Please enable JavaScript.
Coggle requires JavaScript to display documents.
Jackie Brown (Background (Gestational Diabetic (Metformin (Poorly…
Jackie Brown
Background
Native American
G2P0
NKA
Significant other minimally involved
SAB @ 12 weeks only 14 months ago
36.4 was gestation on late US
Late to prenatal care
Blood type : O-
GBS+
Rubella non immune
TDap UTD
BMI 29
Gestational Diabetic
Metformin
Poorly controlled
Smokes 1/2 PPD
Lives with her mother
Medications
MMR, Rhogam within 72 hrs. after delivery (rubella non-immune, O-)
Metformin for gestational diabetes- takes it sporadically
Tums for heartburn symptoms
Prenatals when she thinks of it
Nifedipine for blood pressure
Pitocin 1mu/hr up by 2 every 30 until active labor
Ampicilling 2 gm now, then 1gm Q4
Magnesium Sulfate 4-6 gm IV loading dose. 1-2 gm/hr. Dilute in fluids 60mg/mL, infuse over 2-4 hrs. not to exceed 125 mg/kg/hr.
Assessments for Mag.: Urine output, speech, lung sounds, chest pain, absent DTR, decreased RR, bradycardia, hypothermia, FHTs.
Tylenol 650 PRN headache
PPH Meds: opioid for pain, cytotec RS, pitocin IV/IM, hemabate, methergine (use with extreme caution), TXA
Low dose aspirin 60-80 mg after 12 weeks
Calcium Gluconate: reversal of Mag. Syringe and medication at bedside.
Betamethasone: 12 mg IM, 2 doses (24 hour spacing).
pt. reports taking 800 mg of ibuprofen at 2400 w/ no relief
Education
Signs and symptoms of hypo/hyperglycemia
Inform about the physiology of GDM and preeclampsia
Expectations after delivery regarding child health and follow-up NICU care
Importance of smoking cessation as it relates to personal/infant health
Expected affects of Mg Sulfate and signs/symptoms of toxicity
Importance of nutrition (avoid McD/soda), physical activity, and weight loss as they relate to infant outcomes and prevention of DM2 and cardiovascular disease
Inform about the available support resources available for childcare and stress importance of follow-up care for both patient and infant
Importance of early prenatal care
PPD s/sx, counseling, support groups
Monitoring blood glucose and consistently taking Metformin for GDM
Labor techniques: pushing, bearing down, positioning, breathing
Assessment
Apply fetal heart monitor, watch continuously
Vitals: Auscultate heart and lungs (HR, RR), BP, temp, pain, LOC
Check blood sugar q1 hr.
Obtain an ultrasound to check the biophysical profile/well-being of the fetus
Get some background knowledge from patient. When did symptoms (headache, edema, "heartburn", visual changes) begin? What meds have you taken? What is your blood sugar typically like? What is your normal blood pressure? When did you last urinate and how frequently do you go?
Assess for clonus and reflexes
Check labs for liver enzymes, CBC w/ platelets, creatinine/BUN, proteinuria, ketonuria, hematuria, type and cross
monitor for s/s impaired gas exchange (tachyp/dyspnea, ABG's)
monitor for s/s fluid vol excess (edema, dec urine, inc creatinine, weight gain, dyspnea, crackles)
Postpartum Hemorrhage
Assess for Bleeding
Tone
Empty bladder & massage
Tissue
Manual sweep & removal
Trauma
Assess for laceration & suture
Thrombotic
idiopathic
Administer Uterotonics
Pitocin, IV drip, up to 80 units in LR @ 125-200 mU/min
Misoprostol (cytotec), 600mcg-1000mcg rectally
Hemabate, initial 250mcg, repeat PRN q 15-90 min,
NOT in ASTHMA
Maintain volume and perfusion
Administer IV Fluids - warm LR
Administer high flow O2 @ 10 L
Administer blood products
Anticipate Labs
CBC and PTT
Cross and match for blood products
Bakri for tamponade
Maintain Clotting
TXA, per orders, (100 mg/mL) IV at 1 mL per minute
Notify OR as needed
B-Lynch
Hysterectomy
Preeclampsia/Eclampsia
Patho: Placental abnormality leading to alterations in vessel formation and endothelial dysfunction. Decreased perfusion to placenta and hypoxia. Vasospasm occurs, increased peripheral resistance, endothelial cell permeability.
Diagnosis: HTN after 20 weeks gestation, proteinuria >300 mg, Thrombocytopenia, Impaired liver function, Renal insufficiency
S/sx: HTN, IUGR, increased creatinine, RUQ pain, scotoma, SOB, heartburn, decrease in urine output.
Assessments: clonus, BP, temperature, LE and facial edema, SOB, crackles, HA (cerebral involvement), increased DTRs, weight gain, uterine tenderness/pain, altered LOC.
Orders: VS, CBC, UA, SCDs, Liver func., GFR, meds., seizure precautions (padding on bed, suction, meds), FHR monitoring, IV meds not to exceed 125 ml/hr, Strict I/O (Foley)
HELLP: hemolysis, elevated liver enzymes, low platelet count. symptoms worsen at night.
Complications: DIC, renal failure, pulmonary edema, ARDS, liver failure, sepsis, stroke, and placental abruption
Patho: Deposition of fibrin in vessel walls, platelet adhesion, hemolysis of RBC. Causes liver damage, thrombocytopenia.
Monitor fetal movements, NST, BPP, US
Infant
NRP
3 Questions: Term? Tone? Breathing or crying?
Good baby, continue normal care, dry, warm, clear secretions, skin to skin w/mom & breastfeed
Bad baby - warm, maintain norm temp, airway, clear secretions, dry stimulate
Apnea, gasping, HR<100 - PPV, SPO2 monitoring, consider ECG
HR<100 - check chest movement, ventilation
HR<60 - intubate, chest compressions w/PPV, 100% O2, ECG
HR<60 - IV epi, consider hypovolemia or pneumothorax
Labored breathing or persistent cyanosis - position/clear airway, SPO2 monitor, supplemental O2, consider CPAP
APGAR Activity, Pulse, Grimace, Appearance, Respiration
SPO2: 1 min - 60-65% 2 min - 65-70% 3 min - 70-75% 4 min - 75-80% 5 min - 80-85% 10 min - 85-95%
Possible IUGR d/t preeclampsia
Pre-delivery baby nurse questions: Gestational age? Fluids? FHTs?Relevant maternal Hx?
Nursing diagnosis and intervention
Stephanie/Carrie
N
Place foley to keep track of I&Os
Monitor VS, FHR, BP, changes in mood and LOC
Large bore IV x2
Dim lights/quiet environment
Side rails up and rails padded with pillows
Check labs for liver enzymes, CBC w/ platelets, creatinine/BUN, proteinuria, ketonuria, hematuria
ineffective tissue perfusion r/t preeclampsia/vasospasm
side lying position
monitor FHR, look for late decels
MgSO4 IV
1 more item...
Volume depletion r/t blood loss >500 ml
risk for impaired gas exchange,
risk decreased CO r/t 3rd spacing
risk for bleeding AEB low plt ct
risk for injury/seizure/CNS irritability
VS, LOC, FHR, I/O, DTR,
quiet, dark environ
MgSO4 IV
1 more item...
Provide 8-10 L O2 by mask
Eclampsia Precautions
Knowledge deficit AEB late to prenatal care, unctrl GDM
#
2 more items...
Risk for excess fluid volume r/t preeclampsia as evidenced by third spacing of fluids caused by damage to endothelial tissue
Risk for decreased cardiac output r/t relative hypovolemia
Risk for infection r/t GBS+, Rubella NI, poorly ctrl GDM
#
#
Prophylactic ampicillin
Blood sugar checks Q1hr
MMR post-delivery