UNIT II
Care of At-Risk / High-Risk and Sick Mother and Child
A. Nursing Care of Pregnant Client
1. Identification of Risk Clients
a. Risk Factors
b. Vulnerable Groups
2. Pre-gestation Medical conditions that affects pregnancy
a. RHD (Rheumatic Heart Disease)
b. DM (Diabetes Mellitus)
c. Substance Abuse
d. HIV/AIDS
e. Anemia
3. GESTATIONAL CONDITIONS
A. Abortion
B. Ectopic Pregnancy
C. Gestational Trophoblastic Disease
D. Incompetent Cervix
E. Spontaneous Abortion
F. Placenta Previa
G. Abrutio Placenta
H. PROM- Premature Rupture of Membranes
I. PIH- Pregnancy Induced Hypertension
2. ASSESSMENT OF ALTERED
REPRODUCTIVE FUNCTION
A. NURSING HISTORY
a.1 Demographic Data
>Age –which secondary sexual
characteristics developed-13-15 years old
✓ Cultural beliefs and practices
✓ religious beliefs
✓ number of partners
✓ the contraceptive use
a.2 Family History and Genetic Risk
>helps to determine the client’s risk for condition
that affect reproductive functioning
>ask about the current age and health status of
health members
>the cause of and age of death of certain family
member
>assess health habits (diet, sleep, exercise)
>alcohol, tobacco and drug use
>ask childhood illness
e.g. teratogenic effects on the unborn if the
mother gets rubella during the first trimester of
pregnancy,
a.3 Genitoreproductive History
age of menarche
cycle frequency and duration
amount of flow
spotting between periods
dysmenorrheal and
premenstrual symptoms
>obtain an obstetric history (GTPAL)
>ask about previous pregnancies
>assess signs of intimate Partner abuse ,ask
questions regarding potential abuse (in the
past year has anyone hurt you?, are you
afraid of your spouse or partner?)
a.4 Diet History
❖ poor diet and anemia may cause fatigue
and low libido
❖obesity increases the risk for uterine cancer
❖high fat diet increases the risk for breast,
ovary and prostate cancer
❖ask the client to recall his dietary intake for
the recent 24 hour period to assess diet
quality
a.5 Socioeconomic Status
❖provides insight into the whole person,
including stressors, job history,
education, and support systems
1.Stress- associated with menstrual and
ovulatory problems and infertility
2.Occupation- exposure to potential
teratogenic substances
3.Education
-use a nonjudgmental attitude that may hinder
successful data gathering
4.Current Health problems
>explore the chief complaint
b. Bleeding-
-heavy bleeding or lack of
bleeding,describe the amount and
character of abnormal vaginal bleeding
c. Discharge-
-ask about amount, odor, consistency
B. REVIEW OF SYSTEMS
B.Objective Data
B.1 Obtain Baseline Data
B.2 Physical Examination
>pain or lack of privacy may prevent the client from
relaxing during examination
>show equipment to be used and teach relaxation
techniques to enhance client’s sense of control.
>the presence of a support person
c. Pelvic Examinations (non-pregnant)
>done with the use of vaginal speculum which
should be warmed and lubricated with warm
water.
>lubricant should not be used if cytologic
studies are to be collected because it
interferes with specimen analysis.
>inspect the vagina for erosions, nodules, masses,
discharge andcervix for color, shape, and dilation
of the os and bleeding.
>palpation of the cervix is followed by BIMANUAL
PALPATION
C. DIAGNOSTIC EXAMINATIONS
1.Laboratory Tests
a. Papanicolaou test (pap smear) – a cytologic
study used to detect precancerous and
cancerous cells from the cervix
within 3 years of becoming sexually active or by
21 years of age
annual screening is recommended to 30 years of
age after 3or more consecutive negative test
result, pap smear may be performed least
frequently until 65 to 70 years of age.
also detects viral, fungal disorder
Client preparation :
>no douching, vaginal medications and deodorants or
sexual intercourse 24 hours before the test.
Procedure – lithotomy position, a sample is taken
from the endocervical canal and a second from the
ectocervical ,specimens are transferred to a glass
slide and are preserved.
b. DNA Human Papillomavirus (HPV)
>identifies 13 high risk types of HPV associated
with the development of cervical cancer
>can be done at the same time as the pap test for
women older than 30 years old
2.Blood Studies
a. Pituitary Gonadotropin – determines
the quantitative levels of follicle-stimulating
hormone(FHS),luteinizing hormone(LH),and
prolactin in the diagnosis of male and female
reproductive tract disorders.
b. Serologic test
>detects antigen-antibody reaction
>exposure to organisms causing syphilis
c. VDRL test, Rapid plasma reagent test (RPR),
Serologic test for syphilis (STS) – used to detect
,confirm and monitor cases of syphilis
(Venereal Disease Research Laboratory test)
>recommended for all pregnant women and
persons at risk for syphilis
>the test is usually positive about 2 weeks after
the client has become infected.
RADIOLOGIC
EXAMINATION
>KUB x ray of the abdomen
is used in the assessment of
pelvic masses,calcified
tumors
>Bone scan IV
pyelograms,barium
enema and chest x- ray are
also included in the work up
of clients with metastatic
cancer.
>Computed
tomography
(CT) scans
involves the
abdomen and the
pelvis used to
detect and
evaluate
lymphatic
enlargement
from metastasis
b. Mammography- an x-
ray of the soft tissue of the
breast to assess differences in
the density of the breast tissue.
>annual screening are not
recommended for women
younger that 40 years of
age
>client preparation – no dietary
restrictions, no creams,
powders and deodorant on the
breast or under arms, no to
pregnant women
c. Other Diagnostic tests
1.Ultrasonography –
assess uterine fibroids,
ovarian cyst and pelvic
mass.
>can differentiate solid
tumors from cyst in the
breast examination.
>no specific preparations
are needed women should
have a full bladder to
enable visualization of the
uterus
2.Magnetic Resonance
Imaging (MRI) –
>uses a magnetic field and
radiofrequency energy to
scan for pelvic tumors
>can distinguish between
normal and malignant
tissues.
3.Endoscopic Studies
a.Colposcopy –
> allows 3 dimensional magnification and intense
illuminations of epithelium.
> used to inspect the cervical and vulvar epithelium to
locate the exact site of precancerous and malignant
lesions for biopsy.
>on lithotomy position .no douching or use a vaginal
preparation for 24 – 48 hours before the test .
>provides accurate site selection for tissue biopsy.
b.Laparoscopy -
>a direct examination of the pelvic cavity
through an endoscope,this can rule out an
ectopic pregnancy,evaluate ovarian disorders
and pelvic masses and aid in the diagnosis of
infertility and unexplained pelvic pain.
3. Cervical Tests
a.Cervical biopsy – a
tissue is removed for
cytologic study,indicated
in a client with an
identifiable cervical
lesion.
>performed in a clinic or in
the office ,done in
conjunction with
colposcopy as a follow up
to a suspicious Pap test
finding.
b. Endometrial Biopsy and Aspiration
>both are used to obtain cells directly from the
lining of the uterus to asses for cancer of the
endometrium .
>also used to assess menstrual
disturbances,and infertility
>some cramping is experienced when the cervix
is dilated.
>analgesia and breathing and relaxation
techniques are important.
c. Breast Biopsy and Aspiration
>a surgical removal of tissues from breast mass
>excisional biopsy removes the mass itself for
histologic evaluation
>aspiration biopsy is the removal of fluid or tissue
from the breast mass through a large bore needle.
>pt. to wear supportive bra continuously for 1 week
after surgery
>cold temperature should be avoided to prevent
nipple contractions that can cause stress to the
incision.
FETAL EVALUATION
1.Ultra sonography - intermittent sound waves of high
frequency are projected toward the uterus by a
transducer .
> used to diagnose pregnancy as early as 6 wks.
>confirm the presence,size,and location of the
placenta and amniotic fluid.
>establish that the fetus is increasing in size and has
no gross defects
2.Amniocentesis - aspiration of amniotic fluid from
the pregnant uterus for examination.
>done on the 12th -13th week of pregnancy or maybe
delayed until the 14th -16th week.
>used in late pregnancy to test fetal maturity.
>complications ;
- hemorrhage ,infection and puncture of the fetus,
irritation of the uterus causing premature labor
>preparation ;
- ask the client to void, on supine position ,tip the
body slightly to the left to move the uterus off the vena
cava to prevent supine hypotension .
3.Chorionic Villi Sampling – a biopsy and
analysis of chorionic villi for chromosome
Analysis done at 10 – 12th weeks of pregnancy
4.Percutaneous Umbilical Blood Sampling
(cordocentesis) – aspiration of blood from the
umbilical cord for analysis and gives information
about blood dyscrasias.
5. Non-stress test
measures fetal heart
rate in response to
fetal movement
> done on 3rd
trimester for
suspected fetal
distress or placental
insufficiency
associated with DM,
hypertension,and
heart diseases.
6.Contraction Stress
testing
(oxytocin challenge test )
evaluates the respiratory
function of the placenta and
identifies whether the fetus
will be able to withstand the
stress of labor
F. PREGNANCY RELATED
DISTURBANCES
F.1 ANTEPARTAL PERIOD
Primary causes
1.first trimester -
a. abortion
b. ectopic pregnancy
2.second trimester –
a. hydatidiform mole (H-mole)
b .incompetent cervix
3.third trimester –
a.placenta previa
b. premature separation of the placenta
c. preterm labor
A.1 ABORTION (MISCARRIAGE) –
termination of pregnancy at any given time before
the fetus reached the stage of viability. A non
viable fetus weighs 500g or 20 – 24 wks gestation
>Types :
A. spontaneous abortion – occurs from
natural causes
> early –when it occurs before wk 16 of pregnancy
> late – if it occurs between wk 16 -24 of
pregnancy
Causes :
1. abnormal fetal formation due to teratogenic
factor or cellular aberration
2. implantation abnormalities
3.failure of the corpus luteum to produce enough
progesterone
Categories of Spontaneous abortion
1. threatened abortion –begins as a scant bleeding
,bright red in color with slight cramping but NO
cervical dilatation present on vaginal examination
2.Imminent (Inevitable) abortion
– if cervical dilatation and uterine
contraction occur
- the loss of the product of
conception cannot be halted
- tissue fragments that have passed
from the patient should be saved and
examined
- if no fetal heart sound detected and
sonogram reveals an empty uterus
,D&C is performed To ensure that all
products of conception are removed
and to clean the uterus to prevent
further complication such as infection.
3.Complete abortion – the entire product of
conception (fetus , membranes and placenta) Are
expelled spontaneously without any assistance
- the bleeding usually slows within two hours and
then ceases within a few days after passage of the
product of conception.
4. Incomplete abortion – part of conception (usually the
fetus) is expelled but the membranes or Placenta is retained
in the uterus
- there is a danger of maternal hemorrhage as long as part
of the conceptus remains in the uterus
- D&C is performed to evacuate the remainder of the
pregnancy from the uterus.
5. Missed abortion – the fetus dies in the utero
but is not expelled.
- in pre natal examination ,fundal height is
measured and no increase in size can be
demonstrated or when previously heard heart
sounds cannot be heard.
- symptoms of threatened abortion may be
present(painless vaginal bleeding)or No prior
clinical symptoms.
- a sonogram usually confirms the death of the
fetus and a D&C is done
- - if the pregnancy is more than 14 wks.pregnancy
may be induced by prostaglandin suppository to
dilate the cervix followed by oxytocin
stimulation otherwise D&C is done.
6. Recurrent / Habitual abortion – three
recurrent abortions that occurred at the same
gestation Age in three pregnancies
-possible causes ; defective spermatozoa or ova ,
endocrine factors (poor thyroid function , or
luteal phase defect)
-deviations of the uterus
-infection or autoimmune disorder
B. Induced abortion - artificially brought about
; maybe categorized as –
- Medical or therapeutic abortion
- Criminal or illegal abortion
> assessment findings
- vaginal spotting
- uterine cramping
- cervical opening
> Treatment –restricted activity, IV fluids and blood
replacement
