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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 |
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Risk factors for becoming victim/perp of IPV
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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 |
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Nursing role in IPV
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*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 |
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Consequences of IPV
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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 |
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Why do men abuse?
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*Learned bx - observation, experience, culture
*believe they are entitled to control partner *use stress, anger, drug/alchohol as reason why *many other reasons |
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Screening for IPV
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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 $) |
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Screening pregnant women for IPV
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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 |
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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 |
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3 phases of the cycle of violence
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*Tension building
*Acute battering *Honeymoon |
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Tension building phase of IPV
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Tension builds over common domestic issue.
- verbal abuse - victim tries to control situation by pleasing, giving in or avoidance |
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Acute battering episode of IPV
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Triggered by an external event of abuser's emotional state.
Unpredictable and beyond victim's control |
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Honeymoon phase of IPV
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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. |
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Why do women stay in violent relationships?
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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 |
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Predicting preterm labor - endocervical length
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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. |
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Fetal fibronectin (fFN)
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*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 |
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Fetal fibronectin test:
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*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* |
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Management of fFN results
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Negative fFN w/ no cervical change: managed at home
Postive fFn w/ cervical change: hospital admission |
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Investigational study: Salivary Estriol
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*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 |
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Lifestyle modifications in pre-term labor
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*individualized.
*Activities taht cause s/s of PTL should be avoided - no sexual intercourse - modify job - sit |
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Bedrest and PTL
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*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 |
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Bed rest: Adverse effects
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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. |
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Home care and bed rest
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*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. |
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Hospitalization and bed rest
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Tocolytics - usually hospital
Antenantal corticosteroids - beta methasone (surfactent): 1M *fetal monitoring |
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Tocolytics - reasons why administered
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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. |
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Contraindications for tocolytic use
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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 |
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Names of Tocolytics
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Ritodrine hydrocholride (Yutopar)
Terbutaline (Brethine) off label Mag. sulfate - off label Nifedipine (procardia) off label Indomethacin (Indocin) off label |
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Ritodrine hydrocholride (Yutopar)
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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 |
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Terbutaline (Brethine)
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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 |
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Side Effects of Terbutaline (Brethine)
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Tachycardia:Palpations;Tachypnea;SOB;sweating;tremors;
N/V; decrease calcium levels hypokalemia increase glucose levels do not give to: diabetics or cardiac pts |
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Magnesium sulfate
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Most commonly used tocolytic agent - less maternal/fetal/neonatal adverse reactions.
*Central nervous system depressant *Given IV |
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Magnesium Sulfate - SE
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*Very few to fetus
Maternal: Hot flash - cool cloth, fan N/V SOB decrease calcium/hypocalcemia - give calcium gluconate |
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Assessment/interventions w/ mag sulfate
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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 |
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Critical thinking: why must caution be used when adminstering IV fluid to a woman in PTL esp. if terbutaline or mag. sulfate is used?
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Increased risk of pulmonary edema.
Has to run withother fluids - might have to titrate |
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Nifedipine (Procardia)
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*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 |
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Critical thinking: why must nifedipine not be used w/ mag. sulfate:
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Lowers calcium levels even more. Transition from Mag to nifedipine.
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Hypocalcemia
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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 |
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Trousseau's sign
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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
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Chvostek's sign
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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
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Indomethacin (Indocin)
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*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 |
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Antenatal Glucocorticoids
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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 |
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Fetal HR characteristics
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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 |
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FHR norms/brady/tachy
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Normal: 110-150
bradycardia: <110 for 10 min tachycardia: >160 for >10 min |
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Causes of Fetal Tachycardia
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Maternal causes:
Maternal fever (axillary) >100.4; dehydration; anemia; maternal anxiety Fetal causes: chronic fetal hypoxemia; chorioamnionitis; fetal anemia; cardiac abnormalities |
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Causes of Fetal bradycardia
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Maternal: supine position; hypotension; maternal hypothermia
Fetal: umbilical cord compression; congenital heart disease; cardiac abnormalities |
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Reassuring (Fetal Heart Rate monitoring)
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FHR baseline between 110 and160 bpm.
Variability present Accelerations w/ fetal movement. Absence of late or variable decels. |
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Nonreassuring (FHR)
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Late decels.
Absent variability Prolonged decelerations Bradycardia Variable decel assoc. w/ a decrease in variability. Variable decels w/ a slow return to baseline |
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Early decelerations
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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 |
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Late decelerations
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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 |
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Severe variable decelerations
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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 |
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HELP VC
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Head compression - Early decel
Late decel - Placental insufficiency Variable - Cord compression |
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Non Stress Test
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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 |
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Reasons for NST
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Diabetes
Fetus has decreased movement. Pre-eclampsia Multiple fetus. If no decels >20 min, do again |
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Interpretation of NST
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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 |
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Management of NST results
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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 |
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Biophysical Profile (BPP)
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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 |
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BPP scoring
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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 |
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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 |
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Fetal Movement in BPP
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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 |
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Fetal Tone in BPP
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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 |
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Amniotic Fluid Index in BPP
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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 |
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Amniotic Fluid Index in BPP scoring
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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 |
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NST scoring in BPP
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Normal (2)
Reactive Abnormal (0) Non reactive |
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Scoring (totals in BPP)
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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 |
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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 |
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Contraction stress test (CST)
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Very invasive
Observes FHR response to contractions Underlying uteroplacental insufficiency produces hypoxia = late decels will occur. Indications: Multiples, diabetes. |
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Two methods for completing CST
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Nipple stimulated ( can cause labor)
Oxytocin stimulated (IV) |
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Interpretation of CST
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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 |
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Nursing role in CST
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Emotional support - unknown outcome
Education Counseling |
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Amniotic Fluid Embolism
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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 |
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When does AFE occur
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Usually during labor, but has occurred during abortion, after abdominal trauma, during amniocentecis, and after C section
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Signs of AFE
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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* |
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Prolapsed cord
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Occurs when cord lies beneath presenting part.
May be hidden or seen. Contributing factors: long cord; malpresentation; transverse lie; unengaged fetal part |
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Uterine rupture
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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 |
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S/S of uterine rupture
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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 |
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Placenta Previa
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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 |
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Abruptio Placentae
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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 |
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Grade 1, mild separation, Abruptio placentae
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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 |
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Grade 2, moderate separation, Abruptio Placentae
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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 |
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Grade 3 Severe separation
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>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 |
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Placenta Previa
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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. |
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Pre-eclampsia
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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 |
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Pre-eclampsia
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characterized by vasospasms, changes in teh coagulation system, and disturbances in systems r/t volume and BP control.
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Pulmonary edema in pre-eclampsia
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Arteriolar vasospasm may cause endothelial damage and contribute to an increased capillary permeability. This ^ edema & further decreases intravascular volume, predisposing woman to pulmonary edema
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Severe pre-eclampsia
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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) |
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What causes elevated liver enzymes in pre-eclampsia?
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leak enzymes into blood
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Medications for severe pre-eclampsia
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Magnesium sulfate
Hydralazine - decreases anteriolar spasms to produce vasodilation & a decrease in BP |
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HELLP
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Hemolysis
Elevated Liver enzymes Low platelets |
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Impaired liver function tests
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Alanine Amniotransferase (ALT)
Found in liver only When cells are damaged, teh may leak enzymes into blood |
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Eclampsia
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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 |
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Eclampsia - immediate care
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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 |
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Postpartum care of eclampsia
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Symptoms usually resolve 48 hrs after birth.
Hemmoconcentrated - unable to concentrate excessive blood loss Recovery may be prolonged |
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Disseminated Intravascular Coagulation (DIC)
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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 |
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DIC
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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 |
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Clinical findings of DIC
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Bleeding from gums or nose
Petechiae from BP cuff Bleeding from IV sites, venipuncture. Tachycardia Diaphoresis |
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How clotting should occur
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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 |
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Lab results in DIC
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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 |
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PT - Prothrombin time
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Evaluates clotting abilities of extrinsic pathways; factor 1 (fibrinogen), factor 2 (prothrombin), Factors V, VII, VI and X
Normal 12 to 15 seconds |
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PTT - Partial thromboplastin Time
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Measures integrity of intrinsic pathway of coagulation
- Factors I, II, V, VIII, IX, X XI and XII Normal is 60 to 70 seconds. |