Chapter 20: Nursing Care of a family Experiencing a Pregnancy

Complication from a Preexisting or Newly Acquired Illness

Nursing Process Overview
Assessment
 Requires thorough understanding of the signs and symptoms of the illness
 Establish baseline vital signs as well as subjective factors
Nursing Diagnosis
 Ineffective tissue perfusion (cardiopulmonary) related to poor heart function secondary
to mitral valve prolapse during pregnancy
 Pain related to pyelonephritis secondary to pressure on ureters
 Social isolation related to prescribed bed rest during pregnancy secondary to
concurrent illness
 Ineffective role performance related to increasing level of daily restrictions secondary
to chronic illness and pregnancy
 Knowledge deficit related to normal changes of pregnancy versus illness complications
 Fear regarding pregnancy outcome related to chronic illness
 Health-seeking behaviors related to the effects of illness on pregnancy
 Situational low self-esteem related to illness during pregnancy
Outcome Identification
 Maintain her health during pregnancy
 Allow women to choose alternatives to help her participate in her own care
 Maintain self-esteem to help her step toward parenthood
 Assume care for her family
Implementations
 Focus on teaching her new or additional measures to maintain health during pregnancy
Outcome Evaluation
 Client states she rests for 2 hours morning and afternoon; dependent edema remains at
1 or less at next prenatal visit.
 Family members state they are all participating in an exercise program since mother
developed gestational diabetes.
 Client reports no burning on urination or flank pain at next prenatal visit.
 Client states she understands the importance of taking daily thyroid medicine for total
length of pregnancy

A. The Nursing Role and Nursing Care During Pregnancy Complications

1. Identifying a high-risk pregnancy
 High-risk pregnancy: concurrent disorder, pregnancy-related complication, or
external factor jeopardizes the health of pregnancy
 The term “high risk” rarely refers to just one causative factor but includes
psychological and social as well as physical aspects

B. Cardiovascular Disorders and Pregnancy

1. A woman with cardiac disease
a. A woman with left-sided heart failure
 Occurs in conditions such as mitral stenosis, mitral insufficiency, and aortic
coarctation
 Left ventricle cannot move the large volume of blood forward that it has
received by the left atrium from the pulmonary circulation
 Symptoms: back pressure, pulmonary edema, paroxysmal nocturnal dyspnea,
thrombus formation
 Treatment:
 Anticoagulant: prevent thrombus formation
 Antihypertensives: control blood pressures
 Diuretics: reduce blood volume
 Beta-blockers: improve ventricular filling
 b. A woman with right-sided heart failure
 Occurs when the right ventricle is overwhelmed by the amount of blood
received by the right atrium form the vena cava
 Caused by unrepaired congenital heart defect such as pulmonary valve
stenosis, but Eisenmenger syndrome is most apt to cause
 Symptoms: congestion of systemic venous circulation, decreased cardiac
output to the lungs, both jugular venous distention, increased portal
circulation, distended liver and spleen
 Treatment: They are not advised to be pregnant, if plan na they need oxygen
administration and frequent arterial blood gas assessments

2. A woman with peripartum heart disease

 Peripartal cardiomyopathy: originate in pregnancy in women with no previous
heart disease
 Symptoms: shortness of breath, chest pain and nondependent edema
 Treatment: Diuretic, arrhythmia agent and digitalis therapy

Assessment of Woman with Cardiac Disease

o Health history
o Document woman’s level of exercise performance
o Ask if have cough or edema
o Record baseline blood pressure, pulse rate and respiratory rate
o Assess and compare nail bed filling and jugular venous distention
o Electrocardiogram or echocardiogram

Fetal Assessment
o Provide adequate supply of blood and nutrients to placenta
a. Nursing Interventions During Labor and Birth
 Assess woman’s blood pressure, pulse, respirations and
monitor fetal heart rate and uterine contractions
 Advise woman to assume side-lying positions
 Elevate head and chest if there is pulmonary edema
 Evaluate women carefully, observe fatigue (symptom of heart
decompensation)
 Needed oxygen administration
 Epidural anesthesia

b. Postpartum Nursing Intervention

Note: critical time for woman with heart disease because with delivery
of the placenta, blood that supplied placenta is released into her
general circulation, increasing blood volume by 20% to 40%
 Program with decreased activity
 Anticoagulant and digoxin therapy
 Antiembolic stockings or intermittent pneumatic compression
(IPC) boots
 Prophylactic antibiotics
 Stool softener to prevent straining with bowel movements
 Kegel exercises for perineal strengthening

3. A woman with an artificial valve prosthesis

 Caused increased blood volume gained during pregnancy: not advised to be
pregnant
 Treatment: If plan, oral anticoagulants take to prevent the formation of blood
clots at the valve site

4. A woman with chronic hypertensive vascular disease

  Enter pregnancy with an elevated blood pressure (140/90 mmHg or above)
 Associated with arteriosclerosis or renal disease
 Treatment: Beta-blockers and calcium channel blockers to reduce peripheral
dilatationa; labetazol (trandate) and nifedipine (Procardia) are typical drugs
prescribed

5. A woman with venous thromboembolic disease

 Increase during pregnancy because of combination of stasis of blood in lower
extremities from uterine pressure and hypercoagulability
 Deep vein thrombosis (DVT): formation of blood clot in veins of lower
extremities
 Management: avoid use of constrictive knee-high stockings, not sitting with
leg crossed at knee and avoid standing in one position for long time
 Pulmonary embolism: chest pain, sudden onset of dyspnea, cough with
hemoptysis, tachycardia or missed beats or dizziness and fainting
 Medications: (breastfeeding) coumadin, (not) heparin or sodium warfarin

C. Hematologic Disorders and Pregnancy

1. Anemia and pregnancy
 Woman’s hemoglobin is less than 11g/dl (hematocrit <33%) – 1st and 3rd
trimester while less than 10.5 g/dl (hematocrit <32%)
a. Woman with iron-deficiency anemia
 Most common anemia of pregnancy
 Diet low in iron, heavy menstrual periods or unwise-reducing
programs
 Confirmed by corresponding low serum iron level (under 30 ug/dl)
and increased iron-binding capacity (over 400 ug/dl)
 Type of anemia: 1) microcytic (e.g. small red blood cells) and 2)
hyperchromic (e.g. less hemoglobin than the average red cell)
 Treatment:
 Take prenatal vitamins containing 27 mg of iron as
prophylactic therapy
 Eat a diet high in iron and vitamins
 120 to 200 mg elemental iron per day
 Take iron supplements with orange juice or vitamin C
supplements
Note: ferrous sulfate turn stool black

b. Woman with folic acid-deficiency anemia

Note: folic acid/ folate/ folacin- one of B vitamins for normal formation of
RBC
 Develop megaloblastic anemia (enlarged RBC)
 Treatment:
 Supplement of 400 ug folic acid daily
 Eat folate-acid rich foods

2. A woman with sickle-cell anemia

 Recessively inherited hemolytic anemia caused by an abnormal amino acid in
beta chain of hemoglobin
 Blockage of the placental circulation can directly compromise the fetus,
causing low birth weight and possibly fetal death
 Assessment:
 Hemoglobin level of 6 to 8 mg/100 ml
 Hemoglobin level fall 5 to 6 mg/100 ml in a few hours
 Vascular stasis
 Varicosities or pooling of blood in leg veins
 Treatment: blood transfusions, epidural anesthesia
 3. Coagulation disorders and pregnancy
 Sex linked or occur only in males and so have a little effect on pregnancies
a. Von Willebrand disease
- Coagulation disorder inherited an autosomal dominant trait and so
does occur in women
- Symptoms: spontaneous miscarriage or postpartum hemorrhage
- Treatment: Replacement of the missing coagulation factors by
infusion of cryoprecipitate or fresh frozen plasma before labor to
prevent excessive bleeding
b. Hemophilia B (Christmas disease, factor IX deficiency)
- Sex-linked disorder, occur only in men
- Treatment: infusion of factor IX levels concentrates or fresh frozen
plasma
 Diagnose:
 Maternal serum analysis: use to detect if fetus has a coagulation
disorder
 Fetal scalp blood sampling: determined if fetus ha a coagulation
defect
 Idiopathic thrombocytopenic purpura (ITP): decrease number of
platelets
c. HELLP (Hemolysis, Elevated Liver Enzymes, Low Platelet Count)
- Serious complication of pregnancy
- Treatment: oral prednisone or platelet transfusion or plasmapheresis

D. Renal and Urinary Disorders and Pregnancy

1. Woman with Urinary Tract infection
 Glycosuria: minimal presence of abnormal amounts of glucose
 Caused by women with known vesicoureteral reflux
 Caused by Escherichia coli
 Assessment:
 Frequency and pain on urination
 Accompany by nausea and vomiting, malaise, pain and frequency of
urination
 Temperature: 103 to 104-degree Fahrenheit (39 to 40 degree Celsius)
 100,000 organisms per ml by using urine culture
 Treatment:
 Clean-catch urine sample: for culture and sensitivity to assess
asymptomatic bacteriuria or symptoms of UTI
 Sensitivity test: determine which antibiotic is the best
 Amoxicillin, ampicillin and cephalosporins: effective and safe
 Sulfonamides: can be used early pregnancy but not near term

2. Woman with Hyperactive Bladder

 A bladder that contracts more frequently than usual, causing symptoms of
frequency, urgency and incontinence
 Treatment:
 Fesoterodine: an antispasmodic drug frequently prescribed used
during pregnancy and breastfeeding

3. Woman with Chronic Renal Disease

 Can have renal transplants to have healthy pregnancies and children
 Treatment:
 Synthetic erythroprotein
 Daily routine takes of corticosteroid but infant may be hyperglycemic
at birth
  IM progesterone
 Hemodialysis
 Low-potassium diet

E. Respiratory Disorders and Pregnancy

1. Woman with Acute Nasopharyngitis (common cold)
 More severe in pregnancy that at other times
 Symptoms: difficult to breathe
 Treatment:
 Don’t take high dose aspirin or acetylsalicylic acid interfere blood
clotting
 Extra rest and sleep and eat diet high in vitamin C
 Acetaminophen (Tylenol) every 4 hours
 Room humidifier or apply medicated vapor rub to chest
 Cool or warm compresses

2. Woman with Influenza

 Caused by a virus, identified as type A, B, C.
 Symptoms: high fever, extreme prostation, aching pains in back and
extremities, and sore, raw throat
 Treatment:
 Acetaminophen (Tylenol) to control fever
 Oseltamivir (Tamiflu)
 Influenza vaccine

3. Woman with Pneumonia

 Bacterial or viral invasion of lung tissue by pathogens such as Streptococcus
pneumoniae, Haemophilus influenzae and Mycoplasma pneumoniae
 Treatment: prescribed antibiotic and oxygen administration

4. Woman with Asthma

 Disorder marked by reversible airflow obstruction, airway hyperactivity and,
airway inflammation
 Results in constriction of bronchial smooth muscle, marked mucosal
inflammation and swelling and production of thick bronchial secretions
 Symptoms: difficult breathing and high pitch whistling sound
 Treatment: Intravenous administration of hydrocortisone if taking
corticosteroid; Beta- adrenergic agonist (terbutaline and albuterol)

5. Woman with TB
 Disease that should been eradicated because of effective treatment available
 Assessment:
 Chronic cough
 Weight loss
 Hemoptysis (coughing blood)
 Low-grade fever
 Night sweats
 Treatment:
 Isoniazid (INH), rifampin (RIF) and ethambutol hydrochloride
(myambutol)
 Adequate level of calcium
 Continue taking prescribe medications

6. Woman with Chronic Obstructive Pulmonary Disease (COPD)

 Constriction of the airway associated most often with long-term cigarette
smoking
  Constrictive air disease limits the amount of oxygen that can reach the lungs,
associated with fetal growth restriction and preterm birth
 Treatment:
 Additional rest
 Avoid smoking
 Continuous positive airway pressure (CPAP) if experience sleep apnea
 Cesarean birth

7. Woman with Cystic Fibrosis

 Recessive inherited disease in which there is generalized dysfunction of the
exocrine glands
 Symptoms: chronic respiratory infection, overinflation of lungs, difficult
digesting fat and protein
 Treatment:
 Pancrelipase (pancrease) to supplement pancreatic enzymes
 Bronchodilator 0r antibiotic to reduce pulmonary symptoms
 Perform physiotherapy to reduce buildup of lung secretions
 Modifications for Pregnancy
 Iron supplement
 Close monitoring of serum glucose levels
 Plan more frequent and shorter sessions in modified positions
 Modifications for Postpartum Period
 Plan how to conserve energy for infant care
 Not advised breastfeed because it put infant risk for hypernatremia

F. Rheumatic Disorders and Pregnancy

1. Woman with Rheumatoid Arthritis
 Juvenile Rheumatoid Arthritis (JRA or chronic rheumatoid arthritis)
- Disease of connective tissue marked by joint inflammation and
contractures
- Treatment:
 Frequently take corticosteroids, hydroxychloroquine and
nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent
joint pain and mobility loss
 Oral aspirin therapy
 Decrease intake of salicylates approx. 2 weeks before term
 Low dose methotrexate, a carcinogen
 NSAIDs (can breastfeed) and methotrexate or large dose of
aspirin (cannot)

2. Woman with Systemic Lupus Erythematosus (SLE)

 Multisystem chronic disease of connective tissue that occurs most frequently
in woman 20 to 40 years of age
 Symptoms:
 (skin) erythematous butterfly-shaped rash
 (kidney) fibrin deposits, plugging and blocking the glomeruli and lead
to necrosis and scarring
 (blood vessel) thickening of collagen tissue
 Treatment:
 Combination of NSAIDs, low-molecular-weight heparin, salicylates,
hydroxychloroquine, low dose prednisone or azathioprine

G. Gastrointestinal Disorders and Pregnancy

1. Woman with Appendicitis
 Inflammation of appendix
  Assessment
 Nausea, abdominal discomfort and typical sharp peristaltic, lower
right quadrant pain of acute appendicitis
 Temperature elevated
 Treatment
 Cesarean birth if woman is near term and fetus ismature
 Removed by laparoscopy if occurs in early pregnancy

2. Woman with Gastroesophageal Reflux Disease or Hiatal Hernia (GERD)

 GERD: Reflux of acid stomach secretions into esophagus
 Hiatal hernia: condition which portion of stomach extends and protrudes up
through the diaphragm into esophagus, trapping stomach acid and causing
reflux to stomach
 Symptoms:
 Heartburn
 Gastric regurgitation
 Dysphagia
 Weight loss
 Hematemesis
 Treatment:
 Wear clothe that is lose around waist
 Sleep with head elevated on two or more pillows
 Esomeprazole magnesium to dilute or inhibit gastric acid production
and relieve symptoms

3. Woman with Cholecystitis and Cholelithiasis

 Cholecystitis (gallbladder inflammation)
 Cholelithiasis (gallstone formation)
 Symptoms
 Constant aching and pressure on right epigastrium
 Accompanied by jaundice
 Treatment
 Prevent lower fat intake
 Temporarily halting oral intake to rest the gastrointestinal tract
 Administering IV fluid
 Surgery for gallbladder by laparoscopic technique

4. Woman with Pancreatitis (inflammation of pancreas)

 Rare disorder tends to occur in late adolescents and during pregnancy
 Symptoms:
 Severe epigastric pain
 Nausea
 Vomiting
 Anorexia
 Fever
 Treatment:
 Nasogastric suction
 Bowel rest
 Analgesia
 Intravenous hydration

5. Woman with Hepatitis

 A liver disease that occurs from invasion of hepatitis A, B, C, D or E virus
 Hepatitis A: fecal-oral contact
 Hepatitis B and C: exposure to contaminated blood or blood products or
contact with contaminated semen or vaginal secretions
  Hepatitis D and E: same with B and C but rarely seen in pregnancy
 Symptoms
 Nausea and vomiting
 Tender palpation on liver area
 Dark yellow urine
 Jaundice
 Treatment
 Bed rest and encouraged eat a high-calorie diet
 Cesarean birth
 Fetus must be washed well to remove maternal blood

6. Woman with Inflammatory Bowel Disease

 Crohn Disease (inflammation of terminal ileus)
 Ulcerative colitis (inflammation of distal colon)
 Symptoms
 Chronic diarrhea
 Weight loss
 Occult blood in stool
 Nausea and vomiting
 Treatment
 Administer total parenteral nutrition
 Sulfasalazine: anti-inflammatory and mainstay of therapy
 Infliximab (IFX) and adalimumab ( ADA)

H. Neurologic Disorders and Pregnancy

1. Woman with Seizure Disorder
 Cause head trauma or meningitis
 Treatment:
 At least mild antiseizure drugs (teratogenic)
 Trimethadione, valproic acid, carbamazepine, ethosuximide and
phenytoin sodium
2. Woman with Myasthenia gravis
 Autoimmune disorder characterized by presence of IgG antibody against
acetylcholine receptors in striated muscle
 Treatment:
 Anticholinesterase drugs ( pyridostigmine or neostigmine)
 Atropine: life saving antidote for neostigmine if overdose
 Plasmapheresis to remove immune complexes from bloodstream
 Magnesium sulfate to halt preterm labor or treat hypertension

3. Woman with Multiple Sclerosis

 Symptoms:
 Fatigue
 Numbness
 Blurred vision
 Loss of coordination

 Treatment:
 ACTH (Adrenocorticotropic hormone) or corticosteroid strengthen
nerve conduction
 Immunosuppressants (cyclosporine, azathioprine and
cyclophosphamide)
 Plasmapheresis

I. Musculoskeletal Disorders and Pregnancy

1. Woman with scoliosis
 Begin 12 to 14 years old at girls
  Treatment:
 Wear body brace
 Stainless steel rods surgically
 Cesarean birth if woman’s pelvis is distorted

J. Endocrine Disorders and Pregnancy

1. Woman with Thyroid Dysfunction
a. Hypothyroidism
 Underproduction of the thyroid hormone
 Symptoms
 Fatigue easily
 Obese
 Dry skin
 Cold tolerance
 Nausea and vomiting
 Treatment
 Dose of levothyroxine
b. Hyperthyroidism
 Overproduction of thyroid hormone
 Sometimes called graves disease
 Symptoms
 Rapid heart rate
 Exophthalmos
 Heat intolerance
 Heart palpitations
 Weight loss
 Treatment
 Thioamides reduce thyroid activity
 Surgical treatment

2. Woman with Diabetes Mellitus

 Endocrine disorder in which pancreas cannot produce adequate insulin to
regulate body glucose levels
a. Pathophysiology and clinical manifestations
 Primary concern: controlling the balance between insulin and blood
glucose levels to prevent hyperglycemia or hypoglycemia
b. Diabetes during pregnancy
 Type 1 diabetes: autoimmune disorder because marker antibodies are
present, pancreas fail to produce adequate insulin
 Type 2 diabetes: gradual loss of insulin production
c. Classification of diabetes mellitus
 Gestational diabetes mellitus: at the midpoint of pregnancy
Risk factor (see pp 514)
d. Assessment
 50-g glucose challenge test (between 24 to 28 weeks gestation)
 A fasting plasma glucose greater than or equal to 126 mg/dl
 Non-fasting plasma glucose greater than or equal to 200 mg/dl

e. ‘Monitoring diabetes women

 Woman should use home kit to determine if she is pregnant
 Measurement of glycosylated hemoglobin (Hba1c) to measure amount of
glucose attached to hemoglobin
 Urine culture at each trimester
 Ophthalmic examination
 Laser therapy to halt changes can be done without risk to fetus
f. Treatment
  See table 20. 4 at pp. 518 (insulin therapy, blood glucose monitoring and
insulin pump therapy)
g. Test for Placental Function and Fetal Well-Being
 Serum alpha-fetoprotein level obtained at 15 to 17 weeks for neural tube
defect
 Ultrasound examination
 Creatinine clearance test
 Lecithin/ sphingomyelin ratio by week 36
 Fetal surveillance
h. Timing for birth
 Cesarean birth at 37 weeks of gestation
 Vaginal birth if amniocentesis and pregnancy maintained
i. Postpartum adjustment
 Needs no insulin
 Another few days will return for insulin requirements

K. Mental Illness and Pregnancy

 Schizophrenia and Depression
 Treatment:
 Lithium: mainstay therapy for mood disorder such as bipolar
 Serotonin-reuptake inhibitors to counteract depression (potentially teratogenic)

L. Cancer and Pregnancy

 Biopsy to confirm the diagnosis or surgery to remove tumor