needed items close at hand.
Important to avoid constipation - fiber, colace stool softener, oral fluids
Bed rest: Adverse effects
Physical: wt loss, muscle weakness, potential for thrombus formation
Psychosocial: anxiety, deprs; guilt; emotional lability; increased stress
Support system: financial strain; fear and anxiety re: well being; stress assoc. w/ role reversal, increased responsibility.
Home care and bed rest
*Restructure of family routines - dad takes on
*Mod. of environment - cooler @ bed, cell phone, pc, home care visits from RN
*Daily schedule preparation
Try to keep pt at home if poss.
Hospitalization and bed rest
Tocolytics - usually hospital
Antenantal corticosteroids - beta methasone (surfactent): 1M
*fetal monitoring
Tocolytics - reasons why administered
Allows time to give antenatal gluccorticoids.
More time in utero for fetus to reduce severity of sequelae in nb born preterm. Each day makes big differnce for baby.
Time for maternal transport to facility w/ a NICU - Level 3.
Better to transport mom than to deliver.
Contraindications for tocolytic use
Maternal: severe pre-eclampsia/eclampsia; active vag. bleeding; chorioamnionitis; cardiac disease; dilation greater than 6cm
Fetal: gestational age less than 34wks; fetal death; lethal fetal anomaly; acute fetal distress; chronic IUGR
Names of Tocolytics
Ritodrine hydrocholride (Yutopar)
Terbutaline (Brethine) off label
Mag. sulfate - off label
Nifedipine (procardia) off label
Indomethacin (Indocin) off label
Ritodrine hydrocholride (Yutopar)
Tocolytic - no longer used in US, avail. in Canada
Only med. approved by FDA specifically for purpose to suppress uterine contractions.
No longer marketed in US due to serious SE
Terbutaline (Brethine)
Tocolytic.
- works by relaxing uterine smooth muscle
- B2 receptors stimulated
- affect maternal and fetal cardiopulmonary and metabolic system
- give SQ, by subq pump or PO
- SQ pump in leg, mom () cartrdige
Side Effects of Terbutaline (Brethine)
Tachycardia:Palpations;Tachypnea;SOB;sweating;tremors;
N/V;
decrease calcium levels
hypokalemia
increase glucose levels
do not give to: diabetics or cardiac pts
Magnesium sulfate
Most commonly used tocolytic agent - less maternal/fetal/neonatal adverse reactions.
*Central nervous system depressant
*Given IV
Magnesium Sulfate - SE
*Very few to fetus
Maternal:
Hot flash - cool cloth, fan
N/V
SOB
decrease calcium/hypocalcemia - give calcium gluconate
Assessment/interventions w/ mag sulfate
Assess FHR w/ contractions
Pulse O2
Temp (<100.4)
DTR
RR and APR:full minute
arrythmias
BP -manual cuff
urine output - 30mL/hr
obtain 24hr urine: check for ketones & proteins
Critical thinking: why must caution be used when adminstering IV fluid to a woman in PTL esp. if terbutaline or mag. sulfate is used?
Increased risk of pulmonary edema.
Has to run withother fluids - might have to titrate
Nifedipine (Procardia)
*Calcium channel blocker; relaxes uterine muscles by blocking calcium entry
*Maternal SE r/t hypotension: bradycardia
*few fetal/neonate SE
*Given PO or SL
decrease blood supply to fetus
hypocalcemia
used more often PO in homecare
Critical thinking: why must nifedipine not be used w/ mag. sulfate:
Lowers calcium levels even more. Transition from Mag to nifedipine.
Hypocalcemia
Less than 8.2mg/dl
anxiety, confusion, irritability
arrythmias and decreased CO
brittle nails;dry skin & hair
diarrhea
diminished response to dig.
Hyperactive DTRs
Parasthesia of toes, fingers or face, esp around mouth
spasms of laryngeal and abd. muscles
tetany, tremors, twitchng, muscle cramps
Trousseau's sign or chvostek's sign
Trousseau's sign
apply BP cuff to upper arm & inflate to a pressure 20mmHg above systolic pressure. Trousseau's sign will appear in 1-4 min. Pt will experience adducted thumb, flexed wrist adn metacarpophalangeal joints, adn extended interphalangeal joints - carpopedal spasm - indicating tetany
Chvostek's sign
Tap patients facial nerve adjacent to the ear. A brief contraction of the upper lip, nose or side of face indicate Chvostek's sign and tetany
Indomethacin (Indocin)
*Prostaglandin synthetase inhibitor; relaxes uterine muscles.
*Lowest risk for maternal SE, but severe fetal SE
- premature close of ductus arteriosis - O2
- NEC - bowels start to die
- intraventricular hemmorhage
- Give PO
Rarely given due to fetal SE
Antenatal Glucocorticoids
Stimulates fetal lung maturation
Given to all women btwn 24 and 34 wks gest. when preterm birth is a threat
Betamethasone 12mg IM x 2 doses 24 hrs apart
Fetal HR characteristics
Baseline FHR: AVERAGE of FHR observed btwn contractions during a10 minute period of rounded to 5bpm
*Does not include any decel. or acel.
*Normal range: 110-150
*fetal bradycardia: <110 for 10min
*fetal tachycardia: >160 for >10min
FHR norms/brady/tachy
Normal: 110-150
bradycardia: <110 for 10 min
tachycardia: >160 for >10 min
Causes of Fetal Tachycardia
Maternal causes:
Maternal fever (axillary) >100.4; dehydration; anemia; maternal anxiety
Fetal causes: chronic fetal hypoxemia; chorioamnionitis; fetal anemia; cardiac abnormalities
Causes of Fetal bradycardia
Maternal: supine position; hypotension; maternal hypothermia
Fetal: umbilical cord compression; congenital heart disease; cardiac abnormalities
Reassuring (Fetal Heart Rate monitoring)
FHR baseline between 110 and160 bpm.
Variability present
Accelerations w/ fetal movement.
Absence of late or variable decels.
Nonreassuring (FHR)
Late decels.
Absent variability
Prolonged decelerations
Bradycardia
Variable decel assoc. w/ a decrease in variability.
Variable decels w/ a slow return to baseline
Early decelerations
Gradual decrease in FHR baseline w/ nadir greater than or equal to 30 sec. and returns to baseline, assoc. w/ uterine contractions.
Occurs simutaneously w/ contractions, nadir concludes to acme of contraction.
Cause: head compression
Late decelerations
Shallow decels in FHR that is characterized by gradual decrease.
Begin at acme of contraction w/ return to baseline after contraction has ended. Cause: placental insufficiency.
Interventions: repostion; stop pitocin; give O2 via face mask, 8-10L
Hydration: ^ IV (bolus)
Needs immediate intervention
Severe variable decelerations
Abrupt decrease in fHR lasting less than 10min.
Cause: cord compression
Interventions: reposition; stop pitocin; check for prolapsed cord - get pressure off cord (use gravity)
15 minutes before hypoxic
Variable decel ok if mom is pushing or not in cord
Nuchal cord
HELP VC
Head compression - Early decel
Late decel - Placental insufficiency
Variable - Cord compression
Non Stress Test
Accelrations imply intact CNS
Test involves FHR monitoring and observation of ^FHR w/ fetal movement.
Accel patterns r/t gestational age - FHR does not accel. w/ movement until 30-32 wks GA.
Done in Triage
20 min test
Reasons for NST
Diabetes
Fetus has decreased movement.
Pre-eclampsia
Multiple fetus.
If no decels >20 min, do again
Interpretation of NST
Accels must be 15 bpm above baseline, lasting 15 sec
Reactive - two or more accels w/ in 20 min
Non-reactive - insufficient accels over 40 min
Non Reactive - Not Good
Management of NST results
Varies based on NST interpretation
If reactive, NST may be rescheduled for 2x wkly after 28wks gest for certain populations.
If Non reactive, CST or BPP may be ordered
Biophysical Profile (BPP)
Used in 3rd tri, usually after 32 wks to assess fetal well-being.
Indications: Nonreactive NST; susptected oligohydramnios/polyhydramnios; suspected fetal hypoxemia and/or hypoxia; PROM; maternal infection
BPP scoring
Measurement of 5 variables: breathing, moving (3x in 30 min,) tone (flex, flex-extension,) amniotic fluid index (4 quadrants), NST
Score of 2 for normal finding, 0 for abnormal finding in each part
Fetal Breathing Movements
in BPP
Normal (Score 2)
one or more episodes lasting at least 30 sec w/in 30 min
Abnormal (Score 0)
Episodes absent or none lasting 30 seconds w/ in 30 min
Fetal Movement in BPP
Normal (Score 2)
At least 3 trunk/limb movements w/ in 30 minutes
Abnormal (Score 0)
Fewer than 3 trunk/limb movements w/ in 30 minteus
Fetal Tone in BPP
Normal (Score 2)
At least one episode of active extensions w return to flexion of limb or trunk
Abnormal (Score 0)
Absence of movement
Slow extension/flexion
Amniotic Fluid Index in BPP
AFI = depth measured in cm on amniotic fluid in all 4 quads surrounding maternal umbilicus.
AFI less than 5 cm= oligohydramnios - associated w/ renal issues
Swallow fluid - excrete urine
AFI 5 to 10 cm = normal
AFI greater than 20 = polyhydramnios - assoc. w/ GI, CF, esop. atresia
Amniotic Fluid Index in BPP scoring
Normal (score 2)
AFI greater than 5cm or at least one pocket greater than 2cm
Abnormal (score 0)
AFI less than or equal to 5cm and no single pocket greater than 2cm
NST scoring in BPP
Normal (2)
Reactive
Abnormal (0)
Non reactive
Scoring (totals in BPP)
8 - 10 - Normal
6= suspicious,repeat tesing the next day
Less than 6= assoc. w/ increased perinatal morbidity and mortality (usually delivery occurs)
If not in labor, induce labor - hostile environment
Critical thinking:
How do you respond to a client who has a non reactive NST and a BPP score of 4, but is refusing a C-sec b/c she is afraid of surgery?
Give facts on fetus dying.
Baby more important.
Can get court order - ethics consult
Contraction stress test (CST)
Very invasive
Observes FHR response to contractions
Underlying uteroplacental insufficiency produces hypoxia = late decels will occur.
Indications: Multiples, diabetes.
Two methods for completing CST
Nipple stimulated ( can cause labor)
Oxytocin stimulated (IV)
Interpretation of CST
Negative (GOOD)
Absence of late or sig. var. decels.
Postive (BAD)
Presence of late decls occuring w at leasts 50% of contractions
Nursing role: repostion; prepare for delivery
Nursing role in CST
Emotional support - unknown outcome
Education
Counseling
Amniotic Fluid Embolism
Occurs when amniotic fluid, fetal hair, fetal cells, or other debris enter maternal circulation causing cardio-respiratory collapse
61% maternal mortality rate
79% fetal mortality rate
When does AFE occur
Usually during labor, but has occurred during abortion, after abdominal trauma, during amniocentecis, and after C section
Signs of AFE
Respiratory distress - SOB & cough; restlessness, dyspnea, cyanosis, pulmonary edema, respiratory arrest
Circulatory collapse: hypotension, tachycardia, shock, cardiac arrest - w/ tachycardia, fetus can become hypoxic
Hemmorrhage: coagulation failure, petechiae, ecchymoses
Tonic-clonic seizure activity
*Immediate nursing aciton - establish IV - ICU/TCU*
Prolapsed cord
Occurs when cord lies beneath presenting part.
May be hidden or seen.
Contributing factors:
long cord; malpresentation; transverse lie; unengaged fetal part
Uterine rupture
Most common cause is separation of previous scar.
May be classified as
complete: through unterine wall into peritoneal cavity or broad ligament
or icomplete: extends into peritoneum, but not into peritoneal cavity
S/S of uterine rupture
Vary w/ extent of rupture.
May be silent or dramatic
Incomplete = pain may not be present; FHR will exhibit late or variable decels, or baseline change in FHR; may exhibit vomiting,faintness, ^ abd. tenderness
Complete: Sudden, sharp, "ripping" abd. pain; signs of hypovolemic shock; rapid fetal compromise
Placenta Previa
Placenta implanted in lower uterine seg. or over the internal cervical os.
Painless vag. bleeding after 20 wks
Soft, relaxed nontender uterus w/ normal tone
Diagnosed by ultrasound.
Type of placenta previa depends on management
Abruptio Placentae
Premature separation of implanted placenta from uterine wall.
Occurs after 20 wks, but before birth.
Risk factors: HTN;use of cocaine; maternal smoking
Boardlike abdomen
Grade 1, mild separation, Abruptio placentae
10-20%
Minimal external, vaginal bleeding
<500mL blood loss
dark red blood
shock is rare/none
coagulopathy: rare/none
tenderness/pain: usually absent
Uterine tone: normal
Grade 2, moderate separation, Abruptio Placentae
Absent to moderate vag/external bleeding
1000-1500 mL blood loss
Dark red blood
mild shock
Occasional DIC
uterine tonicity is increased, may be localized to one region, of diffuse over uterus, uterus fails to relax btwn contractions
Tenderness/pain: present
Grade 3 Severe separation
>50%
Minimal to severe and life-threatening bleeding
>1500mL blood loss
Dark red blood
Shock is common; often sudden and profound
Frequent DIC
Uterine tone is tetanic, persisitent contractiions, boardlike uterus
Pain is agonizing, unremitting uterine pain
Placenta Previa
Bleeding eternal/vaginal is minimal to severe and life threatening.
Total amount of blood loss varies.
Blood is bright red.
No coagulopathy.
Uterine tone is normal.
Pain and tenderness is absent.
Pre-eclampsia
Over 20 wks.
Major characteristic is protein in the urine.
Link btwn ratio of prostaglandins: prostacyclin(vasodilator,decreased) & thromboxane (vasoconstrictor) increased. This increases sensitivity to angiotensin II
Pre-eclampsia
characterized by vasospasms, changes in teh coagulation system, and disturbances in systems r/t volume and BP control.
Pulmonary edema in pre-eclampsia
Arteriolar vasospasm may cause endothelial damage and contribute to an increased capillary permeability. This ^ edema & further decreases intravascular volume, predisposing woman to pulmonary edema
Severe pre-eclampsia
BP of 160/110 or higher on 2 occas. 6 hr apart while on bed rst.
Proteinuria>= 2grams in 24 hr or >2+ on dipstick
Oliguria
Cerebral or visual disturbances - do they see spots?
^hct, ^ fluid - pulmonary edema
Epigastric pain
Impaired liver function - distended, ^ pressure
Thrombocytopenia (low platelet)
Fetal growth restriction (not enough O2)
What causes elevated liver enzymes in pre-eclampsia?
leak enzymes into blood
Medications for severe pre-eclampsia
Magnesium sulfate
Hydralazine
- decreases anteriolar spasms to produce vasodilation & a decrease in BP
HELLP
Hemolysis
Elevated Liver enzymes
Low platelets
Impaired liver function tests
Alanine Amniotransferase (ALT)
Found in liver only
When cells are damaged, teh may leak enzymes into blood
Eclampsia
preceded by headaches,severe epigastric pain, and hyperreflexia.
Convulsions can appear w/ only slight BP elevations.
Hypotension, then coma
Eclamptic seizures produce marked metabolic insult to woman and fetus
Eclampsia - immediate care
Ensure patent airway
Assess uterine activity, cervical status, fetal status
- membranes can rupture
- cervical dilation
Pad siderails
Darkened environment
Should not be left alone
Emotional support
Postpartum care of eclampsia
Symptoms usually resolve 48 hrs after birth.
Hemmoconcentrated
- unable to concentrate excessive blood loss
Recovery may be prolonged
Disseminated Intravascular Coagulation (DIC)
Overactivation of the clotting cascade and fibrinolytic system resulting in depletion of platelets and clotting factors.
Formation of multiple fibrin clots throughout blood vessels and RBCS destroyed when passed through
DIC
Usually a 2ndary diagnosis
Triggered by release of large amounts of tissue thromboplatin
- Abruptio placentae
- retained dead fetus
- amniotic fluid embolism
- severe pre-eclampsia
- sepsis
Clinical findings of DIC
Bleeding from gums or nose
Petechiae from BP cuff
Bleeding from IV sites, venipuncture.
Tachycardia
Diaphoresis
How clotting should occur
Injury to blood vessel/tissue
Platelet aggregation
Intrinsic and extrinsic system activate common pathway for fibrin production
Clot formed
Fibrinolytic system form plasmin that degenerate the clot
Cleared by macrophages
Lab results in DIC
Decreased Hct - normal is 37-47%
Decreased Hgb - normal 12-16 g/dl
Decreased platelets - normal
150,000 - 400,000 mm3
Decreased fibrinogen (Factor 1): fibrinogen converted to fibrin during coagulation process. Normal values 200 to 400 mg/dl
Prolonged PT normal range is 12 to 15 sec
Prolonged PT -Normal is 60 to 70 seconds
PT - Prothrombin time
Evaluates clotting abilities of extrinsic pathways; factor 1 (fibrinogen), factor 2 (prothrombin), Factors V, VII, VI and X
Normal 12 to 15 seconds
PTT - Partial thromboplastin Time
Measures integrity of intrinsic pathway of coagulation
- Factors I, II, V, VIII, IX, X XI and XII
Normal is 60 to 70 seconds.