Information
- COMPLICATIONS AFFECTING FLUID-GAS TRANSPORT: HEMORRHAGIC DISORDERS
- General aspects (review Table 4-8. Emergency Conditions )
- Assessment:
- Vital signs, output, general status.
- Evidence of internal/external bleeding.
- Pain.
- Emotional response.
- Perineal pads saturated and number (pad count).
- Speculum examination.
- Analysis/nursing diagnosis:
- Knowledge deficit related to diagnosis, prognosis, treatment, sequelae.
- Anxiety/fear related to loss of pregnancy, surgery.
- Fluid volume deficit, potential/actual, related to excessive blood loss.
- Pain.
- Ineffective coping, individual/family, related to knowledge deficit and fear.
- Anticipatory/dysfunctional grieving, related to loss of pregnancy.
- Disturbance in self-esteem, body image, role performance, related to threat to self-image as woman and childbearer.
- Nursing care plan/implementation:
- Goal: minimize blood loss, stabilize physiological status.
Facilitate prompt medical management.- Administer IV fluids, blood, as ordered.
- Administer analgesics, as needed.
Goal: prevent infection. Strict aseptic technique.- Goal: emotional support.
- Encourage verbalization of anxiety, fears, concerns.
- Supportive care for grief reaction (see Psychosocial Integrity).
- Evaluation/outcome criteria:
- Blood loss minimized; physiological status stable.
- Copes effectively with loss of pregnancy.
- Spontaneous abortion: before viable age of 20 to 22 weeks
- Etiology:
- Defective products of conception.
- Insufficient production of progesterone.
- Acute infections.
- Reproductive system abnormalities (e.g., incompetent cervical os).
- Trauma (physical or emotional).
- Rh incompatibility.
- Assessment: types
- Threatenedmild bleeding, spotting, cramping; cervix closed.
- Inevitablemoderate bleeding, painful cramping; cervix dilated, positive nitrazine test (membranes ruptured).
- Imminentprofuse bleeding, severe cramping, urge to bear down.
- Incompletefetal parts or fetus expelled; placenta and membranes retained.
- Completeall products of conception expelled; minimal vaginal bleeding.
- Habitual/recurrenthistory of spontaneous loss of three or more successive pregnancies.
- Missedfetal death with no spontaneous expulsion within 4 weeks.
- Anorexia, malaise, headache.
- Fundal heightinconsistent with gestational estimate.
- Laboratoryprolonged clotting time, due to resultant concurrent hypofibrinogenemia (disseminated intravascular coagulation [DIC], a major threat to mother).
- Elective abortions (intentionally induced loss of pregnancy).
- Analysis/nursing diagnosis:
- Altered family processes related to pregnancy, circumstances surrounding abortion.
- Sexual dysfunction related to compromised self-image, altered interpersonal relationship, guilt feelings.
- Nursing care plan/implementation:
- ThreatenedGoal: health teaching. Suggest: avoid coitus and orgasm, especially around normal time for menstrual period.
- Incomplete, inevitable, imminent.
- Goal: safeguard status.
- Save all pads, clots, tissue for expert diagnosis.
- Report immediately any change in status, excessive bleeding, signs of infection, shock.
- Prepare for surgery.
- Goal: comfort measures.
Administer analgesics, as necessary.- Bedrest, quiet diversional activities.
- Goal: emotional support.
- Encourage verbalization of fear, concerns.
- Reduce anxiety, as possible.
- If pregnancy terminates, facilitate grieving process; assist in working through guilt feelings (see The Intrapartum Experience).
- Supportive care for grief reaction (see Psychosocial Integrity).
- Goal: prevent isoimmunization (see II. C. 5. Rh incompatibility, Health Promotion and Maintenance).
- Medical management:
- Laboratoryblood type and Rh factor, indirect Coombs' test, platelets, serum fibrinogen, clotting time.
Replace blood loss; maintain fluid levels with IV.- Dilation and curettage or dilation and evacuation.
- Habitualdetermine etiology.
- Evaluation/outcome criteria:
- Threatenedresponds to medical/nursing regimen; abortion avoided, successfully carries pregnancy to term.
- Spontaneous abortionafter uterus emptied.
- Bleeding is controlled.
- Vital signs are stable.
- Copes effectively with loss of pregnancy.
- Expresses satisfaction with care.
- Habitual abortioncause identified and corrected; carries subsequent pregnancy to successful termination.
- Hydatidiform mole(complete)
- Pathophysiologychorionic villi degenerate into grapelike cluster of vesicles; may be antecedent to choriocarcinoma.
- Etiologygenetic base of complete mole (sperm enters empty egg and its chromosomes replicate; 23 pairs of chromosomes are all paternal); rare complication; more common in women over 45 years of age and women who are Asian.
- Assessment:
- Uterusrapid enlargement; fundal height inconsistent with gestational estimate.
- Brownish dischargebeginning about week 12; may contain vesicles.
- Signs and symptoms of preeclampsia/eclampsia (before third trimester), increased incidence of hyperemesis gravidarum.
- Medical evaluationprocedures:
- Sonography, x-ray, amniographyno fetal parts present; "snowstorm."
- Laboratory testfor elevated human chorionic gonadotropin (HCG) levels.
- Follow-up surveillance of HCG levels for at least 1 year; persistent HCG level is consistent with choriocarcinoma; x-ray.
- Analysis/nursing diagnosis:
- Anxiety/fear related to treatment, possible sequelae of hydatidiform mole (choriocarcinoma).
- Potential for injury related to hemorrhage, perforation of uterine wall, preeclampsia/eclampsia.
- Fluid volume deficit related to hemorrhage.
- Nursing care plan/implementation:
- Medical management
- Monitor for preeclampsia.
- Evacuate the uterushysterectomy may be necessary.
- Strict contraception for at least 1 year to enable accurate assessment of status.
Choriocarcinomachemotherapy (methotrexate plus dactinomycin) or radiation therapy, or both.
- Nursing management
- Goal: safeguard status. Observe for hemorrhage, passage of retained vesicles and abdominal pain, or signs of infection (because woman is at risk for perforation of uterine wall).
- Goal: health teaching.
- Explain, discuss diagnostic tests; prepare for tests.
- Discuss contraceptive options.
- Importance of follow-up.
- Goal: preoperative and postoperative care.
- Goal: emotional support. Facilitate grieving.
- Evaluation/outcome criteria:
- Verbalizes understanding of diagnosis, tests, and treatment.
- Complies with medical/nursing recommendations.
- Tolerates surgical procedure well.
- Bleeding controlled.
- Vital signs stable.
- Urinary output adequate.
- Copes effectively with loss of pregnancy.
- Returns for follow-up care/surveillance.
- Selects and effectively implements method of contraception; avoids pregnancy for 1 year or more.
- Tests for HCG remain negative for 1 year; no evidence of malignancy.
- Achieves a pregnancy when desired.
- Successfully carries pregnancy to term; normal, uncomplicated birth of viable infant.
- Ectopic pregnancy (Figure 4-6. Ectopic Pregnancy)
- Pathophysiologyimplantation outside of uterine cavity.
- Types:
- Tubal (most common).
- Cervical.
- Abdominal.
- Ovarian.
- Etiology:
- PIDpelvic salpingitis and endometritis.
- 43% caused by STI-related factors: 25%, chlamydial; 20%, previous STI.
- Tubal or uterine anomalies, tubal spasm.
- Adhesions from PID or past surgeries.
- Presence of IUD.
- Assessment: dependent on implantation site.
- Early signsabnormal menstrual period (usually following a missed menstrual period), spotting, some symptoms of pregnancy; possible dull pain on affected side.
- Impending or posttubal rupturesudden, acute, lower abdominal pain; nausea and vomiting; signs of shock; referred shoulder pain ( Kehr's sign) or neck paindue to blood in peritoneal cavity; blood in cul-de-sac may → rectal pressure.
- Sharp, localized pain when cervix is touched during vaginal examination; shock and circulatory collapse in some, usually following vaginal examination.
- Positive pregnancy test in many women.
- Analysis/nursing diagnosis:
- Fear related to abdominal pain and pregnancy status.
- Grief related to pregnancy loss.
- Nursing care plan/implementation:
Medical management: Methotrexate, a folic acid antagonist, which acts by inhibiting cell division (may be used in early ectopic pregnancy).- Surgical removal/repair.
- Nursing management:
- Goal: preoperative and postoperative care, health teaching.
- Goal: supportive care for grief reaction; encourage verbalization of anxiety and concerns of further pregnancies.
- Evaluation/outcome criteria:
- Woman experiences uncomplicated postoperative course.
- Woman copes effectively with loss of pregnancy.
- COMPLICATIONS AFFECTING NUTRITION/ELIMINATION: HYPEREMESIS GRAVIDARUM
- Pathophysiologypernicious vomiting during first 14 to 16 weeks (peak incidence around 10 weeks of gestation); excessive vomiting at any time during pregnancy. Potential hazards include the following:
- Dehydration with fluid and electrolyte imbalance.
- Starvation, with loss of 5% or more of body weight; protein and vitamin deficiencies.
- Metabolic acidosisdue to breakdown of fat stores to meet metabolic needs.
- Hypovolemia and hemoconcentration; increased blood urea nitrogen (BUN); decreased urinary output.
- Embryonic or fetal death may result, and the woman may suffer irreversible metabolic changes or death.
- Etiology:
- Physiologicalsecretion of HCG, decrease in free gastric HCl, decreased gastrointestinal motility. Increased incidence in hydatidiform mole and multifetal pregnancy (due to high levels of HCG).
- Psychologicalthought to be related to rejection of pregnancy or sexual relations.
- Assessment:
- Intractable vomiting.
- Abdominal pain.
- Hiccups.
- Marked weight loss.
- Dehydrationthirst, tachycardia, skin turgor.
- Increased respiratory rate (metabolic acidosis).
- Laboratoryelevated BUN.
- Medical evaluation: rule out other causes (infection, tumors).
- Analysis/nursing diagnosis:
- Altered nutrition, less than body requirements, related to inability to retain oral feedings.
- Fluid volume deficit related to dehydration.
- Ineffective individual coping related to symptoms, insecurity in role, psychological stress of unwanted pregnancy.
- Personal identity disturbance related to symptoms or perception of self as inadequate in role, sick, socially unpresentable.
- Nursing care plan/implementation:
- Goal: physiological stability.
- Rest GI tract (keep NPO) (e.g., maintain IV fluids, parenteral nutrition).
Progress diet, as ordered; present small feedings attractively; ↑ carbohydrates, ↓ fat, ↓ acidic foods.- Weigh daily, assess hydration; note weight gain.
Antiemetics (IV, suppository).
- Goal: minimize environmental stimuli.
- Limit visitors and phone calls.
- Bedrest with bathroom privileges.
- Goal: emotional support.
- Establish accepting, supportive environment.
- Encourage verbalization of anxiety, fears, concerns.
- Support positive self-image.
- Evaluation/outcome criteria:
- Woman's signs and symptoms subside; she takes oral nourishment and gains weight.
- Woman's pregnancy continues to term without recurrence of hyperemesis.
- COMPLICATIONS AFFECTING PROTECTIVE FUNCTION: SEXUALLY-TRANSMITTED INFECTIONS (STIS).
This category measures applications of knowledge about conditions related to client's capacity to maintain defenses and prevent physical and chemical trauma, injury, infection, and threats to health status. - Vaginitisinflammation of vagina.
- Pathophysiologylocal inflammatory reaction (redness, heat, irritation/tenderness, pain). May cause preterm labor in pregnancy.
- Etiology:
- Common causative organisms:
- Bacteriastreptococci, Escherichia coli, gonococci, Chlamydia, bacterial vaginosis.
- Virusesherpes simplex virus type 2, CMV, HPV
- ProtozoaTrichomonas vaginalis.
- FungiCandida albicans.
- Atrophic changesdue to declining hormone level (women who are postmenopausal).
- Assessment: differentiate among common vaginal infections:
- Vulvovaginal erythema.
- Pruritus, dysuria, dyspareunia.
- Vaginal dischargecolor, consistency.
- Analysis/nursing diagnosis: pain related to inflammation, discharge.
- Nursing care plan/implementation:
- Goal: emotional support.
- Goal: health teaching. Instruct woman in self-care measures to promote comfort and healing:
- Perineal care.
- Sitz baths.
- Douching (as ordered). Not recommended during pregnancy.
- Exposing vulva to air.
- Cotton briefs.
- Proper insertion of vaginal suppository.
- Antibiotic use, as ordered.
- Goal: prevent reinfection.
- Suggest sexual partner use condom until infection is eliminatedor abstain from intercourse.
- Recommend sexual partner seek examination and treatment.
- Goal: medical consultation/treatment. Refer for diagnosis and treatment.
- Evaluation/outcome criteria:
- Woman is asymptomatic; unable to recover organism from body fluids or tissue.
- Woman avoids reinfection.
- Woman carries pregnancy to term without complications.
- Gonorrhea
- Pathophysiology:
- Menearly infection usually confined to urethra, vestibular glands, anus, or pharynx. Untreated: ascending infection may involve testes, causing sterility.
- Womenearly infection usually confined to vestibular glands, endocervix, urethra, anus (vagina is resistant). May ascend to involve pelvic structures (e.g., PID: fallopian tubes, ovaries); scarring may cause sterility.
- Women who are pregnantmay result in preterm rupture of membranes, amnionitis, preterm labor, postpartum salpingitis.
- Sequelae (untreated):
- May develop carrier state (asymptomatic; organism resident in vestibular glands).
- Systemic spread may result in gonococcal:
- Arthritis.
- Endocarditis.
- Meningitis.
- Septicemia.
- Newbornophthalmia neonatorum (gonococcal conjunctivitis). Untreated sequela: blindness.
- Etiology: gram-negative diplococcus (Neisseria gonorrhoeae).
- Epidemiology:
- Portal of entryoral or genitourinary mucous membranes.
- Mode of transmissionusually sexual contact.
- Incubation period: 2 to 5 days; may be asymptomatic.
- Communicable periodas long as organisms are present; to 4 days after antibiotic therapy begun.
- Assessment:
- History of known (or suspected) contact.
- Men:
- Complaint of mucoid or mucopurulent discharge.
- Medical diagnosisprocedure: urethral discharge Gram stain.
- Women:
- Often asymptomatic; acute infection: severe vulvovaginal inflammation, venereal warts, greenish-yellow vaginal discharge.
- Medical diagnosisprocedure: endocervical culture.
- Gonococcal urethritis (men and women)sudden severe dysuria, frequency, burning, edema.
- Salpingitis/oophoritissevere, sudden abdominal pain, fever (with or without vaginal discharge).
- Analysis/nursing diagnosis: impaired tissue integrity related to tissue inflammation.
- Nursing care plan/implementation:
- Goal: emotional support.
- Goal: health teaching to prevent transmission, sequelae, reinfection.
- Need for accurate diagnosis and effective treatment, follow-up examination in 7 to 14 days, and culture.
- All sexual partners need examination, treatment.
- Possible sequelae/complications (sterility, carrier state).
- Goal: medical consultation/treatment.
- Determine allergy to antibiotics.
- Refer for diagnosis and treatment.
- Diagnosis: culture.
Treatmentceftriaxone IM, plus doxycycline PO. May use erythromycin or spectinomycin in pregnancy.- Follow-up culture before birth.
- Notification of sexual partners.
- Evaluation/outcome criteria:
- Verbalizes understanding of mode of transmission, prevention, importance of examination, treatment of sexual contacts.
- Informs sexual contacts of need for examination.
- Returns for follow-up examinations.
- Successfully treated; weekly follow-up cultures: negative on two successive visits.
- Avoids reinfection.
- Chlamydia trachomatis
- Pathophysiology:
- Most common sexually transmitted infection in United States.
- Initial infection mild in women; inflammation of cervix with discharge.
- If untreated, may lead to urethritis, dysuria, PID, tubal occlusion, infertility
- Etiology:
- Chlamydia trachomatis has maternal-fetal effects.
- Bacteria can exist only within living cells.
- Transmission is by direct contact from one person to another.
- Assessmentmaternal:
- Inflamed cervix (may be asymptomatic).
- Cervical congestion, edema.
- Mucopurulent discharge.
- Assessmentfetal-neonatal:
- Increased incidence of stillbirth.
- Preterm birth may result.
- Contact with infected mucus occurs during birth.
- Newborn may be asymptomatic.
- Conjunctivitis; may lead to scarring.
- Chlamydial pneumonia.
- Analysis/nursing diagnosis:
- Pain related to inflamed reproductive organs.
- Fatigue related to inflammation.
- Knowledge deficit related to mode of treatment, disease transmission.
- Nursing care plan/implementation:
Treatment with antibiotics, generally doxycycline or azithromycin. Erythromycin in pregnancy.
Provide pain relief, analgesics.- Counsel regarding use of condoms, spermicidal agents (containing nonoxynol-9) to prevent reinfection.
- Evaluation/outcome criteria:
- Woman understands treatment and shows compliance.
- Woman understands portal of entry and risk for reinfection.
- Herpes genitalis
- Pathophysiologyinitial infection: varies in severity of symptoms, may be local or systemic; duration: prolonged; morbidity: severe.
- EtiologyHerpes simplex virus type 2.
- Epidemiology:
- Portal of entryskin, mucous membranes.
- Mode of transmissionusually sexual.
- Incubation: 3 to 14 days.
- Communicable periodwhile organisms are present.
- Assessment:
- Lesionspainful, red papules; pustular vesicles that break and form wet ulcers that later crust; self-limiting (3 weeks).
- Severe itching, tingling, or pain.
- Dischargecopious; foul smelling.
- Dysuria.
- Lymph nodesenlarged, inflammatory, inguinal.
- Woman who is pregnantvaginal bleeding, spontaneous abortion, fetal death.
- May shed virus for 7 weeks.
- Medical diagnosis: multinucleated giant cells in microscopic examination of lesion exudate; culture for herpes simplex virus (HSV).
- Analysis/nursing diagnosis:
- Pain related to inflammation process.
- Fear related to longevity of disease.
- Fear related to no cure for disease.
- Knowledge deficit related to transmission to future partners, suppressive treatment.
- Nursing care plan/implementation:
- Goal: emotional support.
- Goal: health teaching.
- Virus remains in body for life (dormant, noninfectious) in 25% to 30% of population; small percentage have symptoms.
- Recurrence probable; usually shorter and milder.
- Need for close surveillance during pregnancy; cesarean birth may be indicated if woman has active genital lesions or positive culture.
- Goal: promote comfort.
- Goal: accurate definitive treatment. Refer for diagnosis and treatment.
- Diagnosiscervical smears, labial and vaginal smears.
Treatmentacyclovir; used for suppressive treatment only.
- Evaluation/outcome criteria:
- Woman remains asymptomatic.
- Pregnancy continues to term with no newborn effects.
- Syphilis
- Pathophysiology:
- Primary stage: nonreactive RPR.
- Men: 3 to 4 weeks after contact, painless, localized penile/anal ulcer (chancre); lymph nodesenlarged, regional.
- Women: often asymptomatic; labial, vaginal, or cervical chancre.
- Medical diagnosisprocedure: dark-field microscopic examination of lesion exudate.
- Secondary stage: reactive Venereal Disease Research Laboratories (VDRL).
- 6 to 8 weeks after infection.
- Rashmacular, papular; on trunk, palms, soles.
- Malaise, headache, sore throat, weight loss, low-grade temperature.
- Latent stage: reactive serologic test for syphilis (STS). Asymptomatic; noninfectious.
- Tertiary stage:
- Gumma formation in skin, cardiovascular system, or central nervous system.
- Psychosis.
- Etiology: Treponema pallidum (spirochete).
- Epidemiology:
- Portal of entryskin, mucous membranes.
- Mode of transmissionusually sexual.
- Incubation period9 days to 3 months.
- Communicable periodprimary and secondary stages.
- Assessment:
- Primarychancre, when detectable.
- Medical diagnosisprocedure: dark-field examination of lesion exudate.
- Secondary:
- Malaise, lymphadenopathy, headache, elevated temperature.
- Macular, papular rash on palms and soles; may be disseminated.
- Medical diagnosis(see d., following).
- Tertiary:
- Subcutaneous nodules (gumma).
- Note: Gumma formation may affect any body system; symptoms associated with area of involvement.
- Medical diagnosisprocedures: stages other than primarySTS: VDRL, RPR, T. pallidum immobilization (TPI), fluorescent treponemal antibody absorption (FTA). False-positive STS in: collagen diseases, infectious mononucleosis, malaria, systemic tuberculosis.
- Analysis/nursing diagnosis:
- Pain related to inflammation process.
- Knowledge deficit related to treatment and transmission of the disease.
- Nursing care plan/implementation:
- Goal: emotional support
- Nonjudgmental.
- Caring, supportive manner.
- Goal: health teaching.
- Need for accurate diagnosis and treatment, follow-up examinations.
- All sexual partners need examination and treatment.
- Goal: medical consultation/treatment.
- Refer for diagnosis and treatment. Note: In pregnancytreatment by 18th gestational week prevents congenital syphilis in neonate; however, treat at time of diagnosis.
- Treatment:
Primary, secondarybenzathine penicillin G, 2.4 million units.- Other stages7.2 million units over 3-week period.
- Erythromycin or doxycycline for clients who are allergic to penicillin.
- Evaluation/outcome criteria:
- If treated by 18th week of pregnancy, congenital syphilis is prevented.
- Appropriate treatment after 18th week cures both mother and fetus; however, any fetal damage occurring before treatment is irreversible.
- Follow-up VDRL: nonreactive at 1, 3, 6, 9, and 12 months.
- Tertiarycerebrospinal fluid examination negative at 6 months and 1 year following treatment.
- Verbalizes understanding of mode of transmission, potential sequelae without treatment, importance of examination/treatment of sexual contacts, preventive techniques.
- Informs contacts of need for examination.
- Returns for follow-up visit.
- Avoids reinfection.
- Pelvic inflammatory disease (PID)
- Pathophysiologyascending pelvic infection; may involve fallopian tubes (salpingitis), ovaries (oophoritis); may develop pelvic abscess (most common complication), pelvic cellulitis, pelvic thrombophlebitis, peritonitis.
- Etiology:
- Chlamydia trachomatis.
- Gonococci.
- Streptococci.
- Staphylococci.
- Assessment:
- Pain: acute, abdominal.
- Vaginal discharge: foul smelling.
- Fever, chills, malaise.
- Elevated white blood cell (WBC) count.
- Analysis/nursing diagnosis:
- Pain related to occluded tubules.
- Infertility related to permanent block of tubes.
- Knowledge deficit related to transmission of disease.
- Altered urinary elimination related to dysuria.
- Nursing care plan/implementationfor woman who is hospitalized:
- Goal: emotional support.
- Goal: limit extension of infection.
Bedrestposition: semi-Fowler's, to promote drainage.- Force fluids to 3000 mL/day.
Administer antibiotics, as ordered.
- Goal: prevent autoinocculation/transmission.
- Strict aseptic technique (hand washing, perineal care).
- Contact-item isolation.
- Goal: Health teaching: if untreated: high risk of tubal scarring, sterility, or ectopic pregnancy; pelvic adhesions; transmission of disease.
- Goal: promote comfort.
Analgesics, as ordered.- External heat, as ordered.
- Evaluation/outcome criteria:
- Woman responds to therapy; uneventful recovery.
- Woman avoids reinfection.