Metro Community College NURS 1400 Family Nursing I Unit 1.

Metro Community CollegeNURS 1400 Family Nursing I

Unit 1

CONCEPTION

• Fertilization• Implantation

DEVELOPMENTAL CHARACTERISTICS & FUNCTION

• Placenta• Umbilical cord• Fetus• Fetal circulation

Pregnancy

Psychosocial Effects of Pregnancy

Presumptive Signs of Pregnancy

• Amenorrhea• Nausea and vomiting• Fatigue• Urinary frequency• Breast enlargement and tenderness• Quickening

Probable Signs of Pregnancy

• Goodell’s sign (softening of the cervix)• Chadwick’s sign (bluish vaginal tissue)• Hegar’s sign (softening of the cervix)• Ballottement• Positive pregnancy test

Ballottement

Figure 14–4 Hegar’s sign, a softening of the isthmus of the uterus, can be determined by the examiner during a vaginal examination.

Figure 14–5 Early uterine changes of pregnancy. A, Ladin’s sign, a soft spot anteriorly in the middle of the uterus near the junction of the body of the uterus and the cervix. B, Braun von Fernwald’s sign, irregular softening and enlargement at the site of implantation. C, Piskacek’s sign, a tumorlike, asymmetric enlargement.

Figure 14–5 (continued) Early uterine changes of pregnancy. A, Ladin’s sign, a soft spot anteriorly in the middle of the uterus near the junction of the body of the uterus and the cervix. B, Braun von Fernwald’s sign, irregular softening and enlargement at the site of implantation. C, Piskacek’s sign, a tumorlike, asymmetric enlargement.

Figure 14–5 (continued) Early uterine changes of pregnancy. A, Ladin’s sign, a soft spot anteriorly in the middle of the uterus near the junction of the body of the uterus and the cervix. B, Braun von Fernwald’s sign, irregular softening and enlargement at the site of implantation. C, Piskacek’s sign, a tumorlike, asymmetric enlargement.

Positive Signs of Pregnancy

• Fetal heart tones• Fetal movement• Ultrasound

Abdominal ultrasound Transvaginal probe

Estimation of Due Date

• Naegele’s rule• Uterine size• Ultrasound

Näegle’s Rule

• First day of last menstrual period – 3 months + 7 days = EDB

Expected Date of Delivery

• Other indicators of gestational age– FHT with doppler at 10–12 weeks– Fetal movement felt at about 20 weeks– Fundal height correlation with gestational age

• Ultrasound

Fundal Height related to Gestational Age

Physiologic Adaptation to Pregnancy

Reproductive System

• Uterus– Enlarges to hold a

volume of 15–20 liters– At 12 weeks rises

out of the pelvis– Walls thin, but

strengthened with fibrous tissue

Reproductive System (continued)

• Uterus (continued)– 20–25% of cardiac output

goes to uterus– Braxton Hicks contractions occur throughout

pregnancy• Cervix– Softens and becomes bluish in color– Mucous plug forms to protect the fetus

Reproductive System (continued)

• Vagina, perineum, and vulva– Increased vascularity– Increased vaginal discharge• Acidic environment prevents bacterial infection• Yeast infection (candida) common during pregnancy

Reproductive System (continued)

• Ovaries– Normal function ceases– Corpus luteum secretes progesterone– Placenta produces progesterone by six to seven

weeks and corpus luteum regresses

Reproductive System (continued)

• Breasts– Enlarge and become tender– Increased alveoli– Areola darken – Tubercles of Montgomery enlarge and secrete a

substance to maintain areolar suppleness– Colostrum may leak from the breast

Hematologic System

• Blood volume– Increases by 40–50%– Plasma volume increases by 1,200–1,600 ml– Red blood cells increase by 450 ml– Physiologic anemia results• Hemoglobin drops up to 2 mg/dl• Iron deficiency anemia considered when hemoglobin

drops to 10.5 mg/dl or less

Hematologic System (continued)

• Blood coagulation– Increase in clotting factors and risk of thrombus

Cardiovascular System

• Heart– Displaced up and to the left– Heart enlarges– Systolic murmurs common

Cardiovascular System (continued)

• Cardiac output– Increases by 10 weeks, peaks at 24 weeks– Heart rate increases by 20 beats/minute

• Blood pressure– Decreases in first trimester– Returns to normal reading by term

• Systemic vascular resistance– Decreases during pregnancy

Cardiovascular System (continued)

• Effect of positioning during pregnancy– Supine hypotension

A. Supine position

B. Right lateral position

Descending aorta

Inferiorvena cava

Respiratory System

• Changes in mechanical function– Diaphragm rises 4 cm– Chest circumference increases 5 to 7 cm

• Progesterone– Causes increase in tidal volume (30–40%) and

decrease in Pco2 (compensated respiratory alkalosis)

• Rate does not change• Changes facilitate removal of carbon dioxide

from fetus

Gastrointestinal System

• Mouth– Gums become soft and edematous– Ptyalism may develop– Benign tumors may appear

• Esophagus– Progesterone relaxes cardiac sphincter– Pyrosis or heartburn develops from acid reflux

Gastrointestinal System (continued)

• Stomach and intestine– Delayed stomach emptying– Constipation common

• Gallbladder– Predisposed to stone formation

Gastrointestinal System (continued)

• Liver– Spider angioma– Palmar erythema– Albumin decreased, alkaline

phosphatase increased, cholesterol increased Liver

pushed up

Stomach compressed

Bladder largely in pelvis therefore frequent urination

Endocrine System

• Thyroid– Enlarges, euthyroid state maintained– Increase in BMR by 25%

• Parathyroid– Increased secretion of parathyroid hormone to

meet calcium needs of the fetus• Pituitary– FSH, LH suppressed– Prolactin increased– Oxytocin for contractions and lactation

Endocrine System (continued)

• Adrenal glands– Cortisol• Activates gluconeogenesis• Increases blood glucose levels

– Aldosterone• Increases• Protects the woman from sodium loss

• Pancreas– Beta cells increase in number and size

Endocrine System (continued)

• Placenta – hCG• Confirms pregnancy• Maintains corpus luteum

– Human placental lactogen (HPL)• Produces insulin resistance• Makes adequate glucose available to fetus

Endocrine System (continued)

• Placenta (continued)– Estrogen• Vasodilation, softens cervix, breast development

– Progesterone• Relaxes smooth muscle of uterus, GI tract, GU tract,

and aids breast development

Endocrine System (continued)

• Changes in metabolism– Fetus has constant need for glucose– In fasting state ketosis develops rapidly– Maternal insulin resistance develops – Diabetogenic effect of pregnancy– Increased need for iron– Water retention– Dependent edema common in late pregnancy

Weight Gain in Pregnancy

• Individualized by pre-pregnancy weight• Average weight gain is 27.5 lbs.– 27.5–39.6 lb for underweight women– 25.3–35.2 lb for normal weight women– 15.4–25 lb for overweight women

Urinary System

• Anatomic changes– Kidneys and ureters enlarge– Ureters compressed at pelvic brim– Increased incidence of pyelonephritis– Urinary frequency and incontinence common– Bladder tone relaxed and capacity and pressure

increase– UTIs common in pregnancy

Urinary System (continued)

• Physiologic changes– Increased blood flow by 35–60%– Increase in GFR• Increased urine flow and volume• Decreased BUN, creatinine, uric acid• Increased filtration of solutes

– Glucose– Protein

• Altered excretion of drugs (increased)

Integumentary System

• Spider angiomas and palmar erythema• Hyperpigmentation– Linea nigra– Chloasma

• Striae gravidarum

Musculoskeletal System

• Lordosis develops– Back pain common during pregnancy

• Ligaments soften due to relaxin– Pelvic discomfort– Unsteady gait

Eye, Cognitive, and Metabolic Changes

• Decreased intraocular pressure• Thickening of cornea• Reports of decreased attention, concentration,

and memory• Extra stored water, fat, and protein are stored• Fats more completely absorbed

Nausea and Vomiting

• Probably caused by hormones• Client education– Plenty of fluids, avoid caffeine and carbonation– Frequent, small meals, high protein, and

carbohydrates– Eat crackers to avoid an empty stomach– Avoid noxious odors– Limit stress

Nausea and Vomiting (continued)

• Hyperemesis gravidarum–severe vomiting requiring medical intervention

Heartburn

• Caused by reflux• Client education– Monitor for foods that cause symptoms– Spread liquids throughout the day– Stay upright after meals– Don’t eat close to bedtime, extra pillows– Bend at waist– OTC calcium containing antacids

Heartburn (continued)

• Epigastric pain can also be associated with hypertension in pregnancy

Constipation

• Caused by progesterone’s effect on GI tract• Aggravated by iron supplementation• Client education– Increase fiber– Increase fluids– Regular exercise– Regular time for bowel movements

Fatigue

• More common early in pregnancy• Client education– Meditation may be helpful– Rest when tired– Alleviate stress– Reassurance that the fatigue lessens after the first

trimester

Frequent Urination

• Most common early in pregnancy• Client education– Notify HCP if pain or burning occur– Kegel exercises

Varicosities

• Can occur in the legs, vulva, and rectum

• Client education– Support hose– Avoid long standing,

sitting, leg crossing– Elevate legs when sitting– Loose clothing and avoid

knee-high hose

Other Discomforts in Pregnancy

• Hemorrhoids– Client education• Maintain healthy and regular bowel habits• Sitz bath• Compresses soaked with witch hazel• Reduce external hemorroids if possible

• Back pain– Good body mechanics

Figure 14–1 Vena caval syndrome. The gravid uterus compresses the vena cava when the woman is supine. This reduces the blood flow returning to the heart and may cause maternal hypotension.

Other Discomforts in Pregnancy (continued)

• Leg cramps– Adequate calcium– Stretching exercises

Signs of Potential Problems

• Persistent vomiting• Vaginal bleeding• Edema of face/hands• Temperature >101°F• Persistent abdominal pain, epigastric pain• Dysuria

Health Promotion

• Employment• Travel• Smoking• Alcohol use• Drug use• Medication use

Psychological Response to Pregnancy

• Acceptance of pregnancy• Time for reflection• Body image changes• Becoming a mother• Development of the maternal role– Mimicry, role play, fantasy, role fit

Maternal Tasks

• Safe passage• Acceptance by others• Binding in to the child• Giving of oneself• Conflicting developmental tasks

Paternal Tasks

• Transition to fatherhood• Stress of the paternal role• Bonding between father and infant

Family Response to Pregnancy

• Siblings:– Rivalry– Fear of changing parent relationships

• Grandparents:– Closer relationship with expectant couple– Increasing support of couple

Nursing Process

• Assessment• Nursing diagnosis• Planning• Intervention• Evaluation

Nursing Care of the Pregnant Woman

The Initial Prenatal Visit

• Medical history• Physical exam• Diagnostic tests• Assess risk factors• Education

Nutrition

• Avoidance of potential teratogens• Folic acid supplementation• Prenatal vitamin and mineral supplements• Weight gain– Individualized according to pre-pregnancy weight– Weight assessed at every visit– Weight loss is never normal– Excessive weight gain requires evaluation

Harmful Substances in Pregnancy

• Alcohol• Caffeine• Artificial sweeteners• Herbal supplements• Medications• Pica

Gravidity and Parity

• Gravida–number of pregnancies• Para–number of births after 20 weeks• Five-digit system– G–total number of pregnancies– T–full-term pregnancies (37–40 weeks)– P–preterm deliveries (20–36 weeks)– A–abortions and miscarriages (before 20 weeks)– L–living children

Figure 15–1 The TPAL approach provides more detailed information about the woman’s pregnancy history.

Important Demographic Data

• Age• Occupation• Education• Residence• Ethnicity• Race• Religion• Pets

Medical and Family History

• Includes client and her partner• Information to obtain– Prior or current health issues– Medications and allergies– Possible inherited diseases in the families– Significant health issues in family members– Use of tobacco, alcohol, street drugs

Critical Pathway for Prenatal Care

• Physical exam• Lab work and

testing• Nutrition• Elimination• Rest/activity• Comfort

Critical Pathway for Prenatal Care (continued)

• Psychosocial/family• Developmental/pregnancy progress• Spiritual• Risk assessment• Medications

Assessment of Pelvic Adequacy

• Pelvic inlet• Midpelvis• Pelvic outlet

Figure 15–6 Anteroposterior diameters of the pelvic inlet and their relationship to the pelvic planes.

Figure 15–7 Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, which extends from the lower border of the symphysis pubis to the sacral promontory. B, Estimation of the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior measurements.

Figure 15–7 (continued) Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, which extends from the lower border of the symphysis pubis to the sacral promontory. B, Estimation of the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior measurements.

Figure 15–7 (continued) Manual measurement of inlet and outlet. A, Estimation of the diagonal conjugate, which extends from the lower border of the symphysis pubis to the sacral promontory. B, Estimation of the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum. C and D, Methods that may be used to check the manual estimation of anteroposterior measurements.

Figure 15–8 Use of a closed fist to measure the outlet. Most examiners know the distance between their first and last proximal knuckles. If they do not, they can use a measuring device.

Figure 15–9 Evaluation of the outlet. A, Estimation of the subpubic angle. B, Estimation of the length of the pubic ramus. C, Estimation of the depth and inclination of the pubis. D, Estimation of the contour of the subpubic angle.

Figure 15–9 (continued) Evaluation of the outlet. A, Estimation of the subpubic angle. B, Estimation of the length of the pubic ramus. C, Estimation of the depth and inclination of the pubis. D, Estimation of the contour of the subpubic angle.

Figure 15–9 (continued) Evaluation of the outlet. A, Estimation of the subpubic angle. B, Estimation of the length of the pubic ramus. C, Estimation of the depth and inclination of the pubis. D, Estimation of the contour of the subpubic angle.

Figure 15–9 (continued) Evaluation of the outlet. A, Estimation of the subpubic angle. B, Estimation of the length of the pubic ramus. C, Estimation of the depth and inclination of the pubis. D, Estimation of the contour of the subpubic angle.

Laboratory Analysis and Testingin Pregnancy

• Blood Work– Blood type and Rh status– Antibody screen (Coombs’ test)– CBC– Rubella titer– HIV– Hepatitis B

– Syphilis– Sickle cell– Glucose screen– Triple screen– Cystic fibrosis – Varicella

Laboratory Analysis and Testingin Pregnancy (continued)

• Other Testing– Ultrasound– Urinalysis– Pap smear– GC culture– Chlamydia culture– Group B streptococcus– PPD

First Trimester Ultrasound

• Establish gestational age:– Crown to rump length – Most accurate between 6 and 10 weeks

• Nuchal translucency testing:– Combined ultrasound and serum testing– Risk for chromosomal disorder– Screened between 11 weeks and 1 day and 16

weeks and 7 days

First Trimester Viability Confirmation

• Serial quantitative serum beta hCG testing• Progesterone• Ultrasound

Second Trimester Ultrasound

• Fetal life• Fetal number• Fetal presentation• Fetal anatomy• Gestational age • Amniotic fluid index

Second TrimesterUltrasound (cont’d)

• Placental position• Uterus

Fetal Movement

• Noninvasive• Cost-effective• Indirect measure of the fetal central nervous

system (CNS)• Vigorous movement indicates fetal well-being• Decreased movement is associated with

chronic oxygen compromise

Nonstress Test (NST)

• Accelerations imply an intact CNS.• Acceleration patterns are affected by

gestational age• Accelerations must be 15 beats/minute above

baseline, lasting 15 seconds• Reactive—two or more accelerations within

20 minutes• Nonreactive—insufficient accelerations over

40 minutes

Figure 21–11 Example of a reactive nonstress test (NST). Accelerations of 15 bpm lasting 15 seconds with each fetal movement (FM). Top of strip shows fetal heart rate (FHR); bottom of strip shows uterine activity tracing. Note that FHR increases (above the baseline) at least 15 beats and remains at that rate for at least 15 seconds before returning to the former baseline.

Figure 21–12 Example of a nonreactive NST. There are no accelerations of FHR with fetal movement (FM). Baseline FHR is 130 bpm. The tracing of uterine activity is on the bottom of the strip.

Vibroacoustic Stimulation (VAS)

• Application of sound and vibration to stimulate fetal movement

• Used to facilitate NST

Figure 21–13 Fetal acoustic stimulation testing. SOURCE: Photographer, Elena Dorfman.

Contraction Stress Test (CST)

• Evaluates uteroplacental function• Identifies intrauterine hypoxia• Observes FHR response to contractions• If compromised, FHR will decrease

Interpretation of CST

• Negative • Positive• Equivocal-suspicious• Equivocal-hyperstimulatory• Unsatisfactory

Figure 21–14 Example of a negative CST (and reactive NST). The baseline FHR is 130 bpm with acceleration of FHR of at least 15 bpm lasting 15 seconds with each fetal movement (FM). Uterine contractions recorded on the bottom half of the strip indicate three contractions in 8 minutes.

Figure 21–15 Example of a positive contraction stress test (CST). Repetitive late decelerations occur with each contraction. Note that there are no accelerations of FHR with three fetal movements (FM). The baseline FHR is 120 bpm. Uterine contractions (bottom half of strip) occurred four times in 12 minutes.

Amniotic Fluid Index (AFI)

• Decreased uteroplacental perfusion results in oligohydramnios

• AFI of five or less requires further evaluation

Biophysical Profile (BPP)

• Fetal heart rate acceleration• Fetal breathing• Fetal movements• Fetal tone• Amniotic fluid volume

Maternal Serum Alpha-Fetoprotein

• Component of quadruple check• Screening test for:– Neural tube defects– Trisomy 21 (Down syndrome)– Trisomy 18

• Performed between 15 and 22 weeks of gestation

Amniocentesis

• Used to detect genetic, metabolic, and DNA abnormalities

• Can detect neural tube defects• Amniotic fluid obtained through needle

aspiration• Complications include:– Vaginal spotting and cramping– Mild fluid leaking

Figure 21–19 Amniocentesis. The woman is usually scanned by ultrasound to determine the placental site and to locate a pocket of fluid. As the needle is inserted, three levels of resistance are felt when the needle penetrates the skin, fascia, and uterine wall. When the needle is placed within the amniotic cavity, amniotic fluid is withdrawn.

Chorionic Villus Sampling (CVS)

• Used to detect genetic, metabolic, and DNA abnormalities

• Needle aspiration of chorionic villi from placenta

• Earlier diagnosis than amniocentesis• Cannot detect neural tube defects• Pregnancy loss is twice as high as with

amniocentesis• Potential for limb reduction

Predictors of Preterm Labor

• Fetal fibronectin (fFN):– Presence between 20 and 34 weeks is predictor of

preterm delivery• Cervical length and internal os:– Measured by ultrasound– Shortened cervix and dilated internal os can

predict preterm birth– False-positive common

Fetal Lung Maturity

• Lecithin/sphingomyelin ratio:– Ratio of 2 to 1 indicates fetal lung maturity

• Phosphatidylglycerol (PG): – Presence indicates fetal lung maturity

Return Visits in Pregnancy

• Education• Blood pressure• Weight• Fundal height• Fetal heart tones• Presentation of the

fetus

Return Visits in Pregnancy (continued)

• Urine test for protein, glucose• Assessment for edema• Evaluation for developing complications

Strategies for Labor Management

• Relaxation techniques• Paced breathing• Progressive muscle

relaxation• Neuromuscular

dissociation• Touch• Imagery

Managing the Discomforts of Pregnancy

Round Ligament Pain

• Felt on one or both sides of the lower abdomen

• Client teaching– Calcium

supplementation– Good body

mechanics– Reassurance

Urinary Frequency

• Etiology– Mechanical pressure on the bladder by the

enlarging uterus– Increased fluid volume

• Client teaching– Maintain adequate fluid intake– Report burning or pain with urination

Nausea and Vomiting

• Etiology– Hormones of pregnancy

• Client teaching– Dry diet– Avoidance of offending smells and foods– Ginger or peppermint tea

Indigestion

• Etiology– Hormones cause relaxation of the cardiac

sphincter• Client teaching– Avoidance of offending foods– Extra pillows at night– Avoiding large meals close to bedtime– Antacids may be used, but avoid those with high

sodium content

Constipation and Hemorrhoids

• Etiology– Hormones of pregnancy slow GI motility– Sluggish venous return predisposes to

hemorrhoids• Client teaching– Ample fluid intake– Diet high in fiber– Stool softeners– Exercise

Edema

• Etiology– Increased fluid volume– Sluggish venous return

• Client teaching– Avoid long periods of

standing– Elevate feet– Exercise

Danger Signs in Pregnancy

• Vaginal bleeding• Edema of the face and hands• Severe headache• Vision changes• Abdominal pain• Chills and fever• Persistent vomiting• Fluid from the vagina